Professional Documents
Culture Documents
This booklet is for your general information only and is not the insurance policy. In the pages which follow, you will find a brief description of the benefits to which you and your family are entitled, the rules covering eligibility for these benefits and the procedures that should be followed in the event that it is necessary for you to make a claim. The final determination, however, of any claim, question or problem which may arise will be governed by the Trust Agreement and the Insurance Policy issued by The Manufacturers Life Insurance Company. Both of these documents are available for examination at the Fund Office.
Questo opuscolo disponibile in inglese, francese, italiano e portoghese . Esta brochura est disponvel em Ingls, Francs, Italiano e Portugus.
THIS BOOKLET CONTAINS IMPORTANT INFORMATION AND SHOULD BE KEPT IN A SAFE PLACE FOR FUTURE REFERENCE
L.I.U.N.A. LOCAL 527 BENEFIT, HEALTH AND SAFETY TRUST FUND 6 Corvus Court, Ottawa, Ontario K2E 7Z4 Telephone: (613) 521-6314 Facsimile: (613) 521-0264 e-mail: benefit_office@liunalocal527.com
TRUSTEES R. Bellai B. Carrozzi L. Carrozzi R. DaSilva J. Daoust A. DeMarinis M. Di Pentima K. Grimes LEGAL ADVISOR Gowling, Strathy and Henderson
INSURANCE UNDERWRITERS The Manufacturers Life Insurance Company INSURANCE UNDERWRITERS Shepell-fgi AUDITORS Bouris, Wilson LLP ADMINISTRATOR L.I.U.N.A. Local 527 Benefit, Health and Safety Trust Fund Benefit Office 6 Corvus Court Ottawa, Ontario K2E 7Z4
L.I.U.N.A. LOCAL 527 BENEFIT, HEALTH AND SAFETY TRUST FUND To All Eligible Members:
This revised booklet has been published to give you an up-to-date description of the benefits provided by the Fund, as of May 1, 2013. The booklet provides a description of the benefits to which you and your family are entitled, the rules governing eligibility for these benefits, and the procedures that should be followed when making a claim. We believe the Plan provides an excellent package of benefits. It is our hope to continue to provide the best benefits affordable. However, because of the ever-changing economic environment, the benefits provided in this booklet cannot be guaranteed for the future. In order to protect the Fund, the Trustees have the right to amend, delete, add or change the Plans benefits as they apply to all current and future members and retirees, including the right to add or delete benefits, monetary or otherwise, as circumstances may warrant. We urge you to read your booklet carefully to thoroughly familiarize yourself with the benefits that are available to you and your dependents. While it is our hope that you and your family will enjoy good health, it is comforting to know that these benefits are available when needed. If at any time you have any questions about these benefits, or would like assistance in filing a claim, please do not hesitate to contact the Fund Office where a member of the staff will be pleased to assist you. Sincerely, BOARD OF TRUSTEES
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-INDEX
Section
Schedule of Benefits
Pages
- Active Members......................................................................................................... 3 - Retired Members ....................................................................................................... 5 Eligibility Rules - Active Members......................................................................................................... 6 - Retired Members ..................................................................................................... 11 General Information ............................................................................................................... 14 Member Assistance Program ................................................................................................. 15 Life Insurance for Employees ................................................................................................ 16 Life Insurance for Dependents ............................................................................................... 18 Accidental Death and Dismemberment Benefit..................................................................... 19 Weekly Disability Benefit...................................................................................................... 21 Supplementary Health Care Benefits ..................................................................................... 24 A. Major Medical Expenses...................................................................................... 25 B. Prescription Drug Expenses ................................................................................. 29 C. Vision Care Expenses .......................................................................................... 30
D.
Dental Expense Benefits ........................................................................................................ 32 A. Routine Expenses (Active and Retired Members) ............................................... 32 B. Major Expenses (Active Members) ............................................................................................33 C. Major Expenses (Retired Members) .................................................................... 34 D. Orthodontia Expenses (Active Members)............................................................ 35 Co-Ordination of Benefits...................................................................................................... 38 Termination of Insurance ....................................................................................................... 40 Claim Instructions .................................................................................................................. 41
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DEPENDENTS
Dependent Life Insurance Spouse Each Child $10,000 $5,000
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50% of eligible expenses; 2012 Ontario Dental Association Schedule of Fees; maximum benefit of $1,500 per calendar year with a $3,000 lifetime maximum benefit, for each eligible child.
