Making Insurance Claims After a Diagnosis in Canada

People often have more insurance cover than they realise — including policies arranged through an employer years ago, or creditor insurance attached to a mortgage. After a serious diagnosis, checking every possible source of cover is one of the most important practical steps you can take. This guide explains what to look for, how claims work, and what to do if a claim is denied. If you'd rather have a plan built around your situation, answer a few questions and we'll build one around you →

Types of policy to check

Do not cancel or change any policy while you are working out what you hold. Some policies pay out on diagnosis alone, and cancelling now could forfeit an entitlement. Check everything first, then decide what to do.

Employer group benefits

Many Canadians have insurance coverage through an employer group benefits plan. These are arranged and often partly or fully paid by the employer and may not appear prominently in your pay documents. Ask your HR department or check your benefits booklet for:

• Group life insurance — pays a lump sum to your beneficiaries on death, typically one to three times your annual salary. Many group life policies include a terminal illness or accelerated death benefit that can pay the sum early if a doctor certifies that your life expectancy is less than 12 or 24 months. Check your plan documents and make sure your beneficiary designation is up to date.
• Short-term disability (STD) — replaces a percentage of your salary (often 60–70%) for the first weeks or months of a disability, usually after a short waiting period. Group STD typically bridges the gap at the start of illness before long-term disability or EI Sickness Benefits begin.
• Long-term disability (LTD) — the most significant disability coverage for a serious illness. Kicks in after short-term disability ends, typically after 90 to 180 days. See the full LTD section below.
• Group critical illness insurance — less common than life or disability coverage but offered by some employers. Pays a lump sum on diagnosis of a qualifying condition meeting the policy's definition.
• Accidental death and dismemberment (AD&D) — pays a benefit in the event of accidental death or the loss of a limb or sight. Less relevant for illness, but worth knowing you hold it if you do.

Individual policies

• Individual life insurance — check for a terminal illness or accelerated death benefit clause, which allows early payment if life expectancy is short. The threshold varies by policy — confirm the specific wording with your insurer.
• Individual disability insurance — replaces a portion of your income while illness prevents you from working. The definition of disability and the benefit terms vary significantly between policies. See the LTD section below for what to check.
• Critical illness insurance — a lump sum paid on diagnosis of a covered condition that meets the policy's specific definition. Tax-free when paid. See the critical illness section below.

Mortgage and creditor insurance

Mortgage life insurance and creditor disability insurance are often sold by lenders at the time a mortgage or loan is arranged. Mortgage life insurance pays off the mortgage balance on death; creditor disability insurance covers mortgage payments while you are disabled. Check your original mortgage documents and any loan paperwork — these policies are sometimes arranged without the borrower fully registering what they signed up for.

Travel insurance

If you received your diagnosis around the time of a planned or recent trip, your travel insurance policy may be relevant. Travel insurance typically covers trip cancellation, interruption, and emergency medical costs. If you were diagnosed before or during travel, check whether your policy covers emergency medical treatment and trip cancellation due to a sudden medical condition, and notify the insurer promptly.

Finding forgotten or lost policies

Cover taken out years ago — with a previous employer, a mortgage lender, or through a financial adviser — can easily be lost track of. Here is where to look:

• Your employer's HR department — ask specifically what group benefits were in place during your employment and whether you were enrolled. If you have left a previous employer in the past few years, ask whether their group plan offered a conversion option — the right to convert group coverage to an individual policy without new medical underwriting when you left.
• Bank statements — search for regular premium payments to insurance companies. A small monthly deduction may represent forgotten coverage. Many banks provide several years of statements online.
• Mortgage and loan documents — check for creditor insurance attached to a mortgage, line of credit, or other loan product.
• Previous financial advisers or brokers — if you have used a financial adviser or insurance broker at any point, they may hold records of policies they arranged on your behalf.
• OmbudService for Life and Health Insurance (OLHI) — OLHI (olhi.ca) offers a free lost-policy search service for life and health insurance policies, including searches for a deceased person's policies. This can be particularly useful if you believe a policy exists but cannot locate the documents.

Long-term disability insurance — where things go wrong

Long-term disability insurance is the most common insurance claim for people with a serious illness, and it is also where the most disputes arise. Understanding how these policies work in practice — not just what the brochure says — matters significantly.

Own occupation vs any occupation

The definition of "disability" in your policy determines whether your claim will be paid. Many group long-term disability plans use two different definitions that change over the life of a claim:

• Own occupation — for an initial period (often the first 24 months of benefit), you qualify if you cannot perform the material duties of your own occupation. This is the more generous standard — even if you could theoretically do different work, you qualify based on your specific role.
• Any occupation — after the own occupation period ends, most group plans switch to a stricter test: you must be unable to perform any occupation for which you are reasonably qualified by education, training, or experience. At this changeover point, insurers commonly review and terminate claims. If your policy is approaching this threshold, be prepared for a review and ensure your medical evidence clearly addresses your functional capacity across a range of occupations, not just your own.

