Changes to Member Appeals Process
The Board of Trustees, at their September 2020 meeting, created a Committee of two Trustees to act at the Member Appeals Committee to handle member appeals. The Committee meets every two or three months to deal with the appeals received.
Below are the rules and procedures for appeals to be dealt with by the Committee:
1. Initial Appeal Process
Where a member's claim is denied in whole or in part by the initial OEBAC or NexgenRx adjudication, the member will have the right to file a written appeal and send to OEBAC via email, mail or fax. Appeal forms are available on the OEBAC website, click here.
Appeals will first be reviewed by OEBAC staff to ensure that it complies with the OEBAC rules and that no technical error has been made. If the matter is not resolved, it is then referred to the Appeals Committee and the member will be notified of this by OEBAC. All appeals are in writing only. There will be no in-person hearings.
2. Matters that May be Appealed
Not all claims or eligibility decisions may be appealed. The Committee will NOT deal with:
appeals involving short-term or long-term disability claims as these are determined through medical expertise and any disputes must be dealt with through the Courts;
claims that do not involve insurance and health benefits as these may not lawfully be covered by the Plan;
any claim where the member has exceeded the maximum available for that category of claim (other than drug claims) or where the claim can reasonably be covered through the member's Health Care Spending Account; and
situations where the member has exceeded the lifetime maximum.
All other decisions of OEBAC may be the subject of an appeal and the Committee has discretion in dealing with such matters, subject to the terms of the Plan documents.
3. Decisions of the Appeals Committee
All decisions of the Committee are final and binding on the member and the Plan. There are no further avenues of appeal. The Committee through OEBAC shall provide brief reasons to the member for its decision. Decisions and names of applicants shall not be disclosed for privacy reasons. Decisions in any one case shall not create precedents for other cases.
With respect to any appeal, the Trustees may:
allow the appeal in whole or in part on such terms as it determines are appropriate;
reject the appeal; or
refer the matter to the full Board of Trustees if the issue involves a matter of policy or precedent that, in the view of the Committee, requires attention of the full Board.
Where necessary, the Committee may utilize the advice of the Plan Trustees, consultants, or legal counsel.
To learn more about the Appeals Committee and/or the process, please email us at email@example.com.