Dow Chemical Canada, ULC

Transcription

1 Dow Chemical Canada, ULC Divisions 770, 777, 880, 888, 990 and 999 Group Policy No Group Plan No

2 Dow Chemical Canada, ULC Basic Life Underwritten by: Sun Life Assurance Company of Canada Group Policy No Extended Health Administered by: Sun Life Assurance Company of Canada Group Plan No

3 Client Name Table of Contents Policy Number Your Group Benefits Booklet... 1 Overview... 1 General Information... F-1 Section 1. Insured Provisions Summary of Insurance... A-1 Member Life Insurance Provision... G-1 Section 2. Administered Services Summary of Benefits... A1-1 Extended Health Provision... M-1 Extended Health - Comprehensive Drug Benefit... N-1 Extended Health - Hospital Benefit... P-1 Extended Health - Supplementary Health Care Benefit... Q-1 Extended Health - Out-of-Province Emergency Benefit... Q1-1 Table of Contents i

4 Chapter Group File Your Group Benefits Booklet Keep in a safe place This booklet is a valuable source of information for you and your family. It provides the information you need about the group benefits available through your employer s group plan with Sun Life Assurance Company of Canada (Sun Life), a member of the Sun Life Financial group of companies. Please keep it in a safe place. We also recommend that you familiarize yourself with this information and refer to it when making a claim for group benefits. The contract holder, Dow Chemical Canada, ULC, self-insures the following benefits: Extended Health This means that Dow Chemical Canada, ULC plays a role similar to that of an insurance company for its members. Dow Chemical Canada,ULC has the sole legal and financial liability for the benefits listed above and funds the claims from its net income, retained earnings or other financial resources. Sun Life provides administrative services only (ASO) such as claims processing. All other benefits are insured by Sun Life. The Group Benefits Administration (GBTA) Team at Sun Life is there to help The GBTA Team can: help you enrol in the plan answer any questions you may have Benefits and claims information at your fingertips For more information about your group benefits or claims, please call Sun Life's GBTA Team directly at We're on the Internet! Learn more by surfing Sun Life's website. There's information about group benefits, and about Sun Life's products and services... and a whole lot more! Check us out! Our address is: Accessing your records As required by legislation, for insured benefits, if you reside in Alberta or British Columbia, you may obtain copies of the following documents: your enrolment form or application for insurance. any written statements or other record, not otherwise part of the application, that you provided to Sun Life as evidence of insurability. For insured benefits, on reasonable notice, you may also request a copy of the policy. The first copy will be provided at no cost to you but a fee may be charged for subsequent copies. All requests for copies of documents should be directed to one of the following sources: our Sun Life Financial Plan Member Services website at our Sun Life Financial Customer Care centre by calling toll-free at Your Group Benefits Booklet 1

5 Respecting your privacy At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contract(s) with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, our reinsurers or any other person whom you authorize. In some instances these persons may be located outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us. You have a choice To find out about our Privacy Policy, visit our website at or to obtain information about our privacy practices, send a written request by to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto ON M5V 3C5. The statements in this booklet are only a summary of some of the provisions in the master policy. If you need further details on the provisions which apply to your group benefits you must refer to the master policy (available from the GBTA Team at Sun Life). Your Group Benefits Booklet 2

6 Overview Division Class Post-1992 Grandfathered UCC Surviving Spouses Post-1992 Grandfathered UCC Retirees Pre-1991 Grandfathered UCC Surviving Spouses Pre-1991 Grandfathered UCC Retirees /1992 Grandfathered UCC Surviving Spouses /1992 Grandfathered UCC Retirees Overview 1

