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Seven progressive steps to appeal a denied insurance claim

You have the stress of a breast cancer diagnosis, and now your insurance company has denied your claim.  Hang in there: you don’t have to accept the insurance company’s initial decision as the final word.  You can appeal your denied claim by following these seven steps.

  1.  Review your insurance policy.  See if it indeed covers the denied benefit.  See also if you need to provide more information to support your claim, such as more detailed medical information.  Or perhaps the problem is simply a data-entry or clerical error, such as a misspelled name or wrong procedure code.  If you don’t have the full policy, request a copy from your employer or insurance broker.
     
  2. Find out the insurance company’s appeal process and contact information. Find out to whom you should address your complaint, what documentation is necessary, and what are the process is.  It’s also very important to know the deadline for appeals.  You can get this information by calling the insurance company or by reviewing its website.  For a list of websites for most insurance companies, click here.
     
  3. Telephone a customer service representative.  Have your policy number on hand.  Refer to the appropriate section of your policy, and any new and pertinent information that you didn’t include in your previous claim, state why you think your claim should have been approved.  Whenever you speak to a representative of the company, write down that person’s name and job title, take notes as to what’s being said, record the date and time of the call, and get a call reference number.
     
  4. If your issue is not resolved, file a written complaint.  Write a letter to the insurance company or use the company’s standard appeals form, available on its website.  State what went wrong and when, as well as what solution you are looking for.  Reference the relevant statements in your insurance policy and show how your claim fits within these parameters.
     
  5. Appeal to a higher authority in the insurance company.  This could be the manager of the claims department or the company ombudsman.  The ombudsman can give you a “final position letter,” which you need for Step 6.
     
  6. Appeal to the OmbudService for Life and Health Insurance.  This is a free complaint resolution and information service that is funded by its member insurance companies.  It will review documentation from you and the insurance company, and may also talk to you, the insurance company, and others who have given reports, such as your doctor.  To request a review of your case by the OLHI, complete and print the authorization form and submit the documentation listed here (send photocopies, not originals, as the OLHI will not return your documents.)  For more details on how the OHLI can help, call 1-888-295-8112 or visit the website: olhi.ca.
     
  7. Hire a lawyer.  You can do this at any time during the process.  Be aware of the insurance company’s deadline for bringing in a lawyer.  Look for one who specializes in appeals of your type of insurance claim.  Ask friends, family, your dentist, your accountant or another professional for a referral, or try one of the provincial lawyer referral services (New Brunswick does not have this service):

Lawyers charge fees by the hour or as a percentage of your settlement of your insurance claim.  Be sure to ask about fees at your first consultation.  Also, the legal process can last a year or more.  If you are appealing a long-term disability claim, you could be laid off from your job during this time for failure to fulfill your contract.  Consider your options carefully.

For more information on insurance and benefits, please visit CBCN’s FinancialNavigator.

Photo by Kelly Sikkema on Unsplash