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MEMBERS
Life Insurance $7,500
DEPENDENTS
Dependent Life Insurance Spouse $3,000
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ELIGIBILITY RULES ACTIVE MEMBERS Employees Who May Be Eligible For Benefits
1. An employee who is a member of L.I.U.N.A. Local 527, who is employed under a Collective Bargaining Agreement requiring the employer to make contributions to the Fund. 2. Other full-time employees of those employers for whom coverage under this Plan has been approved by the Trustees. 3. Full-time salaried officers or employees of the Local, for whom coverage under this Plan has been approved by the Trustees. 4. Full-time employees of the Trustees for whom coverage under this Plan has been approved by the Trustees. Contributing employer means any employer who is obligated or permitted to contribute to the Fund. NOTE: All insured persons (Members and Dependents) must be Canadian residents and qualify for provincial health coverage with the province in which they reside in order to be eligible for benefits. You or any of your covered dependents have the right to request a copy of any or all of the following items: The sections of the Group Policy and/or Plan Document that apply to you and your dependents, Your application for group benefits, and Any Evidence of Insurability you submitted as part of your application for benefits. The Plan Administrator reserves the right to charge you for such documentation after your first request.
Eligible Dependents
An employees eligible dependents are: 1. the employees spouse, where spouse means either: (a) a person who, as of the time in question, is legally married to the employee, by virtue of a religious or civil ceremony, or
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(b) a person who is designated by the employee on the Registration Card as his or her spouse, provided, however, that if such designated person is not legally married to the employee, the employee must be living with the designated person for at least one year and publicly represent the designated person as his or her spouse. The Registration Card designating such person as spouse must have been on file in the Administrators office for at least one year before the designated person is eligible for benefits. You should contact the Plan Administrator as soon as possible to avoid undue delays in spousal eligibility. 2. unmarried children from live birth but under the age of 21 who are wholly dependent upon the employee for support, and 3. unmarried children age 21 and over but under the age of 25 who are wholly dependent upon the employee for support and are attending school on a full-time basis.
The word children means, in addition to the employees own or lawfully adopted child, any step-child, or foster child, , who depends upon the employee for support, and lives with the employee in a regular parent-child relationship. Legal supporting documents will be required at the time of the dependents registration and from time to time afterwards. Children of a spouse as defined in paragraph 1(b) above, must also be included on the Registration Card and must satisfy the one-year filing requirement. NOTE: For purposes of Dependent Life Insurance, only 1 and 2 above apply.
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Continuation of Eligibility
110 hours will be deducted from each employees hour bank reserve account for each month of insurance coverage, and employees will continue to remain eligible as long as their reserve account contains at least 110 hours of work credit. An employee working under the Collective Bargaining Agreement must be a member in good standing of L.I.U.N.A. Local 527 during the accumulation of these hours and during the eligibility period. Employees will be allowed to accumulate hours in their hour bank reserve accounts up to a maximum of 1,320 hours. All excess hours are credited to the Fund. All employees who have either not worked or not been in good standing with L.I.U.N.A. Local 527 for a period of 12 consecutive months shall lose the hours remaining to their credit.
Termination of Eligibility
An employees eligibility under this Plan provided that he maintains his status as a member in good standing in L.I.U.N.A. Local 527 will terminate at the end of the second calendar month following the month in which the hour bank reserve account is less than 110 hours.
Reinstatement
An employee whose eligibility has terminated will again become eligible if his hour bank reserve account shows a total of at least 110 hours within the twelve-calendar-month period subsequent to the termination of his eligibility. This employee must be a member in good standing of L.I.U.N.A. Local 527 during the accumulation of these hours and during the eligibility period. Such reinstatement will be effective on the first day of the second month which follows the month in which this requirement was met. If the employee is not reinstated within this twelveL.I.U.N.A. 527 -8-
calendar-month period, any reserve hours in his account will be forfeited. Such an employee will again become eligible for insurance upon completion of the normal initial eligibility requirement.
Continuation of Supplementary Health Care and Dental Care Benefits for Certain Incapacitated Children
If a dependent child is incapable of earning his own living because of functional impairment, and is chiefly dependent on the employee for support, and is covered under the Plan on the date such coverage would otherwise terminate because the child attained the limiting age, benefits for such a child can be continued for the duration of the incapacity provided coverage does not terminate for any other reason. Proof of incapacity must be furnished to the Insurance Company within thirty-one days after the child has reached the limiting age, and thereafter as requested.
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If you do not elect to participate in the Retiree Plan within 15 days of first becoming eligible to do so, you will not be allowed to participate later.
*If you do not meet the 7,500 hours requirement in the ten (10) consecutive years preceding your retirement due to an established disability this requirement may be deemed to have been met. Please contact the Fund Office for details in this regard. ** If you do not meet the 60 years of age requirement due to an established disability this requirement may be deemed to have been met. Please contact the Fund Office for details in this regard. NOTE: All insured persons (Members and Dependents) must be Canadian residents and qualify for provincial health coverage with the province in which they reside in order to be eligible for benefits.
