Group Benefits Plan

GSI supports plan members in leading healthy lives and achieving financial security.  This is accomplished by providing a comprehensive health, dental and employee assistance plan as well as a generous life and disability insurance program.

As the ELCIC benefits plan sponsor, GSI has arranged a disability plan that reflects the caring and compassion of ELCIC employers demonstrated by:

  • Providing an income replacement plan for eligible disabled employees,
  • minimizing the stress associated with the disability application process for both the employer and employee,
  • getting an employee back to work as quickly as possible where medically appropriate in an effort to live a full, healthy and productive life.

Group benefits are important not only for the financial assistance they offer, but also for the security and peace of mind they provide for you and your family should unforeseen needs arise. It is your responsibility to understand the benefits and to put them to the best possible use. The purpose of this information is to outline the benefits for which you are eligible as an employee of the Evangelical Lutheran Church in Canada and its affiliated organizations.

Click on these titles to get the details for each benefit category

Extended Health & Vision  *  Travel Health * Dental Care *  Life Insurance * ADD&D  * Short Term Disability *  Long Term Disability * Criticall Illness

Contact Information for Insurance Companies

Manulife Financial (Extended Health Care and Dental Care Benefits)

Policy # 29835                                                                                                     
For questions regarding claims for Extended Health and Dental Benefits, please contact Customer Service:

1-800-268-6195

Manulife Member Site

Emergency Travel Assistance

World Access Plan # 9081

Canada/US

1-800-265-9977

Mexico

00-1-800-514-3702

Dominican Republic

1-888-751-4403

International Toll Free for participating countries

Country Code + 800-9221-9221

Other countries

use operator to call collect

519-741-8450

The Co-operators (Life, ADD&D and Disability Insurance)

Policy # G6647

Cooperators Site

Please contact ELCIC Group Services if you need to make a claim under benefits provided by Cooperators.

How to Submit a Claim to Manulife

General Submission and Deadline Information

Prescription drug

Present your Manulife Financial Card at the Pharmacy and no further claim submission should be required. If you intend to coordinate your claim with your spouse’s plan a form may be required (see the coordination of benefits section).

Deadline:  Claims must be submitted within 12 months after the date the expense was incurred.

Vision care, professional services, medical services, supplies, and prescription drug claims where the card was not used

Online Claims

Manulife claims for professional services or vision can be made online. You must be registered on the Manulife website. Once you have logged on to the manulife member website, follow the steps under ‘submit a claim’.

Provider eClaims

Manulife is set up to allow many health care providers to submit claims directly from their office.  Here is more information on Provider eClaims

Paper Claims

Extended Health Care claim forms are available on Manulife website.

Provide your Group Policy Number and your Certificate Number (found on your Group Benefit Card) to avoid any unnecessary delays in the processing of your claim. All applicable receipts must be attached to the completed claim form.

Deadline: Claims must be submitted within 12 months after the date the expense was incurred.

Out of province claim for Physician or hospital expenses

Use the Out-of-Province / Out-of-Canada claim form, available on Manulife website.

Always call the toll free number first for instructions. Claims for Out-of-Canada expenses must first be submitted to the Provincial Plan for payment. Any outstanding balance should be submitted to Manulife along with the explanation of payment from the Provincial Plan.

Deadline: Claims must be submitted within 12 months after the date the expense was incurred.

Dental Claims

Most Dentists submit directly to the insurer and usually just require a signature on the form they have prepared.  If your dentist does not, there is a form on the Manulife website

Deadline: Claims must be submitted within 12 months after the date the expense was incurred.

Submission deadline after termination

Upon termination of your health or dental insurance, all claims must be submitted no later than 90 days from the termination date.

Health and Dental Claim Payments

On Line Claims

If you made your claim on line you should receive your payment by direct deposit within 5 days (much faster than a paper claim!).  You will receive an e-mail once your claim is paid.

