INTRODUCTION
Below is a list of benefits associated with the Students' Union Health and Dental Plan. Please be sure to consult the final section, General Information, for important limitations and regulations regarding the terms of the Plan. Please also note that in the case that the information provided deviates from that wich is outlined in the master agreeement, the master agreement will be considered the final authority.
GENERAL INFORMATION
Green Shield will determine the amount of benefits payable, giving consideration to limited procedures, services, or courses of treatment that may be performed to accomplish the desired result. The attending physician or dentist and the patient have the option of which procedure to use, although payment for the procedure may be based on the "limited treatment" principle. The Limited Benefit Clause is a financial limitation and not intended as a comment regarding any treatment recommended or performed by a physician or dentist.
Predetermination:
If the cost of any proposed treatment is expected to exceed $300.00, submit to Green Shield a detailed treatment plan from your provider before your treatment begins. If a description of the procedures to be performed and an estimate of the charges are not submitted in advance, Green Shield reserves the right to make a determination of benefits payable, taking into account alternate procedures, services or course of treatment, based on accepted standards of medical and/or dental practice.
General Overall Exclusions:
Eligible Services do not include and reimbursement will not be made when we are aware of or have been apprised of:
1. Services or supplies received as a result of disease, illness or injury due to any of the following:
- intentionally self-inflicted injury while sane or insane
- an act of war, declared or undeclared
- participation in a riot or civil commotion
- committing a criminal offence
2. Failure to keep a scheduled appointment with a licensed medical or dental practitioner.
3. Services or supplies that are cosmetic in nature.
4. The completion of any claim forms and/or insurance reports.
5. Services or supplies which do not meet accepted standards of medical, dental, or ophthalmic practice, including charges for services or supplies which are experimental in nature.
6. Services or supplies normally paid through any provincial government health plan, workplace safety and/or insurance board, the Assistive Devices Program or any other government agency; or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made.
7. Services or supplies from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body.
8. Services or supplies that are not recommended or approved by the attending physician or dentist.
9. Services or supplies that you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage.
10. Services or supplies that are legally prohibited by the government from coverage.
11. The replacement of lost, missing or stolen items, or items which are damaged due to negligence.
12. Any eligible service that relates to treatment of injuries arising out of a motor vehicle accident.
Coordination Of Benefits:
Where you or your dependents have coverage with more than one carrier, claims shall be coordinated so that reimbursement from all plans shall not exceed 100% of the actual claim. For information on how to do this, visit one of your Students' Union office where staff will assist you.
Subrogation:
Green Shield retains the right to subrogation if benefits have or should have been paid or provided by a third party. In cases of third party liability, you must advise your lawyer of these rights.
SECTION A - PRESCRIPTION DRUGS
- Your drug coverage is 80% (i.e. you pay 20% of the purchase).
- Your drug deductible is zero.
Benefits include drugs legally requiring a prescription, needles and syringes. Unlike many other extended health plans, birth control and anti-depressants are eligible for coverage. Benefits do not include anti-obesity, smoking cessation products, erectile dysfunction and fertility drugs. Serums and vitamins are also ineligible unless injected.
Be sure to bring your Green Shield Health Card with you when visiting your local pharmacy!
SECTION B - HEALTH SERVICES
- Your coverage for health services is 100%, excepting intrauterine devices and colostomy supplies which are covered at 80% (i.e. you pay 20% of these purchases)
- Your overall health deductible is zero.
Health services include non-drug or dental related medical services, including emergency transportation (i.e. ambulances) and paramedical services such as massage therapy and chiropractic treatment, as outlined below.
Emergency Transportation
Ambulance transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.
Accidental Dental Benefits
Accidental dental benefits for costs associated with accident-related dental treatment by a dentist. A dental accident report form must be submitted immediately following the accident.
Medical Items
Prosthetic appliances and durable medical equipment as well as replacements, repairs, fittings and adjustments of such devices are covered. Contact Green Shield through their toll-free number to verify eligibility of a particular benefit.
Paramedical Services
Physiotherapist, chiropractor, podiatrist, licensed naturopath, registered massage therapist (medical referral required), speech therapist, acupuncturist or clinical psychologist up to a $300.00 maximum per paramedical discipline per benefit year (September 1 - August 31).
