Mount Sinai Hospital Benefits - Ontario Nurses' Association

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1. Correspondence from Sun Life to P.J. dated April 14, 2008 with an attached Consultative Nursing Evaluation Report (Ex. 2). 2. Mount Sinai Hospital Request for Proposal dated August 2009 (Ex. 3) 3. Memo from Mount Sinai Hospital Human Resources to Group benefit Plan members-DNA re: Carrier Change (Ex. 4) 4. Documents relating to the reassessment process of Great-West Life (Ex. 5) 5. Correspondence from Great West Life to P.J. dated March 8, 2010 (Ex. 6) 6. Correspondence from Geoff Maier, Senior Account Executive, Group Benefits, Great-West Life dated March 25, 2010 with attached adjudication notes (Ex. 7) 7. Nursing Questionnaire completed by Dr. Samji dated May 23, 2009 (Ex. 8) 8. Sun Life Financial Mount Sinai Hospital, D.N.A. Extended Health and Dental Group Plan (Ex. 10) (the “Sun Life Plan”) 9. Great-West Life Mount Sinai Hospital, O.N.A. Group Benefit Plan (Ex. 11) (the “Great-West Life Plan”) 10. Correspondence from Barb Griffin, Manager Compensation & Benefits Mount Sinai Hospital to Geoff Maier dated October 22, 2009 (Ex. 12) 11. Email correspondence from Dr. Walker to Jennifer Hunter, Sun Life dated May 15, 2009 (Ex. 13) 4
iii. Relevant undisputed facts found within the agreed upon documents The Grievor’s spouse suffers from ALS (Lou Gehrig’s Disease). The disease is well advanced and the Grievor’s spouse is on a ventilator. He requires health care services that would normally be provided in an Intensive Care Unit. The Grievor submitted a claim on behalf of her spouse for private nursing care services under the Hospital’s extended health and dental benefit plans. A Consultative Nursing Evaluation Report from Bayshore Home Health (“Bayshore”) was submitted in support of the claim. Sun Life Financial (“Sun Life”) was the carrier who administered the Hospital’s extended health and dental benefit plans at the time that the Grievor submitted her claim. On April 14, 2008 Sun Life wrote to the Grievor and based on the medical information received, approved the claim for the private nursing care services. Sun Life approved the services of an RN for 24 hours, 7 days a week. The e4ense incurred for the private nursing care services was reimbursed at 100%. In the letter approving the claim, the following was indicated regarding the coverage: “Your Group Health Plan does provide for the services of a Registered Nurse when the services are medically necessary and prescribed by a physician. As well, the duties being performed must require the expertise of a registered nurse.” In February 2010, Great-West Life replaced Sun Life as administrator of the Hospital’s extended health and dental benefit plans. The Grievor was required to submit documentation to Great-West Life to support her ongoing claim for private nursing care services. On February 19, 2010 the Grievor 5
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Mount Sinai Hospital Benefits - Ontario Nurses' Association

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