Insurance Company Appeals

Mantha · 1 Insurance Company Appeals Wed Dec 07, 2011 1:17 pm

Mantha

contributor plus

Number of posts : 924
Registration date : 2009-03-27

Has anyone on this board ever appealed an insurance company decision? In this case, I'm talking about Sun-Life.

Here's a quick version of my story
-my wife did some damage to her discs in her back last year.
-her incompetent GP* labeled it as a 'mystery illness', recommended pain killers.
-a doctor friend in the US was shocked to find out the incompetent GP didn't do an MRI.
-8 months later, the MRI reveals annular tears in discs, which are
leaking fluid that aggravates her nerves. (in a different way than -I-
aggravate them! lol)

We put in a claim to Sun life, who paid short term disability, but refused to pay long term. At that point, the only diagnosis we had was "mystery illness", which let's be honest, isn't covered by insurance.

The tears were eventually properly diagnosed a few months later. Still, I feel like Sun Life is giving us the runaround.

Is there an Insurance Ombudsman or anything? Or do I have to get a lawyer. Subsequently, how stupid do I have to be to think I can sue an insurance company and win?

*Oh, and the GP truly is incompetent. He dismissed the fact that my
wife had a fairly visible SIXTEEN LITRE, THIRTY SIX POUND CYST in her abdomen a few years ago.

Deank · 2 Re: Insurance Company Appeals Wed Dec 07, 2011 1:45 pm

Deank

contributor eminence

Number of posts : 28509
Registration date : 2008-09-28

http://www.icm.mb.ca/

http://www.ccir-ccrra.org/en/consumer/

http://www.clhia.ca/domino/html/clhia/CLHIA_LP4W_LND_Webstation.nsf/index.html?readform

and a list of many other avenues

http://www.gov.mb.ca/fs/cca/firb/other.html

Deank · 3 Re: Insurance Company Appeals Wed Dec 07, 2011 1:48 pm

Deank

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Number of posts : 28509
Registration date : 2008-09-28

and.. sunlife does have an ombudsman

http://www.sunlife.ca/canada/v/index.jsp?vgnextoid=d3bb7cca76a6b110VgnVCM1000002dd2d09fRCRD&vgnextchannel=948d68fb3f2ee010VgnVCM1000006c90d09fRCRD&%20#38;vgnextfmt=default&vgnLocale=en_CA

Deank · 4 Re: Insurance Company Appeals Wed Dec 07, 2011 1:48 pm

Deank

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Number of posts : 28509
Registration date : 2008-09-28

When you have a concern or complaint

Sun Life Financial's Customer Complaint Process

Complaints do arise from time
to time -- you may feel you've been dealt with unfairly, or perhaps
there's been a misunderstanding. Whatever the nature of your concern,
we'll treat it professionally, confidentially and courteously. As a
valued customer, this is what you expect, and deserve.

Working with you on these
matters also presents an important opportunity for us to make
improvements that could enhance the customer service experience for
everyone doing business with us.

Here's how our Customer Complaint Process works

If you have a complaint or
concern about a product or service from one of the Sun Life Financial
group of companies in Canada, you can address the situation by following
the steps below:

Step 1: Let us know

Discuss your concerns with
your advisor or with the appropriate customer service team at head
office. Often, a simple correction or explanation by these front-line
people can quickly resolve the problem.

Here's how to contact our customer service teams at head office:

(for faster service, please provide your policy or contract number and your member ID or certificate number for Group plans)	By phone	By e-mail (Internet e-mail is not a secure method of communication)
Group Benefits	1 800 361-6212	Can_GroupBenefits@sunlife.com
Association & Affinity Groups	For claims-related questions: 1 800 361-6212 For all other inquiries: 1 800 669-7921 or (416) 408-7390 in Toronto	Can_AssocAndAffinity@sunlife.com
Public Service Health Care Plan (PSHCP) and Pensioners' Dental Services Plan (PDSP)	1 888 757-7427 or (613) 247-5100 in the Ottawa area	Can_OttawaService@sunlife.com
Individual Insurance and Investments	1 877 SUN-LIFE (786-5433)	service@sunlife.com
Group Retirement Services (e.g. Group RRSP, DCPP, DPSP)	1 800 387-2636	Can_PenControl@sunlife.com
General question or comment	1 877 SUN-LIFE (786-5433)	Webmaster@sunlife.com

Step 2: Escalate your complaint within the business area

If you are not satisfied with
the outcome of Step 1, ask to whom you can escalate your complaint.
Each business area at Sun Life Financial has a defined complaint
handling process. Depending on your product or service, you will be
referred to a team leader, supervisor, manager or consultant who will
review your complaint with a fresh set of eyes.

