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The Appeal Process

If your claim has been denied or terminated, you are given the opportunity to appeal the decision. You also have the choice to use the services of an OTIP disability representative (DSR) to help you with your appeal.

 

 

Appeal Services


This is a unique benefit offered by OTIP. You have the option of using the appeal services of an OTIP disability service representative (DSR) to help you navigate the appeals process, especially in situations where new medical information becomes available. The services are provided as part of your long term disability benefits, at no additional cost to you. You can choose to use the appeal services of the DSR at any point in the claims process. The DSR can help you by:

 

  • Providing assistance throughout the claim process
  • Involving the designated local affiliate representative when you are appealing a claim that has been denied or when benefits have been terminated
  • Providing you with details related to the claim or appeal decision
  • Conducting visits with you and your affiliate representative to review your individual situation, your options and correspondence
  • Providing information regarding the steps to proceed with an appeal
  • Communicating with your treatment provider
  • Providing information regarding other disability benefit plans, such as the Canada Pension Plan (CPP) and Employment Insurance Sickness Benefits
  • Attending and participating in your CPP tribunal

 

Initiating your Appeal

  • You have 2 years from the date of the claims decision letter to appeal
  • You are required to send an appeal letter outlining the reasons why your claim should be reconsidered
  • New and/or additional medical information to support your claim should be submitted
  • Any costs associated with the appeal are your responsibility

 

Appeal Assessment

  • The appeal information will be reviewed by an appeals specialist
  • If any additional information or investigation is required it will be obtained by the appeals specialist
  • Additional investigations may include, but are not limited to:
    • Clarification from your attending practitioner(s)
    • An independent medical evaluation
    • A functional abilities evaluation
    • A medical consultant review

 

Appeal Decision

  • The appeals specialist may approve the appeal or send it to the Appeals Committee
  • The committee may:
    • Approve your appeal
    • Request additional information
    • Maintain the initial decision to deny or terminate your claim
    • If the Appeals Committee maintains the denial or termination of your claim, and you still wish to pursue your claim, it is recommended that you discuss your options for binding arbitration or litigation with your Affiliate representative or legal counsel.

 

Appeals Committee

  • The committee is comprised of two senior representatives from the insurance company and one senior representative from OTIP LTD Services.
  • This committee makes an independent review of the claim and appeal and comes to a final decision.
     

 

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