How to Appeal a Canadian Private Insurance Claim

• Missing pre-authorization for major dental, equipment or specialty drugs.
• No physician referral on file for a paramedical service that requires one.
• Annual maximum or frequency limit already reached.
• Charge exceeds the plan's reasonable-and-customary fee guide.
• Claim submitted after the plan deadline (often 90 days to 12 months).
• Pre-existing condition exclusion — the usual reason travel claims fail.
• Provider not recognized: wrong designation, unregistered, or out of province.
• Coordination-of-benefits sequencing — submitted to the wrong plan first.
• Waiting period not yet served on a new policy.

Call the member line and ask two questions: "What exact contract provision was applied?" and "Can this be resubmitted with additional documentation instead of appealed?" A large share of denials clear with a referral letter, a corrected provider registration number, or a retroactive pre-approval. Ask for the benefits booklet or policy wording and note the claim number, agent name and date of every call.

Ask for the denial in writing. An insurer's written reason locks in the ground you have to rebut — and prevents a new reason appearing later.

1. Level 1 — Claims department review. Written request with new documentation.
2. Level 2 — Formal internal appeal / medical review. Often reviewed by an in-house consultant physician or dental consultant.
3. Level 3 — The insurer's Ombudsman or complaint officer. Every federally regulated insurer must have a designated complaints officer and publish the process.^[3]
4. Level 4 — OLHI. The OmbudService for Life & Health Insurance reviews unresolved complaints free of charge once the insurer's internal process is exhausted and you have a final position letter.^[1]
5. Level 5 — Regulator or court. Provincial regulators such as FSRA in Ontario handle market-conduct complaints; the FCAC directs consumers on federally regulated financial institutions.^[2],[4] Small claims court is realistic for modest amounts.

If the plan is a workplace group plan, also raise it with your HR or benefits administrator and, where applicable, your union — plan sponsors can press the insurer directly.

• Policy/certificate number, member ID, claim number, dates of service.
• The denial reason quoted verbatim from the letter.
• The contract clause you say applies, quoted from the booklet.
• A short factual chronology.
• A specific ask and a deadline: "Please reconsider and respond within 30 days."
• A list of enclosures.

Send by email with a read receipt, or by registered mail, and keep everything.

• A physician letter of medical necessity naming the diagnosis and why the treatment is required.
• Clinical notes, imaging reports and treatment plans.
• The provider's registration/licence number and professional designation.
• Proof of payment: official receipts, not credit card slips.
• For travel claims: records showing the condition was stable during the plan's look-back window.
• Precedent: previous identical claims the same plan paid.

Long-term disability and high-cost drug denials are their own category. Both usually turn on documentation quality: objective findings and functional limitations for disability; prior-therapy failure and diagnostic criteria for specialty drugs. Ask the insurer for the full claim file, including any independent medical examination or consultant memo, and rebut it point by point. Drug manufacturers' patient support programs often help assemble special-authorization requests at no cost.

A refusal by OHIP, MSP, RAMQ, AHCIP or another provincial plan is not an insurance appeal — it goes through the province. Ontario decisions can be appealed to the Health Services Appeal and Review Board; other provinces have equivalent review bodies or ministerial review processes. The starting point is whether the service is an insured service under the Canada Health Act and provincial regulations.^[5]

Internal appeal windows are set by the policy — commonly 60 to 180 days from the denial. Separately, provincial limitation statutes cap how long you have to sue, generally two years from discovery of the claim. Appealing does not always pause that clock, so if the amount is significant, get legal advice before the two-year mark rather than after the final internal denial.