Step 3: Contact the Ombudsman's Office

If you are still not satisfied after following the previous steps, you can contact the Sun Life Financial Ombudsman's Office:

By mail:	Ombudsman's Office Sun Life Financial 225 King Street W. Toronto, ON M5V 3C5
E-mail:	ombudsman@sunlife.com
Fax:	416-595-1431 or 514-866-2548

The Ombudsman's Office does
not review complaints that have not yet been through Steps 1 and 2, so
you'll want to indicate who you've already contacted, and why you
disagree with their decision.

After the Ombudsman's Office
review, you'll receive a written response, except in some cases where a
simple problem can be cleared up quickly and to your satisfaction over
the phone. Most investigations are completed within 30 days of
receiving your complaint and all supporting information. If this
deadline cannot be met, we will contact you to let you know why the
extra time is necessary and when you can expect a response.

The written response from the
Ombudsman's Office is considered Sun Life Financial's final position on a
complaint. Unless you present any new and relevant information that
was not previously reviewed, your complaint will not be reopened.

Step 4: External recourse options

If you remain dissatisfied
with the Ombudsman's Office's final position and wish to pursue your
complaint further, there are several regulatory and industry bodies
available to you free of charge, depending on the product or service
involved and your province of residence. These third parties will
usually decline to review your complaint until after the Ombudsman's
Office has reviewed it. If your unresolved complaint is eligible for
further review externally, the Ombudsman's office will provide you with
detailed contact information for the appropriate third party(ies) in its
final position letter.

For complaints about...	External recourse option
life and health insurance - individual and group an advisor's conduct (except for mutual funds) trust company products and services annuities Group Retirement Services and pension products	The OmbudService for Life & Health Insurance (OLHI) is part of the Financial Services OmbudsNetwork (FSON), a national industry-based dispute resolution system for consumers of financial services. The OLHI deals with concerns about life and health insurance products and services that have not been resolved through the company's dispute resolution system. Information about the OLHI is available on their website at www.olhi.ca. OLHI's mailing address is: OmbudService for Life & Health Insurance 401 Bay Street, Suite 1507 P.O. Box 7 Toronto, ON M5H 2Y4
...a mutual fund account or a mutual fund dealer or representative (Sun Life Financial Investment Services Inc.) -- outside Quebec	The Mutual Fund Dealers Association of Canada (MFDA) is the national self-regulatory organization for the distribution side of the Canadian mutual fund industry (excluding Quebec). The MFDA's primary focus is on compliance and enforcement rather than customer compensation. You can find out more about the MFDA from their website at www.mfda.ca. MFDA's mailing address is: 121 King Street West, Suite 1000 Toronto, ON M5H 3T9 and/or The Ombudsman for Banking Services and Investments (OBSI) is part of the Financial Services OmbudsNetwork (FSON), a national industry-based dispute resolution system for consumers of financial services. The OBSI deals with concerns about banking services and investments that have not been resolved through the company's dispute resolution system, and may recommend compensation if it determines that a customer has been treated unfairly. Information about the OBSI can be found on their website at www.obsi.ca. OBSI's mailing address is: Ombudsman For Banking Services and Investments 401 Bay Street, Suite 1505 P.O. Box 5 Toronto, ON M5H 2Y4
for Quebec residents only: ...all products and services, including mutual fund dealers or representatives	The Autorité des marchés financiers (AMF) is the body mandated by the government of Quebec to regulate the province's financial markets and provide assistance to consumers of financial products and services. At any time after Step 2 of our Customer Complaint Process (but preferably after Step 3), you can ask Sun Life Financial to send a copy of your complaint file to the AMF by completing a Request for the Transfer of a File form. This form, and other information about the AMF, is available on their website at www.lautorite.qc.ca/index.en.html. The AMF's mailing address is: L’Autorité des marchés financiers Place de la Cité, Cominar Tower 2640 Laurier Boulevard, suite 400 Québec, QC G1V 5C1
...federal consumer provisions. Among the consumer provisions that apply to life and trust companies are those requiring them to: have complaint handling procedures in place join an independent complaint resolution body (such as the CLHIO) file a Public Accountability Statement ...and requirements for them to provide consumers with information about: interest and charges applicable to deposit accounts (not applicable to insurance policy loans) how to contact the FCAC when they have a complaint about the company's compliance with a consumer provision.	The Financial Consumer Agency of Canada (FCAC) supervises federally regulated financial institutions to ensure they comply with federal consumer protection laws (or "consumer provisions"). The FCAC focuses on compliance and enforcement, and does not provide compensation or get involved in individual disputes. For more information about the FCAC, including a complete listing of consumer provisions that apply to Sun Life Financial's insurance and trust companies, please visit the FCAC's website at www.fcac-acfc.gc.ca. FCAC's mailing address is: Financial Consumer Agency of Canada 427 Laurier Avenue West, 6th Floor Ottawa, ON K1R 1B9

