CT Flex. reference guide. Human Resources

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1 CT Flex reference guide Human Resources

2 CT Flex Reference Guide Canadian Tire Health & Dental Care Plan Health Care Spending Account Plan Life Insurance & Long Term Disability Plan The information on all benefits insured or administered by Manulife Financial is up to date as of July 1, The Basic and Voluntary Accidental Death and Dismemberment benefits described in this booklet are insured by ACE INA Insurance. The Vacation Buying, Group RRSP and Taxable Cash options described in this booklet are self-insured by Canadian Tire. All other benefits are insured or administered by The Manufacturers Life Insurance Company. Your Health Care, Dental Care and Health Care Spending Account Benefits are provided directly by Canadian Tire. Manulife Financial has been contracted to adjudicate and administer your claims for these benefits following standard insurance rules and practices. Payment of any eligible claim will be based on the provisions and conditions outlined in this booklet and your employer s Benefit Plan. Canadian Tire reserves the right to change the benefits outlined in this booklet at any point in time. This overview is based on official plan documents. Every effort has been made to describe the program accurately. However, should there be a question of interpretation, the official plan documents will prevail.

3 GENERAL INFORMATION... 1 Introduction...1 What are our Contract Numbers?...1 What is CT Flex and how does it work?...1 Who is Eligible for Coverage?...1 Is there a Waiting Period?...2 Default Coverage...2 Changing Your Coverage...2 Submitting a Claim...3 Online Claims submission...3 Coordination of Benefits...4 General Exclusions...4 When Coverage Ends...4 Annual Enrolment...4 HOW TO ENROL... 5 First Steps...5 Completing the Benefit Selections...5 YOUR BENEFIT OPTIONS... 6 HEALTH CARE... 6 Benefit Summary...6 Choice Chart...6 Annual Enrolment Rules...8 Conditions of Reimbursement...9 Eligible Expenses...9 Drugs - Reasonable and customary charges incurred for medically necessary drugs which...9 Dispensing Limits...9 Payment of Covered Expenses...10 No Substitution Prescriptions...10 Emergency Travel Assistance...10 Hospital...11 Vision Care...11 Eye Exams...12 Ambulance...12 Nursing Care...12 Hearing Aids...12 Stock-Item Orthopaedic Shoes (Modifications or Adjustments only)...12 Custom-Made Orthopaedic Shoes...12 Foot Orthotics...12 Orthotics or Orthopaedic Shoe Coverage Criteria...13 Claim Submission Requirements for Orthotics or Orthopaedic Shoes...13 Accidental Dental...14 Services, Aids and Supplies...14 Diagnostic Tests...15 Paramedical Services...15 Non-Eligible Expenses...16 DENTAL CARE Benefit Summary...17 Choice Chart...17 Annual Enrolment Rules...17 Conditions of Reimbursement...18 Eligible Expenses...18 Basic Diagnostic and Preventative Expenses...18 Diagnostic...18 Preventative...18 Minor Restorative...19 Minor Surgical (once per tooth/lifetime)...19 Additional Services...19 Major Surgical...19 Endodontics (Root Canals) (Once per tooth per lifetime)...19 Periodontics (treatment of gum disease)...19

4 Dentures...19 Options 4 & 5- Fixed Prosthodontics (Bridges)...20 Options 4 & 5- Major Restorative,...20 Options 4 & 5 - Orthodontics (Braces)...20 Exclusions...20 SHORT TERM DISABILITY LONG TERM DISABILITY Benefit Summary...22 Choice Chart...22 Levels of Coverage and Monthly Benefit...22 Cost of Living Adjustments (COLA)...24 Payment of Disability Benefits...24 Recurrence of Disability...25 Annual Enrolment Rules...25 Tax Considerations...25 When Coverage Ends...25 Exclusions...25 Pre-Existing Conditions Clause...26 Submitting a Claim...26 EMPLOYEE & OPTIONAL LIFE INSURANCE Benefit Summary...27 Annual Enrolment Rules...27 Points to Remember...27 Conversion of Your Life Insurance...27 Waiver of Premium for Disability...28 DEPENDENT LIFE INSURANCE Benefit Summary...29 Annual Enrolment Rules...29 Points to Remember...29 Waiver of Premiums...29 Conversion Privileges...29 ACCIDENTAL DEATH & DISMEMBERMENT OPTIONS VACATION BUYING Buying Extra Vacation Time...31 LIFE EVENT CHANGES HEALTH CARE SPENDING ACCOUNT What is a Health Care Spending Account?...33 Account Balance...33 Eligible Health and Dental Care Expenses...33 Out-of-pocket expenses such as deductibles and co-insurance...33 Payments to licensed medical practitioners...33 Transportation Expenses to Receive Medical Care...33 Other Expenses...34 How to Submit a Health Care Spending Account Claim...34 Points to Remember...34 GROUP RRSP TAXABLE CASH QUESTIONS AND ANSWERS TERMS AND DEFINITIONS... 39

