This contains general information and is intended as a reference only. It is not a substitute for independent legal advice regarding your situation. Printable PDF
What is the Joint Insurance Committee?
The Joint Insurance Committee (JIC) is composed of OPSEU/SEFPO union representatives, employer representatives, and the College Employer Council (CEC). The JIC meets monthly to review claim complaints and attempts to resolve them. OPSEU/SEFPO, as your advocate, takes an active role in the Committee meetings.
Who are my Joint Insurance Committee Union Representatives?
- Landyn Blais, Local 415, Algonquin College
- Heather Giardine-Tuck, Local 240, Mohawk College
- Henry Lowi, Local 562, Humber College
- Maria Vasilodimitrakis, Local 560, Seneca College
- OPSEU/SEFPO Staff Resource Luc-Joel Ciza
What if I am denied an insured benefit by the insurer?
If you have submitted a claim to Sun Life and were denied a benefit that you believe is covered under your plan, you can appeal the claim decision. It is important to consider appealing a denied claim as claims can be improperly denied and an appeal may rectify the decision. It is also important to consider appealing a denied claim in that claims that are denied today may highlight important benefits issues that may inform demands for future rounds of bargaining.
You can appeal the denial through the Union representatives of the JIC. The first step is to raise your complaint with Sun Life (through phone call, email or discussion), the College Benefit Administrator at your College and your Local Union, as soon as you are made aware of the denial of benefits by Sun Life. In some cases, submitting additional information directly to Sun Life may resolve the complaint.
If the complaint is not satisfactorily resolved, contact one of the Union representatives of the JIC so they can advocate for you. It is essential that you provide your contact information and any written documentation about what you want to appeal, such as a copy of the denial letter from Sun Life and any notes or reports from your dentist or doctor.
Send your completed appeals package including the authorization form to a Union representative of the JIC or to Luc Ciza, Benefits Officer with OPSEU/SEFPO:
- Attn: Luc Ciza, Benefits Officer OPSEU/SEFPO
- Pension and Benefits Unit 5757 Coopers Ave, Mississauga ON L4Z 1R9 Fax: (905) 712-3009
- Email: [email protected]
All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health care providers, and the committee.
Bargaining Benefit Improvements
Should the insurer correctly deny the coverage, but you believe this coverage is important for your employer to provide, it will be important to identify the lack of coverage to your local leadership and colleagues. In order for coverage to be extended to provide for the benefit you believe should be included, it will likely need to be negotiated with the Employer in a future round of bargaining. If you and your colleagues believe a specific benefit is important, providing information, education and resources to your local leadership and your colleagues will be important to garner support for the change you want to see within your Collective Agreement. Bargaining begins essentially as soon as a Collective Agreement is ratified, meaning, you need to provide information and education to your co-workers often and early. That way, when your next round of bargaining is approaching, the seeds have already been planted and you’ll ideally already have the support necessary to achieve the change you want to see. If you’ve rallied your colleagues, they too will ideally complete the bargaining survey and attend the demand set asking for the change to the Collective Agreement.
If you wish to contact the Pensions and Benefits unit, please email us at [email protected].
Appealing a Benefit Claim Denial
Every month the CAAT Academic Joint Insurance Committee (JIC) reviews cases where decisions made by Sun Life resulted in claim denials the Extended Health, Dental, Long Term Disability, Life Insurance (including Basic, Supplementary, Supplementary Spousal and Dependent) and Critical Illness plans. When, in our analysis, we believe that an error, omission, or unfair decision was made in a claim, we advocate on behalf of members to have the claim reviewed and the decisions reversed so members receive appropriate benefit payments.
Issues that arise and persist are brought forth to the Divisional Executive to be included in the demand setting process.
Why would I want to appeal a claim that has been denied?
- Your claim may have been improperly denied (it happens more often than you think).
- Claims that are denied today may highlight important future bargaining demands.
How can I appeal claims for denied Insured Benefits?
You can appeal the denial through the Union members of the Joint Insurance Committee (JIC). The JIC is composed of OPSEU/SEFPO representatives, employer representatives, and the College Employer Council. Sun Life representatives also attend.
How do I commence an appeal to the Joint Insurance Committee?
- First, make certain (through phone call, email or discussion) to note your complaint with Sun Life, the College Benefit Administrator at your College and your Local Union, when you become aware of the denial of benefits by Sun Life. Sometimes submitting additional information directly to Sun Life will resolve the problem.
- If the complaint is not satisfactorily resolved, contact one of the members of the Joint Insurance Committee so that they can advocate for you. It is essential that you provide your contact information and any written documentation about what you want to appeal, such as a copy of the denial from Sun Life and the signed Authorization form (attached), and any notes or reports from your dentist or doctor.
- Complete the authorization and send it, along with your documentation to your JIC advocate or to Luc-Joel Ciza, Benefits Officer. Luc-Joel works in the Pension and Benefits Unit at OPSEU – 5757 Coopers Avenue, Mississauga, Ontario L4Z 1R9 Fax: (905) 712-3009.
All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health providers and the committee.