Benefits

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

Insurance companies, through the employer and under a group insurance plan, offer extended health care benefits beyond what is provided under Government plans (e.g. OHIP and Assistive Devices Program).

Benefit coverage can vary greatly from plan to plan. You should review your collective agreement and your benefit booklet to determine what your coverage is. Every plan will have a list of exclusions. If you are unsure, you should contact the insurance company directly before you purchase any item.

If you are a new employee, confirm when you can start to use the benefits before purchasing any item.

In order for coverage to be extended to provide for a benefit you believe should be included, it will likely need to be negotiated with the Employer in a future round of bargaining. The key to negotiating any change to your Collective Agreement is mobilizing your membership around issues that are important to you, early and often.

Eligibility for Coverage

The health plan will be effective from the date selected by the employer and stated in the contract with the benefit carrier. Individual employees who are eligible under the plan will have their coverage effective as early as the date that a completed application (enrollment form) is received by the employer, provided that it is not received later than one month following the effective date upon which the employee would have normally become eligible.

If the application is later than one month, eligibility may be restricted until “evidence of insurability” satisfactory to the carrier is submitted and approved (medical evidence of good health). The general practice is to cover employees currently employed by the employer on the effective date of the plan. If the employee is not “actively at work” (e.g. on sick leave) on the date that coverage would have become effective, coverage may not begin until “active full-time employment” resumes.

Payments

Reimbursement or Pay Direct Plans

A pay direct plan pays the provider of the service directly (e.g. drug cards, paramedical providers or vision providers). Under a reimbursement plan, the employees must pay the health care expense and then claim reimbursement from the insurer for that service.

Deductibles

Many plans contain a type of cost-sharing called deductibles. A deductible is the flat dollar amount of expenses an employee must pay out before the insurance company will start paying. For example, if there is a $100 deductible per family for drugs, the family will pay the first $100 of drug expenses every year and then the Insurer will start to reimburse drug expenses.

Co-Insurance

A co-insurance feature provides a formula under which an employer’s health care costs will be shared with the employee. It is usually expressed in percentage terms (e.g. 10%, 20%, 50%). It is often found in health and dental plans. It may be used in combination with deductibles.

Maximums

This provision places a ceiling (a maximum) on amounts that may be claimed for medical or dental expenses by the employee. Most supplementary health and dental plans have one or more combinations of the maximum.

A maximum can be levied in three ways:

• annual – annual amount for total claims (e.g. $2000 per year)
• lifetime – lifetime limit (e.g. orthodontics $1500 maximum)
• frequency – a limit on use of service (e.g. 2 dental visits per year, number of times a drug can be dispensed)
• Reasonable & Customary (R&C) Maximum is the highest amount an insurance company will cover for a specific medical service based on industry standards.

Sometimes, there is an effort to reduce costs by limiting the frequency. An example of this is the insurance company paying for a routine dental checkup not more than every 9 months, instead of every 6 months.

Reasonable and Customary Maximums

Reasonable and customary describes the amount a group benefits provider (i.e. insurer) would expect a health, dental or extended health care provider to charge one of their members for a service. The insurance company establishes those amounts – considered a ‘realistic and expected’ charge for a service – as a starting point for settling claims.

Based on what that reasonable and customary amount is, the insurance provider then determines

how much of what a member is claiming will be covered, according to that member’s plan.

Expense amounts are subject to reasonable and customary limitations because fees across different geographical locations vary. In addition, some health care providers charge more than others for the same service, due to individual fee schedules.

Insurance companies adjudicate claims based on what they determine as the standard amount charged for a particular service, according to:

• the prevailing rate for that service provincially
• fee guides for a specific profession under its regulatory body (e.g., dental fee guide, medical association guide)

Pre-determination

It is recommended that you request a pre-determination from the insurance carrier for any item over $200, or if you are unsure that the benefit you wish to purchase will be covered. A predetermination of benefits is a form or letter that is sent from your medical or treatment provider to your insurer before undergoing treatment. Your insurer can review the proposed treatment and determine how much will be reimbursed by your plan.

How to do a Pre-Determination

• Gather your information (name, birthdate, insurance ID etc.)
• Identify the procedure or treatment (include detailed treatment plan and necessary documentation)
• Complete the pre-determination request form
• Submit the request to the insurance (via fax, email or insurance online portal)

Why should you request a predetermination of benefits?

Whenever you’re about to undergo new or expensive medical treatment or dental procedures, it’s a good idea to find out up front how much your treatment will cost, how much your insurance plan will cover, and whether you’ll have any out-of-pocket expenses.

Submitting a Predetermination of Benefits

To determine coverage in advance, submit a predetermination or claim form detailing the proposed treatments, tests, or necessary medical equipment to your insurance provider. They will typically respond with a statement outlining the expected reimbursement amounts.

How You Can Benefit

Submitting a predetermination of benefits notifies your insurer of your upcoming claim, streamlining the adjudication process. This can lead to a shorter waiting period and faster payments. Additionally, it helps you avoid unexpected out-of-pocket expenses.

Co-ordination of Benefits

Coordination of benefits is an important provision under extended healthcare contracts that allows you and your spouse to coordinate benefit payments under your respective health and dental plans, if each partner has elected family coverage.

For example, a drug benefit may provide only 80% coverage on your plan and your partner’s plan has similar coverage. You submit your claim to your insurer, and you will be reimbursed 80% of the eligible amount. Once you have received payment on the first amount, your partner submits the difference to their plan. The second plan will pay the lower of:

• The amount payable had it been the first plan; or,
• Up to 100% of the eligible expense less the amount paid by the other plan.

For parents who are cohabitating and/or married, dependents’ claims must be submitted by the parent whose birthday is closest to January 1 and then once the insurer has paid, the balance is submitted to the other parent’s insurer to recover the difference.

For other parenting arrangements, it’s best to check with your specific insurance plan for instructions on submission.

Types of Benefits

Drugs

Drug plans vary, and it is important to understand what you are covered for. Some drug plans use a formulary and will only pay for certain drugs. They may insist on the substitute use of generic drugs where available. Other plans may pay for any drug, so long as it has a Drug Identification Number, while other plans may only pay for drugs that legally require a prescription.

Most plans these days offer a drug card. When you have a drug card, you need only pay for the portion of your prescription that is not covered under your drug plan. Each plan varies depending on what is negotiated and can cover up to 100% of the drug cost or a lesser partial percentage and/or a deductible amount (i.e. $3 or $5 for each prescription).

Some drug plans may be “tiered” meaning that you must try older and/or less costly drugs and show that they don’t work for your medical condition before the plan will cover the newer and/or more costly drug available for the same condition. The insurance company may require that you get special authorization before they will pay for very costly medications. When in doubt about your coverage, it’s important to contact the insurance company to clarify what they will cover and under what circumstances.

Government assistance may be available in managing high drugs costs. Check the resources section of this sheet for more information.

Paramedical Services

A few examples of paramedical coverage for health care treatment include Chiropractors, Registered Massage Therapists, Physiotherapists, Osteopaths, Naturopaths, Psychologists and Dietitians. This is just a short list, and there are many other types of treatment providers that may be covered under your extended health care benefits. Payment may be claimed as a maximum amount per visit, a maximum per hour and/or a yearly maximum. Be sure to check your benefit booklet.

To be reimbursed for paramedical expenses under your plan it’s important to ensure that:

• the service is covered under your plan;
• the provider is someone who is licensed in the province in which they are practicing;
• the provider is practicing within the scope of their license;
• the receipt has the name, title, address, date of service and their registration number if applicable
• a copy of the referral (if required under your plan), AND
• Your insurance company hasn’t “delisted” the provider (see below for further information).

A Massage Therapist who is registered in British Columbia may not be eligible for reimbursement in Ontario. They would need to be registered with the Ontario College of Registered Massage Therapists to be reimbursed by the insurance company for treatment provided in Ontario. Ensuring that your treatment providers are licensed protects you as a consumer and ensures that the insurance company will not reject your claim for treatment.

