health
benefits

Extended Health Care

• Plan Summary
• Definitions
• Eligible Expenses
• Out-of-Province
• Exclusions
• Claims
   

The Extended Health Care (EHC) plan is designed to help you pay for specified services and supplies incurred by you and your Dependents, when not provided under a government health plan or by a tax-supported agency. 

All dollar limits included in the benefit descriptions are claimable unless specifically defined as payable. 

To determine the benefit amount claimable, the claim is assessed as follows:

• the total Eligible expense is calculated
• the claimable limits are applied
• the Deductible, when applicable, is subtracted
• the reimbursement percentage is applied, then
• the EHC plan maximum (if applicable) is applied.

• the total Eligible expense is calculated
• the Deductible, when applicable, is subtracted
• the reimbursement percentage is applied
• the payment limits are applied, then
• the EHC plan maximum (if applicable), is applied.

DEFINITIONS

Eligible expense means a charge for any service and/or supply included in this booklet as a benefit that:

1. in our assessment is a customary charge medically necessary for health care and maintenance, or to maintain or restore teeth, and
2. was ordered or referred by a Physician or Dentist, unless otherwise specified in the benefit description, and
3. is not a cost normally paid (in whole or part) or provided by a government plan or any other provider of health coverage, and
4. is incurred while your coverage is valid. An expense is “incurred” on the date the service is provided or the supply is received.

It does not include any payment to a pharmacy or a Practitioner (demanded or received by balanced billing, extra billing, or extra charging) which represents an amount in excess of the schedule of costs prescribed by the government plan. PharmaCare’s Low Cost Alternative and Reference Based Pricing will not be applied unless specified in this booklet. 

Physician means an individual who is duly qualified and licensed to practice medicine or surgery, or both, in the area where the service is provided, but excludes a Physician residing with or related to you or your Dependent.

Practitioner means an individual who is currently licensed, certified, or registered to practice a profession in the area where the care or service is provided.



 

1. Hospital 
   The additional charge for semi-private or private room accommodation in a hospital or the extended care unit of a hospital. Charges for rental of a telephone, television, or similar equipment are not covered.
    
2. Emergency ambulance
   1. charges for licensed ambulance service to and from the nearest Canadian hospital equipped to provide the type of care essential to the patient
   2. air transport will be covered when time is critical and the patient’s physical condition prevents the use of another means of transport
   3. emergency transport from one hospital to another, only when the original hospital has inadequate facilities
   4. charges for an attendant when medically necessary.
       
3. Prescription Drugs 
   Drugs and medicines dispensed by a licensed pharmacist or a Physician, in a quantity we consider reasonable:
   
   1. drugs and medicines which legally require a prescription from a Physician or Dentist, and included with the above;
   2. insulin preparations for diabetics
   3. vitamin B12 for the treatment of pernicious anemia
   4. allergy serums when administered by a Physician.
       
4. Practitioners 
   Professional services of the following Practitioners to the maximum amounts indicated per calendar year, but excluding appliances and tray fees. Only the services of a private duty nurse require referral by a Physician.
   
   Group 903118 and 903211: 
    

   a) acupuncturist	$400
   b) chiropractor	$400
   c) massage practitioner	no Calendar year limit
   d) naturopath	$400
   e) physiotherapist	no Calendar year limit
   f) podiatrist	$400
   g) psychologist	$400
   h) speech language pathologist	$400
   i) private duty care by a registered nurse for a person with an acute condition in the person’s home or in a hospital in the patient’s province of residence.

   Group 903119: 
   

   a) acupuncturist	$400
   b) chiropractor	$400
   c) massage practitioner	no Calendar year limit
   d) naturopath	$400
   e) physiotherapist	no Calendar year limit
   f) podiatrist	$400
   g) psychologist	$400
   h) speech language pathologist	$400
   i) private duty care by a registered nurse for a person with an acute condition in the person’s home or in a hospital in the patient’s province of residence.

   Group 903120: 
   
   

   a) acupuncturist	$400
   b) chiropractor	$400
   c) massage practitioner	no Calendar year limit
   d) naturopath	$400
   e) physiotherapist	no Calendar year limit
   f) podiatrist	$400
   g) psychologist	$400
   h) speech language pathologist	$400
   i) private duty care by a registered nurse for a person with an acute condition in the person’s home or in a hospital in the patient’s province of residence.

