Confusion still reigns for public servants’ health plan

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More than a year after the federal government updated the Public Service Health Care Plan, members continue to face challenges with their insurance.

Amanda Kennard, a retired public servant living in South Carolina, has spent months fighting for reimbursement of her claims and attempting to contact MSH International Canada, a sub‑contractor to Canada Life.

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A few months ago, Kennard was waiting on about $10,000 U.S. in outstanding claims. While she has received a few thousand dollars, she’s still waiting to be paid for several claims that have been wrongly classified, denied or only partially covered.

Kennard said emergency room visits and physician services have been denied despite previously being approved by the plan’s previous administrator, Sun Life.

While Kennard said she was previously covered for all hospital charges other than a facility fee, she said she only had ER visits and her husband’s knee surgery paid out after threatening legal action and speaking with MSH executives.

The Public Service Health Care Plan website says retirees living outside Canada who aren’t covered under provincial or territorial health plans can request comprehensive coverage. They can’t access the provision that provides hospital coverage equivalent to Canadian residents, a part of the plan they also couldn’t access before it was updated last July.

“The Government of Canada is not aware of any discrepancy in (the) adjudication of this benefit,” Treasury Board of Canada Secretariat spokesperson Rola Salem said.

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Gannon Loftus, a spokesperson for Sun Life, would not comment on whether that company or Allianz, the former administrator of the plan for members abroad, had made mistakes in approving claims related to hospital visits for retirees.

Ada Bayli, another TBS spokesperson, said retirees living abroad could be reimbursed between $90 and $250 a day for hospital room and board expenses, but not for services rendered in a hospital.

“Pensioners who are living abroad should obtain coverage for emergency medical services from other providers,” the PSHCP website says.

The website also says, however, that members with comprehensive coverage can access the Basic Health Care Provision, with eligible expenses including optometrist, physiotherapist, ambulance and physician services. Physician services include surgery and diagnosis and treatment of illness and injury. They can be performed in a participant’s home, in a physician’s office or clinic or a hospital as long as the physician is not employed by the hospital.

Some exclusions where benefits aren’t payable exist, including charges for services or supplies provided in hospitals outside Canada that would typically be payable under provincial or territorial plans.

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While most hospital services aren’t covered for retirees living abroad, exceptions can be made on a case-by-case basis.

Kennard says it’s hard to keep track of her claims as MSH’s online portal doesn’t work well and she hasn’t received explanations of benefits to understand which ones have been processed. She has sought clarity from customer service, but has either had to wait on the phone for hours or has been connected with employees who can’t help her.

“They have to stop having excuses, saying it’s beyond their control,” said Kennard, who noted she had reached out to government officials and had either not received a response or had emails bounce back. “I think MSH has proven to be incompetent.”

MSH began administering coverage to public servants and their dependants travelling and living abroad on July 1, 2023. Administration of the health plan for more than 1.7 million public servants, retirees and dependants had transferred to Canada Life from Sun Life following a multi-year tendering process.

In February, the Public Service Alliance of Canada filed a grievance against the government for its conduct in transferring administration of the plan. In July, the Professional Association of Foreign Service Officers announced it had launched human rights complaints against the government and MSH.

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Jean Bilodeau, a former public service executive living in Gatineau, is waiting on a reimbursement of slightly more than $5,600.

After contracting pneumonia while on vacation in Mexico in February, Bilodeau ended up in a hospital for about three hours. While he was away, he tried to call MSH several times for pre-authorization, but couldn’t get through.

Once he was back home, Bilodeau submitted his travel claim, which he said was twice lost by MSH. After making dozens of calls and navigating MSH’s website, Bilodeau was able to submit his claim online and in June received an explanation of benefits for the amount.

Two months later, Bilodeau has yet to receive the funds, though he was told on the phone that MSH made three attempts to transfer money through his bank, but was unable to do so. After deciding to get a paper cheque instead, Bilodeau is still waiting.

“It’s absolutely mind-boggling. It’s the most frustrating thing,” Bilodeau said.

Stephen Lake, a retired military member living in Florida, has been struggling for reimbursement of claims since last year. He has received cheques for incorrect amounts or that he can’t cash despite asking for funds to be sent electronically.

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Lake also recently had surgery for a hernia that cost him about $5,000. Despite putting it off partially due to concerns about the health plan, he said it couldn’t wait any longer.

Now, he has been told he will only receive reimbursement of $200 for a doctor’s referral and an initial doctor’s visit, while his hospital and surgeon bills have been denied.

“Because of PSHCP and (Canada Life) not solving my problem, I have had to cancel everything I don’t need to survive, except my phone, to lessen the financial impact,” Lake said. “If this doesn’t get resolved soon, I cannot afford to carry $5,000 on my credit card for eight months or more, as I have with the smaller claims.”

Pamela Kwiatkowski, a spokesperson with MSH, wrote in an email that the company had been “working directly” with individuals to address their unique concerns.

“Our focus remains on care for plan members, and we expect to resolve the challenges that were mostly caused by factors outside of our control later this summer,” Kwiatkowski said.

Canada Life and MSH are working to clear a backlog of claims that they say has been reduced by more than 80 per cent since March. MSH has also doubled claims processing capacity and increased staff by 52 per cent, now answering phone calls in two minutes on average.

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Retired public servant Brian Price has also faced problems with MSH since the transition, with his initial enrolment taking 10 months.

A year later, Price is owed around $1,000, with some claims dating back to 2023.

“Repeated emails to them come back with absolutely no useful information,” Price said, adding he had re-submitted several claims. “I’ve got a bunch sitting on my table and I’m just wondering how many years that’s gonna take.”

Leezann Freed-Lobchuk, a spokesperson for Canada Life, wrote in an email that the company “empathizes” with members who had experienced difficulties with out-of-country medical claims.

“Those challenges are in part a result of a number of factors inherited and unique to this plan,” she said. “We’ve been working closely with the Government and MSH to resolve those in order to provide members with the timely and quality service they deserve.”

Carolyn Smith, a retired public servant living in Puerto Vallarta, has received pushback from MSH about replacing her husband’s expired CPAP machine and is concerned she won’t be reimbursed for the cost.

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When he first got a CPAP eight years ago, Smith said he couldn’t complete a sleep study as he couldn’t stay asleep, and it was determined through a software program that he needed a machine.

“He does need it,” said Smith, who launched a petition that collected almost 3,000 signatures and was presented to the House of Commons on June 3. “I used to hit him in the middle of the night because he wasn’t breathing.”

After fighting MSH’s argument that her husband needed to get a sleep study done again, Smith said the company has authorized the cost and he has purchased the $1,100 machine.

“We’ll see if they pay out,” Smith said, adding she had looked into filing a lawsuit, but feared it would take too long. “We need our insurance now. We need it fixed now.”

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