Optometry
Optometrist eye examinations performed by a licensed optometrist, to a maximum of $25.00 every two consecutive benefit years (September 1 - August 31).
SECTION C - DENTAL
- Your coverage is 80% for basic services and comprehensive basic services (what is known as a "Plan A").
- Your overall dental maximum is $500.00 per benefit year (September 1 - August 31).
- Your dental deductible is zero.
Your eligible claims are reimbursed at the level stated above and in accordance with the current Provincial Dental Association Fee Guide for General Practitioners.
Basic Services
Basic services cover recalls (appointments) once every five months, and other exams and full mouth x-rays every 3 years.
Recalls include routine exams, bitewing X-rays, cleanings and fluoride treatments.
Other exams include complete, general or comprehensive oral exams, full mouth x-rays and panoramic x-rays.
Basic restorations, fillings and inlays are covered, as well as extractions and surgical services. General anesthetics and intravenous sedation are covered only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.
Comprehensive Basic Services
Comprehensive basic services include coverage for endodontic treatment including root canal therapy, and periodontal treatment including scaling and/or root planning.
Be sure to bring your Green Shield Health Card AND your plan details with you when visiting your local dentist!
SECTION D - TUTORIAL
- Your coverage for Tutorial Services is 100%.
- Your maximum is $1,000.00 per disability.
Private tutorial service of a qualified teacher up to $25.00 per hour, if an accident or illness causes you to be disabled and confined to home or hospital for 15 consecutive school days.
NOTE: Your dependents are not eligible for this benefit.
SECTION E - TRAVEL BENEFITS
IN THE EVENT OF AN EMERGENCY OUT-OF-COUNTRY, YOU MUST CALL GLOBAL EXCEL IMMEDIATELY:
- In Canada and the U.S., call toll-free: 1-866-870-1898
- From anywhere else, call collect: 1-819-566-1898
- Your Policy Number: 28556323
The VAncouver Island University Students' Union health plan includes international travel assistance. Travel in the world without worrying what to do in case of a medical emergency. Global Excel/ETFS coverage includes hospital room and board costs (up to the semi-private room rate charged by the hospital), physician charges, emergency air transportation, and many other services. Global Excel/ETFS must be contacted before you seek medical treatment. If your condition renders you unable to do so, then someone else must immediately contact Global Excel/ETFS for you.
Payment by Global Excel/ETFS for eligible out-of-country hospital, medical, or surgical services is processed only after the provincial government health program in the province in which you reside has made reimbursement towards the service for which an out-of-province benefit is being claimed.
Global Excel/ETFS Claims Procedure
To be followed if Global Excel/ETFS was not contacted before treatment, or if Global Excel/ETFS directs you to submit a paper claim:
- Include the policy number (28556323A), the patient's name (married and maiden, if applicable), date of birth, and Canadian provincial or territorial Government Health Insurance Plan number.
- 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.
- 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.
- Provide proof of the departure date(s) and return date(s).
- Provide written proof of claim within 90 days of the date of receipt of services covered under the policy.
- Provide additional information pertinent to your claim, as may be required by Global Excel/ETFS after receipt of your claim.
- Sign and return "Mandate/Authorization Form", provided by Global Excel/ETFS, 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.
Return the unused portion of your air ticket to Global Excel/ETFS if the Emergency Air Transportation benefit is used.
SECTION F - BASIC ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
The Basic Accidental Death and Dismemberment (AD&D) plan covers you 24 hours a day, anywhere in the world, for specified accidental losses. If you suffer any of the eligible losses listed in the policy as the result of an accidental injury that results directly and independently of all other causes, and the loss occurs within 365 days of the date of the accident, the benefits indicated in the policy will be paid.
Who is covered by this benefit?
- All active full-time students of the policyholder under the age of 70 whose names are on file with the policyholder are entitled to this benefit.
- The amount of insurance (the principle sum) is $7,000.00.
For details regarding the schedule of losses and information on other benefits under the AD&D policy, please contact the Malaspina Students' Union office.
Local 61 - Canadian Federation of Students