EXTENDED HEALTH BENEFIT
The Extended Health Benefit for employees and dependents helps pay for certain medically necessary services and supplies which are not covered under a Provincial Hospital Insurance Act or a Provincial Medicare Act where such Act or Acts do not preclude the insuring of such services and supplies. THERE ARE NO EXCLUSIONS FOR CHRONIC OR PRE-EXISTING CONDITIONS. It is mandatory that all Members, who are residents of BC, register for Fair PharmaCare and provide their registration number to the Administrator. Once Members reach $1,000 in accumulated family drug purchases, if a PharmaCare registration number has not been provided, their benefits will be suspended until the Administrator has received proof of registration for PharmaCare.
This Plan pays all the eligible expenses which you incur in a calendar year in excess of the deductible of $100 per single employee or family. Eligible expenses which you or your dependents incur in the last 3 months of a calendar year and which you use to satisfy all or part of the deductible will also be applied to the deductible for the next year. LTD claimants are exempt from the deductible.
After you have satisfied the deductible, all eligible expenses will be paid. Lifetime maximum amount is $1,000,000. Any amounts over $25,000 for a single injury or sickness will be the responsibility of the reinsurance company as per the policy held by the Plan. Charges for Private Duty Nursing Care are limited to $5,000 each calendar year with a lifetime maximum of $25,000. Benefits for nervous and mental conditions are limited to a lifetime maximum of $25,000. There is no co-insurance charge except for 20% co-insurance on charges incurred out of Canada for care or services not available in Canada.
Covered Services and Supplies
100% of the charges (except for eligible Pharmacare expenses) for the following services rendered in connection with treatment of an illness or injury are eligible expenses:
1. Accidental Dental Expenses The cost of repairing damage caused to natural teeth due to accident provided claim is submitted within 60 days of treatment completion date.
2. Ambulance Services Charges for emergency transportation to and from a hospital, provided the trip is in a professional ambulance, or on a scheduled airline, or railroad, ship or boat, or in an air ambulance to the nearest hospital qualified to provide the necessary treatment.
3. Medical Supplies, Aids and Appliances Charges for supplies, aids and appliances such as the following are covered when provided upon the recommendation or approval of the attending Physician or, if it is legal to do so, by the attending Osteopath or Podiatrist.
(a) Casts, bandages and surgical dressings.
(b) Radium or cobalt or radio-active isotopes.
(c) Charges for oxygen, blood or blood plasma.
(d) Rental for therapeutic use of wheel-chairs, hospital beds, iron lungs, artificial kidney, oxygen or respiratory equipment, etc.
(e) Surgical Supplies.
(f) Orthopedic Shoes prescribed by an Orthopedic Surgeon for the proper management of unusual, congenital or post-traumatic foot problems up to a maximum of $600.00 per calendar year.
(g) Orthotics for employees, spouse or dependent children up to $200 per calendar year.
(h) HearingAids when prescribed by the attending Certified Ear, Nose and Throat Specialist. The maximum benefit during a 5-year period is $500 and does not include payment for repairs and maintenance, batteries or recharging devices, or other such accessories.
(i) Aids and appliances required due to bodily injury to physical organs, or parts, such as eye glasses, contact lenses, hearing aids, dental appliances, provided such injury is sustained in an accident occurring while the individual is insured.
(j) Other surgical supplies, aids and appliances to replace lost physical organs or parts, or to aid in their functions when impaired, including charges for ostomy or ileostomy supplies.
(k) Vision care for employees, spouse and dependent children to provide payment up to a maximum of $400 per person in any 24-consecutive month period, for charges incurred relative to the purchase of lenses and frames or contact lenses when prescribed by a person legally qualified to make such prescription, including prescription sunglasses for employees only.
(l) The cost of eye exams which are not covered under any provincial medical plan.
(m)Surgical Hose to a maximum of 2 pair per calendar year
(n) Wigs or hairpieces when required as a result of medical treatment or injury.
