| This booklet is intended as an overview of the Benefits Program and does not grant or confer any contractual rights. All rights under this Program shall be governed by the provisions of the Master Policies and by applicable law. The section detailing the Supplementary Extended Health Care & Dental Care coverage is the actual policy wording prepared by Echelon General Insurance Company.
The Out-of-Province/Country
Travel Medical Emergency Insurance coverage is provided by Royal & Sun Alliance Insurance Company of Canada and administered by Expert Travel Financial Security (E.F.T.S.) Inc. A separate booklet describing the coverage will be issued along with a wallet card containing the emergency travel numbers.
Notice of Privacy and Confidentiality
Echelon General Insurance Company and/or Alternative Benefit Solutions Inc. collect, use and disclose the personal information which you give for the purpose of providing you with insurance services. To protect it's confidentiality, access to this information will be restricted to those
employees, mandataries, administrators or agents of Echelon General Insurance Company who are responsible for administration of services, underwriting, marketing; and for the processing, facilitating and investigation of claims. When necessary, this information may be shared with others such as, but not limited to, medical facilities, insurance companies, organizations and to any other person you authorize or that is authorized by law. This acknowledges that information may be transmitted by
facsimile (fax), e-mail, postal service, courier service or telephone, and we cannot guarantee the security or privacy of the information that is transmitted through these channels. Call us at 1 800 263-0888 for a copy of our Privacy Statement...
GENERAL PROVISIONS ELIGIBILITY
The Eligibility provisions may vary by insurer providing the various benefits available under the Menuflex™ Benefits Program. The General Eligibility provisions for the overall Program are outlined below. If there is a discrepancy between this booklet and the insurer's contract, the contracts shall prevail. ELIGIBLE INDIVIDUALS
Self-employed individuals, independent contractors, part-time or full-time employees who are between the ages of 18 years and 69 years and are actively working at least 20 hours per week on the day coverage commences are eligible. Application for coverage must be approved prior to age 65. ELIGIBLE DEPENDENTS
Eligible Dependents include your spouse and all unmarried dependent children under 22 years of age, (25 years of age if attending school on a full-time basis) or to age 69 if mentally or physically infirm. Please see your MDSA program for expanded eligibility for dependents under the MDSA. ENROLMENT
A participant eligible for insurance, as described above, must complete the appropriate Menuflex™ Application form and any required Personal Health Declaration, or Health Statement for approval by the respective insurer before  coverage can become effective. EVIDENCE OF INSURABILITY
Evidence of insurability is NOT required in order to participate in the Medical Dental Spending Account (MDSA) provided by your employer. However, in order to be covered by the Supplementary Extended Health Care or Optional Critical Illness Benefit, evidence of insurability must be submitted in the form of a Personal Health
Declaration by all applicants, and their spouse, if applicable, wishing to participate in the coverage.. EFFECTIVE DATE OF COVERAGE
Your MDSA becomes effective on the date selected by the Company (e.g. 1st of the month coincident with or next following date of employment) and in accordance with provisions of any personnel policies as communicated to the
Program Administrator. Coverage under any of the Optional Benefits becomes effective of the 1st of the month following the date evidence of insurability is approved by the insurer of the Optional Benefits that the applicant has applied for. If you are not actively at work or are hospitalized on the day your coverage would normally become effective, you will become eligible upon return to full-time
employment. TERMINATION
Your coverage, and the coverage for your eligible dependents if insured, will terminate on the earliest of: - the date you cease to be eligible for the MDSA program or for any of the
Optional Benefits as described above and in your insurance policy for any of the Optional Benefits that the applicant has applied for.
- the end of the period for which employer contributions have been made for the MDSA, and any required premiums have been paid for your Optional Benefits.
- the date of cancellation of the Insurance Policy.
- the date you cease to participate in the plan upon written notice to the Program Administrator.
SECTION I
MEDICAL DENTAL SPENDING ACCOUNT (MDSA) & SUPPLEMENTARY EHC & DENTAL PROGRAM A
Medical Dental Spending Account (MDSA) is much like a health and dental bank account. Your employer deposits benefit dollars into your MDSA up to the stated maximum per Plan Year via monthly contributions as indicated on the MDSA Enrolment Form.
The MDSA provides you with complete control and responsibility for managing your basic personal health and dental expenses, and those of your dependents. Prior to the end of each Plan Year the Employer determines the
amount of the employer contribution to your MDSA Account for the next Plan Year.
You may claim medical and/or dental expenses, many of which are not normally covered by a traditional group health or dental plan (for example, prescription sun glasses, cosmetic dentistry or laser eye surgery). It is in effect a health and dental fund administered by Alternative Benefit Solutions on behalf of the Employer for the benefit of you, the employee.
Contributions made by the Employer are a tax-deductible business expense and do not confer a taxable benefit to you. The Employer's selected contribution amount remains fixed for as long as the employer desires. At the start of the new Plan Year you will be credited with the annualized amount of the employer contribution per Plan Year. Should you terminate employment during a Plan Year not having earned the full employer contribution amount, any deficit in your MDSA
account will be recovered from your final severance pay based on the number on months remaining in the Plan Year.