Paper Claims

If you complete a paper health or dental claim and send by post, you should receive settlement within three weeks from the date of submission. Your cheque will be attached to your claim statement; simply tear along the perforated line and endorse the back of the cheque. You can then deposit it or cash it at any chartered bank or trust company.

Claim Statement

Once your claim has been processed, Manulife Financial will send a Claim Statement to you. The top portion of this form outlines the claim or claims made, the amount subtracted to satisfy Deductibles, and the coinsurance used to determine the final payment to be made to you. The bottom portion of the form is your claims payment, if applicable.

Coordination of Benefits

If you or your Dependents are insured for similar benefits under another Plan, Manulife Financial will take this into account when determining the amount of expenses payable under this Program. This process is known as Co-ordination of Benefits. It allows for reimbursement of insured medical and dental expenses from all Plans, up to a total of 100% of the actual expense incurred.

For the purposes of this section, Plan means:

  • other group benefit programs;
  • any other arrangement of coverage for individuals in a group;
  • and individual travel insurance plans.

Plan does not include school insurance or Provincial Plans.

Order of Benefit Payment

A variety of circumstances will affect which Plan is considered as the “Primary Carrier” (i.e., responsible for making the initial payment toward the eligible expense) and which Plan is considered as the “Secondary Carrier” (i.e., responsible for making the payment to cover the remaining eligible expense).

If the other Plan does not provide for Co-ordination of Benefits, it will be considered as the Primary Carrier, and will be responsible for making the initial payment toward the eligible expense.

If the other Plan does provide for Co-ordination of Benefits, the following rules are applied to determine which Plan is the Primary Carrier.

For Claims Incurred by You or Your Dependent Spouse

The Plan insuring you or your Dependent Spouse as an employee/member pays benefits before the Plan insuring you or your Spouse as a Dependent.

In situations where you or your Dependent Spouse has coverage as an employee/member under more than one Plan, the order of benefit payment will be determined as follows:

  • the Plan where the person is covered as an active full-time employee;
  • then The Plan where the person is covered as an active part-time employee;
  • then The Plan where the person is covered as a retiree.

For Claims Incurred by Your Dependent Child

The Plan covering the parent whose birthday (month/day) is earlier in the calendar year pays benefits first. If both parents have the same birth date, the Plan covering the parent whose first name begins with the earlier letter in the alphabet pays first.

However, if you and your Spouse are separated or divorced, the following order applies:

  • the Plan of the parent with custody of the child;
  • then The Plan of the Spouse of the parent with custody of the child (i.e., if the parent with custody of the child remarries or has a common-law Spouse, the new Spouse’s Plan will pay benefits for the Dependent Child);
  • then The Plan of the parent not having custody of the child;
  • then The Plan of the Spouse of the parent not having custody of the child (i.e., if the parent without custody of the child remarries or has a common-law Spouse, the new Spouse’s Plan will pay benefits for the Dependent Child).

Where you and your Spouse share joint custody of the child, the Plan covering the parent whose birthday (month/day) is earlier in the calendar year pays benefits first. If both parents have the same birth date, the Plan covering the parent whose first name begins with the earlier letter in the alphabet pays first.

Additional Rules

A claim for accidental injury to natural teeth will be determined under Extended Health Care Plans with accidental dental coverage before it is considered under Dental Plans.

If the order of benefit payment cannot be determined from the above, the benefits payable under each Plan will be in proportion to the amount that would have been payable if Co-ordination of Benefits did not exist.

If the insured person is also covered under an individual travel insurance plan, benefits will be co-coordinated in accordance with the guidelines provided by the Canadian Life and Health Insurance Association.

Submitting a Claim When Co-ordination of Benefits Applies

When submitting such a claim, refer to the following guidelines:

  • As per the Order of Benefit Payment section, determine which Plan is the Primary Carrier and which is the Secondary Carrier.
  • Submit all necessary claim forms and original receipts to the Primary Carrier.
  • Keep a photocopy of each receipt or ask the Primary Carrier to return the original receipts to you once your claim has been settled.
  • Once the Primary Carrier has settled your claim, you will receive a statement outlining how your claim has been handled. Submit this statement along with all necessary claim forms and receipts to the Secondary Carrier for further consideration of payment, if applicable.

