denied claim – OLHI – Free, impartial help with your life & health insurance complaints

Dale had a universal life insurance policy. 

When his insurance company told him they were going to charge him another premium for the policy, Dale decided to terminate it. 

To avoid a Cost of Insurance (COI) charge, the insurer told Dale to send a signed insurance cancellation letter to the same day he terminated his policy.

However, Dale’s insurer didn’t inform him that he needed to include his social insurance number (SIN) in the termination letter. Without the SIN, his policy termination got delayed and Dale was charged the COI. As a result, he received a lower refund than expected. 

After he received a final position letter from the insurer, Dale reached out to OLHI to review his complaint.

OLHI’s review confirmed that his insurance company did not tell Dale he had to include his SIN in the letter. 

OLHI’s review also found that even after Dale sent in the letter with his SIN, the company asked for it again. OLHI recommended that the insurer reconsider the COI charge for two reasons:

The company did not initially communicate that Dale needed to include his SIN in his termination letter. 

When the insurer said Dale needed to include the SIN, he did so, and sent the termination letter within the same day, so the company should have processed it effective as of the receipt date. 

Consequently, the insurer agreed and backdated the termination and refunded the COI charge.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Did you know that you can make a complaint if your life or health insurance company denies your claim?

Before you submit your complaint to us at the OmbudService for Life and Health Insurance (OLHI), you first need to go through your insurance company’s internal complaint process. 

Can I go directly to OLHI with my denied insurance claim?

OLHI can’t review a complaint about a denied claim if you haven’t gone through your insurer’s internal process.

We’ll know that you completed this process if you have a “final position letter”—it’s one of the first things we’ll ask for after you submit a complaint to OLHI.

How to submit a complaint to your life or health insurance company

1. Appeal your denied claim.

If your life or health insurance claim gets denied, a Case Manager will send you a claim denial letter. Each submitted claim gets assigned to a Case Manager, whose job is to review these claims to see if they are payable—or not.

An example of claim denial letter from a life or health insurance company.
A claim denial letter will provide step-by-step instructions on how to appeal your denied claim.

A claim denial letter will provide step-by-step instructions on how to appeal your denied claim. You’ll likely need to provide additional details (in writing) to your insurer to clarify the context of your claim.

If you receive a second claim denial letter, now you have the grounds to file a complaint.


Tip: Be calm and polite.

Trying to resolve a complaint can be frustrating and stressful. Our experience is that a courteous manner leads to an easier and faster resolution.


2. Submit your life or health insurance complaint to a Complaint Officer.

Once you’ve unsuccessfully appealed your denied claim, you can escalate your situation to a Complaint Officer at your insurance company.

A Complaint Officer has the authority to make a final decision about your complaint.

A man calling his insurance company.
Before sending your complaint, contact your insurance company to determine to whom you should address your complaint and what documentation you need to attach.

Tip: Submit your complaint in writing.

It’s usually best to send your complaint in writing. Many insurance companies will have an email address or online form you can use to make your complaint. You may also be able to send it by mail.


Before sending your complaint, contact your insurance company to determine to whom you should address your complaint and what documentation you need to attach.

OLHI has a Consumer Complaint Officer Listing tool that allows you to quickly find the contact information for your insurance company’s Complaints Officer. (If you don’t see your insurance company on this list, it means they aren’t a member company of OLHI.)


Tip: How to format your written insurance complaint

Put “Complaint” at the top of your letter or in the subject of your email.

Be clear about what went wrong and when.  

Tell your insurance company what you expect as a solution.


3. Submit your life or health insurance complaint to a Complaint Officer.

Once you complete your insurance company’s complaint process, you will receive a “final position letter.” If you don’t receive a final position letter, ask for one from the Complaint Officer.

A final position letter with further detail on its contents—date, reference number, context, and the insurer's review process and final position.
If you don’t receive a final position letter, ask for one from the Complaint Officer.

4. Contact OLHI if you haven’t heard from your Complaint Officer in 90 days or more. 

If your insurer takes longer than 90 days to reach a decision, ask OLHI to contact your company to inquire about the status of your complaint.

What to do if you’re unhappy with your insurer’s final decision on your complaint

Followed all the steps above, but you’re still dissatisfied with your insurer’s final position? You can now submit a complaint to OLHI. If your case is reviewable and has merit, we can provide a free, independent, and impartial review.

