Most of the time, our life and health insurance work as expected: You file a claim, and your insurer covers the costs per your policy. But what if you have a complaint?
Every day, insurance companies process thousands of life or health insurance claims for Canadian policyholders. However, mistakes or surprises can happen, leading to complaints.
If you are in a dispute with your insurance company regarding a complaint, rest assured that you have options, including a free, fast, impartial, and independent review of your complaint by the OmbudService for Life and Health Insurance (OLHI).
Alternative dispute resolution for Canadian life and health insurance consumers
OLHI is a free, fast, independent, and impartial alternative dispute resolution public service dedicated to serving Canadian life and health insurance consumers. OLHI’s services include:
- Answering consumers’ questions about life or health insurance concerns
- Helping consumers find old policies or policies of deceased loved ones
- Guiding them through the complaints process
Have a complaint? Talk to your insurer first!
Did your insurer deny your claim or not pay as much as you expected? When this happens, your first step should be to tell your insurance company about your concern. Every insurer has an internal process for addressing consumer concerns and complaints.
You can learn how to start your insurer’s complaint process by visiting its website or calling the company directly. Suppose you don’t know where to begin. In that case, you can find contact information for your insurer’s complaint officer on OLHI’s Consumer Complaint Officer Listing.
In many cases, just knowing where to start with your insurance company can lead to a complaint resolution. At the end of the process, your insurer will provide you with a document called a final position letter outlining its final stance on your complaint.
If you receive a final position letter and are still unhappy, you can go to OLHI.
How OLHI Can Help with Your Complaint
After you have a final position letter, you can submit your complaint to OLHI at www.olhi.ca.
OLHI will then confirm whether your complaint is one that it can help with. If it is, a complaint analyst will review your complaint. If your complaint has merit, OLHI may work with your insurer for early resolution. When a complaint is overly complex, or the attempt at early resolution didn’t work, the analyst may escalate your case to an OmbudService Officer, who will start an investigation. Again, if the investigation finds merit, OLHI may informally discuss a potential settlement with you and your insurer.
The complaint may go to a final investigative stage if informal conciliation does not work. If OLHI finds merit, it will issue a non-binding settlement recommendation to you and your insurer.
Throughout the process, OLHI’s complaints team might ask you or your insurance company for more information. When it’s over, regardless of whether OLHI finds merit, you will receive a plain-language explanation of the findings.
It’s important to remember that OLHI does not represent the consumer or the insurer when reviewing a complaint. This impartiality is a hallmark of alternative dispute resolution, which is non-adversarial by design. That is why OLHI’s recommendations are non-binding.
What Types of Complaints Does OLHI Deal With?
OLHI can review virtually any complaint related to a life or health insurance product sold by a Canadian insurance company, including:
- Group Benefits
- Individual Insurance
- Short- and Long-term Disability
- Dental
- Extended/Supplementary Health
- Job Loss
- Accident Insurance
- Retirement Insurance
- Travel Insurance
- Life Insurance Investments
There are some complaints that OLHI cannot review, including:
- complaints unrelated to life or health insurance (for example, car insurance or banking services)
- complaints about independent insurance advisors
- foreign life and health insurance complaints
- complaints made by businesses
OLHI also can’t review complaints that have already been before a tribunal, a court, or a mediator. This restriction is why it makes sense to go to OLHI first – its alternative dispute resolution process is entirely free and faster than litigation, which can take years and cost thousands of dollars. If you aren’t satisfied at the end of OLHI’s process, you can still pursue legal action.
OLHI’s Dispute Resolution in Action: A Case Study
The following case study shows how OLHI’s complaint process works.
A mother submitted a claim for a custom bed, chair, and orthopaedic equipment she purchased for her daughter, who had a physical disability. When the company denied the claim, she completed the insurer’s complaints process and received a final position letter.
After she submitted her complaint to OLHI, a complaints analyst reviewed the policy and discovered the insurer denied the claim because the policy didn’t specifically cover customized sleeping or sitting equipment. However, the review found that the policy included coverage for orthopaedic equipment if a doctor deemed it necessary to perform daily activities.
OLHI sent the company the family’s receipt for the equipment purchase, the doctor’s prescription stating it was necessary for daily activities, and the policy wording related to orthopaedic equipment. As a result, the insurer changed its decision and covered the portion of the original claim related to the orthopaedic aids.
Want to learn more?
Navigating life or health insurance concerns can be daunting, but OLHI gives policyholders recourse if they have a complaint. Visit olhi.ca to learn more.
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DISCLAIMER The information in this article was correct at time of publishing. The law may have changed since then. The views expressed in this article are those of the author and do not necessarily reflect the views of LawNow or the Centre for Public Legal Education Alberta.
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