COMMERCIAL WORKERS BENEFIT TRUST FUND

Transcription

1 COMMERCIAL WORKERS BENEFIT TRUST FUND DESCRIPTION OF BENEFIT PLAN FOR THE EMPLOYEES OF HOST INTERNATIONAL OF CANADA LTD. JUNE 2018

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3 TABLE OF CONTENTS DESCRIPTION OF BENEFITS Life Insurance... 5 Accidental Death and Dismemberment... 5 Dental... 5 Health... 6 GENERAL PROVISIONS Employee Eligibility... 8 Classification... 8 Dependent Eligibility... 8 Effective Date of Coverage... 9 Absence from Work... 9 Termination of Benefits Continuation of Health Care and Dental Benefits for Incapacitated Children COVERAGE DETAILS Employee Life Insurance Employee Accidental Death and Dismemberment Dental Care Health Care OTHER PLAN PROVISIONS Extension of Benefits Coordination of Benefits Claim Provisions

4 WELCOME ALL ELIGIBLE MEMBERS The Board of Trustees of the Commercial Workers Benefit Trust Fund is pleased to sponsor the benefit plan ( the Plan ) as outlined in this description of benefits. The Plan provides extended health care, dental care, death and accidental death benefits for the full-time bargaining unit employees of Host Canada. This booklet summarizes the benefits to which you are entitled under the Plan. It also provides an explanation of the rules regarding eligibility and the procedure to follow when you submit a claim. The information contained in this booklet does not create or confer any contractual or other rights. All claims are considered and paid in accordance with the Plan documentation. The Trustees have the full authority to resolve all questions related to the provisions of the Plan, and may, from time to time, amend it. Claims and/or any questions you may have regarding the Plan can be submitted to the office of the Plan Administrator at the address noted below or you can visit your Plan website at 61 International Blvd. Suite 110, Toronto, Ontario M9W 6K4 Phone: (416) Fax: (416) A WORD ABOUT YOUR CLAIMS To help you avoid lengthy delays we would like to suggest certain steps you should take before submitting a claim: READ THIS BOOKLET CAREFULLY. ENSURE THAT YOU HAVE PROVIDED ALL THE INFORMATION REQUESTED ON THE CLAIM FORM. ENSURE THAT YOU HAVE INCLUDED ALL RECEIPTS, INVOICES, ETC. BEFORE YOU MAIL YOUR CLAIM. CALL THE PLAN ADMINISTRATOR IF YOU HAVE ANY QUESTIONS. 3

5 PLAN REGISTRATION CARD All new members are asked to complete and sign (in ink) a Plan Registration Card and return it to the office of the Administrator. Plan Registration Cards may be obtained through your employer, local union office or by contacting the Administrator. If any of the information on the Registration Card changes, please complete and remit a new card to the office of the Administrator as soon as possible. Registration Cards can also be completed and submitted via the new Member Portal NOTE: IN THE EVENT THAT THE ADMINISTRATOR DOES NOT RECEIVE A BENEFICIARY DESIGNATION, LIFE INSURANCE BENEFITS MUST BE PAID TO YOUR ESTATE AND WILL BE SUBJECT TO AN OTHERWISE AVOIDABLE PROBATE FEE. PRIVACY POLICY Participation in the Plan depends on the collection, storage, use, and sometimes the destruction of personal information about you the Member, your dependants and beneficiaries. It forms the foundation upon which individual entitlements are built, and from which benefit payments are calculated and made. As well, segments of this personal information may be needed to satisfy government demands for facts, to facilitate audits of the Plan, to estimate future operating costs, to inform Members about their accumulated values, and to transfer data to any replacement program. As well, the information could be called into a court action. In all cases, however, your personal information is stored with the utmost attention to security and deployed sparingly, to fulfill the requirements of the Plan and the law. Registration to participate in the Plan involves an authorization to allow the Trustees to gather and apply personal information in specific ways. You may revoke this authorization, subject to certain legal constraints. However, doing so precipitates the destruction of your personal information file and may, therefore, render ongoing participation impossible. Complaints regarding personal information may be directed to the Administrator s Privacy Officer at the address noted on the previous page, by contacting the Office of the Privacy Commissioner of Canada or, if applicable, the Provincial Commissioner. 4

