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 representatives, employer representatives, and the College Employer Council. Sun Life representatives also attend.
Who are my JIC Union representatives?
(905) 575-1212 x4065
Giulia Volpe, OPSEU Benefits Officer
(416) 443-8888 or 1 800 268-7376 x3563
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 Giulia Volpe, Benefits Officer. Giulia Volpe 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.