Your Rights as a Policyholder

An illustration showing a policyholder standing confidently with a shield, representing their rights and protections against insurance claim denials

Understanding your rights as a policyholder in Canada is crucial when facing claim denials. This comprehensive guide will walk you through the essential aspects of policyholder rights and the appeal process.

Know Your Policy

The first step in protecting your rights is to thoroughly understand your coverage policy. Familiarize yourself with:

  • Coverage limits
  • Exclusions
  • Deductibles
  • Claim filing procedures

Common Reasons for Claim Denials

Coverage companies may refuse to pay claims under certain conditions, including:

  • Policy exclusions
  • Lapsed coverage due to non-payment
  • Misrepresentation on the application
  • Failure to report changes in circumstances

Your Right to Fair Treatment

Canadian law requires coverage companies to act in good faith. This means they must:

  • Investigate claims thoroughly and promptly
  • Provide clear reasons for claim denials
  • Communicate openly and honestly with policyholders

The Appeal Process

If your claim is denied, you have the right to appeal. Follow these steps:

  1. Review the denial letter carefully
  2. Gather supporting documentation
  3. File a formal appeal with your provider company
  4. Consider seeking legal advice if necessary

External Review Options

If your internal appeal is unsuccessful, you can seek external review through:

  • The OmbudService for Life & Health Coverage (OLHI)
  • The General Coverage OmbudService (GIO)
  • Your provincial regulator regulator

Protecting Your Rights

To safeguard your rights as a policyholder:

  • Keep detailed records of all communications with your insurer
  • Respond promptly to all requests for information
  • Be honest and accurate in all dealings with your provider company
  • Stay informed about changes in coverage regulations

Remember, as a policyholder in Canada, you have the right to fair treatment and a transparent claims process. If you believe your coverage company has unfairly denied your claim, don't hesitate to exercise your rights and pursue the appeal process.