Plan Provisions

Claims

A claim must be received by the Administrator within 12 months following the calendar year in which the expense is incurred. 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 will not invalidate the claim, if in the 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. Except in case of medical or psychological incapacity, the administrator has no authority for extending the time period for submitting a claim.

For the assessment of a claim, the Administrator may require itemised hospital, drug, or equipment bills, or dental bills and an itemised statement completed by the physician or other practitioner who attended the participant or other information the Administrator considers necessary before processing the claim. Proof of claim is at the claimant's expense.

Appeals

Where a member does not agree with a decision of the Administrator and wishes a review of their case, a submission may be made to the Trustees. The Trustees have 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 Administrator before submitting an appeal to the Trustees. The Trustees reserve the right to refuse to reconsider their decision on an appeal. The appeal process is the final review level under the PSHCP.

An appeal must be submitted within one year of the Administrator's mailing of an Explanation of Benefits regarding the claim.

Payment of Benefits

The Administrator will reimburse a member when proof is received that a participant has incurred eligible expenses. The amount reimbursed is subject to the provisions described in the Summary of Maximum Eligible Expense and to the application of the annual deductible and co-payment, whenever applicable.

To determine the amount payable, the total eligible expenses claimed are adjusted as follows:

1. the eligible expense maximums are applied; then
2. the deductible, which must be satisfied each calendar year, is subtracted; and finally
3. the co-payment is subtracted.

Deductible Amount

For each calendar year, there is a minimum deductible amount; only the eligible expenses incurred during the year which exceed that deductible amount are eligible for reimbursement under the Extended Health Provision, except for the Emergency Benefit While Travelling and the Emergency Travel Assistance Services to which no deductible applies. The annual deductible amount is $60 per person. If a member has family coverage, but only one member of the family unit incurs eligible expenses in a calendar year, the annual deductible of $60 will apply to those expenses. Where eligible expenses are incurred in a calendar year in respect of more than one member of a family unit, the combined deductible amount which must be exceeded for all members of that family unit is $100.

Co-Payment

Except where otherwise stated, the Plan will reimburse the member 80% of the reasonable and customary charges incurred for an eligible service or product once the annual deductible has been satisfied, 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.

Overpayments

Administrative Error: In situations where the member was reimbursed in excess of what was claimed, the Administrator is authorised to recover overpayments. The 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 authorising the Administrator to deduct the overpayment from future claims. In the event the member does not acknowledge the overpayment within 30 days, the Administrator will automatically deduct the overpayment from future claims reimbursement.

Adjudication Error: In situations where an adjudication error is made or an adjudication decision is reversed based on additional information, the Administrator will not recover the overpayment from the member, but will advise the member in writing that these expenses will no longer be reimbursed.

Co-ordination of Benefits

If a participant is covered under two or more health care plans, payment of benefits under this Plan will be determined as follows:

1. The plan where the person is covered as a member.
2. 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:

1. The plan where the spouse is covered as an employee or pensioner.

Where the claim is in respect of a dependant child:

1. The plan of the parent with the earlier birth date (month/day) in the calendar year.
2. The plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date.
3. 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 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 of the parent not having custody of the dependant child.