Helping you navigate issues with private insurance

A Man working at a desk with a computer and notepad

NOVEMBER 15, 2022

While many in the community are starting to access Trikafta, some individuals continue to struggle to access the drug, being denied coverage by their employee benefit plans. This, despite all of Canada’s public drug programs covering the drug within 11 months of Health Canada application, a speed unheard of in the rare disease space.

“Cystic Fibrosis Canada has pushed private insurers to make sure they’re covering Trikafta and other modulators, encouraged group benefit plans insured through parent insurance companies to use the tools and industry-based evidence designed for the private market and we’re asking insurance companies to provide timely notice of denial so people can start accessing the public system.” Kim Steele, 2022

Still, people are facing challenges and with more than 200,000 employee benefit programs out there, where can you go for help?

To help those navigating issues with private insurance, on October 20, we held a webinar with Stephanie Robillard, Senior Deputy Ombudsman and Tim Wilson, Head of Public Education and Strategic Planning at OmbudService for Health and Life Insurance (OLHI) to better understand how to navigate issues with private health and life insurance. 

What is OmbudService and what do they do?

OmbudService is a free, independent and impartial alternative dispute resolution, available to any consumer who is a member of the OmbudService. As an Alternative Dispute Resolution public service, OLHI provides accessible, impartial and accurate information about life and health insurance. They work to help guide the consumer through the process and find the information they need.

What types of complaints does OLHI look at?

The service looks at any type of insurance of persons at large including but not limited to, group insurance, disability, extended health care, and more. The OmbudService does not look at complaints that were applied for in another country, complaints currently in court or a decision made by court, employee benefits plan provided by the employer and complaints where the consumer is claiming damages.

How does the process work?

Once the consumer has gone through the full complaint process of their personal insurance, OHLI is able to begin to investigate the complaint. The complaint analyst will then determine if the insurance company’s final position is consistent with the terms of the contract. If the file has merit for further investigation, the complaint will be escalated to the OmbudService officer and will be investigated. OLHI will work with the consumer and the insurance company to reach a settlement. If a settlement is not reached, it can be referred to the last level of a Senior Adjudicative Officer (SAO) where the officer will review the complaint and write a recommendation. In summary, when merit is found, the complete process offers the opportunity to the consumer for their file to be reviewed for impartial investigation.

If you want to learn more about how the OmbudService for Life and Health Insurance can assist you, you can learn more on their website here, or watch our webinar with the OmbudService here.