Insurance companies from time to time, may investigate a provider and “delist” them. This is because this provider has allegedly been found by the insurance company to have inappropriate business practices (e.g. submitting improper claims, potential benefits abuse and/or disciplinary action by the regulatory body). If this happens, your insurance company will not pay and/or reimburse you for any services rendered by this provider. Therefore, it is imperative that you check the “delisted” providers list from your insurance company often, particularly before you visit a new provider, or one that you haven’t visited recently.

Some benefit plans may require a referral from your doctor for a service to be covered.

Durable Medical Equipment

Durable medical equipment are items like wheelchairs, crutches, hospital beds and other equipment that you may require to be mobile, or that may assist you in your activities of daily living. Your plan may only pay for rentals of this type of equipment or require pre-authorizations prior to purchase.

Given this type of equipment can be expensive it is best to check with your insurance company on what they will cover, and under what conditions. Surprisingly, many items’ doctors prescribe are not covered under insurance plans. The Provincial Government under the Assisted Devices Program may offer partial or full payments for some items. An explanation on how to access this program is given below.

Vision and Hearing Care

Vision care covers costs associated with a visual impairment, and plans may provide for some or all the following: eyeglasses, contact lenses; routine and special eye exams, laser surgery, glasses and lenses following cataract surgery and other eye related treatments and/or services.

Generally, eyeglasses that are not required to correct a visual impairment will not be reimbursed by a plan. A prescription will always be required. Some plans may allow for tinting of lenses (sunglasses) while others may not. Check your benefit booklet or with the insurer.

It’s useful to know that many benefit plans have “liberated” the benefits so that money allocated for eyeglasses/lenses/frames may be used towards laser eye surgery even if the plan itself does not cover this procedure. Check with your insurance company to find out.

Hearing care provides for hearing aids and sometimes, other assistive devices for the hearing impaired. Hearing aids may also partially covered under the Province of Ontario Assistive Devices Program.

Hospital

Most hospital expenses are covered by the Ontario Health Insurance Plan (OHIP). However, OHIP does not pay for semi-private or private rooms for acute care if they are not medically necessary.

Many plans, however, do provide coverage for either semi-private or private rooms at a partial or full subsidy. You will be responsible for the difference between the partial amount and the actual cost if you elect to use this benefit. You do not have to use the benefits and the hospital will not charge you, but you need to tell them at the time of admission. If you use this benefit, you may get a letter from the insurance company asking you to verify that you utilized a semi-private or private room before they pay the hospital for the service.

Nursing Services

To be covered for nursing services, you must show that the requested services can only be performed by a licensed nurse. Insurance companies will not pay for nurses to be used as caregivers.

You are usually required to get pre-approval for these services before the insurance company will reimburse for them. It is best to get a medical note from a physician confirming the need for the service and to what level, when making the request. The insurer can approve and, in some cases, pay for the services directly to the nursing agency.

Orthotics and Orthopedic Shoes

Usually custom-made orthotics and/or orthopedic shoes will require a prescription from your doctor. In order to be eligible, they will need to address a foot problem (i.e. they need to be medically necessary). Off the shelf shoes and orthotics, or shoes specifically purchased to fit orthotics are not usually eligible for reimbursement. However, costs for some off the shelf orthopedic shoes may be reimbursed if they have been specifically modified for your foot.

Orthopedic shoes are an area of concern for both insured members and insurers these days because of wide-spread insurance fraud. To address this, insurance companies are now seeking a lot of information about the shoe and/or medical condition prior to approving payment. Many claims are being rejected.

It is also important that you review what is required to be reimbursed. If you require a prescription, ensure you are attending the correct specialist for that prescription, and that they have examined you and diagnosed the condition that the equipment will be correcting. In addition, before purchasing ensure that the cost of the shoes/orthotics is reasonable. Sometimes a provider may ask you what your insurance will cover and then charge you that amount. This can be greatly inflated, and you will only be reimbursed for the usual (reasonable) and customary charge.

Play it safe! Get a predetermination in writing prior to purchasing orthopedic shoes or orthotics. Contact your insurer to find out how to do this. Do not rely on your benefit plan booklet or the provider for the information on what your plan will cover.

Out of Province / Country Coverage

Some plans offer coverage for out-of-province/country travel. Carefully review your coverage before you travel, and if your plan has low maximums, co-payments, matches what OHIP pays or the like, buy additional travel insurance. Taking a trip without this insurance could be a very costly and possibly the worst decision you ever make.

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 support 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.

Resources

Government Sponsored Programs to Help with Medical Costs

Generally, to be eligible for any of the services, you must live in Ontario and have a valid Ontario Health Card (OHIP). In some cases, further conditions apply.

Assistive Devices Program (ADP)

The Assistive Devices Program (ADP) helps cover the cost of specialized supplies and equipment. ADP covers over 8,000 separate pieces of equipment or supplies in the following categories:

• prostheses;
• wheelchairs/mobility aids and specialized seating systems;
• enteral feeding supplies;
• monitors and test strips for insulin-dependent diabetics (through an agreement with the Canadian Diabetes Association);
• hearing aids;
• insulin pumps, continuous glucose monitor and related supplies for those with Type 1 Diabetes who meet certain eligibility criteria;
• respiratory equipment;
• orthoses (braces, garments and pumps);
• visual and communication aids;
• oxygen and oxygen delivery equipment, such as concentrators, cylinders, liquid systems and related supplies, such as masks and tubing.

ADP pays up to 75 per cent of the cost of equipment, such as artificial limbs, orthopedic braces, wheelchairs and breathing aids. For others (for example, hearing devices) the ADP contributes 75% up to a maximum amount. In most cases, the client pays a share of the cost at time of purchase and the vendor bills ADP the balance. For device categories, such as ostomy supplies, breast prostheses, insulin syringes for seniors, and enteral feeding pump & supplies, the ADP pays a grant directly to the person to contribute towards the purchase of eligible devices and/or supplies from any retailer that sells these products.

For ADP clients receiving social assistance benefits through Ontario Works (OW), Ontario Disability Support Program (ODSP) or Assistance to Children with Severe Disabilities (ACSD), the ADP will pay 100% of the ADP-approved price or maximum amount.

In most cases, the client pays a share of the cost at time of purchase and the vendor bills ADP the balance.

For ADP supply categories where grants are paid, the client pays 100 per cent of the cost to the vendor.

There are many sources of funding for the client’s share of the cost including clients, voluntary/charitable organizations e.g. March of Dimes, The Easter Seals Society, Kiwanis, Lions Clubs, social assistance, Department of Veteran Affairs and insurance companies.

Eligibility includes any Ontario resident who has a valid OHIP card issued in their name and has a physical disability of six months or longer. Equipment cannot be required exclusively for sports, work or school. ADP does not pay for equipment available under the Workplace Safety and Insurance Board or to Group “A” veterans for their pensioned benefits. There are specific eligibility criteria which apply to each device category.

An individual who has a chronic illness or dysfunction that requires long-term oxygen therapy may be eligible for home oxygen funding.

For more information:

Ministry of Health and Long-Term Care Assistive Devices Program

• 7th Floor, 5700 Yonge Street Toronto, ON M2M 4K5
• 416-327-8804, Toll-free 1-800-268-6021, TDD/TTY 416-327-4282 or 1-800-387-5559
• Fax 416-327-8192
• e-mail: [email protected]
• website: https://www.ontario.ca/page/assistive-devices-program

Trillium Drug Program

Is available to people who live in Ontario who have high prescription drug costs compared to their household income. The Trillium program will cover the full cost of prescription medication until the end of the program year, once you hit the maximum spend threshold. To receive funding through the program, you will be required to pay a deductible equivalent to 4% of your net income (this is the maximum spend threshold). Once you have paid the deductible, your Trillium Drug program coverage begins and you will only pay up to $2 for each drug that is filled or refilled until the end of the program year. The deductible payment is split into 4 payments made quarterly. Once you have paid your deductible for the 3-month period, the Trillium program will pay the rest of your medication costs for that period.

You can apply to Trillium if:

• You live Ontario
• Have a valid Ontario health card number
• Do not already qualify for the Ontario Drug Benefit Program
• Do not have an insurance plan that pays for 100% of your drugs
• Spend about 4% or more of your after-tax household income on prescription-drug costs

OHIP+

Provides coverage for more than 5,000 drug products that are currently available through the Ontario Drug Benefit program to anyone 24 years and under who has OHIP coverage and is not covered by a private plan. Enrolment is not required as access is automatically granted. Coverage stops on the child’s 25th birthday or if your child becomes covered by a private plan.