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Eligible Dependents
An employees eligible dependents are: 1. the employees spouse, where spouse means either: (a) a person who, as of the time in question, is legally married to the employee, by virtue of a religious or civil ceremony, or (b) a person who is designated by the employee on the Registration Card as his or her spouse, provided, however, that if such designated person is not legally married to the employee, the employee must be living with the designated person for at least one year, and publicly represent the designated person as his or her spouse. The Registration Card designating such person as spouse must have been on file in the Administrators office for at least one year before the designa ted person is eligible for benefits. You should contact the Plan Administrator as soon as possible to avoid undue delays in spousal eligibility. 2. unmarried children from live birth but under the age of 21 who are wholly dependent upon the employee for support, and 3. unmarried children age 21 and over but under the age of 25 who are wholly dependent upon the employee for support and are attending school on a full-time basis. The word children means, in addition to the employees own or lawfully adopted child, any step-child, or foster child, who depends upon the employee for support, and lives with the employee in a regular parent-child relationship. Legal supporting documents will be required at the time of the dependents registration and from time to time afterwards. Children of a spouse as defined in paragraph 1(b) above, must also be included on the Registration Card and must satisfy the one year filing requirement. NOTE: For purposes of Dependent Life Insurance, only 1 above applies.
Termination of Eligibility
Coverage under the Retiree Plan will cease upon the earlier of: 1. The date you cease to make the contribution required by the Plan;
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2. The date you cease to be a member in good standing of L.I.U.N.A. Local 527; 3. The date of your re-employment in the industry for a non-participating employer; 4. The date coverage commences under the L.I.U.N.A. Local 527 Benefit, Health and Safety Trust Fund, due to your re-employment with a participating employer; 5. The date of your death. Important: If your coverage terminates for any reason other than number 4 above, your coverage cannot be reinstated.
Continuation of Supplementary Health Care and Dental Care Benefits for Certain Incapacitated Children
If a dependent child is incapable of earning his own living because of functional impairment, and is chiefly dependent on the employee for support, and is covered under the Plan on the date such coverage would otherwise terminate because the child attained the limiting age, benefits for such a child can be continued for the duration of the incapacity provided coverage does not terminate for any other reason. Proof of incapacity must be furnished to the Insurance Company within thirty-one days after the child has reached the limiting age, and thereafter as requested. The Board of Trustees have the right to amend, delete, add or change the Plans benefits at any time, as they apply to all current and future retired members.
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MEMBER ASSISTANCE PROGRAM (MAP): Provided Through Shepell-fgi No charge service For all Active and Retired Members
Your MAP is a confidential support service that can help you solve a wide range of problems and challenges in your life. Call the MAP Care Access Centre toll-free, 24 hours per day, 7 days per week so that you can access support for your problem or concern, when you need it. Your call will be answered by a professional who can help you choose a support option that best suits your needs. If you are experiencing a crisis situation, you can speak to a counsellor right away. Shepellfgi counsellors are experienced professionals who will understand your concern and guide you to resolution. COUNSELLING OPTIONS In-Person Counselling is Shepell fgi traditional session format, ideal for families or couples who need interaction. Telephonic Counselling is convenient and ideal for time-restricted or travelling individuals. E-Counselling via written exchange with a Counsellor is best suited for those most comfortable with written communication. It is also ideal for travelling individuals, providing support anywhere. Video Counselling offers virtual face-to-face support, in the convenience and comfort of your home. First Chat provides instant support with a Counsellor online, via workhealthlife.com. Text-based, self-directed Health and Wellness Resources can also be delivered directly to you. Call your Member Assistance Program (MAP) toll-fre e, 24 hours a day, seven days a week for imme diate , confide ntial help: For Service in English: 1 800 387-4765 For Service in French: 1 800 361-5676 Toll Free Service: 1 877 338-0275 Or, visit online resources: www.workhealthlife.com and E-counselling: www.sh ep el lfg i.co m/ecoun selling
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Beneficiary
You may designate any person or persons you wish and your beneficiary may be changed whenever you wish in accordance with the applicable laws of your province of residence. Whenever you wish to change your beneficiary, you must complete and send a new Registration Card to the Fund Office. You should review your beneficiary designation regularly to be sure that it reflects your current intent.
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Conversion
If your Group Benefits terminate or reduce, you may be eligible to convert your Member Life Insurance coverage to an individual policy, without medical evidence. Your application for the individual policy along with the first monthly premium must be received by Manulife Financial within 31 days of the termination or reduction of your Member Life Insurance. If you die during this 31-day period, the amount of Member Life Insurance available for conversion will be paid to your beneficiary or estate, even if you didnt apply for conversion. For more information on the conversion privilege, please contact your Plan Administrator. Provincial differences may exist.
Extended Benefits
If you should die within 31 days of the date your Employee Life Insurance terminates, the amount you could have converted will be paid as a death benefit under this plan even if you did not apply for conversion. In the event that a member in good standing with L.I.U.N.A. Local 527, who has accumulated the required 220/300 hours, dies prior to the effective date of benefit coverage, special consideration may be granted by the Board of Trustees. If a member was able to continue eligibility by making self-payments, this exception does not apply. This exception only applies when a member could not have been eligible by any other means.
