78129-11.doc

Norfolk General Hospital
Your Group Plan Booklet
Keep in a safe place
This booklet is a valuable source of information for you and your family. It provides the information you need about the group benefits available through your employer’s group plan with Sun Life Assurance Company of Canada (Sun Life), a member of the Sun Life Financial group of companies. Please keep it in a safe place. We also recommend that you familiarize yourself with this information and refer to it when making a claim for group benefits. Your Plan Administrator is there to help
• help you enrol in the plan • provide you with the forms you need to claim group benefits • answer any questions you may have Benefits and claims information at your fingertips
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At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contract(s) with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, our reinsurers or any other person whom you authorize. In some instances these persons may be located outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us. To find out about our Privacy Policy, visit our website at , or send a written request by e-mail to or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto ON M5V 3C5 to request that a copy of our Privacy Brochure be sent to you. The statements in this booklet are only a summary of some of the provisions in the master plan. If you need further details on the provisions which apply to your group benefits you must refer to the master plan (available from your plan administrator). Your Group Plan Booklet
Summary of Benefits
Plan No. 78129
Extended Health
Deductible
Reimburse-
*The deductible applies per calendar year. The deductible applies to the combined eligible expenses of Parts A and D. **Maximum for eyeglasses/contact lenses and laser eye surgery every 24 month period for you and for each covered dependant. Other maximums are listed under the appropriate Provision page. Termination Age:
Active: member's 70th birthday or retirement, if earlier
Retired: member’s 65th birthday
Deductible
Reimburse-
per family
*The maximum amount payable applies to the combined eligible expenses incurred in a calendar year under Part B for you and for each covered dependant. Summary of Benefits (ad01s)
April 1, 2010 (78129)
**The maximum lifetime amount payable applies to the eligible expenses incurred under Part C for you and for each covered dependant. ***The maximum amount payable applies to the combined eligible expenses incurred in a calendar year under Part F for you and for each covered dependant. Late Entrant Maximum: If your eligible dependant becomes covered more than 31 days after the date you became
eligible for the Dental Provision, the maximum amount payable for the combined eligible expenses of all parts incurred
during the first 12 months of coverage will be limited to $250 for each covered dependant.
Termination Age:
Active: member's 70th birthday or retirement, if earlier
Retired: member’s 65th birthday
Dental Fee Guide: The applicable fee guide is the one in force for general practitioners on the day when and in the
province where the expense is incurred or, for expenses incurred outside Canada, in the province of residence of the
member. For expenses incurred in Alberta, or outside Canada by an Alberta resident, the applicable fee guide is the
1997 Alberta Fee Guide for general practitioners plus an inflationary adjustment determined by Sun Life.
Summary of Benefits (ad01s)
April 1, 2010 (78129)
General Information
Eligibility for Active Employees
You are eligible, and continue to be eligible, to be a member while you meet all of the following conditions: You regularly work for us at least 24 hours each week. You have been continuously employed by us at least as long as the waiting period. If you are classified as a contract employee, owner-operator, consultant, independent or if you are self-employed, you are not eligible to join the plan. Waiting Period – 3 months
Eligibility for Retired Employees
A retired employee is eligible, and continues to be eligible, to be a member while you meet all of the following conditions: You are a member immediately before your date of retirement. You are eligible, and continue to be eligible, for dependant coverage while you meet all of the following conditions: Your dependants are residents of Canada. Definitions
Dependant
means your spouse or a dependent child of you or your spouse. Dependent child
means a natural, adopted or step-child who is not married or in any other formal union recognized by law, who is entirely dependent on you for maintenance and support and who is under 25 years of age and attending a college or university full-time, or physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on you for maintenance and support and while eligible under 1) or 2) above. means your spouse by marriage or under any other formal union recognized by law, or a person of the opposite or same sex who is living with and has been living with you in a conjugal relationship. We, us and our
Enrolment
To enrol, you must submit a completed enrolment form. If you have a dependant, request dependant coverage when you enrol. General Information (af03s)
