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For Employees and
Eligible Dependents
The Extended Health Care benefit is designed to provide
valuable supplementary protection to the provincial hospital and
medical care plans. It is not intended to duplicate them.
Therefore, the Extended Health Care benefits exclude services
and supplies to the extent benefits can be obtained under a
provincial plan by fulfilling the requirements of that plan, or
services and supplies where private insurance is prohibited.
Benefits Paid
The insurance applies to expenses for the treatment of
pregnancies, non-occupational accidents and illnesses.
The Plan will pay 90% of all eligible expenses incurred by the
Employee or covered dependent, up to a maximum of $1,000,000 per
lifetime. At the end of each year, up to $1,000 of this maximum,
that has been paid in benefits, will be restored
automatically.
Eligible Out of Canada expenses will be reimbursed at 100% up to
and included in the overall EHB lifetime maximum of $1,000,000.
Coverage is limited to 60 days outside of Canada for emergency
services.
There is a calendar year deductible of $25 per individual or $50
per family, applied only to prescription drugs and oral
contraceptives. This deductible is applied only once a year,
even if the individual has several accidents or illnesses.
Family Deductible Feature
If the total of $50 of eligible expenses is incurred
collectively by the family members during the calendar year, no
further deductibles will be required on any of the family
members for the rest of the year. But, not more than $25 of any
one individual’s expenses may be applied toward the family
deductible.
Deductible Carry-Over Provision
Expenses incurred in the last three months of a calendar year,
which are applied to that year’s deductible, may also be
applied to the deductible for the next calendar year.
Eligible Expenses
(To the extent of expenses not excluded on account of
provincial plans or other exclusions described later.)
Vision Care (part of EHB, paid at 90%)
A benefit of $400 per Employee/spouse and $350 per eligible
dependent child is available for reimbursement of any one pair
of eyeglasses in any 24-consecutive month period, including
charges for examinations (when not covered by the provincial
plan), frames, lenses, and dispensing fees. This limit also
applies to contact lenses purchased in lieu of eyeglasses unless
the contact lenses are the only means available to restore the
visual acuity of the better eye to at least 20/70 or are
purchased following cataract surgery.
Please note that charges incurred in connection with sunglasses
(whether or not prescription) or safety glasses are not a
covered expense. However, prescription safety glasses are an
eligible expense.
Laser Eye Surgery Expenses
For Employees only, expenses for Laser Eye Surgery will
be reimbursed at 100% to a lifetime maximum of $1,500.
Expenses Incurred While Outside Canada
Emergency hospital, medical, surgical, Dental and other
similar expenses incurred by an Employee or his/her eligible
insured dependents while travelling on vacation or business
outside of Canada will be eligible under this Plan, just as they
are while in Canada. (Provided it is within 60 days of leaving
Canada) This benefit is provided through Viator
Out-of-Province/Canada Travel Medical Emergency Insurance Policy
#32445291, through Expert Travel Financial Security (E.T.F.S.).
In the event of an emergency the insured must immediately
contact Global Excel (the company appointed to provide medical
assistance and claims services). Global Excel will open a claim
file, assist in locating proper medical care, verify coverage
and assist in co-ordinating payment of the claim with the
Provincial Medical Plan and the Plan’s policy. A Medical
Assistance Card, with worldwide contact numbers, for the Viator
Emergency coverage should be carried by the Insured when
travelling. These cards can be obtained from the employer or
Administrator. Employees working outside of Canada must arrange
for additional coverage.
Before submitting claims for such expenses, they must be
submitted to the Provincial Medical Plan for payment. To the
extent that expenses are reasonable and customary (relative to
charges in the area in which they were incurred) and there
remains a balance unpaid by the Provincial Medical Plan, it will
be payable under the terms of this Plan, provided payment of the
charges is allowed by law. Coverage for Out-Of-Country/Province
terminates at age 75.
For more information, please see the Out
of Province/Canada Travel Medical Emergency Insurance booklet.
Extension of Benefits
Under certain circumstances, as described in the Group
Policy, Extended Health benefits will be available for 3 months
after the termination of insurance, if that Employee is Totally
Disabled when the insurance terminates. This extension of
benefits will apply only to expenses due to the sickness or
injury which caused the Total Disability.
Benefit Exclusions
- Services or supplies to the extent benefits are provided
under any provincial plan or other government plan or law
under which the individual is or could be covered, or to the
extent to which benefits would be provided had the individual
met the requirements for having the care or services furnished
under the plan or law.
- Services or supplies for which
insurance benefits are prohibited by any provincial plan or
other government plan or law.
- Charges incurred in
connection with an injury or disease related to employment.
- Certain expenses, as described in the group policy, incurred
for government furnished care or treatment.
- Anything not
ordered by a doctor, or not necessary for medical or vision
care.
- The portion of a charge in excess of the reasonable
and customary charge (the usual charge when there is no
insurance) not to exceed the prevailing charge in the area for
a comparable service by a person of similar training and
experience, or for a comparable supply.
- Expenses for
cosmetic surgery unless due to an accident occurring while
covered.
- Treatment of periodontal or periapical disease or
any condition involving teeth, surrounding tissue or
structure, except as described in “Dental treatment due to
accident”.
- Examinations in connection with glasses except
as described in “Vision Care”.
- Charges for “check-ups”
(including screening, routine physical examinations, and
research studies) unless part of an illness, injury or
pregnancy (including pre- and post-natal care).
- Telephone
consultations.
- Nursing, speech therapy, or physiotherapy
rendered by the Employee, Spouse, or a child, brother, sister,
or a parent of the Employee or Spouse.
- Vitamins, minerals,
foods and dietary supplements whether or not a prescription is
given for a medical reason.
- Services of an acupuncturist.
- Services/supplies received as a result of
participation in a riot or civil commotion.
- Services/supplies received as a result of the commission of or
attempted commission of a criminal offense or the provoking of
an assault excluding charges in connection with offenses
related to the operation of a motor vehicle with a blood
alcohol content in excess of the legal limit in the province
of residence of the Insured.
- Services/supplies received due
to intentionally self-inflicted injury while sane or insane.
- Charges for which recipient is not required to make payment or
where payment is received as a result of legal action or
settlement.
- Prescription drugs, medical testing, surgical
procedures and appliances considered by the Plan to be
experimental and not recognized by Health Canada as an
established standard treatment for the condition.
- Charges
for, or in connection with, any services received or performed
outside of Canada which (i) are due to a pregnancy (includes
childbirth, miscarriage, or any complications incident to a
pregnancy) and which are received or performed after the 32nd
week of gestation or (ii) are due to the deliberate inducement
of a miscarriage.
How to File a Claim
A claim form for Extended Health Benefits must be
completed for each person in the family who has eligible
expenses. Specify the dependent’s name, the Employee’s name,
address, policy number, Social Insurance Number/certificate
number and list receipts.
Both the original receipts and the
forms should be sent to the Administrator. Although claims for
Extended Health Benefits can be made at any time, it would be
preferable if they were sent every two or three months. Only
receipts for the current and previous calendar year are payable.
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