grumpy old man · 5 Re: Insurance Company Appeals Wed Dec 07, 2011 2:52 pm

grumpy old man

administrator

Number of posts : 17663
Registration date : 2008-09-27

Who provided the Sun Life coverage? If a company is involved, one that Sun Life would not want to aggravate, try appealing through them...

rosencrentz · 6 Re: Insurance Company Appeals Wed Dec 07, 2011 7:51 pm

rosencrentz

uber-contributor

Number of posts : 9945
Registration date : 2008-10-05

Insurance companies will deny any claim that they can. In your case DeanK has given you all the avenues to follow.

Over the years I have had several cases where going to court to collect what I had been insured for was a necessity.

One major theft, was claimed to be a "mysterious disappearance , discovered upon taking inventory", which wasn't the truth!

I hired a Jewish lawyer, always recommended, and did collect. I think there was a $2-$3000 bill .

Another flood claim, I had a real problem collecting because the insurance companys adjuster was a real dick head. I hired my own adjuster and the reason the dick head was being a dick head came out at a meeting, after I was yelling at the dick head!

Mantha · 7 Re: Insurance Company Appeals Thu Dec 08, 2011 2:07 pm

Mantha

contributor plus

Number of posts : 924
Registration date : 2009-03-27

Thanks, everyone! This is EXACTLY the type of responses I was looking for! Much to go through!

rosencrentz · 8 Re: Insurance Company Appeals Fri Dec 09, 2011 2:03 pm

rosencrentz

uber-contributor

Number of posts : 9945
Registration date : 2008-10-05

If your insurance company hasn't got an update on the cause , that is why they are denying the claim.

Remember , you can hire an independant asjuster to deal with your company, but from their posted ways of moving forward, it appears that you have the opportunity to get the claim fixed.

Good luck!

Guest · 9 Re: Insurance Company Appeals Wed Dec 14, 2011 7:25 pm

Guest

Guest

I treat everything that comes from an insurance adjuster as a outright lie. Go from there.

rosencrentz · 10 Re: Insurance Company Appeals Thu Dec 15, 2011 4:50 am

rosencrentz

uber-contributor

Number of posts : 9945
Registration date : 2008-10-05

Whomever is paying the adjuster is who he/she is working for, and where their loyalties are.

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Insurance Company Appeals

1 Insurance Company Appeals Wed Dec 07, 2011 1:17 pm

Mantha

2 Re: Insurance Company Appeals Wed Dec 07, 2011 1:45 pm

Deank

3 Re: Insurance Company Appeals Wed Dec 07, 2011 1:48 pm

Deank

4 Re: Insurance Company Appeals Wed Dec 07, 2011 1:48 pm

Deank

5 Re: Insurance Company Appeals Wed Dec 07, 2011 2:52 pm

grumpy old man

6 Re: Insurance Company Appeals Wed Dec 07, 2011 7:51 pm

rosencrentz

7 Re: Insurance Company Appeals Thu Dec 08, 2011 2:07 pm

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8 Re: Insurance Company Appeals Fri Dec 09, 2011 2:03 pm

rosencrentz

9 Re: Insurance Company Appeals Wed Dec 14, 2011 7:25 pm

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10 Re: Insurance Company Appeals Thu Dec 15, 2011 4:50 am

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11 Re: Insurance Company Appeals

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