Health Care Benefits

The benefits described in this section apply to both the member and their eligible dependents. Following a description of the benefits covered, you will find a description of how and when to file claims for these benefits.

The Extended Health Care benefit is designed to provide valuable supplementary protection but not to duplicate the Provincial Hospital and Medical Care Plans under which an individual is or could be protected. Therefore, the Extended Health Care Insurance excludes (1) services and supplies to the extent benefits can be obtained for them under a provincial plan by fulfilling the requirements of that plan, and (2) services and supplies where private insurance is prohibited. Additional exclusions are detailed in the section entitled “Exclusions”. You should read the Covered Expenses with these exclusions in mind. Before incurring any major expenses you may submit details to the Claims Department that will inform you what benefits, if any, are available under the Plan.

Percentage Payable

The percentage payable is the maximum percentage of your costs that the plan will reimburse you, for you and your dependents’ Covered Expenses, after any deductible is satisfied.

Deductible

The deductible is the amount of Covered Expenses which you must pay each calendar year before benefits are payable under this plan.

Calendar Year Maximum

The Calendar Year Maximum is the maximum amount the plan will allow any one individual for Extended Health Care Benefits in a single calendar year.

Lifetime Maximum

The Lifetime Maximum is the maximum amount this plan will allow any one individual for Extended Health Care benefits in their lifetime.

Covered Expenses

This insurance applies to expenses you are required to pay for the treatment of pregnancies and non-occupational accidents and sicknesses. The charges will only be considered eligible expenses provided the charges are reasonable and customary. The supplies or services must be medically necessary and prescribed by a physician, or other qualified medical practitioner deemed appropriate by the insurance carrier. A medical expense shall be deemed incurred as of the date the service or supply is furnished to you, and you must be covered on that date for the expense to be considered. The insurance will pay the following covered expenses incurred by you or an eligible dependent up to the limits described below and set out in the "SUMMARY OF BENEFITS".

Drugs including injectibles which are medically necessary, legally require a written prescription from a physician in order to be purchased, and are dispensed by a licensed pharmacist, or physician legally authorized to dispense such drugs, plus drugs that regardless of their legal status are not normally sold except by prescription. These drugs must be prescriptive, restrictive, controlled or narcotic in nature. Included are oral contraceptives and substances used for injections. In an effort to contain costs, it is requested that generic drug substitutes be used whenever possible.

Not eligible for reimbursement: Any drug not approved by the Food and Drugs Act, Canada. Proprietary or patent medicines (off-the-shelf preparations), dietary or health food, Nicorettes and similar anti-smoking related prescriptions, etc, erectile dysfunction drugs, fertility drugs, unless prescribed for other than fertility purposes, nutritional products and charges for the administration of drugs, whether or not a prescription is given for medical reasons, any drug biologic and related preparations which are intended to be administered in hospital on an in-patient basis and are not intended for a patient’s use at home.

The maximum single purchase of drugs that will be considered is the amount that can reasonably be used within 90 days of the date of purchase.

Note: The Trustees reserve the right to modify the drug formularies and definition at any time in the future, in order to deliver the benefit in a contemporary fashion.

Convalescent/Rehabilitation Hospital (within Home Province) daily room and board in excess of ward rate up to the amount specified in the “SUMMARY OF BENEFITS”, provided the individual is admitted to the convalescent hospital immediately following a minimum 14 consecutive day confinement in a hospital. The confinement must be for the continued care of the same condition for which the patient was hospitalised. All confinements in a convalescent hospital will be considered as one period of disability unless confinements are separated by at least 90 days. Disability must commence prior to age 65.

A definition of a Convalescent/Rehabilitation Hospital is included in General Provisions section of this website.

Ambulance service charges within Canada, including emergency air ambulance service, in excess of the amount payable under the insured person’s Provincial Health Plan and to the limits specified by this plan’s “SUMMARY OF BENEFITS”. The services must be required to transport the person from the place of injury (or where illness struck) to the nearest hospital where treatment is available, or directly from that hospital to the nearest hospital for needed specialized treatment not available at the first hospital, or from hospital to a convalescent/rehabilitation hospital.

Out of Hospital Nursing services of a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), a Certified Nursing Assistant (C.N.A.), or a member of the Victorian Order of Nurses (V.O.N.) while the patient is not confined to a hospital, and up to the limit specified in the “SUMMARY OF BENEFITS”. The nursing service must have been ordered by a physician as medically necessary and requiring the specialized training of a registered nurse. The nurse must not ordinarily reside in the employee's home or be a member of the family. Charges for services that are mainly custodial or assist the individual with the functions of daily living are not covered.

