Funding & Insurance
When a Therapy Claim Is Denied: Organising a Review Request
Identify the decision reason, gather relevant records and confirm the applicable review route and deadlines.
Archive edition: 14 August 2026 · assigned for archive organisation
A declined therapy claim can leave two separate questions: why was it declined, and what process can review that decision? Start by obtaining the explanation and matching it with the correct plan information. Repeatedly resubmitting the same documents without understanding the reason may not answer the insurer’s concern.
This guide helps organise a review request for Canadian health insurance. It uses named insurer examples and the OmbudService for Life and Health Insurance, or OLHI. Your own policy, plan type, jurisdiction and decision letter determine which route applies. No particular claim outcome is promised.
At a glance
- Read the decision and identify the specific reason given.
- Check the plan wording and any missing or inaccurate information.
- Use the applicable review route and record its deadlines.
- Distinguish an internal appeal, a complaint and an external review.
Understand what was decided
Save the decision or explanation of benefits, the original claim and the relevant receipt. Check whether the response is a final refusal, a partial payment or a request for further information. These situations may require different next actions, even if the online status initially looks similar.
Write the reason in plain language without changing its meaning. Examples of questions to clarify include whether a document is missing, a provider category is disputed, a limit was applied or the service falls outside a stated provision. Ask the insurer to identify the specific plan wording used in the decision.
Keep clinical need and insurance coverage distinct. A service may have been recommended, but the review still needs to address the payer’s actual reason. Conversely, a clerical mistake should be corrected as a clerical mistake rather than turned into a broad argument about the value of the service.
Build a focused review file
| Item | What to check | Possible next action |
|---|---|---|
| Decision | Claim number, date, amount and exact reason. | Request a clearer written explanation. |
| Plan information | Relevant provision, version and effective period. | Ask how the provision was applied. |
| Service record | Accurate provider, recipient, date and description. | Obtain a genuine correction if information is wrong. |
| Prior correspondence | Any advance review or coverage explanation. | Explain why it is relevant to the current decision. |
| Review route | Accepted format, recipient and deadline. | Submit through the identified process and keep proof. |
Use a short chronology with document references. Explain what each attachment establishes rather than sending a large file with no guide to its contents. Keep original records intact. If a provider supplies a corrected receipt, retain both versions and the explanation for the correction.
A useful request identifies the disputed point: “The decision refers to a missing provider detail. The attached corrected receipt supplies that detail. Please review the claim using this information.” If the disagreement concerns interpretation of the plan, state the provision and the reason you believe it warrants another look.
Follow the insurer’s current process
Canada Life’s published Freedom to Choose health and dental process describes an initial appeal, a further written review with additional information and later escalation into its complaint process. Read Canada Life’s Freedom to Choose claims process. This sequence is specific to that published product guidance; do not apply it automatically to a different workplace plan.
Sun Life’s general complaints guidance describes escalation through its problem resolution and Client Advocacy teams and explains that external options depend on the product and location. Read Sun Life’s complaints process. Use the route for the actual issue rather than a form intended for investments or another product.
Ask the insurer to distinguish a claim appeal from a service complaint if the terms are unclear. You may want both a review of the payment decision and an explanation of how communication was handled. Label the questions separately so that a response to one is not mistaken for a resolution of both.
Check external review eligibility
OLHI says its formal review requires an insurer’s final position letter, a life or health insurance matter and a participating insurer. It can help explain the insurer’s process before that letter is available. Its mandate excludes some matters, including employer plans the insurer only administers, known as ASO plans. Read OLHI’s current process and exclusions.
Ask OLHI whether the specific matter falls within its role rather than assuming that any insurer logo on a benefits card is sufficient. The plan’s structure matters. If another route is more appropriate, ask who can explain it and which deadlines need attention.
Keep expectations accurate: OLHI describes review, possible negotiation and non-binding recommendations in its process. Contacting it is not a guarantee of payment or acceptance for review. Do not assume that a complaints discussion pauses a legal deadline or substitutes for advice about a separate legal remedy.
