Association of Management, Administrative and Professional Crown Employees of Ontario v. Ontario (Ministry of Government Services), 2014 CanLII 63519

minicounsel

GSB#2013-2311

Under

Before

BETWEEN

Association of Management, Administrative and Professional Crown Employees of Ontario (Lee)

Association

and -

The Crown in Right of Ontario (Ministry of Government Services)

Employer

BEFORE

Bram Herlich

Vice-Chair

FOR THE UNION

Christine Davies Sack Goldblatt Mitchell LLP Barristers and Solicitors Counsel

FOR THE EMPLOYER

Roslyn Baichoo Ministry of Government Services Legal Services Branch Counsel

HEARING

May 8, 2014

Decision

1The issue in this case is whether the employer is in breach of the collective agreement by failing to provide a policy of insurance that includes coverage for dental implants within the category of major restorative services. As will be seen, dental implants may well be considered to be a major restorative service. The dispute before me is whether dental implants are a major restorative service for which the employer is required to provide coverage.

2Harris Lee, the complainant, had his claim for such benefits rejected, at least in part, by the carrier administering the dental benefit plan. I say “in part” because while the carrier rejected the claim for any coverage for dental implants, it treated the complainant’s claim as if it had been made for an alternative (and less costly) covered treatment. In the result, the claimant was paid an amount slightly shy of $700 in respect of his claim. There did not seem to be much dispute that had the claim been allowed in the fashion the complainant and the Association assert it ought to have been, the payment in question would have been closer to the maximum possible claim of $2000.00.

3There are no material facts in dispute. The case turns on an interpretation of the collective agreement benefits provisions. There are many of them; some dozen pages of the collective agreement are devoted to benefits. While the provisions directly relevant to our inquiry are, by comparison, relatively few, it is still useful to have an understanding of at least the structure (if not all of the content) of those 12 pages.

4Before considering the collective agreement structure, two notes are in order. First, there is no dispute that the insurance contract the employer has entered into with the carrier in respect of dental benefits (including the policy that was in force as of September 1, 1997) does not include coverage for dental implants. The Association argues that the source of the employer’s obligations and the employees’ entitlements is to be found in the collective agreement, not the insurance contract. Neither is there any surprise regarding the parties’ positions in this case. Indeed, it appears that this difference of interpretation is sufficiently mature that the even the benefits guide issued to employees includes, in a section enumerating “major restorative services”, the following caveat regarding dental implants:

Note: AMAPCEO disputes the failure to provide coverage for dental implants. The Carrier currently denies coverage for implants, but partially pays for it as an alternative treatment to “bridgework”. If you have any questions, contact the AMAPCEO Office for assistance. This Guide will be updated once further details are available.

5Of course, the benefits guide has no legal significance to my determination (no one suggested otherwise), but it is curious to note the identification and delineation of the issue between the parties at least as early as May 2010. It likely dates well before then. There was no suggestion before me, however, that the employer or the carrier have ever treated any claim for dental implants coverage any differently from the treatment afforded the complainant.

6Articles 31 through 36 of the collective agreement deal with Benefits. In the Appendix to this award Articles 31and 32 (which apply to benefits generally) and Article 35 (which applies to the Dental Plan in particular) as well as Article 34 (which deals with Supplementary Health and Hospital Insurance – a matter not directly before me, but referred to in a prior decision between these parties which I shall consider later) are reproduced. For our current purposes it will be useful to provide a skeletal outline of all these provisions and to then reproduce here those which are central to our inquiry.

7Article 31 is titled “Benefits - General”. It identifies 5 different “benefit plans” which were in force as of September 1997 and provides that all of the benefits contained therein are to be provided to full-time bargaining unit employees and that those benefits can only be altered by mutual agreement of the parties. It also provides that the benefits contained in the Benefit Plans are “supplemented” by Articles 32 – 36.

8Article 32, titled “JOINT BENEFITS COMMITTEE”, establishes the committee (with equal employer and Association representation) and its mandate. Among the duties of the committee is to make decisions on complaints or differences involving the denial of benefits provided under the Benefit Plans to an individual. The Article also establishes a claims review process and insures that all complaints by individuals that they have not received their proper entitlement to benefits under the Benefit Plans shall be made to the committee. And where the committee is unable to resolve the matter, the parties have agreed on a further process (which resulted in the hearing before me) to finally resolve the matter. This article is not directly in issue before me.

