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In the year 2014, a total of 83.5 billion was paid to Canadian policy holders and beneficiaries. The benefits were distributed at a rate of 1.6 billion per week.

There should be no reason why your claim cannot be part of this, but it was denied. So what do you do?

Health insurance claims are denied for all sorts of reasons. What is important is that when you receive the note, do not relent and let your benefits go to waste. Before we go over the steps required to deal with a denied health insurance claim, we'll list the two common health insurance plans you can get from a provider. You may have one of these plans already.

Long-Term Care Insurance

Long-term Care Insurance exists to pay for the cost of long-term care. It includes expenses incurred from nursing homes, medical facilities and chronic care treatment. If you require a caregiver at home, the provider is also obliged to pay for her services under this type of insurance. Variations in policies will show between different providers. There are factors you need to consider in your decision such as your age, financial capability and any expected support from your family or friends if you ever need long-term care.

Upon visiting a provider, find out their maximum lifetime payout and the required period in which you have to pay premiums until you are eligible for claims. It would also help to inquire if they have inflation protection because prices can go up any time. Lastly, ask what will happen to your premiums if you start receiving benefits. All this information should weigh in when you choose a provider.

Critical Illness Insurance

In this plan, a person is entitled to a lump sum in cash when he/she is diagnosed with a terminal disease such as heart failure, cancer or stroke. Some plans also cover non-terminal but equally threatening illnesses like blindness, dementia, kidney failure, paraplegia, Alzheimer's disease, and many others. The money is meant to cover operation costs, medical treatments and all other expenses related to ensuring the quality of life of the immediate family and the policy holder despite the illness.

Apart from the lump sum, you will also be entitled to claim living benefits that are meant to pay for your living expenses and medical bills. However, you will need to have diagnostic proof so that the insurance provider can validate your eligibility. Some providers are stricter and require documentation that you only have up to 24 months to live. This is to ensure that the proceeds from your claim is not used for other non-related expenses.

Note: It is best to seek advice from a lawyer or financial advisor when you apply for insurance benefits since there might be overlaps in filing that will affect your eligibility to claim social assistance benefits.

What Happens When a Claim is Denied?

When your claim is denied, the insurance provider is entitled to cancel your policy. All the premiums paid until the date of cancellation will be returned to the policy holder or beneficiaries in a single payout. This process is commonly known as ��claim investigation�� and may apply to most types of insurance including mortgage, life, credit balance or disability insurance.

One of the common reasons why there is denial of insurance claims among some companies is the lack of valid supporting documents. It is very important not to slack off in filling out the forms and answering the medical questions. Once the company issues an order for a medical investigation, the officer will look into every available data. Any inconsistencies in your documents can result to a void of contract which will prompt the company not to pay for the claim even if the premiums are completely paid. If you have inconsistencies in your documents, contact us today for your free consultation: (905) 940-5554.

Once your policy is issued, your premium remains the same even if there is a change in your health conditions. The insurance company cannot command an increase due to inflation, but they can demand for one if you make a claim. Always consider if you can pay for the expense yourself so that your premiums remain unchanged until you fully pay off the plan.

What is Assuris and How they Can Help

Assuris is a non-profit organization aimed to protect Canadian policyholders if their insurance providers fail to provide for them. They minimize loss by assisting policyholders in transferring to another company and have their benefits continued in less time as possible.

The Office of the Superintendent of Financial Institutions regulates most life and health insurance companies throughout Canada. In Quebec, they have the Autorite des marches financiers. These regulators conduct investigation on all providers to ensure their legitimacy. Thus, when you apply for insurance, make sure that they are certified by any of these regulators.

What to Do if Health Insurance Claim is Denied

The most effective method to solve this problem is to consult with PW Lawyers as a disability claim lawyer to oversee the process and negotiations with the company. We are experienced professionals with the necessary knowledge. Our retainer has been stated to be one of the best in the industry. We can handle education, communication, and information on your behalf.

If you decide not to employ lawyers for insurance claims, you can visit your insurance company. Remember, this is a risk you are taking � your health is in your own hands. Ask for a proper explanation as to why the claim has been denied and ask what steps they suggest for you to take to get their approval. You will receive a list of requirements. Comply with these in the allotted time and if the company still renders your application void, you can then follow up with a lawyer for a denied insurance claim (click for more information).

If your application was denied, your benefits have been terminated or need legal advice on your long term disability claim, contact us today for your free consultation: (647) 559-1492.

Remember: Insurance companies have financing, assets, manpower, and systems for making sure your claim is maximized upon financially. Given any reason, an insurance company may deny your claim. We do not suggest taking your claim upon yourself to dispute.

How to File a Complaint

Each insurance company has their own process for processing complaint from clients. All of them are required to provide this information to clients under law, and make sure that they resolve the matter in good faith as soon as possible. If your problem remains unsolved, you can then escalate the complaint to a higher power.

The government understands that it is difficult to have your health insurance claim denied. Go to the (OFSI) website or the Office of the Superintendent of Financial Institutions at www.os-bsif.gc.ca and click on the ��Who We Regulate�� button. You will find all companies that are federally regulated

Complaint Escalation Process

  • If your communication with the company is not successful, you can request for your company to forward the formal complaint to the internal ombudsperson. You will be asked to submit the complaint in the form of writing.
  • If the company itself has been unresponsive, you can then submit a complaint with all supporting documents to the regulator that oversees your insurance provider.
  • If the regulator cannot solve your complaint, you can contact the following institutions to conduct a third party investigation of the situation.

