The appeals process is available to all members of the PSHCP who do not agree with a decision regarding their claim, benefit entitlement, or coverage (e.g., level of coverage, waiting period, refund of contributions) and wish to have their file reviewed. However, prior to submitting an appeal, you should attempt to resolve the issue with the Plan Administrator if your appeal is claim-related, or the Compensation/Pension Office if your appeal is coverage-related.
How to submit an appeal
You must submit your appeal by mail to the PSHCP Administration Authority at the following address:
PSHCP Administration Authority
P.O. Box 2245, Station D,
Ottawa, ON K1P 5W4
Your letter must include your name, current address, certificate number and you, as the member, must sign the document. If you and your spouse are both covered under the PSHCP, and the appeal pertains to both files, both of your signatures are required. Appeals may also be submitted by your legal representative, if applicable.
If your appeal is in relation to a claim or benefit entitlement, it must be submitted to the PSHCP Administration Authority within twelve months of the release of the Claim Statement. Prior to submitting your appeal, review the Plan Directive’s section relevant to your case to verify whether the service or product is covered by the Plan. Provide all the relevant facts in your letter, the reasons for disputing the Plan Administrator’s decision, and any supporting documentation such as:
- A description of the service or product for which the claim was submitted, and dates of purchase or service
- Medical questionnaires submitted to the Plan Administrator
- A copy of the claim, related receipts and Claim Statement issued by the Plan Administrator
- Any relevant correspondence, records (with dates) of related phone calls or e-mails.
If your appeal is in relation to a coverage issue, describe the circumstances leading to your appeal as well as your justification for the requested adjustment, along with any supporting documentation such as:
- Copies of application forms submitted to your employer or pension office
- Forms submitted through the Compensation Web Applications
- Records (with dates) of related phone calls, e-mails, or correspondence.
The appeals process takes approximately four months from the time the PSHCP Administration Authority acknowledges receipt of your appeal, to the approval of the Appeals Committee decision by the Board of Directors. The Appeals Committee meets four times per year, and it reviews each appeal on a case-by-case basis. Decisions are based on the provisions and rules of the Plan, and they are communicated in writing. The appeals process is the final level of review under the PSHCP.