Important Notes

The purpose of this booklet is to outline the benefits for which you are eligible as a retired employee or surviving spouse of an employee/retired employee of the Eastern Synod of the Evangelical Lutheran Church in Canada and its affiliated organizations. The information is a summary of the provisions of the Group Policy. In the event of a discrepancy between this information and the Policy, the terms of the Group Policy will apply.

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.

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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 benefits 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.

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Extended Health Care

Government health plans can provide coverage for such basic medical expenses as hospital charges and doctors' fees.  Often, however, it is necessary to obtain care or treatment that goes beyond “basic” in order to maintain well being and quality of life.  In such cases, financial hardship can be crippling if help in the form of extended coverage is not available.

Private health care supplements government plans and can provide benefits not available through any government plan.  This program provides you with peace of mind and security in the knowledge that financial assistance will be provided when you and your family need it most.

Covered Expenses

The expenses specified are covered to the extent that they are reasonable and customary, as determined by Manulife Financial, provided they are:

• medically necessary for the treatment of sickness or injury and recommended by a physician;
• incurred for the care of a person while insured under this Group Benefit Program;
• reasonable, taking all factors into account;
• not covered under the Provincial Plan or any other government-sponsored program;
• legally insurable.

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Prescription Drug

Coverage:  80% until $250 out-of-pocket maximum per person is reached every calendar year; then 100%to a maximum of $1,000,000 per person per year.

The Generic Drug Plan 2 provides you and your Dependents with convenient Canada-wide coverage on your prescription Drug requirements.   You must the entire amount and submit a claim for the covered benefit.

Your benefit is a Generic Drug plan, which means:

• Covered Expenses for any prescription Drug or medicine 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, subject to coinsurance and maximums.
• Drugs for which there is no generic equivalent will be covered for the full cost of the prescribed product, subject to coinsurance and maximums.
• If your prescription contains a written direction from your Physician or Dentist that the prescribed Drug or medicine is not to be substituted with a generic equivalent and if the prescribed product is a covered expense under this benefit, the full cost will be covered, subject to coinsurance and maximums.  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.

The maximum quantity of Drugs or medicines that will be payable for each prescription will be limited to the lesser of:

• the quantity prescribed by your Physician or Dentist, or
• a three-month supply.

A quantity of up to a 100-day supply may be payable in long-term therapy cases, where the larger quantity is recommended as appropriate by your Physician and pharmacist.

Charges incurred for the following expenses are payable when prescribed in writing by a physician or dentist and dispensed by a licensed pharmacist.

• Drugs or medicines for the treatment of a sickness or injury, which by law or convention require the written prescription of a Physician or Dentist;
• oral contraceptives;
• injectable medications (charges for a practitioner or Physician to administer injectable medication are not covered);
• life-sustaining drugs (necessary for the survival of the patient);
• preventive vaccines and medicines (oral or injected);
• standard syringes, needles and diagnostic aids, required for the treatment of diabetes.

 

Charges that are not covered include:

• cotton swabs, rubbing alcohol, automatic jet injectors and similar equipment generally used in the treatment of diabetes;
• fertility Drugs, anti-smoking Drugs, anti-obesity Drugs;
• Drugs, biologicals and related preparations which are intended to be administered in hospital on an in-patient or out-patient basis and are not intended for a patient's use at home;
• Drugs used in the treatment of a sexual dysfunction.

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Vision Care

Coverage: 100%, subject to maximums and limitations in the table below.

Vision Care	Maximums & Limitations
Eye exams	Once per 12 months for persons under age 18 and once per 24 months for persons age 18 and over
Purchase and fitting of prescription glasses or elective contact lenses, as well as repairs, or elective laser vision correction procedures	Maximum of $150 during any 24 months
Contact lenses that are required to treat a severe condition, or if vision in the better eye can be improved to a 20/40 level with contact lenses but not with glasses	Maximum payable will be $200 during any 24 months
Visual training	Maximum of $200 per lifetime

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Professional Services

Coverage: 100%, subject to maximums and limitations in the table below.
Services provided by the following licensed, certified or registered practitioners:

Practitioners	Maximums & Limitations
Acupuncturist (starting Jan 1, 2009)	$500 per calendar year
Chiropodist	$500 per calendar year
Chiropractor	$500 per calendar year, plus $50 per calendar year for x-rays
Dietician	$500 per calendar year, the recommendation of a Physician is required
Osteopath	$500 per calendar year
Podiatrist	$500 per calendar year
Massage Therapist	$500 per calendar year
Naturopath	$500 per calendar year
Speech Therapist	$500 per calendar year
Physiotherapist / Athletic Therapist / Kinesiologist	$500 per calendar year (combined)
Psychologist / Marriage and Family Therapist (MFT) / Masters in Social Work (MSW) / Registered Social Worker (RSW)	$500 per calendar year (combined)

Provincial Plans may pay part of the expenses for some of these Professional Services. Coverage for the balance of such expenses prior to reaching the Provincial Plan maximum may be prohibited by provincial legislation.  In those provinces where such prohibition exists, expenses under this Benefit Program are payable after the Provincial Plan's maximum for the benefit year has been paid.

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Medical Services and Supplies

Private Duty Nursing

Coverage: 100% to a maximum of $10,000 per calendar year.

Covered Expenses include services which are deemed to be within the practice of nursing and which are provided in the patient’s home by:

• a registered nurse, or
• a registered nursing assistant (or equivalent designation) who has completed an approved medications training program.

It is recommended that a detailed treatment plan with cost estimates be submitted before private duty nursing services begin, so that you can be advised of any benefit that will be provided.

Charges for the following services are not covered:

• service provided primarily for custodial care, homemaking duties, or supervision;
• service performed by a nursing practitioner who is an Immediate Family Member or who lives with the patient;
• service performed while the patient is confined in a hospital, nursing home, or similar institution;
• service which can be performed by a person of lesser qualification, a relative, friend, or a member of the patient’s household.

Ambulance

Coverage: 100%

Licensed ambulance service, including air ambulance, is provided in the patient’s province of residence to transfer the patient to the nearest hospital where adequate treatment is available.

Medical Equipment and Supplies

Coverage: 100%, with the exception of insulin pumps covered at 50%, subject to maximums and limitations.

For all medical equipment and supplies covered under this provision, Covered Expenses will be limited to the cost of the device or item that adequately meets the patient’s fundamental medical needs and is approved by Manulife Financial.

Medical Supplies	Maximums & Limitations
Mobility equipment such as crutches, canes, walkers, and wheelchairs	Rental of, or when pre-approved by Manulife Financial, the purchase of
Durable medical equipment including manual hospital beds, respiratory and oxygen equipment, and other durable equipment usually found only in hospitals	Rental of, or when pre-approved by Manulife Financial, the purchase of
External prostheses
Surgical stockings	A maximum of 4 pairs per calendar year
Surgical brassieres	A maximum of 4 per calendar year
Braces (other than foot braces), trusses, collars, leg orthosis, casts and splints
Stock-item orthopaedic shoes and modifications or adjustments to stock-item orthopaedic shoes or regular footwear	A maximum of $150 per calendar year (recommendation of either a Physician or a podiatrist is required)
Custom-made shoes which are required due to a medical abnormality that, based on medical evidence, cannot be accommodated in a stock-item orthopaedic shoe or a modified stock-item orthopaedic shoe	A maximum of 1 pair per calendar year (must be constructed by a Certified orthopaedic footwear specialist)
Casted, custom-made orthotics	A maximum of $400 per 3 calendar years (recommendation of either a Physician or a podiatrist is required)
Cost, installation, repair and maintenance of hearing aids (including charges for batteries)	A maximum of $1,000 every 5 calendar years
Ileostomy, colostomy and incontinence supplies
Medicated dressings and burn garments
Wigs and hairpieces for patients with temporary hair loss as a result of medical treatment or a medical condition	A maximum of $500 per lifetime
Oxygen
Microscopic and other similar diagnostic tests and services rendered in a Licensed laboratory in the province of Quebec
Charges for the treatment of accidental injuries to natural teeth or jaw, provided the treatment is rendered within 12 months of the accident, excluding injuries due to biting or chewing

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What the Plan Does Not Cover

No Extended Health Care benefits are payable for expenses related to:

• self-inflicted injuries;
• war, insurrection, the hostile actions of any armed forces or participation in a riot or civil commotion;
• committing or attempting to commit an assault or criminal offence;
• injuries sustained while operating a motor vehicle while under the influence of any intoxicant, including alcohol;
• an illness or injury for which benefits are payable under any government plan or workers' compensation;
• charges for periodic check-ups, broken appointments, third party examinations, travel for health purposes, or completion of claim forms;
• services or supplies provided by an employer's medical or dental department;
• services or supplies for which no charge would normally be made in the absence of insurance;
• services and supplies where reimbursement would have been made under a government-sponsored plan, in the absence of insurance;
• services or supplies which are not permitted by law to be paid;
• services or supplies which are required for recreation or sports;
• services or supplies which would have been payable by the Provincial Plan if proper application had been made;
• medical treatment which is not usual or customary, or is experimental or investigational in nature;
• medical or surgical care which is cosmetic;
• services or supplies which are performed or provided by the insured person, an immediate family member or a person who lives with the insured person;
• services or supplies which are provided while confined in a hospital on an in-patient basis;
• services or supplies which are not specified as a covered expense under this benefit;

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Subrogation (Third Party Liability)

If your medical expenses result from an injury caused by another person and you have the legal right to recover damages, Manulife Financial may request that you complete a subrogation reimbursement agreement when you submit a claim for such expenses.

On settlement or judgment of your legal action, you will be required to reimburse Manulife Financial those amounts you recover which, when added to the payments you received from Manulife Financial, exceed 100% of your incurred expenses.

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Drug Benefit for Quebec Residents

If you and your dependents reside in Québec, the following provisions apply to your drug benefit coverage.

Covered Drug Expenses

The following expenses are covered:

• drugs that are on the List of Insured Drugs that is published by the Régie de l’assurance-maladie du Québec (RAMQ List), provided such drugs are on the list at the time the expense is incurred; and
• drugs that are listed as a covered expense in this information package, but are not on the RAMQ List.

Coverage for drugs on the List of Insured Drugs that is published by the Régie de l’assurance-maladie du Québec (RAMQ List)

The following provisions apply only to the coverage of drugs that are on the RAMQ List, as legislated by An Act Respecting Prescription Drug Insurance (R.S.Q. c., A-29-01). Coverage for all other drugs will be subject to the regular provisions included in this information package:

a) Benefit Percentage

Prior to the annual out-of-pocket maximum being reached, the percentage of covered drug expenses payable under this benefit will be as follows:

• For any drug on the RAMQ List which is not otherwise covered under the terms of this Benefit, the percentage payable is the percentage as set out by the then applicable Legislation.
• For any drug on the RAMQ List which is covered under the terms of the prescription drug coverage provision described in the extended health care tab, the percentage payable is the greater of:
• the benefit percentage stated under the prescription drug coverage provision described in the extended health care tab; and
• the percentage as set out by the then applicable Legislation.

After the annual out-of-pocket maximum has been reached, the percentage of covered drug expenses payable under this benefit will be 100%.

b) Annual Out-of-Pocket Maximum

The annual out-of-pocket maximum is the portion of covered drug expenses which must be paid by you and your spouse in a calendar year, before the percentage payable under this benefit will be 100%.

Amounts that will be applied to the annual out-of-pocket maximum are:

• deductible amounts, and
• the portion of covered drug expenses that is paid by an insured person, when the percentage of covered expenses payable under this benefit is less than 100%.

The annual out-of-pocket maximum for you and your spouse is as stipulated in the Legislation and includes those portions of covered drug expenses paid for your dependent children.
For the purposes of calculating the out-of-pocket maximum for you and your spouse, those portions of covered drug expenses paid for your dependent children will be applied to the person who is closest to reaching the annual out-of-pocket maximum.

c) Deductible

Deductible amounts (if any) for the drug benefit will apply, until the annual out-of pocket maximum is reached. Thereafter, the deductible will not apply.

d) Lifetime Maximums

Lifetime maximums (if any) for the drug benefit will not apply. Drug coverage provided after the lifetime maximum stated under the prescription drug coverage provision described in the extended health care tab is reached, is subject to the following conditions:

• only drugs that are on the RAMQ List are covered, and
• the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation.

e) Eligible Dependent Children

Your eligible dependent children who are in full-time attendance at an accredited educational institution will be covered until the later of:

• the age specified in the glossary, and
• age 26.