All MDSA Claims, as well as Health and Dental claims under the Supplementary coverage are administered by Alternative Benefit Solutions Inc.(ABS) You must complete an MDSA Claim Form (sample attached) and submit it with ORIGINAL RECEIPTS to ABS (photocopies are not accepted). ABS will reimburse you directly
for all eligible expenses as per Section 118.2 (2) of the Income Tax Act and Interpretation Bulletin IT-519R2, up to the amount available in your MDSA account. All MDSA claim payments are made to you personally, they cannot be made to the service provider per CCRA regulations.
You will be issued an Express Scripts Pay-Direct Drug and Dental card. The card will be used at the pharmacy for all drug claims incurred. The BIN Number for electronic
dental claims is printed on the reverse side of the card. As there are over 20 different electronic claims payment systems in use in dental offices across the country your dental office may have to call the service number on the card to establish the proper electronic communications.
On your initial claims you will pay the pharmacy or dentist for the services rendered and secure a receipt and submit it with a Claim Form to ABS for reimbursement.
Once you have satisfied the deductible(s) the pay-direct card will be activated.
MDSA claims for expenses other than drugs must be submitted to ABS on a paper claim form, and again these will be paid by ABS up to the amount available in your Account. Claim cheques are made out to you personally, and are tax-free benefits.
If you have MDSA coverage only due to spousal health and dental coverage, please submit your MDSA claims on a MDSA Claim Form available from the
web site here.
The total benefits, which may be claimed from the Medical Dental Spending Account in any Plan Year, are limited to the total amount contributed to that account by the
Employer in that Plan Year, plus any balance remaining from unused credits for the immediately prior Plan Year. Unused contributions from the prior Plan Year at the end of the second Plan Year are forfeited back to the Employer.
Notes: - An unusual feature is that in addition to expenses for your spouse and dependent children, expenses for blood relatives dependent on you for
financial support, may also be claimed under the MDSA (e.g. mother, father).
- Expenses incurred for items such as semi-private hospital accommodation; private duty nursing, and Out-of-Canada emergency medical/hospital expenses would be claimed under the Supplementary EHC Program.
- Medical and Dental expenses which may be claimed against the MDSA include
any items that would qualify as a tax deductible medical expense under the Income Tax Act (please see Section 118.2 (2) of the Act and Interpretation Bulletin IT-519R2 for the list of Qualifying Medical Expenses), and are not reimbursed under any other private or government plan.
There are a number of reasons why an MDSA is tax effective for you. If you paid for the expenses on your own, you would have to use expensive
"after-tax" dollars. Your MDSA is sheltered from federal and provincial (except in Quebec) income tax. This means that when utilizing your MDSA to pay for eligible expenses, you are using less expensive "pre-tax" dollars. This results in extra savings for you.
Employer contributions to the MDSA do not constitute a taxable benefit under current Federal Tax legislation as they are being made to a "Private Health Services Plan" as defined in the Income Tax Act and associated regulations.
In Quebec, employer contributions to any form of employee benefit result in a taxable benefit, regardless of whether the plan is insured, or self insured by the employer.
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ELIGIBLE DEPENDENTS
Under the MDSA your dependents include your eligible dependents (spouse and dependent children up to age 22, or age 25 if in full-time attendance at school) and financially dependent members of your extended family, as defined under the Income Tax Act. This includes: your parents, grandparents, siblings, grandchildren, aunts, uncles, nieces and nephews, who are primarily dependent on you for financial support.
ELIGIBLE MDSA EXPENSES
Your MDSA can reimburse you for all medical and dental expenses allowed by the Income Tax Act. See the list shown below, or call the General Inquiries for Canada Customs and Revenue Agency at 1-800-959-8281 to determine a particular expense's eligibility.
The MDSA can be used in conjunction with the benefit plan of your spouse. The account can be used to pay deductibles, co-payments, or premiums for health-related insurance coverage under the plan of either spouse.
Health and dental claims must be for items defined as eligible expenses under a "private health services plan" as contained in the Income Tax Act and associated regulations. The covered expenses that will be reimbursed at 100% up to your maximum MDSA balance include the following: - Prescription Drugs
- Insulin
- Prescribed Medical Supplies
- Paramedical Services (Chiropractor, Osteopath, Physiotherapist, Speech Therapist, Masseur, Podiatrist, Naturopath and Psychologist)
- Local Ambulance Service
- Orthopaedic shoes and inserts
- Preventive Diagnostic and Emergency Dental Care
- Restorative Dental Services
- Dental Surgical Services
- Endodontic Services
- Periodontal Services
- Denture Services
- Major Dental Care (Crowns, Bridges etc.)
- Orthodontic Services
- Vision Care, including laser eye surgery
- Semi-private Hospital Coverage
Other eligible MDSA expenses not generally covered under most medical and dental plans include: - drugs available over the counter that have been prescribed by a medical practitioner or dentist and dispensed by a pharmacist
- health-related insurance premiums or contributions required under your
spouse's group plan, travel medical insurance, or insurance for contact lenses
- eye examinations
- nursing home care
- cosmetic medical and dental treatment
- nutritional counseling on the written recommendation of a physician
- payments to a medical practitioner (where permitted under Medicare)
- medical equipment such as visual or vibratory signaling devices for those
with a hearing impairment and disability specific computer software and hardware attachments
- services of full-time medical attendants
- rehabilitative therapies to adjust for loss of speech or hearing and special schooling for disabled persons
- modifications to your home to allow a disabled individual to be mobile and functional within the home
If in doubt as to the eligibility of a medical or dental expense contact CCRA as previously indicated.