(o) Medical reports from attending physicians in relation to Long Term Disability claims will be paid by the Plan up to a maximum of $25.00 each up to a maximum of $100.00 per year.
4. Drugs and Medication
The Plan will cover the costs of drugs and medication, which require the written prescription of a Physician and which are dispensed by a licensed Pharmacist, up to the cost of the generic equivalent, except where the Physician has expressed in writing “no alternative”. Contraceptive drugs are not an eligible expense. The Plan will reimburse for prescription drugs based on a maximum supply of 60 days per purchase. With respect to erectile disfunction medications, the Plan will cover 8 pills per month to a maximum of $500/year.
5. Services of Medical Technicians
The following expenses are covered when you or your dependent receive services rendered by a “Licensed, Certified or Registered” Technician. The user fee not covered by M.S.P. is an eligible expense.
(a) Physiotherapy, excluding recreational therapy, when certified as medically necessary by the attending Physician.
(b) Private Duty Nursing Care, when certified as medically necessary by the attending Physician to a maximum of $5,000/yr, $25,000/lifetime.
(c) Approved services of a Clinical Psychologist who is “Licensed, Certified or Registered” provided that if such services are for psychiatric testing, they are rendered in conjunction with medically necessary psychotherapeutic treatment. Please note: If your employer participates in an Employee Family Assistance Program, psychological services should be sought through that program first, to the maximum allowed. Benefits in excess of such maximum may then be claimed through this Plan.
(d) Acupuncture by licensed Physicians or Dentists, or other “Licensed,
Certified or Registered” Technicians in an approved institution and when prescribed by a Physician or Dentist. If the service is wholly or partially provided under a hospital plan, any co-insurance factor or other charges to the individual, including charges for out-patient services, will be covered.
(e) The services of Orthoptic Technicians, Audiologists, Speech Therapists, Occupational Therapists and Inhalation Therapists are covered when certified as medically necessary by the attending Physician.
6. (a) IN THE PROVINCE OF RESIDENCE Standard charges for ward, semi-private or private accommodation including any daily hospital co-insurance charge. Accommodation in a residential treatment centre for substance abuse is covered at the lesser of the actual daily charge or $75.00 per day, subject to the following conditions: (a) coverage will normally be limited to 56 days, unless satisfactory medical evidence is provided that a lengthier period of confinement is necessary for treatment purposes, and (b) coverage is limited to one time only per insured Member, unless satisfactory medical evidence is provided that the insured Member was unable to complete the treatment program due to circumstances beyond his/her control and not related to a failure to follow treatment.
(b) OUTSIDE THE PROVINCE OF RESIDENCE, BUT IN CANADA
In an emergency, standard charges for ward, semi-private or private accommodation including any daily hospital co-insurance.
(c) REFERRAL CARE OUTSIDE PROVINCE OF RESIDENCE Should your Physician refer you to a hospital outside your Province of residence for services not available in your Province of residence, the
Plan will pay 80% of charges outlined above. The differential for semi-private or private room accommodation will be covered in extended care units of acute care general hospitals, including any daily hospital co-insurance charge. The term “private accommodation” as used herein refers to a private single room.
7. Services of Other Practitioners of the Healing Arts Benefits for the services provided by Christian Science Healers or “Licensed, Certified or Registered” Osteopaths, Chiropractors, Homeopaths, Massage Therapists, Naturopaths, or Podiatrists are provided if the services rendered are within the scope of the Practitioner’s profession.
(a) Treatment of mental or emotional disorders are not covered.
(b) Services by a Chiropractor or massage therapist are limited to a maximum of $350 per calendar year (including $20 for x-rays) after M.S.P. benefits have been exhausted.
(c) No payments will be made for duplication of services.
8. For smoking-cessation drugs requiring a prescription, the Plan will reimburse 75% of the cost subject to a maximum benefit of $250 per lifetime.