Individual disability insurance policies sold through advisers more commonly use an own occupation definition throughout the benefit period — check the specific wording in your policy document.

CPP Disability offset

Most group long-term disability plans require you to apply for the federal Canada Pension Plan Disability Pension as a condition of receiving LTD benefits. If you are approved for CPP Disability, the monthly CPP Disability amount is typically deducted from your LTD benefit — the insurer pays the difference. This is called an "offset" and is standard in most group plans. Read your policy to confirm whether this applies and what other income sources are offset.

Tax treatment of LTD benefits

Whether your long-term disability benefits are taxable depends on who paid the premiums:

• If your employer paid the premiums (or if you paid them with pre-tax payroll dollars), your LTD benefits are taxable income, and income tax will be deducted at source.
• If you paid the premiums with after-tax dollars, your LTD benefits are not taxable.
• If the cost was shared between you and your employer, a portion of benefits may be taxable. Check your benefits booklet or ask your HR department to confirm how premiums were structured.

This distinction affects your net monthly income on LTD significantly — a taxable benefit of $4,000/month is worth considerably less than a tax-free benefit of the same amount.

Elimination period and coordination with other benefits

Long-term disability does not begin immediately — there is an elimination (waiting) period before benefits start, typically 90 to 180 days. During this period you are expected to draw on group short-term disability benefits, EI Sickness Benefits, or your own savings. Coordinate the timing carefully so there is no gap between your income sources. Apply for EI Sickness Benefits promptly — they are not backdated.

Critical illness insurance

Critical illness insurance pays a tax-free lump sum on diagnosis of a covered condition — provided the diagnosis meets the policy's specific definition of that condition. Receiving a diagnosis named in your policy is not automatically enough — the clinical details must satisfy the policy's precise criteria.

Common points where definitions matter:

• Cancer — most policies exclude certain early-stage or non-invasive cancers. Common exclusions include carcinoma in situ (cancer that has not invaded surrounding tissue), superficial skin cancers such as basal cell carcinoma, and certain very early-stage cancers below a defined staging threshold. Read your policy's cancer definition carefully before assuming a claim will succeed, and ask your oncologist whether your specific diagnosis and staging fall within it.
• Heart attack and stroke — policies typically require specific clinical evidence: documented biomarker values, ECG changes, or lasting neurological deficit. A clinical diagnosis alone, without the test results in the format the policy requires, can lead to complications at claim stage.
• Survival period — many Canadian critical illness policies require you to survive a specified period (commonly 30 days) after the qualifying event before the benefit is payable. Check your policy for any survival clause and its duration.
• Conditions not listed — policies cover a defined list. Not every serious condition qualifies. Review the full list of covered conditions in your policy schedule before contacting the insurer.

When making a critical illness claim, ask your specialist to provide a written report that explicitly references the clinical criteria relevant to the policy definition — including diagnostic test results, pathology findings, staging, and grading. A letter that states only the condition name without supporting clinical detail may be insufficient.

How to make a claim

The process is broadly similar across policy types. Notify the insurer as soon as you decide to claim — do not wait until you have gathered all documents. Most policies include a notification requirement, and delay can complicate an otherwise valid claim.

• Notify the insurer promptly. Call or write to register your intention to claim. Record the date, the name of the person you spoke to, and any claim or reference number. For group benefits, contact your HR department first — the employer often initiates the claim process with the insurer.
• Complete the claim forms. The insurer will provide a claim package. Read the requirements carefully. Most disability and critical illness claims require an Attending Physician's Statement — a form completed by your treating doctor confirming your diagnosis, functional limitations, and prognosis. Schedule this with your doctor early, as it takes time.
• Provide supporting medical evidence. Depending on the policy, this may include diagnostic test results, pathology reports, specialist letters, and proof of pre-illness earnings for disability claims. The more specific the evidence against the policy's definitions, the stronger the claim.
• Keep copies of everything. Retain copies of all forms, reports, and correspondence before submitting. Record submission dates and obtain written confirmation of receipt. Insurers can lose submissions.
• Expect the insurer to request access to your medical history. You will be asked to sign an authorization allowing the insurer to contact your treating doctors. This is standard and required to process the claim.
• An Independent Medical Examination may be requested. For significant claims, particularly long-term disability, the insurer may ask you to attend an examination by a doctor of their choosing. Cooperating with a reasonable request is generally required under the policy terms. You are entitled to request a copy of the report.

Disclosure and why claims get denied

When you applied for a life, disability, or critical illness policy, you were required to answer the insurer's medical questions truthfully and completely. Failing to disclose a material fact — information that would have affected the insurer's decision to offer cover or on what terms — is called material misrepresentation. If discovered at claim time, it can give the insurer grounds to deny the claim or void the policy entirely.

