EXECUTIVE EMPLOYEES, ELIGIBLE DEPENDENTS, AND PENSIONERS
Effective January 1, 2007
TABLE OF CONTENTS SectionTitlePage
1.0 Overview 1
2.0 Responsibilities 1
3.0 Who Is Covered? 2
4.0 Definitions 4
5.0 Submitting Claims 5
6.0 Right of Recovery 5
7.0 Co-ordination of Benefits 5
8.0 Annual Deductible 6
9.0 Reasonable and Customary Charges 6
10.0 Excluded Charges 7
11.0 Semi-Private and Private Hospital Rooms 8
12.0 The Company’s Drug Plan 8
13.0 Ontario Drug Benefit (ODB) Plan 12
14.0 Extended Health Benefits Plan 12
15.0 Out of Province Health Coverage 19
16.0 Dental Plan - Excluding Orthodontic Benefits 24
17.0 Dental Plan - Orthodontic Benefits 25
18.0 Limitations of Benefits Provided outside Ontario 27
19.0 OHIP Coverage for Pensioners 27
Section 1.0 The Extended Health Benefits Plan, provides eligible employees, pensioners, and their dependents comprehensive medical services which are among the very best available. This includes various levels of coverage for hospitalization, drug products, dental services and many other extended health benefits. The objective of this Plan is to provide comprehensive coverage, in a managed way, to facilitate employees, pensioners, and their dependents in their recovery from illness or injury.
This booklet provides a detailed outline of the products and services covered under these plans. There are, however, limitations to that coverage and employees/pensioners should be aware of these. There are also reasonable and customary limits applied by the carrier (The Great-West Life Assurance Company) in administering these benefits. This booklet also provides illustrations of these limits. If employees/pensioners are uncertain of what these limitations are, they are encouraged to contact Great-West Life at the telephone numbers provided below:
Local Calls within the Toronto Area (416) 544-1594 Long Distance Calls 1-800-318-6098 The Mailing Address for Claims is: The Great-West Life Assurance Company
London Benefit Payments
255 Dufferin Avenue
Great-West Life’s business hours for inquiries are from 8:00 am to 4:30 pm, Monday through Friday (excluding statutory holidays). Messages may be left after 4:30 pm and all calls will be returned the following business day.
Section 2.1 It is the employee's/pensioner's responsibility to ensure that all claims are legitimate.
Eligible pensioners are entitled to the current health and dental benefits on the same basis as the employee group they belonged to at time of retirement. Eligible beneficiaries are entitled to the
current health and dental benefits on the same basis as the employee
group the pension plan member belonged to prior to death or retirement.
It is essential that employees and pensioner keep their “personal information” up to date. For example, if a spouse is added or deleted from coverage, the spouse changes employers and/or insurance carriers, and the addition or deletion of dependent children – employees and pensioners should contact the Human Resources Department.
In the following material, the term "Employee" includes "Pensioners, Beneficiaries, and Eligible Dependents".
THE GREAT-WEST LIFE ASSURANCE COMPANY
Section 2.2 The Company's claims services provider for health and dental coverage is the Great-West Life Assurance Company. It is Great-West Life's responsibility to ensure that all legitimate claims for benefits, that are covered under the contract, are reimbursed in accordance with the contract.
WHO IS COVERED?
Section 3.0 Employee: Probationary and regular employees, including employees receiving LTD benefits, are eligible for coverage immediately from their first day of work and all coverage ceases immediately upon termination except for Society represented employees on recall.
Surplus Society represented employees who are terminated and elect “recall” shall be provided with coverage under The Company’s Health and Dental Plan from the date the right of recall commences for a period of 6 months or until the commencement of alternative employment, whichever comes first.
Employees who go from employee to pensioner without a break in service having had subsidized health and dental coverage will continue to receive benefits during their retirement equivalent to the current benefits available to active employees. Vested/deferred pensioners will be eligible for these benefits providing they had them as employees and had a minimum of 25 years of continuous service with The Company prior to their termination date.
(2) a person who is publicly represented by the employee as his
or her spouse (including same sex spouse).
Only one person shall be considered a Qualified Dependent spouse during a period of time for which any benefits are payable to or for the spouse of an employee.
In the event that an employee takes up residence with an individual and publicly represents that individual as his or her spouse, the spouse status of any other individual shall automatically terminate. An individual who fails or ceases to meet the criteria specified in item (1) or (2) of this paragraph shall immediately be rendered ineligible as a Qualified Dependent spouse.
If a married couple are both employed by The Company and both are eligible for health and dental benefits through The Company, one employee is designated as the “subscriber” and the other employee is designated as the “dependent spouse”.
An unmarried child (of an employee or an employee's spouse) including “legally adopted” who is unmarried, unemployed, attending school full time, up to and including 23 years of age. Coverage for dependent children ceases as of their 24th birthday.
A child to whom the employee stands in the position of a parent for purposes of the Income Tax Act, the Divorce Act, or the Family Law Act.
A child of any age (of an employee or an employee's spouse) who is dependent for financial support upon the employee or the employee's spouse because of physical or mental infirmity, provided the child had the infirmity while eligible for coverage
under the above criteria. Coverage will continue for as long as the child remains continuously dependent for financial support upon the employee or the employee's spouse because of physical or mental infirmity. The Company will determine the eligibility of physically or mentally infirm dependent children as Qualified Dependents and furnish written proof with instructions for Great-West Life to continue coverage.