VISION CARE Plan Document

Transcription

1 VISION CARE Plan Document February 1, 1984 With Revisions Effective January 1, 1985 May 1, 1986 January 1, 1988 September 16, 1988 March 17, 1989 January 1, 1990 January 1, 1992 July 1, 1992 September 1, 1992 October 15, 1992 February 1, 1994 June 17, 1994 July 1, 1995 August 31, 1995 January 1, 1998 April 2, 1998 January 1, 2000 January 1, 2002 September 1, 2003 January 1, 2004 September 1, 2004 January 1, 2006 January 1, 2007 November 1, 2007 January 1, 2008 January 1, 2009 January 1, 2011 January 1, 2012 January 1, 2013 January 1, 2015 April 1, 2015 January 1, 2017

2 Table of Contents 1. Definitions Eligibility Effective Date of Coverage Restrictions on Availability of Coverage, Effective date of Coverage, and Frequency of Choice Termination of Coverage Description of Vision Care Coverage Generally Excluded Expenses Coordination of Benefits Subrogation General Provisions... 21

3 1. DEFINITIONS ( ) 1.1. Actively At Work means an Employee is actively at work on any day in which an Employee performs the usual and customary duties of the Employee's occupation at the Employee's assigned location or at some other location where the Participating Employer requires the Employee to be ( ) 1.2. Added Choice Options 1 and 2 means benefits coverage combinations made available by the Trustees to Participating Employers, Employee Groups, and Covered Members ( ) 1.3. Alberta School Employee Benefit Plan is the trade name owned by the Trustees and under which This Plan and other employee benefit plans operate ( ) 1.4. Approved Provider means an entity that the Trustees in their sole discretion approve as a provider of services or supplies ( ) 1.5. Calendar Year means the period from any January 1 to the following December 31, inclusive 1.6. Covered Member means an Employee, Early Retiree, or School Trustee who meets the conditions of eligibility, satisfies the effective date provisions, and who pays premiums or on whose behalf premiums are paid for coverage under This Plan. A Covered Member is associated with the Participating Employer that employs him/her, with which he/she was employed on the day of his/her retirement, or on which board he/she sits as a School Trustee ( ) 1.7. Dependant means a dependant of the Covered Member who is ( ): a spouse who is ( ): legally married to the Covered Member, or a person who is an adult interdependent partner pursuant to the Adult Interdependent Relationships Act Chapter A 4.5 of the Statutes of Alberta 2002 as amended ( ) a child who is recognized as a dependant child by a Canadian provincial government health plan ( ) Excluded as a Dependant is a dependant who is not resident in Canada or who is on active duty in any military, naval or air force of any country, or peace keeping force ( ) 1.8. Early Retiree means a person who is not working for a Participating Employer and who has agreed to participate in an early retirement agreement with the Trustees, but only if such person is ( ): at least age 50 when retirement began, and ( ) had at least 5 years consecutive employment with a Participating Employer(s) immediately prior to electing early retirement, and ( ) is a resident of Canada ASEBP Vision Care Plan Document 2017/01/01 1

4 1.9. Early Retiree Package 1 means a predefined package of insurance and benefits available to Early Retirees under Added Choice Options 1 and 2 which may include Vision Care Plans 1, 2, or 3 under This Plan. The Plan 1, 2, or 3 determination is based upon which of these plans was in effect for the Employee Group from which the Early Retiree retired and in which the Early Retiree was participating immediately prior to his/her retirement ( ) Employee means a person who is employed by a Participating Employer, but only if such person is a teacher, non teacher involved directly in the operation and administration of the school system, or an employee of a related group whose participation is approved by the Trustees from time to time who is ( ): under age 65, or if still Actively At Work, under age 70, and ( ) employed for at least 0.2 full time equivalent, and ( ) employed for at least the minimum hours set by the Participating Employer if they are greater than those set by the Trustees, and ( ) a resident of Canada ( ) Employee Group means the bargaining or other group to which an employee belongs ( ) Family Coverage means coverage which includes both a Covered Member and one or more Dependants of the Covered Member ( ) Participating Employer means any school board or other employer approved by the Trustees whose application for Vision Care benefits for its Employees has been approved by the Trustees ( ) Physician means a registered member of the College of Physicians and Surgeons in the province of Alberta under the Health Professions Act or other governing legislation who holds a practice permit respecting the practice of medicine, surgery, or osteopathy ( ) Service means the work an Employee is required to perform for the Employee's Participating Employer in accordance with the usual and customary duties relating to normal activities carried out to fulfill requirements of the position ( ) School Trustee means a person who is appointed or elected as a School Trustee for a Participating Employer, but only if such person is ( ): under age 65 at the time of appointment or election, or if serving a consecutive term in office, under age 70, and ( ) a resident of Canada ( ) Single Coverage means coverage for a Covered Member without coverage for Dependants ( ) This Plan means the Vision Care Plan described herein and operated by the Trustees ( ) ASEBP Vision Care Plan Document 2017/01/01 2

