Insurance Claim Denied in Ontario? What to Do Before Contacting the Insurer Again

Receiving a claim denial is unsettling, especially when you believed you did everything correctly. You paid your premiums. You reported the loss. You provided information and followed up. Then the letter or email arrived: the claim was denied.

In Ontario, what you do immediately after a denial can affect how smoothly—or how slowly—the dispute process proceeds.

Before contacting the insurer again, several steps are worth taking, even when you are confident the decision is wrong. That preparation is especially important when you believe the denial is incorrect.

This guide explains what to gather, how to review the denial, and when it may be time to speak with a lawyer.

Step 1: Get the Denial in Writing

If the insurer communicated the denial only by telephone, request a written decision before taking further action. A vague verbal explanation is not enough to prepare a meaningful response.

The written denial should identify:

• The specific reason for the denial.
• The policy provision, exclusion, or condition the insurer is relying on.
• The claim number and date of the decision.
• The adjuster’s name and contact information.
• Any applicable review, appeal, or dispute deadline.

If you already have a denial letter, save it as a PDF and keep the original in a secure location. The written explanation is usually more precise than what was communicated by telephone and becomes the foundation of any reconsideration request, tribunal dispute, or legal review.

Step 2: Build a Claim Timeline

A short, factual timeline is one of the most useful documents you can prepare.

Record:

• The date of the loss and a brief description of what happened.
• The date you first notified the insurer.
• The names of everyone you spoke with.
• The dates and substance of important conversations.
• When documents, photographs, estimates, or reports were submitted.
• Any repair visits, medical appointments, examinations, or assessments.
• The date and method of the denial.

Keep each entry short, objective, and dated. Avoid assumptions or emotional descriptions.

The timeline can be valuable if the file is later reviewed by a lawyer, insurer complaint officer, ombudservice, regulator, or tribunal.

Step 3: Identify Why the Claim Was Denied

Insurance denials generally fall into several recurring categories. Identifying the correct category helps you focus on the evidence that matters.

The Loss Is Not Covered

The insurer may take the position that the type of loss does not fall within the coverage purchased. For example, a property policy may exclude certain forms of groundwater, seepage, or flooding.

A Policy Exclusion Applies

Common exclusions include wear and tear, gradual deterioration, corrosion, faulty workmanship, or damage that was not sudden and accidental.

A Policy Condition Was Not Met

The insurer may allege that the insured failed to report the loss promptly, mitigate further damage, provide requested documentation, attend an examination, or comply with another policy requirement.

Misrepresentation or Material Change

The insurer may allege that information provided during the application process was inaccurate, incomplete, or not updated after a material change in circumstances.

Insufficient Evidence

The insurer may say that the evidence does not establish that the loss occurred, what caused it, or how much it is worth.

Disagreement About the Amount

Sometimes the claim is not denied completely. Instead, the insurer offers an amount that is substantially lower than expected and treats it as full settlement of the claim.

Once the reason is clear, you can respond with evidence directed at the insurer’s actual position rather than sending a general objection.

Step 4: Review the Full Policy Wording

Obtain the complete policy—not only the certificate of insurance or summary page.

Review:

• The complete policy wording.
• The declarations page.
• All endorsements, riders, and optional coverages.
• The definitions section.
• The exclusions section.
• The insured’s duties after a loss.

Locate the exact provision cited in the denial letter. Read the surrounding language as well, because policy provisions must be interpreted in context.

Definitions can be particularly important. Disputes often turn on the policy’s meaning of terms such as “sudden and accidental,” “vacant,” “occupied,” “flood,” or “resulting damage.”

Check the declarations page carefully. In some cases, the issue is not an exclusion but the absence of a particular optional coverage or a lower limit than the insured expected.

Step 5: Request the Claim Materials

Send a written request asking the insurer for the non-privileged documents and information relating to the claim and denial.

Depending on the type of claim, request:

• Adjuster notes and activity logs.
• Correspondence relating to the claim.
• Photographs taken by the insurer, adjuster, or vendor.
• Engineering, medical, appraisal, or independent assessment reports.
• Recorded statements or available transcripts.
• Copies of documents you previously submitted.
• The documents relied on when making the denial decision.

Some records may be withheld because of privilege, privacy obligations, or other legal restrictions. The scope of disclosure can also depend on the type of insurance claim and the stage of the dispute.

Even so, requesting the materials in writing can reveal reports, photographs, or notes that were not previously provided.

Step 6: Check All Applicable Deadlines

Insurance claims may involve strict and claim-specific deadlines.

• Statutory accident benefits claims involve prescribed forms and dispute deadlines.
• Property claims may require a proof of loss within a specified period.
• An insurer may request an examination under oath.
• Disability policies may contain internal appeal deadlines.
• Civil lawsuits are subject to limitation periods.

If the denial letter identifies a deadline for reconsideration, internal review, appeal, or tribunal proceedings, treat it seriously and obtain advice promptly.

Missing a procedural deadline can affect an otherwise valid claim.

Step 7: Gather Evidence That Addresses the Denial

Generic disagreement rarely changes an insurer’s decision. Evidence that directly responds to the insurer’s stated reason is more useful.

