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Employee Life Insurance
Short Term Disability Income Benefits
Long Term Disability Income
Benefits
Health care
Dental Care
Commencement and Termination of Coverage
Survivor Benefits
Dependent Coverage
Employee Life Insurance
Short Term
Disability (Std) Income Benefits
Long Term
Disability (Ltd) Income Benefits
Health
Care
Vision Care
Global Medical Assistance Program
Out-Of-Province Care
Dental
Care
Coordination of Benefits
Great-West Life is a leading Canadian life and health insurer. Great- West
Lifes financial security advisors work with our clients
from coast to coast to help them secure their financial future. We provide a
wide range of retirement savings and income plans;
as well as life, disability and critical illness insurance for individuals and
families. As a leading provider of employee benefits in Canada,
we offer effective benefit solutions for large and small employee groups.
Great-West Life Online
Information and details on Great-West Lifes corporate profile, our products
and services, investor information,
news releases and contact information can all be found at our website
http://www.gwl.ca.
This web page describes the principal features of the group benefit plan
sponsored by your employer, but Group Policy No. 154850
issued by Great-West Life is the governing document. If there are variations
between the information in the booklet and the provisions
of the policy, the policy will prevail.
The Plan is underwritten by
THE Great-West Life ASSURANCE COMPANY
Protecting Your Personal Information
At
Great-West Life, we recognize and respect the importance of privacy. When you
apply for coverage or benefits,
we establish a confidential file of personal information. We limit access to
personal information in your file to
Great-West Life staff or persons authorized by Great-West Life who require it to
perform their duties, to persons
to whom you have granted access, and to persons authorized by law.
We use the personal information to administer the group benefit plan under which
you are covered.
This includes many tasks, such as:
determining your eligibility for coverage under the plan
enrolling you for coverage
assessing your claims and providing you with payment
managing your claims
verifying and auditing eligibility and claims
underwriting activities, such as determining the cost of the plan, and
analyzing the design options of the plan
preparing regulatory reports, such as tax slips
We may exchange personal information with your health care providers, your plan
administrator, other insurance or
reinsurance companies, administrators of government benefits or other benefit
programs, other organizations, or service
providers working with us when necessary to administer the plan.
All claims under this plan are submitted through you as plan member. We may
exchange personal information about
claims with you and a person acting on your behalf when necessary to confirm
eligibility and to mutually manage the claims.
For more information about our privacy guidelines, please ask for GreatWest
Lifes Privacy Guidelines brochure.
Benefit Summary
This summary must be read together with the benefits described
in this booklet.
Employee Life Insurance
Effective May 1, 2003
$82,000
Effective May 1, 2004
$84,050
Effective May 1, 2005
$85,750
Effective May 1, 2006
$87,450
Effective May 1, 2007
$89,200
Short Term Disability
Income Benefits
Waiting Period *
Injury
No waiting period
Disease/Sickness
3 days
1 day if the disease/sickness requires kidney analysis, chemotherapy, radiation
or other similar recurring treatments
If you are hospitalized or have day surgery before the last day of the waiting
period for disease/sickness, benefits will
begin on the day you are hospitalized or the surgery is performed
* You should consult your physician within the first five days of disability
Maximum Benefit Period
52 weeks
Amount
Employees who earn less than $15.50 per hour $415
Employees who earn $15.50 per hour or more $420 plus an
additional $5 for each additional $.25 of earnings you receive over $15.50
Maximum Weekly Benefit
Effective May 1, 2003
$640
Effective May 1, 2004
$655
Effective May 1, 2005
$670
Effective May 1, 2006
$685
Effective May 1, 2007
$700
Long Term Disability Income
Benefits
Waiting Period
52 weeks
from original date of disability
Amount
50% of your monthly earnings to a maximum benefit of $7,500
Any amount of LTD insurance over $3,500 is subject to approval of
evidence of insurability
Health Care
Deductibles
Individual
$10
each calendar year
Family
$25 each calendar year
The individual and family deductibles do not apply to In-province Private
Hospital, Chronic Care, Out-of-province Care and Global
Medical Assistance expenses
Reimbursement Levels
In-province Semi-Private
Hospital,
Chronic Care, Out-of-province
Care and Global Medical
Assistance Expenses
100%
All Other Expenses
80% until
$4,000 of benefits have been paid to you and your
dependents in a calendar year and 100% for the remainder of the calendar year
Basic Expense Maximums
In-province Hospital
Private room
Convalescent Hospital
Semi-private room
Home Nursing Care
720 hours each
calendar year
Chronic Care
Semi-private room $25 per day
In-province Prescription Drugs
Included
Hearing Aids
$600
every 3 years (for eligible children only)
In-province Ambulance
