How to Appeal Denied Insurance Claim in Ontario

Getting denied by your insurance company can feel like a punch to the gut. You went through the injury, the forms, the back and forth, only to be told you don’t qualify for any number of reasons. Denials happen more often than people think, but they’re also often incorrect.

Insurance companies can point to minor technicalities in your policy to justify saying no. At McNally Gervan LLP, we’re here to help you fight those unjust denials to get the benefits you deserve. If your claim was rejected, here’s what to focus on.

Tips for Appealing a Denied Insurance Claim in Ontario

Read the denial letter carefully

Don’t set it aside or assume you already know what it says because your denial letter is often the only written explanation the insurer will give you. It might refer to an exclusion, a deadline, or a lack of supporting information that was the reason for the denial, and the language will probably be dry and legalistic. You’ll need to translate it into plain language so you understand what you’re being told. If the insurer believes your injury isn’t severe enough or your treatment wasn’t necessary, that will shape how you respond. Look for the exact wording used and keep a copy of the final position letter for your file.

Build a stronger file with better documentation

If your insurer denied the claim because there wasn’t enough medical evidence, that doesn’t mean the claim wasn’t valid. It just means the file was incomplete and, unfortunately, that’s all it takes.

Start with the basics. Medical records, test results, clinical notes, doctor’s letters. If a specialist assessed you, ask for their report. If your claim relates to a car accident, get the police report and hospital intake records. If you’ve been off work, find your pay stubs or ask your employer for a letter confirming your absence. 

What many people don’t realize is how the insurer’s internal process affects them. Claims are reviewed by people who don’t know you, often relying on a checklist. If a key piece of information isn’t there, it makes it easy for them to check a box and close the file. That’s especially common in disability claims involving pre-existing medical conditions, where the burden shifts to you to prove your condition is either new or made worse since the policy took effect.

Insurers aren’t likely to chase down missing information. That part falls to you. Or, if we’re involved, to us. And while that may seem unfair, it’s also an opportunity. Because once the right medical assessment and required medical evidence are in the file, the entire conversation changes.

Go through your policy, not just the paperwork

You can’t rely on the insurer’s version of what your policy says, so it is extremely important that you read your actual contract carefully and in its entirety. Focus on the definitions section and the eligibility rules, since these sections will usually include terms like “total disability,” “accident,” or “medically necessary.” 

Don’t assume their definition lines up with what’s common sense, as insurance policies often narrow the meaning of everyday terms. If your claim involves long-term disability, check the difference between the coverage period for “own occupation” and “any occupation.” Knowing how your coverage is written is key to challenging how it’s being applied.

Write a clear appeal and explain the gap

Your appeal should be in writing and supported by evidence. Don’t just say the insurer made a mistake; you need to show them why. You can refer to the denial letter directly and explain how your case fits within the wording of your policy. If you’ve added new evidence since your original claim, include it. If your doctor has written a new report or filled in a functional limitations form, attach it. 

Be direct. This is a formal response to a legal decision. Appeals that reference specific clauses in the policy will carry more weight. If you’re confused on where to begin you can contact us, our insurance claim lawyers at McNally Gervan will be more than happy to help.

Watch the deadline

Most policies give you a short window to appeal a denial that’s often between 30 and 90 days from the date of the letter, and that window doesn’t pause while you gather documents or book appointments. If you’re unsure about your time limit, it should be stated clearly in the denial letter or your policy.

You need to mark the date and work back from there. If you’ve already missed the deadline, one of our lawyers may still be able to help, but acting quickly gives you better options. We’ve seen too many valid claims thrown out because someone waited too long to respond. 

Legal advice shifts the balance

If you’re dealing with a complex claim (like long-term disability, short term disability, permanent injury, or lost income) or a significant amount of money, don’t handle it alone. These claims are sometimes denied because the insurer expects people to give up, but a disability insurance lawyer can review your file, identify weak points in the insurer’s argument, and respond in a way that puts pressure on them to take your claim seriously. 

If the appeal doesn’t succeed, legal representation also prepares you to take further action. This is especially important in disability cases where coverage might span years.

Know when to escalate

If your appeal is rejected, you can still take further steps. In Ontario, you can file a complaint with the Financial Services Regulatory Authority or reach out to the OmbudService for Life and Health Insurance. These organizations review how the insurer handled your case and whether the process was fair. They don’t represent you, but they can add pressure. 

If your claim is still being denied after that, you may have grounds for legal action. Some insurers rely on delay tactics, especially in complex cases, but filing a legal claim signals that you’re not walking away quietly. For some, it’s the only way to get a real response.

Take The Next Steps with McNally Gervan

Appealing a denied claim takes time and effort, but it’s often worth it. The appeal process isn’t about finding a loophole. It’s about holding the insurer to the terms of the contract they wrote. You have every right to do that, and you also have the right to get help.

At McNally Gervan LLP, we help clients in Ottawa and across Ontario with insurance disputes, personal injury claims, and disability claim appeals. If you’ve been denied coverage, we’re here to help you understand your next steps and push for a better result.

Contact us today for a free consultation with a disability insurance or personal injury lawyer. If your long-term disability benefits have been denied, or you’re being told something in your insurance contract means you’re out of options, it’s time to talk to someone who sees the full picture. We know how insurers operate, how the fine print is used to justify denials, and how to push back when those denials don’t hold up.

There’s a legal process behind every denied claim, but most people don’t get a clear look at what that actually involves. That’s what we offer from the start. We’ll explain what your rights are, how your policy fits into the bigger picture, and what legal options are realistically available to you. You don’t need to have it all figured out. You just need to start the conversation.