Health Practitioner Benefits charges, including x-ray charges, up to the amounts specified in the “SUMMARY OF BENEFITS” for a properly accredited Chiropractor, Naturopath, Osteopath, and Chiropodist/Podiatrist. Licensed Clinical Psychologist, Registered Massage Therapist and Speech Therapist, acting within the scope of their licences. Registered Massage Therapy must be prescribed by a physician, and the prescription must include the nature of the condition being treated and the estimated duration of therapy.
No amount will be paid for any Health Care Practitioner services until any applicable Provincial Health Plan benefit is exhausted.

Physiotherapy charges up to the amounts specified in this Plan’s “SUMMARY OF BENEFITS”, by a physiotherapist who is registered and legally practising within the scope of his license. No amounts will be payable for any visits for which any amount is payable under the insured person’s Provincial Health Plan, unless permitted by law.
Dental Care for Accidental Injury charges up to the amounts specified in the Plan’s “SUMMARY OF BENEFITS”, for necessary dental care by a licensed dentist for the prompt repair of sound natural teeth when required for a non-occupational accidental injury, external to the mouth, which occurs while insured. The dental work must be completed within 12 months of the accident to be a covered medical expense.

Diagnostic Laboratory and X-Ray Expenses not covered by any provincial health plan.

Durable Medical Equipment and Supplies - Charges for the rental of or, at the option of Insurance Company, the purchase of durable medical equipment of the type and model adequate for the insured person’s medical needs based on the nature and severity of the disability, such as but not limited to:

Hospital beds, wheelchairs, canes, crutches, walkers and trusses;
Rigid or semi-rigid braces for back, neck, arm or leg and non-dental prosthesis, such as artificial limbs and eyes, a surgical corset, including replacement if required because of a change in physical condition;
Respiratory equipment, including oxygen;
Splints, casts, catheters, and hypodermic needles;
Plasma, blood or blood substances;
Breast prosthesis – refer to limits in “SUMMARY OF BENEFITS”;
Purchase of surgical brassieres when required following a mastectomy – refer to limits in “SUMMARY OF BENEFITS”;
Surgical stockings, excluding elastic stockings – refer to limits in ““SUMMARY OF BENEFITS”;
Wigs – refer to limits in ““SUMMARY OF BENEFITS”; and
Glucometer to the limits in “SUMMARY OF BENEFITS”.

Not eligible are items of personal comfort, convenience, exercise, safety, self-help or environmental control items, or items which may also be used for non-medical reasons, such as, but not limited to heating pads or lamps, communication aids, air conditioners or cleaners, and whirlpool baths or saunas.

Before incurring any major expenses you are encouraged to submit details to the Claims Office to determine to what extent benefits are payable. In any event, a letter will be required from a licensed physician describing the nature of the disability, the type of durable medical equipment required, why it is needed and the estimated duration of this need.

Note: The Ontario Assistive Devices Program may provide partial reimbursement for certain expenses listed above, e.g. prosthetic devices, respiratory equipment, hearing aids, wheelchairs, hospital beds, etc. Further information regarding this program may be obtained by calling 1-800-268-6021.

Foot Care benefits are subject to the limits specified in the “SUMMARY OF BENEFITS”. Charges for orthopedic shoes (including repairs) and orthotics which have been specially designed and molded for the insured individual and are required to correct a diagnosed physical impairment, provided that the following information is supplied:

a diagnosis, including list of symptoms and the primary complaint;
a description of the physical findings from the clinical examination;
a brief description of the gait abnormality associated with the diagnosis; and
confirmation that the product has been custom-made, including a copy of the detailed lab invoice issued to the provider by the manufacturer of the custom-made shoe or orthotic.

In order to be eligible for reimbursement, orthopedic shoes and orthotic devices must be prescribed, on an annual basis, by either a licensed physician or Chiropodist/Podiatrist, and must be dispensed by one of the following provider types: licensed physician, Chiropodist/Podiatrist, Orthotist, or Pedorthist.

Hearing Aid charges, including replacement and repair, and excluding batteries, when provided by a certified, clinical audiologist, up to the amount specified in the “SUMMARY OF BENEFITS”.

