5.1 Claims
5.1.1 A claim must be received by the Plan Administrator within 12 months following the calendar year in which the expense is incurred and paid in full. Claims will not be accepted after the 12-month deadline unless the late claim is the result of unavoidable circumstances such as medical or psychological incapacity. Failure to submit a claim within 12 months following the calendar year in which the expense is incurred and paid in full will not invalidate the claim if, in the Plan Administrator’s opinion, it was not reasonably possible to submit the claim within the time, provided the claim is submitted within 18 months following the calendar year in which the expense was incurred and paid in full. Except in case of medical or psychological incapacity, the Plan Administrator has no authority to extend the time period for submitting a claim.
5.1.2 For the assessment of a claim, the Plan Administrator may require supporting documents, such as: bills and invoices, pharmacy receipts, prescriptions, itemized statements from a physician or other medical practitioner, or other information the Plan Administrator considers necessary, before processing the claim. Costs incurred to obtain proof of claim or additional information are not eligible under the PSHCP and are at the claimant’s expense.
5.2 Appeals
5.2.1 Where a member does not agree with a decision of the Plan Administrator and wishes a review of their case, a submission may be made to the PSHCP Administration Authority for review by its Appeals Committee. The Appeals Committee has the discretion to reach a decision that embodies due consideration for individual circumstances and Plan provisions. Members should endeavour to exhaust all avenues of review with the Plan Administrator before submitting an appeal to the PSHCP Administration Authority. The Appeals Committee reserves the right to refuse to reconsider their decision on an appeal. The appeal process is the final review level under the PSHCP.
5.2.2 An appeal of a decision of the Plan Administrator must be submitted to the PSHCP Administration Authority within one year from the mailing of the Plan Administrator’s Explanation of Benefits statement or the date of the pharmacy receipt from a benefit card transaction.
5.3 Payment of Benefits
5.3.1 The Plan Administrator will provide reimbursement to the member when proof is received that an eligible expense has been incurred and paid in full. The amount reimbursed is subject to the provisions described in the Summary of Maximum Eligible Expenses and to the application of the co-payment, whenever applicable.
5.3.2 The amount payable is determined by applying the eligible expense maximum and subtracting the applicable co-payment.
5.4 Co-Payment
5.4.1 Except where otherwise stated, the Plan will reimburse the member 80% of the reasonable and customary charges incurred for an eligible service or product, subject to the Plan’s stated maximums for the service or product, as identified in the Summary of Maximum Eligible Expenses. The co-payment is the remaining 20% of such eligible expenses paid by the member.
5.5 Overpayments
5.5.1 Administrative Error: In situations where the member was reimbursed in excess of what was claimed, the Plan Administrator is authorized to recover overpayments. The Plan Administrator will proceed with the recovery process by advising the member of the overpayment and asking how they would like to reimburse the amount, i.e., either by cheque for the amount of the overpayment or by authorizing the Plan Administrator to deduct the overpayment from future claims. In the event the member does not acknowledge the overpayment within 30 days, the Plan Administrator will automatically deduct the overpayment from future claims reimbursement.
5.5.2 Adjudication Error: In situations where an adjudication error is made or an adjudication decision is reversed based on additional information, the Plan Administrator will not recover the overpayment from the member, but will advise the member in writing that these expenses will no longer be reimbursed.
5.6 Coordination of Benefits
5.6.1 If a participant is covered under two or more health care plans, payment of benefits under this Plan will be determined as follows:
- if the other plan does not contain a coordination of benefits clause, payment under the other plan must be made before the Plan Administrator will pay under this provision;
- if the other plan does contain a coordination of benefits clause, priority of payment will be attributed in the following order, in accordance with Canadian Life and Health Insurance Association (CHLIA) principles:
- where the claim is in respect of a PSHCP member:
- the plan where the person is covered as a member,
- if a person is covered under two plans, priority goes to:
- the plan where the member is a full-time employee,
- the plan where the member is a part-time employee,
- the plan where the member is a pensioner;
- where the claim is in respect of a spouse or common-law partner, the plan where the spouse or common-law partner is covered as an employee or pensioner;
- where the claim is in respect of a dependant child:
- the plan of the parent with the earlier birth date (month/day) in the calendar year,
- the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date;
- in situations where parents are separated/divorced, then the following order applies:
- the plan of the parent with custody of the dependant child,
- the plan of the spouse or common-law partner of the parent with custody of the dependant child,
- the plan of the parent not having custody of the dependant child,
- the plan of the spouse or common-law partner of the parent not having custody of the dependant child.
- where the claim is in respect of a PSHCP member:
5.6.2 If priority cannot be established in the manner outlined in subsection 5.6.1, the benefits will be prorated in proportion to the amount that would have been paid under each plan had there been coverage by only that plan.
5.6.3 The amount of benefit payable under this Plan will not exceed the total amount of eligible expenses incurred less the amount paid by any other plan.
5.6.4 If a dental accident occurs, health plans with dental accident coverage must pay benefits before dental plans.
5.6.5 Coordination of benefits is allowed in cases where both spouses or common-law partners (as defined by the Plan) are members of the Public Service Health Care Plan on the same basis as the coordination of benefit provisions would apply where a Plan participant is entitled to reimbursement from two or more health care plans.
5.6.6 A member may only hold one valid PSHCP certificate number in their own right.
5.7 Subrogation
5.7.1 The Plan Administrator shall, on behalf of the Partners Committee, except where otherwise directed by the Partners Committee, take all such actions or do such things as may reasonably be required or considered commercially prudent to preserve or to pursue the right, if any, of the Partners Committee to be subrogated to the rights of a claimant in relation to any matter that is or was the subject of an eligible claim, and to seek or have such rights in respect of whom the Partners Committee have the right of subrogation discharged or satisfied, other than by the institution of judicial proceedings or by the engagement of legal counsel for the purpose of enforcing such rights, unless directed or otherwise authorized by the Attorney General of Canada.
5.8 General Exclusions and Limitations
5.8.1 No benefit is payable for:
- expenses for which benefits are payable under a Workers’ Compensation Act or a similar statute or enactment, or by any government agency;
- expenses for services and supplies, 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, marriage, or common-law partnership;
- expenses for services or products for cosmetic purposes only, or for conditions not detrimental to health, except those required as a result of accidental injury;
- expenses for services or products normally rendered without charge;
- expenses for services rendered in connection with medical examinations for insurance, school, camp, association, employment, passport or similar purposes;
- expenses for services provided by a physician licensed and practicing in Canada where the participant is eligible to be insured under a provincial/territorial health insurance plan, except for such services which are specifically included under the section entitled Plan Provisions;
- expenses for experimental products or treatments, for which substantial evidence provided through objective clinical testing of the product’s or treatment’s safety and effectiveness for the purpose and under the conditions of the use recommended does not exist to the Plan Administrator’s satisfaction;
- expenses for benefits which are legally prohibited by a government from coverage;
- the portion of charges which are payable under a provincial/territorial health insurance plan, a provincial/territorial drug plan, or any provincially/territorially sponsored program, whether or not the participant is participating in the plan or program;
- the portion of charges for services rendered or supplies provided in a hospital outside of Canada, that would normally be payable under a provincial/territorial health or hospital insurance plan if the services or products had been rendered in a hospital in Canada. This limitation does not apply to the eligible expenses under the Hospital (Outside Canada) Provision and the Extended Health Provision – Out-of-Province Benefit;
- the portion of charges which is the legal liability of any other party;
- specific exclusions identified under each Plan benefit.