CLAIMS APPEAL PROCESS

• You must present in writing to us a request to have your claim reviewed. The request for review must be sent to our Plan Administrator's address within 30 days of the date on which the claim was denied or settled in a manner unsatisfactory to you.
• The request should clearly state the reasons that you feel should justify a review of the claim and should be accompanied by supporting medical or other information that will assist us in our deliberations.
• We will, as soon as is reasonably possible after receiving the request for review, examine the claim and advise you that:
  The information provided with the request for review is sufficient to allow a reversal of the original claim decision, or;
  • We are satisfied that the original claim decision was correct under the terms of the Plan and a Hearing will not be granted, or;
  • The information provided with the request is insufficient to allow reversal of the original decision, but further investigation is warranted.
• Based on a majority vote amongst ourselves, we will make the final decision.
• You may be required to attend a Hearing but may be represented by, or assisted by, your Union Representative.
• In submitting claims for review, you should be aware that we are able to:
  • interpret information that is submitted with respect to a claim to determine if the claim meets the conditions specified by the Plan,
  • amend the terms of the Plan with respect to coverage on the understanding that it applies to all members,
  but are not able to make exceptions to the terms of the Plan to accommodate individual members' concerns.