Submitting An MDSA Claim
The MDSA works on a basic reimbursement system, except for those drug and dental claims which can be processed electronically. With respect to any paper
claims you must submit ORIGINAL eligible receipts to ABS the MDSA Administrator on the approved MDSA claim form. You will be notified of the balance in your MDSA with each payment by ABS, except for those paid electronically. MDSA RULES & REGULATIONS
- Do not submit an MDSA claim unless the expense is at least $100.00.
- You may claim expenses actually incurred within the Plan Year up to the maximum amount on deposit in your MDSA at any time during the year. Claims for expenses during a Plan Year can be submitted until the end of the
first month of the following Plan Year. If you have expenses greater than the annual MDSA amount, these expenses cannot be carried forward to the next Plan Year.
- The MDSA will be closed at 11:59 p.m. on the last day of the Plan Year.
- If you leave the employer and have a positive balance, claims incurred while
you were a plan member must be submitted within 30 days after you leave.
- No interest is charged, and no interest is credited to MDSA balances.
- You are financially responsible for any expenses which are in excess of the annual allocation to your MDSA, and which are not covered by the
Supplementary EHC or Dental Programs. It is therefore necessary to plan your health and dental care expenditures carefully, as much as possible, to coincide with the MDSA plan year.
- Amounts reimbursed under the MDSA cannot be claimed as an income tax deduction on your Federal Income Tax Return.
- The eligibility of a claim is determined on an incurred basis (based on the
dates the services were performed or the dates the drugs/supplies were purchased).
- When an employee goes on maternity leave, coverage under the MDSA will continue until the end of the maternity leave.
- If you are on a leave of absence at the end of the calendar year, MDSA
coverage will terminate at the end of that plan year.
- You will not have any entitlement to receive monies from the MDSA account other than for the payment of eligible health and dental claims as defined under a "private health services plan" in accordance with Section 248.1 of the Income Tax Act, and Subsection 118.2 (2).
- If the expense was partially reimbursed under any other plan you must attach a copy of the Explanation of Benefits, which was attached to your cheque, and copies of your receipts to the Claim Form. The Explanation of Benefits is the statement you receive from the other plan with your reimbursement, itemizing your entitlement. If the expense was not covered under any other plan, you must attach the original itemized receipt.
- Eligible expenses are defined under the Income Tax Act. If an expense is disallowed by Revenue Canada, it will be your responsibility to pay any resulting taxes.
- You cannot withdraw cash from the MDSA.
- Health or Dental expenses incurred before your effective date of coverage
are not eligible for reimbursement.
- In order for it to be eligible, the expense must be health or dental related.
- To plan your spending carefully, review your medical and dental expenses over the last year and think about the expenses that are likely to come up
next year. For example, do you or your family members require new glasses, extensive dental treatment, etc., you should try to time your expenses to have them covered under the MDSA.
- Your MDSA claim form can be obtained from the Menuflex™ web site here, or by calling the Program Administrator. Complete the form and then submit it to Alternative Benefit Solutions Inc. directly. The confidentiality of your health information is thus fully protected.
Please Note:
According to Revenue Canada, any unused positive balance will be carried forward to the next Plan Year and any portion of this amount, which remains unused at the end of the second Plan Year, will be forfeited to your employer. Carry forward employer contribution amounts will be used ahead of the following year's allocation. Claim expenses cannot be carried forward from one year to the next. . MEDICAL DENTAL EXPENSES BEYOND THE AMOUNT IN YOUR MDSA
The SELECT Extended Health Care (EHC) Program has been designed to cover a wide range of medical/hospital expenses over and above those claimed under the MDSA.
In order to be covered under the Optional SELECT EHC and Optional Dental Plans you must have completed the required Application and Personal Health Declaration (PHD), and the PHD must have been approved by the Insurer. Coverage becomes effective on the 1st of the month following the date of approval. SECTION II SELECT EXTENDED HEALTH CARE & OPTIONAL DENTAL CARE INSURANCE POLICY
This portion of the Program is provided through:
Echelon General Insurance Company
Claims Service is provided by:
Alternative Benefits Solutions Inc. (ABS)
This section of the booklet outlines the benefits of Your Supplementary Extended Health Care Plan and Dental Care Plan. The premiums for your Supplementary EHC and Dental coverage will be deducted on a monthly basis by the Program
Administrator, Alternative Benefit Solutions Inc. (ABS) from the employer contributions to your MDSA Account. This section of the booklet is your Supplementary EHC & Dental coverage insurance policy.
Possession of this booklet alone does not mean that You or Your dependents are insured. The premium must be paid, the policy must be in effect and You must satisfy all the requirements of the policy. Please attach Your confirmation of
coverage letter to Your policy booklet and write Your policy number in the space provided at the front of this booklet.
It is important to read the policy carefully in order to understand what is covered and what is not covered. Please keep it in a safe place with your other important documents.
Menuflex™ MDSA Benefits Program SELECT EXTENDED HEALTH CARE & OPTIONAL DENTAL CARE INSURANCE POLICY Underwritten by:
Echelon General Insurance Company (hereinafter referred to as the Company).
This policy is issued in consideration of the application by the Applicant and payment of the required premium.
Important Notice: This policy describes the benefits, terms and conditions of coverage. It also includes the limitations and exclusions. Please read it carefully.
