OSSTF ELHT

• Contract Teachers and Education Workers
• Eligible Long Term Occasional (LTO) Teachers who have an assignment of 90 calendar days or longer
• Eligible Adult Day Teachers who have an assignment of 90 calendar days or longer
• Eligible Long Term Assignment Education Workers who have an assignment of 90 calendar days or longer

Retirees: Eligible retirees will be eligible to participate in the OSSTF Benefits Plan if they are were covered in a board-owned retiree plan at the transition date for active members of their bargaining unit into the OSSTF Benefits Plan and still have coverage in a board-owned retiree plan.

The transition of the coverage for eligible retirees into the OSSTF Benefits Plan is being worked on. All involved parties are evaluating current arrangements in board plans and details will be shared once further information is available.

Claims can be submitted by:

• The service provider (e.g. pharmacist, dentist, paramedical practitioner, etc.)
• Using My Claims
• Completing the Extended Health Benefits Claim Form (776kB PDF) and mailing it OTIP Health Claims
• Completing the Standard Dental Claim Form (691kB PDF) and mailing it to OTIP Health Claims
• Completing the Out-of-Province Claim Form (710kB PDF) and mailing it to OTIP Health Claims

OSSTF Benefits has worked closely with OTIP to design a made for OSSTF members Benefit plan. The plan provides comprehensive coverage provisions, however, there may be occasions when a claim is partially or wholly denied and you may be unclear, or may disagree, with the reason for the claim denial. To cover these types of situations, an appeal process is built into the OSSTF Benefit plan where you may appeal a claim denial by following the process outlined below:

Step 1 – Clarification and Further Information

OSSTF Benefits encourages members to review the Benefits Booklet for clarification of the provisions of the OSSTF ELHT Benefits Program.  The booklet is posted under My Benefits for your access.  You can also call into OTIP Benefit Services at 1 866 783 6847 to discuss your claim with an OTIP Benefits Services representative who can assist you in understanding the OSSTF Benefits Plan and why certain benefits may not be covered and/or explain additional information that may be needed to have the claim further reviewed.

If this does not answer your questions or you still disagree with the handling of the claim, you should request that your concerns are escalated 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 that the claim is processed correctly.

If these actions do not resolve your concern, you may officially file an appeal.

Step 2 – OTIP Appeal Process

• Appeal requests must be submitted in writing and must outline the reason(s) you believe the 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, 25 Northfield Dr. W., PO Box 218, Waterloo ON  N2J 3Z9.
• The appeal will be reviewed by the OTIP Appeal Committee, who has the authority to approve claims on a one time, without prejudice basis up to a limit of $5,000 per claim.
• If you are not satisfied with the decision of the OTIP Appeal Committee, you may ask to move the appeal to the OSSTF ELHT Appeal Committee for their review and decision.

Step 3 – OSSTF ELHT Appeals Committee

• The OTIP Appeals Committee will present the details of your appeal on a confidential anonymous basis to the OSSTF ELHT Appeals Committee for their review and decision. The OSSTF ELHT Appeals Committee may approve the appeal on a one time, without prejudice basis, maintain the denial or it can refer the appeal to the OSSTF ELHT Board for a final decision. The OSSTF ELHT Appeals Committee/Board is the final authority of the Appeal Process.
• The OSSTF ELHT Appeals Committee will report the decision on an appeal to OTIP and the OTIP Benefits Services Department will communicate the appeal outcome to you.

Note: Appeals must be in writing, the claim must be a minimum value of $150 and the appeal must be initiated within 90 days of the initial claim settlement date for health or dental and within 1 year of the settlement date of a life claim.