9Articles 33 through 36 deal specifically with each of the benefit plans enumerated in Article 31: Basic Life Insurance and Supplementary & Dependent Life Insurance (dealt with together in Article 33); Supplementary Health and Hospital Insurance (Article 34); Dental Plan (Article 35); and Long Term Income Protection (Article 36).

10While Articles 31 and 35 have been set out in full in the Appendix to this award, I now set out those portions of these articles which are particularly relevant to the instant determination:

ARTICLE 31 - BENEFIT PLANS FOR FULL TIME EMPLOYEES

Benefits - General

31.1 “Benefit Plans” in Articles 31-36 means the Basic Life Insurance Plan, the Supplementary & Dependent Life Insurance Plan, the Supplementary Health and Hospital Insurance Plan, (including vision and hearing aid coverage), the Dental Plan, and the Long Term Income Protection Plan in force as of September 1, 1997 with the Great West Life Assurance Company or any successor Plan.

31.2 Subject to the provisions of this Agreement, the benefits contained in the Benefit Plans as they were constituted on September 1, 1997 shall be provided to full time employees on the same terms and conditions as were in place on September 1, 1997. These benefits and terms and conditions may only be altered by mutual agreement of the parties.

31.5 The benefits contained in the Benefit Plans are supplemented by the provisions of Articles 32 -36. Where a conflict exists between the provisions of a Benefit Plan and this Agreement, the provisions of this Agreement shall prevail.

ARTICLE 35 - DENTAL PLAN

Reimbursement of Dental Expenses

35.1 The Employer shall pay one hundred percent (100%) of the monthly premiums for basic dental care services, denture services, orthodontic services and major restorative services for all full time employees covered by this agreement.

35.2 Employees shall pay the cost of dental care directly and the insurance carrier shall reimburse the employee, based on the current Ontario Dental Association fee schedule at the time the dental work is performed, at the following percentages:

(a) eighty-five percent (85%) for basic dental care services, which effective March 1, 2002 shall be amended to include the following coverage:

(i) pit and fissure sealant treatment shall be added to the Plan for eligible dependant children; and

(ii) the dental recall period shall be extended to nine (9) months except for dependant children age twelve (12) and under.

(b) fifty percent (50%) for denture services with a lifetime maximum amount payable of three thousand dollars ($3,000) per person;

(c) fifty percent (50%) for orthodontic services for dependent children between the ages of six (6) and eighteen (18) with a lifetime maximum amount payable of three thousand dollars ($3,000) per child;

(d) fifty percent (50%) for major restorative services with an annual maximum amount payable of two thousand dollars ($2,000) per person.

11The parties’ positions are clear and straightforward; the resolution of the interpretive difference that separates them is less so.

12First, and as already indicated, the Association readily concedes that the benefit claimed is not found within the four corners of the pre-existing dental plan referred to in Article 31 of the collective agreement.

13The parties filed a document they agreed is the insurance policy referred to in that article (the “policy”). It does not define the term “major restorative services”. Indeed, as a general matter, the policy prefers taxonomy to definition. Covered services are listed individually without any definition of categories of covered benefits. Thus, the policy defines “covered expenses” to mean “… services listed in the SCHEDULES OF ROUTINE, MAJOR, and ORTHODONTIC COVERED DENTAL EXPENSES contained in the Benefit Provision entitled DENTAL CARE EXPENSE BENEFITS FOR EMPLOYEES AND DEPENDENTS” [emphasis in original]. The three schedules are headed:

Routine Covered Dental Expenses (some seven pages which include a sub-heading of “Restorative services”);
Major Covered Dental Expenses (one page which enumerates “Crown and Bridgework Restorative Services”; another which lists denture services); and
Orthodontic Covered Dental Expenses

14Each of the schedules is comprised of two columns: one for the Ontario Dental Association (“ODA”) code number, the other for a brief phrase describing the procedure in question. Hundreds of codes are included. The schedules contain no codes or other descriptions referable to dental implants. Hence the Association’s concession (though it may not view it as such) that if we restrict our view to the insurance contract referenced in Article 31 of the collective agreement, coverage for dental implants is not to be found.

