Insurance Claim Denied in Canada: Provincial Appeal Rights and OLHI

An insurance claim denied Canada isn't the end. Canada has multiple regulatory layers—federal, provincial, and independent ombudsmen—that give you strong appeal rights. This guide walks you through every option, from internal appeal to independent mediation.

Whether you're in Ontario, British Columbia, Alberta, or another province, you have clear paths to challenge a denial. The system varies by province and insurance type, but all provinces have consumer protections and independent dispute resolution.

Here's how to win.

Your Rights in Canada's Insurance System

Canada's system is federal/provincial. Each province has its own rules, but all protect consumers:

OLHI (OmbudService for Life and Health Insurance): Handles life and health insurance complaints for several provinces (Ontario, Manitoba, Saskatchewan, Alberta, and more). Free, independent, and can award compensation up to CAD 350,000.

Provincial Insurance Regulators: Each province has its own regulator (FSRA in Ontario, BCFSA in BC, etc.). They set rules and investigate complaints.

FCAC (Financial Consumer Agency of Canada): Federal regulator for federally-regulated banks and insurance companies.

Insurance Act (Provincial): Each province has insurance legislation protecting consumers.

Right to Internal Appeal: All insurers must have a formal complaints process.

Right to External Review: You can escalate to OLHI or provincial regulators.

The key: your location matters. You'll need to know which province your insurer is licensed in.

Step 1: Understand Your Denial

Your insurer must provide a detailed written explanation. If you don't have one, request it immediately.

The explanation must:

• Quote the specific policy clause being cited
• Explain how your claim doesn't meet that clause
• Reference the evidence reviewed
• Show the insurer considered your situation
• Include information about complaints and appeals

If the explanation is vague, that's a red flag. Push for specificity.

Keep this letter. It's the foundation of your appeal.

Step 2: File Your Internal Appeal

Every insurer in Canada must have a documented complaints procedure and must respond within specific timeframes (usually 30 days).

How to Appeal:

1. Write to the insurer's Complaints Department
2. State: "I am lodging a formal complaint under [Provincial] Insurance Act"
3. Include: policy number, claim number, date of denial, why you believe it's wrong
4. Attach new evidence: medical reports, doctor's letters, policy analysis
5. Send by registered mail with proof of delivery or email with read receipt

What to Include:

• Clear statement you're formally complaining
• Reference to the denial letter and date
• Specific policy clauses you believe support your claim
• Medical evidence or documentation
• Factual, professional tone (not emotional)
• Request for written decision within 30 days

Timeline by Province:

• Ontario: 30 days
• BC, Alberta, Saskatchewan, Manitoba: 30 days
• Other provinces: Check your provincial Insurance Act (usually 30 days)

If the insurer doesn't respond within the required time, that's itself a breach that strengthens your position for escalation.

What Happens:

• The insurer acknowledges receipt
• They review your new evidence and original claim
• They issue a decision letter (uphold denial, approve claim, or offer settlement)
• They inform you about escalation rights

Step 3: Escalate to OLHI (OmbudService for Life and Health Insurance)

If your claim is for life or health insurance and the insurer rejects your appeal (or doesn't respond in time), you can escalate to OLHI.

What is OLHI? OmbudService for Life and Health Insurance is an independent, free ombudsman for life and health insurance across multiple provinces. OLHI is funded by the insurance industry but operates independently with no insurer control.

Which Provinces Does OLHI Cover?

• Ontario
• Manitoba
• Saskatchewan
• Alberta
• Newfoundland and Labrador
• Nova Scotia
• New Brunswick

(Check olhi.ca for current coverage—it expands regularly.)

OLHI's Authority:

• Can award up to CAD 350,000 in compensation
• Can order the insurer to approve the claim
• Decisions are binding on the insurer
• You're not bound by OLHI's decision (you could pursue legal action, though that's rare)

How to File with OLHI:

1. Visit olhi.ca
2. Complete the online complaint form or request a paper form
3. Provide: your details, insurer name, policy number, what happened, why you disagree
4. Attach: denial letter, internal appeal outcome, medical evidence, policy document, supporting documents
5. Submit

Timeline: Most cases are resolved within 6-12 months. Simpler cases can be faster.

Cost: Completely free.