DEFINITIONS
When used in this policy the term:
Act of War or Terrorism means, and is not limited to: civil war, rebellion,
revolution, insurrection, civil commotion, invasion, acts of foreign enemies, hostilities, or warlike operations by any government or sovereign, using military personnel or other agents (personnel), with the use of force or violence and/or the threat thereof or commission or threat of a dangerous act, against any person or group(s) or government(s); committed for political, religious, ideological, social, economic or similar purposes including the intention to intimidate, coerce or
overthrow a government (whether defacto or de jure) or to influence, affect or protest against any government and/or to put the civilian population, or any section of the civilian population in fear.
Applicant means a self-employed individual, independent contractor, part-time or full-time employee who is between the ages of eighteen (18) years and sixty-nine (69) years who applies and is approved for coverage under this policy prior to age
sixty-five (65). The Applicant must be actively working at least twenty (20) hours per week on the day coverage commences.
Child means an unmarried, unemployed, natural, adopted, or step-child of the Applicant dependent upon the Applicant for maintenance and support and under twenty-two (22) years of age, or under twenty-five (25) years of age if attending school on a full-time basis, or to age sixty-nine (69) if mentally or physically handicapped.
Claims Administrator
means the provider of claims services for the policy, Alternative Benefit Solutions Inc..
Company means the insurer, ECHELON GENERAL INSURANCE COMPANY.
Couple means an Applicant and one (1) eligible Dependent.
Critical means in danger of death or life threatening.
Dentist
means a person, not related by blood or marriage to an Insured Person and not ordinarily resident with the Insured Person or a business associate of the Insured Person, who is legally qualified and licensed to practice dentistry in the jurisdiction where the services are rendered.
Dependent(s) means an Applicant's Spouse and/or Child for whom coverage has been applied and is approved for coverage under this policy.
Elective Treatment
means non-Emergency Treatment, surgery or any other procedure scheduled by a Physician to occur at a future date.
Extended Family means the Insured Person's spouse, children or their spouse, the Insured Person's parents or guardians, in-laws, brothers, sisters, grandparents and grandchildren.
Family means an Applicant and his/her eligible Dependents.
Government Health Insurance Plan (GHIP) means any health or hospital
insurance plan operated or sponsored under a Provincial or Federal Government Health and Welfare Act, including Workers' Compensation Act or any similar legislation.
Hospital means a licensed institution which operates in accordance with the laws of the jurisdiction in which it is located and which: - is licensed as a hospital where such licensing laws exist;
- primarily provides acute care;
- has on the premises medical, surgical and diagnostic facilities; and
- is continually staffed or supervised by Physicians and has registered nurses on duty twenty-four (24) hours a day.
The term Hospital as used in this policy does not include an institution or part thereof (whether or not such institution is commonly known as a hospital) which is used as a rest home, a nursing home, a domicilliary care home, a
maternity home, an extended care facility, a long term care facility, a convalescent home, a rehabilitation centre, a home for the aged, the blind or the deaf, or any similar institution providing primarily custodial care.
Injury means sudden bodily harm directly caused by an accident which is independent of Sickness and all other causes.
Insured Person means the Applicant and any Dependent for whom
commencement of coverage has been confirmed or for whom insurance is in force under this policy.
Medical Director means Echelon General's medical doctor acting for the Company.
Medically Necessary means, in relation to any care, service, supply or other matter, that is ordered by a Physician, Dentist or Paramedical Practitioner and that the Company determines is:
- appropriate and consistent with the symptoms and findings or diagnosis and
treatment of the Insured Person's Sickness or Injury;
- provided in accordance with generally accepted medical practice on a national basis; and
- the most appropriate supply or level of service that can be provided on a cost effective basis.
The fact that the Insured Person's attending Physician prescribes the service or supplies does not automatically mean such services or supplies are Medically Necessary and covered by this policy.
Nuclear Incident means any occurrence causing bodily Injury, Sickness, disease, or death or loss of or damage to property, or for loss of use of property, arising
out of or resulting from the radioactive, toxic, explosive, or other hazardous properties of source, special nuclear, or by-product material.
Paramedical Practitioner(s) means a person, not related by blood or marriage to the Insured Person and not ordinarily resident with the Insured Person
or a business associate of the Insured Person, who is legally qualified and licensed to practice one (1) of the paramedical professions listed in the applicable Extended Health Care Benefits Provision.
Physician means a person, not related by blood or marriage to the Insured Person and not ordinarily resident with the Insured Person or a business associate of the Insured Person, who is legally qualified and licensed to practice medicine or perform
surgery in the jurisdiction where the services are rendered.
Plan Administrator means the provider of administration services for the policy, Alternative Benefit Solutions.
Reasonable and Customary Charges means:
1. actual charges made to the Insured Person for services or supplies, but not more than the fees and prices generally charged in the area concerned as determined by the Company, for cases of severity and nature comparable to the severity and
nature of the case being treated; or
2. the lowest charge indicated in the most current Provincial Dental Association Schedule of Fees, for the same services or supplies.
Semi-Private Room means a Hospital room that contains two (2) beds, regardless of whether both beds are in active use.
Sickness means illness or disease.
Spouse means a person of the same or opposite sex who is legally married to the
Applicant, or who has cohabited with the Applicant for a minimum period of twelve (12) months in a relationship which entails the rights and obligations of marriage, but which does not constitute a legally valid marriage, and is publicly represented as the Applicant's spouse. In no event will more than one (1) spouse be insured under this policy as a Dependent at any one (1) time.