6 COVERAGE SCHEDULE LIFE INSURANCE Classification Amount All eligible active full-time hourly airport employees: $20,000 ACCIDENTAL DEATH & DISMEMBERMENT Classification Amount All eligible full-time hourly airport employees: $20,000 DENTAL CARE BENEFITS Classification All eligible full-time hourly airport employees of Host Canada and their eligible dependents. Fee Guide Payments will be based on the Dental Association Fee Guide for Dental Practitioners of the insured person s Province of residence for the year prior to the year in which the expense was incurred. Amount Calendar Year deductible Nil Percentage payable Basic Preventative 100% Major Restorative 50% Orthodontic (Children Under 18 years) 50% Benefit Maximum (per calendar year) Basic Preventative and $2,000 Major Restorative Combined Orthodontic Lifetime Maximum $2,000 5

7 HEALTH CARE BENEFITS Classification All eligible active hourly airport employees of Host Canada under age 70 and their eligible dependents. Amount Calendar Year Deductible $10 per person but not (does not apply to vision care) more than $20 per family Percentage Payable Out of country referral 80% All covered charges As indicated Hospital (within home province) Room and board limit (100%) semi-private Out-of-Hospital nursing benefit Maximum (per calendar year) (100%) $10,000 Health Practitioners Benefit Maximums (All claims for health practitioners must be accompanied by a written referral from a Medical Doctor (M.D.) Chiropractor, Osteopath, $500 per type of Acupuncturist, Chiropodist, practitioner per year Podiatrist, Naturopath, Registered Massage Therapist, Speech Therapist, Psychologist and Christian Science Practitioner (80%) Physiotherapist (100%) $500 per calendar year Ophthalmologist or $25 per 2 calendar Optometrist (80%) year period Mammary prostheses $200 (per calendar year) (100%) 6

8 Out-of-Province Benefit Maximum (per lifetime) (100%) $1,000,000 Emergency care Hospital Maximum Stay 14 days* Hospital Room and Board Limit In Canada semi-private Out of Canada average semi-private On referral (100%) Benefit duration Hospital Room and Board Limit 60 days semi-private *does not apply if licensed doctor (MD) certifies that the insured person should not be moved back to such person s home Province Amount Hearing Care Benefit Maximum (in any 60-month period) (100%) $500 Vision Care (100%) (in any 24-month period) $250 or per 12-month period if under age 18 $150 Foot Care Annual Benefit Maximums (All claims for orthopedic shoes and orthotics must be accompanied by a written referral from a Medical Doctor (M.D.), and dispensed by a registered Podiatrist or Chiropodist. Orthopedic Shoes (1 Pair per calendar year - 100%) $150 Orthotic devices (100%) $300 Prescription Drug Care Maximum $10,000 per calendar year 7

9 GENERAL PROVISIONS Employee eligibility To be eligible for insurance an employee must be: an active permanent employee working full-time for at least 24 hours per week and not working on a seasonal basis; a member of the United Food and Commercial Workers International Union and employed by Host International of Canada Ltd. who is obligated, by virtue of a collective agreement to remit contributions to the plan; in a class shown in the Schedule of Benefits listed below; and insured under a Provincial Health Insurance Plan. An employee will be come eligible for insurance upon completion of 12 months of continuous employment. Classification Active full-time hourly airport employees 8 Dependent Eligibility To be eligible for Plan coverage your dependent must be covered under a Provincial Health Insurance Plan. Your dependent becomes eligible for coverage when you become eligible or, if acquired later, upon becoming your dependent. You must be covered in order for your dependents to be covered. Dependent means a spouse/partner or unmarried child at least 24 hours of age but under age 21 years (under age 25, if regularly attending school and solely dependent upon the employee for support). Spouse means a husband or wife by virtue of a religious or civil marriage ceremony; except that, a person living with the employee will be deemed to be the employee s spouse, if such person: is publicly represented as the employee s spouse/partner; and, has been living with the employee for a period of at least one continuous year.

