Green Shield Canada (GSC) Extended and Individual Travel Health Plans for GMCL Salaried Retirees

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1 Green Shield Canada (GSC) Extended and Individual Travel Health Plans for GMCL Salaried s The base travel plan for GMCL Salaried s (who retired on or after January 1, 1995) provides coverage for the first 60 days of any trip. We have provided you with details of your current base 60-day Travel Coverage for reference. GSC is pleased to offer you a limited one-time opportunity to purchase additional travel coverage that allows you to extend the duration of your existing base 60-day Travel Coverage to help meet your personal travel needs. Please be advised that this additional coverage is not provided by GMCL; this product is being made available to you by GSC and all questions regarding this program should be addressed directly to GSC. Option #1 Extended Travel Plan Going away for longer than 60 days at a time? GMCL Salaried s who are eligible for the base 60-day Travel Coverage now have the opportunity to purchase an additional 30, 60, 90 or 120-day per trip top-up extension to their existing base 60-day Travel Coverage. The GSC Extended Travel Health Plan is fully paid by you AND you do not have to worry about preexisting conditions or answer medical questions to qualify. This is your only opportunity to access the GSC Extended Travel Health Plan which will be effective from August 1, 2013, to July 31, Future GMCL Salaried s (those who have not retired as of the date of this mailing) will also be provided with a one-time opportunity to enrol in the GSC Extended Travel Health Plan upon retirement. Remember this is a special one-time offer You must respond withing 50 days of your retirement! To enrol, you must complete and return both sides of the enclosed Enrolment and Payment Authorization Form. Select your preferred trip duration option and provide your payment information to GSC. Important note: To qualify for this coverage, you must maintain eligibility under your provincial government s health insurance plan, and you can t be out of your province or out of the country longer than the number of days allowed by your provincial health plan. Please contact your provincial health plan for details. May 2013 P a g e 1

2 Your trip extension options The GSC Extended Travel Health Plan allows you to select the number of days you would like to add to your existing base 60-day Travel Coverage for an unlimited number of trips per year outside the province/country. Extension options include: 1. Add 30 days (to your current 60 for a total trip duration of 90 days) 2. Add 60 days (to your current 60 for a total trip duration of 120 days) 3. Add 90 days (to your current 60 for a total trip duration of 150 days) 4. Add 120 days (to your current 60 for a total trip duration of 180 days) Competitive premiums yes, this is a good deal! This GSC Extended Travel Plan is available to you at a very competitive premium and, although the coverage is annual (for 12 full months regardless of the number of months you travel), we ve made it easier on you by breaking down the annual premium into 12 equal monthly payments outlined in the chart below: Additional Top- Up Coverage GSC Extended Travel Health Plan Premiums In effect August 1, 2013 July 31, 2014 Under age 65 MONTHLY PREMIUM Age Age 75 and over Single Family Single Family Single Family 30 days (Total 90) $10.49 $23.08 $22.27 $45.60 $34.06 $ days (Total 120) $12.24 $26.93 $28.79 $57.57 $58.42 $ days (Total 150) $14.58 $32.05 $48.05 $96.09 $ $ days (Total 180) $22.15 $48.74 $ $ $ $ Your automatic monthly premium payments (details) Here are a few important points about your monthly premium payments: The GSC Extended Plan will renew automatically each year. These premiums are guaranteed for the first year only and may change in the future based on claims experience. You will receive notification at least 60 days in advance of any rate changes. Premium payment will be via pre-authorized withdrawals from your bank account on or about the first of every month. You will pay the monthly premium amount from your date of retirement through the policy year. Notification of any premium change (if applicable) will be communicated to you by July 1 each year. Monthly premiums are age banded and will be automatically adjusted the month following your 65 th and 75 th birthday. Your coverage status (single or family) for the GSC Extended Travel Health Plan will be the same as your current coverage status under your GMCL Salaried Plan. May 2013 P a g e 2

