Introduction
The CUPE Education Workers’ Benefits Trust (“EWBT”) is an employee life and health trust providing life, health and dental benefits to eligible CUPE members.
The EWBT has worked closely with OTIP to design a made for CUPE members benefit plan. The plan provides comprehensive coverage provisions, however there may be occasions when a claim is partially or wholly denied and a Plan Member (“Member”) may be unclear or may disagree with the reason for the claim denial. To address these situations, an appeal process is built into the CUPE EWBT plan where a Member may appeal a claim denial by following the process outlined below. For the purposes of this policy, the term “Plan Member” includes any eligible dependent.
A ‘claim settlement decision’ is the Administrator’s determination concerning eligibility for and the extent of coverage for any given benefit claimed by a Member under the CUPE EWBT Plan. When a Member does not understand or agree with the claim settlement decision, the Member is encouraged to review the CUPE EWBT Plan material (booklets, claim history, etc.).
Principles and Assumptions
- At all steps of the process, Trustees are not provided with identifying member information. That information is held in confidence by the CUPE EWBT staff.
- The CUPE EWBT plan interpretation process supports accurate, systematic and consistent interpretation of the plan documents and relevant legislation.
- Members have the right to appeal the interpretation of plan terms and adverse benefit determinations of Canada Life (formerly Great-West Life) and Chubb, the benefit adjudicators. An adverse benefit determination is any denial, reduction or termination of, or failure to provide, or make payment, in whole or in part, for a benefit under the Plan.
- Appeals are expected to typically be related to missed deadlines, plan interpretation, benefits not provided, eligibility for benefits, administrative errors and/or levels of coverage.
- An appeal of a benefit determination made by Canada Life or Chubb must first be made through the appeal process of Canada Life or Chubb.
- The Board of Trustees are not able to overrule adjudication decisions in respect of insured benefits. Insured benefits are life insurance, accidental death and dismemberment and emergency out of Canada benefits.
- The Board of Trustees is the ultimate authority over the plan interpretation and appeals process and changes to the plan documents.
Roles & Responsibilities
- Canada Life or Chubb
Canada Life or Chubb will interpret the plan terms in accordance with the agreements with CUPE EWBT. Canada Life or Chubb will allow Members to access their internal appeals process and report all appeal requests to the CUPE EWBT. - CUPE
Union staff or the Union Local representative may be contacted by a Member concerning a benefit decision. Union staff will forward any enquiries to the CUPE EWBT appeals process. This process will be disclosed on the CUPE EWBT website. - CUPE EWBT Appeals Committee
An issue may be escalated or come directly to the Appeals Committee for an appeal. The issue will be reviewed, and a recommendation made to the Board of Trustees, based upon relevant factors that may include any or all of the following:- the plan document;
- previous interpretations of plan terms related to the issue;
- any comments or arguments made by the Member requesting the review or appeal;
- financial impact on the CUPE EWBT;
- any potential precedents approval of the appeal may create;
- applicable law, other regulations and available case law; and
- advice from the CUPE EWBT advisors, as necessary, including legal counsel, benefits consultant, actuary and/or medical experts.
- The Board of Trustees of the CUPE EWBT
The Board of Trustees has the ultimate authority to render a decision on all appeals. The Board will consider the recommendation of the Appeals Committee and all other facts they deem appropriate. - Individual Board of Trustees Members
A Trustee may be approached directly by a Member or beneficiary with a dispute or concern. The Trustee will refer the Member (or forward the Member’s concern) to the CUPE EWBT staff or Appeals Committee for resolution in accordance with this policy.
Review Criteria
The following preconditions must be satisfied to initiate the Claims Review and Appeal Process:
- The amount of the claim settlement decision exceeds $150 for a single claim, or $150 for cumulative claims for a single benefit;
- The Claims Review and Appeal Process is initiated within 90 days of the date of the claim settlement decision for health and dental matters; and
- Depending on the nature of the claim settlement decision, a Member may be asked to provide additional information or supporting documentation as part of the Claims Review and Appeal Process at any step. The Member is responsible for any costs associated with providing documentation in support of their appeal.
Members are encouraged to provide all applicable documentation to support their claim at all steps of the appeal.
A Member may use the Claims Review and Appeal Process only once for a claim settlement decision, and any subsequent claim settlement decision dealing with the same claim shall not be the subject of review and appeal again.