5 1.19. Trustees are those individuals who are appointed from time to time as trustees of the Alberta School Employee Benefit Plan pursuant to a Deed of Trust entered into by the Alberta School Boards Association and the Alberta Teachers Association. Whenever any right is conferred or obligation is imposed herein upon a Trustee or Trustees, it shall be conferred or imposed upon the Trustees solely in their capacity as Trustees and not in their personal capacities ( ) Vision Care Professional means a registered ophthalmologist, registered optometrist, or registered optician under the Health Professions Act or other governing legislation who holds a practice permit respecting the practice of vision care ( ) ASEBP Vision Care Plan Document 2017/01/01 3

6 2. ELIGIBILITY 2.1. Eligibility by plan is as follows ( ): Plan Eligibility Plan 1 Employees of Participating Employers that select Added Choice Option 1 or 2 if Plan 1 is selected by the Participating Employer ( ) Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 1 ( ) School Trustees of Participating Employers that select Added Choice Options 1 or 2 if the Participating Employer participates in Plan 1 with respect to nonteachers ( ) Plan 2 Employees of Participating Employers that select Added Choice Option 1 or 2 if Plan 2 is selected by the Participating Employer ( ) Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 1 ( ) School Trustees of Participating Employers that select Added Choice Options 1 or 2 if the Participating Employer participates in Plan 2 with respect to nonteachers ( ) Plan 3 Employees of Participating Employers that select Added Choice Option 1 or 2 if Plan 3 is selected by the Participating Employer ( ) Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 1 ( ) School Trustees of Participating Employers that select Added Choice Options 1 or 2 if the Participating Employer participates in Plan 3 with respect to nonteachers ( ) 2.2. Date of eligibility is determined as follows ( ): an Employee is eligible to be covered under This Plan on the later of: the date the Employee s Participating Employer becomes included under This Plan, and ASEBP Vision Care Plan Document 2017/01/01 4

7 the date on which the Employee completes one day of Service ( ) the date on which the Employee completes the waiting period set by the Participating Employer if greater than the period stipulated in paragraph ( ) an Early Retiree is eligible to be covered under This Plan the day after his or her retirement ( ) a School Trustee is eligible to be covered under This Plan from the date of election or appointment to the participating school board ( ) 2.3. Eligibility for Early Retirees participating in Early Retiree Package 1 ( ): shall be restricted to the plan (as described in paragraph 2.1), if any, provided from time to time to the Employee Group to which an Early Retiree belonged immediately prior to his or her retirement. Early Retirees shall cease to be eligible for any coverage under This Plan if and when the Early Retiree s former Employee Group ceases to be covered under This Plan ( ) provided however that entitlement to coverage under the Early Retiree Packages is suspended as of the date the Early Retiree becomes eligible for group employment benefits through a Participating Employer or other school board and resumes subject to the terms of This Plan upon any resumption of Early Retiree status ( ) 2.4. Eligibility is subject to policies, practices and decisions made or taken by the Trustees ( ): requiring minimum levels of participation in This Plan or other plans offered by the Trustees as a condition for eligibility in This Plan ( ) requiring the inclusion of other Employee Groups of the same Participating Employer in coverage under This Plan or other plans offered by the Trustees as a condition for eligibility in This Plan ( ) terminating eligibility for coverage under This Plan or other plans offered by the Trustees in the event that a Participating Employer terminates coverage or the Trustees terminate coverage under This Plan or other plans offered by the Trustees ( ) stipulating conditions upon which an Employee Group that was formerly covered under This Plan may be eligible for readmission to coverage under This Plan ( ) ASEBP Vision Care Plan Document 2017/01/01 5