Drug coverage provided for dependent children after the age specified in the glossary is subject to the following conditions:

• only drugs that are on the RAMQ List are covered, and
• the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation.

f) Termination Age

Provided you are otherwise eligible for the drug benefit, the Termination Age (if any) for the drug benefit will not apply. Drug coverage provided after the Termination Age specified under the prescription drug coverage provision described in the extended health care tab is subject to the following conditions:

• only drugs that are on the RAMQ List are covered,
• the percentage payable by Manulife Financial for covered expenses is the percentage as stipulated in the then applicable Legislation,
• the Annual Out-of-Pocket Maximum is as stipulated in the then applicable Legislation,
• the premium required for the drug coverage is the premium for Extended Health Care,

Coverage for Drugs That are Listed as a Covered Expense in This Information Package but are not on the RAMQ List

Coverage for drugs that are listed as a covered expense under this Benefit but not on the RAMQ List will be subject to all the standard provisions included in this information package.

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Glossary

The following is an explanation of the Insurance terms used in this Benefit Booklet.

Certified, Licensed or Registered - 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.

Co-insurance - the percentage of Covered Expenses which is payable by Manulife Financial.

Covered Expenses - expenses that will be considered in the calculation of payment
due under your Extended Health Care benefit.

Deductible - the amount of Covered Expenses that must be incurred and paid by you or your dependents before benefits are payable by Manulife Financial.

Dependent - your Spouse or Child who is insured under the Provincial Plan.

Dependent Child/Children - your natural or legally adopted child, dependent on you or your spouse for financial support), or stepchild (living with you), who is: unmarried; under age 21, or under age 25 if a full-time student; not employed on a full-time basis; and not eligible for insurance as an employee under this or any other group benefit program.

A child who is incapacitated on the date he or she reaches the age when insurance would normally terminate will continue to be an eligible dependent.  However, the child must have been insured under this benefit program immediately prior to that date.

A child is considered incapacitated if he or she 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 child's condition as often as may reasonably be necessary.

Drug- medications that have been approved for use by the Federal Government of
Canada and have a Drug Identification Number.

Experimental or Investigational - not approved or broadly accepted and recognized by the Canadian medical profession, as an effective, appropriate and essential treatment of a
sickness or injury, in accordance with Canadian medical standards.

Immediate Family Member - you, your spouse or child, your parent or your spouse's parent, your brother or sister, or your spouse's brother or sister.
Medically Necessary - broadly accepted and recognized by the Canadian medical
profession as effective, appropriate and essential in the treatment of a sickness or
injury, in accordance with Canadian medical standards.

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 by the Canada Health Act.

Reasonable and Customary - within the usual range of charges being made by others of
similar standing in the area in which the charge is incurred when providing the same or comparable services or supplies.

Spouse – the person to whom you are legally married; or a person continuously living with you in a role like that of a marriage partner for at least one year.  In the latter case, discontinuation of cohabitation with you terminates coverage for such a person.  Only one spouse will be eligible for insurance, and will be as indicated by the member on the applicable form. 

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Submitting a Claim

To submit an Extended Health Care claim, you must complete an Extended Health Care Claim form which is available from your Plan Administrator or the Manulife website.  All claim forms, must be correctly completed, dated and signed.  Remember, always provide your Group Policy Number and your Certificate Number to avoid any unnecessary delays in the processing of your claim.

All claims must be submitted within 12 months after the date the expense was incurred.  However, upon termination of your insurance, all claims must be submitted no later than 90 days from the termination date.

Online Claims

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

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Claim Payment

Once the 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 benefit percentage used to determine the final payment to be made to you.  The bottom portion of this form is your claims payment, if applicable. Simply tear along the perforated line, endorse the back of the cheque and you can cash it at any chartered bank or trust company.

You should receive settlement of your claim within three weeks from the date of submission to Manulife Financial. If you have not received payment, please contact your Plan Administrator.

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