3 Why should I purchase the GSC Extended Travel Health Plan? The GSC Extended Travel Health Plan provides the same coverage and benefits as the GMCL Salaried s base 60-day Travel Coverage and presents a unique lifetime and limited opportunity for you to extend your trip durations without completing a medical questionnaire. An opportunity like this is not available in the travel insurance market. Additional highlights of selecting any of these top-up options include: Coverage up to a lifetime maximum of $1,000,000 per person is available for emergency services. Multi-trip travel coverage includes protection for an unlimited number of trips during the year, with each trip duration up to the maximum number of total days selected. This eliminates the need for purchasing single-trip top-up coverage for each trip. Note: you must return to your province of residence for at least 24 hours before your trip duration coverage resets. Future changes you will have a one-time only opportunity at the start of a policy year (August 1) to change your trip duration top-up option. Changes may include: Reduce your trip duration move to an option with a reduced number of days per trip. Just send us a written request to do so. Increase your trip duration move to an option with a higher number of days per trip. In this instance, a medical questionnaire is required and is subject to GSC approval. You may also request a change to your trip duration top-up option if you are adding or removing a spouse or dependent within 60 days of a change in your coverage status. How do I enrol? It s easy! If you would like to purchase the GSC Extended Travel Health Plan, please complete both sides of the attached Enrolment and Payment Authorization Form. Return the completed form to GSC, either via toll-free fax at or by using the enclosed prepaid business-reply envelope. What happens after I enrol? After we receive your completed enrolment form (via fax or postal mail) you will receive a letter from us confirming your coverage along with detailed benefit plan information. The best part is, you can continue to use your current GSC ID number and ID card. Your travel plan information, including the emergency travel assistance numbers to call in case of an emergency do not change and are located on the back of your current GSC ID card the same card you use to access your health and dental benefits. Also remember: prior to departure, you can contact GSC Travel Assistance for Canada Direct Calling Codes, information about vaccinations, government issued travel advisories, and VISA/document requirements for entry into your country of destination. May 2013 P a g e 3

4 Option #2 Individual Trip Travel Plan What if I don t normally travel for more than 60 days at a time? The GSC Individual Travel Health Plan might be for you! For members who prefer to purchase additional coverage on a per trip basis, we also offer the GSC Individual Travel Health Plan at competitive premiums, which are also fully paid by you. Because this coverage is issued on an individual basis for each trip, you re required to answer a medical questionnaire and coverage is subject to approval by GSC. This option may be of interest to you if you: Don t routinely travel for long periods Don t want to commit to regular premium payments for the GSC Extended Travel Health Plan Didn t enrol for the GSC Extended Travel Health Plan and you now have an opportunity to travel and need additional coverage Your GSC Individual Travel Health Plan options If you would like to top up a single, specific trip, you have the option to apply for and purchase an additional number of days over and above your base 60-day Travel Coverage. Trip duration options include trips of up to an additional 15, 30, 60, 90, or 120 days. The chart below outlines the one-time premium for the individual trip options based on your applicable age band: Age GSC Individual Travel Health Plan Premiums Currently in effect and are subject to change 15 days (Total 75) Premiums per person for a single trip top up 30 days (Total 90) 60 days (Total 120) 90 days (Total 150) 120 days (Total 180) 49 $ 35 $ 65 $ 135 $ 220 $ $ 45 $ 80 $ 165 $ 250 $ $ 60 $ 110 $ 225 $ 350 $ $ 90 $ 165 $ 340 $ 525 $ $ 120 $ 220 $ 475 $ 775 $ 1, $ 190 $ 380 $ 830 $ 1,290 $ 2,315 Contact GSC at to obtain an Individual Travel Plan information package or visit the GMCL Salaried website at to download plan and pricing details and an application form. Please note: You must apply at least two weeks prior to your trip departure date. If you have questions about your travel plan options A GSC telephone hotline is in place to respond to your inquiries about purchasing these additional travel plans and to review available options. Please call between the hours of 8:30 a.m. and 4:30 p.m. Eastern Time. You can also send an anytime to with your questions. May 2013 P a g e 4