Patient Assistance Programs

Many pharmaceutical companies offer patient assistance programs (PAPs). PAPs are available to patients who despite their insurance coverage, are unable to afford the out-of-pocket costs for medications. These programs will typically reduce or offset the out-of-pocket costs as those costs will be paid by the drug manufacturer.

What to do if you are denied a benefit by the Insurance Company?

Reasons for a denial will be outlined in the predetermination or explanation of benefits from the insurer and can include:

• Insufficient documentation was submitted
• There is no coverage under your plan for the type of benefit you are requesting
• You have already reached your maximum allowed – yearly or lifetime

You should call the insurer and inquire why you were denied and if there is any additional information you need to submit that would allow the claim. Keep copies of all paperwork you submit and receive from your insurer. You may need this documentation later on if there is a dispute.

If the insurer maintains the denial and no further documentation will assist, then contact your employer and/or local union representative to confirm your coverage, and if the claim was correctly denied.

OPSEU/SEFPO does not represent members in appeals for extended health care benefits unless there is a formal Joint Insurance Committee in place through your collective agreement. You may have the option to grieve denial of your extended health care benefits. You should refer to your collective agreement and/or contact your local representative.

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

Dental benefits that are provided through the employer and under a group insurance program, are usually reimbursed according to the Ontario Dental Association’s (ODA) suggested fee guide for general practitioners. Some dental benefit plans may have a lag in the year of the ODA Fee Guide on which they will pay. For instance, if the year is 2025, and a plan has a 1-year lag, dental expenses will be paid based on the ODA Fee Guide that was in effect for 2024. You will be responsible for the difference.

Coverage for dental services can vary greatly from plan to plan. Dental benefit services can generally be broken down into three different categories:

Basic Services

While every plan is different, basic services are usually reimbursed at a higher rate than major services or orthodontics. A typical plan will cover anywhere from 75-100% of costs for Basic Services.

Examples of Basic Services:

• Oral examinations such as initial, recall and emergency exams
• X-rays, fillings, polishing/cleaning and topical fluoride treatment (fluoride is sometimes limited to children)
• Diagnostic testing
• Retentive pins
• Extraction of teeth
• Endodontics, periodontics and oral surgery

Major Services

While every plan is different (not all plans cover major services). Major Services are usually covered at a lower rate than Basic Services. If a plan covers Major Services, it will typically reimburse anywhere from 50-75% of Major Services costs.

Examples of Major Services:

• Dentures, partial dentures, complete dentures, lab fees and repairs
• Bridges and repairs to bridges
• Crowns and repairs to crowns

• Inlays and onlays
• Pins in inlays, onlays and crowns
• Post and core

Orthodontics

Some dental plans do not cover orthodontics. When a dental plan does provide for orthodontic coverage, it is often for children up to the age of 18 (sometimes longer); coverage for adults is sometimes seen, but more often coverage is provided for children only. Reimbursement can range 40-75%. This benefit will usually have its own yearly or lifetime maximum that is separate and apart from Basic and/or Major Services.

Examples of Orthodontic Services:

• Diagnostic services, orthodontic cast, observation & adjustment, repairs, alterations, re-cementations
• Fixed bilateral/unilateral or removable orthodontic appliances
• Appliances to control oral habits

It is important to note, that most plans will also have provisions that will only allow reimbursement over a period of time (usually the length of the treatment plan suggested by the orthodontist). Insurers will often only pay up to 30% up front. Even if the provider offers a discount to pay via lump sum, it is important to note that you will only be reimbursed a maximum amount and that will be reimbursed over time, even if you pay in a lump.

In every instance, get a pre-determination!

Be sure of what your dental plan will pay – Get a predetermination!

Before you undertake any significant dental work, it is imperative to seek a predetermination. A predetermination is a way of getting a commitment from the insurance company of what they will pay, before you get the work done.

You can ask your dentist to request a predetermination before any major dental work. They will send a treatment plan to the insurance company. The insurance company will then assess the proposed course of dental treatment and provide an estimate of what will be reimbursed under the dental plan.

By submitting a predetermination, you can avoid any unpleasant surprises with respect to your dental coverage and be assured of payment.

Insurance companies will often allow for direct electronic payment to your dentist, so that you need only pay the outstanding amount. However, it is up to the dental office as to whether they accept this form of payment; therefore it is important to ask this question prior to your appointment so there are no surprises.

What to do if you are denied a dental benefit by the insurance company?

Reasons for a denial will be outlined in the predetermination or explanation of benefits from the insurer and can include:

• Insufficient documentation was submitted
• There is no coverage under your plan for the type of benefit you are requesting
• You have already reached your maximum allowed – yearly or lifetime

You should call the dental insurer and inquire why you were denied and if there is any additional information you could submit that would allow the claim. Keep copies of all paperwork you submit and receive from your dental insurer. You may need this documentation later if there is a dispute.

If the insurer maintains the denial and no further documentation will assist, then contact your employer and/or local union representative to confirm your coverage, and if the claim was correctly denied.

OPSEU/SEFPO does not represent members in appeals for dental benefits unless there is a formal Joint Insurance Committee in place through your Collective Agreement. You may have the option to grieve denial of your extended health care benefits. You should refer to your collective agreement and/or contact your local representative to confirm.

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 support 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.

If you wish to contact the Pensions and Benefits unit, please email us at [email protected]

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

Most employers offer some type of group life insurance benefits. Dependent on the insurance policy, the life insurance can allow for separate coverage for the member, spouse and dependents. Life insurance benefits can be paid as a lump sum amount or have a formula (i.e., one, two- or three-times salary).

At the time of hire or when you become eligible, your employer should provide you with information on what group life insurance is available. You will need to decide how much coverage you want, generally within 31 days. If you have a change in your life circumstances (e.g. change in marital status or new dependents), you generally need to tell the employer within 31 days of the event. If you wish to add additional coverage after that date, you may have to provide evidence of insurability (i.e. medical evidence) for any additional coverage. Depending on the wording of your Collective Agreement, the employer may pay all or some part of the life insurance premium. The employer submits the life insurance premium every month to the insurer and collects any payments made by the employee by payroll deduction. You cannot increase your life insurance coverage amount if you are in receipt of long-term disability benefits (sometimes known as LTD or LTIP). The insurance company will often waive the premium for your life insurance while you are receiving LTD and your life insurance coverage continues. However, if you paid life insurance premiums for supplementary life insurance coverage through payroll deduction, you may have to continue the payments to the employer, while on LTD/LTIP.

Taxes and Life Insurance

If the employer pays premiums for your life insurance, those premiums are considered taxable income by Canada Revenue Agency. This means that the amount paid by your employer will be added to your taxable income on your annual T4 slip and you will be required to pay tax on it.

Life insurance payments to your beneficiary or beneficiaries are not considered taxable income.

Naming Beneficiaries

It’s important to designate a beneficiary, and you can name more than one beneficiary for your life insurance. You must put the request in writing, and the employer will ask you to complete a form which will allow you to list one or more beneficiaries. If you wish to change a beneficiary, it must be in writing to the employer, and you should request a written acknowledgement that the change has been done. If you are not sure who you have listed, contact the employer. The employer informs the insurer of the change. In the Province of Quebec, spousal beneficiary designations are non-revocable.

There can be significant tax consequences if you fail to designate a beneficiary, or you designate your estate as the beneficiary. If the money is paid to the estate, it will be subject to federal and provincial tax along with inheritance tax where applicable. Thus, it is important to ensure that a beneficiary is named and reviewed periodically as circumstances change over time.

Your executor should be aware that life insurance information is available from your employer and how to contact them in the event of your death.

Conversion Option

Most group life insurance policies have a conversion option. This means that the group life policy can be converted at the time of termination from the employer to an individual life insurance policy, without evidence of insurability (good health). This can be important for someone who is in poor health when they are leaving their employer.