April 1, 2010 (78129)
Effective Date
Your coverage is effective on the date you become eligible. Your dependant coverage is effective on the latest of • the date that you become eligible for dependant coverage, or • the date that you request dependant coverage. If you are absent from work on the date your coverage or your dependant coverage would be effective, then that coverage will not be effective until the date you return to active work. Comparable Coverage
If you are covered for comparable coverage under your spouse's plan, you may decline the Extended Health/Dental coverage offered under this plan. If this comparable coverage stops you will be covered for the similar coverage provided by this plan. If your dependant is covered for comparable coverage under another plan, you may decline the dependant coverage for the Extended Health/Dental coverage offered under this plan. If this comparable coverage stops, you may request the similar coverage offered under this plan. The coverage that replaces the comparable coverage is effective on the date that the comparable coverage stops. Termination of Coverage
Your coverage could terminate for a number of reasons. For example, • you are no longer eligible, (i.e. you are no longer actively working), • you reach the Termination Age, • the provision or the plan terminates. General Information (af03s)
April 1, 2010 (78129)
Extended Health Provision
To qualify for the Extended Health coverage, you or your dependant must be entitled to benefits under a provincial medicare plan or federal government plan that provides similar benefits. You will be reimbursed when you submit proof to Sun Life that you or your covered dependant has incurred any of the eligible expenses for medically necessary services required for the treatment of disease or bodily injury. To determine the amount payable, the total amount of eligible expenses you claim will be adjusted as follows: the maximums described throughout the extended health benefit provisions are applied, then the deductible, which must be satisfied each calendar year, is subtracted, and the reimbursement percentage is applied. The intentional omission, misrepresentation or falsification of information relating to any claim constitutes fraud. Co-ordination of Benefits
If you or your dependants are covered under this plan and another plan, Sun Life will co-ordinate benefits under this plan with the other plan following insurance industry standards. These standards determine which plan you should claim from first. The plan that does not contain a co-ordination of benefits clause is considered to be the first payer and therefore pays benefits before a plan which includes a co-ordination of benefits clause. For dental accidents, health plans with dental accident coverage pay benefits before dental plans. Following payment under another plan, the amount of benefit payable under this plan will not exceed the total amount of eligible expenses incurred less the amount paid by the other plan. Where both plans contain a co-ordination of benefits clause, claims must be submitted in the order described below. Claims for you and your spouse should be submitted in the following order:
the plan where the person is covered as an employee. If the person is an employee under two plans, the following order applies: • the plan where the person is covered as an active full-time employee, • the plan where the person is covered as an active part-time employee, • the plan where the person is covered as a retiree. the plan where the person is covered as a dependant. Claims for a dependent child should be submitted in the following order:
the plan where the dependent child is covered as an employee, the plan where the dependent child is covered under a student health or dental plan provided through an educational institution, the plan of the parent with the earlier birth date (month and day) in the calendar year, the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date. The above order applies in all situations except when parents are separated/divorced and there is no joint custody of the dependent child, in which case the following order applies: 1. the plan of the parent with custody of the dependent child, 2. the plan of the spouse of the parent with custody of the dependent child, 3. the plan of the parent not having custody of the dependent child, 4. the plan of the spouse of the parent not having custody of the dependent child. When you submit a claim, you have an obligation to disclose to Sun Life all other equivalent coverage that you or your dependants have. Extended Health Provision (am01s032)
April 1, 2010 (78129)
A claim must be received by Sun Life within 18 months of the date that the expense is incurred. However, if your coverage terminates, any claim must be received by Sun Life no later than 90 days following the end of the coverage. For the assessment of a claim, itemized bills, attending physician statements or other necessary information are required. If your physician is recommending medical treatment that is expected to cost more than $1,000, you should request pre-authorization to ensure that the expenses are covered. There is a time limit for proceedings against us for payment of a claim. A proceeding must be started within 1 year of Sun Life’s receipt of the proof of claim. Exclusions
