Provincial Insurance Act legislation and the contract itself set out a framework for how claims are submitted, investigated, and resolved.
Notice of claim: most policies require the insured to give written notice to the insurer within a specified period after a disability, illness, or other covered event occurs. Under the Ontario Insurance Act Part V statutory conditions for accident and sickness contracts, notice is required within 30 days of the commencement of disability (or as soon as reasonably possible). Late notice may give the insurer a defence, particularly if the insurer was prejudiced by the delay.
Proof of claim (proof of loss): the insured must submit proof of claim, typically including a claimant's statement, an attending physician's statement, and supporting medical documentation, within the period prescribed by the policy and the applicable statute. Under Ontario statutory conditions, proof of loss for a disability claim is generally required within 90 days of the commencement of the period for which benefits are sought.
Physical examination: the insurer has the right to require the insured to submit to medical examinations by a physician of the insurer's choice as often as is reasonably required during the claim period. Refusal to submit may constitute a breach of the claims conditions.
Rehabilitation: most modern disability policies include a rehabilitation provision that allows the insured to attempt to return to work without immediately losing benefits. Benefits are reduced or modified during a rehabilitation trial rather than cut off entirely if the attempt fails.
Recurrence: if a disability recurs within a specified period after return to work (commonly six months), many policies treat the recurrence as a continuation of the original claim rather than a new claim, so the elimination period does not restart.
Limitation periods: under most provincial insurance statutes, an action on an A&S policy must be commenced within a fixed limitation period after the claim is due. In Ontario, the general limitation period under the Limitations Act, 2002, S.O. 2002, c. 24, Sched. B, is two years from the day the claim was discovered. Policy conditions and the statutory conditions under the Insurance Act interact with this general provision.