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Extended Benefits
If your dependent spouse dies within 31 days of the date your Dependent Life Insurance terminates, the amount your spouse could have converted will be paid as a death benefit under this plan even if your spouse did not apply for conversion.
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ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT FOR EMPLOYEES ACTIVE MEMBERS Benefit
The following schedule shows the amount that will be paid for losses which occur as a result of an accident while covered under this Plan. Losses occurring up to 365 days after such accidents are eligible, in accordance with the schedule. Payments for all losses will be made to you, except for loss of life which will be paid to your designated beneficiary.
Beneficiary
You may designate any person or persons you wish and your beneficiary may be changed whenever you wish in accordance with the applicable laws of your province of residence. Whenever you wish to change your beneficiary, you must complete and send a new Registration Card to the Fund Office. You should review your beneficiary designation regularly to be sure that it reflects your current intent.
Amount
$50,000 $50,000 $50,000 $50,000 $33,334 $25,000 $16,666 $ 6,250
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2. Disability resulting from (a) injuries sustained while doing any act or thing pertaining to any occupation or employment for remuneration or profit, or (b) sickness for which benefits are payable in accordance with the provisions of any Workplace Safety and Insurance Board or similar law. 3. Any period you are entitled to pregnancy or parental leave of absence, by statute, contract or employer agreement, no benefits are payable for the period during which you would be away from work on pregnancy or parental leave of absence. This plan will, however, pay benefits for the post-natal recovery period of maternity leave, in accordance with Manulife Financials claims practices. 4. Any disability resulting from or contributed to by a motor vehicle accident. 5. Any day on which you are performing work of any kind, anywhere, for compensation or profit. 6. The first seven days of a period of disability due to sickness or pregnancy, except that if the employee is confined in a hospital for at least twenty-four consecutive hours during the first seven days of a disability due to sickness or pregnancy, the benefit shall be payable from the first day of hospitalization. 7. Any period of sickness or disability which commences while insurance is not in force. 8. Any period of sickness or disability which commences after you have applied for a pension benefit (including but not limited to a CPP/QPP or Labourers Pension Fund pension benefit). 9. Weekly Disability payments will terminate on the date you commence receiving a pension benefit (other than a disability pension) including but not limited to a pension benefit from CPP/QPP or the Labourers Pension Fund. 10. Weekly Disability Benefits will be reduced by the amount of disability pension benefits you receive (including but not limited to a disability benefit from CPP/QPP or the Labourers Pension Fund). 11. Weekly Disability benefits not payable while the insured is incarcerated. 12. Any disability resulting from an intentional self-inflicted injury. 13. Any disability resulting from drug or alcohol dependency while the member is not admitted in an accredited substance abuse facility. As part of proof of claim for Weekly Disability Benefits, the Insurance Company has the right to have you examined by a physician (designated and paid by the Insurance Company) when and as often as it may be reasonably required. Failure to report for the examination will result in termination of benefits.
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Third Party Liability If you receive disability benefit payments under this plan for loss of income for which there may be a cause of action against a third party, you will be required to complete a Reimbursement Agreement. This will entitle Manulife Financial to be reimbursed for any amount(s), including interest, you recover from a third party for;
which, together with any amount(s) paid or payable under any of the Benefits of this plan, would exceed your actual loss. Following notification to Manulife Financial of payment by a third party of any judgment or settlement, further disability benefit payments under this plan will terminate until Manulife Financial has been reimbursed the amount set out in the Reimbursement Agreement. If a lump sum payment is made under judgment or settlement for loss of future income, no further disability benefits will be paid until such time as the sum of the benefit payments otherwise payable equals the amount of such lump sum.
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SUPPLEMENTARY HEALTH CARE BENEFITS ACTIVE AND RETIRED MEMBERS AND THEIR DEPENDENTS Benefit
The Supplementary Health Care benefit pays for certain services and supplies, which are not covered by a Provincial Plan. The benefit pays 100% of covered expenses (90% with respect to Prescription Drugs expenses for retired members and 50% with respect to Orthopedic Shoes and Orthotics expenses for active members).
Maximum Benefit
Supplementary Health Care Benefits are limited to a combined maximum of $60,000 per person per calendar year. Covered Expenses for Nursing benefits or Out-Of-Province benefits are each subject to a lifetime maximum of $10,000.
Reinstatement
At any time that the Maximum Nursing Benefit or the Maximum Out-Of-Province Benefit of a family member is reduced by at least $1,000 on account of benefits which have been collected, reinstatement of the maximum may be requested provided the family member is then in good health. It will be necessary to submit medical evidence of the good health of such member to the Insurance Company at your own expense. The new maximum becomes effective on the date the Insurance Company acknowledges the evidence as satisfactory.
