Appealing OPS Denied Benefits Claim - Fact Sheet #1
Appealing OPS Denied Benefit Claims
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 is denied?
You believe your claim has been improperly denied. Sometimes too it can point out deficiencies that need to be addressed in bargaining.
How can I appeal claims for denied insured benefits?
If you work in the Ontario Public Service (OPS) and are represented by OPSEU, you can appeal the denial through the Joint Insurance Benefits Review Committee (JIBRC). The JIBRC is comprised of OPSEU representatives and Employer representatives from Treasury Board Secretariat. The OPSEU member representatives are Carl Thibodeau (Co-Chair), Dylan Lineger, Johanne Bourgeois and Cheri Hearty (OPSEU Benefit Officer).
The Joint Insurance Benefits Review Committee will review the claim, determine if there is a legitimacy to the claim 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 (CRS). If the claim is referred to CRS then it will be heard before designated arbitrators and a final binding decision will be made.
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, please forward your appeal request by mailing, faxing or emailing the Joint Insurance Benefits Review Committee. In your appeal request please forward 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.
Joint Insurance Benefit Review Committee - OPS
Ontario Public Service Employees Union
5757 Coopers Avenue
Telephone: (416) 443-8888 ext. 5560 or 1-800-268-7376 ext. 5560
Fax: (905) 712-3009
Email: firstname.lastname@example.org or email@example.com or firstname.lastname@example.org
I’ve filed an appeal, 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.
Information specific for LTIP Appeals:
For an LTIP appeal, once filed, you should contact your local employer (and your local union representative) to advise them you have filed an appeal through JIBRC and request a leave of absence. 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). It is important to note that your personal medical information is kept in strict confidence, and is not released outside of the members of the committee, including anywhere outside of the employer representatives of the committee. Information is NOT given to your local employer, Disability Accommodation Specialist (if applicable), or local union representative.
Frequently more medical information will be required for 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 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 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 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.