10 Child means: a naturally or legally adopted child; or, a stepchild or other child, who is dependent upon the employee for support and lives with the employee in a regular parent-child relationship. Effective Date of Coverage An employee s coverage will become effective on the date the employee becomes eligible. If the employee is absent from work because of disability due to illness or injury on the date the employee s insurance, or any increase in such insurance, would otherwise become effective, such insurance will not become effective until the date the employee returns to active full-time work for 1 full day. Coverage, or any increase in coverage, for your dependent (other than a new-born child who becomes covered within 31 days of becoming eligible) who is confined in a hospital because of illness or injury on the date such coverage would otherwise become effective, will not become effective until the date such dependent is no longer confined. Absence From Work You and your dependents may continue to be covered, at the option of the Board of Trustees and subject to continued contributions, if your absence from work is not due to termination of employment or retirement. For absence due to illness or injury, coverage will be continued by the Fund for up to 24 months from the first of the month in which such absence began. For absence due to approved temporary leave without pay, you may continue all benefits, but not beyond 12 months from the date such absence began. For absence due to approved temporary leave without pay for Union activities, all Benefits may be continued by the Local Union. For absence due to maternity or parental leave, all benefits will be continued for the period of such leave, provided the required contributions are remitted by your employer. 9

11 For absence due to temporary lay-off with the right to recall, coverage will not be continued during such a period of absence, but if you are recalled back to work you will not have to meet the initial eligibility requirements. For absences due to permanent lay-off (as defined in the Ontario Employment Standards Act) coverage of all benefits will continue by the Fund for up to 3 months from the end of the month in which such lay-off began. Termination of Benefits Coverage for you and your dependents will terminate on the earliest of, the date: you retire; or, your employment terminates or you cease active work, except as noted under the Temporary Absence from Work provision; or, you cease to be a member of an eligible class; or, premium payments cease; or, this plan is discontinued. Coverage for your dependents will terminate on the date such dependents cease to be eligible. Continuation of Health Care and Dental Care Benefits for Incapacitated children Health Care and Dental Care benefits will continue beyond the date an unmarried child attains the limiting age for coverage, provided proof is submitted to the Plan Administrator within 31 days after such date that such child: is incapable of self-sustaining employment by reason of mental retardation or physical handicap; became so incapacitated prior to the attainment of the limiting age; and, is chiefly dependent upon you for support and maintenance. Thereafter, such proof must be submitted to the Plan Administrator as required, but not more often than yearly. 10

12 EMPLOYEE LIFE INSURANCE BENEFIT (See schedule for amount) Death Provision If you die while covered, your Employee Life Insurance will be paid to your named beneficiary(ies), if living, otherwise to your estate. Disability Provision If you: become Totally and Permanently disabled while insured; continue to be so disabled for the next 6 months; and are under age 65; the Employee Life Insurance at the time the employee becomes so disabled will continues while so disabled, but not beyond the employee s 65 th birthday, subject to any reduction or termination indicated in the Schedule due to a change in class. The insured employee must submit proof satisfactory to the Insurance Company, within 12 months of the date of cessation of active work, that you are so disabled. From then on proof satisfactory to the Insurance Company must be submitted, as required, that you are still so disabled. Totally and Permanently disabled means that solely because of an illness or injury, you are, and will continue to be, unable to work at any occupation for which you are, or may reasonably become, fitted by education, training and experience. 11

13 Conversion Option If your employee Life Insurance reduces or terminates, you may be eligible to convert the terminated amount to an individual life insurance policy without a medical examination or health questionnaire being required. The eligibility requirements, the type of policy and the amount of coverage that you may convert are described in the Contract issued to the Board of Trustees. Contact the Plan Administrator or the nearest office of the Insurance Company for details. Written application, together with the initial premium due, must be submitted to the Insurance Company within 31 days of the date your Employee Life Insurance terminates. Extension of Benefit If you die within 31 days of the date your Employee Life Insurance terminates, the amount the employee could have converted will be paid as a death benefit under this plan even if you did not apply for conversion. 12

