EXTENDED HEALTH CARE BENEFITS

This is an optional benefit for firms that have chosen the term life and long term disability insurance. All eligible CAs and employees of the firm must participate and must be eligible for benefits under their provincial government health plan.

Definitions

Spouse: includes a person who is publicly represented as your spouse, and with whom you have been living for at least one year. In the event of a divorce, your spouse is no longer an eligible dependent.

Child: a natural or adopted child, stepchild (spouse’s child who lives with you), a child under your custody, or a child related by blood or marriage for whom you are the legal guardian. The child must be unmarried and dependent on you for support.

  • Age: a dependent child must be under the age of 21, or under age 25 if in full-time attendance at a recognized school or university. If the child is physically or mentally disabled and was covered as a dependent before age 21, the child continues to be eligible for benefits.
  • Residence: children must reside with you unless at school; if the child resides with your ex-spouse, you must have a significant financial responsibility as outlined in a legal agreement.
  • If a child ceases to meet any of the above criteria during the year, the child is no longer an eligible dependent. Please contact your firm administrator to remove your child within 31 days of becoming ineligible.

You must notify CAIPW of changes to your dependent’s status within 31 days of the change, including:

  • Addition of a spouse as a result of a marriage or a common-law relationship.
  • Addition of a child as a result of a birth, adoption, custody, marriage/common-law relationship or legal guardianship.
  • Death of a spouse or child.
  • Loss of eligibility (separation, divorce or child reaching the maximum eligible age).
  • Total and involuntary loss of a spouse’s benefits (important if you co-ordinate benefits with your spouse).

Co-Ordination of Medical/Dental Benefits

If your spouse also has a benefit plan, you may submit claims to both plans to receive the maximum coverage on your expenses. For this to work, you must follow some insurance industry guidelines:

  • Submit your personal expenses to the CAIPW plan first, and then to your spouse’s plan for any remaining expenses.
  • Your spouse must submit his/her personal expenses to their employer’s plan first, and then to CAIPW for any remaining expenses.
  • Submit claims for children to the plan of the spouse whose birthday is first in the calendar year, then to the other plan for any remaining expenses.

Benefits Payable

Benefits are payable for the following expenses that are medically necessary and are not paid or payable under any government plan.

  • Charges for drugs and medicines (including oral contraceptives) as prescribed by a licensed physician and legally available for sale in Canada. Erectile dysfunction drugs are covered up to $1,000 annually. Smoking cessation products purchased with a doctor’s prescription are covered up to a lifetime limit of $300.
  • Charges for a professional ambulance service for transportation to the nearest hospital where satisfactory treatment can be provided.
  • Normal fees for the services of a registered massage therapist, physiotherapist or athletic therapist, chiropractor, acupuncturist, osteopath, naturopath, podiatrist, registered dietician and registered clinical psychologist to a maximum of $500 per service per calendar year. Speech therapist to a maximum of $1,000 per calendar year.
  • Services of a registered nurse or registered nursing assistant when recommended by a physician, up to a maximum of $10,000 per year, provided such nurse is not related to and/or does not normally reside in the individual’s home. From January 1st coincident with or next following you or your dependent’s 65th birthday, the maximum payable is $10,000 per calendar year with a lifetime maximum of $25,000. Note: The services will not be considered as eligible expenses while you or your dependent are residing in a nursing home, home for the aged, rest home or any other facility providing similar care, or confined in a Licensed Hospital. Payment will not be made for services that are for custodial care and do not require the skill of a registered nurse or registered nursing assistant.
  • Hospital charges in the province of residence for semi-private room accommodation (not including rental of telephone, TV, etc.)
  • Fees of a dentist for repairs to natural teeth as a result of an accidental blow to the mouth which occurs when the person is insured under this plan, and if treatment is given within one year of the accident. If treatment is to be received more than 90 days after the accidental blow, a treatment plan must be submitted to Great-West Life within 90 days of the accident.
  • Charges for the provision of oxygen, blood, blood plasma, artificial limbs or eyes, crutches, splints, casts, trusses or braces, and custom orthopedic shoes. Orthopedic shoes are limited to one pair per year. Orthotics up to $200 per year.
  • Charges for the rental, or where more economical the purchase, of equipment for therapeutic treatment, including wheelchairs and hospital beds.
  • Wigs and hairpieces purchased as a result of chemotherapy or the disease Alopecia Totalis up to $200 every five years.
  • Charges for eyeglasses and frames, contact lenses, or laser surgery when prescribed by an optometrist or physician for the correction of defective vision, to a maximum of $300 every 24 months. Sunglasses and safety glasses are excluded. One eye exam every 24 months.
  • Charges for hearing aids, when prescribed by a physician, to a maximum of $500 every four years.
  • Charges, up to a lifetime amount of $10,000, for hospital and physician services outside your province of residence if they are not available in your province. Full details of the services to be provided must be submitted by your doctor and approved by Great-West Life in advance.