Understanding the Licence Appeal Tribunal Process

If the denial involves Statutory Accident Benefits after a motor vehicle collision—such as medical, rehabilitation, attendant care, or income replacement benefits—the dispute will generally proceed through the Licence Appeal Tribunal, commonly called the LAT.

Important points include:

• A dispute is generally subject to a two-year limitation period running from the insurer’s denial, although the specific denial and circumstances must be reviewed.
• The matter commonly proceeds through a case conference before a hearing.
• Updated medical evidence may be required, particularly for treatment, income replacement, attendant care, or injury-classification disputes.
• The LAT process involves procedural directions, evidence requirements, deadlines, and hearing rules.

The insurer’s denial letter and accompanying explanation should be reviewed carefully to determine whether the decision is sufficiently clear and whether the limitation period has begun.

Because the deadline can be decisive, this is often an appropriate stage to speak with a personal injury lawyer.

Should You Give Another Recorded Statement?

An insurer may request another recorded statement after denying the claim. This is not automatically improper, but it should be approached carefully.

Before agreeing, ask:

• Why another statement is required.
• Which issue the insurer wants to address.
• Whether the interview will be recorded.
• Whether a copy or transcript will be provided.
• Whether the policy requires your attendance or cooperation.

If you provide a statement:

• Answer only the question asked.
• Stick to facts you clearly remember.
• Do not guess about dates or details.
• Do not speculate about causation.
• Correct any misunderstanding immediately.
• Request a copy of the recording or transcript.

Where the claim involves a serious injury, significant financial loss, an allegation of misrepresentation, or a possible fraud investigation, obtain legal advice before providing another statement.

Escalating the Matter Within the Insurance Company

A written escalation is usually more effective than repeatedly calling the insurer’s general telephone line.

1. Write to the adjuster with the new evidence and a specific request for reconsideration.
2. If the issue is not resolved, request a review by a supervisor or claims manager.
3. Ask whether the insurer has a formal complaint, reconsideration, or internal appeal process.
4. Request the contact information for the insurer’s complaint officer or ombudsperson.

Keep each request specific, professional, and dated. Preserve copies of all correspondence and delivery confirmations.

This creates a record that may later be relevant to an internal complaint, ombudservice review, LAT proceeding, regulatory complaint, or lawsuit.

If You Suspect Unfair Claim Handling

Document patterns such as:

• Unexplained or repeated delays.
• Changing reasons for denial.
• Failure to address documents you submitted.
• Requests for the same information multiple times.
• Pressure to accept a quick or substantially reduced settlement.
• Statements that conflict with the written policy or denial letter.

Keep the record factual and dated. A clear paper trail is more useful than an undocumented telephone complaint.

Whether the conduct supports a legal claim or regulatory complaint depends on the full facts, the insurance contract, and the applicable law.

When to Speak With a Lawyer

Some denials can be resolved through a focused reconsideration request supported by the right documents.

Legal advice may be particularly important when:

• Statutory accident benefits have been denied or terminated.
• A LAT limitation period may be running.
• The insurer alleges misrepresentation or non-disclosure.
• The denial reasons keep changing.
• The claim involves a serious injury or substantial financial loss.
• The insurer is relying on an engineering, medical, or expert report.
• A recorded statement, examination under oath, or insurer examination has been requested.

A personal injury lawyer may assist by:

• Reviewing the policy and denial letter.
• Identifying the applicable deadline and dispute forum.
• Requesting and reviewing relevant claim materials.
• Preparing a reconsideration request.
• Gathering medical, financial, or expert evidence.
• Preparing and filing a LAT application where appropriate.
• Negotiating directly with the insurer.

Frequently Asked Questions

What should I do immediately after receiving a claim denial?

Obtain the denial in writing, identify the policy provision relied on, preserve all correspondence, create a timeline, and confirm whether a review, appeal, tribunal, or limitation deadline applies.

How long do I have to dispute a denied accident benefits claim?

A statutory accident benefits dispute is generally subject to a two-year limitation period from the insurer’s denial. The wording and legal sufficiency of the denial should be reviewed because the specific facts can affect the analysis.

Why are insurance claims commonly denied?

Common reasons include lack of coverage, a policy exclusion, failure to meet a condition, alleged misrepresentation, insufficient evidence, a causation dispute, or disagreement about the value of the loss.

Can I request my claim file from the insurer?

You can request relevant non-privileged claim documents in writing. The insurer may withhold certain records because of privilege, privacy obligations, or other legal restrictions. What must be provided can depend on the type of claim and the stage of the dispute.

Do I need a lawyer to dispute a denied claim?

Not in every case. Some denials can be resolved through a clear, well-supported reconsideration request. Legal advice becomes more important when statutory accident benefits, strict deadlines, serious injuries, significant losses, changing denial reasons, or allegations of misrepresentation are involved.

Should I speak with the adjuster before reviewing the denial letter?

It is usually better to read the written denial, identify the policy provision, and organize the evidence before responding. An unprepared telephone conversation may create confusion or an incomplete record.