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Benefits Fact Sheet #5

Benefits Fact Sheet #5


LCBO Benefit Claim Denials

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)

The LCBO benefit booklet outlines the different benefits that you are eligible for. Benefit coverage differs depending on your employment status with the LCBO (i.e. casual, permanent part time, seasonal or permanent full time).

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

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

The first step is to contact Manulife 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 Manulife 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 can review the claim denial and attempt 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 Manulife, supporting documentation from your doctor (if applicable) and any other information related to your claim) along with an explanation of the problem:

Attn: Luc Joel Ciza, Benefits Officer
OPSEU – Pension & Benefits Unit
5757 Coopers Ave
Mississauga ON L4Z 1R9
Telephone:  (416) 443-8888 ext. 3562
Toll Free: 1-800-268-7376 ext. 3562
Fax:     (905) 712-3009
Email: lciza@opseu.org

Before incurring any expense larger than $300, it is very 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 actually being completed.  This will give you an idea of the amount that will be reimbursed to you thereby avoiding disappointing surprises.

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 may be able to help. The LBED Pensions and Benefits Committee members are Shelly Robitaille (Chair), Jessica Marciniak (VP), Taidgh McGuinness (member) and Luc Joel Ciza (OPSEU Benefits Officer).

If you wish to contact the Pensions and Benefits unit, please email us at pensionsandbenefits@opseu.org.

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.