Claim Problems, Mistakes and Official Sources
Health or dental claim denied in Canada? How to appeal and where to complain
Step-by-step: what to do when a health, drug or dental claim is refused in Canada, from the insurer's internal review to OLHI and provincial regulators, with a sample appeal outline.
If a private health, drug or dental claim is denied in Canada, start by getting the reason in writing and checking it against your plan booklet or policy. Many refusals are fixable: a missing receipt detail, a referral the plan requires, a prior authorization form, or a claim sent to the wrong plan first. If the refusal is a real disagreement, use the insurer's internal complaint process, which ends with a final written position from its designated complaints officer or ombudsman. If you are still not satisfied, you can take a complaint about a life or health insurer to the OmbudService for Life and Health Insurance (OLHI), which is free and independent, or contact your provincial insurance regulator about conduct issues. In Quebec, the Autorité des marchés financiers (AMF) handles complaints and can offer dispute resolution. For group plans, also involve your employer's benefits contact.
This guide is part of the common health insurance mistakes in Canada overview.
Step 1: understand why
Read the explanation of benefits (EOB) or refusal letter and match the reason to your plan wording.
| Reason given | What it usually means | Often fixable by |
|---|---|---|
| "Not an eligible expense" | Service or product not covered by the plan | Checking the booklet; if covered, asking for review |
| "Practitioner not eligible" | Practitioner not licensed or not in a recognized category | A receipt showing registration number and professional body |
| "Referral required" | Plan needs a physician or nurse practitioner referral | Submitting a dated referral |
| "Prior authorization required" | Drug needs a special authorization form | Asking the prescriber to complete the insurer's form |
| "Generic price paid" | Brand drug reimbursed at generic price | A medical exception form from the prescriber, if justified |
| "Maximum reached" | Annual or per-practitioner cap used | Checking the reset date; claiming under a second plan |
| "Coordination of benefits" | Another plan should pay first | Claiming the right plan first |
| "Pre-existing condition" or "misrepresentation" | Insurer relies on an exclusion or disclosure issue | Formal review; possibly advice |
| "Late submission" | Claim outside the time limit | Asking for discretion if there was a good reason |
Step 2: fix and resubmit, or ask for a review
If the problem is paperwork, resubmit with the missing document. If you disagree, write to the insurer asking for a review. Keep it factual:
- Your name, plan or policy number, certificate or member ID, and claim number.
- The service, date and amount.
- The reason given for refusal.
- Why you think the claim should be paid, quoting the plan wording.
- Supporting documents: receipts, referral, prescriber letter, earlier correspondence.
- What you are asking for: payment, a written explanation of the clause relied on, or both.
Send it in a way you can track, and note the date.
Step 3: use the insurer's complaint process
Canadian insurers must have a complaint-handling process and must tell you how to use it. It typically has two levels: front-line customer service, then a designated complaints officer or internal ombudsman who issues a final written response. Ask for that final response if the first reply does not resolve things; independent bodies usually require you to have it, or to have waited a reasonable period.
Step 4: take it to an independent body
- OmbudService for Life and Health Insurance (OLHI). Free, independent help with complaints about life and health insurance, including group benefits and individual health plans. It reviews cases after the insurer's process, can make recommendations, and does not charge consumers.
- Provincial regulators. For concerns about the conduct of an insurer or licensed agent, contact the regulator in your province: for example the Financial Services Regulatory Authority of Ontario (FSRA), the BC Financial Services Authority (BCFSA), the Alberta Superintendent of Insurance, or the Financial and Consumer Affairs Authority of Saskatchewan.
- Quebec. The Autorité des marchés financiers receives complaints about insurers and representatives and can offer mediation or conciliation after the insurer's process.
- Courts. Small claims court is an option for smaller amounts; limits differ by province. For large or complex refusals, especially misrepresentation disputes, consider legal advice. Limitation periods apply, so do not wait.
Worked example: a physiotherapy claim
A claim for six physiotherapy sessions at $120 ($720) is refused: "practitioner not eligible". The receipt showed the clinic name but not the practitioner's name or registration number. You ask the clinic for itemized receipts showing the physiotherapist's registration with the provincial college and resubmit. The plan pays 80% up to its $500 maximum: 80% x $720 = $576, capped at $500. Total time: one email and one resubmission. If the clinic had used an assistant who is not a registered physiotherapist for those sessions, the refusal might stand, and you would discuss it with the clinic.
Group plans: who decides?
For an insured group plan, the insurer decides claims under the contract. For an administrative services only (ASO) plan, the employer funds the claims and an insurer or administrator processes them; the employer may have the final say on some decisions. Ask human resources which kind your plan is, and include them in a review request if appropriate.
Mistakes to avoid
- Arguing by phone only. Put requests in writing.
- Missing the final-response step before going to OLHI or the AMF.
- Ignoring limitation periods for legal action.
- Resubmitting without fixing the documented reason.
Frequently asked questions
Does OLHI cost anything?
No. Its service is free to consumers.
Can my employer see why my claim was denied?
Insurers protect personal health information under privacy laws. For ASO plans, employers may see limited claim information. Ask how your information is shared.
How long does a review take?
It depends on the insurer and complexity. Ask for an expected timeline and escalate if it is exceeded.
Sources
- OmbudService for Life and Health Insurance — independent complaint help
- Financial Services Regulatory Authority of Ontario — Ontario regulator
- BC Financial Services Authority — British Columbia regulator
- Autorité des marchés financiers — Quebec complaints and dispute resolution
- Canadian Council of Insurance Regulators — fair treatment of customers guidance
- Office of the Privacy Commissioner of Canada — personal health information