$500 each calendar year
Custom-fitted Orthopedic Shoes 1
pair every 12 months for a maximum of $400 per pair
Custom-made Foot Orthotics
$250 each calendar year
Myoelectric Arms
$10,000 per
prosthesis
External Breast Prosthesis
1 every 12 months
Surgical Brassieres
2 every 12
months
Mechanical or Hydraulic Patient Lifters
$2,000 per lifter once every 5 years
Outdoor Wheelchair Ramps
$2,000 lifetime
Blood-glucose Monitoring Machines Included
Transcutaneous Nerve Stimulators $700
lifetime
Extremity Pumps for Lymphedema $1,500
lifetime
Custom-made Compression Hose $100
each calendar year
Wigs or Hairpieces for Patients suffering from
Cancer or Alopecia
$500 lifetime
Intra-uterine Devices Included
Out-of-province
Non-emergency Care
$50,000 lifetime
Out-of-province Care
(Emergency and Non-emergency combined) $1,000,000
lifetime
Paramedical Expense Maximums
Acupuncturists
$150 per
person each calendar year
Chiropractors
$150
per person or $500 per family each calendar year
(including $10 per person for x-rays each calendar year)
Massage Therapists
$300 per person
each calendar year
Naturopaths
$150
per person or $500 per family each calendar year
Osteopaths
$150 per person or $500 per family each calendar year
(including $10 per person for x-rays each calendar year)
Podiatrists
$150 per person or $500 per family each calendar year
(including $10 per person for x-rays each calendar year)
Physiotherapists
$300 per
person each calendar year
Psychologists
$350
per person each calendar year
Speech Therapists
$100 per
person each calendar year
Vision care Expense Maximum
Glasses and Contact Lenses
$350 every 24 months
Lifetime Healthcare Maximum
Unlimited
Dental Care
Payment Basis The dental fee guide in effect in your province of residence
on the date treatment is rendered
Deductible
Nil
Reimbursement Levels
Basic Coverage
90%
Major Coverage
50%
Orthodontic Coverage
50%
Plan Maximums
Orthodontic Treatment
$3,500 lifetime
All Other Treatment
Unlimited
COMMENCEMENT AND
TERMINATION OF COVERAGE
You are eligible to
participate in the plan after 40 days of continuous employment. You are
considered continuously employed
only if you satisfy the actively at work requirement throughout the eligibility
waiting period.
You and your dependents will be covered as soon as you become eligible.
You may waive health and dental coverage if you are already covered for these
benefits under your spouses plan.
If your coverage under your spouses plan terminates, you must apply for
coverage under this plan no later than 60 days
after termination. After 60 days, you must provide evidence of insurability
for you and your dependents before you can participate.
Your dental benefits will be subject to certain restrictions.
You must be actively at work when coverage takes effect, otherwise the
coverage will not be effective until you return to work.
Increases in your benefits while you are covered by this plan will not become
effective unless you are actively at work.
Temporary, part-time and seasonal employees may not join the plan.
Your coverage terminates when your employment ends, you are no longer
eligible, or the policy terminates, whichever is earliest.
Your dependents coverage terminates when your insurance terminates or your
dependent no longer qualifies, whichever is earlier.
When your coverage terminates, you may be entitled to an extension of benefits
under the plan. Your employer will provide you with details.
Survivor Benefits
If you die while
your coverage is still in force, the health and dental benefits for your
dependents will be continued for a period
of 12 months or until they no longer qualify, whichever happens first, provided
they have no other coverage.
DEPENDENT COVERAGE
Dependent means:
Your spouse, legal or common-law.
A common-law spouse is a person who has been living with you in a conjugal
relationship for at least 12 months.
Your unmarried children under age 21. Full-time students are covered without
age limit.
Children under age 21 are not covered if they are working more than 30 hours
a week, unless they are full-time students.
Children who are incapable of supporting themselves because of physical or
mental disorder are covered without age limit if the
disorder begins before they turn 21, or while they are students, and the
disorder has been continuous since that time.
EMPLOYEE LIFE INSURANCE
You may name a
beneficiary for your life insurance and change that beneficiary at any time by
completing a form available from your
employer. On your death, your employer will explain the claim requirements to
your beneficiary. Great-West Life will pay your life
insurance benefits to your beneficiary.
You are entitled to waiver of premium benefits after you have been
continuously disabled for 52 weeks from original date of disability.
You will be considered disabled during the period you are entitled to receive
Long Term Disability benefits.
If any or all of your insurance terminates, you may be eligible to apply for
an individual conversion policy without providing
proof of your insurability. You must apply and pay the first premium no later
than 31 days after your group insurance terminates.
See your employer for details.
SHORT TERM DISABILITY
(STD) INCOME BENEFITS
The plan provides you with benefits to replace income lost because of a
disability due to disease/sickness or injury.