7 F bf03v General Information Eligibility A retired employee is eligible, and continues to be eligible, to be a member while you meet all of the following conditions: 1. You are a member immediately before your date of retirement. 2. You are a resident of Canada. 3. You meet the criteria set up by the plan sponsor. A survivor is eligible, and continues to be eligible to be a member while you meet all of the following conditions: 1. Your spouse was a member immediately before his death. 2. You are a resident of Canada. 3. You meet the criteria set up by the plan sponsor. Waiting Period nil You are eligible, and continue to be eligible, for dependant coverage while you meet all of the following conditions: 1. You are a member. 2. You have at least one dependant. 3. Your dependants are residents of Canada. Definitions Dependant means your spouse or a dependent child of you or your spouse. Your dependent must have been covered as your dependent under your employer s group plan on the day proceeding your retirement or death. Dependent child means a natural, adopted or step-child who is not married or in any other formal union recognized by law, who is entirely dependent on you for maintenance and support and who is 1. under 21 years of age, 2. under 26 years of age and attending a college or university full-time, or 3. physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on you for maintenance and support and while eligible under 1) or 2) above. He, his and him refer to both genders. Spouse means your spouse by marriage or under any other formal union recognized by law, or a person of the opposite or same sex who is living with and has been living with you in a conjugal relationship. Effective Date (Divisions 777, 888 and 999) Your coverage is effective on the date you retire. Your dependant coverage is effective on the date you request dependent coverage. Termination of Coverage Your coverage could terminate for a number of reasons. For example, you are no longer eligible, the provision or the policy terminates. General Information (bf03v) F-1 October 1, 2012 (83140/150028)

8 A ba00s Section 1. Insured Provisions Summary of Insurance Policy Number Divisions 777, 888 and 999 Dow UCC Grandfathered Retirees Life Insurance (All Classes) Class of Members Benefit Formula Maximum Benefit All Retirees -- amount as determined by the policyholder Termination of Insurance: none Summary of Insurance (ba00s) A-1 October 1, 2012 (83140)

9 G bg02v013 Member Life Insurance Provision Benefit The amount of benefit will be paid to your beneficiary upon your death. If no beneficiary has been appointed or if the beneficiary has predeceased you, payment will be made to your estate. A minor cannot personally receive a death benefit under the plan until reaching the age of majority. If you reside outside Québec and are designating a minor as your beneficiary, you may wish to designate someone to receive the death benefits during the time your beneficiary is a minor. If you reside outside Québec and have not designated a trustee, current legislation may require Sun Life to pay the death benefit to the court or to a guardian or public trustee. If you reside in Québec, the death benefit will be paid to the parent(s)/legal guardian of the minor on the minor s behalf. Alternatively, you may wish to designate the estate as beneficiary and provide a trustee with directions in your will. You are encouraged to consult a legal advisor. Claims A death claim must be received by Sun Life within 6 years of the date of death. The claimant must submit proof of the claim and the right to receive the benefit to Sun Life. Except where or when applicable legislation permits the use of a different limitation period, every action or proceeding against an insurer for the recovery of insurance money payable under the policy is absolutely barred unless commenced within the time set out in the Insurance Act or the time set out in such other legislation as may apply to a claim, action or proceeding for insurance money. Where or when applicable legislation permits the use of a different limitation period, no legal action or proceeding may be brought against Sun Life: 1. regarding any claims for which no payment has been made by Sun Life, more than one year after the end of the time period in which the initial submission of proof of claim is required by the terms of the policy, or 2. regarding claims for which some payment has been made by Sun Life, more than one year after the last payment made by Sun Life with respect to the claim. At Termination If your Life Insurance ends for any reason other than your request, you may apply to convert the group Life Insurance to an individual Life policy with Sun Life without providing evidence of insurability. The request must be made within 31 days of the reduction or end of the Life Insurance. There are a number of rules and conditions in the group policy that apply to converting this insurance, including the maximum amount that can be converted please contact the GBTA Team at Sun Life or the nearest Sun Life office for details. Member Life Insurance Provision (bg02v013) G-1 October 1, 2012 (83140/83141)