14 EMPLOYEE ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT (see schedule for amount) If an employee sustains an accidental bodily injury while insured and if an insured loss occurs as a direct result of the accident, the amount shown in the Table of Benefits will be paid to the employee, if living, otherwise to the named beneficiary(ies), if living, or the employee s estate: For loss of: Percentage of Amount Covered Life 100% Both hands or both feet 100% Both arms or both legs 100% Sight of both eyes 100% One leg 75% One arm 75% One hand 50% One foot 50% Sight of one eye 50% Speech 50% hearing in both ears 50% thumb and index finger of same hand 33% For loss of, or loss of use of: Both legs 100% Both arms 100% Both hands 100% Both feet 100% One leg 75% One arm 75% One hand 50% One foot 50% No more than the largest percentage shown for a body member will be paid for the loss of more than one part thereof. Not more than 100% will be paid for all losses sustained in any one accident. 13

15 Loss of an arm or leg means severance at or above the elbow or knee joint; loss of a hand or foot means severance at or above the wrist or ankle joint; loss of a thumb, finger or toe means severance of the entire digit; loss of sight, speech, hearing or loss of use means loss that is total, cannot be recovered, lasts at least 1 year and is deemed to be permanent. Exposure and Disappearance Loss due to exposure will not be deemed to be accidental if the exposure was a direct result of an accident. If you disappear as a direct result of the accidental disappearance, wrecking or sinking of the conveyance in which you were an occupant, accidental death will be deemed to have occurred; provided, there is no evidence within 1 year thereafter that you are still alive. Limitations No amount will be paid for a loss that results from or is contributed by: illness or disease of any kind; infection, unless the result of an accidental wound; medical or surgical treatment of other than accidental injury war, whether declared or not; insurrection, rebellion or participation in a riot or civil commotion; an accident that occurs while you are in the care or control of a motor vehicle where the insured employee s bloodalcohol level exceeds 80mg of alcohol in 100mL of blood; suicide or attempt thereat, while sane or insane; self-inflicted injury, while sane or insane; or your commission of, or attempt to commit, an assault or a criminal offence. 14

16 DENTAL CARE BENEFITS (See schedule for amounts) Percentage Payable This is the part of Covered Charges shown in the schedule that the Plan pays. Covered Charges are charges up to the amount shown in the Fee Guide for needed dental care, services or supplies, as described below, and received while the person is covered, for either a disease or injury that is not covered under any workers compensation law: BASIC PREVENTATIVE Charges up to the Benefit Maximum shown in the Schedule for: Oral examination Complete examination- limited to one during any 24 month period Recall examinations- must be separated by an interval of at least 9 months Specific examinations (once every 9 months) Emergency examinations Radiographs Complete series of radiographs and/or panographic x-rayslimited to one during any 24 month period Sets of bitewing radiographs- must be separated by an interval of at least 12 months Prophylaxes and topical fluoride applications- must be separated by an interval of at least 9 months and limited to two such treatments per calendar year Scaling (limited to 10 units per calendar year) Emergency or palliative services Diagnostic tests and laboratory examinations; Removal of impacted teeth and related anaesthesia Provision of space maintainers for missing primary teeth Pit and fissure sealants (under age 14) Oral hygiene instruction- must be separated by an interval of at least 9 months 15

17 Fillings- amalgam, composite, acrylic o equivalent Removal of teeth Repairs to crowns, provided not being replaced Root canal therapy Space Maintainers Surgery and related anaesthesia other than implants and transplants; or repositioning of the jaw. MAJOR RESTORATIVE Changes up to the Benefit Maximum shown in the Schedule for the following services. Major services such as crowns, inlays, onlays, bridges, dentures or alternates are eligible once every 5 years. Inlays and onlays Crowns and repairs to crowns other than preformed stainless steel crowns Repair of bridges or dentures Rebase or reline of an existing partial or complete denture; Bruxism appliances once evry 24 months. Periodontics- treatment of disease of the gum and other supporting tissues of the teeth Charges for replacement bridge or replacement standard denture are not considered a Covered Expense during the 5 year period following the construction or insertion of a previous bridge or standard denture, unless: it is needed to replace a bridge or standard denture which has caused tempormandibular joint disturbances, and which cannot be economically modified to correct the condition; Must be submitted or pre-authorization and submitted with clinical notes, images and/or x-rays; or it is needed to replace a transitional denture which was inserted following extraction of teeth and which cannot be economically modified to the final shape required. 16

