Appealing OPS Denied Benefit Claims

What insured benefits can I appeal?

• Supplementary Health and Hospital Insurance
• Dental
• Long Term Income Protection (LTIP)
• Group Life Insurance (including Basic, Supplementary and Dependent Life Insurance)
• Any other benefits that may be added to the Group Insurance Plan.

How can I appeal claims for denied insured benefits?

If you work in the Ontario Public Service (OPS) and are represented by OPSEU/SEFPO, you can appeal the denial through the Joint Insurance Benefits Review Committee (JIBRC). The JIBRC is comprised of OPSEU/SEFPO representatives and Employer representatives from Treasury Board Secretariat.

Union Representatives

Richard Dionne

Peter Figliola Christ Eckert

Ram Selvarajah

Kenneth Steinbrunner, Executive Board Member

Paula Van Dusen

OPSEU/SEFPO Staff Resources

Cheri Hearty

Luc-Joel Ciza Jannet Geddes

 

The JIBRC will review the claim, determine if there is a viable avenue to appeal and attempt to resolve the claim. OPSEU/SEFPO takes an active role in the Committee meetings as your advocate. All information submitted to the JIBRC is confidential.  Meetings are usually held monthly.

If the appeal cannot be resolved at the Committee level, the appeal can be referred to the Claims Review Subcommittee (CRS). If the claim is referred to CRS, then it will be heard before designated arbitrators and a final binding decision will be made.

How do I commence an appeal to the Joint Insurance Benefits Review Committee?

Discuss your complaint with your employer, the union and the insurance carrier when you become aware of the denial of benefits by the insurance carrier. Sometimes, submitting additional information directly to the insurance carrier may resolve the problem.

If the complaint is not satisfactorily resolved, please forward your appeal request by mail, fax or emailing the Pension & Benefits Unit. In your appeal request please forward the following documentation:

• Copies of any denials from the insurance carrier;
• Your reasoning about why your appeal should be approved;
• Your contact information; and,
• Any other information you think is relevant and useful for the committee.

 Joint Insurance Benefit Review Committee – OPS

Ontario Public Service Employees Union

5757 Coopers Avenue

Mississauga, Ontario

L4Z 1R9

Telephone:    (416) 443-8888 or 1-800-268-7376 ext. 3560

Fax:                (905) 712-3009

Email:             OPSBenefitAppeal@opseu.org

Why would I want to appeal an insured benefit claim that is denied?

You believe your claim has been improperly denied. Sometimes too it can point out deficiencies that need to be addressed in bargaining.

I’ve filed an appeal, what can I expect?

Depending on the type of benefit denied, an appeal will take some time, often months or longer. This is particularly true for complex appeals.

Bargaining Benefit Improvements

Should the insurer correctly deny the coverage, but you believe this coverage is important for your employer to provide, it will be important to identify the lack of coverage to your local leadership and colleagues. In order for coverage to be extended to provide for the benefit you believe should be included, it will likely need to be negotiated with the Employer in a future round of bargaining. If you and your colleagues believe a specific benefit is important, providing information, education and resources to your local leadership and your colleagues will be important to garner support for the change you want to see within your Collective Agreement. Bargaining begins essentially as soon as a Collective Agreement is ratified, meaning, you need to provide information and education to your co-workers often and early. That way, when your next round of bargaining is imminent, the seeds have already been planted and you’ll ideally already have the backing necessary to support the change you want to see. If you’ve rallied your colleagues, they too will ideally complete the bargaining survey and attend the demand set asking for the change to the Collective Agreement.

Information specific for LTIP Appeals:

For an LTIP appeal, once filed, you should contact your local employer (and your local union representative) to advise them you have filed an appeal through JIBRC and request a leave of absence. Your local employer may not be automatically notified of the appeal and therefore it is important to contact them and request the leave of absence.

A copy of your entire Manulife file will be sent to the members of the JIBRC committee (including the employer representatives). It is important to note that your personal medical information is kept in strict confidence and is not released outside of the members of the committee, including anywhere outside of the employer representatives of the committee. Information is NOT given to your local employer, Disability Accommodation Specialist (if applicable), or local union representative.

Frequently more medical information will be required for your appeal, and it will be requested. You may be asked to attend an Independent Medical Examination.

After all information available is gathered and if your claim remains denied, the OPSEU/SEFPO members of the committee will review to determine next steps, including whether there is merit to the appeal and if there is a chance of success if forwarded to CRS for review by an arbitrator. During these discussions, you will likely be asked to speak to the OPSEU/SEFPO members of the committee to confirm whether there is any outstanding information that can be gathered. They may discuss other options as well, such as accommodation requests, grievances, and in some cases may request that you return to work.

This publication contains general information and is intended as a reference only. It is not intended as a substitute for independent legal advice regarding your particular situation.

Appealing OPS Denied Benefit Claims
Appendix 5