Keep the request clear and track it
- Identify. Establish the reason and the provision being applied.
- Respond. Supply accurate relevant information through the correct route.
- Track. Keep the acknowledgement, next step and any review deadline.
Before sending the request, verify the official destination and accepted format. Include the claim reference, a concise explanation, the outcome requested and a list of attachments. Ask how receipt will be confirmed. Keep the submission date and exact copy with your records.
When a response arrives, compare it with the question you asked. Does it explain the disputed point? Does it identify any remaining information or another review step? Record those items explicitly. A courteous response or acknowledgement is useful, but it may not yet be the substantive decision you requested.
In a fictional example, Priya’s claim is declined because the recorded provider category does not match the submitted service. Priya checks the receipt and asks the provider to clarify the accurate details. The review request identifies the discrepancy and includes the relevant documents. It does not relabel the service or assume that correcting the record guarantees coverage.
Common questions
Is a request for more information the same as a denial?
Not necessarily. Read the insurer’s wording and ask what stage the claim has reached. If information is missing, identify the exact item and any response deadline. Keep the request connected to the original claim. Avoid creating a duplicate submission until you understand how the insurer wants the information supplied.
Should I resubmit the same claim immediately?
First check the reason and the correct review process. The insurer may need a specific correction, document or explanation rather than another identical claim. If resubmission is the requested route, clearly identify it as the relevant review or correction and retain the original reference so the records remain connected.
What if the provider believes the claim should be covered?
Ask the provider for accurate factual information that addresses the disputed point, such as credentials or the actual service description. The insurer applies the plan’s terms. A provider’s opinion can suggest a useful question, but it does not by itself establish coverage or justify changing an invoice to a misleading description.
How much medical information should I send?
Ask what information is required for the specific review and how to submit it securely. Connect each document to the issue being considered. Do not send an entire history merely because it is available. If the request is unclear or seems broader than necessary, ask the reviewer to explain it.
Is there one appeal deadline for all insurers?
This guide does not assume a common deadline. Check the decision letter, plan information and current review procedure for your case. Ask for clarification promptly if they differ or are silent. Keep any legal time limit separate from an insurer’s estimated response time, and obtain relevant advice when needed.
When should I ask for a final position letter?
Ask the insurer how its internal process reaches a final position and what remains to be completed. OLHI requires that letter for a formal review within its mandate. An ordinary claim statement or first refusal should not automatically be treated as the final response to a complaint without confirmation.
Can OLHI review every workplace health plan?
No. OLHI identifies limits to its mandate, including plans the insurer only administers for an employer. Ask about your actual plan structure and complaint. A familiar insurance company name on the paperwork does not settle the question. OLHI can explain whether its process is available for the matter.
Does an external review guarantee reimbursement?
No. Acceptance for review, assessment of the complaint and any resulting recommendation are distinct stages. The outcome depends on the relevant information and process. Keep your request factual and understand the review body’s powers rather than budgeting for payment simply because you have contacted an external organisation.
Can someone help me write the review request?
You can ask a trusted person to help organise the chronology and questions. Confirm any permission needed for them to communicate with the insurer or receive records. Keep your own account and preferences central, and use official representation arrangements rather than sharing passwords to private benefits accounts.
What if the review response still does not answer my question?
Identify the unresolved point and ask which further review or complaint route is available, including its requirements and deadlines. Keep earlier responses together so the next reviewer can follow the sequence. If the issue involves legal rights or a separate remedy, seek advice appropriate to that situation.
Sources
Official insurer and ombudservice pages opened and checked on 21 October 2026. Product-specific processes and OLHI mandate limits are identified explicitly. The preparation table and Priya example are original editorial material. No individual policy or claim was assessed.
- Canada Life: Freedom to Choose health and dental claims process.
- Sun Life: How to make a complaint.
- OLHI: Our process — review requirements, stages and exclusions.