Benefits begin after the waiting period is over and continue until you are no
longer disabled, until the end of the benefit
period, until you reach age 65 or retire, whichever comes first. However, if
disability began prior to age 65, STD benefits
will continue until you have received at least 15 weeks of benefits, or until
you are no longer disabled or retire, whichever comes first.
Check the Benefit Summary for the benefit amount, waiting period and
benefit period.
STD benefits are payable after the waiting period if disease/sickness or
injury prevents you from doing your own job.
You are not considered disabled if you can perform a combination of duties
that regularly took at least 60% of your time to complete.
Benefits will not be payable until after your first visit to the physician.
However, if you consult your physician within the
first five days of disability, benefits will be payable at the end of the
waiting period.
Separate periods of
disability arising from the same disease/sickness or injury are considered to be
one period of disability
unless they are separated by at least 2 weeks of continuous full-time work.
Because your employer contributes to the cost of STD coverage, benefits are
taxable.
Other Income
Your STD benefit is reduced by other income you are entitled to receive
while you are disabled. Other income includes:
disability benefits you or another member of your family is entitled to on the
basis of your disability under the Canada or
Quebec Pension Plan that are paid directly to you, except for increases that
take effect after the benefit period starts
benefits under any Workers Compensation Act or similar law
benefits under a legislated automobile insurance plan where permitted by law
Earnings received from an approved rehabilitation plan or program are not used
to reduce your STD benefit unless those earnings,
together with your income from this plan and the other income listed above,
would exceed your weekly earnings before you
became disabled. If it does, your benefit is reduced by the excess amount.
Vocational Rehabilitation Benefits
Vocational rehabilitation involves a work related activity or training
strategy that is designed to help you return to gainful employment
and a more productive lifestyle. A plan or program will be approved if it is
appropriate for the expected duration of your disability and
it facilitates your earliest possible return to work.
Medical Coordination Benefits
Medical
coordination is a process of early involvement to ensure that you are diagnosed
quickly and receive appropriate treatment on a timely basis.
The goal is to enable you to return to work as early as possible and to prevent
the disability from becoming long term or permanent.
Limitations
No benefits are paid for:
Any period in which you do not participate or cooperate in a prescribed plan
of medical treatment appropriate for your condition.
Depending on the severity of the condition, you may be required to be under
the care of a specialist.
If substance abuse contributes to your disability, the treatment program must
include participation in a recognized substance withdrawal program.
The scheduled duration of a lay-off or leave of absence. However, if
disability began prior to notice of lay-off, STD benefits
will continue until you have received at least 15 weeks of benefits or until
you are no longer disabled or retire, whichever comes first.
This does not apply to any portion of a period of maternity leave during
which you are disabled due to pregnancy.
Any period of employment, except in an approved rehabilitation plan or
program.
Any period after you fail to participate or cooperate in an approved
rehabilitation plan or program.
Any period after you fail to participate or cooperate in a recommended medical
coordination program.
Disability due to or associated with cosmetic treatment.
Any period of confinement in
a prison or similar institution.
Disability arising from war, insurrection or voluntary participation in a
riot.
Any claim submitted more than 90 days after the onset of your disability.
Any period during which you are receiving long term disability benefits under
the recurrence provision of your employers
long term disability plan
How to Make a Claim
Notify your employer of your disability as soon as possible. Obtain an
Employee Claim Submission Guide (form M5454) from
your employer and follow the guides instructions. Please ensure that your claim
is submitted to Great-West Life within 10 days
after the onset of your disability for prompt assessment of your claim, but
never more than 90 days after the onset of your disability.
LONG TERM DISABILITY
(LTD) INCOME BENEFITS
The plan provides you with benefits to replace income lost because of a
lengthy disability due to disease/sickness or injury.
Benefits begin after the waiting period is over and continue until you are no
longer disabled as defined by the policy or you
reach age 60 (if you have less than 11 years of service) or age 65 (if you have
11 years or more of service), whichever comes first.
Check the Benefit Summary for the benefit amount and waiting period.
If disability is not continuous, the days you are disabled can be accumulated to
satisfy the waiting period as long as no interruption
is longer than 2 weeks and the disabilities arise from the same disease/sickness
or injury. If your STD benefits are still being paid
when the waiting period ends, the waiting period will be extended until the end
of the STD benefit period, but not later than one
year after your disability started.
LTD benefits are payable for
the first 18 months following the waiting period if disease/sickness or injury
prevents you from
doing your own job. You are not considered disabled if you can perform
a combination of duties that regularly took at least
60% of your time to complete.
After 18 months, LTD benefits will continue only if your disability prevents
you from being gainfully employed in any job.
Gainful employment is work you are medically able to perform, for which you
have at least the minimum qualifications, and
provides you with an income of at least 50% of your indexed monthly earnings
before you became disabled.
After the waiting period, separate periods of disability arising from the same
disease/sickness or injury are considered to be
one period of disability unless they are separated by at least 6 months.