Manulife Mobile App

Fresh, intuitive design allows you to conveniently access your Manulife Benefits Plan.

Here’s a list of what you can use the mobile app for:

  • submit your claims
  • review recent claims and payment information
  • find health care providers in your area with direction on how to get there
  • search My Drug Plan for a drug and find the lowest cost alternative
  • find places to get your prescriptions for less with pharmacy saving search.

Download the app from  Google Play or Apple app store. There are several Manulife Apps. Search Manulife and select the “Group Benefits Mobile”.

Submitting Claims to Co-operators Life

Please contact ELCIC Group Services Inc. for forms for any claims for:

  • Life Insurance
  • Accidental Death, Disease and Dismemberment
  • Short Term Disability
  • Lion Term Disability.

Please see each of these sections for deadlines and other information regarding making a claim.

Protecting Your Personal Information

We recognize and respect every individual’s right to privacy.  When you apply for coverage or benefits personal information about you, your spouse or dependents, must be gathered and kept in a confidential file.

This personal information is used for the purposes of providing group benefit plan administration services and insurance products to you.

Maintaining the security of your personal information is a top priority.  Only authorized personnel have access to your information, and the systems and procedures are designed to prevent the loss, misuse, unauthorized access, disclosure, alteration, or destruction of your information.

Personal information is not collected, used or disclosed without your consent, except where authorized by law.

Glossary

Definitions of Terms Used

Actively at Work, Actively Employed or Active Work shall mean being present at the normal place of business of an Employer or at any such other place to which and Employer requires the Employee to travel, and being able to perform and actually performing all the usual and customary duties of the Employee’s own occupation on a full pay status and on a regular and continuing basis.

On weekends or holidays, or when on vacation, an Employee is deemed to be Actively at Work if the Employee was Actively at Work on the last normal working day or scheduled shift.

Adherence means to use Drugs, services or supplies in accordance with the terms for which such were prescribed.

Advisory Body is a Manulife Financial approved external expert(s) that may provide Manulife Financial with recommendations, applying a Pharmacoeconomic or cost effectiveness evaluation.

Benefit Percentage (Co-insurance) is the percentage of Covered Expenses which is payable by the insurer.

Birth means the complete expulsion or extraction from the mother of a feuts, irrespective of the duration of pregnancy, which, after complete separation from its mother, breathes or shows any sign of life.

          Stillbirth means the complete expulsion or extraction for the mother of a fetus weighing 500 grams or more; or with a body length of 25 centimeters or more; or gestational age of 20 weeks or more which, after complete  separation from the mother, does not breathe or show any sign of life at or after birth.

Children (Co-operators Policy) shall mean: (a) the unmarried, natural or adopted children of an Employee; (b) unmarried children who have cohabited with the Employee for a minimum of twelve (12) consecutive months, and have been publicly represented as the Employee’s children.

Child (Manulife Policy) is an Employee’s or Spouse’s natural or legally adopted child, or stepchild, who (a) is dependent on the Employee or the Spouse for financial support; (b) is a child of a Surviving Spouse who was insured under the Policy at the time of the Employee’s death; (c) is unmarried; (d) is not employed on a full-time basis; (e) is not eligible for insurance as an employee under this or any other group policy; and (f) is either under 21 years of age, or, if a full-time student at an accredited school, college or university, under 25 years of age.

A child insured under Manulife Financial’s Policy who is incapacitated due to a mental or physical disability on the date the child reaches the age when the child would otherwise cease to be an eligible Dependent, will continue to be an eligible Dependent under the Manulife Financial’s Policy.

A child is considered incapacitated if the child is incapable of engaging in any substantially gainful activity and is dependent on the Employee for support, maintenance and care, due to a mental or physical disability.

Manulife Financial may require written proof of the Dependent’s condition as often as may resonably be necessary.