You or Your means an Insured Person.
INSURING AGREEMENT
If an Insured Person incurs charges for care, services or supplies as described in this policy, the Company will pay benefits for those charges in excess of the applicable Deductible and subject to the exclusions, limitations and conditions stated in this policy, and/or amendments to this policy.
Notwithstanding the foregoing, benefits are payable only to the extent that: - they are Reasonable and Customary Charges, as determined by the Company, and are within the maximum amount stated in any Benefit Summary or elsewhere;
- reimbursement of any care, service or supply covered by this policy is not
prohibited by law, and is not available under the Insured Person's GHIP;
- the care, services or supplies are Medically Necessary; and
- in the case of Out-of-Province Emergency Travel Medical Care Benefits, were incurred while the Insured Person was outside the boundaries of his or her
province or territory of residence in Canada, and were incurred as a result of a Medical Emergency.
GENERAL PROVISIONS
ELIGIBILITY
Full-time or part-time employees who are between the ages of 18 years and 69 years and are actively working at least 20 hours per week on the day coverage commences are eligible. Application for coverage must be approved prior to age 65. The Insured Person must be a Canadian resident, age 69 or under, and eligible for GHIP benefits in order to continue to be insured under this policy.
EVIDENCE OF INSURABILITY
Evidence of insurability may be required of any employee and/or eligible dependent that for whatever reason was not enrolled in the Program within 30 days of their original eligibility date.
EFFECTIVE DATE OF COVERAGE
Insurance coverage becomes effective on the 1st of the month following completion of the probationary period, normally 90 days, or where evidence of
insurability is required following approval by the Company. If the Applicant is not actively at work or is hospitalized on the day coverage would normally become effective, he or she will become eligible upon return to full-time employment.
HOW TO CLAIM
The Program Administrator, Alternative Benefit Solutions Inc. (ABS), has been provided with a supply of claim forms. Health and Dental claims payments will be made by ABS on behalf of Echelon General.
It is important that all claims be reported promptly, that the claims documents are properly identified and show the Insured Person's name, policy number and address.
ADDING DEPENDENTS
The Applicant may change his or her coverage from Single to Couple or from Couple to Family by submitting an application within 30 days of the change of status. A request for a change submitted after 30 days will require the provision of
evidence of insurability. It is not necessary to supply evidence of insurability for a newborn Child if the application is submitted within thirty (30) days after the date of birth. If a Dependent, other than a newborn Child, is confined in a Hospital on the date his or her insurance would otherwise become effective, no insurance on that Dependent shall become effective until he or she ceases to be so confined.
TERMINATION
Termination of Applicant's Coverage
Coverage on the Applicant will terminate, on the earliest of the following dates: - the date the Company terminates this policy;
- the date the Applicant ceases to meet the eligibility requirements of the
policy;
- the date the Applicant ceases to be a permanent resident of Canada;
- the date of the Applicant's death; or
- the premium due date coinciding with or immediately following:
a) the date on which the Applicant turns age seventy (70),
b) the date on which the Applicant instructs the Company in writing to terminate such insurance; or
c) the end of the Grace Period if the Applicant fails to make a premium payment as required.
Termination of Dependent's Coverage
Coverage on an Insured Dependent will terminate on the earliest of the following:
- the date on which the Applicant's coverage terminates;
- the date the Dependent ceases to meet the eligibility requirements of the policy;
- the premium due date coinciding with or immediately following:
a) the date on which the Dependent no longer qualifies as a Dependent;
b) the date on which the Dependent turns age seventy (70);
c) the date on which the Applicant requests the Company in writing to terminate such insurance; or
d) the end of the Grace Period if the Applicant fails to make a contribution to premium as required. No premium is payable for any coverage after it ends. If any premium is paid after
termination, the Company's only liability will be to refund that premium (without interest).
The policy of any one (1) Applicant cannot be singled out for termination, however, if deterioration of the experience of a Class Grouping cannot be improved through normal rate and underwriting corrective measures, the Company may terminate the policies issued to that Class Grouping. The Company will provide written notice
at the most recent address on the Plan Administrator's record to the Applicant no less than thirty (30) days prior to the effective date of the termination.
CURRENCY
Amounts payable under this policy, either to or by the Company, shall be payable in the lawful currency of Canada, or in the currency where the expense occurred if the
expense occurred during an Insured Trip.
AGE
In this policy when we refer to the Insured Person's age on any date, we mean his or her age on their last birthday.
MISSTATEMENT OF AGE
If the Insured Person's date of birth has been misstated in the application for coverage under this policy, all benefits payable under this policy will be those that the premiums paid would have purchased at the correct age but shall not exceed
the Company's issue or qualifying limits in effect at that time.
If, because of the misstatement, the Company accepts a premium for a period or periods beyond the date coverage would have ceased according to the correct age, or if at the correct age the coverage would not have become effective, the Company's liability will be limited to the refund of all premiums paid (without interest) for the period during which coverage would not have been in effect. In no
event will any adjustment under this provision cause the amount of any benefit to increase over any maximum limit stated in this policy.
CONFORMITY WITH LAW
This policy is subject to all applicable laws of Canada or any of its provinces or territories. Notwithstanding any other provisions contained herein, this policy shall be governed by the laws of Ontario in all respects including matters of construction,
validity and performance. Legal actions or proceedings must be brought in the Canadian province where the Insured Person permanently resides.