Review Process
Overview
When a Member is not satisfied with the interpretation of plan provisions or the benefit determination decision, the Member may make an appeal.
If the Member has a dispute with the decision of Canada Life or Chubb, the Member must first utilize the appeals process of Canada Life or Chubb, as appropriate.
Step One
Member appeals Canada Life or Chubb decision directly with Canada Life or Chubb.
If the Member is not satisfied with the claims settlement decision in Step One, the Member can officially file a written appeal. It is noted that since life and AD&D claims are insured, those appeals can only be made to the insurer.
Step Two
Member submits a Formal Written Appeals Process to the CUPE EWBT. All appeals must be received no later than two (2) weeks prior to the Board of Trustees’ meeting in order to be considered at the meeting.
Step Three
Appeals Committee reviews and makes recommendation to the Board of Trustees.
CUPE EWBT Board of Trustees renders a decision.
Step Four
An appeal by a Member to the Appeals Committee must be made using the CUPE EWBT Appeals form. This form is provided as an appendix to this policy and is available on the CUPE EWBT website. Members are encouraged to include any supplementary documentation in support of their appeals. Appeals must be made in writing to the CUPE EWBT Appeals Committee:
- By email to appeals@cupe-ewbt.ca
- By mail to CUPE EWBT, 304 Toronto Street South, Unit 204, Uxbridge, ON L9P 1Y2
The CUPE EWBT Appeal Committee will meet quarterly, or on an as-needed basis, and is comprised of:
- Three (3) trustees of the CUPE EWBT, appointed by the Board of Trustees
- The Chair of the CUPE EWBT, as an ex-officio member
The CUPE EWBT Appeal Committee will make a recommendation to the CUPE EWBT Board of Trustees on an appeal based on accurate, consistent and fair interpretation and application of the CUPE EWBT Benefits Plan. CUPE EWBT Appeal Committee may request further information be submitted by the Member to facilitate its review and consideration of the appeal.
Recommendations of the CUPE EWBT Appeal Committee shall be referred to the CUPE EWBT Board of Trustees. The CUPE EWBT Board of Trustees may:
- Approve the appeal, in whole or in part; or
- Maintain the original claim settlement decision.
Decisions made by the CUPE EWBT Board of Trustees shall be at its sole discretion and shall be final. All decisions will be communicated to the Member in writing including the rationale for the decision.
Timelines to appeal
Appeals are reviewed at the CUPE EWBT Board of Trustees meetings. In order for a Member’s appeal to be reviewed at a certain Board of Trustees’ meeting, the Member must submit their appeal form no later than two (2) weeks prior to the next meeting. Dates of upcoming meetings are published on the CUPE EWBT website.
If a Member’s appeal is received later than two (2) weeks prior to the next Board of Trustees meeting, the Board of Trustees may not hear the appeal until the following meeting.
Deferrals
The Board of Trustees reserves the discretion to defer deciding an appeal when necessary, including where:
- The Member has not appealed first to Canada Life for benefit claims;
- Additional information is required from the Member’s health care providers, Canada Life,
OTIP and/or any other relevant party.
Expiry Date
All appeals must be received within one (1) year of the date the expense has been incurred. This includes all documentation the CUPE EWBT requests from the Member to process the appeal. The Board of Trustees reserves the right to not review an appeal if information is received outside this timeline.
Communication of the Appeal Process
This Claims Review and Appeals Policy will be available to all Members on the CUPE EWBT website.
Inquiries or Complaints
Member questions or complaints regarding this Claims Review & Appeals Policy may be addressed to:
Managing Director
CUPE Education Workers Benefits Trust
304 Toronto St. South, Unit 204
Uxbridge, Ontario L9P 1Y2
info@cupe-ewbt.ca
www.cupe-ewbt.ca
It is the responsibility of all EWBT employees, personnel engaged by the EWBT to provide services (such as third-party service providers, independent contractors, consultants, or the personnel of a company engaged by the EWBT to provide services), and Board Members to comply with this Policy and report breaches of this Policy.
This Claims Review and Appeal Policy may be amended from time to time and should be reviewed at least every 3 years by the Board of Trustees.
CUPE EWBT CLAIM APPEAL FORM
Download the policy PDF to access the included appeal form.