• expenses for which benefits are payable under a Workers' Compensation Act, Workplace Safety and Insurance Act • expenses incurred due to intentionally self-inflicted injuries, • expenses incurred due to civil disorder or war, whether or not war was declared, • expenses for services and products, rendered or prescribed by a person who is ordinarily a resident in the patient's home or who is related to the patient by blood or marriage, • expenses for which services are payable under a government plan, • expenses for benefits which are legally prohibited by the government form coverage, • out-of-province expenses for elective (non-emergency) medical treatment or surgery. At Termination
If, on the date of termination of your coverage, • you have a medically determinable physical or mental impairment due to injury or disease which prevents you from performing the regular duties of the occupation in which you participated just before the impairment started, regardless of the availability of work for you, or • your covered dependant has a medically determinable physical or mental impairment due to injury or disease, is receiving treatment from a physician and is confined to a hospital or his home, benefits will be payable for eligible expenses related to the impairment provided they are incurred within 90 days of the date of termination and this provision continues in force. My Health CHOICE Coverage
If your coverage under this plan terminates, you may purchase Sun Life's My Health CHOICE coverage. This coverage is different from your group plan. To be eligible, you must: • apply for My Health CHOICE coverage within 60 days after the termination of your coverage, and • be a resident of Canada and covered under the provincial health plan. My Health CHOICE coverage may also include Dental coverage if you had both Extended Health and Dental Benefits under this group plan, and both benefits terminated. You may cover your spouse and dependants if those family members were covered under your group plan. If you have any questions about this product, please call our Customer Solutions Centre at 1-877-893-9893 Monday to Friday, 8:00 am to 8:00 pm EST. Extended Health Provision (am01s032)
April 1, 2010 (78129)
Extended Health - Pay Direct Drug Benefit
Eligible Expenses
Eligible expenses are the reasonable and customary charges for the following items of expense, provided they are medically necessary for the treatment of disease or injury, prescribed by a physician or dentist and dispensed by a registered pharmacist or physician: drugs which legally require a prescription and are identified in the Monographs section of the current Compendium of Pharmaceuticals and Specialties as a narcotic, controlled drug, or requiring a prescription. drugs which are identified in the Monographs section of the current Compendium of Pharmaceuticals and Specialties as not legally requiring a prescription and which are only available for purchase at an accredited pharmacy (over the counter (OTC)) and which, in Sun Life's opinion, have a known therapeutic value. compounded prescriptions where one of the ingredients is an eligible expense. needles, syringes, and chemical diagnostic aids for the treatment of diabetes. smoking cessation aids (Zyban) limited to a lifetime maximum of $500 for you and for each covered dependant. Generic Substitution
The maximum amount payable for an eligible brand name drug will be limited to the lowest priced item in the appropriate generic category. Drug Utilization Review (DUR)
Sun Life provides a Drug Utilization Review (DUR) service to ensure the safe and effective use of drugs prescribed for you and your insured dependant. Your pharmacist will review an eligible drug against your past drug claims for possible harmful effects to your health, such as a severe drug interaction. Other Health Professionals Allowed to Prescribe Drugs
Certain drugs prescribed by other qualified health professionals will be reimbursed the same way as if the drugs were prescribed by a physician or a dentist if the applicable provincial legislation permits them to prescribe those drugs. Limitations and Exclusions
the portion of expenses for which reimbursement is provided by a government plan, expenses for drugs which, in Sun Life's opinion, are experimental, expenses for dietary supplements, vitamins and infant foods, expenses for contraceptives (other than oral), expenses for drugs which are used for cosmetic purposes, expenses for drugs used for the treatment of erectile dysfunction, expenses for drugs for the treatment of infertility, expenses for drugs used for the treatment of obesity, and expenses incurred under any of the conditions listed on the Extended Health Provision page as an Exclusion. Extended Health - Pay Direct Drug Benefit (anpvd80g)
April 1, 2010 (78129)
Extended Health - Vision Benefit
Definitions
Ophthalmologist
means a person licensed to practise ophthalmology. Optometrist
