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General Information

Definitions

Deductible
means the initial portion of the Eligible expenses, which you must pay before we will reimburse charges for any Eligible expense.

Dentist
means a doctor of dentistry who is duly qualified and licensed to practice dentistry or oral surgery in the area where the service is provided. For the purposes of this booklet, Dentist may also mean dental specialist, or denturist.

Dependent
means any of the following persons for whom coverage is provided under this Plan:

1. one Spouse, and
2. any unmarried natural child, stepchild, legally adopted child, foster child, or legal ward who is under age 19 and financially dependent on you or your Spouse, and
3. under age 25 if the unmarried child is also in full-time attendance at a recognized educational institute, and
4. any unmarried handicapped child to any age who is living with you or your Spouse, is financially dependent and is incapable of self-sustaining employment.

Duplicate Coverage
means that you (and your Dependents) are eligible to claim certain benefits under more than one plan.

Fee Guide
means the Canadian provincial/territorial dental Fee guide that contains dental services and fees in effect on the date the dental services are performed.

Fee Schedule
means Schedule 1 of the Pacific Blue Cross Fee schedule that contains eligible dental services, financial limits, treatment frequencies, and fees in effect on the date the dental services are performed.

Non evidence Limit
means the maximum amount of insurance we will provide without evidence of insurability as indicated in the Schedule of Benefits.

Spouse
means your legal spouse or a person who has been living with you in a common law relationship for at least one full year and who is publicly represented as your spouse.

Integration with Government Plans

Extended health care benefits are intended to supplement and not overlap benefits under government plans such as the Medical Services Plan and Fair PharmaCare Program of British Columbia. You are required, as a condition of coverage, to take all reasonable steps to qualify and obtain the fullest extent of coverage, benefits, contribution, or reimbursement available under all applicable government plans. We will also make payment only where permitted by provincial legislation or other applicable law.

Who is Eligible?

Members of the Telecommunication Workers Union who are employed by SHAW Cablesystems, are eligible to join PART D of the Plan.
Application forms are available from the Plan Administration Office and must be completed at the start of employment.
New application forms must be completed if you have been off the Plan for more than four months.

Medical Services Plan (MSP) Eligibility

Only residents of British Columbia are eligible for coverage under the Medical Services Plan. "Resident" means a person who:

1. is a citizen of Canada or is lawfully admitted to Canada for permanent residence;
2. makes his or her home in British Columbia; and
3. is physically present in British Columbia at least six months in a calendar year;

and includes a person who is deemed under the Regulations to be a resident but does not include a tourist or visitor to British Columbia.

The deeming provision in the Regulations allows us to cover persons who would not otherwise qualify as "residents" because they don't meet all three criteria stated in (a), (b) and (c) above.

These are persons who are temporarily absent from B.C. for more than six months because they are - full-time students attending school or university elsewhere in Canada; full-time students attending school or university in another country (eligible for coverage for a maximum of 60 months); persons on vacation or working outside B.C. (eligible for a maximum of 12 months); persons employed by or under a contract with Canada World Youth, Canadian Executive Services Overseas, Canadian University Services Overseas, Canadian International Development Agency, Department of National Defence Teacher Loan Program (eligible for a maximum of 24 months).
Persons who are not residents of British Columbia lose their eligibility for MSP coverage and other provincial health care benefits. For example, a person who chooses to live in Washington State is not eligible for coverage, regardless of whether he/she commutes to Vancouver to work every day.

When is Coverage Effective?

For Members New to the Plan:
Coverage will commence on the first day of the month immediately following the month in which employment commences

For Previously Covered Members:
A Member previously covered by PART D of the Plan, CAN receive coverage on the first day of employment.

Coverage Exceptions
If you are not actually at work on the date you would otherwise be eligible for coverage you are not insured until you return to active work. A dependent of a Member is covered by PART D of the Plan at the same time as the Member's effective date.

Class A

• Members with more than 18 months of employer contributions within a 24 month period, in the past 5 years.
• Full coverage.
  

Class B

• Members with less than 18 months of employer contributions within a 24 month period, in the past 5 years.
• Short Term Disability benefits will be limited to the current E.I. maximums;
• Dental benefits will be limited to Plan A & B only. For the initial installation of a bridge or denture, it will be necessary to have a natural tooth extracted in order to be compensated.

Members covered under Class B will be notified when they are eligible for Class A coverage and benefits.

Identification (ID) Cards

We will issue identification (ID) cards for distribution by your Plan Administrator.

These cards identify you and your enrolled Dependents as Plan Members and also contains information regarding your dental coverage and prescription drug coverage. As such, they must be provided to your Dentist prior to receiving dental treatment and to your pharmacist when filling a prescription. The portion of your claims cost which is covered by the Plan will then be paid directly to the service provider and you will only need to pay the provider for the portion of the costs not covered by the Plan.

Only you and your enrolled Dependents are entitled to use this card. Should you (or your Dependent) allow an ineligible person to use this card, your coverage may be suspended without notice.

You may be asked to substantiate that an individual you claim as a Dependent meets the definition of Dependent for your group.

CareCard
The CareCard is the health care identity card for British Columbia residents. A separate CareCard is issued for each person covered. Each CareCard will display the lifetime Personal Health Number assigned to that card holder. This Personal Health Number will remain the same for each person, regardless of changes to personal status such as leaving home, getting married, change of employer, etc..

