Public Service Health Care Plan

How can I make changes to my Public Service Health Care Plan (PSHCP) coverage?
A website has been created that allows you to start, stop, amend, or reinstate your PSHCP coverage and to keep track of your insurance online.

What type of health insurance coverage is available, and what options are available?
An overview of the PSHCP and its various options can be found here.

This summary will help you choose what type of coverage best suits your particular needs. Do not hesitate to contact your insurance provider and your compensation officer should you need additional information.

For complete information on the PSHCP, consult the following:


Who do I contact if I am not satisfied with a decision or if I want information about the various provisions of the PSHCP?

Inquiries should be directed to the following

Tel.: (613) 247-5100 (National Capital Region) or 1-888-757-7427 (toll-free)
You may also visit the Sun Life website.

Can I file a complaint if I disagree with a decision?
If you do not agree with a decision made by the Administrator and wish a review of your case, a submission may be made to the Administration Authority. The Administration Authority has the discretion to reach a decision, but you should endeavour to exhaust all avenues of review with the Administrator before submitting an appeal to the Administration Authority.

The PSHCP is managed through the Administration Authority, which has Directors appointed by the three PSHCP Partners:

Where do I send my complaint?
Federal PSHCP Administration Authority
P.O. Box 2245, Station D
Ottawa ON K1P 5W4

What is the deadline for submitting review claims?
An appeal must be submitted within one year of mailing by the Administrator, Sun Life of Canada, of an Explanation of benefits regarding a claim.

Long-term Disability Insurance Plan
The Long-term Disability Insurance Plan was developed in 1970 to provide income protection for federal public service employees who are unable to work for a lengthy period of time because of a totally disabling illness or injury. The Sun Life Assurance Company of Canada is the Insurer and Administrator of the Plan.

Disability Insurance Plan brochure (DI):
The Disability Insurance (DI) Plan brochure is available online.

Process for complaints or comments
Comments or complaints concerning the employer’s insurance plan may be directed to several bodies. Hence, you may contact the Insurer, Sun Life, directly; its ombudsman’s office; the National Joint Council; or the Treasury Board of Canada, which writes the administrative policies for the various insurance plans.

1) Sun Life
A) Sun Life – internal recourse

B) If you are not satisfied with a decision made by the Insurer, or if you simply wish to get in touch with the Insurer, you may contact the Insurer at:

Tel.: (Toll-free) 1 800 361-5875

https://www.sunnet.sunlife.com/signin/mysunlife/home.wca

You will need your group policy number (12500) and your certificate number.

Level one
Should you disagree with a decision, you may choose to appeal it by providing additional information to the Insurer. Your claim and the additional information you have provided will then be reviewed at a more senior level within the Insurer's claim department.

Level two
Should you disagree with the resulting decision, you may ask that your claim be reviewed by senior management at Sun Life. The resulting decision will constitute the final decision under the internal review process.

As a final recourse, once all internal mechanisms have been exhausted, a decision may be appealed before the National Joint Council.

C) Sun Life Ombudsman’s Office – Non-medical issues
Apart from medical issues, if you are not satisfied with the service you have received or believe that you have been treated unfairly, you may file a complaint with the Sun Life Ombudsman’s Office, where a decision will be made to investigate the matter or to try to resolve the conflict to the extent possible.

2) National Joint Council
http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/tb_865/dis01-eng.asp

In the event that you disagree with decisions rendered by Sun Life, you may request an independent review, to be conducted by the Disability Insurance Plan Board of Management, which is made up of employer and employee representatives. The Board reports to the National Joint Council and makes recommendations on matters that are under dispute.

If you or your representative wish to have your claim reviewed by the Board, you should write to:

Tel.: (613) 990-1834

3) Treasury Board
http://www.tbs-sct.gc.ca/pol/doc-eng.aspx?id=13848&section=text
A case may also be put forward for review by the Board of Trustees, which has power only to make recommendations to the Insurer. The Long-term Disability Insurance Plan and the Public Service Management Insurance Plan (PSMIP) have the same Board of Trustees, whose responsibility it is to ensure that benefits are paid to members while costs are also taken into account. The members of the Board of Trustees are appointed by the President of the Treasury Board; its members include a deputy commissioner, a deputy minister and the President of the Public Service Commission, among others. Submissions should be sent to:

Or at the same address, directly to:

Tel.: (613) 946-4336


Who can I contact for additional information?
Information requests:
Enquiries about the public service’s Long-term Disability Insurance Plan should be directed to:


http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/tb_865/siglist-eng.asp

Your compensation specialist or the Insurance Section of the Superannuation Directorate in Shediac, New Brunswick (toll-free telephone number: 1-800-561-7930), can provide you with further information on benefits or conditions of membership.


CAPE’s role in redress procedures
Should it become necessary for you to appeal a decision rendered by the employer’s health care plan or its disability insurance plan, your CAPE Labour Relations Officer can assist you in preparing your written submission.

The Public Service Health Care Plan is among the National Joint Council Directives included in the collective bargaining agreements of CAPE members, and it is always possible to file a grievance on the interpretation and application of such a directive. After reviewing the facts of the case, your CAPE Labour Relations Officer will be able to determine whether CAPE should file a grievance in this particular instance.

http://acep-cape.ca/pdfs/General/files/Protocole1_sept_2008_b.pdf

 

Disclaimer: Material contained on this page is intended for general information purposes only. It is not intended as
professional counsel or legal opinion. Any analysis or interpretation contained herein should not be considered to be CAPE’s final
analysis or interpretation and is subject to change. It is not binding on CAPE. Every case is highly fact specific and as a result, the
outcome of any particular case will vary depending on the unique facts and legal issues involved.