means a member of the Canadian Association of Optometrists or of a provincial association associated with it. Reasonable and customary charges
mean those which are usually made to a person without coverage for the items of expense listed under Eligible Expenses and which do not exceed the general level of charges in the area where the expense is incurred. Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense: eye examinations by an ophthalmologist or optometrist limited to one examination in a 24 month period for you and for each covered dependant. laser eye surgery and eyeglasses and contact lenses and repairs to them that are necessary for the correction of vision and are prescribed by an ophthalmologist or optometrist, limited to the maximum specified in the Summary of Benefits for eligible expenses incurred during a 24 month period for you and for each covered dependant. eyeglasses and contact lenses certified by an ophthalmologist as necessary due to a surgical procedure or the treatment of keratoconus, limited to a lifetime maximum of $200 for the non-surgical treatment of keratoconus for you and for each covered dependant and a maximum of $200 for expenses incurred within six months of each surgical procedure. Exclusions
expenses incurred under any of the conditions listed on the Extended Health Provision page as an Exclusion. Preferred Vision Services (PVS)
The Preferred Vision Services (PVS) vision care program enables you to purchase eyewear at savings of up to 20% and save 10% on laser eye correction surgery. Savings on eyewear are available on all frames, prescription lenses and lens add-ons at registered PVS locations and online suppliers. Most locations will also apply the discount to non-prescription eyewear and accessory items. Discounts for laser eye correction surgery only apply to service providers registered in the PVS network. PVS locations can be identified by calling the PVS information centre toll-free number 1-800-668-6444, or visiting the PVS website at . After selecting your eyewear, but before the purchase, tell the practitioner that you are covered under a plan through Sun Life (proof of plan membership may be required) and pay the reduced price. If you are considering laser eye correction surgery with a PVS provider, identify yourself as a Sun Life plan member with PVS coverage when booking your consultation appointment. This PVS program provision applies if your plan has extended health coverage. You do not have to be covered for Vision Care benefits to receive the discount. If your plan includes vision care coverage, submit your claim to Sun Life. Visit the PVS website for more details about the program and to find a provider. Extended Health - Vision Benefit (ao01v032)
April 1, 2010 (78129)
Extended Health - Hospital Benefit
Definitions
Chronic Hospital
means a legally licensed hospital with beds or units designated for chronic care and which provides facilities for diagnosis, care and treatment of a person suffering from disease or injury on a 24 hour basis, with 24 hour services by registered nurses and physicians. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care. Hospital
means a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury, on an in-patient basis, with 24 hour services by registered nurses and physicians. This includes legally licensed hospitals providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons when approved by Sun Life. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care. Reasonable and customary charges
mean those which are usually made to a person without coverage for the items of expense listed under Eligible Expenses and which do not exceed the general level of charges in the area where the expense is incurred. Eligible Expenses
Eligible expenses mean reasonable and customary charges for accommodation in a hospital, limited to the difference between the charges for public ward and private room for each day of hospitalization. Room and board charges for semi-private accommodation for chronic care (not custodial care) provided in a licensed hospital. Confinement must be certified as medically necessary by a physician and is limited to $3 per day and 120 days per disability in 12 consecutives months. Room and board charges in a private hospital, when certified as medically necessary by a physician and is limited to $10 per day to a maximum of 120 days per disability in 12 consecutive months. Exclusions
expenses incurred under any of the conditions listed on the Extended Health Provision page as an Exclusion. Extended Health - Hospital Benefit (ap01v032)
April 1, 2010 (78129)
Extended Health - Supplementary Health Care Benefit
Definitions
Chiropodist, Podiatrist
means a person licensed by the appropriate provincial licensing authority. Chiropractor
means a member of the Canadian Chiropractic Association or of a provincial association affiliated with it. Emergency
means a sudden, unexpected occurrence (disease or injury) that requires immediate medical attention. This includes treatment (non-elective) for immediate relief of severe pain, suffering or disease which cannot be delayed until you or your covered dependants return to your province of residence. Hospital
