How to Submit An Appeal
Stage 1 – Preparation of the appeal
Prior to submitting an appeal, you should make every effort to resolve the issue with Sun Life or your benefits administrator.
To prepare the appeal, you should:
Review the Plan Document
Review sections of the Plan Document relevant to your appeal, such as the provisions of the Plan in relation to your claim, general exclusions and limitations, or terms related to coverage levels and eligibility.
Collect related documentation
If your appeal is in relation to a claim, the appeal must be submitted within 12 months of the expenses being denied. Documentation submitted with your appeal may include:
- Copies of prescriptions and receipts
- Copies of questionnaires or claim forms submitted to Sun Life
- Copies of your Claim Statement
- Copies of any relevant correspondence with Sun Life
If your appeal is in relation to coverage issues, such documentation may include:
- Copies of application forms submitted to the designated officers of your employer or pension office
- Printed copies of forms submitted through Compensation Web Applications
- Records (with dates) of related phone calls, e-mails, or letters, if possible
Note: Copies will not be returned.
Stage 2 – Appeal submission
Submit a letter of appeal to the Administration Authority
You must submit a letter requesting a review of your file to the Federal Public Service Health Care Plan Administration Authority. Appeals may also be submitted by a Power of Attorney (POA) or Executor. (Note: It is the responsibility of the POA to understand the provisions of the Plan.)
The letter must include your:
- Full name
- Current address
- Certificate number
If your appeal is in relation to a claim, your letter should also include the following:
- A description of the service or product for which the claim was submitted, and dates of purchase or service
- Dates and details of conversations, if any, with Sun Life representatives
- The reason you feel the claim should be appealed
- A copy of? the claim and related receipts
- A copy of the Claim Statement issued by Sun Life
If your appeal is in relation to coverage, you should describe ?circumstances leading to your appeal as well as your justification for a possible adjustment. Include any other documentation or information relevant to your appeal.
Letters of appeal and relevant documents must be sent to the following address:
Federal PSHCP Administration Authority
PO Box 2245, Station D
Ottawa ON ??K1P 5W4
Please note that appeals cannot be submitted by fax or e-mail.
Stage 3 – Review of appeal
The Administration Authority will send you a letter confirming that the appeal request has been received.
The Appeals process generally takes about four months to complete.
The Administration Authority will prepare your file for hearing by the Appeals Committee. The preparation includes reviewing all documents submitted as well as information from Sun Life, the employer, or the pension office.
Stage 4 – Decision
The Appeals Committee reviews each appeal on a case-by-case basis and makes a decision based on the provisions and rules of the Plan Document and the information provided. You will be informed of the Committee’s decision in writing. The appeals process is the final level of review under the PSHCP.