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Health Insurance Claim Denied: What can I do? Insurance Declined Claims

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If you are dealing with a Disability Claim, call the experts at PW Lawyers.

Health Insurance Claim Denied: What can I do? Insurance Declined Claims

We’re always there for you.

We get many individuals asking whether or not insurance can deny coverage, such as “can I be denied health insurance?” or, “what can I do if insurance denied my claim”? If your health insurance company has denied coverage, this article will answer most of your questions and, most of all, provide a solution so you can make the most educated choice about your future.

Health Insurance Rejected My Claim

Your health insurance company can deny coverage for a variety of reasons , which you, legally, are able to dispute . If your Health Insurance Claim is Denied, we recommend hiring PW Lawyers . Contact us today for expert advice and professional, legal representation.

There are a few possibilities in regards to next steps for a denied health insurance claim. Disability Insurance Lawyers will seek to appeal a claim which may go through 3 stages (illustrated here in the case of Sun Life Disability Complaints) before being seen by a board, and ultimately, judged upon via ordained tribunal in most cases. If you choose working with a disability lawyer, here are a few obligations and ethical considerations which you will need to consider when hiring a lawyer – and when you work with your long term disability insurance attorney

Ideally, before you seek a free consultation from any lawyer, you should keep documentation of all of your records – including the insurance company’s reasons for not continuing your benefits, (or your denied claim). Most cases require thorough paperwork as objective evidence through your claim. These can be records such as Doctors’ Visits, Imaging Results, Consultations, Medical Reports, etc. They can be helpful in your denied health insurance claim.

Reasons for Insurance Claim Denial

Because there is no federal standard for long term disability benefits, unfortunately, contracts and terms are subject to change. This poses a problem for claimants who have subscribed to an insurance policy – only to find out it will not support them anymore. If your health insurance is not paying claims, and your insurance provider has refused to pay insurance claim funds, you run the risk of deteriorating health. If a third party insurance claim denied its obligations to pay, you should immediately seek retribution in a disability dispute . These options fall under a Disability Claim Denial case.

Some reasons for denied health insurance & claim denial, when creating a denied health insurance claim, are as followw. These are also common reasons for rejections of pharmacy insurance claims.

  • Required documentation was not submitted (denied health insurance due to negligence)
  • Fail to report for a medical examination
  • 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
  • You recover fully
  • Refuse to participate in treatment program
  • Start a new job
  • Refuse to continue application process
  • Death (in some cases your estate can receive a lump sum of your benefits)

Insurance Claim Dispute: Disability Insurance Lawyers will help.

Disability Claims are complex, especially when your insurance declined a claim you have made. If your disability claim denied the first time and you are looking for an alternative solution, seek a lawyer immediately. 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. Your waiting period for receiving your DENIED insurance claim letter may occur between 4 and 52 weeks. This can be much too long for some individuals to wait for a DENIED insurance appeal letter. 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. In some cases, you may have a chance of appealing insurance denial. Many people simple give up fighting insurance claim denials.

Can you sue an insurance company?

If you wish to do so, you may pursue a lawsuit in court. Unless you are an expert in law, or, are a lawyer, we do not recommend you do so. Disability Insurance Lawyers have experienced many cases and will provide a wide variety of angles for the insurance company to have to deal with. In many cases, lawyers will advise you before a claim in case they do not believe you have a case, such as when insurance claims are rejected. But when a lawyer takes on a case, they will:

  • Maintain a professional relationship
  • Protect and act in the clients’ own interests
  • Reveal information for a long term claim client only when truly necessary

Please refer to our helpful page on Disability Insurance Lawyers’ Long Term Claims & Obligations in order to learn more about what a disability insurance claim attorney can do for you – and how they work.

Fighting insurance claim denials takes time, energy, and financing. That’s why the team at PW lawyers, as Disability Insurance Lawyers, are always there for you. Contact us today for more details in regards to any Long Term Claims.

Insurance Claim Letter / Insurance Appeal Letter: Crafting one yourself? This is not your best option.

In case you were wondering how to write an appeal letter for medical insurance, our advice is to stop and retain a lawyer. Learning how to fight insurance claim denial takes years of experience and hard work. An insurance dispute lawyer such as ours will help you gain the maximum amount possible for your claim. PW Lawyers represents a wide range of clients that have been denied benefits under their group benefits packages. Every long term disability policy is different, however, many policy applications contain time limits, mandatory medical records, and updates on treatment.?Often, these policies are subject to a change of definition in which the insurer’s interpretation of disability changes or the time limit is disputed. Any of these circumstances can happen to you during your claim. We are here to help.

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 : (905) 940-5554 .

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..



Getting injured is stressful, you can incur physical and financial loss.
We can assist you to make your recovery a smooth transition.

Beware of “over-hyped” credentials, customer reviews, and experience. While we tout our experience, a lawyer for disability benefits should be proud of his success rate. We encourage you to ask about the success rate in your consultation. The best disability lawyer will be up-front with this fact.

What is the ||waiting period||?
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. /contact-us/

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.

After my injury, I had no hope left. When Dana and Paul took on my case, they told me they would help me reach my goal to get money for the settlement. They took the time and had the patience to help me achieve my personal goals.

Dana had great suggestions for me. It was comforting to know what I should be prepared for, and how I should prepare. If I didn’t achieve goal 1, what would my second goal would be?

Plan A doesn’t always work. The team helped me to prepare myself to put 100% hope in the settlement, and for Plan B to be the best fallback.

I’m very satisfied with the money I got for the settlement – which was more than I expected with Paul’s support and hard work. The organization has great teamwork.

There are people that I have referred to Paul who are interested in legal matters, or accident disability, and some of them have already gotten their case going. In the future, for somebody that needs help, I would suggest them to go with PW Lawyers.

I was hoping that I could pay them back somehow. Perhaps this review is the best way.

Jane PW Lawyers - Long Term Disability Lawyers