10 A1 aa00s Section 2. Administered Services Summary of Benefits Plan Number Extended Health Part Benefit per person Deductible per family unit Reimbursement Maximum A Drug $10* $20* 90% $10,000** C D Hospital: ward to semi-private Supp. Health Care and Out-of-Province Emergency none none 100% -- $10* $20* 90% $10,000** *The deductible applies per calendar year. The deductible applies to the combined eligible expenses of Parts A and D. **The maximum lifetime amount payable applies to the combined eligible expenses incurred under Parts A and D for you and each covered dependant. After the $10,000 maximum has been reached, an amount of $1,000 will be reinstated on January 1 st of the following year. If any portion of the $1,000 is paid during the calendar year, the amount will be reinstated on January 1 st of the following year, subject to the $1,000 yearly maximum. Other maximums are listed under the appropriate Provision page. Termination Age: none Drug coverage for Québec residents For all members under age 65 and members age 65 and over who are not covered by the Québec Drug Insurance Plan of the Régie de l'assurance-maladie du Québec (RAMQ) In addition to the above provisions, the following applies to the Drug Benefit for Québec residents who purchase an eligible drug that is included on the Régie de l'assurance-maladie du Québec (RAMQ) formulary: Annual Out-of-Pocket Maximum: The maximum for out-of-pocket eligible expenses is limited to the amount specified by law and applied in the provincial drug plan administered by the RAMQ. The annual out-of-pocket maximum amount applies separately to each adult under the plan. However, your out-of-pocket maximum includes expenses for each dependent child. Out-of-pocket eligible expenses include any deductible and co-payment. Lifetime/Annual Maximum: The combined lifetime/annual maximum does not apply to the Drug Benefit. Deductible: The deductible is applied up to the annual out-of-pocket maximum and will not apply after the annual maximum has been reached. Reimbursement: The reimbursement percentage is applied up to the annual out-of-pocket maximum. After the annual maximum is reached, eligible expenses will be reimbursed at 100%. The reimbursement percentage applies after any deductibles have been satisfied. Termination Age: none if you meet all of the conditions of Eligibility Summary of Benefits (aa00s) A1-1

11 M am01v032 Extended Health Provision Benefit Te qualify for the Extended Health coverage, you or your dependant must be entitled to benefits under a provincial medicare plan, or federal government plan, or Inpatriate Health Plan approved by Sun Life that provides similar benefits. You will be reimbursed when you submit proof to Sun Life that you or your covered dependant has incurred any of the eligible expenses for medically necessary services required for the treatment of disease or bodily injury. To determine the amount payable, the total amount of eligible expenses you claim will be adjusted as follows: 1. the maximums described throughout the extended health benefit provisions are applied, 2. then the deductible, which must be satisfied each calendar year, is subtracted, and 3. the reimbursement percentage is applied. The intentional omission, misrepresentation or falsification of information relating to any claim constitutes fraud. Co-ordination of Benefits If you or your dependants are covered under this plan and another plan, Sun Life will co-ordinate benefits under this plan with the other plan following insurance industry standards. These standards determine which plan you should claim from first. The plan that does not contain a co-ordination of benefits clause is considered to be the first payer and therefore pays benefits before a plan which includes a co-ordination of benefits clause. For dental accidents, health plans with dental accident coverage pay benefits before dental plans. Following payment under another plan, the amount of benefit payable under this plan will not exceed the total amount of eligible expenses incurred less the amount paid by the other plan. Where both plans contain a co-ordination of benefits clause, claims must be submitted in the order described below. Claims for you and your spouse should be submitted in the following order: 1. the plan where the person is covered as an employee. If the person is an employee under two plans, the following order applies: the plan where the person is covered as an active full-time employee, the plan where the person is covered as an active part-time employee, the plan where the person is covered as a retiree. 2. the plan where the person is covered as a dependant. Claims for a dependent child should be submitted in the following order: 1. the plan where the dependent child is covered as an employee, 2. the plan where the dependent child is covered under a student health or dental plan provided through an educational institution, 3. the plan of the parent with the earlier birth date (month and day) in the calendar year, 4. the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date. The above order applies in all situations except when parents are separated/divorced and there is no joint custody of the dependent child, in which case the following order applies: 1. the plan of the parent with custody of the dependent child, 2. the plan of the spouse of the parent with custody of the dependent child, Extended Health Provision (am01v032) M-1

