Standard Process in Appealing a Claim

The ETFO ELHT has worked closely with the Ontario Teachers Insurance Plan (OTIP), the plan administrator, to design a made for ETFO ELHT benefits plan. The ETFO ELHT Benefits Plan design sets out provisions and coverage limits for life, health and dental benefits. OTIP and the insurance carrier will adjudicate claims within the established limits set out in the plan design.

There may be occasions when a claim is partially or wholly denied and a plan member may be unclear, or may disagree, with the reasons why the claim was denied. In this case, you can appeal a claim denial by following the process below.

Appeal Criteria

• Appeals must be initiated within 90 days for health and dental, and within one year for life, of the claim settlement date.
• The claim being appealed must be above a minimum financial threshold of $250.
• Once an appeal claim is reviewed and a decision made, the claim will not be reviewed again.

Step 1

If you receive a claims settlement decision you do not agree with, or do not understand, you should:

• Review the benefits booklet for clarification
• Call OTIP Benefits Services at 1-866-783-6847

An OTIP Benefits Services Representative can help you understand the plan’s benefits and reasons why certain benefits may not be covered and/or explain additional information that may be needed to have the claim reviewed.

Step 2

If you are not satisfied with your claims settlement decision in Step 1, you can request to escalate your concern to an OTIP Benefits Services Technical Specialist who will investigate the claim, review the plan design, and consult with senior technical staff, the insurance carrier and underwriting as needed, to ensure your claim was processed correctly.

If the actions taken in Step 1 and 2 did not resolve your claim concern, you may appeal.

Step 3

If you wish to make an appeal, you must do it in writing and outline the reason(s) you believe your claim should be paid. Appeals can be sent:

• by email to BenefitAppeal@otip.com
• by fax to 1-866-404-6847
• by mail to OTIP Health & Dental Appeal Committee, 125 Northfield Dr.W., PO Box 218, Waterloo, ON   N2J 3Z9

The appeal claim will be reviewed by the OTIP Appeal Committee which has the authority to approve the appeal, uphold the denial, or refer the appeal to the ETFO ELHT Claims Review Committee. The OTIP Appeal Committee’s authority to approve claims is limited to $5,000, on a one-time, without prejudice basis.

Step 4

If you are not satisfied with the outcome of your appeal claim after the OTIP Appeal Committee has made a decision, you may ask to have your appeal reviewed by the ETFO ELHT Claims Review Committee.

The OTIP Appeal Committee will present your appeal to the ETFO ELHT Claims Review Committee for review and decision. The ETFO ELHT will review appeal claims on a confidential, anonymous basis; you may not make in person, oral arguments.

The ETFO ELHT Claims Review Committee will meet quarterly to review appeals.

The ETFO ELHT Claims Review Committee may:

• recommend to the ETFO ELHT Board of Trustees to approve the appeal; or
• recommend to the ETFO ELHT Board of Trustees to maintain the original claim settlement decision.

Recommendations of the ETFO ELHT Claims Review Committee shall be referred to the ETFO ELHT Board of Trustees. The ETFO ELHT Board of Trustees may:

• approve the appeal, in whole or in part, provided it reflects an accurate, consistent and fair interpretation and application of the ETFO ELHT Plans; or
• maintain the original claim settlement decision.

Decisions made by the ETFO ELHT Board of Trustees shall be final, and will be communicated to the OTIP Appeal Committee. OTIP will communicate the final decision to you directly.