5 GMCL SALARIED RETIREES TRAVEL COVERAGE Travel Group Number 4787 This brochure highlights important answers to questions that you may have. These benefits will allow for your peace-of-mind while travelling anywhere around the world. Use this brochure as a helpful guide in the event of a medical emergency. WHAT MUST I BRING WITH ME WHEN I AM TRAVELLING? Green Shield Canada (GSC) identification card Provincial health care card This brochure (for reference only) If you do not have a GSC ID card, contact GSC toll free at or call prior to your departure. WHAT BENEFITS AM I COVERED FOR? Eligible services described below will be reimbursed based on the usual, reasonable, and customary charges in the area where the services were received. Hospital services and accommodation up to a standard ward rate in a public general hospital. Medical/surgical services rendered by a legally qualified physician or surgeon. Emergency AIR ambulance (including a medical attendant when necessary) when it is medically necessary for you to travel from a location in North America to your province of residence. Ambulance transportation when required as the result of an accident or acute physical disability by professional land ambulance from the site of the medical emergency to the nearest medical facility. Emergency commercial transportation costs may be covered for a patient when medically fit to travel home for treatment, and may also cover the cost to transport a spouse to accompany the patient. Call GSC Travel Assistance Service for verification. Referral services including hospital services and accommodation up to a standard ward rate in a public general hospital, and/or medical/surgical services rendered by a legally qualified physician or surgeon. NOTE: You must receive pre-authorization from your provincial government health plan and GSC prior to the commencement of any referral treatment. You must also provide GSC with a letter from your attending physician stating the reason for the referral, and a letter from your provincial government health plan outlining their liability. Failure to comply in obtaining pre-authorization may result in non-payment. MANDATORY REPATRIATION Upon notification of the necessity for treatment of an accidental injury or medical emergency, GSC Travel Assistance reserves the right to determine whether repatriation is appropriate if the patient s medical condition will require immediate or scheduled care. Such repatriation is mandatory, where the attending physician and family or admitting physician determine that the patient is medically fit to travel and appropriate arrangements have been made to admit the patient into the provincial health care system. Repatriation will ensure continued coverage under the plan. Should the patient opt not to be repatriated, no further benefits will be paid under the plan for the resolved emergency. $1,000 will be allowed to return the patient s personal use motor vehicle to the patient s residence or nearest rental agency, as applicable. WHAT ARE THE LIMITATIONS TO THESE BENEFITS? Effective July 1, 2008, the maximum lifetime "Out-of-Province" benefit payable is limited to $1,000,000 per covered person. Coverage is limited to a maximum of 60 days per trip, commencing with the date of departure from your province of residence. If you are hospitalized on or before the 60 th day, benefit coverage will be extended until the date of discharge. Services eligible only when required as a result of accidental injury or emergency while traveling, or referral by your attending physician. Eligible only if your provincial government health plan pays a portion of the cost. Air ambulance eligible if: - there is a medical need for you to be confined to a stretcher or for a medical attendant to accompany you during the journey, and - you are admitted directly to a hospital in your province of residence. Land ambulance service if medically necessary, up to the usual, reasonable and customary rate for the area. WHAT IS NOT COVERED UNDER THIS PLAN? Exclusions include but are not limited to: Charges for services over and above the usual, reasonable, and customary charges in the area the services were received. Transportation and lodging. Cost to repatriate remains. Cost for rest cures, health spas, or travel for reasons of health, even if the trip is on the recommendation of a physician. Treatment or services for ongoing care, elective surgery or check-ups. Elective health services are defined as those services: - where vacation or travel is solely for the purpose of obtaining treatment, or - which can be planned or anticipated ahead of time, or - which has not received "prior approval" from the provincial health plan ministry. Services received from a chiropractor, chiropodist, podiatrist, or for osteopathic manipulation. Benefits and services for which you receive reimbursement from a third party. GMCL SALARIED RETIREES Travel Coverage Brochure