5 GENERAL INFORMATION Introduction This user's guide will assist you in making your benefit choices. The following pages detail each benefit area. Please read the reference guide carefully and take time to compare your needs with the benefits offered before making your final CT Flex choices. What are our Contract Numbers? Your contract number is for life insurance and long term disability. Your contract number for health and dental coverage is Your contract number for Health Care Spending Account coverage is Your certificate or identification number is you employee number. Manulife Financial administers the plan. What is CT Flex and how does it work? CT Flex is an innovative benefits program which enables you to choose benefit coverage to suit your individual needs. Canadian Tire provides you with flex dollars which you use in combination with your own money (via payroll deductions) to purchase varying levels of coverage in these benefits areas: Health Care; Dental Care; Long Term Disability; Employee & Optional Life Insurance; Employee & Voluntary Accidental Death and Dismemberment Insurance; Dependent Voluntary Accidental Death and Dismemberment Insurance; Dependent Life Insurance; Vacation Buying; Health Care Spending Account; Group Registered Retirement Savings Plan; Taxable Cash. Who is Eligible for Coverage? If you are a permanent full-time employee of Canadian Tire working a minimum of 37.5 hours per week or a permanent part-time employee of Canadian Tire working a minimum of 15 hours per week, you may purchase coverage for yourself and your eligible dependents, provided you are covered under your provincial health plan. Eligible Dependent is defined as the Spouse or Child of the employee who is covered under the Provincial Medical Plan. Definitions of Spouse and Child are as follows: Spouse The Employee s legal spouse or common-law partner. Common-law partner refers to a person who cohabits in a conjugal relationship and a) has cohabited continuously for a period of at least 12 months; and/or b) is the natural or adoptive parent of a child of whom the employee is also the parent. A spouse or common-law partner shall not include a person living separately and apart for more than 6 consecutive months. Only one Spouse will be eligible for coverage under the plan, and will be as indicated by the Employee on the application for insurance under this plan. Where this information is not contained on the Employee s application, the person who qualified last under this plan s definition of Spouse will be the eligible Spouse. 1

6 Child The employee s natural, adopted child or stepchild who meets all the following criteria: a) Is unmarried b) Is not employed on a full-time basis c) Is not covered for benefits as an employee under this or any other group contract; d) Is either under 21 years of age, or, if a full-time student at an accredited school, college or university, under 25 years or age. Proof of full-time student status must be provided when the child reaches the age of 21 on an annual basis otherwise coverage will be terminated. A newborn child shall become eligible from 15 days for Dependent Life insurance and from the moment of birth for all other benefits. A child covered under this plan, who is incapacitated due to a functional impairment on the date the child reaches the age when they would otherwise cease to be an eligible Dependent, will continue to be an eligible Dependent under this plan. A child is considered incapacitated if he/she is incapable of engaging in any substantially gainful activity and is dependent on the Employee for support, maintenance and care, due to a functional impairment. If the employee should die, coverage for health and dental benefits under the plan will continue for eligible dependents for up to 24 months providing the employee was enrolled in this coverage. This coverage ends earlier should the spouse remarry or if dependent children reach the plan s maximum age. Is there a Waiting Period? Permanent full-time employees receive benefit coverage effective on their date of hire. Coverage is effective on hire date providing the employee is active at work and Manulife Financial approves any required Evidence of Insurability. Permanent part time employees have a six (6) month waiting period. Default Coverage Should you not make any benefit selections during your initial enrolment period, you will be provided with the following Default Coverage: Health Care Option 3 Employee Only Dental Care Option 3 Employee Only Long Term Disability Option 1 Life Insurance two times base salary Accidental Death and Dismemberment Insurance two times base salary Excess flex dollars will be allocated to your Health Care Spending Account. Changing Your Coverage You select your coverage when you first join Canadian Tire. You may then change your coverage during the Annual Enrolment Period (effective July 1st each year) or if you have a Life Event Change; when you either marry, divorce, acquire a common-law partner, lose or gain your spouse's benefits, acquire a dependent, change your employment status, or become widowed. Note: You must notify Manulife Financial of your Life Event change within 31 days of the event by contacting the Manulife Call Centre at or visit the Manulife website. You may be asked to provide evidence of your Life Event Change. You must be actively at work to change coverage levels - employees on Long Term Disability (LTD), Sick Leave or Leave of Absence (LOA) other than maternity leave or a legislated leave of absence must return to work before coverage levels may be changed. 2