15The source of the employer’s obligation to cover expenses for dental implants, says the Association, is found in Article 35 – it points particularly to 35.2(d) which requires that employees be reimbursed (50%) of their expenses for “major restorative services” (to a maximum of $2000.00). The term “major restorative services” is not defined in the collective agreement or the insurance contact (although, as was seen earlier, the term is used in the “Guide to Your Benefits” document, precisely in the spot where the parties’ disagreement regarding coverage for dental implants is noted).

16However, continues the Association, whether we simply attribute the normal everyday meaning of words (dictionary definitions were proffered) or consider the view of the ODA (documents filed on consent from that organization demonstrate its view of dental implants as a “restorative” procedure), there can be little doubt that dental implants are properly described as a “major restorative service”. The parties have agreed (in Article 31.5) that the provisions of Article 35 supplement the benefits contained in the Benefit Plan. In the wording of Article 35.2(d) the parties have contemplated reimbursement for expenses for “major restorative services”. It matters not that the code or descriptions for a major restorative service, dental implants, are not found in the insurance contract. The parties have supplemented the limited coverage of the insurance contract. Expenses for dental implants are to be reimbursed in accordance with Article 35.2 (d).

17The Association points to a number of authorities in support of its position, including City of London and CUPE, (2008) 169 L.A.C. (4th) 134 (Brandt); City of Hamilton and Hamilton Professional Fire Fighters Association, (2009) 189 L.A.C. (4th) 80 (Kaplan); City of Mississauga and Mississauga Professional Fire Fighters Association, (2012), 222 L.A.C. (4th) 209 (Luborsky); and Wellington County Catholic District School Board v OECTA [2012], O.L.A.A. No. 115 (Trachuk). It also relied on a decision of this Board involving the same parties and a similar, at least by analogy, issue: AMAPCEO (Union Grievance) and Ministry of Government Services GSB #2004-0050, November 15, 2005 (Nairn).

18The employer views the matter differently. First of all, in its view, Article 31 serves to incorporate the (pre-existing) Dental Plan, i.e. the policy, into the collective agreement. That policy (as all agree) does not provide coverage for dental implants. The benefits provided under the terms of that incorporated policy can only be altered by mutual consent of the parties. There has been no such mutual consent.

19Article 35.2 (d), to which the Association points as the asserted foundation for dental implants coverage, provides no such coverage. Indeed, submits the employer, Article 35 is not a provision designed to confer eligibility, it is headed “Reimbursement of Dental Expenses”. It must be seen to be contemplating dental expenses covered under the terms of the policy. Moreover, Article 35 is not designed to confer benefits as such, it is a mechanical provision which speaks to the extent of the employer’s obligation to pay premiums (100% employer paid) and the level of reimbursement for covered expenses (e.g. 85% for basic services and 50% (to a stated maximum) for other dental expenses). The dental expenses referred to must be seen as restricted to those covered by the terms of the policy.

20Put somewhat differently, since Article 35 does not establish eligibility, there must have been a dental expense within the contemplation of the collective agreement, i.e. the incorporated policy, to trigger any obligation to reimburse such expense. To get to the 50% maximum of $2000 reimbursement contemplated by Article 35.2 (d), one must find eligibility in the policy. There is none. Article 31 speaks to entitlement and eligibility. Article 35 does not – it merely identifies who pays the premiums and the levels of reimbursement for covered expenses.

21By and large, I am satisfied that the Association has provided the better analytical framework for the interpretive exercise required to resolve the instant matter. Notwithstanding that, and for the reasons that follow, I am not persuaded that its position as to the disposition of the matter ought to prevail.

22For our purposes, a review of the structure of the collective agreement provisions begins with the specific “Benefit Plans” defined in Article 31.1. And while it may be a distinction without an immediate significant meaningful difference for our purposes, the employer’s suggestion that the specific plans identified are incorporated by reference into the collective agreement is not entirely accurate. Rather, Article 31.2 serves, subject to the terms of the collective agreement, to freeze the benefits (as well as the terms and conditions attached thereto) contained in those specified plans. No change is permitted except by agreement of the parties.