Occasionally, it will be necessary for an insured person to travel away from his or her home for medical treatment. Due to the nature of the treatment, it is sometimes impossible for the insured to return home immediately after their treatment. The Trustees recognize that there may be a rare but real need for such an insured person to stay overnight nearby the treatment facility. Therefore, the Trustees have agreed that effective May 1, 2005, they would implement an Accommodation Policy. The policy will reimburse the Member 50% of the cost of lodging expenses subject to the following conditions:
• the treatment must be for a serious medical condition;
• the necessity for the insured person to stay overnight nearby the treatment facility must be certified as medically necessary by the insured person’s attending physician;
• the Plan will reimburse 50% of the cost of lodging, subject to a $25 per day minimum and a $50 per day maximum;
• the Plan will reimburse an overall maximum of $1,000 per insured person, per medical condition;
• the benefit will apply only to the expenses of the insured person and not a companion;
• lodging expenses must be supported by valid original receipts.
Out-of-Province Emergency Expenses
Travel insurance is designed to cover losses arising from sudden and unforeseeable circumstances occurring while you are temporarily 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 Global Excel Management Inc. (called “Global Excel”) to provide medical assistance and claims services under the Policy. (Policy # 32445233.)
Coverage Period: 60 days per trip IN THE EVENT OF AN EMERGENCYYOU MUST CALL GLOBAL EXCEL IMMEDIATELY:
From Canada & USA: 1-866-870-1898
From Anywhere: +(819) 566-1898
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.
Emergency Air Transportation Reasonable & Customary Costs
Paramedical Services $250 per Profession
Prescription Drugs 30 day supply per Prescription
Private Duty Nurse
Return of Deceased up to $5,000
Transportation to Bedside Economy Round-trip Airfare
Plus up to $150 per day, to $3,000
Return of Travelling Companion One-way Airfare
Treatment of Dental Accidents up to $2,000
Meals and Accommodation up to $150 per day, to $3,000 per Trip
Incidental Expenses up to $250
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; subject to the Overall Maximum per Insured Person specified in the Schedule of Benefits of the contract. In the event of an Emergency, the following benefits are payable under the Policy. However, certain expenses, as specified below, are covered only if you obtain the prior approval of Global Excel.
Co-ordination of Benefits
The policy includes a co-ordination of benefits provision which describes the method of payment of claims when an individual is also insured under some other group insurance plan which provides similar benefits.
Extension of Benefits
Extended Health Benefits for an employee who is Totally Disabled will remain in force while the employee is receiving Long Term Disability Benefits.
No benefits are payable for any of the following charges:
1. Charges for which an individual obtains or is entitled to obtain benefits under the terms of any government plan or for which no actual charge is made.
2. Any service or supply for which the charge is incurred previous to the effective date of coverage.
3. Those charges incurred due to pregnancy, childbirth or miscarriage or any complications thereof, when incurred after the date of termination of insurance, except as indicated in the Extension of Benefits above.
4. Those charges due to intentionally self-inflicted sickness or injury while sane or insane; insurrection or war, whether war be declared or not; any act incident there to, or participation in any riot.
5. Charges in connection with general health examination or any service provided by telephone.
6. Charges that are not reasonable, including those charges which are in excess of those which would have been made in the absence of insurance under this Plan.
7. Charges by any person who is a member of the immediate family of the Insured Individual or who ordinarily resides in the Insured Individual’s home.
8. Any charge excluded in the group policy.
How to Make an EHB Claim
When you or any of your registered dependents have accumulated eligible expenses in excess of the required deductible, obtain a claim form from the
Administrator or your employer. The claim form must show: that you belong to the B.C. Marine Industry Employee Health Benefit Plan, your name, your Identification Number, your home address, the name and date of birth of the person incurring the expense,
and the type of expense. The completed claim form together with the original receipts should be sent to the Administrator.
Note: No action may be brought against the Plan for any claim unless submittedwithin 24 months of the date of service.