8 3. EFFECTIVE DATE OF COVERAGE 3.1. An Employee s effective date of coverage is determined as follows ( ): if participation is a condition of employment under Added Choice Option 1 or 2, an Employee must make application and the effective date of coverage is the date the Employee becomes eligible as long as the Employee is Actively at Work. If the Employee is not Actively at Work, the effective date of coverage is delayed until the Employee has been Actively at Work for one complete working day ( ) if participation is optional under Added Choice Option 1 or 2, an Employee must make application and the effective date of coverage is the date the Trustees approve coverage as long as the Employee is Actively at Work. If the Employee is not Actively at Work, the effective date of coverage is delayed until the Employee has been Actively at Work for one complete working day ( ) the effective date of subsequent changes to coverage is the date the Trustees approve such changes ( ) 3.2. An Early Retiree must make application and the effective date coverage is the date the Trustees approve coverage. The effective date of subsequent changes to coverage is the date the Trustees approve such changes ( ) 3.3. A School Trustee s effective date of coverage is determined as follows ( ): under Added Choice Option 1 or 2, participation in coverage is mandatory for School Trustees when such coverage is a condition of employment for non teachers. A School Trustee must make application and the School Trustee s effective date of coverage is the later of ( ): November 1 of the year in which the term of office begins ( ) the date of appointment or election if the School Trustee is appointed or elected at some time between the normal election dates ( ) under Added Choice Option 1 or 2, participation in coverage is optional for School Trustees when such coverage is optional for non teachers. A School Trustee must make application and the School Trustee s effective date of coverage is the date the Trustees approve coverage ( ) the effective date of subsequent changes to coverage is the date the Trustees approve such changes ( ) 3.4. A Covered Member must make application for coverage for Dependants and the effective date is the date the Trustees approve coverage. The effective date of subsequent changes to coverage is the date the Trustees approve such changes ( ) ASEBP Vision Care Plan Document 2017/01/01 6

9 4. RESTRICTIONS ON AVAILABILITY OF COVERAGE, EFFECTIVE DATE OF COVERAGE, AND FREQUENCY OF CHOICE ( ) 4.1. The Trustees may refuse to cover or may establish additional preconditions for coverage, including, but without restricting the generality of the foregoing, proof of good health, delayed effective dates of coverage, increased deductibles, or restrictions on coverage for any of the following individuals or dependants of the following individuals who would otherwise be eligible for coverage, namely ( ): anyone whose application for coverage is incomplete or who fails to provide the Trustees with necessary information to properly identify a Covered Member or Dependant ( ) anyone who applies for coverage after a deadline established by the Trustees ( ) anyone whose premiums are in arrears ( ) anyone who elects coverage under This Plan for a leave of absence but purports to cancel such coverage after the commencement of the leave of absence ( ) anyone who has previously opted out of coverage by the Trustees in favour of spousal or dependant coverage under another plan and wishes to reinstate coverage with the Trustees ( ) where the Covered Member is associated with a Participating Employer that selects Added Choice Options 1 or 2, anyone for whom coverage under This Plan was not mandatory and who has opted out of coverage or who has failed to apply for coverage ( ) 4.2. The effective date of coverage for any Covered Member or Dependant of a Covered Member who is associated with a Participating Employer for whom coverage under This Plan is not mandatory shall be determined by the Trustees at the time of application for coverage ( ) 4.3. Early Retirees must apply for coverage prior to retirement ( ) 4.4. Retroactive changes to coverage are not permitted ( ) ASEBP Vision Care Plan Document 2017/01/01 7

10 5. TERMINATION OF COVERAGE 5.1. A Covered Member s coverage terminates on the earlier of: when the Covered Member ceases to be eligible, or when This Plan terminates, or the date of default in making payment of a required premium if the Trustees elect to terminate coverage, or ( ) when the Covered Member ceases to be a resident of Canada, or on June 30 coinciding with or next following the date on which the Employee reaches age 65, or if still Actively at Work, age 70, or ( ) when the Employee is no longer in the Service of the Participating Employer, except that the Participating Employer may, without discrimination among Employees, continue to consider the Employee as being in Service, but no longer than90 days following termination of Service for an Employee who is temporarily laid off, or months from the commencement of a Participating Employer approved leave of absence, or ( ) a maximum extension of 18 months following the period referred to in paragraph for an Employee who is on a Participating Employer approved leave of absence and only when coverage during such extension is pre approved by the Trustees ( ) the last day of the month in which an Early Retiree reaches age 65, or ( ) if any School Trustee is no longer eligible because he/she is age 65, coverage terminates on October 31 of the year in which a School Trustee s term of office ends or at age 70 should the School Trustee subsequently serve a consecutive term in office, or ( ) the date a School Trustee is no longer serving in office ( ) 5.2. A Dependant s coverage terminates on the earlier of: the Covered Member s coverage terminates, or the Dependant ceases to be eligible under the definition of Dependant found in paragraph 1.7 However, if the Dependant s coverage terminates solely because of the Covered Member s death, upon application coverage for benefits shall be continued on a premium free basis until the earliest of the following dates ( ): the date on which the surviving spouse remarries ( ) ASEBP Vision Care Plan Document 2017/01/01 8