Because your employer contributes to the cost of LTD coverage, benefits are
taxable.
Your LTD insurance terminates when you reach age 65.
Other Income
Your LTD benefit is reduced by other income you are entitled to receive
while you are disabled, but your LTD benefit will never be
lower than $25 per month. Your benefit is first reduced by:
disability benefits you or another member of your family is entitled to on the
basis of your disability under the Canada or
Quebec Pension Plan that are paid directly to you, except for increases that
take effect after the benefit period starts
retirement benefits under the Canada or Quebec Pension Plan, except for
increases that take effect after the benefit period starts
benefits under any Workers Compensation Act or similar law
There is a further reduction
of your LTD benefit if the total of the income listed below exceeds 70% of your
indexed monthly
earnings before you became disabled. If it does, your benefit is reduced by the
excess amount.
your income under this plan
loss of income benefits available through legislation, except for Employment
Insurance benefits, which you and any other
member of your family are entitled to on the basis of your disability,
including automobile insurance benefits where permitted by law
disability benefits under a plan of insurance available through membership in
an association
employment income, disability benefits, or retirement benefits related to any
employment except an approved rehabilitation plan or program
(termination pay and severance benefits are included as employment income
under this provision)
Earnings received from an approved rehabilitation plan or program are not used
to reduce your LTD benefit unless those earnings,
together with your income from this plan and the other income listed above,
including any increases in Canada or Quebec Pension
Plan benefits that take effect after the benefit period starts, would exceed
your indexed monthly earnings before you became disabled.
If it does, your benefit is reduced by the excess amount.
Vocational Rehabilitation Benefits
Vocational rehabilitation involves a work related activity or training
strategy that is designed to help you return to gainful employment
and a more productive lifestyle. A plan or program will be approved if it is
appropriate for the expected duration of your disability and
it facilitates your earliest possible return to work.
Medical Coordination Benefits
Medical
coordination is a process of early involvement to ensure that you are diagnosed
quickly and receive appropriate treatment
on a timely basis. The goal is to enable you to return to work as early as
possible and to prevent the disability from becoming long
term or permanent.
Limitations
No benefits are paid for:
Disability arising from a disease/sickness or injury for which you received
medical care before your insurance started.
This limitation does not apply if your disability starts after you have been
continuously insured for 1 year, or you have
not had medical care for the disease/sickness or injury for a continuous
period of 90 days ending on or after the date
your insurance took effect.
Any period in which you do not participate or cooperate in a prescribed plan
of medical treatment appropriate for your condition.
Depending on the severity of the condition, you may be required to be under the
care of a specialist.
If substance abuse contributes to your disability, the treatment program must
include participation in a recognized substance
withdrawal program.
The scheduled duration of a lay-off or leave of absence.
This does not apply to any portion of a period of maternity leave during which
you are disabled due to pregnancy.
Any period after you fail to participate or cooperate in an approved
rehabilitation plan or program.
Any period after you fail to participate or cooperate in a recommended medical
coordination program.
Any 12-month period in which
you do not live in Canada for at least 6 months.
Any period of confinement in a prison or similar institution.
Disability arising from war, insurrection, or voluntary participation in a
riot.
How to Make a Claim
Before the end of the short term disability benefit period, Great-West Life
will ask your employer to provide information to begin
processing your LTD claim. All information must be submitted within 6 months of
the request.
HEALTH CARE
A deductible may be applied before you are reimbursed. All expenses will be
reimbursed at the level shown in the Benefit Summary.
Benefits may be subject to plan maximums and frequency limits. Check the
Benefit Summary for this information.
The plan covers the following services and supplies if they are not covered
under your provincial government plan and provincial
law permits the plan to cover them. All covered services and supplies must
represent reasonable treatment. Treatment is
considered reasonable if it is accepted by the Canadian medical profession, it
is proven to be effective and it is of a form, intensity,
frequency and duration essential to diagnosis or management of the
disease/sickness or injury.
Covered Expenses
Ambulance transportation to the nearest centre where adequate treatment is
available
Private room and board in a
hospital in the province of residence
For out-of-province accommodation, any difference between the hospitals
standard ward rate and the government
authorized allowance in your home province is covered.
Great-West Life also covers the hospital facility fee related to dental surgery
and any out-of-province hospital out-patient
charges not covered by the government health plan in your home province.
Convalescent care for a condition that will significantly improve as a result
of the care and follows a 3-day confinement
for acute care. Confinement in a convalescent care hospital provided that it
occurs within 48 hours following discharge
from an active unit in a public hospital and is required for at least 5
consecutive days.
The government authorized co-payment for accommodation in a nursing home.
Residences established primarily
for senior citizens or which provide personal rather than medical care are
not covered.