Claims are also denied for other reasons:

• Pre-existing condition exclusions — many policies exclude conditions that existed before the policy was taken out, for a defined period. If your diagnosis relates to a condition you had symptoms of or received treatment for before the policy began, the insurer may invoke this exclusion.
• Policy definition not met — your diagnosis is real, but the clinical presentation does not meet the policy's precise definition of the covered condition.
• Contestability — most Canadian life and health insurance policies contain a contestability clause: within the first two years the policy is in force, the insurer can investigate and deny a claim based on misrepresentation in the original application. After two years, most policies become incontestable — the insurer generally cannot void the policy on the basis of application misrepresentation, except in cases of fraud. Verify the exact wording of the contestability and incontestability clauses in your specific policy, as the terms vary.

If your claim is denied for any of these reasons, the denial is not necessarily final. See the next section.

If your claim is denied

A denied claim has a clear, free escalation path in Canada. Do not simply accept the insurer's decision without going through it.

Step 1 — internal complaints process

Before escalating, you must first use the insurer's internal complaints process. Write a formal complaint setting out clearly why you believe the decision was wrong, referencing the relevant policy wording and the medical evidence. Ask the insurer to provide all documents and information it relied on in reaching its decision — they are required to provide this.

The insurer must provide you with a written final decision on your complaint — sometimes called a Final Position Letter. Keep this letter: it is what you need to take the complaint further.

Step 2 — OmbudService for Life and Health Insurance (OLHI)

If the insurer's internal process does not resolve your complaint, you can take a life, health, or disability insurance complaint to the OmbudService for Life and Health Insurance (OLHI) — a free, independent service that reviews disputes between consumers and life and health insurers in Canada.

OLHI reviews the insurer's decision impartially and makes a non-binding settlement recommendation. If OLHI recommends in your favour, the insurer is not legally required to comply (unlike a court judgment), but most insurers take OLHI's recommendations seriously. If the recommendation does not resolve the matter, you remain free to pursue legal action.

• Website: olhi.ca
• Phone: 1-888-295-8112 (toll-free)
• Note the time limit for bringing a complaint — check OLHI's current requirements at olhi.ca before submitting.

Provincial and territorial insurance regulators

If you believe an insurer has breached its obligations under provincial or territorial insurance legislation — for example, by acting in bad faith, failing to investigate a claim properly, or engaging in misleading conduct — you can report this to your provincial or territorial insurance regulator. Examples:

• Ontario — Financial Services Regulatory Authority of Ontario (FSRA) at fsrao.ca
• Quebec — Autorité des marchés financiers (AMF) at lautorite.qc.ca
• British Columbia — BC Financial Services Authority (BCFSA) at bcfsa.ca
• Other provinces and territories have their own insurance regulators — find yours through your provincial government website.

Regulators investigate systemic or conduct issues and can impose penalties on insurers, but they generally do not resolve individual claim disputes — that is OLHI's function for life and health insurance.

General Insurance OmbudService (GIO)

For disputes involving home, auto, or property insurance — rather than life, disability, or critical illness — the relevant body is the General Insurance OmbudService (GIO) at giocanada.org. GIO handles conduct complaints about general insurers in most provinces (Quebec complaints go to the AMF).

Legal action

You can pursue a denied insurance claim through the courts regardless of whether you have used OLHI or a regulator. For significant disputed disability or critical illness claims, a disability insurance lawyer can advise on the legal merits and may take the case on a contingency basis. The Law Society in your province can provide a referral to a lawyer specialising in insurance disputes.

Work-caused illness — a separate route

If your illness was caused or significantly contributed to by your workplace — occupational cancer, asbestos-related disease, noise-induced hearing loss, or another prescribed occupational condition — the route is through your provincial or territorial workers' compensation board, not through private insurance. Workers' compensation is a no-fault system separate from your personal insurance coverage. This is covered in the work and income guide.

Getting help

• OmbudService for Life and Health Insurance (OLHI) — 1-888-295-8112 or olhi.ca. Free independent review of life and health insurance disputes, including disability and critical illness claims. Also offers a lost-policy search service.
• Your provincial or territorial insurance regulator — for conduct complaints against an insurer. Find yours through your provincial government website (e.g., fsrao.ca for Ontario, lautorite.qc.ca for Quebec, bcfsa.ca for BC).
• Your insurer's complaints officer — every federally regulated insurer is required to have an internal complaints officer or ombudsperson. Ask the insurer for their contact details as part of the internal complaints process.
• General Insurance OmbudService (GIO) — giocanada.org. For disputes about home, auto, and property insurance.
• A disability insurance lawyer — for disputed long-term disability or critical illness claims involving significant sums, a specialist lawyer can assess the legal merits and may work on a contingency basis. Contact the Law Society in your province for a referral.
• Canadian Cancer Society — 1-888-939-3333 or cancer.ca. Can connect you with patient navigators who can help you understand your coverage options and support you through the insurance and benefits process.