    

5. Dental Accident
   Dental treatment by a Dentist, which is required, performed, and completed within 52 weeks after an Accidental injury which occurred while covered under this EHC plan, for the repair or replacement of natural teeth or prosthetics. No payment will be made for temporary, duplicate, or incomplete procedures, or for correcting unsuccessful procedures.
   
   Accidental means caused by a direct external blow to the mouth or face resulting in immediate damage to the natural teeth or prosthetics and not by an object intentionally or unintentionally being placed in the mouth. 
   
   We pay benefits based on eligible Dental services and financial limits in our current Fee schedule, and we pay the fees in our current Fee schedule or, if applicable, the Fee guide in the province/territory of service.
   
6. Medical aids and supplies
   Charges for the following services and supplies:
   
   1. testing supplies, needles, and syringes for diabetics
   2. oxygen, blood, and blood plasma
   3. ostomy and ileostomy supplies
   4. walkers, canes and cane tips, crutches, splints, casts, collars, and trusses, but not elastic or foam supports
   5. rigid support braces and permanent prostheses (artificial eyes, limbs, larynxes, and mastectomy forms). Myoelectrical limbs are excluded, but we will pay the equivalent of a standard prostheses
   6. mastectomy brassieres to a maximum of 1 brassiere per breast prosthesis to a maximum of 2 per lifetime
   7. charges for the following items to the maximum amounts indicated per calendar year:
      1. stump socks - no limit
      2. surgical stocking - 2 pairs
   8. wigs and hairpieces required as a result of medical treatment or injury to a lifetime payable maximum of $500
   9. when prescribed by a Physician or podiatrist as medically necessary, charges for one pair of custom fitted orthopedic shoes or orthotics and replacements when necessitated by normal wear and tear
   10. hearing aids and repairs to the maximum shown below. Batteries, recharging devices, and other such accessories are not covered. Replacement will be covered only when the hearing aid cannot be repaired satisfactorily.
       1. For groups 903118 and 903211, a lifetime maximum of $500. Dependent children are covered for an additional benefit of $400 per 60-month period.
       2. For group 903120, a maximum of $300 in a 60-month period.
       3. Hearing aids are not an Eligible expense for group 903119.
          
7. Standard durable medical equipment
   
   1. Preauthorization is required from us for expenses in excess of $5,000
   2. Charges for standard durable medical equipment when rented from a medical supplier. If unavailable on a rental basis, or required for a long-term disability, purchase of these items from a provider may be considered.
   3. Repairs to purchased items. We will replace the item when it can no longer be made functional. We may request trade-in or return of replaced equipment.
   4. Reimbursement on rental equipment will be made monthly and will in no case exceed the total purchase price of similar equipment.
   5. Standard durable equipment includes:
      1. manual wheelchairs, manual type hospital beds, and necessary accessories – electric wheelchairs and hospital beds will be covered only when the patient is incapable of operating a manual wheelchair, otherwise we will pay the manual equivalent
      2. medical monitors including heart and blood glucose monitors, and cardiac screeners
      3. bi-osteogen systems (when recommended by an orthopedic surgeon) and growth guidance systems
      4. breathing machines and appliances including respirators, compressors, percussors, suction pumps, oxygen cylinders, masks, and regulators
      5. insulin infusion pumps for diabetics – when basic methods are not feasible
      6. transcutaneous electric nerve stimulators (TENS) when prescribed for intractable pain
      7. transcutaneous electric muscle stimulators (TEMS) required when, due to an injury or illness, all muscle tone has been lost.
         
8. Vision Care
   Charges for non-prescription eyewear are not covered.
   1. Groups 903118 and 903211: Charges for the purchase and/or repair of eyewear when prescribed by a Physician or optometrist to a maximum of $150 in a 12-month period.
   2. Group 903119: Not covered.
   3. Group 903120: Charges for the purchase and/or repair of eyewear when prescribed by a Physician or optometrist to a maximum of:
      1. $175 in a 24-month period for adults.
      2. $175 in a 12-month period for children.
         