Restoration
On January 1 of each year, the amount which has been counted against the Maximum Nursing or the Maximum Out-Of-Province Benefit of an insured family member and not previously restored or reinstated will be automatically restored up to $1,000. No evidence of good health is required for this automatic restoration but it is not available after insurance has terminated. For example, if you incur $1,700 in Nursing benefit payments in one calendar year, your Maximum Nursing Benefit will automatically be restored by $1,000 on next January 1, and by the remaining $700 on the following January 1, assuming no further benefits have become payable in the meantime.
Covered Expenses
Covered expenses are the reasonable and customary charges (for the area in which they are incurred) which an employee is required to pay for the following services and supplies received by a covered member for the necessary treatment of a non-occupational injury and nonoccupational disease, vision care or for pregnancy.
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A.
but not charges made by a resident physician or intern of a hospital. 3. Registered Nurse (R.N.), Registered Practical Nurse (R.P.N.) and Licensed Practical Nurse (L.P.N.) (to a lifetime maximum of $10,000 per person) for services ordered by a physician as medically necessary and requiring the specialized training of a such nurse, provided the nurse does not ordinarily reside in the members home , or is not a member of the patients family and while the patient is not confined to a hospital. 4. Convalescent/rehabilitation hospital room and board and other necessary services and supplies for average semi-private coverage for up to 120 days during any one period of disability provided the individual is admitted to the convalescent/rehabilitation hospital within 14 days following confinement in a general hospital. All confinements in a convalescent/rehabilitation hospital will be considered as one period of disability unless the confinements are separated by at least 90 days. A convalescent/rehabilitation hospital is a place that:
provides inpatient nursing care (that meets minimum Provincial regulations) for the convalescent/rehabilitation stage of an injury or illness; and
is approved as a convalescent/rehabilitation hospital for payment of the ward rate under the Provincial Health Plan.
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Note: This coverage does not include reimbursement for Complex Continuing Care Co-Payments. Note: This coverage does not apply to the charges for semi-private or private room upgrades in a general hospital.
5. Out-Of-Province emergency treatment incurred while the individual is travelling or vacationing outside the province in which he normally resides for periods of not more than 60 days, to a lifetime maximum of $10,000 per individual as follows: charges by a General Practitioner or Specialist in excess of the amount allowed by OHIP or any other government plan, in the individuals normal province of residence, provided such charges are reasonable and customary for the area in which they were incurred. charges for hospital confinement in excess of the allowance for ward accommodation payable by OHIP or any other government plan provided all or part of such charges are payable under such government plan. No charges will be considered for any type of accommodation for which the individual would not have been hospitalized in his normal province of residence.
A Medical Emergency occurs when an insured person requires immediate medical attention while travelling outside his province of residence due or related to: i) ii) a sudden, unexpected injury which occurs or a new medical condition which begins while a covered person is travelling outside his province of residence; or a previously identified medical condition that was Stable*, but not diagnosed as terminal or prescribed for palliative care, at the time of departure from his province of residence.
Such Medical Emergency no longer exists when, in the opinion of the attending physician and supporting medical evidence, the covered person is able to return to his province of residence. No coverage is provided for any Medical Emergency related to a pregnancy for covered persons who are pregnant and travelling within 4 weeks of the due date.
* Stable means a condition, whereby a covered person: a) has not in the 90 days before the departure date: i) been under treatment or evaluation for new symptoms or conditions uncovered in a medical examination, or
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ii)
experienced a worsening or increased frequency of existing symptoms or examination findings related to the medical condition, disease or illness diagnosed or undiagnosed if the insured/covered person has been seen by a medical professional in relation to the symptoms, or
iii) been prescribed or recommended a change in treatment or medication related to the medical condition by a Physician or other medical professional, not including regular changes in medication that are made as part of an ongoing treatment or a reduction in medication due to an improvement in the medical condition, or iv) been admitted to or treated at a hospital for the medical condition, or b) did not have future non-routine tests, investigations or new treatment planned for a previously identified medical condition or future medical appointment planned with respect to an undiagnosed medical condition. NOTE: The maximum reimbursement available for these expenses is $10,000 during the lifetime of each insured person (a separate maximum applies for you and for each of your dependents). If you, or your family, travel outside Canada, even for a short period of time, it is recommended that you obtain additional coverage for medical emergencies outside Canada.
6. Treatment by a provincial licensed Chiropractor, Osteopath, Speech Therapist, Naturopath, Podiatrist, Chiropodist, Acupuncturist or Christian Science Practitioner. Benefit payments for all treatments combined are limited to a calendar year maximum of $500 for Active members*, and $300 for Retired members. Also included is up to $25 per disability for x-rays. However, no benefit will be paid while the individual is entitled to similar benefits under any provincial health plan regardless of whether the provincial plan pays all or only part of such charges. *Dietician and Social Worker are included in the list of eligible Paramedical practitioners for Active members only. NOTE: The Dietician must be prescribed by a licensed doctor (M.D.) as to duration and type. NOTE: The Social Work service provider must: be working in a recognized mental health clinic, community agency or hospital, be a member of the association governing their particular profession, and provide treatment at the request of, or in association with, a medical practitioner.
