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.