9. Medical Examinations
   Charges of a Physician for medical examinations required by government statute or regulation for employment purposes provided such charges are not payable by your employer under a collective agreement. 

Out-of-Province Non-Emergency Eligible Expenses 
We will reimburse you (and your Dependents) for non-emergency Eligible expenses incurred while travelling outside your province of residence subject to the Deductible, in-province reimbursement percentage, and maximums. We will not reimburse any expenses payable or provided under a government plan. 

Out-of-Province Emergency Eligible Expenses
Travel insurance is designed to cover losses arising from sudden and unforeseeable circumstances occurring while you are temporarily travelling outside your province or territory of residence. It is important that you read and understand your Plan before you travel. In the event of any discrepancy between the provisions of a booklet or other document you hold and the provisions of the Policy, the provisions of the Policy shall govern. The insurer has contracted Viator/Global Excel Management Inc. (called Global Excel”) to provide medical assistance and claims services under the Policy.

IN THE EVENT OF AN EMERGENCY, YOU MUST CALL GLOBAL EXCEL IMMEDIATELY:

The emergency telephone numbers are listed on the back of the Medical Assistance Card provided. 

Global Excel must be contacted before you seek medical treatment. If your condition renders you unable to do so, then someone else must contact Global Excel immediately for you. Do not assume that someone will contact Global Excel on your behalf. It remains your responsibility to ensure that Global Excel has been contacted prior to receiving medical treatment or as soon as reasonably possible. 

If you incur any expenses without prior approval by Global Excel, such expenses will be covered, except where the policy expressly requires the prior approval or authorization of Global Excel, on the basis of the reasonable and customary costs that would have been payable for such expenses by the insurer in accordance with the terms and conditions of the policy. Such expenses may be higher than this amount, therefore you will be responsible for paying any difference between the amount you incur and the reasonable and customary costs reimbursed by the insurer. 

The Policy covers expenses that are:

• incurred outside the province or territory of residence of the insured person;
• medically necessary;
• Reasonable and customary costs;
• incurred as a result of an emergency due to sudden and unforeseen sickness and/or injury occurring during the coverage period;
• in excess of those covered by the Government Health Insurance Plan or other insurance under which you may have coverage; and
• legally insurable;

1. Hospital Accommodation: Reasonable and customary room and board costs up to the semi-private room rate charged by the hospital. If medically necessary, expenses for treatment in an intensive or coronary care unit are also covered. If coverage terminates for any reason during your hospital stay, benefits continue until discharge, to a maximum of one year. In no case will expenses for In-patient stays be covered for a period greater than 365 days per insured person.
2. Physician Charges: Reasonable and customary charges for treatment by a physician.
3. Diagnostic Services: Reasonable and customary charges for laboratory tests and x-rays prescribed by the attending physician and that are part of the emergency treatment. The policy does not cover magnetic resonance imaging (MRI), cardiac catheterization, computerized axial tomography (CAT) scans, sonograms or ultrasounds and biopsies unless such services are authorized in advance by Global Excel.
4. Paramedical Services: The services (including x-rays) of a licensed chiropractor, physiotherapist, podiatrist or osteopath, to the maximum of $250 per insured person, per profession listed above, when approved in advance by Global Excel.
5. Prescriptions: Drugs, including injectable drugs, and sera that can only be obtained upon medical prescription, that are prescribed by a physician and that are supplied by a licensed pharmacist when medically necessary for emergency treatment, except when needed to stabilize a chronic condition or a medical condition which you had before your trip. This benefit is limited to a 30-day supply per prescription, unless you are hospitalized.
6. Ambulance Services: Reasonable and customary costs when reasonable and medically necessary, for licensed ground ambulance service to the nearest medical facility.
7. Medical Appliances: When approved in advance by Global Excel, reasonable and customary costs for minor appliances such as crutches, casts, splints, canes, slings, trusses, braces, walkers and/or the temporary rental of a wheelchair when prescribed by the attending physician, obtained outside your province or territory of residence and medically necessary.
8. Private Duty Nurse: The professional services of a registered private nurse, when medically necessary and while hospitalized, to the maximum of $5,000 per insured person, when approved in advance by Global Excel.
9. Emergency Air Transportation: When approved and arranged in advance by Global Excel, the reasonable and customary costs for:
   