7 If you are increasing your Optional Life Insurance, Dependent Life Insurance or LTD coverage, you will be required to complete an Evidence of Insurability form. Any increases in coverage will become effective after our insurer has authorized the increase. During a Life Event change you are not able to reallocate flex dollars previously selected to purchase Vacation Buying or to your Health Care Spending Account. Submitting a Claim Claim forms are available in your area's kiosk, from your Human Resources Department or online via InTireNet or CTFS Bulletin Board. Health and Dental claim forms must be completed in full and submitted to Manulife Financial with any original bills within twelve months of the date the expense occurred. Disability Claims must be submitted within 180 days of completion of the qualifying period. There is also a 90-day limit to submit claims if your coverage terminates. Online Claims submission Submitting your health and dental claims just got easier. Online claims submission lets you enter all the information online. It s quick, easy, secure and now just 3 steps. It s Easy When you login to the Plan Member Secure Site at you simply select Claims from the top navigation and then Online Claims or simply select Online Claims which is located under the Quick Links navigation. Once you confirm your direct deposit and contact information you re ready to tell us about your claim. Follow the steps Each step is easy to understand. Enter the requested information found on your receipt and then submit your claim. You only need to provide your receipts if we ask for them. Get paid sooner Sign up for direct deposit and you ll receive your money up to 70% faster than by cheque. You ll even receive an as soon as your claim is paid! Safe and Secure All your personal information, such as your banking information, is always retrieved from Manulife s secure system network. There is no way for the general public to access your personal information from our website. What you ll need Be sure you have the receipts from your provider, including details on your provider s name, address and other information. Once you ve registered all you have to do is.. Go to Select Plan Member then Login/Register from the left hand side of the screen Enter your plan contract number Confirm your plan contract number then enter your plan certificate number and password Select Claims from the top navigation and then Online claims or select Online Claims which is located on the Quick Links navigation Enter the details of your claim found on your receipt from your provider, along with details on your provider s name, address and their contact information Make sure you ve signed up for direct deposit too! 3

8 Coordination of Benefits If you and your dependents are covered under more than one Health or Dental plan, it is to your advantage to coordinate benefits to receive the maximum reimbursement. Your personal Health and Dental claims must be submitted to the Canadian Tire plan first. If you coordinate benefits with your spouse's plan, the balance of your claim goes to your spouse's plan second. If there is any remaining balance after the claim has been processed through your spouse's plan, you can then put through a third claim to your Health Care Spending Account. Spousal claims must be submitted to their carrier first then to Canadian Tire's plan. Dependent claims must always be submitted first to the plan of the parent whose month and day of birth comes earlier in the calendar year (excluding the year of birth). Expenses not covered under your benefit plan or any other plan for which benefits may be payable, i.e., spousal plan, may be claimed against the Health Care Spending Account directly by requesting that the unpaid portion of the plan be paid on your Health and /or Dental claim form. Claims should be submitted to all other benefit plans under which you and your dependents are covered before they are submitted for reimbursement through the Health Care Spending Account. General Exclusions Listed below are some of the general exclusions in this plan: No amount of benefit will be payable for any charge that resulted either directly or indirectly from, or as in any manner associated with, any of the following: Self-inflicted injuries or illnesses, whether the person is sane or insane; War, insurrection or hostilities of any kind whether or not you or your dependent was a participant in such action; Participation in a riot or civil commotion; Committing or attempting to commit a criminal offense. The exclusions listed above do not apply to Life Insurance (refer to page 21). 2 When Coverage Ends Your coverage terminates on the earliest of the following: Non-payment of contributions; A change in your classification to one not covered; Termination of your employment; Termination or amendment of the Master Contracts or Administrative Services Only Agreement; Your commencing active duty in any armed forces; The date outlined in the Summary of Benefits. Note: In the event you are absent from work due to sickness, injury, layoff or leave of absence, your coverages may continue for a period as outlined in the Master Contracts and Administrative Services Only Agreement, provided the required contributions are made. Annual Enrolment At Annual Enrolment time, you are automatically enrolled in CT Flex at the same level of coverage as you had the prior year. However, funds currently directed to the Group RRSP and vacation buying will not automatically be continued and must be re-elected online annually. Your Manager must approve vacation buying. Please keep the coverage statement as your record of your benefit choices and payroll deductions (if applicable). 4

9 HOW TO ENROL First Steps 1. Review your Enrolment Kit, CT Flex Reference Guide and Web Enrolment Tool. 2. Go online and register with Manulife Financial. 3. Enrol your benefit selections online. 4. Send any required forms, beneficiary form and Evidence of Insurability form (if applicable) to Manulife Financial. Completing the Benefit Selections When you are ready to complete your Enrolment simply follow the instructions on the Web Enrolment Tool. 5

