We all know that an insurance company is in business to make money, and some of them will do just about anything to limit or eliminate the benefits they are required to pay under the terms of your policy.

As a matter of fact, quite often, insurance companies will use any number of false reasons to dissuade the insured from using their coverage in an attempt to make millions of dollars in profits down the road.

First and foremost, it is important to understand that in our province, like any other business, an insurance company is a company constituted by a NEQ number. It is a company regulated by the Insurance Act and supervised by the AMF.

In this province, as there are no government regulations regarding most fields of  alternative medicine, an insurance company cannot refuse to pay coverage for a service rendered by a health care provider or a practitioner member in good standing of a respective professional association in the field of natural medicine on the on the basis that the insurance company does not  recognize the professional association or its member.  For the reasons stated above, Insurance companies do not have any list of standards and criteria for a professional association or its members. 

Furthermore, the insurance company cannot legally refuse a claim from a service provider on grounds that the health care provider  does not meet the insurer’s standards and criteria for the simple reason that the insurance company does not have the power or the authority to assess the  competence of a health care provider. The assessment of the health care provider is determined according to the  professional association’s standards. 

Thus,  when you find yourself in a situation in which your insurance company refuses to reimburse your claim, it is important to ensure that the service provider you consulted  is a member in good standing of a respective association for the coverage you submit the claim under. 

Therefore in the event that your insurance company refuses to reimburse your claim under the allegation that the CPMDQ member is not in good standing, first make sure to verify the status of the member at the link below is active and in good standing in order to make sure that your insurance company is not denying your claim under a false pretense.  

                                                                                   KNOW YOUR RECOURSE 

Insurance is an area where government institutions abound. So by the above facts, when an insured is in this kind of situation with his insurer, the fastest and most economical process for the insured to resolve this problem with his insurer is to file a complaint with the insurer. Autorité des Marchés Financiers, the body mandated by the government to regulate all insurance companies in Quebec. The AMF’s mission is to protect the public by providing assistance to policyholders by handling complaints received from policyholders and giving them access to dispute resolution services.

Following the filing of his complaint, in the event that the insured is dissatisfied with the way in which the Autorité des Marchés Financiers has handled his complaint, the insured may file a complaint against the Autorité des Marchés Financier with the Protecteur du Citoyen.

The mission of the Protecteur du Citoyen is to protect the rights of citizens against all public services and government agencies in Quebec. The Protecteur du Citoyen is a neutral, impartial and independent institution of the government.

In the event that the insured is dissatisfied with the way the Protecteur du Citoyen is handling his complaint against the AMF, the insured may file a claim with the Small Claims Division court.

The Small Claims Division is a court where you must represent yourself, without a lawyer. However, you can consult a lawyer to help you prepare your case. Your case may be heard if you claim an amount that does not exceed $ 15,000, without interest. 

If you are an SSQ policyholder

EXAMPLE OF A FORMAL NOTICE 

If, despite everything, your dissatisfaction still remains, you can file a formal complaint with the authorities below.