means a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury, on an in-patient basis, with 24 hour services by registered nurses and physicians. This includes legally licensed hospitals providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons when approved by Sun Life. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care. Physiotherapist
means a member of the Canadian Physiotherapy Association or of a provincial association affiliated with it. Psychologist
means a permanently certified psychologist who is listed on the appropriate provincial registry in the province in which the service is rendered. Reasonable and customary charges
mean those which are usually made to a person without coverage for the items of expense listed under Eligible Expenses and which do not exceed the general level of charges in the area where the expense is incurred. Registered Massage Therapist
means a person licensed by the appropriate provincial licensing body or in the absence of a provincial licensing body, a person whose qualifications Sun Life determines to be comparable with those required by a licensing body. Registered Nurse, Registered Nursing Assistant, Certified Nursing Assistant, Licensed Practical Nurse,
Registered Practical Nurse
means a nurse, nursing assistant or practical nurse or certified nursing assistant who is listed on the appropriate provincial registry. Speech Language Pathologist
means a person who holds a master's degree in Speech Language Pathology and is a member or is qualified to be a member of the Canadian Speech and Hearing Association or any provincial association affiliated with it. Eligible Expenses
To be eligible, the expenses must be medically necessary for the treatment of disease or bodily injury and prescribed by a physician. Eligible expenses are the reasonable and customary charges for the items of expense listed below. Active Employees: the services of a registered nurse (R.N.), registered nursing assistant (R.N.A.), certified
nursing assistant (C.N.A.), licensed practical nurse (L.P.N.) or registered practical nurse (R.P.N.) when provided
in the patient's home, with an unlimited maximum in a calendar year. To qualify as an eligible expense, the
patient's treatment must require the level of expertise of an R.N., R.N.A., C.N.A., L.P.N., or R.P.N.
Retired Employees: the services of a registered nurse (R.N.), registered nursing assistant (R.N.A.), certified
nursing assistant (C.N.A.), licensed practical nurse (L.P.N.) or registered practical nurse (R.P.N.) when provided
in the patient's home, limited to a maximum of $25,000 in a calendar year. To qualify as an eligible expense, the
patient's treatment must require the level of expertise of an R.N., R.N.A., C.N.A., L.P.N., or R.P.N.
the services of a speech language pathologist, limited to a maximum of $200 in a calendar year. the services of psychologist*, limited to the first visit at $35 and each subsequent hour of $20 to a maximum of $200 in a calendar year. Extended Health - Supplementary Health Care Benefit (aq02v032)
April 1, 2010 (78129)
the services of a physiotherapist*, limited to a maximum of $350 in a calendar year. the services of a chiropractor*, limited to a maximum of $350 in a calendar year. the services of a massage therapist, limited to a maximum of $350 in a calendar year. *A physician’s prescription is not required. the services of a dental surgeon, including dental prosthesis, required for the treatment of a fractured jaw or for the treatment of accidental injuries to natural teeth if the fracture or injury was caused by external, violent and accidental means, provided the services are performed within 12 months of the accident but excluding services required in conjunction with such fracture or injury due to a condition that existed before the accident. A physician's prescription is not required. licensed ground ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation. 10. emergency air ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation, and, if the patient requires the services of a registered nurse during the flight, the services and return air fare for a registered nurse. 11. custom made orthopaedic shoes, orthopaedic modifications to shoes, when they are required for the correction of deformity of the bones and muscles and provided they are not solely for athletic use and are prescribed by a physician, podiatrist, chiropodist or chiropractor, limited to 2 pairs in a calendar year. 12. custom made orthotics, when they are required for the correction of deformity of the bones and muscles and provided they are not solely for athletic use and are prescribed by a physician, podiatrist, chiropodist or chiropractor, limited to 2 pairs in a calendar year to a maximum of $400 per pair. 13. hearing aids and repairs to them, excluding batteries, limited to a lifetime maximum of $500 for eligible expenses. 15. plaster of paris or fibreglass casts. 16. braces, provided they are not solely for athletic use. 17. artificial limbs or other prosthetic appliances. 19. surgical stockings limited to 6 pairs in a calendar year. 20. diagnostic laboratory and x-ray examinations. 