10 YOUR BENEFIT OPTIONS HEALTH CARE Benefit Summary There are five options offered under Health Care, varying according to levels of coverage offered deductibles and co-insurance. The chart below outlines your Health Care options. You have three choices you can choose to cover just yourself, yourself plus one dependent or yourself plus two or more dependents. If you choose to elect Option 1, you receive opt-out flex dollars. Choice Chart Benefit Year Deductible Option 1 Option 2 Option 3 Option 4 Option 5 Prescription Drug Expenses No Coverage None None None None Drugs other than Drugs other than Drugs other than Drugs other compound compound compound than compound medications are medications are medications are medications are subject to an $8 subject to an $8 subject to an $8 subject to a $12 prescription prescription prescription prescription dispensing fee dispensing fee dispensing dispensing cap cap fee cap fee cap Co-Insurance for Prescription Drugs Plus Standard/Volun tary Generic Substitution Out-of-pocket maximum per Benefit Year for Health Care, including Prescription Drugs Plus Standard/Volun tary Generic Substitute but excluding Vision Care and Emergency Out of Country No Coverage Plan pays 50%, unless otherwise stated, up to the Out-of-pocket maximum and 100% thereafter You pay 50% up to the Out-ofpocket maximum No coverage $5,000 per person Plan pays 75%, unless otherwise stated, up to the Out-of-pocket maximum and 100% thereafter You pay 25% up to the Out-ofpocket maximum $2,500 per person Plan pays 90%, unless otherwise stated, up to the Out-of-pocket maximum and 100% thereafter You pay 10% up to the Out-ofpocket maximum $1,000 per person Plan pays 100% None 6

11 Health Care Benefits continued. Other Health Care Expenses Option 1 Option 2 Option 3 Option 4 Option 5 No Coverage None None None None Benefit Year Deductible Co-Insurance No Coverage Plan pays 50%, unless otherwise stated, up to the Out-of-pocket maximum and 100% thereafter You pay 50% up to the Out-ofpocket maximum Out-of-pocket maximum per Benefit Year for Health Care, including Prescription Drugs Plus Standard/Volun tary Generic Substitute but excluding Emergency Out of Country and Vision Care Emergency Out of Country and Travel Assistance Hospital No Coverage Covers out-of country emergency expenses only. Limited to 60 days of travel. Ward accommodation through your provincial $5,000 per person Covers out-of country emergency expenses only. Limited to 60 days of travel. Ward accommodation through your provincial health health plan. plan. Vision Care No Coverage Medically required contact lenses only Ambulance No Coverage Local Unlimited Emergency equal to economy airfare. Plan pays 75%, unless otherwise stated, up to the Out-of-pocket maximum and 100% thereafter You pay 25% up to the Out-ofpocket maximum $2,500 per person Covers out-of country emergency expenses only. Limited to 60 days of travel. Ward accommodation through your provincial health plan. Medically required contact lenses. Once per 24 months for eye exams. Local Unlimited Emergency equal to economy airfare. Plan pays 90%, unless otherwise stated, up to the Out-of-pocket maximum and 100% thereafter You pay 10% up to the Out-ofpocket maximum $1,000 per person Covers out-of country emergency expenses only. Limited to 60 days of travel. Semi-private accommodation, no maximum. $200/24 months combined for prescription glasses, elective contact lenses and laser vision correction. Once per 24 months for eye exams. Local Unlimited Emergency equal to economy airfare. Plan pays 100% None Covers out-of country emergency expenses only. Limited to 60 days of travel. Semi-private accommodation, no maximum. $300/24 months combined for prescription glasses, elective contact lenses and laser vision correction. Once per 24 months for eye exams. Local Unlimited Emergency equal to economy airfare. 7

