We all know that the whole purpose of an insurance company is to make money and that some of them will stop at nothing to limit or eliminate the benefits they owe their policyholders.
In fact, very often insurers use all kinds of inaccurate pretexts to justify the rejection of a claim in order to rake in millions of dollars in profits annually.
When an insured is opposed to the reimbursement of an insurance claim for services rendered by a member of the CPMDQ, this does not mean the end of the procedures for the insured because this marks only a step leading ultimately to the compensation in most cases.
When an insurer does not respect the terms of an insured contract and the latter refuses to pay the benefit as per the terms of the contract, regardless of the pretext for refusal, this is often only a tactic on the part of the insurance company. the insurer to discourage the insured from using the coverages of his contract and thus generate more profit each year.
When this situation turns out, according to the law on insurance, under any circumstances the insured should abandon his dispute to force his insurer to respect the terms of his contract, because if the insured does not dispute, the abuse of the The insurer’s share could persist and even worsen.
In reality, an insurance company is only a company incorporated by an NEQ number with the Registrar of Enterprises of Quebec (REQ). It is a company governed by the law on insurance, a company subject to the law of the Autorité des Marchés Financiers.
Thus, when an insurer refuses to reimburse a service for services rendered by a member of the CPMDQ, we are talking here about services to which the insured is entitled under the terms of his insurance contract, only the parties to the contract hold the legal rights to contest this dispute.
It is important to first understand group insurance contracts.
In a group insurance contract, three distinct parties are involved, namely the policyholder (the insured’s employer), the insurer (the insurance company) and the members (the insured).
The policyholder (the employer) is the party who concludes the insurance contract with the insurance company. It is this contract which describes the terms of the coverage offered and its content is binding on any person insured under this contract.
The participant is the person eligible for the contract who has completed an insurance enrollment form. (the insured)
The insurer (the insurance company)
The insurer is required to send the policyholder certificates attesting to the insurance coverage so that the policyholder can send them to each of the members (the policyholders).
In practice, the insurer also sends the policyholder (the employer) brochures describing the content of the insurance guarantees that are given to each of the members (the insured).
In the absence of government regulations regarding the practice of alternative medicine in Quebec, the fact that an insurance company is not a monitoring body mandated by the government, an insurer has no legal powers of investigation. with regard to the functioning of the CPMDQ nor on the evaluation of the academic skills of its members.
For this reason, an insurer cannot therefore refuse to pay for a service on the pretext that the service provider does not meet the criteria and requirements of the insurer or other pretexts prejudicial to the CPMDQ or to screw one of its members. Judgment CPMDQ c. SSQ November 2014
For the aforementioned reasons, when an insurer refuses to reimburse a receipt issued by a CPMDQ member because of a reproach from the CPMDQ or vis-à-vis the qualifications of its member, this can probably only be a pretext to on the part of the insurer to discourage the insured from continuing to consult therapists in order to eliminate a huge percentage of reimbursement requests by his insured.
Si vous êtes un assuré de la SSQ
KNOW YOUR REMEDIES
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 Citizen’s Protector. .
The mission of the Protecteur du Citoyen is to protect the rights of citizens against all public services and government agencies in Quebec. The Citizen’s Protector is a neutral, impartial and independent institution of the government.
In the event that the insured is dissatisfied with the way the Citizen’s Protector 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.