If you are losing your life insurance at the time of termination of employment, and are healthy and under age 65, it is a worthwhile endeavour to shop around and see if you can obtain life insurance at a cheaper rate. However, you will need to show evidence of good health and that you are insurable. It is important to do this quickly however as there is usually a deadline (often 31 days) to apply to convert your life insurance.

Insurers will provide you the information on premiums rates to continue coverage at the same or lesser insurance coverage. You elect the coverage and pay the premium directly to the insurer. Your coverage will stop when you stop paying premiums. You will also need to list your beneficiary with the insurer when you complete the insurance application for the individual insurance policy.

Terminal Illness and Your Life Insurance

Some life insurance companies will allow a person covered under a group life insurance plan, an advance on a portion of their life insurance benefits if they are diagnosed by a physician as having less than one or two years to live. To determine if this is an option available for your life insurance, ask your Employer or the insurance company for information.

Other types of insurance

Critical Illness Insurance

Critical Illness Insurance allows for a lump sum payout (after an application by the insured individual with supporting medical documentation and approval process by the insurer) if the insured member is diagnosed with a critical illness such as cancer, stroke or heart attack. Critical illness is used to help offset the cost of the surviving a serious illness whereas terminal illness is an advance on the insured’s life insurance.

Accidental Death and Dismemberment (AD and D) Insurance

You may have this workplace insurance coverage with or without other life insurance. Accidental Death and Dismemberment Insurance allows for a lump sum payment (after an application by the insured individual with supporting medical documentation and approval process by the insurer) due to an accidental physical loss (or loss of use) of a body part, or death. There is normally a schedule for what amount would be paid for a physical loss.

Insurance Tips

• Determine your coverage when you first become eligible and consider what the maximum amount of coverage you want. It can be difficult to add additional coverage later without being subject to proof of good health.
• List your beneficiary and review it periodically. Any changes need to be in writing; keep a copy of the change.
• If you are not sure of your coverage, contact your employer human resources contact.
• If you want to add your spouse or dependent on to your insurance, you need to do it generally with 31 days of the life event (e.g. marriage or birth) and inform your employer in writing.
• At the time of termination of employer, explore the conversion option to see if you wish to continue coverage.

This is general information and is intended as a reference only. It is not a substitute for independent legal advice regarding your situation. Download a printable PDF.

What type of insured benefits does the LCBO provide?

Depending on your employment status with the LCBO, the following benefits may be available to you:

• Supplementary Health and Hospital
• Dental
• Long Term Income Protection (LTIP)
• Life Insurance (including Basic, Supplementary and Dependent Life Insurance)
• Accidental Death & Dismemberment (AD&D)

The LCBO benefit booklet outlines the different benefits that you are eligible for. Benefit coverage differs depending on your employment status.

What if I am denied an insured benefit by the insurer?

If you have submitted a claim to the insurer and were denied a benefit that you believe is covered under your plan, you can dispute the claim.

The first step is to contact the insurer directly and discuss why the claim was denied and what information may need to be submitted to have the claim accepted. Make sure you keep a record of the date, time and the name of the Customer Service Representative you spoke with. If the insurer has suggested some additional information that may help to have your claim paid, submit the extra information. Sometimes, submitting additional information directly to the insurance carrier may resolve the problem.

If the denial remains and you still believe that your benefit claim should have been paid, discuss your complaint with your employer benefits administrator.

OPSEU/SEFPO staff can provide education, guidance and resources to you in an appeal. We can assist by reviewing the claim denial and potentially intervene in attempting to resolve the dispute with the carrier (this includes helping you appeal a Long-Term Disability denial). To do this you will need to send all of the documentation you have regarding your claim denial (copies of receipts, copies of the denial from the insurer, supporting documentation from your doctor, if applicable and any other information related to your claim) along with an explanation of the re

Members receiving a denial decision regarding their LTIP claim are strongly advised to contact our office immediately so that the appeal process can begin without delay. There are strict timelines for filing an appeal.

OPSEU/SEFPO – Pension & Benefits Unit

• Email: [email protected]
• Mail: 5757 Coopers Ave Mississauga ON L4Z 1R9
• Fax: (905) 712-3009, Telephone: (416) 443-8888, Toll Free: 1-800-268-7376

Before incurring any expense greater than $200, it is strongly recommended that you submit a pre-determination. A pre-determination is an estimate of how much of your claim will be paid, prior to the service being completed. This will give you an idea of the amount that will be reimbursed to you thereby avoiding disappointing surprises. To submit a pre-determination, ask for an “estimate” of the cost from your medical provider, then submit the information to the insurer for review.

In any interaction with the insurer, make sure you record who you spoke with, the date and time of the call and the outcome.

If you have questions or concerns regarding your benefit plan, the Pensions & Benefits Committee can provide guidance.

The LBED Pensions and Benefits Committee members are:

• Stephanie Hickman (Chair)
• Lee Hamilton
• Trisha Harrison
• Jacqueline Rigitano (OPSEU/SEFPO Benefits Officer)

If you wish to contact the Pensions and Benefits unit, please email us at [email protected]

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

What insured benefits can I appeal?

• Supplementary Health and Hospital Insurance (SH&H)
• Dental
• Long Term Income Protection (LTIP)
• Group Life Insurance (including Basic, Supplementary and Dependent Life Insurance)
• Out of Country claims under the optional “upgrade” offered
• All benefits negotiated by the Union under the Group Insurance Plan.

Should you have any trouble/denials with the group insurance plans you may be able to appeal. Please contact us to discuss your situation.

Why would I want to appeal an Insured Benefit claim that is denied?

• If you believe your claim has been improperly denied, an appeal will seek reimbursement for money you paid out or are entitled to.
• Appeals can help the Union identify and strategize how to improve benefit deficiencies in bargaining.

How can I appeal claims for denied insured benefits?

OPS (Ontario Public Service) Members represented by OPSEU/SEFPO can appeal benefit denials through the Joint Insurance Benefits Review Committee (JIBRC).

The JIBRC is comprised of OPSEU/SEFPO members:

• Co-Chair and representative of the First Vice President’s office – Melissa Penner
• Corrections Representatives – Peter Figliola and Paula Van Dusen
• Unified Representatives – Chris Eckert and Jamie Tynan-Byrd-Owen.
• Staff: Isabella Calandrino, A/Benefits Officer (OPSEU/SEFPO) and Jacqueline Rigitano, Benefits Officer (OPSEU/SEFPO);
• Employer representatives from Treasury Board Secretariat.

How do I commence an appeal to the JIBRC Committee?

First, discuss your complaint with the insurance carrier, your employer and the Union when you become aware of the denial by the insurance carrier. Sometimes, submitting additional information directly to the insurance carrier may resolve the benefit denial.

If the complaint is not satisfactorily resolved, forward your appeal request to the Joint Insurance Benefits Review Committee by email, mail, or fax. In your appeal request please provide 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.

The Joint Insurance Benefits Review Committee will review your claim, to determine if there is legitimacy to the claim and attempt to resolve your appeal. OPSEU/SEFPO members act as your advocate in the Committee meetings. All information submitted to the JIBRC is confidential.

If the appeal cannot be resolved at the Committee level, the appeal can be referred to the Claims Review Subcommittee (CRS). If your claim is referred to CRS, it will be heard by designated arbitrators who will make a final binding decision.

OPSEU/SEFPO Joint Insurance Benefit Review Committee

• OPS 5757 Coopers Avenue, Mississauga, Ontario L4Z 1R9
• Email:   [email protected]
• Telephone: (416) 443-8888 or 1-800-268-7376
• Fax: (905) 712-3009

Please note that an appeal cannot be filed for something that is a bargaining issue. For example, there is no coverage for medical cannabis. While we know and understand that this is something that members may desire to have coverage for, because there is no coverage provided by the Collective Agreement, coverage, even for compassionate reasons, cannot be garnered via an appeal.

I’ve filed an appeal through JIBRC, 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. There is no cost to OPS members to appeal via JIBRC.

You will be updated on the progress of your appeal by OPSEU/SEFPO staff throughout the process.

Information specific for LTIP Appeals:

Once you have filed an LTIP appeal, you should contact your local employer (and your local union representative) to advise them you have filed an appeal through JIBRC. Request a leave of absence as you are not able to return to work. 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) to review Manulife’s decision and determine how to proceed.