12 Health Care Benefits continued. Option 1 Option 2 Option 3 Option 4 Option 5 Private Nursing No Coverage $20,000/benefit $20,000/benefit $20,000/benefit $20,000/benefit year year year year After age 65, lifetime maximum of $25,000. After age 65, lifetime maximum of $25,000. After age 65, lifetime maximum of $25,000. After age 65, lifetime maximum of $25,000. Reasonable and Customary $500/48 months including repairs Lab Tests and X-Rays No Coverage Reasonable and Customary Reasonable and Customary Reasonable and Customary Hearing Aids No Coverage $500/48 months $500/48 months $500/48 months including repairs including repairs including repairs Stock-Item No Coverage Unlimited Unlimited Unlimited Unlimited Orthopaedic Shoes (modifications & adjustments only) Custom-Made No Coverage Shoes One Shoes One Shoes One Orthopaedic pair/benefit year pair/benefit year pair/benefit year Shoes Orthotics No Coverage Children 18 years and under $300/benefit year Adults - $300/2 benefit years Psychologist No Coverage $1,000/benefit year Speech No Coverage $1,000/benefit Therapist year to lifetime (requires a maximum of doctor s note) $10,000 Physiotherapist (requires a doctor s note) Chiropractor, Osteopath, Podiatrist, Naturopaths, Massage Therapist, Acupuncturist, Chiropodist, Dietician Children 18 years and under - $300/benefit year Adults - $300/2 benefit years Children 18 years and under - $300/benefit year Adults - $300/2 benefit years Shoes One pair/benefit year Children 18 years and under - $300/benefit year Adults - $300/2 benefit years $1,000/benefit year $1,000/benefit year $1,000/benefit year $1,000/benefit $1,000/benefit $1,000/benefit year to lifetime year to lifetime year to lifetime maximum of maximum of maximum of $10,000 $10,000 $10,000 No Coverage $500/benefit year $500/benefit year $750/benefit year $1,000/benefit year No Coverage $500 per benefit year per type of practitioner to a combined maximum of $500 per benefit year $500 per benefit year per type of practitioner to a combined maximum of $1,000 per benefit year $500 per benefit year per type of practitioner to a combined maximum of $1,250 per benefit year $750 per benefit year per type of practitioner to a combined maximum of $1,500 per benefit year Annual Enrolment Rules Note: Dental Care and Health Care Option 5 has a 2 year lock-in provision. In Quebec, employees selecting Option 1 or Option 2 must provide proof of coverage under a spousal plan. The proof must be forwarded to Manulife Financial. 8

13 Conditions of Reimbursement You will be paid for any of the charges incurred by you or your dependents provided that the charge meets all of the following conditions: 1. It is medically necessary; 2. It is reasonable and customary; 3. It is recommended and authorized by a physician or surgeon legally licensed to practice medicine; 4. Payment is not prohibited by the government sponsored plan in your province of residence; 5. It is not more than the difference between the actual cost of the charge and the amount you are entitled to apply for and receive under any government sponsored plan in your province of residence. Option 2 Option 3 Option 4, Eligible Expenses Drugs Plus Standard/Voluntary Generic Substitute - Reasonable and customary charges incurred for medically necessary drugs which 1) are dispensed by a licensed pharmacist or physician legally authorized to dispense such drugs, and 2) are prescribed by a physician or other professionals who are authorized by the provincial legislation to prescribe drugs, for the treatment of an illness or injury and are either: a) drugs requiring a prescription in accordance with the Food and Drugs Act, Canada, or b) other specified drugs which have been identified by the carrier as covered expenses and are by convention usually not dispensed without a prescription, or c) injectable preparations identified by the carrier, insulin preparations and supplies, and allergy serums. Note: Smoking cessation aids that require a prescription are covered, subject to a lifetime maximum benefit of $500 per individual. Fertility drugs, lab tests and x-rays, including ultrasound are covered, subject to a lifetime maximum benefit of $6,000 per individual. Sclerotherapy is covered, subject to $20 per day, per individual. General supplies, as well as fees for the services of physicians, nurses, technicians, anesthetists, and administrative staff are not covered. Dispensing Limits Reimbursement for Drug purchases is limited to any single purchase of drugs which would be considered reasonable and customary to be consumed or used within a 34-day period or, with respect to maintenance drugs, a 100-day period. The following is a list of covered maintenance drugs: Anti-asthmatics; Antibiotics for acne; Anticoagulants; Anti-convulsants; Anti-hypertensives; Potassium replacements; Thyroid agents; Cardiac agents; Estrogens; Glaucoma; Hypoglycoemic; Anti-parkinson; Anti-tuberculosis; Oral contraceptives. 9