11 the date which is one year from the date on which the Covered Member died ( ) in respect only of the surviving spouse, the date on which the surviving spouse dies ( ) in respect only of a surviving child, the date on which the Dependant dies, or ceases to qualify as a Dependant as defined in paragraph 1.7 ( ) The survivor s coverage will be restricted to the plan made available to the Employee Group to which the deceased Employee belonged ( ) ASEBP Vision Care Plan Document 2017/01/01 9

12 6. DESCRIPTION OF VISION CARE COVERAGE 6.1. Table of Benefits: Plan Benefits Plan 1 covered vision care expenses to a maximum of $150 every two years ( ) Plan 2 ( ) covered vision care expenses to a maximum of $250 every two years ( ) Plan 3 ( ) covered vision care expenses to a maximum of $350 every two years ( ) 6.2. This Plan covers vision care expenses as follows: Covered ( ): eye glass lenses eye glass frames prescription sunglasses ( ) repairs and maintenance ( ) contact lenses contact lens fitting fees ( ) eye examinations corrective eye surgery ( ) lens implants ( ) Not covered ( ): artificial eyes non corrective lenses safety glasses ASEBP Vision Care Plan Document 2017/01/01 10

13 6.3. Limitations: Payment is subject to the maxima and conditions listed in the Table of Benefits in paragraph 6.1 above Payment is subject to paragraph 7 Generally Excluded Expenses Expenses will be covered only if ( ): incurred while the Covered Member or Dependant is covered under This Plan; an expense is considered to be incurred on the date the service or supply was provided, and unless expressly stipulated herein otherwise, the service or supply is ordered or prescribed by a Physician or Vision Care Professional other than an optician and provided by an Approved Provider, and ( ) the Covered Member or Dependant is covered by a Canadian provincial government health plan ( ) ASEBP Vision Care Plan Document 2017/01/01 11

14 7. GENERALLY EXCLUDED EXPENSES 7.1. Expenses incurred for the following are not covered under This Plan: Services and supplies: furnished by or on behalf of any government, unless payment is legally required, except for services and supplies which are eligible for additional payment under the Non Insured Health Benefits Program of the Government of Canada as a subsequent payment ( ) when, and to the extent to which, an expense for a service or supply is or would be covered or paid for under a generally available government or government sponsored program for which an Employee or Dependant is eligible for coverage, whether or not the Employee or Dependant has elected to acquire such coverage and whether or not payment of a premium or other charge was required for such coverage ( ) to the extent that group benefits are prohibited in connection with such expense provided by a medical department maintained by the Employer, a mutual benefit association, labour union, trustee or similar type of group not reasonably necessary for the medical care of the Covered Member s or Dependant s condition. To be considered reasonably necessary, the service or supply must: be ordered by a Physician or Vision Care Professional other than an optician, and ( ) be commonly and customarily recognized throughout the Physician s or Vision Care Professional s profession as appropriate in the treatment of the Covered Member s or Dependant s diagnosed condition, or ( ) not be educational or experimental in nature nor provided primarily for the purpose of medical or other research The portion of any expense which is in excess of the reasonable and customary expense, as determined by the Trustees. The reasonable and customary expense is the usual expense of the provider, in the absence of coverage, but not more than the prevailing expense in the area for a similar service or supply. Area means the municipality (or in the case of a large city, the subdivision thereof) or designated Regional Health Authority or equivalent in which the service or supply is actually rendered or provided or such greater area as is necessary to obtain a representative cross section of expenses for a similar service or supply. A similar service or supply is one of the same nature and duration, requires the same skill, and is performed by a provider of similar training and experience ( ) ASEBP Vision Care Plan Document 2017/01/01 12