Your personal medical information is kept in strict confidence. Your medical information is not released outside of the union and employer members of the committee. Medical information is NOT given to your local employer, Disability Accommodation Specialist (DAS), if applicable, or local union representative.

Often, more medical information will be required to support 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 contains general information and is intended as a reference only. It is not a substitute for independent legal advice regarding your situation. Printable PDF

What is the Joint Insurance Committee?

The Joint Insurance Committee (JIC) is composed of OPSEU/SEFPO union representatives, employer representatives, and the College Employer Council (CEC). The JIC meets monthly to review claim complaints and attempts to resolve them. OPSEU/SEFPO, as your advocate, takes an active role in the Committee meetings.

Who are my Joint Insurance Committee Union Representatives?

• Landyn Blais, Local 415, Algonquin College
• Heather Giardine-Tuck, Local 240, Mohawk College
• Henry Lowi, Local 562, Humber College
• Maria Vasilodimitrakis, Local 560, Seneca College
• OPSEU/SEFPO Staff Resource Luc-Joel Ciza

What if I am denied an insured benefit by the insurer?

If you have submitted a claim to Sun Life and were denied a benefit that you believe is covered under your plan, you can appeal the claim decision. It is important to consider appealing a denied claim as claims can be improperly denied and an appeal may rectify the decision. It is also important to consider appealing a denied claim in that claims that are denied today may highlight important benefits issues that may inform demands for future rounds of bargaining.

You can appeal the denial through the Union representatives of the JIC. The first step is to raise your complaint with Sun Life (through phone call, email or discussion), the College Benefit Administrator at your College and your Local Union, as soon as you are made aware of the denial of benefits by Sun Life. In some cases, submitting additional information directly to Sun Life may resolve the complaint.

If the complaint is not satisfactorily resolved, contact one of the Union representatives of the JIC so they can advocate for you. It is essential that you provide your contact information and any written documentation about what you want to appeal, such as a copy of the denial letter from Sun Life and any notes or reports from your dentist or doctor.

Send your completed appeals package including the authorization form to a Union representative of the JIC or to Luc Ciza, Benefits Officer with OPSEU/SEFPO:

• Attn: Luc Ciza, Benefits Officer OPSEU/SEFPO
• Pension and Benefits Unit 5757 Coopers Ave, Mississauga ON L4Z 1R9 Fax: (905) 712-3009
• Email: [email protected]

All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health care providers, and the committee.

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 approaching, the seeds have already been planted and you’ll ideally already have the support necessary to achieve 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.

If you wish to contact the Pensions and Benefits unit, please email us at [email protected].

Appealing a Benefit Claim Denial

Every month the CAAT Academic Joint Insurance Committee (JIC) reviews cases where decisions made by Sun Life resulted in claim denials the Extended Health, Dental, Long Term Disability, Life Insurance (including Basic, Supplementary, Supplementary Spousal and Dependent) and Critical Illness plans.  When, in our analysis, we believe that an error, omission, or unfair decision was made in a claim, we advocate on behalf of members to have the claim reviewed and the decisions reversed so members receive appropriate benefit payments.

Issues that arise and persist are brought forth to the Divisional Executive to be included in the demand setting process.

Why would I want to appeal a claim that has been denied?

• Your claim may have been improperly denied (it happens more often than you think).
• Claims that are denied today may highlight important future bargaining demands.

How can I appeal claims for denied Insured Benefits?

You can appeal the denial through the Union members of the Joint Insurance Committee (JIC).  The JIC is composed of OPSEU/SEFPO representatives, employer representatives, and the College Employer Council. Sun Life representatives also attend.

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

• First, make certain (through phone call, email or discussion) to note your complaint with Sun Life, the College Benefit Administrator at your College and your Local Union, when you become aware of the denial of benefits by Sun Life. Sometimes submitting additional information directly to Sun Life will resolve the problem.
• If the complaint is not satisfactorily resolved, contact one of the members of the Joint Insurance Committee so that they can advocate for you. It is essential that you provide your contact information and any written documentation about what you want to appeal, such as a copy of the denial from Sun Life and the signed Authorization form (attached), and any notes or reports from your dentist or doctor.
• Complete the authorization and send it, along with your documentation to your JIC advocate or to Luc-Joel Ciza, Benefits Officer. Luc-Joel works in the Pension and Benefits Unit at OPSEU – 5757 Coopers Avenue, Mississauga, Ontario L4Z 1R9 Fax: (905) 712-3009.

All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health providers and the committee.

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

What is the Joint Insurance Committee?

The Joint Insurance Committee (JIC) is composed of OPSEU/SEFPO union representatives, employer representatives, and the College Employer Council (CEC). The JIC meets monthly to review claim complaints and attempts to resolve them. OPSEU/SEFPO, as your advocate, takes an active role in the Committee meetings.

Who are my Joint Insurance Committee Union Representatives?

• Dan Brisson, Local 672, Collège Boréal
• XiaoYan Wang, Local 561, Seneca College
• Laura Carcelen, Local 137, St. Clair College
• Owen Smith, Local 731, Confederation College
• OPSEU/SEFPO Staff Resource, Luc-Joel Ciza

What if I am denied an insured benefit by the insurer?

If you have submitted a claim to Sun Life and were denied a benefit that you believe is covered under your plan, you can appeal the claim decision. It is important to consider appealing a denied claim as claims can be improperly denied and an appeal may rectify the decision. It is also important to consider appealing a denied claim in that claims that are denied today may highlight important benefits issues that may inform demands for future rounds of bargaining.

You can appeal the denial through the Union representatives of the JIC. The first step is to raise your complaint with Sun Life (through phone call, email or discussion), the College Benefit Administrator at your College and your Local Union, as soon as you are made aware of the denial of benefits by Sun Life. In some cases, submitting additional information directly to Sun Life may resolve the complaint.

If the complaint is not satisfactorily resolved, contact one of the Union representatives of the JIC so they can advocate for you. It is essential that you provide your contact information and any written

documentation about what you want to appeal, such as a copy of the denial letter from Sun Life and any notes or reports from your dentist or doctor.

Send your completed appeals package including the authorization form to a Union representative of the JIC or to Luc Ciza, Benefits Officer with OPSEU/SEFPO:

Attn: Luc Ciza, Benefits Officer OPSEU/SEFPO

• Pension & Benefits Unit 5757 Coopers Ave
• Mississauga ON L4Z 1R9 Fax: (905) 712-3009
• Email: [email protected]

All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health care providers, and the committee.

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 support 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.

If you wish to contact the Pension & Benefits unit, please email us at [email protected].

PDF version of Reporting and Filing Workplace Accidents – WSIB Fact Sheet 1

When Should You Report an Accident/Injury/Illness?

A work-related accident/injury/illness should be reported immediately. If that is not possible, it should be reported to your supervisor before leaving the workplace on the date of injury. Accidents must be reported to the Workplace Safety and Insurance Board (WSIB) no later than 6 months from the date of the accident.

Occupational illness must be reported no later than 6 months from when the member learns that they suffer an occupational illness.

If there is any doubt whether your injury/illness is work related, file a claim immediately. Workers who do not report workplace accidents may lose the protection of the Workplace Safety and Insurance Act. Some of those protections may include health care, loss of earnings payments and the obligation to re-employ the injured worker.

The WSIB is an independent agency who determines whether an accident/injury is work-related and if benefits (health care treatment, loss of earnings) will be granted to the worker. Decisions made by the WSIB to deny entitlement can be appealed. Please see WSIB Fact Sheet # 2 Appealing a Workplace Safety and Insurance Board Decision for more information on the appeal process.

Forms that Initiate a Claim

• Form 7
• Form 8

Filing a Claim with the Workplace Safety and Insurance Board

Once you have reported the accident to the employer, the employer must report it to the WSIB if, due to the accident or injury, you:

• Require health care
• Are absent from regular work
• Earn less than regular pay for regular work (e.g., part-time hours)
• Require modified work at less than regular pay
• Require modified work at regular pay for more than seven calendar days following the day of the accident

The WSIB defines healthcare as services requiring the professional skills of a health care practitioner (e.g., doctor, nurse, nurse practitioner, chiropractor, physiotherapist, hospital and health care facilities, prescriptions, etc.).

