Appealing OPS Denied Benefits Claim
What insured benefits can I appeal?
Supplementary Health and Hospital Insurance
- Long Term Income Protection (LTIP)
- Group Life Insurance (including Basic, Supplementary and Dependent Life Insurance)
- Any other benefits that may be added to the Group Insurance Plan
Why would I want to appeal an Insured Benefit claim that had been denied?
- Your claim may have been improperly denied.
- Claims that are denied today may highlight important bargaining demands for tomorrow.
How can I appeal claims for denied insured benefits?
If you work in the Ontario Public Service (OPS) and represented by OPSEU, then you can appeal the denial through the Joint Insurance Benefits Review Committee (JIBRC). The JIBRC is comprised of OPSEU representatives and Employer representatives from Management Board Secretariat. The OPSEU member representatives are Carl Thibodeau (Co-Chair), Dylan Lineger, John Watson and Cheri Hearty (OPSEU Benefit Counsellor).
The Joint Insurance Benefits Review Committee will review the claim problems and attempt to resolve the appeal. OPSEU takes an active role in the Committee meetings as your advocate. All information submitted to the JIBRC is confidential. Meetings are usually held monthly.
If the appeal cannot be resolved at the Committee level, the appeal can be referred to the Claims Review Subcommittee and will be heard before designated arbitrators.
How do I commence an appeal to the Joint Insurance Benefits Review Committee?
Discuss your complaint with your employer, the union and the insurance carrier when you become aware of the denial of benefits by the insurance carrier. Sometimes, submitting additional information directly to the insurance carrier may resolve the problem.
If the complaint is not satisfactorily resolved, you can appeal to in writing to the Joint Insurance Benefits Review Committee by mailing or faxing the written documentation about what you wish to appeal, copies of any denials from the insurance carrier and your contact information to:
Joint Insurance Benefit Review Committee - OPS
Ontario Public Service Employees Union
5757 Coopers Avenue
This publication contains general information and is intended as a reference only. It is not intended as a substitute for independent legal advice regarding your particular situation.