Home nursing services of a registered nurse, licensed practical nurse or
registered nursing assistant who is not a
member of your family, but only if the patient requires the specific skills
of a trained nurse
You should apply for a pre-care assessment before home nursing begins
Chronic care, provided in a hospital, nursing home or for home nursing care,
for a condition where improvement or
deterioration is unlikely within the next 12 months. Confinement in a chronic
care hospital provided that it occurs within
48 hours following discharge from an active unit in a public hospital and is
required for at least 5 consecutive days.
Drugs and medicines which
require the written prescription of a physician or dentist and are dispensed by
a licensed
pharmacist, as well as certain life-sustaining drugs, injectable drugs and
syringes for self-administered injections, when
provided in the province of residence. Benefits for drug expenses outside the
province of residence are payable only as
provided under the out-of-province care provision.
For drugs eligible under a provincial drug plan, coverage is limited to the
deductible amount and coinsurance you are
required to pay under that plan.
Rental or, at Great-West Lifes discretion, purchase of certain medical
supplies, appliances and prosthetic devices
prescribed by a doctor
Intra-Uterine Devices (I .U.D.s)
Custom-made foot orthotics and custom-fitted orthopedic shoes, including
modifications to orthopedic footwear
Hearing aids including batteries, tubing and ear molds provided at the time of
purchase for eligible children only
Diabetic supplies including insulin, syringes, Novolin pens, testing supplies
and insulin infusion sets
Blood-glucose monitoring machines
Diagnostic x-rays and lab tests
Treatment of injury to sound natural teeth. Treatment must start within 60
days after the accident unless
delayed by a medical condition
A sound tooth is any tooth that did not require restorative treatment
immediately before the accident.
A natural tooth is any tooth that has not been artificially replaced
No benefits are paid for:
- accidental damage to dentures
- dental treatment completed more than 12 months after the accident
- orthodontic diagnostic services or treatment
Out-of-hospital services of a qualified acupuncturist
Out-of-hospital treatment of muscle and bone disorders, including diagnostic
x-rays, by a licensed chiropractor
Out-of-hospital services of a qualified massage therapist
Out-of-hospital services of a licensed naturopath
Out-of-hospital services of a licensed osteopath, including diagnostic x-rays
Out-of-hospital treatment of foot disorders, including diagnostic x-rays, by a
licensed podiatrist
Out-of-hospital treatment of movement disorders by a licensed physiotherapist
Out-of-hospital treatment by a registered psychologist
Out-of-hospital treatment of speech impairments by a qualified speech
therapist
Vision Care
Glasses and contact lenses required to correct vision when provided by a
licensed ophthalmologist, optometrist or optician
For information on available discounts on eyewear and vision care services,
refer to the Preferred Vision Services section of this
booklet following the Healthcare benefit.
Global Medical Assistance
Program
This program
provides medical assistance through a worldwide communications network which
operates 24 hours a day.
The network locates medical services and obtains Great-West Lifes approval of
covered services, when required as a result
of a medical emergency arising while you or your dependent is traveling for
vacation, business or education. Coverage for
travel within Canada is limited to emergencies arising more than 500 kilometres
from home. You must be covered by the
government health plan in your home province to be eligible for global medical
assistance benefits.
The following services are covered, subject to Great-West Lifes prior approval:
On-site hospital payment when required for admission, to a maximum of $1,000
If suitable local care is not available, medical evacuation to the nearest
suitable hospital while traveling in Canada.
If travel is outside Canada, transportation will be provided to a hospital in
Canada or to the nearest hospital outside
Canada equipped to provide treatment
Transportation and lodging for one family member joining a patient
hospitalized for more than 7 days while traveling alone.
Benefits will be paid for moderate quality lodgings up to $1,500 and for a
round trip economy class ticket
If you or a dependent is hospitalized while traveling with a companion, extra
costs for moderate quality lodgings for the companion
when the return trip is delayed due to your or your dependents medical
condition, to a maximum of $1 ,500
The cost of comparable return transportation home for you or a dependent and
one traveling companion if prearranged, prepaid
return transportation is missed because you or your dependent is
hospitalized. Coverage is provided only when the return fare is
not refundable. A rental vehicle is not considered prearranged, prepaid
return transportation
In case of death,
preparation and transportation of the deceased home
Return transportation home for minor children traveling with you or a
dependent who are left unaccompanied because of your
or your dependents hospitalization or death. Return or round trip
transportation for an escort for the children is also covered
when considered necessary
Costs of returning your or your dependents vehicle home or to the nearest
rental agency when illness or injury prevents you or
your dependent from driving, to a maximum of $1 ,000. Benefits will not be
paid for vehicle return if transportation reimbursement
benefits are paid for the cost of comparable return transportation home
Benefits payable for moderate quality accommodation include telephone expenses
as well as taxicab and car rental charges.
Meal expenses are not covered.