Exclusions

No benefits are payable under this plan for charges for care, services or supplies:

that were furnished without the recommendation and approval of a physician acting within the scope of his license;
that are not medically necessary to the care and treatment of any existing or suspected injury, disease or pregnancy, such as but not limited to, charges for a surgical procedure or treatment performed primarily for beautification, or charges for hospital confinement for such surgical procedure or treatment;
if payment is prohibited by law;
that an insured person may obtain as a benefit under any governmental plan or law;
for occupational injury or disease covered by Workplace Safety and Insurance law or similar legislation;
for which no charge would have been made in the absence of this insurance;
for dental work, except as provided under the Dental Care for Accidental Injury;
for any drugs or services that are not approved by Health and Welfare Canada, or are experimental or limited in use whether or not so approved;
for experimental procedures or treatment not approved by the Canadian Medical Association or the appropriate medical specialty society;
for health examinations that are requested by a third party;
for broken appointments, travel, communication costs, filling in of forms or physician’s supplies;
which were considered an insured service of any provincial government plan at the time this plan/benefit was issued and subsequently were modified, suspended or discontinued;
for any services covered in whole or in part by any government plan, services for which no charge is made, or services which the insurer is not permitted by law to cover.

No amount will be paid for any charge incurred that results from or is contributed by:

war, whether declared or not;
insurrection, rebellion or participation in a riot or civil commotion;
purposely self-inflicted injury; or
the insured person’s commission of, or attempt to commit, an assault or a criminal offence.

Co-ordination with Other Benefits

This plan has been designed to help you meet the cost of disease or injury. Since it is not intended that you receive benefits greater than the actual expenses incurred, any health care coverage you have under other “plans” will be taken into account in determining the amount of benefit payable under this plan, that is, the benefits under this plan will be coordinated with the benefits of the other plans.

Plan means any contract of group insurance or other arrangement for members of a group (whether on an insured basis or not), prepaid health care coverage, or student accident insurance.

Specifically, this plan will pay either its regular benefits in full, or a reduced amount which, when added to the benefits available under the other plan, or plans, will equal 100% of “allowable expenses”.

Allowable expense means any necessary, reasonable and customary expense, incurred while eligible for benefits under this plan, part or all of which would be payable under any of the plans, but not any expenses contained in the list of Exclusions.

The manner in which this is done determines which plan pays first (and thus where to submit the claim first) and which plan(s) pays next. The plan that does not have a co-ordination of benefits provision pays before the plan that does (most, if not all, insurance company plans have such a provision).

For any person who is covered under more than one plan, benefits will be payable first under the plan where he is the insured Member and secondarily where he is covered as a dependent.

Dependent children are covered first by the parent whose birthday comes first in the year, and any unpaid balance can then be submitted to the other parent’s plan.

If priority cannot be established in the above manner, the benefits shall be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan had there been coverage by just that plan.

To implement this provision, the Trust Fund and the insurer may:

Subject to the consent of the covered person, if required by law, obtain from or release to any other person, corporation or organization any information deemed to be needed; or
Pay to or recover from any person, corporation or organization any excess payment; any payment so made will be deemed to be benefits paid and, to the extent of such payments, will fully discharge the Trust Fund and the insurer from all liability under this plan.

Extension of Benefits in the Event of Your Death

Extended Health Expense coverage for dependents shall continue without premium payment following in the event of your death up to a maximum of 12 months from the date of death but not beyond the date your spouse remarries or the date the dependent is no longer a dependent, as defined in this website, or to the date the policy or benefit terminates, whichever is earlier.

Any extended benefits payable are subject to the provisions and limitations of the plan.

How To File Extended Health Claims

Claim forms may be obtained from the Trust Fund’s administrator, or the Claims Office.

Before submitting the claim form, ensure that all questions, have been answered, that you have signed your name and clearly identified yourself by full name, return mailing address and your employer and Union. Faulty or missing information will only result in a delay in processing your claim.

If the claim is for your dependent, provide the dependent's first name, date of birth and relationship to you.

When you are sure that all of the above has been completed, forward the form and all attachments to the Claims Office. Your benefit cheque will be mailed directly to you.

Each expense should be listed separately, by insured individual, on the appropriate claim form. Submit claims together with originals of bills or receipts, no more than once a month or every 2 to 3 months if bills are small. Claiming more frequently for small amounts ties up service for everyone and delays payment on larger claims where there is a real need for timely benefits.

Bills and receipts must be complete. Each bill, or receipt, other than for drugs, and vision care, must show the:

patient's full name
date(s) the service was rendered or purchase made
nature of the sickness or injury
itemized charges
physician's written recommendation

Drug expenses are billed directly to the insurer and no written claim form is required. Simply present your drug card to the dispensing pharmacist. In the event you do not have your drug card with you at the time of purchase, a paper claim form may be submitted to the insurer.

CASH REGISTER RECEIPTS OR LABELS FROM CONTAINERS ARE NOT ACCEPTABLE.

Summary of Benefits