Step 4: Provincial Regulatory Escalation

Each province also has an insurance regulator (separate from OLHI) that handles complaints. You can escalate to them for:

• Insurer misconduct
• Breach of provincial Insurance Act
• Unfair claims handling
• Consumer protection violations

Provincial Regulators:

• Ontario: FSRA (Financial Services Regulatory Authority)
• BC: BCFSA (BC Financial Services Authority)
• Alberta: AESO (Alberta Financial Services Commission)
• Saskatchewan: FSCA (Financial Services Commission of Saskatchewan)
• Manitoba: MPI (Manitoba Public Insurance) and private insurers through OLHI or OB (Manitoba Insurance Brokers Association)
• Quebec: Autorité des marchés financiers (AMF)
• Atlantic Provinces: Provincial regulators through OLHI

When to Use: If the insurer has breached regulations or acted unfairly, complain to your provincial regulator. This is separate from OLHI and can result in regulatory investigation and fines.

Common Denial Reasons in Canada—And How to Challenge Them

"Pre-existing condition": The insurer says your condition existed before coverage began. Counter with: doctor's letter with dates, medical records, evidence you disclosed what was required, policy definition of "pre-existing."

"Not medically necessary": The insurer claims the treatment wasn't clinically justified. Fight back with: doctor's letter explaining necessity, clinical guidelines (from medical colleges), evidence similar patients receive the same treatment.

"Waiting period not met": Your claim is for something with a waiting period. This is hard to overturn unless the waiting period wasn't clearly disclosed.

"Exclusion applies": The insurer says a policy exclusion covers your situation. Counter with: policy wording supporting coverage, medical evidence showing treatment for a covered condition, industry standards interpretation.

"Insufficient documentation": Ask exactly what's missing. Then provide it. If vague, that's a weakness in their position.

Evidence That Wins OLHI Cases

Build a compelling evidence pack:

Medical Evidence:

• Doctor's letter addressing the denial reason
• All medical records and test results
• Specialist opinion (if applicable)
• Clinical guidelines supporting the treatment
• Evidence of treatment delivery and cost

Policy Analysis:

• Full policy document with relevant clauses highlighted
• Schedule of benefits
• Comparison showing similar claims approved
• Communications from the insurer about coverage

Documentation:

• Your complaint letter to the insurer
• The insurer's response
• Email correspondence
• Timeline of events
• Proof of how you submitted the claim

Expert Opinion:

• Doctor's detailed letter
• Specialist opinion
• References to treatment guidelines
• Evidence of standard medical practice

Writing Your OLHI Complaint

Your complaint to OLHI must be clear, specific, and evidence-backed.

Structure:

1. Brief summary of what happened
2. Why you believe the denial is wrong (with specific references to policy and evidence)
3. What regulations the insurer may have breached
4. What outcome you're seeking
5. All supporting documents attached and referenced

Keep it professional. Facts only. Let evidence speak.

ClaimBack can analyse your case and write your complaint letter in minutes — Start Free →

We'll analyze your denial, your policy, your medical records, and Canadian insurance law, then generate a professional letter that OLHI reviewers take seriously.

Timeline for Appeal in Canada

• Internal appeal: 30 days
• OLHI investigation: 6-12 months
• Provincial regulatory investigation: 2-6 months (if applicable)
• Total: 7-18 months in most cases

During this time, try to avoid paying disputed medical bills.

Special Consideration: Group Insurance (Employer Plans)

If your coverage is through an employer group plan:

• The appeals process may be slightly different
• You may have additional protections under the Employment Standards Act
• OLHI still has jurisdiction over group health and life insurance

Check with your employer's benefits administrator about the specific appeals process for group plans.

If You Used an Insurance Agent or Broker

If you purchased through an agent or broker, they also have responsibilities. If they:

• Misrepresented coverage
• Failed to disclose exclusions
• Recommended an unsuitable policy
• Failed to follow your instructions

...then the agent/broker shares liability with the insurer. You can also complain about them to your provincial regulator.

Pre-Appeal Checklist

• I have my denial letter with detailed reasoning
• I have filed an internal appeal and received the response
• I have gathered all medical evidence
• I have my full policy document
• I know my province and which regulator oversees my insurer
• I know if OLHI covers my insurance type (health or life)
• I have drafted a clear, evidence-backed complaint
• I have proof of how I'm submitting (registered mail or email)
• I have contact details for OLHI (olhi.ca)

Canada's system is designed to protect you. Use it.

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Disclaimer: ClaimBack provides AI-generated appeal assistance for informational purposes only. ClaimBack is not a law firm and does not provide legal advice. Always review your appeal letter before sending and consider professional advice for complex or high-value claims. Regulatory processes vary — always verify current procedures with your insurer or regulator.

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