23In addition to providing that this “freeze” is subject to the terms of the collective agreement, Article 31 continues even more explicitly (in 31.5) and provides that the “frozen benefits” are “supplemented” by the following articles (32-36) of the agreement and, lest there be any doubt as to the effect of such supplementation, mandates that any conflict between the latter and the former is to be resolved in favour of the supplementation.

24What then, for our purposes, are the significant supplementary provisions? First, Article 32 (which applies to all benefit plans) provides the specific dispute resolution process (different from the usual dispute and arbitration procedures found in Article 15 of the collective agreement) which has resulted in the instant decision.

25Of course the central supplementary provision, at least in the Association’s view, is found in Article 35, which is specific to the dental plan in its application. And it is the use of the phrase “major restorative services” which the Association claims adds dental implants to the procedures covered by the collective agreement.

26The employer’s position is not only that Article 35 does not, through the use of the phrase “major restorative services”, provide coverage for dental implants. Indeed, it appeared to go even further, suggesting that Article 35, since it does not deal with, as the employer put it, “entitlement” is not the collective agreement location in which one would even expect to find the claimed supplementation of the policy.

27I must categorically reject this latter view, although in fairness to the employer, its commitment to this position was not unwavering. First, I believe it is something of a misnomer to describe what Article 35 is (or is not) as related to entitlement. The chief question before me relates to coverage. There was no issue that the complainant was indeed eligible for the coverage the collective agreement provides and that, if he incurred a covered expense, he would be entitled to be reimbursed to the extent provided. There is equally no question that the policy does not provide the coverage claimed by the union. The only question is whether the employer, pursuant to Article 35, is obligated to provide that coverage.

28Further, it is precisely in Article 35 that one would expect to find any agreed supplementation to the terms of the policy. The obvious example is in Article 35.2 (a) which explicitly provides that coverage is amended to include “pit and fissure sealant treatment” and to alter the length of the dental recall period.

29The employer accepts that, if there is a conflict between the terms of the collective agreement and the policy, the former prevails. What it asserts is that there is no conflict because Article 35 does not provide any expanded dental coverage and certainly nothing which would permit claims for dental implants.

30The employer’s position, at least to the extent that it acknowledges the paramountcy of the collective agreement in cases of conflict with the policy, appears to be based on, or at least an acknowledgement of, the previous AMAPCEO case (cited earlier and to which I shall refer as the “prescription/diagnosis case”). At page 19 of that decision Vice-Chair Nairn offered the following:

As a general matter, the fact that the collective agreement may provide a benefit which is greater than that provided by the insurance plan in existence at September 1, 1997, does not create any ambiguity. The collective agreement contemplates that it may contain conflicts or enhancements. The parties have provided for that circumstance in Article 31.2 and, more particularly, in Article 31.5. Article 31.2 is clear that the benefits contained in the September 1, 1997 insurance plan are frozen, "subject to" the terms of the collective agreement. Article 31.5 recognizes that the collective agreement "supplements" the plan, that is, it provides additional material, and further provides that the collective agreement terms prevail over the plan in the event of any conflict between the two.

31With the possible exception of the prescription/diagnosis case, to which I shall return, the cases relied upon by the Association are of little assistance. They can be seen to stand generally for the proposition that an employer must provide insurance coverage consistent with the collective agreement requirements, and cannot rely on restrictions imposed by the selected policy or carrier to defeat rights negotiated by the union. That is neither a startling nor controversial proposition in the matter before me. The question before me is simply whether the collective agreement provides the asserted coverage.

32As the Association’s claim is rooted in Article 35, it is useful to again set out the relevant portions thereof:

ARTICLE 35 - DENTAL PLAN

Reimbursement of Dental Expenses

(a) eighty-five percent (85%) for basic dental care services, which effective March 1, 2002 shall be amended to include the following coverage:

(i) pit and fissure sealant treatment shall be added to the Plan for eligible dependant children; and

(ii) the dental recall period shall be extended to nine (9) months except for dependant children age twelve (12) and under.

(b) fifty percent (50%) for denture services with a lifetime maximum amount payable of three thousand dollars ($3,000) per person;

(d) fifty percent (50%) for major restorative services with an annual maximum amount payable of two thousand dollars ($2,000) per person.