   1. air ambulance to the nearest appropriate medical facility or to a Canadian hospital for immediate emergency treatment;
   2. transport on a licensed airline with an attendant (where required) to return you to your a province or territory of residence for immediate emergency treatment.
10. Transportation to Bedside: When approved in advance by Global Excel, a single round-trip economy airfare from Canada plus up to $150 per day up to a maximum of $3,000 for the cost of meals and commercial accommodation for one of the following: Spouse, parent, child, brother, sister or business partner, to:
    
    1. be with you if you are travelling alone and have been hospitalized as the result of an emergency. To be payable, this benefit requires that you eventually be hospitalized as an inpatient for at least three (3) consecutive days outside your province or territory of residence and that the attending physician provide written certification that the situation was serious enough to warrant the visit; or
    2. identify the deceased insured person prior to the release of the body, where necessary.
    The insurer will only reimburse covered expenses evidenced by original receipts.
11. Return of Travelling Companion: If you are returned to your province or territory of residence under the Emergency Air Transportation benefit or the Return of Deceased benefit, the insurer will reimburse the cost of a single one-way economy airfare for a travelling companion to return to Canada, when approved in advance by Global Excel.
12. Treatment of Dental Accidents: Up to $2,000 per insured person for emergency Dental treatment to repair natural, vital and sound teeth or permanently attached artificial teeth provided the Injury was caused by an external, accidental blow to the mouth or face. you must consult a physician or Dentist immediately following the Injury. Treatment must begin during the coverage period and be completed prior to returning to your province or territory of residence. An accident report is required from a physician or Dentist for claims purposes.
13. Meals and Accommodation: Up to $150 per day to a maximum of $3,000 per trip per participant, for the cost of commercial accommodation and meals for the participant and/or any of his/her dependents when their trip is extended beyond the last day of the coverage period due to the sickness and/or Injury suffered by an insured person. This benefit must be authorized in advance by Global Excel. The fact that you are unable to travel must be certified by the attending physician and supported with original receipts from commercial organizations.
14. Vehicle Return: Up to $5,000 if neither you, nor someone travelling with you, are able to operate your vehicle, whether owned or rented, during your trip due to sickness and/or injury. Arrangements and payment will be made for the return of the vehicle to your home in your province or territory of residence or the nearest appropriate rental agency. Benefits will only be payable for a single person to return the vehicle when approved and/or arranged in advance by Global Excel. This benefit does not cover wages lost by the person driving your vehicle. The insurer will only reimburse covered expenses evidenced by original receipts.
15. Return of Deceased: Up to $5,000 towards the cost of preparation and transportation of the deceased insured person to their province or territory of residence in the event of death due to a sickness and/or injury. 
    In the case of cremation and/or burial at the place of death of the insured person, this benefit is limited to $2,500. 
    The cost of the casket or urn is not covered.
16. Incidental Expenses: Up to $250 for your out-of-pocket expenses such as telephone charges, television rental and parking while you are hospitalized for an emergency and the expenses are incurred, as a direct result of such hospitalization. The insurer will only reimburse covered expenses evidenced by original receipts.

1. include the policy number, the patient’s name (married and maiden, if applicable), date of birth, and Canadian provincial or territorial Government Health Insurance Plan number with its expiry date or version code (if applicable);
2. submit all original itemized bills from the medical provider(s) stating the patient’s name, diagnosis, all dates and type of treatment, and the name of the medical facility and/or physician;
3. provide the original prescription drug receipts (not cash receipts) from the pharmacist, physician or hospital showing the name of the prescribing physician, prescription number, name of preparation, date, quantity and total cost;
4. provide proof of the departure date(s) and return date(s);
5. provide written proof of claim within ninety (90) days of the date of receipt of services covered under the Policy;
6. provide additional information pertinent to your claim, as may be required by Global Excel after receipt of your claim;
7. sign and return the authorization form, provided by Global Excel, allowing the insurer to recover payment from the Canadian provincial or territorial Government Health Insurance Plan. The insurer will coordinate and pay your claim to the participating medical providers and where permitted, coordinate claims directly with the Canadian provincial or territorial Government Health Insurance Plan on your behalf; and
8. return the unused portion of your air ticket to Global Excel if the Emergency Air Transportation benefit is used.

