Additional Policy Information

For additional questions, please contact GSI – we are always happy to help.

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 Pharma-co-economic 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 fetus, 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 reasonably 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 attendance 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 Pharma-co-economics, 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 pensionable 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 affiliated 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.

Pharma-co-economics the scientific discipline that compares the value of one pharmaceutical Drug or drug therapy to another. Pharma-co-economic 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 Pharma-co-economic 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 to whom at least one of the following situations applies:

a. they have been living with the employee, in a conjugal relationship for at least 12 continuous months. Note in this definition, 12 continuous months includes any period you were separated for less than 90 days because of a breakdown in the relationship.

b. they are the parent of your child by birth or adoption

c. they have custody and control of your child (or had custody and control immediately before the child turned 19 years of age) and your child is wholly dependent on that person for support.

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, remuneration, 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, remuneration, 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, remuneration 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.