On or Off the Hook: Dealing effectively with insurance claim denials and employer liability issues
Employers and unions routinely negotiate a range of insured benefits for employees, from coverage for prescription medications and paramedical services to disability and life insurance. Appealing denials of claims for these benefits can, however, be anything but routine. It is not always apparent whether arbitration or the court system is the appropriate forum for redress, and employers sometimes find themselves liable to pay benefits they thought they had contracted with an insurance company to provide. In this session, experts will provide guidance on determining the appropriate forum for resolving disputes regarding insured benefits. They will discuss potential employer liability for discriminatory or inadequate benefit policies, as well as for bad faith or negligent conduct.
- When do you have to go to court for disputes related to insurance benefit claims? When can you grieve? How does Brown and Beatty's "four categories" test help to answer these questions?
- What is the extent of an employer's liability if it fails to purchase the benefits bargained for in the collective agreement? What if the insurance company changes the terms of the policy purchased by the employer? What steps should an employer take to make sure that the insurance policy it purchases provides the benefits stipulated in the collective agreement?
- Is it advantageous to unions or employers – or both – to provide for a special procedure outside the regular grievance process to resolve disability benefit disputes?
- In what circumstances does a union have an obligation to assist its members in applying for insured benefits or in appealing denials?
- Is an employee's ability to apply for long-term disability benefits automatically extinguished by termination of employment?
- Is there an implied collective agreement obligation requiring employers to ensure that benefit plans they purchase do not discriminate on the basis of grounds prohibited in human rights legislation?
- Following the Talos decision – in which the Ontario Human Rights Tribunal declared as unconstitutional provisions of Ontario's Human Rights Code and Employment Standards Actthat permit age-based distinctions in pension, benefit, and insurance plans for employees aged 65 and over – what is the extent of the liability faced by Ontario employers that provide different benefits to employees under the age of 65 than to those over 65?
- What obligation does the employer have to provide information about insured benefits to employees? Can employers provide the information through booklets or must they provide the benefit plans themselves? In what circumstances will an employer be held liable for misrepresentation of insured benefits available to an employee?
- Do employers risk liability for insurance claim denials if they take an active a role in an insurance company's decision to deny or terminate disability insurance benefits?
- What type of insurer or employer conduct in administering benefits has attracted awards of damages for mental distress or aggravated or punitive damages? If an employer becomes aware that the insurance company with which it has contracted is engaging in malicious or harassing conduct in administering benefits, what, if anything, must the employer do to avoid liability for employees' mental distress resulting from such conduct?