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7. Physiotherapy by a person duly qualified and registered and legally engaged in the practice of physiotherapy. Reimbursement is limited to a maximum of $500 per person per calendar year. 8. Diagnosis, assessment and treatment by a person duly qualified and registered and legally engaged in the practice of Psychology. All treatment by a licensed Psychologist is payable up to a calendar year maximum of $800 for Active members, and $200 for Retired members. NOTE: Services rendered by anyone other than a licensed Psychologist are not covered under the plan, even if the individual is being directly supervised by a licensed Psychologist. 9. For Active Members only, 50% of charges for smoking cessation treatment (on the written referral of a physician) with a lifetime maximum benefit of $300. Eligible charges include prescription drugs, as well as over the counter nicotine patches, inhalers and gums. Eligible charges do not include hypnotherapy, acupuncture or laser therapy. 10. Miscellaneous expenses: Charges for supplies and the rental of, or at Manulife Financials option, the purchase of, durable medical equipment of the type and model adequate for the covered persons medical needs based on the nature and severity of the disability, such as, but not limited to: rental of iron lung or other durable, medical or surgical equipment artificial limbs, eyes and larynx; casts, crutches, splints, trusses and braces for back, neck, arm or leg including replacement due to a change in physical condition; and electronic heart pacemakers when prescribed or ordered by the attending physician Expenses for apnea machines (CPAP machines) will be limited to one apnea machine and to $500, every 60 months. One replacement mask and or hose to a maximum of $250 every 60 months for Active members only. dental work performed by a dentist for the prompt repair of sound natural teeth that is required as a result of a non-occupational and accidental injury external to the mouth, occurring while insured anesthesia, oxygen, blood and blood products diagnostic laboratory and x-ray expenses physician charges in connection with psychoanalysis treatment, payable at 50% (for Quebec residents only)
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For Active Members only, Orthopedic shoes and orthotics payable at 50% and up to $250 for one pair every 12 consecutive months, when they have been specially designed and molded for the insured person and provided that the following requirements are met: - must be prescribed by a licensed Physician (M.D.), Podiatrist (D.P.M.) or Chiropodist (D. Ch or D. Pod. M) - The prescription must indicate the diagnosis necessitating the custommade orthopedic shoes or custom made orthotics - a copy of the biomechanical examination results is required - a copy of the Gait Analysis is required, and - a description of the casting technique is required - The orthopedic shoes and orthotics must be dispensed by a Podiatrist (D.P.M.), Chiropodist (D.Ch or D Pod M), Pedorthist (C.Ped(s) or C Ped (MC)), or Certified Orthotist (C.O. (c) or CPO (c))
Your orthopedic shoes and orthotics must be prescribed on an annual basis. For more information, please contact your Benefits Administrator for a copy of the plan member information sheet.
B.
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C.
D.
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Charges for services or supplies which are paid for or otherwise provided for under any law of a government except where the payments or benefits are provided under a plan specifically established by a government for its own civilian employees and their dependents; or Charges for services or supplies which are furnished, paid for or otherwise provided for by reason of the past or present service of any person in the armed forces of a government; or Charges for services and supplies which are not necessary for treatment of the injury or disease or are not recommended and approved by the attending physician or charges which are unreasonable; or Charges of a physician or other person or agency in excess of the amount payable under a provincial health plan are not covered except in the case of emergency treatment while travelling outside your normal province of residence; or Charges for services or supplies in connection with occupational accidents or illnesses; or Charges for drugs, medicines, sera, or injectable drugs when administered in a hospital setting, whether administered on an inpatient or outpatient basis, except as provided under the out-ofprovince benefit. No benefits are payable under this Plan if the provision of such benefits are prohibited by law.
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DENTAL EXPENSE BENEFITS ACTIVE AND RETIRED MEMBERS AND THEIR DEPENDENTS Benefits
Active Members Subject to the deductible, this benefit pays 100% of Routine Expenses, 80% of Major Expenses and 50% of Orthodontia Expenses in accordance with the 2012 Ontario Dental Association Schedule of Fees. Orthodontia expenses are covered only for dependent children under the age of 21. Retired Members Subject to the deductible, this benefit pays 50% of Routine Expenses and 50% of Major Expenses in accordance with the 2012 Ontario Dental Association Schedule of Fees.
Deductible
$15 per person, but not more than $25 per family in each calendar year.
Maximum Benefit
Active Members Payments for eligible Routine and Major Expenses will be paid up to a maximum of $2,000 per calendar year for each covered family member. Payments for eligible Orthodontia Expenses will be paid up to a maximum of $1,500 per calendar year, with a $3,000 lifetime maximum benefit. Retired Members Payments for eligible Routine and Major Expenses will be paid up to a maximum of $500 per calendar year for each covered family member.