SUBROGATION
If any benefits are payable in accordance with the terms of this policy to an Insured Person, and such Insured Person has a right to recover damages from any person or organization, then the Company will be subrogated to the rights of the Insured Person and:
1.the Insured Person will reimburse the Company in the amount of any benefits paid under this policy out of the damages recovered from such person or organization, or
2.the Company will acquire the rights of recovery of the Insured Person in the amount of any benefits paid under this policy against such person or organization.
RIGHT OF RECOVERY
In the event of an overpayment of benefits under this policy, the Company
reserves the right to demand repayment of any such overpayment or reduce any benefits payable to an Insured Person until such time as the overpayment has been repaid to the Company in full.
PREMIUM PROVISIONS
PREMIUMS PAYABLE
Premiums are payable to the Company via the Plan Administrator, during the life of this policy. The first premium is due and payable on the Effective Date of Coverage and thereafter on the 1st day of each month. If any cheque or other instrument given for payment is not honoured, the premium will be considered unpaid.
CHANGE IN PREMIUM
The policy of any one (1) Applicant cannot be singled out for a premium change after the policy has been in force, however, the Company reserves the right to change the premium from time to time: - due to adverse experience in any particular Class Grouping;
- in the event the Company's liability for benefits payable under this policy or
the amount of those benefits changes as a result of any:
a) change in the amount or type of hospital room or board charges made by eligible institutions;
b) change in any governmental hospital, medical or dental plan; change in any provincial dental fee guide;
c) repeal of, or enactment of, any law or regulation by any governmental authority;
d) change in the Compendium of Pharmaceuticals and Specialties, whether or not such change has been published in a revised Compendium of
Pharmaceuticals and Specialties; or
- in the event of a change in the Company's liability for taxes payable to any governmental authority on account of premiums or benefits paid in connection with this policy.
The Company will change the premium no more than once a year, due to adverse
experience in any particular Class Grouping, however, the Company may change the premium at any time due to any of the events described in 2) or 3) above. If the Company finds it necessary to change the premium it will give at least thirty (30) days prior written notice to the Applicant at the most recent address as shown on Plan Administrator's records.
The Applicant must notify the Plan Administrator in writing of any change in
occupation or province or territory of residence and the date the change occurred.
The Company also reserves the right to change the premium, as a result of a change in occupation or upon discovery of any misstatement, misrepresentation or omission relative to the Insured Person's insurability or a change in the province or territory of residence of the Insured Person, to the premium for the Class Grouping to which the Insured Person becomes a member or to the appropriate insurable
morbidity for the Insured Person.
GRACE PERIOD
Thirty (30) days of grace will be allowed for payment of each overdue premium after the first premium during which time this policy will continue in effect. If any premium is wholly or partially unpaid at the end of the Grace Period, this policy will then lapse. There will be no Grace Period if the Applicant has already given the Company notice to terminate this policy.
REINSTATEMENT
If any renewal premium is not paid before the Grace Period ends, the policy will terminate. However, the policy may be reinstated without additional evidence of insurability, if application for reinstatement is made within ninety (90) days following the date the first unpaid premium was due. The reinstated policy will
only cover losses sustained after the date of reinstatement.
COORDINATION OF BENEFITS
This policy is classified as a supplemental benefit plan. It covers expenses that are not covered under any other benefit or insurance plan, collectible or not. In the event that the Insured Person is entitled to similar benefits under any other individual or group contract including, but not limited to any GHIP, credit card
coverage, private or auto insurance, benefits will be coordinated and/or reduced to the extent that benefits payable from all plans shall not exceed one hundred percent (100%) of reasonable and customary charges incurred.
After the benefits payable by government plans have been determined, excess benefits available under this policy will be coordinated with those of other contracts or plans if the Insured Person is eligible for similar benefits simultaneously under any
other non-government plan as follows: - if any other plan does not contain a provision for co-ordination with or reduction of benefits payable hereunder, the benefit payable under such other plan will be determined first;
- if any other plan contains a provision for co-ordination with or reduction of
benefits payable hereunder, the benefits shall be prorated between or among the plans in proportion to the amounts that would have been paid under each plan had there been coverage by only that plan;
- the Company will abide by the coordinating coverage guidelines for out-of-country/province health care expenses as set out by the Canadian Life and Health Insurance Association Inc. guidelines.
The Company shall (with the consent of the Insured Person) have the right to release to or obtain from any insurance company, organization or person, information that in the opinion of the Company is necessary to the application and implementation of this Coordination of Benefits provision.
If payments, which should have been made under this policy by the terms of this
Coordination of Benefits provision, have been made under any other plan, the Company shall have the right to pay to any other insurance company or organization, the amount necessary to satisfy the intent of this Coordination of Benefits provision. The amounts paid in this manner shall be considered benefits paid under this policy and the Company shall be fully discharged from liability to the extent of the payments made.
If payments have been made by the Company under this policy which are in excess of the maximum amount of payment necessary to satisfy the intent of this Coordination of Benefits clause, the Company shall have the right to recover any such excess from any persons to or for whom such payments were made, or any other insurance companies, or any other organizations.
STATUTORY CONDITIONS
It is a legal requirement that these conditions be reproduced in this policy in the following form. In these statutory conditions loss means a benefit for which a claim is made under this policy.
THE CONTRACT
The application, any evidence of insurability, this policy, any document attached to
this policy when issued, and any amendment to the contract agreed upon in writing after this policy was issued, constitute the entire contract, and no agent has authority to change the contract or waive any of its provisions.