1. except as specifically included in this booklet: dentures or dental treatments, hearing aids, eyeglasses, contact lenses, surgical lens implants, or examinations for the prescription or fitting of any of these, x-rays, hospital coinsurance, vitamins and/or minerals, contraceptives, fertility drugs, erectile dysfunction drugs, medications used to treat or replace an addiction or habituation, support stockings, orthotics, arch supports, transportation charges incurred for elective treatment and/or diagnostic procedures or for health or health examinations of any kind, and professional services of Physicians or any person who renders a professional health service in the patient’s province of residence
2. general anesthetic, medications used to prevent baldness or promote hair growth, food replacements or supplements, HCG injections, drugs not approved for sale and distribution in Canada, and medications available without a prescription
3. any drug, vaccine, item or service classified as preventive treatment or administered for preventive purposes, and which is not specifically required for treatment of an illness or injury
4. allergy testing unless rendered by a naturopath
5. personal comfort items, items purchased for athletic use, air humidifiers and purifiers, services of Victorian Order of Nurses or graduate or licensed practical nurses, services of religious or spiritual healers, occupational therapy, services and supplies for cosmetic purposes, public ward accommodation, rest cures
6. charges for completion of forms or written reports, communication costs, delivery and mailing or handling charges, interest or late payment charges, non-sharable or capital costs levied by local hospitals, or charges for translating documents into English
7. any payment to a pharmacy, a Practitioner, or a Physician (demanded or received by balanced billing, extra billing or extra charging) which represents an amount in excess of the schedule of costs prescribed by the government plan
8. that portion of a claim normally covered by the government plan which has been refused on the basis that the claim was not submitted within the government plan’s time limits
9. expenses incurred, outside your province of residence, due to elective treatment and/or diagnostic procedures, or complications related to such treatment
10. expenses incurred, outside your province of residence, due to therapeutic abortion, childbirth, or complications of pregnancy occurring within 21 days of the expected delivery date
11. charges incurred outside your province of residence for continuous or routine medical care normally covered by the government plan in your province of residence
12. expenses of a Dependent hospitalized at the time of enrolment
13. services performed by a Physician who is related to or resident with you or your Spouse
14. fees for ambulance services when an ambulance is called but not used
15. ambulance charges for work-related illness or injury assessed by the Workers’ Compensation Board to be your employer’s responsibility
16. retroactive coverage and payment of any expense, including expenses that receive special authorization from Pharmacare
17. any other item not specifically included as a benefit.

1. Because we do not return receipts after the claim is processed, we recommend that you keep a photocopy of the receipts that you submit. We will send you a remittance statement for your records each time you submit a claim.
2. If you have Duplicate coverage, please review the Coordination of Benefits section under General Information. Two separate claim forms (one for the primary plan and one for the secondary plan) must be completed. The remittance statement from the first plan must be submitted to the second plan. Because claims information regarding the other plan is not retained on our files, be sure to provide information on the second plan on both claim forms. Incomplete claims will be returned for clarification.
3. Certain medical expenses are covered under the government plan. If you submit your claim to us before you submit your claim to the government plan, we will deduct what the government plan would normally pay (e.g. Pharmacare expenses) from your EHC claim. The balance of the EHC claim is then paid according to the plan design selected by your employer. Information for claiming Pharmacare expenses may be obtained from your pharmacist.
4. Accumulate receipts and when reasonable reimbursement is due, submit a claim as follows:
   
   1. Obtain a claim form from your Plan Administrator.
   2. Follow the instructions on the claim form. To avoid delay in claims payment, please include original receipts and all other requested information with your claim. (Photocopies of receipts are acceptable only when accompanied by a claims payment statement from another carrier).
   3. We suggest you submit claims within 90 days from the date the expense was incurred. However, we must receive your claim by June 30th of the year following the calendar year in which the expense being claimed was incurred. If not, your claim will not be paid under any circumstances. Example: We must receive your receipts for 2005 before June 30, 2006.