15 When expenses are for supplies purchased from providers outside Canada any additional charges resulting from purchasing the item from outside Canada are ineligible expenses ( ) No benefits will be payable for expenses incurred for any of the following ( ): expenses incurred when on active duty in any military or peacekeeping force ( ) expenses incurred as a result of participation in any conduct which would constitute an offence which may be prosecuted by indictment had the offence been prosecuted in Canada ( ) broken appointments ( ) the completion of claim forms required by the Trustees ( ) any service rendered after termination of the Covered Member s or Dependant s coverage under This Plan ( ) for services that are self performed or supplies that are self ordered ( ) Where the Covered Member is required to pay a portion of the cost of services or supplies and the Approved Provider waives payment of the Covered Member's portion or fails to collect such portion from the Covered Member ( ) ASEBP Vision Care Plan Document 2017/01/01 13

16 8. COORDINATION OF BENEFITS 8.1. All benefits provided under This Plan are subject to this provision: Definitions: Other Plan is defined as any group insurance or any other arrangement of coverage for individuals in a group, whether on an insured or an uninsured basis, as long as the group is not formed solely for the purpose of obtaining insurance. This includes any prepayment coverage or capitation plan or coverage for students sponsored by or provided through an educational institution above the high school level. This definition of Other Plan does not include individual travel insurance ( ) Eligible Expenses are defined in each carrier s contract or plan document before payment limitations such as deductibles, co insurance, lagging fee guides, and/or maximums are applied. Each carrier adjudicates the claim taking into account reasonable and customary expenses, maximums, and contractual fee guide limits in the normal fashion ( ) Effect on Benefits: The Trustees may reduce the amount of any benefits otherwise payable under This Plan to ensure that the amount received by the Covered Member or Dependant from this and any Other Plan for which benefits are payable does not exceed the actual eligible expense incurred by the Covered Member or Dependant ( ) The benefits of any Other Plan will not serve to reduce benefits payable under This Plan if: that Other Plan contains a provision coordinating its benefits with This Plan or other plans, and both the rules of that Other Plan and the rules set forth in paragraph would require This Plan to determine its benefits before such Other Plan Rules establishing the order of benefit determination regarding a Covered Member or Dependant on whose expenses a claim is based are as follows: the plan with no coordination of benefits provision shall determine benefits first ( ) if the Other Plan(s) contains a coordination of benefits provision, priority goes to the plan in the following order ( ): the plan where the person is the member holding coverage ( ) ASEBP Vision Care Plan Document 2017/01/01 14

17 the following order applies where the person is a member holding coverage in two plans ( ): the plan where the member is an active full time employee ( ) the plan where the member is an active part time employee ( ) the plan where the member is a retiree or trustee ( ) the plan where the person is covered as a dependant spouse ( ) the plan where the person is covered as a dependant child in the following order ( ): by the parent with the earlier month and day of birth in the calendar year ( ) by the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same month and day of birth ( ) the following order applies where the person is covered as a dependant child and the parents are separated or divorced ( ): the plan of the parent with custody of the child ( ) the plan of the spouse of the parent with custody of the child ( ) the plan of the parent not having custody of the child ( ) ASEBP Vision Care Plan Document 2017/01/01 15

18 the plan of the spouse to the parent in paragraph ( ) for dental accidents, health plans with dental accident coverage determine benefits before dental plans ( ) If priority cannot be established in the above manner, the benefits shall be pro rated between or amongst the plans in proportion of the amounts that would have been paid under each plan had there been coverage by just that plan Any benefits payable by This Plan under paragraph shall be charged against the applicable limits of This Plan ( ) Right to Receive and Release Necessary Information: For the purpose of determining the applicability of This Plan s coordination of benefits provision and implementing its terms or those of any provision of similar purposes of any Other Plan, the Trustees, without the consent of or notice to any person, may release to or obtain from any insurance company, organization, or person any information, with respect to any person, which the Trustees deem to be necessary for such purposes. Any Covered Member or Dependant claiming benefits under This Plan shall furnish to the Trustees such information as may be necessary to implement this provision Facility of Payment: Whenever payments which should have been made under This Plan in accordance with this provision have been made under any Other Plans, the Trustees shall have the right to pay over to any organization making such other payments any amounts determined by the Trustees to be warranted in order to satisfy the intent of this provision. Amounts so paid shall be deemed to be benefits paid under This Plan and, to the extent of such payments, the Trustees shall be fully discharged from liability under This Plan Right of Recovery: If at any time payments have been made by the Trustees with respect to allowable expenses, and such payments are in excess of the maximum amount necessary at that time to satisfy the intent of this coordination provision, the Trustees shall have the right to recover such payments, to the extent of such excess, from any person to or with respect to whom such payments were made, any insurance company, and any other organizations ASEBP Vision Care Plan Document 2017/01/01 16