Out-Of-Province Care
Emergency care outside your home province is covered if it is required as
a result of a medical emergency arising while
you or your dependent is temporarily outside your home province for vacation,
business or education purposes. To qualify
for benefits, you must be covered by the government health plan in your home
province.
A medical emergency is either a sudden, unexpected injury, or a sudden,
unexpected illness or acute episode of disease/sickness
that could not have been reasonably anticipated based on the patients prior
medical condition.
Emergency care is covered medical treatment that is provided as a result of
and immediately following a medical emergency.
If your condition permits a
return to your home province, benefits are limited to the lesser of:
- the amount payable under this plan for continued treatment outside your home
province, and
- the amount payable under this plan for comparable treatment in your home
province plus the cost of return transportation.
No benefits are paid for:
- any further medical care related to a medical emergency after the initial
acute phase of treatment. This includes
non- emergency continued management of the condition originally treated as an
emergency
- any subsequent and related episodes during the same absence from your home
province
- expenses related to pregnancy and delivery, including infant care:
- after the 34th week of pregnancy, or
- at any time during the pregnancy if the patients medical history indicates a
higher than normal risk of an early delivery or complications.
Non-emergency care outside your home province is covered for you and your
dependents if:
- it is required as a result of a referral from your usual physician in your
home province
- it is not available in your home province and must be obtained elsewhere for
reasons other than waiting lists or scheduling difficulties
- you are covered by the
government health plan in your home province for a portion of the cost, and
- a pre-authorization of benefits is approved by Great-West Life before you
leave your home province for treatment.
No benefits will be paid for:
- investigational or experimental treatment
- transportation or accommodation charges.
The plan covers the following services and supplies when related to out- of
-province care:
treatment by a physician
diagnostic x-ray and laboratory services
hospital accommodation in a standard or semi-private ward or intensive care
unit, if the confinement begins while you or
your dependent is covered
medical supplies provided during a covered hospital confinement
paramedical services provided during a covered hospital confinement
hospital out-patient services and supplies
medical supplies provided out-of-hospital if they would have been covered in
your home province
drugs
out-of-hospital services of a professional nurse
for emergency care only:
- ambulance services by a licensed ambulance company to the nearest centre where
essential treatment is available
- dental accident treatment if it would have been covered in your home province.
Limitations
No benefits are paid for:
Expenses private insurers are not permitted to cover by law
Services or supplies you are entitled to without charge by law or for which a
charge is made only because you have insurance coverage
The portion of the expense for services or supplies that is payable by the
government health plan in your home province, whether or
not you are actually covered under the government health plan
Services or supplies that do not represent reasonable treatment
Services or supplies associated with:
- treatment performed only for cosmetic purposes
- recreation or sports rather than with other daily living activities
- the diagnosis or treatment of infertility
- contraception, other than oral contraceptives and intra-uterine devices
Services or supplies not listed as covered expenses
Extra medical supplies that are spares or alternates
Services or supplies received outside Canada except as listed under
Out-of-province Care and Global Medical Assistance
Services or supplies
received out-of-province in Canada unless you are covered by the government
health plan in your
home province and Great-West Life would have paid benefits for the same
services or supplies if they had been received
in your home province
This limitation does not apply to Global Medical Assistance
Expenses arising from war, insurrection, or voluntary participation in a riot
Visioncare services and supplies required by an employer as a condition of
employment
Any drug or item which does not have a drug identification number as defined
by the Food and Drugs Act, Canada
Proprietary or patent medicines registered under the Food and Drugs Act,
Canada
Homeopathic preparations, unless federal or provincial legislation requires a
prescription for their sale
Food products, weight-loss products and drugs prescribed for the treatment of
obesity
Vaccines used to prevent disease/sickness
Smoking cessation products
Fertility drugs, whether or not prescribed for a medical reason
Drugs used to treat erectile dysfunction
How to Make a Claim
Out-of-country
claims (other than those for Global Medical Assistance expenses) should be
submitted to Great-West Life as
soon as possible after the expense is incurred. It is very important that you
send your claims to the Great-West Life Out-of-Country
Claims Department immediately as your Provincial Medical Plan has very strict
time limitations.
Obtain form M5432 (Statement of Claim Out-of-Country Expenses form) from your
employer. Residents of all provinces except
Manitoba and the Territories must also obtain the Government Assignment form and
residents of British Columbia, Quebec and
Newfoundland & Labrador must also obtain the Special Government Claim form. The
Great-West Life Out-of-Country Claims Department
will forward the appropriate government forms to your attention when required.
If you are a resident in the Territories or Manitoba, you must submit your
out-of-country claims to your provincial or territorial
government for processing before submitting the claim to Great-West Life. When
you receive your Explanation of Benefits back
from the province or territory, please send the following to the Great-West Life
Out-of- Country Claims Department
(be sure to keep copies for your own records):
- a copy of the payment from your province or territory
- a completed Statement of Claim Out-of-Country Expenses form (form M5432)
- all required information
- copies of all original receipts
Residents of all other provinces should complete all applicable forms, making
sure all required information is included.