In addition, for the first 60 days* of a trip, the plan will reimburse 100% of the following:

  • In the event of an emergency while traveling in Canada outside of the normal province of residence, reasonable charges for physicians’ services to the extent that they are not payable under a government medical insurance plan, and reasonable charges of a hospital for semi-private room accommodation with reimbursement being made on the basis of comparable charges in the province of residence.
  • In the event of an emergency while traveling out of Canada, reasonable and customary charges for hospital room, hospital services and supplies, and physician’s diagnosis and treatment, in excess of the amount provided under your provincial medical coverage, up to $1,000,000 per individual per event.
* Dependent students attending an accredited educational institution or university will not be subject to the 60 day limitation provided they maintain their provincial medical coverage.

Great-West Life Emergency Medical Insurance and Travel Assistance offers extensive emergency assistance (separate brochure).

The Travel Assistance Centre must be contacted as soon as reasonably possible or reimbursement may be limited.

No benefits are payable as a result of an accident in which the covered person was impaired by alcohol or drugs.

Costs associated with a pregnancy or childbirth outside of Canada within 9 weeks of the expected delivery date are not covered.

Exclusions

No benefits are payable for expenses incurred as a result of:

  • The failure of any person to claim benefits under a provincial medical insurance plan.
  • Dental services except as specifically provided, or care of dentures.
  • The treatment of diseases, conditions or injuries for which care, benefits or services are provided under a government medical insurance plan,or provided without cost or at nominal cost by public authorities.
  • The treatment of any ailment for which the person is hospitalized at the time of becoming insured. After a three month period, during which the ailment requires no treatment, eligible expenses related to such an ailment may be included.
  • War or participation in a riot, or self-inflicted injury.
  • Active participation in a criminal offence.
  • Cosmetic surgery.
  • Charges for items such as vaccinations, vitamins, cosmetics, cold medications, “household” remedies, diet aids or weightloss products, or any item available without a prescription, are not covered whether or not they have been prescribed for medical reasons.

Single/Family Coverage

In the event of a change in status, you must complete and return a transaction card within 31 days of the date of the change.

Spousal Exemption

If you do not require the extended health care plan because similar coverage is provided by your spouse’s plan, complete the spousal exemption information on the reverse side of the transaction card to obtain exemption.

Termination Provision

Extended health care benefits will automatically terminate on the employee’s 65th birthday, and in the case of a CA, 69th birthday. If you leave your employer, the insurance terminates immediately.

Filing a Claim

You must pay eligible expenses and then claim for reimbursement. Proof of expense (original receipts or itemized bills) is required. All claims are sent to Great-West Life for authorization and payment. Please ensure the correct policy, division and certificate numbers are on your claim form.

A claim may be filed when the expense is incurred, or at the end of the year.
Please accumulate expenses until your claim is over $75. Claims for expenses in respect of a calendar year must be submitted by March 31 of the following year.

Keep copies of your health and dental receipts. Great-West Life will only return receipts in cases where the claim should have gone to another insurance carrier first. The explanation of benefits statement, in conjunction with the photocopied receipts, can be used to co-ordinate benefits and for income tax submissions.

Online Access

Once you are enrolled for Extended Health and/ or Dental benefits, you can access your claims history and claim forms at www.greatwestlife.com
Follow these steps to register and log in for the first time:

  1. Visit www.greatwestlife.com
  2. Have the following information ready so we can indentify you:
    • Plan Number (56579) and your certificate number (available on your certificate)
    • Your date of birth
    • Date of birth of one of your dependants
    • Your postal code
    • Your Email address
    • Your name must be entered exactly as it appears on “Explanation of Benefits” (refer to a prior claim reimbursement).
  3. Follow the registration instructions to choose your own user name and password.
  4. Enjoy the benefits — 24 hours a day, 7 days a week!
  5. Registration will be confirmed in writing by posted mail.

Sign up once and return anytime. All you need to remember is the personalized password and user name you’ve selected!

Premiums

Rates vary by province. Please contact CAIPW for current rates.
Extended Health Care Benefits are underwritten by Great-West Life, policy number 56579.