19 9. SUBROGATION ( ) 9.1. Definitions: Subrogation means the Trustees' right of subrogation which arises when the Covered Member or his/her Dependant, as a result of the wrongful act or omission of a third party, recovers ( ): damages representing the amount of any benefits paid or payable under This Plan, whether or not the Covered Member or his/her Dependant recovers, in whole or in part or at all, any additional damages from the third party, and ( ) amounts representing the amount of any benefits paid or payable under This Plan, from the Covered Member s or his/her Dependant s insurer under a family protection endorsement or other similar coverage (hereinafter referred to as a Family Protection Endorsement ) ( ) Covered Member includes the Covered Member s Personal Representative, Trustee, Guardian or the Estate of the deceased Covered Member ( ) Dependant includes the Dependant s Personal Representative, Trustee, Guardian or the Estate of the deceased Dependant ( ) Judgment or Settlement means an order of a court of competent jurisdiction or an agreement whereby the Covered Member or his/her Dependant agrees to accept any sum of money representing past or future loss of any goods or services provided to the Covered Member or his/her Dependant of the type for which the Covered Member or his/her Dependant is entitled to indemnity pursuant to the provision of This Plan (hereinafter referred to as the cost of care ), either by lump sum, periodic payment(s), or through the purchase of an annuity, or any of them, covering period within which benefits under This Plan have been paid or will be payable ( ) Interest means that interest will accrue, and is payable by the Covered Member or his/her Dependant as provided hereafter, calculated in accordance with the provisions of the Alberta Judgment Interest Act, Chapter J 1, RSA, 2000, and amendments and regulations thereto ( ) 9.2. In the event that benefits under This Plan are payable to a Covered Member or his/her Dependant as a result of a wrongful act or omission of a third party, the Trustees are subrogated to any right of recovery of the Covered Member or his/her Dependant in the amount of any benefits paid or payable under This Plan and, without restricting the generality of the foregoing, the following provisions apply ( ): in any claim made or action commenced by the Covered Member or his/her Dependant against a third party or insurers under a Family Protection Endorsement, the Covered Member or his/her Dependant shall include in the amount of that claim the amount of the cost of care as a result of any disability arising from the act of the third party (including the amount of benefits paid under This Plan to the Covered Member or his/her Dependant for such disability) plus, if the Covered Member or his/her ASEBP Vision Care Plan Document 2017/01/01 17

20 Dependant remains disabled or is likely to resume his/her disability as a result of the act of the third party at the time the action is commenced, the amount of all anticipated future cost of care (including the anticipated amount of benefits to be paid to the Covered Member or his/her Dependant under This Plan) ( ) the Trustees shall have the right (but not the obligation) to maintain an action in the name of the Covered Member or his/her Dependant to recover its subrogated claim and the Trustees may at any time engage a solicitor to recover its subrogated claim and for that purpose the Covered Member or his/her Dependant shall permit the Trustees to engage his/her solicitor to pursue its subrogated claim ( ) the Covered Member or his/her Dependant agrees to fully cooperate with the Trustees in pursuing their subrogated claim and upon the Trustees request the Covered Member or his/her Dependant shall provide to the Trustees all records, transcripts, reports and information with respect to the calculation or allocation of damages, and attend examinations for discovery or assist as a witness where required ( ) the Covered Member or his/her Dependant will not settle his/her claim without the prior written consent of the Trustees. Any settlement by the Covered Member or his/her Dependant without the consent of the Trustees shall be deemed to be a fundamental breach by the Covered Member or his/her Dependant of his/her obligations under This Plan and, in addition to any other remedies available to the Trustees, the Trustees may forthwith terminate payment of any benefits payable under This Plan. No release given by the Covered Member or his/her Dependant without the consent of the Trustees shall release anyone from any liability to the Trustees for their subrogated claim ( ) the Trustees consent to settlement shall not be unreasonably withheld but the Trustees shall not be obliged to consent to any settlement in which, as a result of any proposal to defer payment of the principal amount of such settlement to the Covered Member or his/her Dependant under any form of structured settlement or otherwise, the Covered Member or his/her Dependant would receive insufficient funds to pay any amount which after any settlement would be payable to the Trustees plus the amount of legal fees payable thereon ( ) Settlement or Judgment with the consent of the Trustees: when as a result of Judgment or Settlement with the consent of the Trustees, the Covered Member or his/her Dependant recovered all cost of care ( ): the Covered Member or his/her Dependant shall, as of the date of Settlement or Judgment, pay to the Trustees 100% of the benefits paid to the Covered Member or his/her Dependant in accordance with This Plan plus interest, less a proportionate share of legal fees payable thereon by the Covered Member or his/her Dependant to his/her solicitor with respect to such recovery, and ( ) ASEBP Vision Care Plan Document 2017/01/01 18