Emergency Travel Assistance (ETA) Card
Your ETA Card lists the toll-free number to call in case of an emergency, while travelling outside Canada. The Card also lists your Group Policy Number.

Effective Date of Coverage and Enrolment

Your effective date of coverage will be determined by your Plan Administrator.

You should apply for Dependent coverage (when applicable):

1. on the same date you apply for your own coverage, or
2. within one month if you have a new Spouse, or
3. within four months of the birth of a newborn child.

Should you require additional information about when your coverage starts, please contact your Plan Administrator.

Beneficiary

You must designate a beneficiary on your application card. If at any time you wish to change this beneficiary, contact your Plan Administrator for the appropriate form.

Claims

1. All claims must be submitted to us in English.
2. We pay eligible claims when we receive all the required information within the required time limits. We encourage you to become familiar with the time periods allowed for claiming benefits. Under the Claims sections, we fully describe the claiming deadlines for each benefit. No payment will be made if we receive your claim after the time limits described in this booklet.
3. We may reject your claim if sufficient information is not provided to enable a full assessment of the claim, or if an attempt is made, except through unintentional error, to make an excessive claim, or if a claim is made for a person who is not entitled.
4. The necessary claim forms are available from your Plan Administrator.
5. The exchange rate on foreign currency is payable at the rate quoted by selected Canadian financial institutions for the date on which the expense was paid. Fluctuations in exchange rates are not our responsibility.

Duplicate Coverage

If you and your Spouse are members of the Telecommunication Workers Benefit Plan, please check with your Plan Administrator to see if Duplicate coverage is allowed for dental and extended health care benefits.

If you and your Spouse work for different employers and you are both enrolled for similar benefits, Duplicate coverage is allowed.

If you are eligible for Duplicate coverage, you and your family should discuss both plans (and what portion of the benefits you pay) to determine whether it is to your advantage to enroll under more than one plan.

Your Plan Administrator will advise you if you are eligible to waive certain benefits under this group plan.

Coordination of Benefits

If Duplicate coverage is allowed, we pay claims based on the rules of the Canadian Life and Health Insurance Association guidelines. They are:

1. Dependent 00 is always the primary claimant. Dependent 01 (or 90 to 99) is always the secondary claimant.
2. Dependent children are always covered primarily under the parent who has the earliest birthdate in the year (month and day).
3. In situations of separation or divorce, the following order applies:
   a) the plan of the parent with custody of the child
   b) the plan of the Spouse of the parent with custody of the child
   c) the plan of the parent not having custody of the child
   d) the plan of the Spouse of the parent in c) above.
4. Total reimbursement shall never exceed 100% of the Eligible expenses.

General Exclusions

1. We will not be liable for any portion of an expense for which you or your Dependent is entitled to reimbursement:
   a) under any other group or individual benefit plan or insurance policy, or
   b) due to the legal liability of any other party.
2. In no event will benefits be payable for expenses resulting directly or indirectly from, or in any manner or degree associated with, any of the following:
   a) intentional self-inflicted injury while sane or insane, war, whether declared or undeclared, or any act of war, or participation in a riot, insurrection, or civil commotion
   b) active duty in the military forces of any nation or international organization, or in any civilian noncombatant unit which serves with such forces in combat
   c) a direct or indirect attempt at, or commission of, an indictable offense under the Criminal Code of Canada or similar law of any other country
   d) false pretences or fraudulent misrepresentation
   e) any injury, illness, or condition for which care is provided or may be provided or available without cost by public authorities or by a tax-supported agency, including preventive treatment and services available under any Workers' Compensation Act or similar plan.

Termination of Coverage

Generally, your coverage (and any Dependent coverage) terminates if your employer ceases to be a participating employer in the Plan, required contributions to the Plan are not made, you voluntarily chose to terminate your employment with the employer or the Plan is terminated. For further details on termination of coverage, contact your Plan Administrator.

Survivor Benefit

If you die while covered under this plan, coverage for your Dependents will continue without payment of contributions until the earliest of the following occurs:

1. 24 months after your death
2. the date your Dependent ceases to be a Dependent other than as a result of your death
3. the date your surviving Spouse remarries
4. the date your Dependent becomes eligible for coverage under a similar group plan.

Termination of the contract/policy with the insurer will have no effect on insurance continued under this benefit.

Conversion to an Individual EHC and/or Dental Plan

Should your group coverage terminate for any reason, you may purchase an individual plan from Pacific Blue Cross if you live in British Columbia, or an individual plan offered by your local Blue Cross organization if you live elsewhere in Canada.

To convert coverage you must ensure that your application and full payment is received by us or Blue Cross within 60 days of the date your group plan terminates. Coverage will become effective immediately after your group coverage terminates.

If you qualify for one of our individual plans under the conversion option, we will waive the Pre-existing condition contained in the individual plan.

Pre-existing condition
means any illness or condition for which you receive medical attention, consultation, diagnosis, or treatment in the 12 month period before you apply for the individual plan.

Call our Individual Products Department at 604 419-2200 for an application form.
If you are converting to an individual plan offered by Blue Cross, contact your local Blue Cross organization for full details before your group coverage terminates.

CARESnet

CARESnet is an online service from Pacific Blue Cross that offers you convenient and secure access to your benefit information 24 hours a day. Information about benefit coverage, claim status, and easy access to claim forms are the enhanced services CARESnet provides. To access CARESnet, visit our website: http://www.pac.bluecross.ca/caresnet/