Harold B. suffered a severe health problem related to his kidneys and had to have one removed. Worried about his clients, Harold returned to his job as soon as he felt able after the surgery.

When Harold returned to work, he had to periodically reduce his work hours and was never able to work full-time again because of his health. Nearly two years later, Harold quit his job and submitted a total disability claim to his individual disability insurance provider.

The insurance company denied the claim, even after Harold appealed the decision. At this point, Harold came to the OmbudService for Life and Health Insurance.

OLHI reviewed the complaint and learned:

  • Harold’s policy only covered losses for “total disability.”
  • He had returned to work part-time and before he completed the waiting period required by his policy.
  • Harold submitted his final claim after the policy deadline.
  • The insurer’s decision strictly followed the policy’s terms, but the company could have communicated the process earlier and more clearly to Harold.

As OLHI cannot consider damages or extenuating circumstances outside of insurance policy, we advised Harold to consider pursuing his complaint in court with a disability lawyer.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Mrs. T. purchased medical travel insurance ahead of a trip abroad. On that holiday, she fell ill and had to be treated in hospital. Afterward, she submitted her claim. It was declined because the insurance plan did not cover anyone who had been treated for three specific medical conditions. In its final position letter, the insurance company wrote that Mrs. T. had been treated for these conditions.

Mrs. T. contacted OLHI, asking for a free, independent review of her case. She told our Dispute Resolution Officer (DRO) that she had been diagnosed and treated for two of the medical conditions. But she had never been diagnosed or treated for the third condition: hypertension/high blood pressure.

OLHI’s DRO asked Mrs. T. and her insurance company to provide all their information relating to this case. In his review, he found that Mrs. T. was taking a medication for stroke management. The medication prescribed is also used to treat blood pressure. However, this was not the reason why it was prescribed for Mrs. T. In her case, it was for stroke management.

The DRO recommended that the case be escalated to an OmbudService Officer (OSO) for further investigation. Looking at all the files, the OSO read that Mrs. T.’s doctor had confirmed with the insurance company that she had never been diagnosed with high blood pressure. Although it was acknowledged that this particular medication is often prescribed for hypertension, Mrs. T. was taking it to control her history with strokes – and not hypertension/high blood pressure.

The OSO reached out to Mrs. T.’s insurance company and recommended they revisit the case. Because of a history of strokes, controlling blood pressure was necessary but it did not mean that she was hypertensive. The insurance company agreed with the OSO’s suggestion and paid out Mrs. T.’s claim for her hospital expenses.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

 

Mr. and Mrs. H. applied for life insurance and were approved. When her husband died several months later, Mrs. H. claimed the benefits under the policy. The insurance company denied the claim for failing to disclose information about Mr. H.’s health.

Mrs. H. brought her final position letter to OLHI. She explained to our Dispute Resolution Officer (DRO) that a nurse had come to their home on behalf of the insurance company to collect blood and urine samples and fill out a questionnaire. During their conversation, Mr. H. told her about his high iron levels and his visits to a hematologist. The nurse noted “blood work normal” in her report despite his disclosure. Mrs. H. and her husband gathered the high iron was not important since the nurse did not take it into account, nor did the insurance company analyze his blood for this.

After his review of the information from Mrs. H. and the insurance company, the DRO recommended an OmbudService Officer (OSO) investigate further.

The OSO discovered that the company had not contacted the nurse to find out more about her visit with Mr. and Mrs. H. He recommended Mrs. H. contact this nurse, to see if she could validate their conversation. The nurse was unable to recall the specifics of their meeting.

While Mr. H.’s medical records showed he had been diagnosed with a blood condition, it was not disclosed in his insurance application. However, Mr. H. had signed this application, along with the report that the nurse prepared, confirming that all information provided was accurate. For this reason, the OSO recommended that there was no reason to further pursue this complaint.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

We’ve had a facelift!

What’s new?

  • Submitting a complaint is just a few clicks away! We are Canada’s only financial services OmbudService accepting document submissions online, using e-signature technology.
  • You can now search our website using keywords.
  • Have an old insurance policy? No problem – we will help you find out which company now holds your policy. OLHI is the only place in Canada that offers this information on mergers, acquisitions or renaming of old companies.

What’s been improved?

  • Finding insurance has a new look and feel. It is the same great service. OLHI is the only place in Canada that offers this comprehensive list of member companies and the products they sell.
  • We remain Canada’s only service that searches for policies of a deceased person. Consumers can now submit their search requests online.

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