Attach all original receipts and forward the claim to the Great-West Life Out-of
Country Claims Department.
Be sure to keep a copy for your own records. The plan will pay all eligible
claims including your Provincial Medical Plan portion.
Your Provincial Medical Plan will then reimburse the plan for the governments
share of the expenses.
Out-of-country claims must be
submitted within a certain time period that varies by province. For the claims
submission
period applicable in your province or territory or for any other questions or
for assistance in completing any of the forms,
please contact Great- West Lifes Out-of-Country Claims Department at
1-800-957-9777.
For all other Healthcare claims, obtain form M635D from your employer.
Complete this form making sure it shows all required information.
Attach your receipts to the claim form and return it to the Great-West Life
Benefit Payment Office as soon as possible, but no later than
15 months after you incur the expense.
PREFERRED VISION SERVICES (PVS)
Preferred Vision Services (PVS) is a service provided by Great- West Life
to its customers through Preferred Vision Services.
Preferred Vision Services (PVS) entitles you to a discount on a wide
selection of quality eyewear and lens extras (scratch guarding, tints, etc.)
when you purchase these items from a PVS network optician or optometrist. You
are eligible to receive the PVS discount through the network
whether or not you are enrolled for the healthcare coverage described in this
booklet. You can use the PVS network as often as you wish to
purchase eyewear for yourself and your dependents at a reduced cost.
Shopping for eyewear through PVS:
Call the PVS Information Hotline at 1-800-668-6444 or visit the PVS
Web site at www.pvs.ca for information about PVS locations
and the program
Arrange for a fitting or eye examination, if needed
Present your group benefit
plan identification card to identify your preferred status as a PVS member
through Great-West Life
at the time of purchase
Select your eyewear and pay the reduced PVS price, If you have vision care
coverage, obtain a receipt and submit it with a
claim form to your insurance carrier in the usual manner.
DENTAL CARE
All expenses will be reimbursed at the level shown in the Benefit
Summary. Benefits may be subject to plan maximums
and frequency limits. Check the Benefit Summary for this information.
The plan covers reasonable and customary charges to the extent they do not
exceed the dental fee guide level shown in the
Benefit Summary.
Treatment Plan
Before incurring any large dental expenses, or beginning any orthodontic
treatment, ask your dentist to complete a
treatment plan and submit it to Great-West Life. Great-West Life will
calculate the benefits payable for the proposed treatment,
so you will know in advance the approximate portion of the cost you will have
to pay.
Basic Coverage
The following expenses will be covered:
Diagnostic services including:
- one complete oral examination every 36 months
- limited oral examinations twice every 12 months, except that only one limited
oral examination is covered
in any 12-month period that a complete oral examination is also performed
- limited periodontal examinations twice every 12 months
- complete series of x-rays
every 36 months
- intra-oral x-rays to a maximum of 15 films every 36 months and a panoramic
x-ray every 24 months.
Services provided in the same 12 months as a complete series are not covered
Preventive services including:
- polishing and topical application of fluoride each twice every 12 months
- scaling, limited to a maximum combined with periodontal root planing of 16
time units every 12 months
A time unit is considered to be a 15-minute interval or any portion of a
15-minute interval
- pit and fissure sealants on bicuspids and permanent molars once per tooth
every 24 months
- space maintainers including appliances for the control of harmful habits
- finishing restorations
- interproximal disking
- recontouring of teeth
Minor restorative services including:
- caries, trauma, and pain control
- amalgam and tooth-coloured fillings. Replacement fillings are covered only if
the existing filling is at least 2 years old or
the existing filling was not covered under this plan
- retentive pins and
prefabricated posts for fillings
- prefabricated crowns for primary teeth
Endodontics. Root canal therapy for permanent teeth will be limited to one
course of treatment per tooth.
Repeat treatment is covered only if the original treatment fails after the
first 18 months
Periodontal services including:
- root planing, limited to a maximum combined with preventive scaling of 16 time
units every 12 months
- gingivectomy, limited to once every 5 years per site
- occlusal adjustment and equilibration, limited to a combined maximum of 8 time
units every 12 months
A time unit is considered to be a 15-minute interval or any portion of a
15-minute interval
- periodontal appliances once every 5 years
Denture maintenance, after the 3-month post-insertion care period, including:
- denture relines for dentures at least 6 months old, once every 24 months
- denture rebases for dentures at least 2 years old, once every 24 months
- resilient liner in relined or rebased dentures, once every 36 months
Oral surgery
Adjunctive services
Major Coverage
Crowns. Coverage
for crowns on molars is limited to the cost of metal crowns. Coverage for
complicated crowns is limited to the
cost of standard crowns
Onlays. Coverage for tooth-coloured onlays on molars is limited to the cost of
metal onlays
Replacement crowns and onlays are covered when the existing restoration is at
least 5 years old and cannot be made serviceable
Standard complete dentures, standard cast or acrylic partial dentures or
complete overdentures or bridgework when standard
complete or partial dentures are not viable treatment options. Coverage for
tooth-coloured retainers and pontics on molars is
limited to the cost of metal retainers and pontics. Replacement appliances
are covered only when:
- the existing appliance is a covered temporary appliance
- the existing appliance is at least 5 years old and cannot be made serviceable.
