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When Your Insurance Company in Canada Isn’t Taking Care of You (And What to Do)

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Working with the best insurance company in Canada is the top priority of every resident. It doesn’t matter whether you live in Ontario, Toronto, Vancouver, Ottawa, etc.

According to the Canadian Life and Health Insurance Association (CLHIA), approximately $103 billion was paid out to Canadians with health and/or life insurance benefits in 2020, and consumers received a total of $41.5 billion in 2019 as a result of property and casualty insurance claims, according to the Insurance Bureau of Canada (IBC).

You’d think that with all of this money being handed out by insurance companies, all claims submitted to them would be processed and paid. According to CLHIA, the majority are, but what if yours isn’t? What if you file an insurance claim in Canada that you believe is valid, but your insurer denies it? The good news is that you still have alternatives for recouping some of your lost funds. 

This is the advantage of working with a reliable insurance company in Canada that won’t give you a headache.

How to Challenge a Claim Denied by an Insurance Company in Canada

Whether it’s a health, life, travel, or auto insurance claim, the steps to try to get it handled are the same in Canada if you’ve gone through your policy cover to cover and can’t see why your claim was denied.

1. Examine and re-examine your paperwork

A claim can be refused merely because you committed a clerical error, rather than because the insurer is attempting to deny it. Some information, such as an account number or birthday, can be electronically scanned, and if it doesn’t match what’s on the provider’s computers, the claim will be denied. Check what you sent to your provider and resubmit the claim with the correct information if you detect an issue.

2. Take the phone

If you find that the information you provided was right but the firm is still refusing your claim, call your insurance provider’s customer care line and gather as much information as possible about why the claim wasn’t paid out or why you didn’t receive as much as you expected. If you don’t get satisfactory answers, it’s time to escalate your case and speak with a claims manager.

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3. Maintain accurate records

Keep a careful record of what was said, who said it, and what the next steps are every time you contact your insurer during the process, especially if a claim dispute escalates. If you know when to make a claim and you submit all the required documents to your insurance company in Canada, you will mostly not be delayed.

4. File a Complaint

Still haven’t found a way to be satisfied? Most, if not all, insurance companies have a claim dispute resolution specialist as staff. A policy is a contract, and a complaint liaison is in charge of ensuring that the policy is followed to the letter. 

You may feel like you’re just repeating yourself, but the liaison will need as much specific information as possible from you in order to resolve the claim dispute. This is when your comprehensive list comes in helpful.

5. Take a walk outside

Finally, if your insurance provider hasn’t handled your claim to your satisfaction, you can speak with an independent third party to assess the situation. Based on the insurance contract, an insurance ombudsperson is expected to make an independent judgment. 

In Canada, an ombudsman is a person who has been appointed to look into complaints about companies and organizations. Ombudsmen are independent, free and impartial – so they don’t take sides.

Before approaching them, request a letter from your insurance company outlining their position in the issue, and then register your complaint. General Insurance OmbudService and OmbudService for Life and Health Insurance are two Canadian resolution bodies. Your state’s regulator is a smart place to start in Canada.

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Medications and Health-Care Claims

According to CLHIA, about 29 million Canadians have supplementary health insurance policies, whether purchased privately or through their workplaces. It’s no surprise that the majority of insurance claims are submitted to health insurers, whether for braces for your nine-year-old or a prescription for an untimely UTI.

In general, these claims are straightforward: the drug is covered—yes or no—and for a specified proportion of the overall cost (for instance, 80 percent of the total cost of the medication or treatment). The claim is processed, and the funds are deposited into your account a few days later. But, if things don’t go according to plan, what happens to the clock?

Do your study before using the send button to send your health claim to your provider. Check with your insurance provider before you buy if it’s a high expense, especially if you haven’t filed a claim for a specific drug, medical supply, or dental gadget with them previously.

Find Out What Is Covered by Your Health Insurance Company in Canada – Don’t Assume

Find Out What Is Covered by Your Health Insurance Company in Canada

It’s tempting to assume that a product or service will be covered since something comparable has been covered previously, but this isn’t always the case. You may need a prescription or a doctor’s note, depending on your plan. Preauthorization from the insurer may be required for some procedures (such as extensive dentistry or orthodontia).

New pharmaceuticals and medical equipment may be ready for purchase, but it may take your insurance company longer to determine whether or not it will be covered than you anticipated when you opted to get that snazzy new glucose sensor system or the latest smoking-cessation prescription.

The healthcare system in the United States can appear even more convoluted than the one in Canada. Your broker or agent may be able to explain some of the plan’s details to you. If your benefits are provided by your employer, someone in the human resources department is likely to be knowledgeable about the plan or can connect you to your insurer’s customer support number. Yes, your employer is responsible for your health insurance coverage.

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Conclusion

Insurance claim complaints are frequently easily resolved simply because a misstep was made somewhere along the way, but if you need to take additional steps to have it resolved, try to put your rational self ahead of your emotional self, be as clear as possible, and deal with only the facts, as with all contracts.

Desmond Dickson
Desmond Dickson is a freelance writer, business coach, and lead content manager of MyTopInsuranceBlogs.com. He supervises all insurance-related content targeting the United States & Canada.

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