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

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.

Mr. Q. wanted to buy new glasses through his employer’s group health insurance plan. Employees could only buy new glasses every two years – a standard period for many plans. He could not remember the last time he bought glasses.

Logging onto the insurance company’s website, Mr. Q. accessed his personal list of transactions made over the last two years. He did not see any purchase for glasses during this time so he bought new glasses and submitted his claim.

The insurance company denied Mr. Q.’s claim because he had in fact purchased glasses the prior year. They said that this claim was listed under the website’s section about “My Claims” – and not under “My Transactions.” They explained that there were two lists on their website: one for claims that an employee filed online (My Transactions) and one for claims that employees filed manually (My Claims). Because Mr. Q. had submitted his glasses claim last year manually, it did not show up on his list of “My Transactions.”

The insurance company suggested that if Mr. Q. was dissatisfied with the decision, he could contact OLHI for a free, impartial review. He brought his final position letter to OLHI and a Dispute Resolution Officer (DRO) started to review his case. Mr. Q. explained to the DRO that the insurance company’s website doesn’t direct people to look under both sections. Mr. Q. felt that a reasonable person would not think to check both places as a list of transactions implies all transactions ever made through his benefit plan.

OLHI’s DRO noted that Mr. Q. had a point: the website did not warn that an employee should look at both lists because each list showed a history of claims transactions depending on the way they were submitted. For this reason, OLHI contacted the insurance company and explained how confusing the process could be for an employee and how a mistake of this nature could be made.

The insurance company agreed to reimburse Mr. Q. for half of the cost of the glasses and he accepted this offer.

 

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.

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