If the employer is required to report your accident to the WSIB, they must complete and submit the WSIB Form 7, Employer’s Report of Injury/Disease, within 3 working days of the date the accident was reported. The employer is required to give you a copy of this completed form. The employer does not have to report the accident to the WSIB if only first aid was given and/or the worker required modified work for less than 7 calendar days. However, the employer must keep records of the accident.

If you lose time from work on the day of the accident, the employer must pay your wages for that day. Also, the employer must permit you to seek medical attention from a health care professional and pay for the cost of transportation to the health care facility. This can include a walk-in clinic, the hospital, your doctor, or other health care professional treatment centre.

When an injured worker seeks medical attention for an injury, the worker’s treating health care professional is obligated to complete and submit a Form 8, Healthcare Professional’s Report. This is the reporting of the accident based upon medical examination of the injured worker. If, for some reason, the Form 6 or 7 does not get filed, Form 8 will also trigger the start of a WSIB claim. In other words, the submission of one of these forms will initiate a WSIB claim. In Form 8 the first page contains the diagnosis and general information and the second contains the member’s functional abilities. The Form 8 will be sent to WSIB by your doctor. Since the form contains the member’s functional abilities, it must be shared with the member’s employer. The employer may still request that the worker have a Functional Abilities Form (FAF) completed by their health care professional from time to time. If employers are using their own FAF forms the employer must pay the health professional directly for completing that form.

Worker’s Consent to Release Functional Abilities

Every injured worker is obligated to consent to the release of functional abilities information. Functional abilities information is information regarding what the member can and cannot physically do (e.g., no lifting, no standing longer than 15 minutes, etc.). The information is provided to employers and is used to assess whether a member can return to their regular job, or if accommodations are needed. If the worker does not sign the consent, the WSIB may not approve their claim for benefits.

Consent can be given in the following ways:

• Signing a section at the bottom of Form 6
• Signing a section at the bottom of Form 7
• Signing the health professional completed Form 8
• In some cases, by signing a Functional Abilities Form (FAF)

An FAF may be given to the injured worker by the employer for completion by the member’s health professional. If the WSIB requests the FAF form be completed, they pay the cost for completion.

Your employer is only entitled to functional abilities information as it relates to your workplace accident/injury. Employers should not have unlimited access to an injured member’s medical history and injured members should not grant an employer open-ended access to medical information. There is no limit to the number of times a request for functional abilities can be made.

Obligation to Cooperate in the Work Reintegration Process

The Workplace Safety and Insurance Act sets out the responsibilities of the member and employer in the Work Reintegration process. Both parties are required to contact one another as soon as possible after an accident or injury occurs and maintain communication throughout the period of the worker’s recovery or impairment.

Employers must attempt to provide suitable employment that is available and consistent with a member’s functional abilities. Members must assist the employer as required or requested to identify suitable work that is available, consistent and within the member’s functional abilities. Your OPSEU/SEFPO Local can assist in this process if requested. For more information refer to WSIB Fact Sheet # 4 Return to Work.

If you need help with reporting and filing your WSIB claim, contact your Local union or your worker health and safety representatives.

Contact Us

To contact the OPSEU/SEFPO Worker Safety Unit:

Email: [email protected]

Call: 1-800-268-7376

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

PDF version of Appealing a Workplace Safety and Insurance Decision – WSIB Fact Sheet 2

If the Workplace Safety and Insurance Board (WSIB) denies or terminates your claim and you do not agree with the decision, you have the right to appeal. There are appeal time limits that NEED to be met according to the issue under dispute.

• Failure to meet the appeal deadlines may prevent you from proceeding with your appeal.

What Are the Appeal Time Limits?

The time limits to appeal a written WSIB decision should be indicated within the letter and are calculated using the date of that decision. The time limits to appeal are:

• 30 days for return-to-work disputes
• 6 months for all other appeals

How Do You Appeal a WSIB decision?

When you receive a decision from the WSIB decision maker that you do not agree with, you must complete and submit the WSIB Intent to Object Form (ITO). This form is available from the WSIB website at https://www.wsib.ca/en/forms#Object. Members can also call or write the WSIB to request the form and they will forward a blank copy. While we recommend that you complete and submit the WSIB ITO, you can also send a letter explaining what decision you are objecting to and your reasoning why.

• Failure to submit your objection within the prescribed time limits may result in a loss of the right to appeal the decision.

A decision letter may contain multiple decisions on more than one issue. You should indicate the issue(s) you are objecting to and clearly indicate the date of the decision letter that addresses that issue. If you disagree with decisions made in more than one claim, you must submit an Intent to Object Form under each claim in order to meet the objection time limits. When completed, the ITO should be faxed, uploaded online, or mailed directly to the WSIB. Follow up with the decision maker prior to the appeal deadline to confirm receipt of your completed ITO form.

Upon receipt, the WSIB will review the objection and reconsider their decision if any new information is provided. The decision maker may confirm, amend, or revoke the decision. The WSIB will advise you of the outcome of their review. If the decision to deny remains unchanged, you will be sent a copy of your WSIB claim file with a new form called the Appeal Readiness Form.

The Appeal Readiness Form should only be submitted when the decision maker at the WSIB operations level has considered all the information related to the issue(s) under dispute and you are ready to proceed to a hearing at the Appeals Services Division (ASD). It is recommended that you seek advice and/or assistance from a representative prior to submitting the Appeal Readiness Form.

• OPSEU/SEFPO cannot go on record as your representative until we have reviewed your file and the Retainer is completed.

If OPSEU/SEFPO agrees to represent you in your appeal, you agree to the Retainer, have signed and sent it back to OPSEU/SEFPO, the OPSEU/SEFPO representative will complete and submit the Appeal Readiness Form on your behalf. Please refer to WSIB Fact Sheet # 3 WSIB Appeals Assistance for more information.

The Appeals Readiness Form will require you to indicate your preferred method of resolution (Hearing in Writing or Oral Hearing). If you request an oral hearing, you may need to provide reasons why you think one is necessary. The method of hearing will be determined by the Appeals Services Division (ASD) staff, and you will be advised of their decision. The decision to deny an oral hearing cannot be appealed. Since the COVID-19 pandemic of March 2020 and resulting suspension of in-person hearings both the WSIB and WSIAT have offered hearings via teleconference or video conference. These options continue to be available.

If the ASD decides an oral hearing is necessary, they will attempt to schedule one to be held within 90 calendar days after they confirm the oral hearing is required. Therefore, it is imperative that you are ready to proceed when the form is submitted.

If the ASD decides that your hearing will be dealt with in writing, you will be sent a letter and asked to forward any written submissions within 30 days (plus 5 days for mailing). The file will be forwarded to an Appeals Resolution Officer (ARO), and a written decision will be made based on the information on file and any additional submissions made within the deadline.

The ARO will either allow the appeal or uphold the original decision. You will receive the Appeals Resolution Officer’s decision in writing. This final WSIB decision can be appealed to the Workplace Safety and Insurance Appeals Tribunal (WSIAT).

How Do I Appeal to the Workplace Safety and Insurance Appeals Tribunal?

The final level of appeal takes place at the WSIAT. You must complete the Notice of Appeal form and submit it to the WSIAT within 6 months of the date of the final WSIB ARO decision. The ARO decision must also be attached to the Notice of Appeal form.

The Notice of Appeal is available on the WSIAT site https://www.wsiat.on.ca/en/forms/index.html. You can mail, fax or e-file the Notice of Appeal form and the attached ARO decision to WSIAT. You should keep a copy of the fax or upload confirmation for your records. You may wish to follow up with the WSIAT to ensure they have received the WSIAT Notice of Appeal form.

• Decisions made at the WSIAT level are final.

For more information on obtaining assistance, please see WSIB Fact Sheet # 3 WSIB Appeals Assistance.

