What to Do When a Canadian Insurance Claim Is Denied: Appeal Steps That Stay Factual

A denied claim goes quiet when the letter feels final. It is final only inside the insurer’s first decision. Canadian property, auto, life, and health contracts still have an internal complaint step, and member companies sit under an ombuds service after that. The path is factual. You answer the exclusion they cited. You do not send a mood, a forum thread, or a demand that they “be fair” without the wording.

How to open a home claim, including Ontario’s notice and proof-of-loss timing, is already written. This page starts when the answer is no. It is not a claims mill, and it does not send you to hire anyone.

Read the denial letter for policy wording citations—not just ‘not covered’

Read the letter once for the result and a second time for the citation. You want the policy form number, the section or exclusion, and the fact they say triggers it. “Water is not covered” is not yet a reason. Sudden discharge from a plumbing system, sewer backup, overland flood, and groundwater are different grants and different exclusions. The water endorsement guide and the overland flood guide are the map. Your declarations page is the proof of which grants you bought.

If the letter does not cite wording, reply once, in writing, and ask for it. Keep the reply short: the claim number, the date of the letter, and a request for the section relied on and the facts applied to your loss. Do not argue the whole case in that note. You cannot match evidence to a sentence they have not written.

Gather contemporaneous evidence that matches the cited exclusion

Contemporaneous means the photo, report, or receipt existed because of the loss, not because the denial arrived. Adjusters discount a reconstruction built after the “no.” Build the folder around the citation.

• The exclusion they named. If they say the roof leaked for months, you want the repair invoice from the last time you actually fixed it, or you acknowledge the leak was old. Pretending is how a denial becomes an allegation of a false statement.
• The endorsement they ignored. If you bought sewer backup, the declarations page and the limit belong on top of the folder. A denial that treats every water loss as groundwater has to meet that page.
• Official records. Fire department, police, a municipal flood notice, or a weather record for the date. Save the PDF. A screenshot of a social post is weaker than the office that attended.
• Your own timeline. When you noticed the loss, when you mitigated, when you gave notice. The home claim guide states Ontario’s “forthwith” notice and “as soon as practicable” proof of loss. Other provinces use their own conditions. Late notice is a defence only if you leave it unexplained.

For an auto denial, add the liability card, the police report threshold that applied in your province, and any written fault code. The collision checklist has those clocks. Do not mix a fault-chart argument into a home-exclusion folder.

Internal appeal and ombuds timelines

Use the company’s complaint officer, not a second call to the adjuster who signed the denial, when the adjuster has already closed the point. Ask for a final position letter. That letter is the ticket for the ombuds and, in Ontario, for FSRA.

General Insurance OmbudService handles eligible home, auto, and business disputes with subscriber companies. Its process page, used 24 Sep 2026, says investigation officers review a case once you have a final position letter. Published stage aims, barring exceptional circumstances, are 45 days for informal conciliation, 60 days for mediation, and 90 days for senior adjudication, each measured from when the file enters that stage. Senior adjudication issues non-binding recommendations. Most files, GIO has reported, close earlier at the assistance stage. A 45-day line on a website is not a promise that your cheque is rewritten in 45 days.

OmbudService for Life and Health Insurance is the door for life, health, disability, and similar products at participating companies. OLHI’s process, used 24 Sep 2026, requires a final position letter. The stated objective is to complete a review within 120 days from the written acknowledgment that the complaint was accepted. An OmbudService Officer investigation is aimed at 45 days if the file is escalated. Recommendations are non-binding. OLHI asks the parties to sign an agreement suspending the limitation period while it reviews. Its own FAQ says that suspension is not legally allowed in Québec. If you live in Québec, or the policy says Québec law, speak to a lawyer about the deadline before you wait on a file. Everywhere else, still write the deadline down yourself. A form you have not signed has not paused anything.

Regulator complaint paths differ for P&C vs life/health

Regulators supervise conduct and licensing. They are not a second adjuster who can be talked into a larger contents cheque.

FSRA’s property-complaint page, used 24 Sep 2026, says the contact centre aims to assess within 3 business days whether the company or person is licensed, and that the service goal is to complete a review of 80 percent of complaints within 90 days. Complex files take longer. FSRA’s decision on a complaint is not a court judgment, and it does not award you the claim. Use it when the issue is how you were treated, a licensing problem, or a failure to answer. Use the policy and, if needed, a lawyer when the issue is whether the loss is covered.

When an independent appraisal or legal consult is proportional

Appraisal, where the provincial conditions provide it, decides the amount of a loss after a proof of loss. The home-claim guide records Ontario’s rule that you demand appraisal in writing after the proof is delivered, and that a party who does not appoint an appraiser within seven clear days can have one appointed by the court. Appraisal does not, by itself, decide that an excluded peril was covered. Hiring a second contractor to argue value can be proportional on a large contents list. Hiring one to re-litigate a flood exclusion is the wrong tool.

A legal consult is proportional when any of these is true: the denial cites misrepresentation, the amount you would absorb is large relative to a short consult, a limitation date is close, or someone was injured. It is not proportional for a $400 contents dispute you can document yourself. This page cannot tell you which limitation period applies. Ontario’s Limitations Act, 2002, uses a basic two-year period for many claims, running from discovery, and policies sometimes print a shorter clause. Whether that shorter clause binds you is a legal question. Read the clause, read the denial date, and do not assume a forum’s “one year from the fire” sentence is still your statute. The home-claim guide makes the same warning.

Some provinces license public adjusters. They charge a fee, often a share of the claim. This guide does not recommend that hire. The complaint officer, GIO or OLHI, appraisal on amount, and a lawyer when the dollars or the deadline justify it, are available without that contract.

Parallel path: mitigate damage anyway so losses do not grow

The duty to limit the loss does not pause because you are appealing. A house that stays wet grows mould. A car left unrepaired in a live lane is a second loss. Do the reasonable thing, keep every receipt, and tell the insurer in writing that you are mitigating while you dispute coverage. Ask, if you can, before you start a full rebuild. Emergency dry-out and a tarp are not a renovation.

Mitigation is not an admission. Paying a plumber to stop the water does not mean you agree the exclusion applies. Say that in the email so a later letter cannot pretend you abandoned the claim. If you eventually repair because people cannot live in the house, keep the invoices in the same folder as the denial. If the appeal succeeds, those invoices are the proof of the amount. If it fails, you at least did not add a second excluded loss by waiting.

Injury and liability claims are not a DIY pause either. Tell the insurer, follow the auto injury clocks on the collision checklist, and get care. An appeal about property damage does not delay a medical report someone else needs.