Hello,
I want to thank you for your helpful advice, guidance and especially your encouragement. I have just been approved after many many months of stress, anguish and struggle following the denial of my claim.
After initially opting to prepare an appeal to the denial, I eventually realized it was pointless. After spending months trying to get answers and clarifications from my case manager (unsuccessfully) until they refused to cooperate entirely, i decided to file a complaint with the ombudsman’s office via the governing organization in my province.
I am ecstatic to announce that I received my approval letter today, advising me that I would receive retroactive payments.
There were some brutally low moments, I was made to doubt myself and I have struggled to cope with the damage to my life, notably the financially devastating consequences. I lost my apartment, most of my belongings, was forced to do a consumer proposal, destroyed my credit, my dignity and my self worth. All while I was severely ill. But I refused to let the insurance company win.
I want to tell anyone who is going through the same situation not to give up. It may take a while and it will be hard but you can do it.
-
Read the policy and the denial letter in detail. Many many times and understand them. By going back to the letter and policy repeatedly is how I was able to figure out how to react. I caught something that I had missed almost every time.
-
Find similar cases on CanLII to get an idea of your options and what the law says about situations similar to yours. Search using all kinds of applicable search terms.
-
Read this site, forum and everything you can find online.
-
Challenge the insurance company’s explanations, they are creative with their interpretation of the policy and your claim. They seem to work in reverse. They start with conclusions and then cherry pick the information to make it appear correct. They even twist the actual basis of your claim and change the premise to confuse you. They have all the power and they don’t even put much effort into justifying their decision.
-
Beware of follow-up requests to your doctor for additional information. Watch out for the wording. They may seem identical to questions from the initial doctor form but they are not. The difference in wording is very subtle and it’s a trap.
-
Question them on everything that is not clear or illogical demand that they back up what they say with specific text in the policy. Make them clarify. If your situation deviates from the norm and what the policy text specifically addresses, they need to be able to justify their conclusions.
-
If it’s not in the policy, challenge it. They make up rules and interpretations that are convenient for them. Don’t assume they are correct even if you might expect them to know more than you do because they are experts. They will tell you whatever suits them.
-
Get everything in writing. They won’t give you much but you can write it yourself and it’s up to them to respond, otherwise what you summarize is unchallenged and presumably accurate.
-
Back them into a corner. The claim manager is really limited in what they can say or do.
-
Beat them with logic and arguments. They fail at this if you make the right arguments.They will avoid most of your questions but the act of persistently challenging their statements and requesting clear definitions or interpretations gradually makes their reasoning sound absurd.
-
Document everything, write up a detailed Timeline and keep records.
-
Be polite, don’t get angry. The claims manager really doesn’t have much power in what they can say or how they can decide to deny or approve. If there is any ambiguity or any way to deny, they have to. And they can’t say much when you ask questions. They have a terrible job and probably feel bad for you. Keep a good rapport but be persistent and thorough.
-
If you hit a brick wall and believe that appealing is pointless because the insurance company is not playing fair, don’t waste your time.
-
Take all the information you have gathered and make a formal complaint detailing everything or if you can, get a lawyer.
Don’t let them beat you down. That’s what they are counting on and they know all the tricks in the book.
Feel free to contact me privately for any questions or comments.
Good luck!