What happens if a life or health insurance company denies your claim? – 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.

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