/

Notice of Appeal

LTD.3 (08/2016)

/ NOTICE OF APPEAL
LONG TERM DISABILITY INCOME (LTDI) CONTINUANCE PLAN

To be completed by LTDI Liaison Officer.

EMPLOYEE NAME / HOME PHONE NO.
ADDRESS
E-MAIL
MINISTRY /

DATE

APPEAL TIMELINES:
First Level Appeal (A discussion with the Adjudicator, Great West Life, to review the claim):
  • An employee must submit a request for a review (Notice of Appeal form) within 30 calendar days of receiving notice of the Adjudicator’s decision. The 30 days to submit the Notice of Appeal form expires on

.
  • Medical evidence and other submissions in support of the appeal must be submitted within 90 calendar days of receiving notice of the Adjudicator’s decision. The 90 days to submit the information to support your appeal

expires on / .
Second Level Appeal(A hearing with the LTDI Appeal Board to review the claim and adjudication decision, including first level appeal information.):
  • An employee must submit a request for a review (Notice of Appeal form) by the independent appeal board within 30 calendar days of receiving notice of the Adjudicator’s decision from the first level appeal. The 30 days

to submit the Notice of Appeal form expires on / .
  • Medical evidence and other submissions in support of the appeal must be submitted within 90 calendar days of receiving notice of the Adjudicator’s decision. The 90 days to submit the information to support your appeal

expires on / .

To be completed by Employee

I understand that my claim for LTDI benefits has been declined or discontinued. This is my request for a review based on the following information. I am aware that any fee incurred for the provision of this information is my responsibility.
Please check all applicable boxes:
The reason for my appeal is medical reasons. Full medical details from a licensed physician(s) will be forwarded directly to the Adjudicator, Great West Life, to support my claim.
The reason for my appeal is misinterpretation of evidence that was previously submitted. Please enclose a detailed explanation.
For my first level appeal, I am requesting an appointment to meet with the Adjudicator, Great West Life, to discuss my claim. I understand Great-West Life will contact me to arrange the appointment date.
Date / Applicant’s Signature
If you are a Bargaining Unit employee, the Alberta Union of Provincial Employees (AUPE) can provide you with assistance during the appeal process. Please indicate if you will be accessing AUPE Representation for this appeal. Please check applicable box.
Yes No
For further information, please contact the AUPE LTDI Liaison Officer at 780-930-3300 or 1-800-232-7284 (
I authorize Great West Life Assurance Company to discuss my claim and release a copy of my LTDI file to my AUPE Representative.
Date / Applicant’s Signature

Please send the completed form directly to the Adjudicator, Great-West Life, at the following address:

Great-West Life Assurance CompanyTelephone:780-917-7776 or 1-888-328-8688
202 Cecil Tower. 10110 – 104 StreetFax:1-888-425-0155
Edmonton, Alberta T5J 4R5E-mail:

LTD.3 (08/2016) / Page 1

Long Term Disability Income (LTDI) Continuance Plan Appeal Process

General Information on the Appeal Process:

If your LTDI benefits are terminated or if the Adjudicator (Great West Life) denies your claim, you may file an appeal. There are two levels of appeal.

The appeal process provides you with the opportunity to provide additional information (written and verbal) you feel is relevant to your claim.

You also have the option of having one representative with you at the appeal, such as a family member. If you are a Bargaining Unit employee, you can request assistance from the Alberta Union of Provincial Employees (AUPE). If you choose to do so, you will need to complete the Representation Release Form from AUPE and submit it to Great-West Life.

First Level Appeal:

The first level of appeal is a discussion with the Adjudicator to review the claim.

When the Adjudicator receives the Notice of Appeal form and you have indicated a request for an appointment, the Adjudicator will contact you to make the necessary arrangements.

When all relevant information has been submitted or presented, the Adjudicator will review the claim and make a ruling.

If the initial decision is overturned, LTDI benefits approved or continued will be paid for as long as you remain eligible.

If the initial decision remains the same, you have the option of proceeding to the second level of appeal. If you choose to do so, you will need to submit another Notice of Appeal form and medical evidence or other written material.

Upon receipt, the Adjudicator will review any new medical evidence and reconsider their ruling. If the ruling remains unchanged, the second level appeal will be independent of the Adjudicator.

Second Level Appeal:

The second level of appeal is a presentation of your case to an LTDI Appeal Board.

The Bargaining Unit Second Level Appeal Board is made up of three individuals: a representative from the Alberta Union of Provincial Employees; a representative from the employer; and a third person agreed upon by both organizations.The Management, Opted Out & Excluded Second Level Appeal Board is made up of four individuals appointed by the Public Service Commissioner.

The Appeal Board will contact the employee, Adjudicator and either the AUPE LTDI Officer or a person of the employee’s choice to make the necessary arrangements for the representation.

You may attend the appeal meeting when the Appeal Board reviews the claim. You or someone you choose to speak for you will be allowed to present your case. The Adjudicator will be there to present a summary of your case and the reasons for the first appeal decision. Both you and the Adjudicator will likely be asked questions.

When all relevant information has been presented, the Appeal Board will review the claim and adjudication decision and make a decision. The Appeal Board may: agree with the Adjudicator’s original decision; authorize paying benefits to you for a specific period of time; or offer benefits to you for a specific period of time, subject to your written agreement to meet certain conditions related to rehabilitation or retraining.

You will receive a written copy of the decision shortly afterwards. The decision of the Appeal Board is final and binding on all parties involved.

If you need more information on the appeal process, please contact the LTDI Liaison Officer or if you are a Bargaining Unit employee, you can also contact the Alberta Union of Provincial Employee’s LTDI Liaison Officer.

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