12 3. the plan of the parent not having custody of the dependent child, 4. the plan of the spouse of the parent not having custody of the dependent child. When you submit a claim, you have an obligation to disclose to Sun Life all other equivalent coverage that you or your dependants have. Claims A claim must be received by Sun Life within 18 months of the date that the expense is incurred. However, if your coverage terminates, any claim must be received by Sun Life no later than 90 days following the end of the coverage. For the assessment of a claim, itemized bills, attending physician statements or other necessary information are required. If your physician is recommending medical treatment that is expected to cost more than $1,000, you should request preauthorization to ensure that the expenses are covered. There is a time limit for proceedings against Sun Life for payment of a claim. A proceeding must be started within 1 year of Sun Life s receipt of the proof of claim. Exclusions No benefit is payable for expenses for which benefits are payable under a Workers' Compensation Act, Workplace Safety and Insurance Act or a similar statute, expenses incurred due to intentionally self-inflicted injuries, expenses incurred due to civil disorder or war, whether or not war was declared, expenses for services and products, rendered or prescribed by a person who is ordinarily a resident in the patient's home or who is related to the patient by blood or marriage, expenses for services or supplies payable or available (regardless of any waiting list) under any governmentsponsored plan or program, except as described below under Integration with Government Programs, expenses for services or supplies that are not approved by Health Canada or other government regulatory body for the general public, expenses for services or supplies that are not generally recognized by the Canadian medical profession as effective, appropriate and required in the treatment of an illness in accordance with Canadian medical standards, expenses for services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada), out-of-province expenses for elective (non-emergency) medical treatment or surgery, a portion of expenses for which reimbursement is made due to the legal liability of another party, eyeglasses, hearing aids, eye refractions and the fitting of eyeglasses and hearing aids, acupuncture. claims for an illness resulting from any work for which you were compensated that was not done for the employer who is providing this plan. Integration with Government Programs This plan will integrate with benefits payable or available under the government-sponsored plan or program (the government program). The covered expense under this plan is that portion of the expense that is not payable or available under the government program, regardless of: whether you or your dependant have made an application to the government program, whether coverage under this plan affects your or your dependant s eligibility or entitlement to any benefits under the government program, or any waiting lists. At Termination (Divisions 777, 888 and 999) If you die, your surviving spouse on the plan will be offered the opportunity to enrol for Basic Medical coverage. They will be contacted by the GBTA team. Extended Health Provision (am01v032) M-2

13 My Health CHOICE Coverage If your coverage under this plan terminates because your employment has ended, you may purchase Sun Life's My Health CHOICE coverage. This coverage is different from your group plan. To be eligible for My Health CHOICE coverage, you must: apply for My Health CHOICE coverage within 60 days after the termination of your coverage, be under age 75 on the date you apply, and be a resident of Canada and be covered under the provincial health plan. My Health CHOICE coverage may also include Dental coverage if you were covered for both Extended Health Care and Dental Care benefits under this group plan, and both benefits terminated. You may cover your spouse and dependents if those family members were covered under your group plan. Your spouse must be under age 75 on the date you apply for this coverage. From time to time, Sun Life may review the eligibility requirements and, on the date you apply for My Health CHOICE coverage, they may be different from those listed in this booklet. To apply for My Health CHOICE or if you have any questions, please call our Customer Solutions Centre at Extended Health Provision (am01v032) M-3