21. blood glucose monitors, limited to a maximum of $150 for eligible expenses incurred during a 5 year period. 22. rental, or purchase at Sun Life’s option, of medically necessary durable equipment that meets the patient’s basic medical needs and is approved by Sun Life. If alternate durable equipment is available, eligible expenses are limited to the cost of the least expensive equipment that meets the patient's basic medical needs. Eligible durable equipment includes, but is not limited to, items such as: • wheel chairs, • wheel chair repairs, limited to a lifetime maximum of $250, 23. to be covered for the emergency services, you and your covered dependants must have provincial health coverage. The following items of eligible expenses are based on reasonable and customary changes. less the amount payable by a government plan: • public ward accommodation and auxiliary hospital services in a general hospital, and Exclusions
expenses for the services of a homemaker, expenses for items purchased solely for athletic use, dental expenses, except those specifically provided under Eligible Expenses for treatment of accidental injuries to natural teeth, utilization fees which are imposed by the provincial health care plan for the use of a service, expenses incurred under any of the conditions listed on the Extended Health Provision page as an Exclusion. Extended Health - Supplementary Health Care Benefit (aq02v032)
April 1, 2010 (78129)
Dental Provision
You will be reimbursed when you submit proof to Sun Life that you or your insured dependant has incurred any of the eligible expenses for necessary dental services performed by a dentist, a dental hygienist or a denturist. To determine the amount payable, the total eligible expenses claimed are adjusted as follows: 1. the deductible, which must be satisfied each year, is subtracted, 2. the reimbursement percentage is applied, and 3. the maximums specified in the Summary of Benefits are applied. The intentional omission, misrepresentation or falsification of information relating to any claim constitutes fraud. Co-ordination of Benefits
If you or your dependants are covered under this plan and another plan, Sun Life will co-ordinate benefits under this plan with the other plan following insurance industry standards. These standards determine which plan you should claim from first. The plan that does not contain a co-ordination of benefits clause is considered to be the first payer and therefore pays benefits before a plan which includes a co-ordination of benefits clause. For dental accidents, health plans with dental accident coverage pay benefits before dental plans. Following payment under another plan, the amount of benefit payable under this plan will not exceed the total amount of eligible expenses incurred less the amount paid by the other plan. Where both plans contain a co-ordination of benefits clause, claims must be submitted in the order described below. Claims for you and your spouse should be submitted in the following order:
the plan where the person is covered as an employee. If the person is an employee under two plans, the following order applies: • the plan where the person is covered as an active full-time employee, • the plan where the person is covered as an active part-time employee, • the plan where the person is covered as a retiree. the plan where the person is covered as a dependant. Claims for a dependent child should be submitted in the following order:
the plan where the dependent child is covered as an employee, the plan where the dependent child is covered under a student health or dental plan provided through an educational institution, the plan of the parent with the earlier birth date (month and day) in the calendar year, the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date. The above order applies in all situations except when parents are separated/divorced and there is no joint custody of the dependent child, in which case the following order applies: the plan of the parent with custody of the dependent child, the plan of the spouse of the parent with custody of the dependent child, the plan of the parent not having custody of the dependent child, the plan of the spouse of the parent not having custody of the dependent child. When you submit a claim, you have an obligation to disclose to Sun Life all other equivalent coverage that you or your dependants have. Dental Provision (ar01v010)
April 1, 2010 (78129)
A claim must be received by Sun Life within 18 months of the date the expense is incurred. However, if your coverage terminates, any claim must be received by Sun Life no later than 90 days following the end of the coverage. For the assessment of a claim, itemized bills, commercial laboratory receipts, reports, records, pre-treatment x-rays, study models, independent treatment verification or other necessary information may be required. If your dentist has recommended dental treatment that is expected to cost more than $500, you must have your dentist prepare a pre-treatment plan. There is a time limit for proceedings against Sun Life for payment of a claim. A proceeding must be started within 1 year of Sun Life's receipt of the proof of claim. Exclusions and Limitations