21 the Trustees shall, from the amount of any future benefits otherwise payable until the amount of the said net recovery is exhausted, off set the full amount of the Covered Member s or his/her Dependant s cost of care (actuarially or otherwise calculated), less a proportionate share of legal fees payable thereon by the Covered Member or his/her Dependant to his/her solicitor with respect to such recovery, or ( ) when as a result of Judgment or Settlement with the consent of the Trustees, the Covered Member or his/her Dependant recovered less than all cost of care ( ): the Covered Member or his/her Dependant shall, as of the date of Settlement or Judgment, pay to the Trustees a percentage of all benefits paid by the Trustees to the Covered Member or his/her Dependant in accordance with This Plan plus interest, which is equal to the percentage of past cost of care recovered by the Covered Member or his/her Dependant less a proportionate share of the legal fees payable thereon by the Covered Member or his/her Dependant to his/her solicitor with respect to such recovery, and ( ) the Trustees shall, from the amount of any future benefits otherwise payable until the amount of the said net recovery is exhausted, off set the full amount of the Covered Member s or his/her Dependant s recovery for cost of care (actuarially or otherwise calculated) less a proportionate share of the legal fees payable thereon to his/her solicitor with respect to such recovery ( ) Settlement without the consent of the Trustees: in the event the Covered Member or his/her Dependant settles any claim without the consent in writing of the Trustees, in addition to any other remedies available to the Trustees then, notwithstanding any express terms of any such settlement ( ): the amount of such recoveries shall be deemed to have been paid firstly with respect to any claim in which the Trustees may have a subrogated interest under any other plan or plans under which the Covered Member or his/her Dependant has received benefits arising from the act or omission of the third party, and ( ) the amount of such recovery shall be deemed to have been paid secondly with respect to past cost of care as of the date of settlement and the Covered Member or his/her Dependant shall promptly upon recovery pay to the Trustees the amounts which would otherwise be payable to the Trustees on a settlement with consent of the Trustees with the Covered ASEBP Vision Care Plan Document 2017/01/01 19

22 Member s or his/her Dependant s recovery being that deemed by the provisions of this paragraph, and ( ) the amount of such recovery shall be deemed to have been paid thirdly with respect to future cost of care (actuarially or otherwise calculated) as of the date of settlement and the Trustees shall off set the full amounts which would otherwise be off set on a settlement with the consent of the Trustees with the Covered Member s or his/her Dependant s recovery being that deemed by the provisions of this paragraph, and ( ) the balance, if any, shall be deemed to have been paid with respect to other claims of the Covered Member or his/her Dependant ( ) As a condition precedent to the ongoing receipt of benefits otherwise payable to the Covered Member or his/her Dependant under the provisions of This Plan, the Trustees may require the Covered Member or his/her Dependant to execute documents, agreements or assurances, including but not limited to a Reimbursement Agreement, on terms consistent with the provisions herein ( ) Where a Judgement or Settlement against or with a third party does not indemnify a Covered Member or his/her Dependant for his or her entire loss, ASEBP shall be entitled to recover as its subrogated claim a proportionate amount of all benefits paid in the past or payable in the future equal to the percentage recovered by the Covered Member or his/her Dependant of all damages to which she or he was entitled ( ) For the purpose of this paragraph, percentage shall mean: in the case of a Judgement, the percentage of damages specified in the Judgement as being recoverable by the Covered Member or his/her Dependant (subject to any reduction for uncollectability), and ( ) in the case of a Settlement, the percentage of all damages (fairly assessed) which the Covered Member or his/her Dependant acting reasonably agrees to accept in any bona fide Settlement ( ) ASEBP Vision Care Plan Document 2017/01/01 20