OmbudService for Life and Health Insurance (OLHI)

www.olhi.ca

1-888-295-8112 (English)

1-866-582-2008 (French)

L'Autorité des marchés nanciers (AMF)

www.lautorite.qc.ca

Quebec: 418-525-0337

Montreal: 514-395-0337

Other regions: 1-877-525-0337

If you want further guidance, you can visit the Financial Consumer Agency of Canada (FCAC) website at (fcac.gc.ca). You will find a complaint-handling tool to help you go through the process with your insurer.

Pointers to make an effective complaint:

  • State the problem and what you want to happen clearly and concisely.
  • Provide copies of all supporting documents such as the policy contract, account statements, medical records, etc. Make sure you don't give away the originals.
  • Record all persons you have come in contact with, especially the key point persons. Keep a brief summary of what was said including the date and location of the conversation.
  • Most importantly, request for an official letter from your insurance company regarding their decision on the matter. This will serve as their official statement.If you need to appeal an insurance claim on your own, you risk the chance of having to put forth a second insurance claim appeal. A denied health insurance claim will go for another round of inspection, and a twice-denied claim may be in order for an insurance company who does not think you have a legitimate claim.

Types of Disability Claims

There are many types of Disability Claims based on your insurance package, or lack of insurance package as a result of your employment terms. Here are a few.

Typically there are three types of waiting periods that you encounter when filing a health insurance claim. Click here to learn more.

Avoid disability claim internal appeals. You do not have to go through the insurance appeal process before you can contact a disability claim lawyer.

A waiting period is the qualifying period the insurance company takes to clarify your policy. This period can range from four months to 52 weeks. However, in some claims, an employee can qualify for early intervention.

An early intervention is when the insurance company gets involved in your claim within a few days of incurring your injury.

What are time limits?

Time limits are the amount of time you have to file your claim. Each and every policy is different. If you occur any delays in your policy, it can change the outcome of your benefits.

What records should I provide?

Your insurance company will request from you a series of documentations for your application. As each insurance company is different, most request the following:

  • A physician statement
  • Employee's statement
  • Medical information and employer's statement
  • More documents may be required by your insurance company.

What types of disability are covered?

Each coverage varies from policy to policy. Usually, policies cover any type of injury or illness that prevents you from being able to work.

Some policies exclude certain illness and work-related injuries. To find out if your injury or illness is covered, contact us.

What reasons could terminate my Long Term Disability Claim?There are many reasons you claim may be rejected or terminated.

Below is a list of most common and possible reasons:

  • You are the age of 65 or attain the age of 65
  • You are in prison
  • You are retired or retire during the duration of the claim
  • Required documentation was not submitted
  • You recover fully
  • Refuse to participate in treatment program
  • Fails to report for a medical examination
  • Start a new job
  • Refuse to continue application process
  • Death (in some cases your estate can receive a lump sum of your benefits)

My insurance company changed the definition of my disability and now I am no longer eligible to receive my benefits! What does this mean?

Since Long Term Disability is not standardized, your contract can be subjected to change. Usually, policies require that the insurance company pay for your benefits for two years, as long as you are unable to work your previous job. After the two year mark, your insurance company can stop your benefits unless you provide evidence that you are unable to work any job due to your disability.

My insurance company terminated my claim but I am not recovered to go back to work! What do I do?

Document and keep all records of your insurance company telling you about your termination. In many cases, policies require an objective tracking of evidence throughout your claim.

Objective evidence is physical evidence that supports your injury. Such evidence includes doctor visit documentation, test and imaging results, consultation documentation etc..

It is important that if your claim has been terminated and you are not ready to go back to work; you need to keep a paper trail and you will need to seek legal advice.

Does my age matter?

Yes.

The benefit period ends at the age of 65. With some insurance companies, if you are totally disabled at 65, your benefit can extend for 24 months before the age of 75.

You could be eligible for the Canada Pension Plan (CPP) disability benefit. The CPP disability benefit is available to those that have made a contribution to their CPP and who are not able to work regularly due to their disability.

I am part of a union, are the claims different for me?

Yes. Being a unionized worker means you have other factors to consider, compared to a group or individual insurance policy.

If you have a ��self-insure�� benefits package, you have entered into the Administrative Service Only (ASO) Agreement with the insurance company. This allows the insurance company to act as the administrator of your plan. The insurance company will process and cover all the significant steps in your claim.

When a claim is denied or terminated under ��self-insure��, you are eligible under the Collective Bargaining Agreements (CBA) to dispute your termination or denial. This dispute will go through a hearing with the union.

Legal representation is required in these hearings.

My payable income has reduced significantly! Why?

Other sources of income during your claim can reduce the amount of payable income of your benefit. This may be due to direct and indirect offsets.

Below is a list of direct and indirect offsets:

Direct Offsets

-Any income received by the government (Ex. Social Services Ontario Works)

-Benefits programs including Canada Pension Plan (CPP), employee disability benefits, Worker's Compensation

-Benefits paid under an auto insurance plan

Indirect Offsets

-Retirement benefits linked to any employment

-Canada Pension Plan (CPP) disability pension benefits payable to you by your dependants

-Benefits payable from any association or other group benefit program

-Income from any job or business for profit

Filing for your Long Term Disability claim can be a rigorous and strenuous process. At PW Lawyers, we are able to help you through this process so you receive the care you deserve.

If you have any questions, do not hesitate to call us for a free consultation at (905) 940-5554.


Paul Wilkins

Principal Partner

Paul is a member of the Ontario Trial Lawyer’s Association and the Advocates Society. Frequently involved in pursuing his clients’ claims, his areas of focus include statutory accident benefits, short term and long term disability benefits, disability claims and Canada Pension Plan disability benefits.

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