A stepchild must be living with the Employee to be an eligible Dependent.

Covered Person shall mean an eligible Employer of any eligible Dependent of an Employee for whom insurance under the Policy, for the benefits under consideration, has been taken and remains in effect. The Covered Person must be insured under a provincial Government Health Insurance Plan.

Critical Disease (Co-operators Policy) shall mean any of the following diseases, diagnosed after the Effective Date and prior to the termination date of the Employee’s Accidental Death, Disease and Dismemberment Benefit under this Policy: Poliomyelitis, Parkinson’s Disease, Huntington’s Chorea, Multiple Sclerosis, Alzheimer’s Disease, Type I Diabetes (insulin Dependent), Amyotrophic Lateral Sclerosis (ALS), Peripheral Vascular Disease and Necrotizing Fascitis.

Dentist is a doctor of dentistry, licensed to practice dentistry in the place where services are provided.

Dependent (Co-operators Policy) shall mean an Employee’s: (a) Spouse; (b) Children from birth to attainment of the 21st birthday, and/or attainment of the 25th birthday if in full-time attendence at an accredited university or similar institution and for whom the Employee is legally and financially responsible, (although the child is not required to reside with the employee), and who are not, on a full-time basis, engaged in any occupation or performing any work for wage, remuneration or profit; or (c) Children (regardless of age) who are suffering from a permanent mental or physical infirmity and who developed such infirmity while otherwise eligible as a Dependent under (b), and who are wholly financially dependent on the Employee. No person residing outside of Canada will be considered a Dependent unless the person is classified as a full-time student and normally resides in Canada. Payment for a student shall be in accordance with the province of residence of the insured Employee.

Dependent (Manulife’s Policy) and Employee’s or enrolled Early Retiree’s or enrolled Retiree’s Spouse or Child who is insured under the Provincial Plan.

Disease Management Programs  is an approach to healthcare that teaches patients how to manage a chronic disease. A system of coordinated healthcare interventions and communications for patients with conditions in which patient self-care efforts are significant in the management of their condition.

Drug is a medication that has been approved for use by Health Canada and has a Drug Identification Number.

Due Diligence is a process employed by Manulife Financial to assess new Drugs, existing Drugs with new indications, services or supplies to determine eligibility under the Policy. This process may use Phamacoeconomics, cost effectiveness analysis reference information from existing Federal or Provincial formularies, recognized clinical practice guidelines, or an Advisory Body.

Employee shall mean a person who is directly employed by the Employer, is compensated for services by the Employer and who meets on of the following criteria:

A. is Rostered, earning at least 25% of the yearly maximum pensionable earnings, or

B. is Non-Rostered on a full-time or part-time basis, working a minimum of 20 hours per week, and earning at least 25% of the yearly maximum persionable earnings.

Employee (additional definition for Manulife Policy) must reside in Canada. For the purposes of the Benefits which continue beyond retirement, the term Employee also means Early Retiree and Retiree. (For the Eastern Synod subsidized Retiree Health Plan it also includes Surviving Spouse).

Early Retiree (Manulife Policy) is a person who was age 60 to 64 on their date of retirement and who was an Employee of an Employer immediately prior to their retirement.

Retiree (Manulife Policy) is a person who was an Early Retiree and has attained age 65; or a person who was at least age 65 on their date of retirement and who was an Employee of an Employer immediately prior to his retirement.

ELCIC shall mean Evangelical Lutheran Church in Canada.

Employer shall mean the Policyholder and any of the following that have executed a subscription agreement with the Policyholder: ELCIC, member congregations of ELCIC, colleges, seminaries and other entities associated with ELCIC, and organizations which employ Rostered Employees and any not-for-profit faith based body corporate and alliliated corporation of such faith based body corporate.

Exclusive Distribution (Manulife Policy) are Manulife Financial approved vendors.

Experimental or Investigational  (Manulife Policy) is not approved as an effective, appropriate and essential treatment of an illness or injury.