18 ORTHODONTIC TREATMENT Charges up to the Benefit Maximum shown in the schedule for Dependent Children under 18 Years of Age include the following. Diagnostic procedures, including models Therapy and appliances, retainers, etc. Correction of malocclusion Habit breaking appliances OTHER DENTAL PRACTITIONERS Dental care, services or supplies must be rendered and dispensed by a licensed dentist, except that: scaling and cleaning of teeth may be done by a licensed dental hygienist; installation, adjustment, repair, relining or rebasing of dentures, may be done by a denturist, denture therapist, technician or mechanic, who is registered and practicing within the scope of their license. Charges for such care, services and supplies will be deemed to be Covered Charges up to the lesser of: the amount shown in the practitioner s tariff of the province where the charges are incurred; or, the Fee Guide for dentists. Alternative Services If alternative services may be performed for the treatment of a dental condition, the maximum amount payable will be the amount shown in the Suggested Fee Guide for the least expensive service of supply required to produce a professionally adequate result. Predetermination of Benefits If a planned course of treatment by a licensed dentist would exceed $500.00, proposed details and x-rays should be submitted to the Plan Administrator for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. 17

19 Course of Treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid under Dental Care Benefit for: dental care which is cosmetic; completion of claim forms; broken appointments; dental care covered under a medical plan provided by an employer or government; charges which would not have been made in the absence of this benefit program; stainless steel crowns on permanent teeth; protective athletic appliances; prosthesis, including crowns and bridgework, and the fitting thereof which were ordered while the person was not covered but which were finally installed and delivered after this benefit is discontinued and for more than 31 days after the termination of coverage for any other reason; replacement of a lost or stolen prosthesis; or, a full mouth reconstruction, for vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction. in-office (non-comercial) laboratory tees dentalservices supplied outside of Canada 18

20 HEALTH CARE BENEFITS (See Schedule for amounts) Calendar Year Deductible This is the amount of Covered Charges shown in the Schedule that an insured person must pay before any amount is paid by the Plan. A new deductible will begin each January 1. Percentage Payable This is the part of Covered Charges shown in the Schedule that the Plan pays after the Calendar Year Deductible is satisfied. Covered Charges are reasonably and customary charges for needed medical care, services or supplies, as described below, and received while the person is insured, for either an illness or injury that is not covered under any Worker s Compensation Law or for pregnancy; 1. Hospital (Within Home Province) Daily charges in excess of the ward rate up to the Room and Board Limit shown in the Schedule plus user fees. A hospital is a place that: chiefly provides inpatient medical care to the injured, sick or chronically ill; has a staff of licensed doctors (MD) and 24-hour nursing care by registered nurses (RN); and, is approved as a hospital for payment of the ward rate under the Provincial Health Plan. 2. Ambulance Charges in excess of the amount payable under the covered person s Provincial Health Plan for professional licensed ambulance service, including air or rail ambulance service subject to prior approval by the Plan, to transport the injured person: from the place of injury (or where illness struck) to the nearest hospital where treatment is available; directly from the first hospital where treatment is given to the nearest hospital for needed specialized treatment not available at the first hospital; or from a hospital to a convalescent/rehabilitation hospital. 19

21 3. Out-of-Hospital Nursing Charges for home nursing care, up to the Benefit Maximum shown in the Schedule, by a registered nurse (R.N.), a registered practical nurse (R.P.N.), a licensed practical nurse (L.P.N.), or a licensed nursing assistant (L.N.A.) who: is not a member of the employee s family; and does not normally live in the employee s home; When ordered by a licensed doctor (M.D.) as medically necessary for a disability that requires the specialized training of a R.N., R.P.N., L.N.A., or L.P.N. 4. Physiotherapy Charges, including x-rays, up the Benefit Maximum shown in the Schedule, for the services of a licensed physiotherapist. No amount will be paid for any visits for any amount that is payable under the insured person s Provincial Health Plan, unless permitted by law. 5. Health Practitioners written recommendation from M.D. required Charges, including x-ray charges, up to the Benefit Maximum shown in the Schedule, by a practitioner who is registered and legally practicing within the scope of his license as: a chiropractor, osteopath, naturopath, podiatrist, chiropodist, psychologist, speech therapist, Christian Science Practitioner, massage therapist and acupuncturist; and an ophthalmologist or optometrist for eye examinations, including refractions. No amount will be paid for any visit for any amount that is payable under the insured person s Provincial Health Plan, unless permitted by law. 6. Dental Care for Accidental Injury Charges for dental care by a licensed dentist for the prompt repair of sound natural teeth when required for a non-occupational accidental injury, external to the mouth, that occurs while the person is covered. Treatment must be completed within 6 months of the accident. 20