23 10. GENERAL PROVISIONS A Participating Employer participates under This Plan as of the date of acceptance by the Trustees of its application for Vision Care benefits for some or all of its Employees ( ) A Participating Employer ceases to participate under This Plan on the effective date of any notice given by the Trustees that the Participating Employer is no longer eligible to participate ( ) At the time of application a Participating Employer shall inform the Trustees of the Added Choice Option and plans within that Added Choice Option which have been selected for each Employee Group for which coverage is to be provided and shall provide the Trustees with reasonable advance notice of any requested changes ( ) Premiums are due and payable on the first day of the month to which they apply ( premium due date ) ( ) The premium due by a Participating Employer on each premium due date is the sum of the premium expenses for the coverage then provided under the benefits of This Plan, determined from the applicable premium rates then in effect and the number of Covered Members ( ) When premiums under This Plan are payable by the Participating Employer directly to the Trustees at the office of the Alberta School Employee Benefit Plan ( ): a grace period of 45 days is allowed for the payment of each premium ( ) if any premium is not paid within its grace period (as provided in paragraph above), the date of default is the premium due date ( ) When premiums under This Plan are payable by the Covered Member directly to the Trustees at the office of the Alberta School Employee Benefit Plan, if any premium is not paid on the due date, the date of default is the premium due date ( ) The Trustees have the right to change premium rates as of (1) any premium due date, (2) any date a Participating Employer becomes or ceases to be included under This Plan, and (3) any date the extent or nature of the risk is changed by amendment, termination, or by reason of any provision of law or any governmental program or regulation. However, the premium rates for coverage under a benefit, or portion separately rated, will not be changed under (1) above before the first anniversary date of This Plan. The Participating Employer or Covered Member making payment of premiums directly to the Trustees is to be given 45 days written notice whenever a change in the premium rate is made ( ) When the Participating Employer has chosen Added Choice Option 1 or 2, the Trustees may terminate the participation in This Plan by any Participating Employer if the number of Covered Members of the Participating Employer is less than 75% of those eligible to be covered. The Trustees must provide notice of intention to terminate to the Participating Employer at least 31 days prior to the effective date of such termination ( ) ASEBP Vision Care Plan Document 2017/01/01 21

24 Either the Participating Employer or the Trustees, as mutually agreed, shall keep a record of the Covered Members containing the essential particulars of the coverage. The Participating Employer shall forward the information periodically required by the Trustees in connection with the administration of This Plan and the determination of the premium rates. All records of the Participating Employer which have a bearing on the coverage shall be open for inspection by the Trustees at any reasonable time ( ) Where participation in This Plan is not optional, coverage in This Plan shall not be denied by reason of the inadvertent failure of the Covered Member s Participating Employer to register such Covered Member for coverage, provided that the Participating Employer ( ): immediately takes steps to register the Covered Member for coverage under This Plan, and ( ) pays to the Trustees all premiums due with respect to the Covered Member from the date of the Covered Member s eligibility for coverage ( ) This Plan Document, together with the relevant Participation Agreement and the individual application of the persons covered hereunder constitute the entire contract. Without restricting the generality of the foregoing ( ): all statements made by Participating Employers, and ( ) all statements made by Union representatives, and ( ) the content of any individual certificate evidencing coverage to a Covered Member, and ( ) the content of any handbook published by the Trustees, Participating Employer or Union ( ) shall be interpreted subject to the provisions of This Plan Document and where and to the extent that they are in conflict with This Plan Document are void and of no force or effect ( ) The Trustees have the authority to waive or change any of the conditions or provisions of This Plan. Any such change will take effect on the date determined by the Trustees and may coincide with or occur after a Covered Member s or Dependant s effective date of coverage under This Plan, and, in the case of Early Retirees, after retirement ( ) All monies payable under This Plan, whether payable to or by the Trustees shall be in lawful money of Canada ( ) Covered Members and Dependants may assign benefits payable for certain claims made under This Plan directly to their service provider when approved by the Trustees. The Trustees may refuse to honour any assignment of benefits in circumstances where the assignment was associated with or obtained by fraud, misrepresentation, negligence or other improper means by a provider of services or supplies or by a Covered Member or Dependant ( ) ASEBP Vision Care Plan Document 2017/01/01 22

25 Claim Provisions: These provisions apply to each coverage under This Plan ( ): Written proof of the expense incurred under a coverage upon which claim may be based must be furnished to the Trustees within 18 months after the date the expense was incurred ( ) The Trustees at their own expense shall have the right and opportunity to examine the Employee or Dependant whose Illness or accidental injury is the basis of claim when and so often as it may reasonably require during pendency of claim No action to recover benefits payable under this Plan shall be commenced later than two years from the date that the Covered Member is informed of the Trustees decision to refuse payment of the expense ( ) This Plan shall be interpreted in accordance with the laws of the province of Alberta ( ) ASEBP Vision Care Plan Document 2017/01/01 23