Definition of Calendar Year Maximum

“Calendar Year Maximum” is the maximum amount the Plan will allow in a calendar year for any one individual for the specified benefit(s).

Definition of Lifetime Benefit Maximum

“Lifetime Benefit Maximum” is the maximum amount the Trust Fund will allow any one individual for Extended Health Benefits in his or her lifetime. 

Definition of Coinsurance

“Coinsurance” is the maximum percentage of your eligible expenses that the Trust Fund will reimburse you. 

Definition of Dependent Spouse

“Spouse” means (a) a husband or wife by virtue of a valid religious or civil marriage ceremony, (b) a person living with the member in a common-law relationship for a minimum period of twelve consecutive months if such a person is publicly represented as the member’s spouse, (c) the person to whom the member was most recently married using the above criteria if the member has been married to more than one person. Divorced or separated spouses (with or without a court order or separation agreement) are not eligible for coverage.

Definition of Dependent Child  

"Child" means (a) your unmarried children (over 14 days of age with respect to Dependent Life Insurance only) and under 22 years of age provided they are not employed on a regular full-time basis; (b) your unmarried children under 25 years of age provided they are not employed on a regular full-time basis and they are in full-time attendance at a university or similar institution (annual proof of student registration is required after the child attains age 22); (c) your legally adopted children, stepchildren, or children of your common-law spouse provided your spouse or common-law spouse lives with you and has custody of the child and provided they meet the requirements set out above; (d) children outlined above must be solely dependent upon the member for support.

Definition of Coordination of Benefits

“Coordination of Benefits” is a process for reimbursing families who are insured under multiple benefit plans. This procedure ensures that the reimbursed amount does not exceed the expenses you originally incurred by determining which plan pays first (and thus where to submit the claim first) and which plan(s) pays next. 

For example, your benefits will be payable first under the plan where you are the insured Member and second where you are covered as a Dependent. If the Trust Fund is paying first, original receipts are required. If the Trust Fund is not paying first, an Explanation of Benefits (EOB), or breakdown of what the previous insurer paid, may replace receipts.

Definition of Predetermination of Benefits

“Predetermination of Benefits” tells you how much the Trust Fund will reimburse you for dental work before the work is done. If the cost of services is expected to exceed $500, we strongly recommend that you ask your dentist to submit a Treatment Plan to the Claims Office. A Treatment Plan contains the following information: 

• the dentist’s recommended services,
• the dentist’s charge for each service, and
• supporting X-rays or a letter of expertise