Contact Us

To contact the OPSEU/SEFPO Worker Safety Unit:

Email: [email protected]

Call: 1-800-268-7376

THIS PUBLICATION CONTAINS GENERAL INFORMATION AND IS INTENDED AS REFERENCE ONLY. IT IS NOT INTENDED AS SUBSTITUTE FOR INDEPENDENT LEGAL ADVICE REGARDING YOUR PARTICULAR SITUATION.

PDF version of Workplace Safety and Insurance Appeals Assistance – WSIB Fact Sheet 3

How The Worker Safety Unit Can Help You

If you disagree with a WSIB decision denying entitlement to benefits, the first step is to complete and submit a WSIB Intent to Object Form (ITO). Please refer to WSIB Fact Sheet #2 Appealing a Workplace Safety and Insurance Decision. It is your responsibility to meet all time limits for each and every decision you wish to appeal.

• Failure to submit the Intent to Object Form (ITO) by the appeal deadline may result in the loss of your right to appeal.

It is imperative to meet the appeal deadline. Often, the reason for denial of a benefit is as a result of a lack of information or insufficient medical documentation. If you do have some additional medical or other supportive documentation, you can include it with your objection form when submitting it to the WSIB. If you are unsure of what is required, it would be helpful if you contact the WSIB decision maker to determine what is needed.

Do not jeopardize missing the time limit while you are pursuing additional medical information. Any additional information can be submitted at a later date if required. Meeting the time limit will preserve your right to appeal and will allow you the time to pursue additional information and/or schedule medical appointments if necessary.

Benefits Officers in the OPSEU/SEFPO Worker Safety Unit assist, and may represent members, in their WSIB and WSIAT appeals. If you would like OPSEU/SEFPO’s assistance, the Worker Safety Unit will require a complete and up-to-date copy of your claim file for review. The WSIB will send you a complete copy of your claim file if, after they have reviewed the Intent to Object form and any other information submitted, the decision to deny remains unchanged. If you do not receive a copy of your file, you can request one under the Freedom of Information and Protection of Privacy Act. You will find a WSIB Worker Request for Copy of Claim File form on WSIB’s website at the following: https://www.wsib.ca/en/forms#Request. WSIB will only send electronic versions of your claim file. If a paper copy is required due to some type of accommodation, you will need to formally request a paper file from the access department at WSIB.

Your Role and Responsibilities

Meeting the Appeal Deadline

It is each worker’s responsibility to meet all deadlines to appeal. This is done by submitting an ITO form to the WSIB within the time limits specified in the WSIB decision. On the ITO form, identify each and every issue you are objecting to and clearly indicate the date of the WSIB decision that addressed that issue(s). Additional ITO forms must be completed and submitted within the prescribed timelines for any subsequent decision letter that may deal with additional issues. If you have multiple claim files you must submit an objection form for each respective claim file for any decision you do not agree with.

When completing the ITO form, check “I will represent myself in the objection process, or I am currently seeking representation” in section 4 (Representation).

The WSIB decision maker will review your Intent to Object form, reasoning, any new information, and reconsider the original decision.

If the decision remains unchanged, the WSIB will send you a copy of your claim file along with an Appeal Readiness Form. Do not complete the Appeals Readiness Form at this time.

Once you receive your claim file, forward the complete original copy, in the order it was received, along with the blank Appeals Readiness Form to the Worker Safety Unit by:

• Emailing it to [email protected]. If you receive notice that the file is too large to email, please advise the Worker Safety Unit of this for further instructions on how to forward it.
• Dropping off a paper file, or an electronic file on a USB drive to your nearest OPSEU/SEFPO regional office and request it be sent to the OPSEU/SEFPO Worker Safety Unit via courier. You can locate the closest OPSEU/SEFPO office by visiting www.opseu.org and clicking on the Contact Us then OPSEU Regional Offices and Membership Centres.
• Send your file via regular mail (either paper or USB drive) directly to: OPSEU/SEFPO Worker Safety Unit, 5757 Coopers Avenue, Mississauga, Ontario L4Z 1R9.

You will receive written confirmation from the Worker Safety Unit that your file has been received and a brief outline of the process to follow. Your file will be assigned to a Benefits Officer for review to determine whether it meets our case representation criteria. The appeal must also have a reasonable chance of success based on the information in your WSIB claim file and any additional information you submit. If there is not a reasonable likelihood of success based on the current information, the Benefits Officer will outline the reasons in writing.

If a decision is made to represent you, you will be sent a Retainer and WSIB Direction of Authorization form that advises WSIB that you have given us authorization to represent you. We cannot begin to represent you until you have signed and returned the Retainer and the WSIB Direction of Authorization form to our office.

Return to Work (RTW)

While receiving or appealing WSIB benefits, the workplace parties have an obligation to co-operate throughout the RTW process. Please refer to WSIB Fact Sheet #4 Return to Work for more detailed information on the WSIB Return-to-Work principles.

Although not specifically addressed under WSIB policies, applying for WSIB benefits brings with it a duty on your part as the injured worker, to mitigate your circumstances while awaiting or appealing benefits. This means you are expected to try and take whatever measures you can to recover and get yourself back to work at the earliest opportunity.

You should work with your union, employer, and health professional(s) to return to work with proper accommodation(s), if possible. If you are having difficulties with return to work/accommodation issues, please contact your Local’s union representatives or an OPSEU/SEFPO staff representative for assistance.

If you are having difficulties with your working duties, contact your treating heath care professional to review your medical condition and modified work duties. Another Functional Abilities Form will need to be completed. Provide a copy of the updated Functional Abilities Form to your employer and the WSIB.

Reporting a Material Change in Circumstances

Remember to inform your WSIB Case Manager of any changes concerning your claim such as healthcare status, earnings/income, and return to work status. The Board refers to this as a “material change in circumstances.” You are required to inform the WSIB of any material changes within ten (10) calendar days.

Contact Us

To contact the OPSEU/SEFPO Worker Safety Unit:

Email: [email protected]

Call: 1-800-268-7376

THIS PUBLICATION CONTAINS GENERAL INFORMATION AND IS INTENDED AS REFERENCE ONLY. IT IS NOT INTENDED AS SUBSTITUTE FOR INDEPENDENT LEGAL ADVICE REGARDING YOUR PARTICULAR SITUATION.

PDF version of Return to Work (RTW) – WSIB Fact Sheet 4

Rehabilitation and Return to Work (RTW) planning begins the day of the worker’s absence from work or when the worker requires accommodation as a result of a workplace injury or illness.

The RTW process should:

• Ensure a health recovery process for the injured worker
• Provide a safe return to work as soon as is medically possible
• Identify any limitations that should be placed on the worker if the worker comes back to a pre-injury job on a modified or part time schedule (until capable of returning to normal job functions)

The worker, the employer and the union should provide effective, ongoing communication and documentation where requested. Based on this information, a return to work or a written accommodation plan should be developed and implemented between the workplace parties.

As an injured worker returning to work, you should:

• Seek medical attention immediately upon experiencing any new work-related injury or re-injury
• Report any injury to the employer as soon as you are aware of the new injury or re-injury
• Maintain effective communication between you, the employer, the union representative, and WSIB during recovery and RTW process
• Comply with recommendations for treatment
• Help to identify suitable work with respect to your functional abilities and contribute to the development of your RTW plan
• Report any significant change in your circumstances, which may include returning to work, additional income, or any changes in your medical condition. These changes must be reported within ten (10) days of the change occurring
• Provide functional abilities information regarding your restrictions and limitations including your medical prognosis

You can expect ongoing evaluations of your work progress in relation to your injury from both your employer and WSIB. This is to ensure that you are progressing towards being able to perform your pre-injury job functions or whether there is a need to modify your RTW plan.

The WSIB monitors all claims for worker opportunities to return to part-time, modified, or full-time work whether it is the worker’s home position or alternative employment. If a job is available, WSIB will arrange a meeting with a Return-to-Work Specialist at the worksite/online to discuss return to work options with the worker, the employer, and the union. The WSIB will attempt to arrange a meeting no later than twelve (12) weeks after the claim is approved. However, a meeting can be arranged much sooner based on the worker’s ability to return to work.