22 7. Diagnostic Laboratory and X-Ray Expenses 8. Prescription Drugs Charges for drugs that require a prescription by a licensed doctor (MD) or licensed dentist and dispensed by a registered pharmacist, excluding anti-obesity products, smoking cessation products, vitamins, contraceptives- other than oral, dietary foods/supplements, and common household products such as, but not limited to soap and toothpaste. Included are charges for preventative vaccines, allergy serums and diabetic supplies. A Maximum Dispensing Fee of $10.00 per prescription will be applied. 9. Durable Medical Equipment and Supplies Charges for supplies and the rental of, or, at the Plan s option, the purchase of durable medical equipment, only from Shoppers Drug Mart Home Health Care or Rexall Pharma Plus locations with home health care services, for the type and model adequate for the insured person s medical needs based on the nature and severity of the disability, such as, but not limited to: Hospital beds, wheelchairs, canes, crutches, walkers and trusses; Rigid or semi-rigid braces for back, neck, arm or leg and non-dental prostheses (including mammary prostheses up the Benefit Maximum shown in the Schedule), such as artificial limbs and eyes, including replacement if required because of a change in physical condition; Respiratory equipment, including oxygen; Kidney dialysis equipment; Colostomy supplies; Contact lenses or glasses following cataract surgery (limited 1 pair per lifetime); and Splints, casts, catheters and hypodermic needles; but excluding personal comfort, convenience, exercise, safety, self-help or environmental control items, or items which may also be used for non-medical reasons, such as, but not limited to: 21

23 heating pads or lamps, communication aids, air conditioners or cleaners, and whirlpool baths or saunas. Before incurring any major expenses details must be submitted to the Plan Administrator to determine to what extent benefits are payable. In any event, a letter will be required from a licensed doctor (M.D.) describing the nature of the disability and the type, medical need and estimated duration of any required durable medical equipment. 10. Out-of-Province Emergency Care Charges incurred while travelling or vacationing outside the insured person s home Province for periods of not more than 6 weeks, provided part of the charge is payable under the insured person s Provincial Health Plan, that are: Hospital charges, but not beyond the Hospital Maximum Stay shown in the Schedule for: room and board in excess of the ward rate under the insured person s Provincial Health Plan up to the Hospital Room and Board Limit shown in the Schedule plus user fees; and other inpatient and outpatient medical services; and Reasonable and customary charges for the area in which they are incurred, that are in excess of the amount payable under the insured person s Provincial Health Plan for: a licensed doctor (M.D.); a professional licensed ambulance service, including air or rail ambulance service, to transport the insured person back to a hospital within such person s home Province, provided prior approval is obtained from the Insurance Company; and blood, blood products and their transfusion. 22

24 On Referral Charges, up to the benefit maximum, incurred for care unavailable in Canada, when referred by a licensed doctor (M.D.) and approved in advance by the Insurance Company, provided part of the charge is payable under the insured person s Provincial Health Plan, but not beyond the Benefit Duration shown in the Schedule, that are: Hospital charges for: room and board in excess of the ward rate under the insured person s Provincial Health Plan up to the Hospital Room and Board Limit shown in the Schedule plus user fees; and other inpatient and outpatient medical services. Reasonable and customary charges for the area in which they are incurred, that are in excess of the amount payable under the insured person s Provincial Health Plan for: a licensed doctor (M.D.); and, blood, blood products and their transfusion. 11. Vision Care Charges for lenses and frames, or for contact lenses, when prescribed by an ophthalmologist or optometrist, up to the Benefit Maximum shown in the Schedule. No amount will be paid for safety or sunglasses, anti-reflective coatings, or for tints other than No. 1 or No Hearing Care Charges for hearing aids, excluding batteries, when recommended by an otolaryngologist, up to the Benefit Maximum shown in the Schedule. 13. Foot Care Charges up to Benefit Maximum shown in the Schedule for: orthopedic shoes when recommended by a licensed doctor (MD); and arch supports, molds or orthotic devices but not for sports, when recommended by a licensed doctor (MD). 23