6 WHAT SHOULD I DO IN THE EVENT OF A MEDICAL EMERGENCY? Call GSC Travel Assistance Service 24 hours per day, seven days per week: Toll free from within Canada and the USA Collect from all other countries You MUST call GSC Travel Assistance as soon as possible or within 48 hours of the commencement of treatment to ensure charges are usual and customary for the area and to ensure you are not exposed to any potential liability for services not eligible or that are unreasonably charged. These numbers appear on your GSC ID card. Quote your Travel Group Number 4787 and patient number found on your GSC ID card and explain your medical emergency and location. A multilingual assistance specialist will provide direction to the best available medical facility or physician that can provide the appropriate care. The specialist will then contact the provider and provide confirmation that you have GSC out-of-province benefits for the services that are being considered. The assistance-provider physicians and medical team will follow your progress to ensure that you are receiving the best available medical treatment. These physicians also keep in constant communication with your family physician and your family depending on the severity of your condition. GSC Travel Assistance Service will pay the provider (hospital, clinic, or physician) on your behalf for any expenses over $ Canadian. GSC Travel Assistance Service will assist you to procure, but will not pay for, the following services: Verification of insurance coverages, pre-travel inquiries, claims inquiries. Special assistance for coordination of claims payments. Prior approval for a patient (and possibly for an accompanying spouse) to be commercially transported back to your province of residence for treatment. Assistance in locating the nearest, most appropriate medical care. Consultative and advisory services, including second opinion and review of medical care. Monitor progress during treatment and recovery. Emergency message transmittal services for contact with family, personal physician, and employer.* Translation services.* Arrangement of repatriation of remains.* Arrangements for interrupted and disputed travel plans resulting from emergency situations*, including: - the return of unaccompanied travel companions - travel to the bedside of a stranded person - rearrangement of ticketing due to accident or illness and other travel-related emergencies - the return of standard motor vehicles and related personal items Legal referral and coordination of securing bail bonds or other legal instruments.* Replacing lost or stolen travel documents including passports.* Assistance in securing incidental aid.* Emergency and payment assistance for major health expenses that would result in payment of over $ Canadian. * Your coverage will provide for the arrangements involved in securing these services, but not the cost of the services. WHAT SHOULD I DO IF I PAID FOR MY OWN MEDICAL EXPENSES? GSC Travel Assistance Service will coordinate reimbursement of any paid expenses with your provincial health plan. Submit original itemized receipts with detailed statements showing the services rendered and the fees charged for each service, along with your GSC ID number, Travel Group Number, patient name, address, and provincial health plan number to: GSC Travel Assistance Green Shield Canada 4273 King Street East 8677 Anchor Drive, P.O. Box 1606 Kitchener, ON N2P 2E9 Windsor, ON N9A 6W1 Reimbursement will be made in Canadian funds at the rate of exchange in effect on the date your claim is processed. All claims must be submitted within 12 months from the date the service was incurred. General Motors of Canada Limited ( General Motors ) reserves the right to amend, modify, suspend or terminate any of its programs (including benefits) and policies covering employees and former employees, including retirees, at any time, including after employees retirements, without notice, by action of its Board of Directors or other committee expressly authorized by the Board to take such action. The programs, benefits and policies to which an employee or former employee, including retiree, is entitled are determined solely by the provisions of the applicable program, benefit or policy as amended from time to time. Absent an express delegation of authority from the Board, no one has authority to: commit General Motors to: any program, benefit, policy or provision under a program, benefit or policy not provided for under the written terms of applicable programs, benefits or policies; or change the eligibility criteria or any other provisions of such programs, benefits or policies. The Travel Coverage description provided in this brochure is for information purposes only. While every effort has been made to ensure its accuracy, the actual coverage under your group benefits plan is subject to the Group Master Policy between General Motors of Canada Limited and Green Shield Canada. In the event of a discrepancy, the contract will prevail. GMCL SALARIED RETIREES Travel Coverage Brochure