Immediate Family Member (Manulife Policy) is a person who is (a) the Employee; (b) the Employee’s Spouse or child; (c) the Employee’s or Spouse’s parent, or (d) the Employee’s or Spouse’s brother or sister.

Injury (Co-operators Policy) shall mean an accidental bodily injury.

Interchangeable Drug (Manulife Policy) includes but is not limited to:

a) a generic equivalent to the brand name Drug deemed to be interchangeable by law where the Drug is dispensed;

b) a Drug that contains the same active ingredient that has not been deemed interchangeable in the province where the Drug is dispensed; but has been identified as interchangeable by Manulife Financial.

Licensed, Certified or Registered is the status of a person who legally engages in practice by virtue of a license or certificate issued by the appropriate authority, in the place where the service is provided.

Life-Sustaining Drugs (Manulife Policy) are non-prescription Drugs which are necessary to sustain life.

Lower Cost Alternative  (Manulife Policy) if two or more Drugs, supplies or services result in therapeutically similar results, the Lower Cost Alternative will be considered.

Medical Care (Cooperators Policy) shall mean necessary services, supplies, treatment or surgery, including hospitalization, provided or ordered by a licensed Physician in the treatment of a Covered Person’s Sickness of Injury.

Medically Necessary (Manulife Policy) accepted and recognized by the Canadian medical profession and Manulife Financial as effective, appropriate and essential treatment of a phase of an illness or injury. Manulife Financial has the right after Due Diligence has been completed to determine whether the Drug, service or supply is eligible under the Policy.

Patient Assistance Program (Manulife Policy) a program that provides assistance to insured persons prescribed select Drugs, supplies or services. Manufacturers and distributors may provide Patient Assistance Programs that include financial support, along with education and training.

Pharmacoeconomics the scientific discipline that compares the value of one pharmaceutical Drug or drug therapy to another. Pharmacoeconomic studies serve to guide optimal healthcare resource allocation, in a standardized and scientifically grounded manner as determined by Manulife Financial.

Physician a Doctor of Medicine licensed to practice medicine in the place where the services are provided.

Policyholder shall mean ELCIC Group Services Inc.

Pre-Existing Condition shall mean Injury of Sickness for which the Employee received medication, treatment or medical advice, or for which there were symptoms which would have caused an ordinary person to seek diagnosis, care or treatment within the  90 day period immediately prior to becoming insured under this Policy.

Prior Authorization is a claims management feature applied to a specific list of Drugs, supplies or services to determine eligibility based on predefined clinical criteria and a Pharmacoeconomic or cost effectiveness evaluation.

Provincial Plan any plan which provides hospital, medical, or dental benefits established by the government in the province where the insured person lives and which is governed b the Canada Health Act.

Reasonable and Customary – the lowest of:

  • the prevailing amount charged for the same or comparable service or supply in the area in which the charge is incurred, as determined by Manulife Financial; or
  • the amount shown in the applicable professional association fee guide; or
  • the maximum price established by law.

Rostered shall mean an ordained minister or consecrated diaconal minister on the roster of:

  • ordained or consecrated ministers of the ELCIC or
  • an ordained minister or consecrated diaconal minister in good standing of a church which is a full communion partner of the Church.

Salary shall mean:

  1. gross earnings paid including overtime, bonuses and vacation pay,
  2. plus housing equity paid or housing allowance paid.

Monthly Salary shall mean 1/12 of the annual Salary

Additional Cooperators Policy For a member who is ministering in a foreign country, Salary shall mean the actual salary in Canadian dollars paid to the member, including any housing allowance, provided that the Salary was paid by an Employer in Canada and was subject to Canadian Income taxation.

For the purpose of determining the amount of an Employee’s benefit at the time of claim, an Employee’s Salary will be the amount reported by the Employer to Co-operators Life, for which premiums have been paid, and confirmed by ELCIC Group Services Inc.