[emphasis added]

33The phrase “major restorative services” is found only in Article 35 (though, as noted, it is used in both Articles 35.1 and 35.2 (d)) – neither party suggested there was, and I was not pointed to, any other use of the term in the agreement.) Neither does the phrase appear in the policy. It is the use of this phrase which the Association points to as effecting the inclusion of dental implants as a covered expense under the collective agreement. Is the use of the phrase in Article 35 sufficient to result in coverage for dental implants? I think not. Another way of phrasing the ultimate issue (perhaps less accurate, but with greater demonstrative value) is: are the words “major restorative services” in Article 35 to be read as:

all dental services, whether or not included in the policy, which might be described as major restorative (thereby capturing dental implants), or
“major restorative services”, to the extent coverage has been provided for such.

34I begin by acknowledging that the Association has advanced a plausible and credible case for the conclusion that the phrase “major restorative services” ought to be seen to include dental implants. Whether one considers the dictionary meanings of “major” and “restorative”, as the Association did, or whether we turn to the ODA for guidance, dental implants can be viewed as a major restorative service. (The documentation from the ODA clearly identifies dental implants as a restorative procedure. And it is similarly clear from the ODA literature describing the process that there is nothing minor about dental implants.)

35That, however, is not sufficient to resolve the question before me. I must decide whether by the limited use of the term “major restorative services”, read in the context of the relevant collective agreement provisions as a whole, the parties intended to and did import the entire universe of major restorative services, including dental implants, into the realm of benefits the employer is obligated to provide by the collective agreement. In other words, the question is not simply whether the phrase, “major restorative services”, viewed in isolation, should be seen to include dental implants. Rather, the question is whether the use of the phrase, in its collective agreement context, extends the coverage of the policy to the entire universe of major restorative services, including dental implants.

36I agree with the employer that Article 35.1 is not a provision designed to establish the nature of the employer’s obligation to provide benefits coverage. Rather, it establishes the extent of the employer’s obligation (i.e. 100%) to pay any premiums associated with the required coverage. And this is a necessary provision given that the policy (which, of course, is between the employer and the carrier) does not speak to the obligations if any, of employees to pay (any or all portions of) premiums. That was a matter for the collective bargaining parties to negotiate. They did.

37And even if one were inclined (and I am not) to consider this provision as one which might otherwise establish the required coverage, I am not persuaded that it imports coverage for dental implants, a procedure not included in the policy. The provision refers to four extremely broad categories of dental services. As the schedules to the policy demonstrate, there are dental services which fall under each of these broad categories that are covered by the policy. I am not persuaded that the use of these broad categories in Article 35 was, by itself, intended to or thereby did import the entire universe of dental services, including dental implants into the realm of covered expenses.

38My conclusion in that regard is only reinforced when I consider Article 35.2, upon which the Association principally relied. The principal purpose of this provision appears, subject to one exception, to be to set out the extent to which employees are to be reimbursed for covered expenses. One need tread somewhat carefully before finding this provision establishes coverage not previously included in the policy. At the same time, however, I have already indicated my view that Article 35 is precisely where one would expect amendments, augmentations or supplements to the terms of the policy to be found. And it is the exception in Article 35.2(a) which proves the rule. In this provision the parties have clearly and specifically agreed to make modifications to the terms of the policy (regarding two specifically enumerated basic dental care services: pit and fissure sealant treatment and dental recalls).

39Nothing in Article 35 specifically identifies or adds dental implants as a covered dental expense. And neither does the phrase “major restorative services” accomplish this task. With the exception of paragraph (a), the purpose of Article 35.2 is to set out the extent to which claims are to be paid (percentage and maximum). The categories it employs to catalogue these amounts are a broad generic list whose items appear to correspond, in broad general terms, to the titles employed in the schedules to the policy. They are not there to itemize the coverage with respect to a multitude of possible expenses. Had the parties wished to add a significant benefit such as dental implants to the list of covered expenses, I would have expected them to do so with at least the same level of precision and clarity they employed with respect to pit and fissure treatments and dental recalls. They have not. In this context, the absence of the words “dental implants” is more significant than the presence of the phrase “major restorative services”.