No benefit is payable for • expenses for which benefits are payable under a Workers' Compensation Act, Workplace Safety and Insurance Act • expenses incurred due to intentionally self-inflicted injuries, • expenses incurred due to civil disorder or war, whether or not war was declared, • expenses for which benefits are payable under a government plan. Anaesthesia and laboratory procedure charges must be completed in conjunction with other services and the amount payable will be limited to the reimbursement percentage of the services they are being performed in conjunction with. Dental Provision (ar01v010)
April 1, 2010 (78129)
Dental Provision - Basic Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • oral examination (once every 3 years), • recall oral examination (once every 6 months under age 19 and once every 9 months age 19 and over), • special oral examination, • treatment planning, • consultation, • house call, institutional call and office visit, • microbiological test, • caries susceptibility test, • biopsy of oral tissue, • cytologic smear from oral cavity, • pulp vitality tests, • complete series (once every 3 years), • periapical, 1 to 15 films, • occlusal, • bitewing (once every 6 months under age 19 and once every 9 months age 19 and over), • extraoral, • sialography, • radiopaque dyes to demonstrate lesions, • temporomandibular joint, • panoramic (once every 3 years), • cephalometric film, • interpretation of radiographs received from another source, • tomography, • hand and wrist (as diagnostic aid for dental treatment), • dental polishing (once every 6 months under age 19 and once every 9 months age 19 and over), • topical application of fluoride, • oral hygiene instruction (once every 6 months under age 19 and once every 9 months age 19 and over), • caries control, • interproximal discing of teeth, • recontouring to teeth for functional reasons, • occlusal adjustment/equilibration (8 units of time every 12 months combined with scaling and root Dental Provision - Basic Benefit (av01v172)
April 1, 2010 (78129)
• amalgam, • retentive pins, • acrylic or composite resin, • prefabricated restorations, Dental Provision - Basic Benefit (av01v172)
April 1, 2010 (78129)
Dental Provision - Denture Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • complete dentures (once every 3 years), • partial dentures (once every 3 years), • remake dentures, Dental Provision - Denture Benefit (av02s172)
April 1, 2010 (78129)
Dental Provision - Orthodontic Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • space maintainers, • diagnostic cast, • observation and adjustment, b. active appliances for tooth guidance or uncomplicated tooth movement • appliances to control oral habits, • myofunctional therapy, • repairs and maintenance, Dental Provision - Orthodontic Benefit (av03s172)
April 1, 2010 (78129)
Dental Provision - Endodontic and Periodontic Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • non surgical services, • surgical services, • post-surgical treatment, • scaling and root planing, (8 units of time every time 12 months combined with occlusal • adjunctive procedures, • alveoloplasty, • pulpotomy, • root canal therapy, • periapical services, • other endodontic procedures, • emergency procedures, Dental Provision - Endodontic and Periodontic Benefit (av04v172)
April 1, 2010 (78129)
Dental Provision - Denture Repair Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • adjustment to dentures, • repairs/additions to dentures, • denture rebasing and relining, Dental Provision - Denture Repair Benefit (av05s172)
April 1, 2010 (78129)
Dental Provision - Crown and Bridge Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - a. crowns, inlays, onlays (once every 3 years) • gold foil restorations, • inlay restorations, • onlay restorations, • crowns, • other restorative services, • bridge pontics, • repairs to bridges, • retainers, • other prosthetic services, Replacement of an existing denture or bridgework is an eligible expense if the replacement is required to replace an existing denture or bridgework which was installed at least 3 years before the replacement, limited to a maximum eligible expense of the value and quality of the original denture or bridgework. Dental Provision - Crown and Bridge Benefit (av06s172)
April 1, 2010 (78129)
Dental Provision - Surgical Removal Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • uncomplicated removals, • surgical removals, Dental Provision - Surgical Removal Benefit (av07s172)
April 1, 2010 (78129)
Dental Provision - Surgical Services and Drug Benefit
Eligible Expenses
Eligible expenses mean reasonable and customary charges for the following items of expense - • surgical exposure, transplantation and repositioning, • surgical excision, • surgical incision, • fractures, • frenectomy, • miscellaneous surgical services, Dental Provision - Surgical Services and Drug Benefit (av08s172)
April 1, 2010 (78129)

Source: http://www.ngh.on.ca/images/hospital/exec-contract/schedule%20c%20-%201%20of%203%20management%20benefit%20booklet%20apr%202010.pdf