7 Completed forms can be returned by mail or by toll-free fax. GMCL SALARIED RETIREES GSC EXTENDED TRAVEL HEALTH PLAN ENROLMENT FORM Mailing Address: ATTENTION: IAT TRAVEL Green Shield Canada P.O. Box 1606 Stn A, Windsor, ON N9A 9Z9 Toll-free Fax: Important Information: This is a one-time election option. Appropriate premiums will apply. You will NOT be able to opt out of this coverage until August 1, This form must be returned witin 50 days of retirement. For any updates to your Plan Member Information, please contact the GM Canada Benefits Centre at PLAN MEMBER INFORMATION Last Name: GSC ID#: Legal First Name: Preferred First Name: Mailing Address: Date of Birth: (YYYY/MM/DD) Age: Gender: Home #: ( ) Cell #: ( ) Address: GSC EXTENDED TRAVEL PLAN ELECTION Please check only ONE of the following extended travel options Rates shown below are monthly Extended Travel Options [Additional Top Up ] Internal Use Only Offering Code Under age 65 Age Age 75 and over Current Coverage Status Single Family Single Family Single Family 30 days T3 $10.49 $23.08 $22.27 $45.60 $34.06 $ days T6 $12.24 $26.93 $28.79 $57.57 $58.42 $ days T9 $14.58 $32.05 $48.05 $96.09 $ $ days T2 $22.15 $48.74 $ $ $ $ By signing this enrolment form or by providing my personal information to Green Shield Canada, I agree the information is complete and accurate to the best of my knowledge. I also authorize the deduction of the above payments directly from my bank account, per the Pre-Authorized Payment Authorization Form on the reverse. Signature of Plan Member: Date: For further information on GSC s privacy policies and procedures, please refer to your benefit plan booklet and our website at PLEASE COMPLETE BOTH SIDES OF THIS FORM GMCL SALARIED RETIREES Travel Coverage Brochure

8 GMCL SALARIED RETIREES PRE-AUTHORIZED PAYMENT AUTHORIZATION FORM Completed forms can be returned by mail or by toll-free fax. Important Information: PLAN MEMBER INFORMATION Last Name: Mailing Address: ATTENTION: IAT TRAVEL Green Shield Canada P.O. Box 1606 Stn A, Windsor, ON N9A 9Z9 Toll-free Fax: Your monthly premium payment will be withdrawn directly from the bank account you indicate below. Please complete and return this form, including a sample cheque OR a copy of a sample cheque marked VOID, from the account indicated. GSC ID#: Legal First Name: Date of Birth: (YYYY/MM/DD) Preferred First Name: Age: Mailing Address: Home #: ( ) Cell #: ( ) Address: FINANCIAL INSTITUTION INFORMATION FOR PRE-AUTHORIZED PAYMENT I authorize Green Shield Canada to withdraw premium payments directly from this bank account, on or about the first business day of each month. The payer waives the right to receive pre-notification of the amount of the PAD and agrees that you do not require advance notice of the amount of the PAD before the debit is processed. Green Shield Canada may terminate coverage should a withdrawal be refused for any reason and the financial institution shall in no way be held liable should such an event occur. This authority is to remain in effect until Green Shield Canada has received written notification from you. This notification must be received at least 10 business days before the next debit is scheduled at the address provided above. You may obtain a sample cancellation form or more information on your right to cancel a PAD Agreement at your financial institution or by visiting You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. To obtain a form for a Reimbursement Claim, or for more information on our recourse rights, you may contact your financial institution or by visiting Signature of Account Holder Date Signature of Joint Account Holder (if Joint Account) Date Please provide the following bank account information which can be found on the bottom of your cheque. Cheque Number You do not need to provide us with a cheque number Transit Number Bank Number Account Number Account numbers are anywhere from 6 to 12 digits long. Your transit number is 5 digits long and identifies your branch. This 3-digit number identifies your bank. Include a sample cheque or a copy of a sample cheque marked VOID from the account you are authorizing Green Shield Canada to withdraw your premiums from on a monthly basis. For further information on GSC s privacy policies and procedures, please refer to your benefit plan booklet and our website at PLEASE COMPLETE BOTH SIDES OF THIS FORM GMCL SALARIED RETIREES Travel Coverage Brochure

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