Covered Expenses
Covered expenses are the reasonable and customary charges (for the area in which they are incurred) which an employee is required to pay for the following services and supplies received by a covered member for the necessary treatment of a non-occupational injury and nonoccupational disease.
A.
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2. Scaling and root planing (limited to 10 units per calendar year for all procedures combined, however, children under 13 years of age are limited to 1 unit every 6 months for all procedures combined). 3. Occlusal equilibration, limited to 8 units per calendar year. 4. Topical application of sodium or stannous fluoride for dependents under 16 years of age 5. Dental x-rays (Full mouth series of x-rays up to once every 36 months) 6. Extractions 7. Oral surgery, including excision of impacted teeth 8. Fillings (including white fillings on molars) 9. Local anesthesia when administered in conjunction with a covered dental service (Note general anesthesia is covered only when administered in connection with oral surgery) 10. Treatment of periodontal and other diseases of the gums and tissues of the mouth including night guards and periodontal appliances. 11. Endodontic treatment, including root canal therapy and Dental Sealants 12. Injections of antibiotic drugs by the attending dentist 13. Space maintainers and prefabricated full coverage restorations for primary teeth.
B.
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4. Replacement of an existing partial or full removable denture or fixed bridgework by a new denture or new bridgework, or the addition of teeth to an existing partial removable denture to replace extracted natural teeth, but only if evidence satisfactory to the Insurance Company is presented that (a) the replacement or addition of teeth is required to replace one or more additional natural teeth extracted after the existing denture was installed and while the individual is insured; (b) the existing denture or bridgework was installed at least 5 years prior to its replacement and that the existing denture or bridgework cannot be made serviceable; or (c) the existing denture is an immediate temporary denture replacing one or more natural teeth extracted while the individual is insured and replacement by a permanent denture is required and takes place within 12 months from the date of installation of the immediate denture. The limitation applicable to natural teeth extracted while insured in 1, 3, 4(a) and 4(c) above are not required for those members who have been eligible and covered under this Plan for at least the 12 consecutive months immediately preceding the service date.
C.
2. 3.
(b) (c)
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4.
Retirees are not eligible for reimbursement of initial bridgework. However, if a retiree has bridgework that was reimbursed under the Active member coverage, repair of the existing bridgework, or the replacement of the existing bridgework by a new bridgework will be covered, but only if evidence satisfactory to the Insurance Company is presented that the existing bridgework was installed at least five years prior to its replacement and that the existing bridgework cannot be made serviceable.
D.
Services and supplies, in the case of each Dental Expense, must have been rendered and dispensed by a legally qualified dentist except that: (i) cleaning or scaling of teeth may be performed by a licensed dental hygienist if such treatment is rendered under the supervision and direction of such dentist, and (ii) installation, adjustments, repairs and relining of complete dentures may be made by a dental mechanic or denturist legally practicing within the scope of his license, but any charges in excess of the specified charges for such services and supplies in the dental mechanics or denturists tariff of the Province where such services and supplies are received will be disregarded. Reasonable and customary charges by an anesthetist for the administration of a general an aesthetic in connection with oral surgery deemed to be Covered Charges. If alternate services may be performed for the treatment of a dental condition, the amount included as a Covered Expense will be the amount specified for the least expensive service or supply which, as determined by the Insurance Company, will produce a professionally adequate result. X-rays are required for gold restorations, crowns, or bridgework and will be returned promptly to your dentist. Predetermination of Benefits: If dental expenses in connection with a course of treatment planned by a dentist for a covered family member will exceed $200, the proposed course of treatment should be filed with and approved by the Insurance Company prior to the commencement of treatment. Failure to file and obtain approval may result in benefits for the course of treatment in a lesser amount than would otherwise have been payable because of the difficulty of determining the necessity for the types of services involved after they have been
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rendered. After reviewing the proposed course of treatment, the Insurance Company will notify both you and your dentist of the estimated payment. This is intended as verification of the coverage provided by the Benefit Plan, and is not a guarantee of payment. If the employee or his dependents have a break in coverage or are not eligible for coverage on the date these services are actually performed, these services will not be eligible for reimbursement.
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11. Dental care covered under a medical plan provided by an employer or government; which, in the absence of coverage, there would be no charge. 12. Charges for completion of claims forms. 13. Charges for oral hygiene instruction, nutritional counseling, or protective athletic appliances. 14. Charges for appointments broken without notice. 15. Services and supplies rendered for a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction. 16. Space maintainers and prefabricated full coverage restorations for permanent teeth.