An offer of work should include:

• What work is being offered
• Nature of the work
• Hours of work
• Associated remuneration
• Location of work site

If you are unable to return to work or to perform the job duties included in your RTW plan, you must:

• Notify your employer that the job is not within your functional capabilities
• Communicate with your employer with respect to any alternate accommodations available
• Inform the WSIB immediately

The WSIB should consider all relevant functional abilities/health care information; all information regarding the job description including information pertaining to the physical and cognitive demands associated with the job offered; and any other relevant considerations, such as whether changes in the location of work or the hours expected to work will negatively impact your recovery. WSIB may ignore the opinion of your treating health care practitioner and deem you capable of a RTW despite medical information supporting total disability. It is vital to appeal these determinations, as these decisions have a 30-day time limit.

There is an obligation on your part to mitigate your financial loss while appealing or waiting for benefits. This means you are expected to continue to seek medical treatment for your injury and to seek suitable alternative employment in the labour market (e.g., job searching).

You should work cooperatively with your union, employer, and health care professionals to return to work.

You should contact and arrange for a Local Union Representative and/or OPSEU/SEFPO Staff Representative to assist you throughout the RTW process. You and your Local may seek the assistance of a WSIB RTW Specialist.

A return-to-work dispute has a 30-day time limit to appeal. If you wish to appeal any other WSIB decision, there is a 6-month time limit from the date of that respective decision. Refer to WSIB Fact Sheet # 2 Appealing a Decision. You should appeal as soon as possible to ensure that you do not miss the appeal deadline.

Contact Us

To contact the OPSEU/SEFPO Worker Safety Unit:

Email: [email protected]

Call: 1-800-268-7376

THIS PUBLICATION CONTAINS GENERAL INFORMATION AND IS INTENDED AS REFERENCE ONLY. IT IS NOT INTENDED AS SUBSTITUTE FOR INDEPENDENT LEGAL ADVICE REGARDING YOUR PARTICULAR SITUATION.

PDF version of Work-Related Stress – WSIB Fact Sheet 5

• Traumatic mental stress (TMS)
• Chronic mental stress (CMS)
• Post-traumatic stress disorder (PTSD) in First Responders and Other Designated Workers

A worker may be entitled to benefits for work related mental stress arising out of and in the course of employment. However, a worker is not entitled to benefits for work-related stress caused by an employer’s decisions or actions that are part of the employment functions, such as:

• Changes in working hours
• Productivity expectations
• Terminations
• Demotions
• Transfers

Overview

Filing a Claim

You must file a claim with the Workplace Safety and Insurance Board (WSIB) as soon as possible, but no later than six (6) months from the date you became aware the condition was related to work or a work incident.

Diagnostic Medical Requirement

Before any work-related stress claim is considered, there must be a diagnosis in accordance with the Diagnostic and Statistical Manual for Mental Disorders (DSM) from an appropriate health care professional. Sometimes a work-related stress claim may be denied due to pre-existing or non-work-related psychological factors.

Return to Work

Regardless of the type of injury/illness, a worker has an obligation to participate in the return-to-work process. The employer will likely initiate a modified work offer outlining their intention to accommodate your medical condition. The modified work offer should be communicated in writing. For more information, refer to WSIB Fact Sheet # 4 Return to Work (RTW).

Alternative Income Sources and Accommodation

In the interim, if you have been denied benefits from WSIB and you are medically unable to return to work, you may be able to access your Short Term and/or Long-Term Income Benefits, if applicable. If you do not have benefits or have exhausted your benefits, you may qualify for Employment Insurance Sickness Benefits or Social Assistance Benefits.                                                                                             

If Your Claim is Denied

You have a right to appeal a negative WSIB decision. You must submit an Intent to Object form (ITO) to WSIB no later than six (6) months from the date of the written decision (RTW decisions have 30-day time limits). For more information, refer to WSIB Fact Sheet # 2 Appealing a Workplace Safety and Insurance Board Decision.

Traumatic Mental Stress (TMS – for accidents on or after January 1, 2018)

A worker must have suffered or witnessed the work-related traumatic events first-hand or heard the work-related traumatic events first-hand through direct contact with the traumatized individuals. In addition, there must be a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) which may include, but is not limited to:

• Clearly and precisely identifiable (who, what, where, when and how)
• Objectively traumatic

A worker must have suffered or witnessed the work-related traumatic events first-hand or heard the work-related traumatic events first-hand through direct contact with the traumatized individuals. In addition, there must be a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) which may include, but is not limited to:

• Acute stress disorder
• Post-traumatic stress disorder
• Adjustment disorder
• Anxiety or depressive disorder

Cumulative Effect

A worker may be exposed to multiple traumatic events over time. A final reaction to a series of traumatic events is considered to be a cumulative effect. A worker may be entitled to benefits because of the cumulative effect, even if the most recent event is not the most traumatic.

Exclusions

A worker is not entitled to benefits for TMS caused by decisions or actions of the worker’s employer that are related to the worker’s employment, including:

• A decision to change the work performed
• The working conditions
• Disciplinary Action
• Termination of employment

However, a worker may be entitled to benefits for TMS due to employer’s decisions or actions that are not part of the employment functions such as violence, threats, or conduct that a reasonable person would perceive as shocking or abusive.

Chronic Mental Stress (CMS – for accidents on or after January 1, 2018)

A worker is entitled to benefits for Chronic Mental Stress (CMS) arising out of and in the course of employment. Work-related CMS is a diagnosable mental disorder that has been predominantly caused by a substantial work-related stressor or a series of stressors. A work-related stressor can be considered substantial if it is excessive in duration and/or intensity in comparison to the expectedpressures and tensions of the job. This includes being subjected to bullying or harassing behaviour at the workplace, which is known, or ought to be reasonably known, to be unwelcome.

Consistent exposure to a high level of routine stress over time may be considered a substantial work-related stressor only in jobs with a high degree of routine stress.  Routine high level stress can be found in jobs that typically have responsibility over matters involving life and death and/or involve routine work in extremely dangerous situations.

To be entitled to benefits for work-related Chronic Mental Stress, all the following criteria must be met:

1. A regulated health care professional has provided a diagnosis based on the Diagnostic and Statistical Manual of Mental Disorder (DSM). In complex CMS cases, WSIB may require a diagnosis from a psychiatrist or psychologist.
2. The worker has experienced substantial work-related stressor, like workplace bullying or harassment.
3. The work-related stressor was the predominant cause of the appropriately diagnosed mental stress injury.

Exclusions

A worker is not entitled to chronic mental stress caused by an employer’s decisions or actions that are part of the employment functions such as:

• Changes in working hours
• Productivity expectations
• Terminations
• Demotions
• Transfers

Interpersonal conflicts between workers and their supervisors, co-workers or customers are not generally considered to be a substantial work-related stressor, unless the conflict amounts to workplace harassment and/or results in conduct that a reasonable person would perceive as shocking or abusive.

Post-Traumatic Stress Disorder (PTSD in First Responders and Other Designated Workers)

If a first responder or other designated worker is diagnosed with Post-Traumatic Stress Disorder (PTSD) and meets specific employment and diagnostic criteria, a first responder or other designated worker’s PTSD is presumed to have arisen out of and in the course of employment, unless the contrary is shown.

Transitional Claims

There are special criteria for pending claims prior to April 6, 2016. Please refer to WSIB Operational Policy Document 15-03-13.

Who is Covered?

Refer to Section 14 of the Workplace Safety and Insurance Act for covered occupations.  On May 8, 2018, Bill 31 amended Section 14 of the WSIA to expand the presumption of work relatedness for PTSD to add six additional categories of workers: including nurses (which directly provide patient care), provincial bailiffs, and probation officers.

Diagnosis and Rebutting the Presumption

The diagnosis of PTSD must be made by a psychiatrist or psychologist and must be consistent with the description in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). Your employer has the right to challenge the presumption if they believe they can demonstrate that the employment was not a significant contributing factor in causing PTSD.

Exclusions

A first responder or other designated worker is not entitled to benefits for PTSD caused by decisions or actions of the worker’s employer relating to the worker’s employment, including:

• A decision to change the work performed or the working conditions
• Disciplinary Action
• Termination of employment

Contact Us

To contact OPSEU/SEFPO Worker Safety Unit, email [email protected] or call 1-800-268-7376.

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