WAIVER
The Company shall be deemed not to have waived any condition of this contract,
either in whole or in part, unless the waiver is clearly expressed in writing and signed by the Company, or the Plan Administrator.
COPY OF APPLICATION
The Company shall, through the Plan Administrator, upon request, furnish to the Insured Person or to a claimant under this contract a copy of the application.
MATERIAL FACTS
No statement made by any Insured Person at the time of application for this
contract shall be used in defence of a claim or to void this contract unless it is contained in the application or any other written statements or answers furnished as evidence of insurability.
CHANGES IN OCCUPATION
If after the contract is issued the Insured Person engages for compensation in an occupation that is classified by the Company as more hazardous than that stated in the contract, the liability under this contract is limited to the amount that the
premium paid would have purchased for the more hazardous occupation according to the limits, classification of risks and premium rates in use by the Company at the time the Insured Person engaged in the more hazardous occupation.
If the Insured Person changes his or her occupation from that stated in this contract to an occupation classified by the Company as less hazardous and the Company is so advised in writing, the Company shall either: - reduce the premium rate; or
- issue a policy for the unexpired term of this contract at the lower rate of premium applicable to the less hazardous occupation, according to the limits, classification of risks, and premium rates used by the Company at the date of receipt of advice of the change in occupation, and shall refund to the
Insured Person the amount by which the unearned premium on this contract exceeds the premium at the lower rate for the unexpired term.
NOTICE AND PROOF OF CLAIM
Any Insured Person, or a beneficiary entitled to make a claim, or the agent of any of them shall: - give written notice of claim to the Company,
a) by delivery thereof or by sending it by registered mail to the Plan Administrator, or the head office or chief agent of the Company in the province, or
b) by delivery thereof to an authorized agent of the Company in the province,
c) not later than thirty (30) days from the date the claim arises under the contract;
- within ninety (90) days from the date a claim arises under the contract,
furnish to the Company such proof of claim as is reasonably possible in the circumstance of the happening, and the loss occasioned thereby, the right of the claimant to receive payment, his/her age, and the age of the beneficiary, if relevant; and
- if so required by the Company, furnish satisfactory certificate as to the cause
or nature of the event for which the claim may be made under the contract and as to the duration of such an event
.
FAILURE TO GIVE NOTICE OR PROOF
Failure to give notice of claim or furnish proof of claim within the time
prescribed by this statutory condition does not invalidate the claim if the notice or proof is given or furnished as soon as reasonably possible, and in no event later than one (1) year from the date a claim arises under the contract if it is shown that it was not reasonably possible to give notice or furnish proof within the time so prescribed.
PLAN ADMINISTRATOR TO FURNISH FORMS FOR PROOF OF CLAIM
The Plan Administrator shall furnish forms for proof of claim within fifteen (15) days after receiving notice of claim, but where the claimant has not received the forms within that time he or she may submit his or her proof of claim in the form of a written statement of the cause or nature of the event giving rise to the claim.
WHEN MONEYS PAYABLE
All moneys payable under this contract shall be paid by the Company within sixty
(60) days after it has received satisfactory proof of claim.
LIMITATION OF ACTIONS
An action or proceeding against the Company for the recovery of a claim under this contract shall not be commenced more than one (1) year (three (3) years in Quebec) after the date the insurance money became payable or would have become payable if it had been a valid claim.
SELECT EXTENDED HEALTH CARE BENEFITS
(Coverage is valid only if purchased and a Personal Health Declaration is approved by Echelon General)
BENEFIT SUMMARY - Eligible expenses are not subject to a Deductible amount.
- Reimbursement for eligible expenses, up to the annual maximum of $25,000 per insured person will be made at eighty percent (80%) of all eligible expenses subject to the following benefit limits:
Drugs
– up to $5,000 per policy year (Not available in Quebec)
Medical & Surgical Supplies – up to $1,500 per policy year
Durable Medical Equipment & Prosthetics – up to $1,750 per policy year
Professional Services, including:
Private Duty Nursing – up to $2,000 per policy year
Paramedical Practitioners – up to $500 per practitioner per policy year
after any GHIP Benefits, subject to a maximum of $50.00 per visit
Psychologist Services – up to $360 per two policy years
Ambulance – services not covered by GHIP up to $250 per trip
Accidental Dental – up to $2,500 per policy year
Hearing Aids – up to $300 once every five (5) policy years
Orthopedic Footwear – up to $150 per policy year.
Hospital Services: Semi-Private Hospital
– up to $170 per day for 30 days per policy year
Vision – Eye Glasses/Contacts -75% reimbursement up to $150 every 2 policy years (subject to a 6 month waiting period). Eye examinations up to $100 per 24 months..
For Quebec residents only, Drugs are not included in this policy.
This benefit provides reimbursement for Reasonable and Customary Charges
incurred for Medically Necessary drugs or supplies required as a result of Sickness or Injury, maximum limits or reimbursement percentages outlined in the Benefit Summary. The reimbursement percentage represents the portion of the charges payable by the Company.
DRUGS
If an Insured Person incurs eligible expenses for drugs or medicines, the Company will pay Reasonable and Customary Charges subject to the following conditions: - drugs, insulin and medicines must be ordered by a Physician or Dentist in the treatment of Sickness or bodily Injury; and
- eligible expenses require the written prescription and must be dispensed by a registered Pharmacist; and
- where the appropriate generic substitution is available, the Company will
provide reimbursement for the drug or medicine that incurs the lowest amount of charges.