14 N an01s032 Extended Health - Comprehensive Drug Benefit Eligible Expenses Eligible expenses are the reasonable and customary charges for the following items of expense, provided they are medically necessary for the treatment of disease or injury, prescribed by a physician or dentist and dispensed by a registered pharmacist or physician. Drugs covered under this benefit must have a Drug Identification Number (DIN) in order to be eligible. 1. drugs, including over-the-counter drugs. 2. injectible drugs. 3. compounded preparations, provided that the principal active ingredient is an eligible expense and has a DIN. 4. needles, syringes, and chemical diagnostic aids for the treatment of diabetes. Régie de l'assurance-maladie du Québec (RAMQ) Formulary Drugs for Québec Residents In addition to the above eligible expenses, this benefit includes all drugs covered by Québec's basic drug formulary, as established by the RAMQ. The minimum reimbursement percentage required by provincial legislation is applied up to the annual out-of-pocket maximum, as specified by law. This formulary is reviewed on a regular basis and is subject to change as new drugs and drug products are introduced. For Québec residents, any maximums included in this benefit do not apply to eligible drugs covered by the RAMQ formulary. Other Health Professionals Allowed to Prescribe Drugs Certain drugs prescribed by other qualified health professionals will be reimbursed the same way as if the drugs were prescribed by a physician or a dentist if the applicable provincial legislation permits them to prescribe those drugs. Exclusions No benefit is payable for 1. the portion of expenses for which reimbursement is provided by a government plan, 2. expenses for drugs which, in Sun Life's opinion, are experimental, 3. expenses for publicly advertised items or products which, in Sun Life's opinion, are household remedies, 4. expenses for contraceptives (other than oral), 5. expenses for vitamins, minerals, protein supplements and therapeutic nutrients, 6. expenses for diets and dietary supplements, infant foods and sugar or salt substitutes, 7. expenses for lozenges, mouth washes, non-medicated shampoos, contact lens care products and skin cleansers, protectives and emollients, 8. expenses for surgical supplies and diagnostic aids, 9. expenses for drugs which are used for cosmetic purposes, 10. expenses for drugs used for the treatment of sexual dysfunction, 11. expenses for drugs used for the treatment of obesity, 12. expenses for natural health products, whether or not they have a Natural Product Number (NPN), 13. expenses for drugs and treatments, and any services and supplies relating to the administration of the drug and treatment, administered in a hospital, on an in-patient or out-patient basis, or in a government-funded clinic or treatment facility, and 14. expenses incurred under any of the conditions listed on the Extended Health Provision page as an Exclusion. Extended Health - Comprehensive Drug Benefit (an01s032) N-1

15 P ap01v032 Extended Health - Hospital Benefit Definitions Hospital means a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury, on an in-patient basis, with 24 hour services by registered nurses and physicians. This includes legally licensed hospitals providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons when approved by Sun Life. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care. Reasonable and customary charges mean those which are usually made to a person without coverage for the items of expense listed under Eligible Expenses and which do not exceed the general level of charges in the area where the expense is incurred. Eligible Expenses Eligible expenses mean reasonable and customary charges for: 1. hospital room and board charges up to the difference between the charges for public ward and semi-private accommodation for each day of hospitalization. 2. hospital charges for that portion of the cost of public accommodation which the hospital must bill directly to the patient, according to the provincial government regulations. Exclusions No benefit is payable for 1. expenses incurred under any of the conditions listed on the Extended Health Provision page as an Exclusion. Extended Health - Hospital Benefit (ap01v032) P-1

16 Q aq01v027 Extended Health - Supplementary Health Care Benefit Definitions Chiropodist, Podiatrist means a person licensed by the appropriate provincial licensing authority. Chiropractor means a member of the Canadian Chiropractic Association or of a provincial association affiliated with it. Hospital means a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury, on an in-patient basis, with 24 hour services by registered nurses and physicians. This includes legally licensed hospitals providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons when approved by Sun Life. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care. Naturopath means a member of the Canadian Naturopathic Association or any provincial association affiliated with it. Osteopath means a person who holds the degree of doctor of osteopathic medicine from a college of osteopathic medicine approved by the Canadian Osteopathic Association or a person who holds a Diploma in Osteopathic Manual Practice (DOMP). Physician means a person who is licensed to practice medicine. Physiotherapist means a member of the Canadian Physiotherapy Association or of a provincial association affiliated with it. Psychologist means a permanently certified psychologist who is listed on the appropriate provincial registry in the province in which the service is rendered. Reasonable and customary charges mean those which are usually made to a person without coverage for the items of expense listed under Eligible Expenses and which do not exceed 1. the general level of charges in the area where the expense is incurred, or 2. for eligible expenses incurred outside Canada, the general level of charges for comparable services in the person's province of residence Registered Massage Therapist means a person licensed by the appropriate provincial licensing body or in the absence of a provincial licensing body, a person whose qualifications Sun Life determines to be comparable with those required by a licensing body. Registered Nurse, Registered Nursing Assistant, Licensed Practical Nurse means a nurse, nursing assistant or practical nurse who is listed on the appropriate provincial registry. Speech Language Pathologist means a person who holds a master's degree in Speech Language Pathology and is a member or is qualified to be a member of the Canadian Speech and Hearing Association or any provincial association affiliated with it. Extended Health - Supplementary Health Care Benefit (aq01v027) Q-1