14 Payment of Covered Expenses Covered expenses for any prescribed drug will not exceed the price of the lowest cost generic equivalent product that can legally be used to fill the prescription, as listed in the Provincial Drug Benefit Formulary. If there is no generic equivalent product for the prescribed drug, the amount covered is the cost of the prescribed product. No Substitution Prescriptions If your prescription contains a written direction from your physician or dentist that the prescribed drug is not to be substituted with another product and the drug is a covered expense under this benefit, the full cost of the prescribed product is covered. When you have a "no substitution prescription", please ask your pharmacist to indicate this information on your receipt, when you pay for the prescription. This will help to ensure that your expenses will be reimbursed appropriately when your claim is submitted to Manulife Financial for payment. Emergency Travel Assistance Manulife Financial offers Emergency Travel Assistance (ETA) services which are administered by Mondial Assistance. Only covered individuals under age 70 who are not retired are eligible for this coverage. The employee's spouse and eligible dependents are eligible as long as the employee is covered. Coverage is limited to a period of 60 days from the date the covered person leaves their province of residence. The following benefits are covered in the event of an emergency that occurs while you or your dependents are traveling for non-medical reasons outside your province of residence. The total lifetime benefit payable in respect to a covered employee or dependent is unlimited. If you or your eligible dependents require medical assistance while traveling, contact Mondial Assistance as soon as possible (before seeking treatment) so they can ensure you get the care you need without incurring unnecessary expenses. The following eligible expenses are covered: Multilingual assistance by toll-free telephone ( ), 24 hours a day, 365 days a year, for covered individuals and providers of medical services to obtain aid and assistance; Referral to a legally qualified physician, dentist, legal advisor, or an appropriate medical care facility; Assistance in replacement (but not cost) of necessary travel documents or tickets in the event of theft or loss; A centre for communication of messages between you and your family, friends or business associates. Messages are held for 15 days; Medical consultation and monitoring of medical care and services if you or your dependent(s) is hospitalized, and arrangement for contact with the patient, the attending physician and the patient s personal physician and family if necessary; Medical services - Charges incurred for medical and surgical fees, semi-private hospital accommodation and prescribed drugs; Emergency transportation - Emergency transportation to the nearest appropriate medical care facility and if medically necessary from the medical care facility to a hospital in Canada. Upon written recommendation of a physician, such charges shall include a medical attendant if necessary who is neither a resident in your home nor a relative of you or your spouse; Return of deceased - Charges incurred for the return of a deceased employee or dependent to the place of former residence in Canada, subject to a maximum benefit of $5,000 per individual; Return of dependent children - Charges incurred for the return of dependent children to their residence in Canada in the event you and/or your spouse is hospitalized and the children are left 10

15 unattended. The children must be under 16 years of age. Arrangements for an escort to accompany the children will be made if necessary; Return trip delay (transportation) - Charges incurred for delay of the return trip of a covered individual due to the hospitalization of that individual or another covered individual with whom the individual is traveling, limited to the cost of one way economy class transportation. If a covered person must return home due to the hospitalization or death of an immediate family member, one-way economy transportation will be arranged and expenses incurred, over and above any allowance available under pre-paid travel arrangements, will be paid. Visit of family member - Charges incurred for transportation of an immediate family member to visit a hospitalized covered individual. The covered individual must have been traveling alone and confined to a hospital for more than seven consecutive days. The cost of transportation is limited to return economy fare for one family member. An immediate family member is defined as a spouse, parent, child, brother or sister or a person with whom the covered individual normally resides; Return of vehicle - Charges incurred in connection with the return of your vehicle. In the event you are unable to return it due to illness, injury or death, subject to a maximum benefit of $1,000 per trip. The vehicle will be returned to your residence or nearest appropriate rental agency. Such charges shall not include commercial transport vehicles; Return trip delay (accommodation) - Charges incurred for commercial accommodation and meals for covered individuals while staying with a hospitalized covered family member when their return trip is delayed due to an illness or accident. Such charges are subject to a maximum benefit of $2,000 per emergency; and Convalescent benefit - Charges incurred for accommodation for covered individuals requiring convalescence following hospitalization. Hospital The difference between the charges made for ward and semi-private room and board in a licensed Canadian hospital. Please note that there should be no charge for semi-private accommodation if a ward room is unavailable. Vision Care For all Options, charges for one pair of contact lenses if visual acuity is improved to at least 20/40 level and this level of acuity is not possible through wearing eye glasses, to a maximum of $150 per 24 months. Eligible charges for vision care are limited to: $200 per 24 months per covered person for Option 4 $300 per 24 months per covered person for Option 5 Eligible charges include the following: 7 Charges for eye glasses or contact lenses and the fittings of such eyewear, Charges for Laser Eye Surgery. Charges defined above may be included only to the extent that they are recommended or approved by a legally licensed physician, surgeon, ophthalmologist or optometrist. 11

