For information on our Health Plans and other Group Benefits, please access the RTO/ERO provincial web pages at http://www.rto-ero.org/index-en.htm. When you are on the provincial website click the Health and Insurance Plans on the left of your screen.
For additonal information, you may wish to contact: Susan Leppington at susanleppington@rogers.com or phone 905-882-5015.
Comparison of RTO/ERO with RTIP/ARM
To view a chart comparing our benefits with the plan offered by RTIP and ARM, click here.
Change in Claims Appeal Process
The Health Services and Insurance Committee (HS&IC) has always been concerned with issues of good governance and fiduciary responsibility. In order to improve the services provided…there has been a change in the Claims Appeal Process that is to take effect April 2, 2007, for any claims denied on or after that date.
a) Benefit Entitlement Review Process:
Plan participants who contact RTO/ERO after a claim has been denied will be directed to a claims specialist from Johnson Inc. to discuss the rationale of the decision. If the participant is not in agreement with the reason from Johnson Inc. and contacts RTO/ERO again, the participant will receive information and a form from RTO/ERO. This information will describe the review process and contain a form that the plan participant must complete and return to RTO/ERO in order for the claim to be reviewed. The plan participant will be required to specifically indicate which of the following criteria apply that would permit the denial to be overturned and the claim paid.
b) Criteria
- Ambiguous wording of the RTO/ERO health plans (reviews will be based on the intent of the benefit coverage in the policy indication industry guidelines where applicable);
- Incorrect written representation provided by Johnson Inc. or World Access Canada to the members of RTO/ERO ;
- A misrepresentation by Johnson Inc. of the RTO/ERO health plans
c) Upon receiving the form and any other pertinent information from the member, RTO/ERO will keep a copy and send the originals to Johnson Inc. Subsequently, Johnson Inc. will have an independent review of the claim at their head office in Newfoundland. The adjudication of the benefit entitlement will be measured against the three criteria. Johnson Inc. will notify the member if the denial was upheld or overturned.
d) Johnson Inc would report the individual reviews and outcomes to each Health Services and Insurance Committee meeting. If the HS&IC determined that a review was not handled as it should been and that any of the three criteria applied, then HS&IC would provide Johnson Inc. with the direction which would apply to the review and all future claims.