17 Eligible Expenses Eligible expenses mean reasonable and customary charges for the following items of expense, provided they are prescribed by a physician: 1. services of a registered nurse (R.N.) provided in the patient's home. If a registered nurse is not available when required, expenses incurred for the nursing services of a registered nursing assistant (R.N.A.) or licensed practical nurse (L.P.N.) in the patient's home shall be considered eligible. 2. services of a massage therapist up to $8 per visit limited to $200 in a calendar year. 3. rental or purchase of wheel chair, at Sun Life's option, and wheel chair repairs. 4. rental, or purchase at Sun Life s option, of medically necessary durable equipment that meets the patient s basic medical needs and is approved by Sun Life. If alternate durable equipment is available, eligible expenses are limited to the cost of the least expensive equipment that meets the patient s basic medical needs. 5. trusses, crutches and braces, including spencer type corsets. 6. artificial limbs or other prosthetic appliances, including colostomy supplies. 7. birth control devices. 8. oxygen, blood, plasma, and their administration. 9. elastic support stockings. 10. heart pacemaker. 11. diagnostic laboratory and x-ray examinations. 12. wigs and hairpieces when required as a result of medical treatment, limited to a lifetime maximum of $ licensed ground ambulance service to and from the nearest hospital equipped to provide the required treatment, when the physical condition of the patient prevents the use of another means of transportation. 14. emergency ambulance service by a licensed ambulance, air ambulance, or by any other vehicle normally used for public transportation, to the nearest hospital equipped to provide the required treatment, limited to one return trip in a calendar year and limited to the charge made in the area where the expense is incurred. Only expenses incurred in Canada, the United States or Puerto Rico are eligible. Licensed ground ambulance service to and from the points of departure and arrival is also considered eligible. Eligible expenses also mean reasonable and customary charges for the following items of expense: 1. services of a speech therapist up to $25 for the initial visit, and up to $8 for subsequent visits limited to $200 in a calendar year. 2. services of a psychologist. 3. services of a dental surgeon, including dental prosthesis, required for the treatment of a fractured jaw or for the treatment of accidental injuries to natural teeth if the fracture or injury was caused by external, violent and accidental means, provided a detailed treatment plan including x-rays is received within 12 months of the accident and the services are performed while the patient is covered under this plan, but excluding services required in conjunction with such fracture or injury due to a condition that existed before the accident. 4. services of a chiropractor provided no portion of a charge for these services is payable under a government plan, up to $8 per visit and one x-ray examination up to $15, limited to $200 in a calendar year. 5. services of an osteopath provided no portion of a charge for these services is payable under a government plan, up to $8 per visit and one x-ray examination up to $15, limited to $200 in a calendar year. 6. services of a podiatrist, provided no portion of a charge for these services is payable under a government plan up to $8 per visit, limited to $200 in a calendar year. In addition, up to $100 for the surgical removal of toe nails, or the excision of plantar warts. 7. services of a naturopath provided no portion of a charge for these services is payable under a government plan, up to $8 per visit, limited to $200 in a calendar year. 8. services of a physiotherapist. The practitioner must be registered with the appropriate association or registry. Where applicable, expenses for practitioners' services eligible under a provincial health care plan will not be reimbursed until your expenses exceed the annual maximums under your provincial plan. 9. orthopaedic shoes which are part of a brace, including modifications to these, provided that the shoes or modifications are prescribed by a physician or podiatrist. Extended Health - Supplementary Health Care Benefit (aq01v027) Q-2