16 Eye Exams Eye examinations by a legally licensed Ophthalmologist or Optometrist, one per 24 months for Options 3, 4 and 5 Ambulance Licensed ambulance or other emergency services used to transport you or your dependent to the nearest hospital where adequate treatment can be rendered. Nursing Care The services of a registered nurse or registered practical nurse at your residence up to an individual maximum of $20,000 per benefit year. However, the maximum for each covered person will be $25,000 during any period from the first day of the benefit year coinciding with or following a covered person's 65th birthday, until their death. The types of nursing designations covered under this benefit are RN, CNA, RNA, RPN, LPN, LNA, or VON. 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 confinement in a licensed hospital. Payment will not be made for services which are for custodial care and do not require the skill of a registered nurse or registered practical nurse. The service will not be considered an eligible expenses if the RN or RPN is an immediate family member or is normally a resident in your home. Hearing Aids The purchase of hearing aids and repairs, including batteries, provided by a certified clinical audiologist, up to an individual maximum of $500 every 48 months. Stock-Item Orthopaedic Shoes (Modifications or Adjustments only) Unlimited Custom-Made Orthopaedic Shoes 1 pair per Benefit Year Foot Orthotics $300 per covered person every benefit year for children 18 years of age and under $300 per covered person every 2 benefit years for any other person 12

17 Orthotics and Orthopaedic Shoes Claiming Instructions Effective January 1, 2012 This information sheet outlines the requirements and the documentation you must submit for an Orthotic or Orthopaedic shoe claim to be considered eligible. Manulife recommends that, once you have obtained the required information outlined below, you submit a predetermination for coverage of your orthopaedic shoes to Manulife prior to purchasing them. This can be done either in writing or by telephone and will provide you with confirmation of contractual eligibility prior to incurring any expenses. Orthotics or Orthopaedic shoe Coverage Criteria: Your benefit program (Health options 2, 3, 4 & 5) provides coverage to you and your dependents for Orthotic and Orthopaedic shoes that are medically necessary. Coverage is as follows: Stock-item Orthopaedic Shoes (modifications or adjustments ONLY): Unlimited Custom-made Orthopaedic Shoes: 1 pair per Benefit Year Custom-made Orthotics 1 pair every benefit year, to a maximum of $300 for persons under age 18 and 1 pair every 2 benefit years, to a maximum of $300 for persons age 18 and over Claim Submission Requirements for Orthotics or Orthopaedic Shoes Manulife does not wish to cause unnecessary delays in processing your claim, yet Manulife needs specific and complete information to accurately adjudicate your claim. The claim requirements listed below will assist Manulife in evaluating your claim in a timely manner and help ensure the purchase of good quality, custom-made Orthotics or Orthopaedic shoes. 1. Charges for modifications or adjustments to stock-item orthopaedic shoes or regular footwear which are recommended by a Physician or podiatrist, up to the Stock-Item Orthopaedic Shoes maximum shown in the Benefit Schedule. Physician, Podiatrist/Chiropodist referral including the diagnosis The following information from the supplier of the footwear: o Name of manufacturer and model name and/or model number of the shoes or boots; o Confirmation that the shoes are attached to or part of a brace, if applicable; o Confirmation of any alterations/adjustments made by the supplier for the specific medical needs of the wearer, including a description of the alterations; o A complete, itemized list of all costs, with costs for the footwear shown separately from the costs for any alterations; o The date the shoes or boots were picked up from the supplier; o Original receipt, showing the date and method of payment. 2. Charges for Custom-made shoes which are: constructed by a Certified Orthopaedic Footwear Specialist; and Required because of a medical abnormality that, based on medical evidence, cannot be accommodated in a stock-item orthopaedic shoe or a modified stock-item orthopaedic shoe. Charges will be subject to the Custom-made Orthopaedic Shoes maximum shown in the Benefit Schedule. Physician, Podiatrist/Chiropodist referral including the diagnosis Confirmation that the shoes were made from a last of the patient's foot. Confirmation that the patient can not be accommodated in a stock-item or stock modified orthopedic shoe, and the reason why Original receipt. 3. Charges for casted, custom-made orthotics which are recommended by a Physician or podiatrist, up to the Custom-Made Orthotics maximum shown in the Benefit Schedule. Casted, custom-made orthotics that are purchased from BMSI Orthopedics and are dispensed from the on-site physiotherapist, do not require a recommendation from a Physician or podiatrist. Physician, Podiatrist/Chiropodist referral including the diagnosis 13

