By providing you with health and dental benefits, the ETFO Employee Life and Health Trust (ELHT) is working to take care of the health and wellness of you and your family.

That is why it is a shared responsibility between you and the ETFO ELHT to protect your health and dental benefits from abuse, misuse, and fraud.

What is benefits abuse?

If benefits are abused, it impacts everyone. It can increase the cost of the benefits plan, resulting in increased premiums or in some cases, reduced or lost coverage.

Some service providers can also commit benefit abuse. Claims from providers deemed to be fraudulent by Manulife, will not be approved.

To view a list of Manulife’s uncovered providers, log in to OTIP’s secure member site at www.otip.com and go to the Wellness centre in My Claims. Members can also call OTIP Benefits Services at 1-866-783-6847 to inquire about these providers. Be sure to check this list to minimize delays to your claims.

Here are some examples of benefits abuse:

1. A health-care provider overcharges for a service, bills for a treatment or service they didn’t provide or performs unnecessary medical services.
   • E.g. Instead of charging the cost of the orthotics, the provider invoices the maximum amount that the member has for orthotics.
2. A member submits a claim for a service they didn’t receive or claims more for the service than they were billed.
   • E.g. Purchasing regular retail footwear or sport shoes and submitting the claim to be reimbursed for orthopaedic shoes.
3. A member and their health-care provider work together to submit claims for products or services that would not be covered under the benefits plan or that the member did not receive.
   • E.g. Billing a spa treatment as a therapeutic massage, or teeth whitening as regular dental care.

What we’re doing to protect your benefits plan:

Working closely with Manulife (insurer) and OTIP (plan administrator), the ETFO ELHT is responding to benefits fraud and abuse.

Detecting suspicious claims

ALL submitted claims go through advanced analytics to identify potential benefits abuse and fraudulent activity.

The staff and systems used for handling claims are constantly being monitored with various detection tools including:

• Fraud recognition training
• Advanced data analytics
• System controls
• Drug management
• Specialized staff

Manulife routinely and randomly audits benefit claims. For example, a claim audit questionnaire may be sent to you via letter or email to:

• ask for additional information about the claim
• confirm the services the health/dental provider has billed for

To minimize delays in paying you or your service provider, be sure to complete and send the questionnaire back to Manulife as soon as possible.

In addition, your ETFO ELHT has an Anti-fraud Policy (171kB PDF).  When a member is identified as committing benefits fraud, actions taken by the ETFO ELHT will include but are not limited to:

• Suspension of, or permanent removal of access to online claims
• Referral of all future claims to Manulife Risk Management for monitoring and verification
• Pursue overpayment through Manulife
• Filing a statement of facts with law enforcement
• Civil litigation

Knowing how to recognize benefits abuse will help you to refuse it and/or avoid taking part. Test your benefits abuse IQ! Take OTIP’s short quiz.

Want to learn more about how you can help protect your benefits? Check out these articles!

Safeguarding your benefits with the three Rs

Can you recognize benefits fraud?

Refuse benefits fraud to protect your benefits

Reporting benefits fraud

Related links:

How do I find which claim is being audited?

How do I send documents related to a claim online?