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Denied Insurance Overview

Facing a denied disability claim can be frustrating. Whether it’s a car collision, a diagnosed terminal illness or a flooded house, insurance is there to help you get back up and return to your normal life. Getting an insurance plan will provide you with peace of mind no matter what kind of risks you undergo. If you are dealing with a Long Term Disability Claim, call our legal experts at PW Lawyers.## Denied Claim Inner Workings

Insurance providers offer several different insurance plans to businesses and individuals. When you buy insurance, you contribute money called a premium. This money is pooled with other funds to serve as a security deposit in case one of the members need financial assistance. Depending on the company, you will be required to pay a certain number of premiums. Once you complete the target number, you can then claim your benefits whenever a calamity or incident happens.

An insurance policy is very useful. Moreover, the statistics for denied insurance claims in Canada remains very low. In the year 2014 alone, insurers had to pay a total of $83.5 billion to Canadian policy holders and their beneficiaries. This number is multiple times as much as the 2013 figure for natural catastrophe payout of $3.2 billion.

Canadian Insurance Plans

There are several insurance types you should be aware of:

  • Disability Income Insurance aims to cover lost income. They normally amount to a certain percentage of a person’s regular earnings and is paid periodically to the policy holder. This type of insurance is closely tied up with benefits from Worker’s Compensation and Employment Insurance (WSIB), as well as from the Canada/Quebec Pension Plans (CPP). It is crucial that you understand the framework of your insurance policy for this particular type so you know what to do when you get your disability insurance claim denied.
  • Long-term Care Insurance provides financial aid to people who lost the ability to care for themselves for a period of more than six months. This may be caused by a terminal disease, a chronic illness or a physical disability. The financial coverage for this plan may include hospital bills, medication and salaries for care personnel. By the end of 2014, it has been recorded that 348,000 Canadians were covered up to 75% through cluster arrangements.
  • Auto/Home/Business Insurance is a specialized plan aimed to cover damage costs caused by unforeseen events in relation to the policy coverage. For example, if you get involved in a car accident and accidentally injure the other driver, your insurance may cover the medical bills the the other party is entitled to. A similar situation can also happen to your house or your business, such as flooded. It is important to have insurance, for it is needed to help you financially when you are faced with fixing damages.

How to File Insurance Claims

Insurance claims refer to financial aid requests filed to your insurance provider. Filing claims are relatively easy, but the process may vary in length among different providers. Moreover, there will also be variations between different insurance plans. Take health insurance claims, for example. You want to get money to pay for the hospital fees incurred during your operation. A provider may require you to pay the bills beforehand and hand them the receipt for reimbursement. Another provider might request for a billing request direct from the hospital. It is very important that you know the procedures of your insurance provider for your particular policy. If you do not know these procedures, be sure to refer to your Insurance Benefits Booklet, or speak with your office insurance representative.

Filling out Forms

Once you know the requirements to submit a claim, be sure to comply fully to it's terms and deadlines. Completely fill out the forms clearly and as accurately as possible. If the insurer finds any discrepancy in your application, your claim might be denied and this will prolong the process.Essentially, you have one year from the date you incurred the expenses to file a claim. This is possibly the maximum period, although other filing periods may vary for other companies. Once your application is approved, the company will issue a cheque or deposit the money into your bank account, along with a voucher detailing the amount sent.

The most convenient way to file a claim is by hiring the services of a disability lawyer for insurance claims. They will take care of all the documentary requirements, as well as follow-up. They will act as your voice when dealing with the insurance company, and act as a major legal asset in your case, given there lengthy knowlege of insurance companies and your legal rights.

Denied Insurance: Next Steps

Claims can be denied by an insurance company because of numerous reasons. Most common reasons are:

  • Material Misrepresentation: This happens when you fail to present all the details in your claim accurately. One of the common versions of this incident is when you fail to update the company of your current home address. This might seem insignificant, but it can cost you the entire insurance coverage if the company finds a loophole.
  • Non-covered Charges: If you file a claim for an expense that is clearly not covered by your policy, the application will surely be denied.
  • Claims Related to Unacceptable Behavior: There are companies that lay weight on why you have run into a car accident or incurred an injury. If this is because of DUI or any similar reckless behavior such as recreational drugs, the company can deny you from getting a claim. In these cases, you should consider lawyers for car insurance claims and coverage of costs.
  • Document Mix-ups: This happens often for health insurance claims. Make sure that your doctor sends the billing info to the right insurance company. If you have two policies, make sure that there is no double charge. This can happen when both policies cover the same incident and one of them is automatically initiated with or without your authorization.

Imperative Judgement

The first thing you need to do is examine whether any of the above reasons apply. If you still believe that your claim is valid, initiate contact with your insurance company. If they fail to resolve the issue, you can contact any of the governing bodies listed below for assistance.

Hire a Lawyer

There is always the option of hiring a lawyer to settle a denied disability claim dispute. We pride ourselves in providing personalized service, including extensive interviews and preparation for all clients and their witnesses. We believe that preparation is key to effectively, and successfully representing our clients.

Our experienced attorneys are available 24/7 to offer injury victims a free consultation. If you have been seriously injured and would like to speak to an attorney, we will make arrangements to travel to meet you. Call us today at (905) 940-5554.

Significant Organizations in Canada

OmbudService for Life & Health Insurance (OLHI)

OmbudService for Life and Health Insurance (OLHI) – is an independent service for complaints resolution and information dissemination available throughout the country. They cater to Canadian life and health insurance policy holders, as well as disability, travel, and many more. Matters concerning investment products like segregated funds and annuities can be discussed as well with this agency.

Superintendent of Financial Institutions

Office of the Superintendent of Financial Institutions (OSFI) – is another independent agency that aims to maintain the safety and soundness of Canada’s financial system. They examine all financial insurance providers for legitimacy and capacity. This ensures that Canadians have access to reliable insurance services throughout the country.

General Insurance OmbudService

General Insurance OmbudService (GIO) – is a national independent dispute resolution service that caters to all insurance types from home, automobile or business insurance. They act as an intermediary between the complainant and the concerned party to resolve issues in a more standardized manner in the least possible time.

Insurance Bureau of Canada

Insurance Bureau of Canada (IBC) – is a national association governing the private insurance sector. Apart from providing support to its members, they also provide resolution services to complaints related to any of its members. They host several information online, including helpful tips on what to do if health insurance claim is denied.


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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