25 LIMITATIONS No amount will be paid for care, service or supplies if: the payment is prohibited by law; the benefit could have been obtained under a government plan or law; no charge would have been made in the absence of this insurance; or, it is for dental work, except as provided under Dental Care for Accidental Injury. No amount will be paid for any charge incurred that results from or is contributed by: war, whether declared or not; insurrection, rebellion, or participation in a riot or civil commotion; purposely self-inflicted injury; or, commission of, or attempt to commit, an assault or other criminal offense. EXTENSION OF BENEFITS If an insured person is Totally Disabled on the date coverage under these benefits terminates, entitlement to benefits will be the same as though such coverage had not terminated, for as long as such person remains continuously so disabled, but not beyond the earlier of: the date such person becomes covered under any group-type plan providing similar coverage; or, 3 months. Totally Disabled means for an employee, such a person cannot, because of illness or injury, engage in such person s regular occupation and is not working for pay or profit; and, for a dependent, that such a person cannot, because of illness or injury, engage in most of the normal activities of a person of the same age and sex. 24

26 COORDINATION OF BENEFITS (FOR HEALTH CARE AND DENTAL CARE BENEFITS ONLY) If a person covered under this Plan is also covered under another plan, benefits under all plans are adjusted so as to limit the combined payment to 100% of the total allowable expense. The manner in which this is done is to determine which plan pays first (and thus determines where to submit the claim first) and which plan(s) pays next. The plan that does not have a coordination of benefits provision pays before the plan that does (most, if not all, Insurance Company plans have such a provision). The plan that covers the person as: other than a dependent pays before the plan that covered such a person as a dependent; or a dependent child of the parent, covered as an employee or member, whose birthday occurs first during the calendar year, pays first. If priority cannot be established in the above manner, the benefits shall be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan had there been coverage by just that plan. To implement this provision, The Plan Administrator may: subject to the consent of the covered person, if required by law, obtain from or release any other person, corporation or organization any information deemed to be needed; or pay to or recover from any other person, corporation or organization any excess payment; any payment so made will be deemed to be benefits paid and, to the extent of such payment, will fully discharge the Insurance Company from all liability under this Plan. 25

27 Allowable expense means any necessary, reasonable and customary item of expense, at least a portion of which is covered under at least one of the plans covering the person for whom the claim is made. When a plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered will be deemed to be both an allowable expense and a benefit paid. plan means any contract of group insurance or other arrangement for members of a group (whether on an insured basis or not). CLAIM PROVISIONS How to Claim Claim forms are available from the Administrator, your Employer or online at workersbenefits.ca. Be sure to complete them fully, attach original receipts, where applicable, to substantiate your claim and submit to the Plan Administrator. For Health Care and Dental Care Benefits, do not submit a claim until the amount of Covered Charges exceeds the amount of any Calendar Year Deductible. Beneficiary For employee death benefits, you may name a beneficiary(ies) and, from time to time, change such named beneficiary(ies), subject to Provincial Law, by written request filed at the office of the Plan Administrator, to take effect as of the date such request was executed, but without prejudice to the Insurance Company for any payments made before such request is received at its Head Office. 26

28 Proof of Loss Written proof stating the occurrence, character and extent of loss must be submitted for each Benefit to the Plan Administrator: 18 months after the date of loss, but not more than 6 months after the date the Benefit is discontinued, for Health Care, Vision Care and Dental Care benefits. Legal action to recover benefits under this contract must begin within 2 years of the date of the loss. The Plan shall have the right and opportunity to examine any person whose injury or illness is the basis of claim, when and as often as it may reasonably require during the pendency and payment period, if any, of such claim. 27

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32 Commercial Workers Benefit Trust Fund Suite International Blvd. Toronto, Ontario M9W 6K4 Telephone: (416) Facsimile: (416)