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If you are separated or divorced the plan which will pay benefits for your children will be determined in the following order: 1. the plan of the parent with custody of the child; 2. the plan of the spouse of the parent with custody of the child; 3. the plan of the parent without custody of the child;
4. the plan of the spouse of the parent without custody of the child. You may submit a claim to the plan of the other spouse for any amount which is not paid by the first plan. If priority cannot be established in the above manner, the benefits shall be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan had there been coverage by just that plan. To implement this provision, Manulife Financial may: subject to the consent of the covered person, if required by law, obtain from or release to any other person, corporation or organization any information deemed to be needed; or pay to or recover from any other person, corporation or organization any excess payment; any payment so made will be deemed to be benefits paid and, to the extent of such payments, will fully discharge Manulife Financial from all liability under this plan.
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Allowable expense means any necessary, reasonable and customary item of expense, at least a portion of which is covered under at least one of the plans covering the person for whom claim is made. When a plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered will be deemed to be both an allowable expense and a benefit paid. Plan means any contract of group insurance or other arrangement for members of a group (whether on an insured basis or not), prepaid health or dental care coverage, or student accident insurance.
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TERMINATION OF INSURANCE
Life Insurance Coverage terminates on the date you lose eligibility however, you may be entitled to convert your coverage to an individual policy, as outlined earlier. Accidental Death and Dismemberment Insurance These benefits cease immediately upon the date you lose eligibility. Weekly Disability Benefit This coverage ceases on the date you lose eligibility unless you are totally disabled in which case benefits will continue until the end of the benefit period under the Plan, or your prior recovery. Supplementary Health Care Benefits If an individual is totally disabled at the time his insurance terminates, coverage of Supplementary Health Care Benefits other than dental expense benefits will be extended during the uninterrupted period of such disability until the earlier of the following: the end of a three month period from the date of termination; the maximum benefits have been paid; the individual becomes insured for similar benefits.
An individual will be considered to be totally disabled at termination of insurance if: an employee he is unable because of disease or injury to engage in his regular occupation and is not working for any kind of compensation. a dependent he is prevented because of injury or disease from engaging in substantially all of the normal activities of a person of like age, sex and health.
Dental Benefits
The installation or delivery of prosthetic devices (including bridges and crowns), which were ordered while the individual was insured will be extended 90 days from the date of termination of insurance. No other dental benefits will be extended. Note: Those employees whose eligibility terminates should refer to the Extension of Coverage by Self-Payment section of the Eligibility Rules contained in this booklet.
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Life Insurance
1. The beneficiary should notify the Fund Office immediately to obtain the necessary claim forms. 2. A certified copy of the death certificate as filed with the Department of Vital Statistics, or an original or certified copy of the med ical examiners report, or an original Funeral Home Certificate should be submitted to the Fund Office as soon as it can be obtained.
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Medical, Drug, Vision and Hearing Aid Benefits 1. When you or your dependents have incurred covered expenses, obtain the appropriate claim form from the Fund Office. 2. A separate claim form must be used for each individual except for drug expenses. 3. Complete the form and return it to the Fund Office along with all necessary bills and receipts. Only original bills and receipts will be accepted and should clearly indicate the name of the individual involved. Claims should be submitted when you have accumulated a reasonable number of bills and receipts. We suggest you avoid frequent submissions of small claims, but any large claims should be submitted promptly. All claims must be submitted within 12 months of the date the expense was incurred, but not more than 6 months after the date your coverage terminates or the Benefit is discontinued. Dental Benefits 1. Obtain a claim form from the Fund Office. 2. Have your dentist complete and sign his portion stating the following: (a) Name of patient (b) Dates and nature of treatment (c) Procedure number for each treatment performed (d) The charge for each service rendered. 3. Return the completed claim form to the Fund Office within 12 months of the date the expense was incurred, but not more than 6 months after the date your coverage terminates or the Benefit is discontinued. Proof of Loss Written proof stating the occurrence, character and extent of loss must be submitted for each Benefit to the Insurance Company within: 12 months after the date the employee ceases active work because of Total and Permanent Disability under the Disability Provision for Life Insurance Benefits; 18 months after the date of death for Life Insurance and Accidental Death Benefits;
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6 months after the date of the loss for Accidental Dismemberment Benefits; 6 months after the start of disability for the Weekly Disability Benefit; 12 months after the date of the loss, but not more than 6 months after the date your coverage terminates or the Benefit is discontinued, for Supplementary Health Care and Dental Care Benefits.
Time Period for Legal Action You may not commence legal action against the Plan Administrator or Manulife Financial less than 30 days after proof has been filed as outlined under Submitting a Claim. Every action or proceeding against the Plan Administrator or Manulife Financial for the recovery of money payable under this plan is absolutely barred unless commenced within the time period set out in the Insurance Act or applicable legislation. Send all completed claim forms to: L.I.U.N.A. Local 527 Benefit, Health and Safety Trust Fund Benefit Office 6 Corvus Court Ottawa, Ontario K2E 7Z4 The Insurance Company shall have the right and opportunity to examine any person whose injury or illness is the basis of claim, when and as often as it may reasonably require during the pendency and payment period, if any, of such claim.
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