18 10. orthopaedic shoes when they do not form part of a brace or specially adjusted shoes for the patient, provided the shoes are prescribed by a physician or podiatrist, limited to one pair per year. 11. orthotics, when they are required for the correction of deformity of the bones and muscles and provided they are not solely for athletic use and are prescribed by a physician, podiatrist, chiropodist or chiropractor, limited to one pair in a calendar year. 12. hospital room and board charges up to the difference between the charges for semi-private and private accommodation for each day of hospitalization. 13. hospital charges incurred as an out-patient, excluding physician's or special nurse's fees. Extended Health - Supplementary Health Care Benefit (aq01v027) Q-3

19 Q1 aqoopv33 Extended Health - Out-of-Province Emergency Benefit To be covered for this benefit, you and your covered dependant must have provincial health care coverage. Expenses for hospital/medical services are eligible if 1. they are incurred as a result of emergency treatment of a disease or injury which occurs outside your home province, and 2. they are medically necessary. Definitions Emergency means an acute illness or accidental injury that requires immediate, medically necessary treatment prescribed by a physician. Emergency services mean any reasonable medical services or supplies, including advice, treatment, medical procedures or surgery, required as a result of an emergency. When you or your covered dependant has a chronic condition, emergency services do not include treatment provided as part of an established management program that existed prior to leaving your province of residence. Family member means you or your covered dependant. Reasonable and customary charges mean those which are usually made to a person without coverage for the items of expense listed under Eligible Expenses and which do not exceed the general level of charges in the area where the expense is incurred. Emergency Services At the time of an emergency, the family member or someone with the family member must contact Sun Life's Emergency Travel Assistance provider, Europ Assistance USA, Inc. (Europ Assistance). All invasive and investigative procedures (including any surgery, angiogram, MRI, PET scan, CAT scan), must be pre-authorized by Europ Assistance prior to being performed, except in extreme circumstances where surgery is performed on an emergency basis immediately following admission to a hospital. If contact with Europ Assistance cannot be made before services are provided, contact with Europ Assistance must be made as soon as possible afterwards. If contact is not made and emergency services are provided in circumstances where contact could reasonably have been made, then we have the right to deny or limit payments for all expenses related to that emergency. Neither we nor Europ Assistance is responsible for the availability, quality or results of the medical treatment received by the family member, or for the failure to obtain medical treatment. An emergency ends when the family member is medically stable to return to his province of residence. Emergency Services Excluded from Coverage Any expenses related to the following emergency services are not covered: 1. services that are not immediately required or which could reasonably be delayed until the family member returns to his province of residence, unless his medical condition reasonably prevents him from returning to his province of residence prior to receiving the medical services. 2. services relating to an illness or injury which caused the emergency, after such emergency ends. 3. continuing services arising directly or indirectly out of the original emergency or any recurrence of it, after the date that we or Europ Assistance, based on available medical evidence, determines that the family member can be returned to his province of residence, and he refuses to return. Extended Health - Out-of-Province Emergency Benefit (aqoopv33) Q1-1

20 4. services which are required for the same illness or injury for which the family member received emergency services, including any complications arising out of that illness or injury, if the family member had unreasonably refused or neglected to receive the recommended medical services. 5. where the trip was taken to obtain medical services for an illness or injury, services related to that illness or injury, including any complications or any emergency arising directly or indirectly out of that illness or injury. Eligible Expenses for Hospital/Medical Services Eligible expenses mean reasonable and customary charges for the following items of expense incurred for emergency services, less the amount payable by a government plan: 1. public ward accommodation and auxiliary hospital services in a general hospital, 2. services of a physician, limited to 31 days per period of disability. Expenses that are included as Eligible Expenses under Drug, Hospital or Supplementary Health Care benefits are also eligible while you or your covered dependant is travelling outside Canada. These expenses are subject to the deductibles and reimbursement percentages listed under the appropriate benefit in the Summary of Benefits. Claims for Eligible Hospital/Medical Services 1. pay for the expense as soon as it is incurred, 2. submit your claim to the provincial health care plan for consideration, 3. submit any unpaid amounts of your claim to Sun Life. Exclusions and Limitations No benefit is payable for 1. expenses incurred on a non-emergency or referral basis, 2. expenses incurred under any of the conditions listed as an Exclusion in the Extended Health Provision. Extended Health - Out-of-Province Emergency Benefit (aqoopv33) Q1-2