40The prescription/diagnosis case supports this conclusion. Although the result in that case with respect to both prescription drugs and diagnostic services (the third issue in the case is not relevant for our purposes) was different (both claims were allowed), the analytical exercise is similar. I have already cited the general observation from that case which acknowledged the possibility that the parties might negotiate supplements to the policy (in that case the Supplemental Health and Hospital Insurance Plan). My consideration of that case, however, need go no further than a comparison of the language of 35.2 in our case with that of Article 34.2 (set out in the Appendix; it is the functional equivalent of our 35.2) which was considered in the other. The level of precision and specificity found in 34.2 goes well beyond anything found in 35.2 (again, save for the treatment of pit and fissure sealants and dental recalls). I need not review that provision in detail. It suffices to note that it runs some three pages and includes 10 paragraphs, some with up to four sub-paragraphs. The level of detail provided with respect to prescription drugs (Article 34.2(a)) left little to doubt. And with respect to diagnostic procedures (Article 34.2(c)), the policy in question made no provision to cover such expenses and hence their clear and explicit inclusion in Article 34 was found to prevail. Importing a specific benefit not included in the policy is different from our case – one in which the Association seeks to improve the frozen benefits of the policy to include dental implants without any specific or explicit reference to that benefit.

41In our case Article 35 speaks of major restorative services. The policy covers (some, not all) major restorative services. Dental implants are mentioned nowhere in the policy or the collective agreement. I am not persuaded that the result of simply using the term major restorative services in Article 35 of the collective agreement is that the employer is obliged to provide coverage for dental implants.

42Having regard to the foregoing, I am satisfied that the employer is not required to provide coverage for dental implants and I so find.

Dated at Toronto, Ontario this 6th day of August 2014

APPENDIX – COLLECTIVE AGREEMENT PROVISIONS

ARTICLE 31 - BENEFIT PLANS FOR FULL TIME EMPLOYEES

Benefits - General

31.3 During leaves-of-absence with pay, full benefit coverage will continue. The Employer and employee will continue to pay the applicable premiums.

31.4 During pregnancy and parental leave, an employee who participates in any Benefit Plan may continue to do so unless he or she elects in writing not to do so. Unless an employee gives the Employer this written notice, the Employer and the employee shall continue to pay the applicable premiums.

31.5 The benefits contained in the Benefit Plans are supplemented by the provisions of Articles 32 - 36. Where a conflict exists between the provisions of a Benefit Plan and this Agreement, the provisions of this Agreement shall prevail.

31.6 Where an existing OPS employee permanently moves into or from a position not covered by a Benefit Plan (as defined in Article 31.1) coverage for Basic, Supplementary and Dependent Life Insurance shall continue without there being any requirement for the employee to provide evidence of insurability. In addition, in the case of a bargaining unit employee moving to a permanent position not covered by the Benefit Plans, coverage under the Benefit Plans shall cease on the date on which coverage under any new insurance plan covering the employee in the new permanent position commences. In the case of existing OPS employees moving into a permanent position covered by the Benefit Plans, coverage shall commence on the date on which coverage under any previous insurance plans ceases.

31.7 Employees are entitled to a full explanation from the Carrier(s) when claims are refused under a Benefit Plan.

31.8 Family coverage for the following benefits shall include coverage for same sex partners; Supplementary and Dependant Life Insurance (Article 33), Supplementary Health and Hospital Insurance (Article 34), Dental Plan (Article 35).

31.9 The employee’s share of the annual Employment Insurance (EI) rebate will be retained by the Employer towards offsetting the cost of the benefits contained in this Agreement.

ARTICLE 32 - JOINT BENEFITS COMMITTEE

32.1 Composition of Committee

The Joint Benefits Committee shall be composed of an equal number of representatives from the Employer and from the Association, with up to six (6) representatives in total. At meetings of the Committee, each party may be accompanied by an actuary or other resource persons to provide technical advice and counsel.