18 Description of the casting technique and the materials used. copy of the biomechanical exam and gait analysis report Original receipt including any breakdown of charges. Note: You must include the above documentation with the original claim submission to avoid delays in claim assessments and payments. Please keep a copy of all receipts and documents you submit for your records. To be considered eligible for payment, Orthotics or Orthopedic shoes MUST also meet the following criteria: They must be medically necessary (i.e. used to treat a diagnosed physical condition) The prescription must be written prior to you purchasing the Orthotics or Orthopaedic shoes They cannot be solely used for sporting activities They must be custom-made (this DOES NOT INCLUDE an off-the-shelf product) Modification and/or Adjustment to an off-the-shelf product are an eligible expense. They must be dispensed and paid in full Please note that any costs associated with obtaining this information are the responsibility of the patient. It should also be noted that upon Manulife s review, additional information may be required. You will be notified in writing as to Manulife s decision or, when necessary, Manulife s requirement for additional information. If you have any questions please contact Manulife at to speak With a Customer Service Representative. Accidental Dental Charges by a legally licensed dentist for dental treatment of injuries to natural teeth, or replacement of natural teeth due to accidents suffered by you or your dependent while covered under this benefit, subject to a maximum of $5,000 per accident. The charge will be subject to all of the following conditions: The treatment is necessitated by a direct, accidental blow to the mouth and not by an object or food placed wittingly or unwittingly in the mouth; The accidental blow occurs while the person is covered; The treatment is received within 12 months of the accidental blow; The treatment is the least expensive that will provide a professionally adequate treatment; and No payment will be made for any part of the charge which exceeds the amount shown for the treatment in the current Dental Association Schedule of Fees for General Practitioners in your province of residence. Services, Aids and Supplies Purchase of braces, crutches, artificial limbs or eyes and prosthetic devices approved by Manulife Financial. Two breast prostheses every two years and two surgical brassieres per benefit year. Rental of a wheelchair, hospital bed or other approved durable equipment for temporary therapeutic use. This equipment must be purchased subject to Manulife Financial's approval prior to the purchase. Oxygen. Two pairs of surgical stockings per plan year. Wigs and hairpieces for temporary hair loss as a result of medical treatment, up to a lifetime maximum of $

19 Diagnostic Tests Charges for microscopic and other similar diagnostic tests and services rendered in a licensed laboratory in the province of Quebec. Paramedical Services Expenses for some of these Professional Services may be payable in part by provincial plans. Coverage for the balance of such expenses prior to reaching the provincial plan maximum may be prohibited by provincial legislation. In those provinces, expenses under this Benefit are payable only after the provincial plan's maximum for the benefit year has been paid. Remember: If you have dollars in your Health Care Spending Account any amounts not reimbursed through the Provincial or Manulife Financial's Health Plan can be reimbursed through your Health Care Spending Account. Laboratory tests and X-ray examinations recommended or approved by a legally licensed chiropractor, osteopath, or podiatrist are covered. The services of any of these legally licensed practitioners are covered: Chiropractor; Chiropodist; Osteopath; Podiatrist; Naturopath; Massage Therapist; Acupuncturist; Psychologist; Speech Therapist (requires a doctor s note); Physiotherapist (requires a doctor s note); Dietician. Benefit claims for health practitioners are adjudicated according to Manulife Financial s reasonable and customary fee schedules, based on published guidelines established by the various health practitioners associations. See your choice chart for benefit maximums. 15

20 Non-Eligible Expenses Charges for the following are not covered whether or not they have been prescribed for medical reasons: 1. First aid kits or equipment, spring loaded devices used to hold lancets, alcohol, alcohol swabs, disinfectants, cotton, bandages or supplies and accessories for the above. 2. Oral vitamins, minerals, dietary supplements, infant formulas or injectable total parenteral nutrition solutions whether or not prescribed for a medical reason, except where Federal or Provincial law requires a prescription for their sale. 3. Diaphragms, condoms, jellies/foams/sponges/ suppositories, intrauterine devices, contraceptive implants or appliances normally used for contraception, whether or not prescribed for a medical reason. 4. Proprietary medicines which a. are registered under Division 10 of the Food and Drug Act, Canada, and b. bear a General Public (GP) number on their label. 5. Prescriptions dispensed by a physician, clinic, dentist or in any non-accredited hospital pharmacy, or for treatment as an in-patient or out-patient in any hospital, including emergency status and investigational status drugs, unless otherwise approved by Manulife Financial. 6. All preventative immunization vaccines and toxoids. 7. All homeopathic preparations. 8. Items deemed cosmetic (even if a prescription is legally required) e.g. topical minoxidil, sunscreens, etc. 9. Any medication which the covered person is eligible to receive under a Provincial Drug Benefit Plan, except for residents of the province of Quebec. 10. Supplies for recreation or sports, whether or not medically necessary. 11. Any service or treatment which you or your dependent would receive without being charged. There is no reimbursement for any costs resulting directly or indirectly: a) From an accident occurring while the covered person was operating a vehicle, vessel or aircraft, if the covered person: was impaired by drugs or alcohol, or had a blood alcohol level higher than 80 milligrams of alcohol per 100 millilitres of blood. b) From the abuse of illegal substances. Other exclusions: 1. Any cause which entitles you or your dependent to apply for and receive indemnity or compensation under the Workers Compensation Board. 2. An examination by, or the services of, a physician or surgeon, if required solely for the use of a third party other than Manulife Financial or Canadian Tire Corporation, Ltd. 16

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