If the existing appliance is less than 5 years old,
a replacement will still be covered if the existing appliance becomes
unserviceable as a result of the placement of an initial opposing
appliance or the extraction of additional teeth.
If additional teeth are extracted but the existing appliance can be made
serviceable, coverage is limited to the replacement of the
additional teeth
Denture-related surgical services for remodeling and recontouring oral tissues
Denture and bridgework
maintenance following the 3-month post insertion period including:
- denture remakes, once every 36 months
- denture adjustments, once every 12 months
- denture repairs and additions, tissue conditioning and resetting of denture
teeth
- repairs to covered bridgework
- removal and recementation of bridgework
Orthodontic Coverage
Orthodontics are covered for persons age 6 or over when treatment starts
Limitations
No benefits are paid for:
Duplicate x-rays, custom fluoride appliances, any oral hygiene instruction and
nutritional counseling
The following endodontic services - root canal therapy for primary teeth,
isolation of teeth, enlargement of pulp chambers and endosseous
intra coronal implants
The following periodontal services - desensitization, topical application of
antimicrobial agents, subgingival periodontal irrigation, charges
for post surgical treatment and periodontal re-evaluations
The following oral surgery
services - implantology, surgical movement of teeth, services performed to
remodel or recontour oral tissues
(other than minor alveoloplasty, gingivoplasty and stomatoplasty) and
alveoloplasty or gingivoplasty performed in conjunction with extractions.
Services for remodelling and recontouring oral tissues will be covered under
Major Coverage
Hypnosis or acupuncture
Veneers, recontouring existing crowns, and staining porcelain
Crowns or onlays if the tooth could have been restored using other procedures.
If crowns, onlays or inlays are provided, benefits will
be based on coverage for fillings
Overdentures or initial bridgework if provided when standard complete or
partial dentures would have been a viable treatment option.
If overdentures are provided, coverage will be limited to standard complete
dentures.
If initial bridgework is provided, coverage will be limited to a standard cast
partial denture and restoration of abutment teeth when required
for purposes other than bridgework
If additional bridgework is performed in the same arch within 60 months,
coverage will be limited to the addition of teeth to a denture
and restoration of abutment teeth when required for purposes other than
bridgework
Benefits will be limited to standard dentures or bridgework when equilibrated
and gnathological dentures, dentures with stress breaker,
precision and semi-precision attachments, dentures with swing lock connectors,
partial overdentures and dentures and bridgework related
to implants are provided
Expenses covered under another group plans extension of benefits provision
Services or supplies covered
under Healthcare. If the amount payable would be greater under this Dentalcare
benefit, then benefits
will be paid under Dentalcare and not Healthcare
Expenses private plans are not permitted to cover by law
Services and supplies the person is entitled to without charge by law or for
which a charge is made only because the person has
insurance coverage
Services or supplies that do not represent reasonable treatment
Treatment performed for cosmetic purposes only
Congenital defects or developmental malformations in people 19 years of age or
over, except orthodontics
Temporomandibular joint disorders, vertical dimension correction or myofacial
pain
Expenses arising from war, insurrection, or voluntary participation in a riot
How to Make a Claim
Obtain form M445D from your employer. Have your dentist complete the form
and return it to the Great-West Life Benefit Payment Office
as soon as possible, but no later than 15 months after the dental treatment.
COORDINATION OF BENEFITS
Benefits for you
or a dependent will be directly reduced by any amount payable under a government
plan. If you or a dependent are entitled
to benefits for the same expenses under another group plan or as both an
employee and dependent under this plan or as a dependent of both
parents under this plan, benefits will be co-ordinated so that the total
benefits from all plans will not exceed expenses.
You and your spouse should first submit your own claims through your own group
plan. Claims for dependent children should be submitted
to the plan of the parent who has the earlier birth date in the calendar year
(the year of birth is not considered). If you are separated or divorced,
the plan which will pay benefits for your children will be determined in the
following order:
1. the plan of the parent with custody of the child;
2. the plan of the spouse of the parent with custody of the child;
3. the plan of the parent without custody of the child;
4. the plan of the spouse of the parent without custody of the child