32.2 Duties of Committee

32.2.1 The duties of the Committee shall consist of the following:

(a) Resolve communications issues regarding the Benefit Plans insofar as they affect AMAPCEO Unit employees;

(b) Review the performance of the Carrier(s) regarding claims of the Benefit Plans insofar as they affect AMAPCEO unit employees;

(c) Ensure that benefits information summarizing all employee benefits, is made available to all employees. The Employer shall cover all costs related to the provision of this information.

(d) Meet and review annually the financial experience of the Plans, including all financial reports ordinarily provided to the Employer by the Carrier(s);

(e) Meet monthly or as required to review and make decisions on complaints or differences involving the denial of benefits provided under the Benefit Plans to an individual, when such issues have not been resolved through the existing administrative procedures.

32.2.2 Claims Review

32.2.2.1 All complaints by individuals that they have not received their proper entitlement to benefits under the Benefit Plans shall be made to the Committee.

32.2.2.2 Where a claim dispute, and/or Committee related procedural issues, cannot be resolved by consensus of the Committee, the parties will be joined by a seventh member who shall be a mutually agreed upon independent third party. The selection of the independent third party shall be made on agreement of the parties from the GSB Roster provided for under the collective agreement.

32.2.2.3 The Committee, with signed authorization from the employee, shall be entitled to full disclosure from the Carrier(s) when claims are refused under a Benefit Plan.

32.2.2.4 Appropriate impartial medical consultants shall be available to the committee in an advisory capacity to provide information on the nature of specific illnesses or disabilities.

32.2.2.5.1 The fees and expenses of the medical consultants referred to in this Article and the independent third party referred to in this Article shall be divided equally between the Employer and the Association.

32.2.2.6 The Employer shall provide relevant information on the claim denial to the Committee for its consideration.

32.2.2.7 The independent third party shall have the powers of a Vice Chair of the Grievance Settlement Board under the Crown Employees Collective Bargaining Act. He or she shall adopt such procedures as he or she considers appropriate in the circumstances having regard to the nature of the dispute, the need for a fair process of dispute resolution, and the desirability of ensuring the resolution of the dispute in an expeditious and informal manner. This may include limiting the nature and extent of the evidence; determining the manner in which the complaint shall be resolved, with or without an oral hearing; and imposing such other conditions as he or she considers appropriate.

32.3 The Carrier(s) shall provide additional information for the Committee’s consideration as may be reasonably requested by a member of the Committee.

32.4 Membership on the Committee shall be for a one (1) year period, and is renewable at the discretion of the nominating party. The term of the independent third party shall be for as long as the terms and conditions of this Agreement continue, unless the parties determine otherwise.

32.5 Decisions of the committee or, where the Committee cannot reach consensus, decisions of the independent third party referenced in Article 32.2.2 are final and binding on the Employer, the Association, the employees and the Carrier.

32.6 Leaves of absence with no loss of pay and no loss of credits shall be granted to a member of the Association who participates in meetings of the Joint Benefits Committee provided that no more than three (3) employees at one time shall be permitted such leave. Leaves of absence granted under this Article shall also include reasonable travel time.

ARTICLE 34 ‑ SUPPLEMENTARY HEALTH AND HOSPITAL INSURANCE

34.2 The Supplementary Health and Hospital Insurance Plan shall include reimbursing employees for the following:

(a) ninety percent (90%) of the cost of all prescription drugs that by law require a physician’s prescription, including injectable drugs, and medicines prescribed by a licensed physician or other licensed health professional who is legally authorized to prescribe such drugs, and dispensed by a licensed pharmacist or by a physician legally authorized to dispense such drugs and medicine. For clarity, life-sustaining drugs or medicines shall continue to be covered on the same basis as under the previous collective agreement. Provided that a generic drug is listed in the Canadian Pharmaceutical Association Compendium of Pharmaceuticals and Specialities, reimbursement for drugs covered by the Plan will be based on the cost of the lowest priced generic version of the drug that the dispensing pharmacist can readily provide, unless the prescribing physician or health professional stipulates no substitution, in which case the reimbursement will be based on the cost of the drugs prescribed.

(b) Reimbursement for hospital care for private or semi-private room and board shall be up to one hundred and twenty dollars ($120.00) per day beyond the cost of standard ward care.