LIMITATIONS AND EXCLUSIONS
The following limitations and exclusions shall apply to this Drug Benefit. No benefits shall be payable for any of the following:
- Contraceptive implants and contraceptive devices.
- Drugs used to promote fertility.
- Smoking cessation products and drugs containing nicotine resin.
- Food or dietary supplements.
- Preventive vaccines.
- Drugs that are, in the opinion of the Company, experimental or not approved by Health and Welfare Canada (Food and Drugs) or are limited in use whether or not so approved.
- Drugs that can be obtained over the counter.
- Drugs used to treat erectile dysfunction.
- Anorexiants, anti-obesity and weight-loss medications.
- Vitamin products, patent medicines, blood or blood plasma, cosmetic
products.
- Delivery or Transportation charges.
- Quantities of drugs or medicines which exceed a 100 day supply.
MEDICAL & SURGICAL SUPPLIES
Subject to any maximum limits specified in the Benefit Summary, if an Insured Person incurs expenses for medical supplies when ordered by a Physician, the Company will pay reasonable charges for: - oxygen and the equipment required for its administration;
- syringes and needles required for insulin administration, glucose monitoring
machines up to $250 every forty-eight (48) months, blood letting devices and test strips for insulin dependent diabetics;
- blood pressure monitors to an eligible maximum of $50 per policy year;
- custom-made compression hose to an eligible maximum of $100 per policy year;
- any other supplies which the Company may elect to recognize.
DURABLE MEDICAL EQUIPMENT AND PROSTHETICS
Subject to any maximum limits specified in the Benefit Summary, if an Insured Person incurs expenses for durable medical equipment and prosthetics when ordered by a Physician, the Company will pay reasonable charges for:
- purchase of artificial limbs and artificial eyes required as a result of accident or Sickness which occurs while the individual is insured for this benefit;
- rental, or at the option of the Company, purchase of a wheelchair up to $750 per policy year, hospital bed or respirator/ventilator;
- custom-made braces provided they are not required for athletic use;
- wigs required as a result of chemotherapy, to an eligible maximum of $150 per policy year;
- external breast prostheses to an eligible maximum of $200 per two (2) policy years;
- surgical brassieres to an eligible maximum of two (2) per policy year.
PROFESSIONAL SERVICES
If an Insured Person incurs expenses for professional services during the diagnosis or treatment of a Sickness or Injury, the Company will pay Reasonable and Customary Charges for:
- services of a registered graduate nurse provided in the Insured Person's home to an eligible maximum of $2,000 per policy year. The service must be certified as essential by the attending Physician, but not by a person related
by blood or marriage to an Insured Person and not ordinarily resident with the Insured Person or a business associate of the Insured Person. No payment will be made if the services could have been performed by an individual of lesser qualifications. Prior approval of the Medical Director is necessary;
- treatment by the following licensed, certified or registered paramedical
practitioner. Benefits are payable up to an eligible maximum of $500 per specialty per policy year, subject to a maximum of $50.00 per visit – physiotherapist, chiropractor, chiropodist, osteopath, speech pathologist, massage therapist (when such treatment is recommended in writing by your physician) podiatrist, or dietician / nutritionist.
- services of a licensed psychologist, to an eligible maximum of $360 per two
policy years;
- professional licensed ambulance service to the nearest Hospital, that in the opinion of the Company is reasonable and justified, to an eligible maximum of $250 per policy year, after any GHIP benefits;
ACCIDENTAL DENTAL
The Company will pay Reasonable and Customary Charges if an Insured Person incurs expenses for professional services performed by a dentist to replace or repair natural teeth as a direct result of accidental injury to the teeth (not as a result of the deliberate introduction of food or an object into the mouth) sustained while this policy is in force. The accident must be reported within sixty (60) days and expenses must be incurred within twelve months (12) after the date of the
accident. Reimbursement is subject to a maximum of $2,500.
HEARING AIDS
When an Insured Person is diagnosed as having a hearing impairment and the attending Physician or specialist provides written authorization for the purchase of a hearing device, the Company will pay the charges for a hearing aid up to a
maximum of $300 once every five (5) policy years.
ORTHOPEDIC SHOES
The Company will pay Reasonable and Customary Charges for custom-made orthopedic boots or shoes to a maximum of $150 per policy year.
VISION
When an insured person incurs charges for the purchase of prescription eye glasses (frames and lenses) or contact lenses on the written authorization of a physician, optometrist or ophthalmologist to correct visual impairment, the company will pay
75% of the eligible charges incurred, up to the maximum amount of $150.00 once every two (2) years, provided the insured person incurring the expense has been insured under this policy for at least (6) consecutive months.
Eye Examinations by an Optometrist or Ophthalmologist are covered up to $100 per 24 months.
No benefit is payable for:
1. replacement of eye glasses or lenses which have been lost, stolen or broken;
2. the cost of fitting lenses or glasses;
3. sunglasses, monogrammed or special frames and non-prescription lens tint;
4. industrial safety glasses, except those which are specifically recommended by the attending physician for use in place of regular prescription glasses or lenses.
ORTHOPEDIC FOOTWEAR OR ORTHOTICS
The Company will pay Reasonable and Customary Charges for cus |