Spouse means the legal spouse, or the person who has, for at least one year, been continuously living with the Employee in a role like that of a marriage partner. Only one Spouse will be eligible for insurance under the Policy, and will be as indicated by the Employee on the applicable form for insurance under the Policy. Where this information is not contained on the Employee’s application, the person who qualifies last under this Policy’s definition of Spouse will be the eligible Spouse.

Total Disability and Totally Disabled (Cooperators Policy) for the Critical Disease Benefit shall mean disability as a result of Injury or Sickness, to the extent that the Employee:

  • is under the regular care and following the prescribed treatment of a Physician, and
  • are not engaged in any occupation or performing any work of any sort for wage, renumeration, or profit, and
  • is prevented from engaging in any occupation or performing any work of any sort for wage, remuneration or profit for which the Employee is able or may reasonably become able, by means of education, training or experience.

Total Disability and Totally Disabled (Cooperators Policy) for the All Other Benefits shall mean disability as a result of Injury or Sickness, to the extent that the Employee:

  • is under the regular care and following the prescribed treatment of a Physician, and
  • are not engaged in any occupation or performing any work of any sort for wage, renumeration, or profit, and
  • during the elimination period and the next 24 months of disability is unable to perform the usual and customary duties of the Employee’s occupation, and
  • thereafter is prevented from engaging in any occupation or performing any work of any sort for wage, renumeration or profit for which you are able or may reasonably become able, by means of education, training or experience.

The Employee will not, however, be considered to be Totally Disabled or prevented from engaging in any occupation or performing any work of any sort for wage, remuneration or profit by virtue of the unavailability of such occupation(s) or work in the place in which the Employee resides.

Important Notes (the fine print)

Administration – Manulife Financial

Manulife Financial may from time to time adopt such administrative practices as are reasonably necessary in providing benefits under this Policy, as determined in its sole discretion.

Administration – Plan Sponsor

The group benefits are provided under a group insurance policy arranged by ELCIC Group Services Inc (GSI) with insurance companies as GSI does not provide benefits itself under this plan. Any benefit to which plan members may become entitled will be determined pursuant to the provisions of such group insurance policy. GSI will have no responsibility to plan members other than forwarding premiums received by it on account of plan member enrollment in the Plan to the applicable Insurance Company.

GSI contracts the plan with insurance companies on an annual calendar year basis and there is no guarantee that the contract will be renewed at the conclusion of its present term or that it will be renewed with the current insurance company or with the current benefits covered. Notice of such events or circumstances will be given within a reasonable timeframe.

GSI will establish premiums on an annual basis for the benefits which will include administration fees.

Claims will be adjudicated solely by the insurance company. Questions regarding claims must be directed to the insurance company.

The information that follows is a summary of the benefit coverages provided under the Group Policies. In the event of a discrepancy between this information and the Policies the terms of the Group Policies will apply. This information in either paper or electronic form does not create or confer any contractual rights or obligations. Possession of this information alone does not mean that you or your Dependents are insured. The Group Policies must be in effect and you must satisfy all the requirements of the Policies.

This information in either its paper or electronic form does not create or confer any contractual rights or obligations.

Possession of this information alone does not mean that you or your Dependents are insured. The Group Policy must be in effect and you must satisfy all the requirements of the Policy.

Non-Disclosure (Cooperators Policy)

Subject to the incontestability provision of the Uniform Life Insurance Act, if medical evidence of insurability is required on behalf of either an Employee or a Dependent, and it is subsequently learned that the information regarding that Employee’s or Dependent’s medical history or condition was not disclosed, that Employee’s or Dependent’s insurance will be voidable at the option of Co-operators Life. Any premiums paid on behalf of the ineligible Employee or Depenent will be refunded. Any claim payments made will be recovered.

Age (Co-operators Policy)

Co-operators Life shall be entitled to proof of the age of an Employee before making payment or settlement of any claim under this Policy. Where the age of an Employee has been misstated and the correct age is such that no insurance would be in force under this Policy at the date of claim, there shall be no liability under this Policy with respect to that Employee.