Understand the payment
Why reimbursement can be lower than the invoice
A payment can be reduced by excluded items, a deductible, your percentage share or a benefit limit. A partial
payment does not necessarily mean the entire condition was rejected.
Example with the deductible already met
Suppose an invoice totals $1,000, including $100 in excluded charges. The eligible amount is $900. With an
80% reimbursement rate, no remaining deductible and enough benefit allowance, the insurer pays $720 and your
total share is $280.
This is a hypothetical Canadian-dollar example, not a claim assessment. Actual calculation order and policy
rules may differ.
Ask for a line-by-line explanation if the decision is unclear. Our coverage guide
explains the benefits and restrictions to compare with your statement.
If you disagree with the decision
Request the policy clause and medical records used in the assessment. Explain the specific point you dispute
and provide relevant supporting information. Ask about the insurer’s reassessment process, complaint route and
applicable deadlines.
For an unresolved complaint, check whether the insurer and issue fall within the General Insurance OmbudService’s scope. Its
guidance requires completion of the insurer’s complaint process and a final position letter before review.
External review does not guarantee payment.