(d) vision and hearing aid coverage shall include reimbursing employees for the following, subject to a ten dollar ($10) deductible per person per calendar year, to a maximum of twenty dollars ($20) per family per calendar year. Vision and hearing aid coverage shall be reimbursed:

        • up to three hundred and forty dollars ($340.00) per person in any consecutive twenty-four month period following the date the expense is incurred, for the purchase, fitting or repair of spectacle lenses, frames or contact lenses prescribed by an Ophthalmologist or Optometrist, or laser eye correction surgery performed by a licensed practitioner providing services within the scope of their license.

up to twenty-five hundred dollars ($2500.00) per person in a five (5) year period for the purchase and/or repairs of hearing aids (excluding batteries) prescribed by a physician certified as an otolaryngologist or by a qualified audiologist.

(e) paramedical services include the following coverage per employee and each of their dependants:

(i) the services of an acupuncturist, at the rate of thirty-five dollars ($35) per visit, to an annual maximum of twelve hundred dollars ($1200);

(ii) the services of a speech therapist, at the rate of forty dollars ($40) per half hour, to an annual maximum of fourteen hundred dollars ($1400);

(iii) the services of a chiropractor, osteopath, naturopath, podiatrist, chiropodist, physiotherapist and masseur, if licensed and practising within the scope of their license to a maximum of thirty-five dollars ($35) per visit for each visit not subsidized by OHIP and to an annual maximum of twelve hundred dollars ($1200) for each type of service.

(f) the services of a psychologist, at the rate of forty dollars ($40) per half hour, to an annual maximum of fourteen hundred dollars ($1400). Coverage shall also include services rendered by a social worker with a Master’s Degree in Social Work, where such services are equivalent to the services that would otherwise be provided by a psychologist;

(g) Orthopaedic Shoes: Custom-made orthopaedic shoes, or modifications to stock, off-the-shelf orthopaedic shoes, specifically designed and constructed for the employee or dependent (or have been modified to accommodate the person’s particular medical needs) when prescribed by a physician, podiatrist or chiropodist are covered at seventy-five percent (75%) of the cost or repair per year to a maximum of five hundred dollars ($500) per year;

(h) Orthotic Appliances: Corrective shoe inserts specifically designed and constructed for the employee or dependent and prescribed by a physician, chiropractor, podiatrist or chiropodist are covered at one hundred percent (100%) of the cost or repair per year to a maximum of five hundred dollars ($500) per year;

(i) Effective January 1, 2007 the Supplementary Health & Hospital Plan will be amended to include expanded coverage for Diabetic Pumps and Supplies as follows:

(i) Purchase of Insulin Infusion Pumps to a maximum of two thousand five hundred dollars ($2,500) every 5 years per person.

(ii) Purchase of Insulin Jet Injectors (eg. Medi-injectors, preci-jets) to a maximum of one thousand dollars ($1,000), every five years per person.

(iii) Purchase and/or repair of one Blood Glucose monitoring machine per consecutive four (4)-year period to a maximum of four hundred ($400) per person,

(iv) 100% of the purchase of supplies required for the use of the above referenced diabetic appliances (Insulin will continue to be reimbursed as an eligible drug, not through this article).

ARTICLE 35 - DENTAL PLAN

Reimbursement of Dental Expenses

(a) eighty-five percent (85%) for basic dental care services, which effective March 1, 2002 shall be amended to include the following coverage:

(i) pit and fissure sealant treatment shall be added to the Plan for eligible dependant children; and

(ii)the dental recall period shall be extended to nine (9) months except for dependant children age twelve (12) and under.

(b) fifty percent (50%) for denture services with a lifetime maximum amount payable of three thousand dollars ($3,000) per person;

(d) fifty percent (50%) for major restorative services with an annual maximum amount payable of two thousand dollars ($2,000) per person.

35.3 Coverage for Dependants of Deceased Employees

The Dental Plan coverage for eligible dependants of a deceased employee shall continue for one (1) year from the date of the death of the employee.

Association of Management, Administrative and Professional Crown Employees of Ontario v. Ontario (Ministry of Government Services), 2014 CanLII 63519

Case Summary

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Association of Management, Administrative and Professional Crown Employees of Ontario v. Ontario (Ministry of Government Services), 2014 CanLII 63519

Case Summary

BETWEEN