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FSD 39 - Health Care Expenses

Scope

Introduction

This directive provides financial assistance to employees who incur health care expenses outside Canada which exceed those permissible under the Comprehensive Coverage of the Public Service Health Care Plan (PSHCP) and the Public Service Dental Care Plan (PSDCP), subject to certain conditions as specified in this directive.

Definitions

Note: This definition only applies to this directive.

Dependant (personne à charge) means each dependant or dependent student as defined in FSD 2 - Definitions, respectively, who resides with the employee at the post, or is in full-time attendance at an educational institution outside of Canada.

Directive

39.1 Application

39.1.1 Subject to the provisions of section 39.2, where expenses have been incurred for health care, drugs or dental treatment in respect of an employee and/or a dependant which are in excess of eligible expenses under the Comprehensive Coverage of the Public Service Health Care Plan or the Public Service Dental Care Plan, the deputy head may authorize reimbursement to the employee of the amount in excess, provided:

  1. the employee pays the deductible share under the Comprehensive Coverage of the Public Service Health Care Plan or the Public Service Dental Care Plan or the share which would have been applicable for insurance under these plans;
  2. the employee pays any co-insurance applicable under the Comprehensive Coverage of the Public Service Health Care Plan or the Public Service Dental Care Plan or the amount of co-insurance which would have been applicable for insurance under these plans;
  3. the expenses involved have been incurred pursuant to consultation with a medical practitioner or dentist acceptable to Health Canada; and
  4. the employee submits a claim under the Comprehensive Coverage of the Public Service Health Care Plan or the Public Service Dental Care Plan within the time constraints of the plan.

39.1.2 Where the treating physician certifies that a psychiatrist is not available at the post and therefore recommends treatment by a psychologist, the deputy head may authorize reimbursement of psychologist fees which may be in excess of the maximum amount reimbursable under the PSHCP.

39.1.3 The health care referred to in this directive may include para-medical care and the services of medical and dental specialists, provided such services have been recommended pursuant to consultation with a medical practitioner or dentist acceptable to Health Canada.

39.1.4 The amount payable under section 39.1 shall not exceed the amount over and above that which the employee is eligible to receive as a participant in any other plan of health insurance, such as expenses incurred outside Canada while still covered by a provincial health insurance plan.

39.1.5 Each mission shall compile a roster of qualified local medical practitioners and dentists whom personnel at the post may consult. The roster should include medical internists, obstetricians, pediatricians and general practitioners and dental general practitioners and specialists.

39.1.6 Where a Health Canada physician certifies, and where the appropriate foreign service inter-departmental coordinating committee recommends that the treatment that occurred is consistent with the treatment which would have occurred within a hospital in Ontario, the deputy head may authorize reimbursement of a claim that has been denied by the Public Service Health Care Plan because services were not provided in a hospital.  Exception is made for the services of a midwife and the services of an anesthesiologist for which the deputy head may authorize the reimbursement of a claim that has been denied by the Public Service Health Care Plan without the recommendation of the appropriate foreign service inter-departmental coordinating committee.

39.1.7 In claiming for excess hospital costs, an adjustment will be made where an employee has less than maximum coverage. For example, an employee incurs excess costs of $200.00 per day for semi-private hospital coverage and has Level I coverage which provides a benefit of $60.00 per day rather than Level III coverage which provides a benefit of $220.00 per day. The claim would be reduced by the difference between Level III and Level I coverage, that is, $160.00, and the employee would receive an adjusted amount of $200.00 minus $160.00, or $40.00.

39.1.8 Where eligible dental expenses under the Public Service Dental Care Plan which are incurred outside Canada are higher than the fee for the same service as set out in the Ontario fee guide used under the Public Service Dental Care Plan, and employees must as a result pay a higher co-payment amount as defined in the Public Service Dental Care Plan, employees may submit a claim, for payment under this directive, for that portion of the co-payment amount which exceeds the amount which they would have been required to pay if the treatment had occurred in Ontario. For example, and assuming the deductible has been paid and reimbursement under the Plan is at 50%, if under the Ontario fee guide the eligible expense for a service is $400 (with the employee paying $200) and outside Canada the eligible expense is $600 for the same service (with the employee paying $300), then the cost to the employee is $100 more than it would be had the service been rendered in Ontario. The employee could then claim $100 under this directive. This would place the employee outside Canada in the same position as the employee in Ontario.

39.1.9 Where a claim is denied under the Public Service Dental Care Plan because it is for treatment which was previously claimed, and the required time has not elapsed before another claim may be made, the deputy head may authorize reimbursement in such amount as may be recommended by the Administrator of the Plan to reflect the amount which would otherwise have been payable under the PSDCP as an initial claim, plus any excess dental costs identified by the Administrator of the Plan and payable under this directive. This provision is designed to provide for those necessary additional costs resulting from initial incompetent/inadequate treatment, where the employee is no longer at the location where the original treatment took place or, in the opinion of Mission administration, cannot obtain redress from the original practitioner.

39.2 Expenses Due to Conditions at Post

39.2.1 Health care expenses incurred at post, on behalf of a dependant, are treated in accordance with subsection 39.2.2 should they be incurred because of:

  1. an illness due to conditions at a location where the employee and/or a dependant is or has been residing and which is of a type, the incidence of which is greater than in Canada as determined by Health Canada; or
  2. an injury resulting from an event at a location where an employee and/or dependant is or has been residing, and which would not normally occur in Canada, or which gives rise to circumstances not experienced in Canada as determined by Health Canada.

39.2.2 The deputy head shall, in determining the amount of reimbursement payable, as a result of illness or injury in accordance with section 39.1, include for payment:

  1. the deductible share attributable to the difference between single and family coverage under the Comprehensive Coverage of the Public Service Health Care Plan or the Public Service Dental Care Plan as applicable; and
  2. the actual amount of co-insurance for which the employee was responsible under the Comprehensive Coverage of the Public Service Health Care Plan or the Public Service Dental Care Plan.

39.2.3 In reviewing claims for payment pursuant to subsection 39.2.1, the deputy head shall seek and take into consideration the advice of Health Canada in order to confirm that the illness or injury is attributable to conditions at post.

39.2.4 Where an employee's medical, hospital or dental care insurance under the Comprehensive Coverage of the Public Service Health Care Plan is exhausted by expenses incurred as a result of an illness or injury described in subsection 39.2.1, the deputy head shall authorize payment of the amounts that would have been paid under such plans until such time as the employee's normal coverage is re-established.