Insurer Rejected Your Claim
What Is Your Recourse

Over the course of the past decade, insurance companies have increasingly refused to provide payment for services rendered to their policyholders, under their extended private group health insurance benefit plans. It’s become increasingly problematic where companies go so far as to defame some practitioners, labeling them as unqualified in order to claim that the practitioner does not meet policy standards.

It should be known however, that it does not fall to the insurance company to dictate a practitioner’s qualifications, rather, it falls to the professional governing body who’s role is to oversee the legitimate practice of a given profession and protect the public from truly unqualified practitioners.

Compounding this issue, the criteria insurance companies use in order to judge a practitioner’s level of competency is aggregate, proprietary, and confidential information that is kept from both, professionals and policyholders alike. As such, even practitioners themselves do not know what criteria insurance companies are using when judging professional standards.

Furthermore, an insurance company is governed by the Insurance Act, which means that the company is expected to respect the terms of its policyholders’ contracts.

As private group insurance contracts are made up of three distinct parties: – the employer, – the insured, – and the insurance company. Should an insurer deny payment for services rendered by a member of a respected professional association within the scope of one’s insurance coverage, the service provider is legally unable to intervene, as they are not a party to the terms and conditions of the contract. Because of this, many insurance companies refuse to speak with practitioners regarding rejected claims.

As such, only the parties involved within the insurance contract are legally entitled to take action regarding this particular matter.

For these reasons, should your insurer refuse to reimburse your claim thereby refusing to honour the terms of your contract, regardless of the reason given by your insurance provider, you, as a party to the insurance contract, have the right to send a formal notice to the insurer, and contest this dispute before a Small Claims Court.

In conclusion, because Antonio Colasurdo is not considered a distinct party to the private group insurance contract formed between your employer, yourself, and the insurance company, he cannot be held liable nor responsible in the event of insurance non-reimbursement.