Microsoft word - 162661 bklt_3_ class 3 - casual employees.doc

THE KETTLE FRIENDSHIP SOCIETY
Casual Employees
BENEFIT DETAILS

Great-West Life is a leading Canadian life and health insurer. Great-
West Life's financial security advisors work with our clients from coast to
coast to help them secure their financial future. We provide a wide range
of retirement savings and income plans; as well as life, disability and
critical illness insurance for individuals and families. As a leading
provider of employee benefits in Canada, we offer effective benefit
solutions for large and small employee groups.
Great-West Life Online
Information and details on Great-West Life's corporate profile, our
products and services, investor information, news releases and contact
information can all be found at our website www.greatwestlife.com.

Great-West Life Online Services for Plan Members
As a Great-West Life plan member, you can also register for
GroupNet™ for Plan Members at www.greatwestlife.com.
This service enables you to access the following and much more, within
a user friendly environment twenty-four hours a day, seven days a week:
 your benefit details and claims history
 personalized claim forms and cards  online claim submission for many of your claims, as outlined in the Healthcare and Dentalcare sections of this booklet  extensive health and wellness content Using our GroupNet Mobile app, you can access certain features of GroupNet for Plan Members to:  submit many of your claims online – part of our industry-leading GroupNet online services  access personalized coverage information about benefits, claims and more – quickly and easily, any time  view card information  locate the nearest provider who has access to Provider eClaims, through a built-in GPS mapping tool
Great-West Life's Toll-Free Number
To contact a customer service representative at Great-West Life for
assistance with your medical and dental coverage, please call
1-800-957-9777.


This booklet describes the principal features of the group benefit plan
sponsored by your employer, but Group Policy No. 162661 issued by
Great-West Life is the governing document. If there are variations
between the information in the booklet and the provisions of the policy,
the policy will prevail.
This booklet contains important information and should be kept in a safe
place known to you and your family.
The Plan is underwritten by
ICBA Benefit Services Ltd. Ste. 211 - 3823 Henning Drive Burnaby, B.C. V5C 6P3 Phone: (604) 298-7752 Fax: (604) 298-7749 Access to Documents
You have the right, upon request, to obtain a copy of the policy, your
application and any written statements or other records you have
provided to Great-West Life as evidence of insurability, subject to certain
limitations.
Legal Actions
Every action or proceeding against an insurer for the recovery of
insurance money payable under the contract is absolutely barred unless
commenced within the time set out in the Insurance Act or other
applicable legislation (e.g. Limitations Act, 2002 in Ontario, Quebec Civil
Code).
Appeals
You have the right to appeal a denial of all or part of the insurance or
benefits described in the contract as long as you do so within one year
of the initial denial of the insurance or a benefit. An appeal must be in
writing and must include your reasons for believing the denial to be
incorrect.
Benefit Limitation for Overpayment
If benefits are paid that were not payable under the policy, you are
responsible for repayment within 30 days after Great-West Life sends
you a notice of the overpayment, or within a longer period if agreed to in
writing by Great-West Life. If you fail to fulfil this responsibility, no further
benefits are payable under the policy until the overpayment is
recovered. This does not limit Great-West Life's right to use other legal
means to recover the overpayment.
Protecting Your Personal Information

At Great-West Life, we recognize and respect the importance of privacy.
Personal information about you is kept in a confidential file at the offices
of Great-West Life or the offices of an organization authorized by Great-
West Life. Great-West Life may use service providers located within or
outside Canada. We limit access to personal information in your file to
Great-West Life staff or persons authorized by Great-West Life who
require it to perform their duties, to persons to whom you have granted
access, and to persons authorized by law. Your personal information
may be subject to disclosure to those authorized under applicable law
within or outside Canada.
We use the personal information to administer the group benefits plan
under which you are covered. This includes many tasks, such as:
 determining your eligibility for coverage under the plan  enrolling you for coverage  investigating and assessing your claims and providing you with  managing your claims  verifying and auditing eligibility and claims  creating and maintaining records concerning our relationship  underwriting activities, such as determining the cost of the plan, and analyzing the design options of the plan  preparing regulatory reports, such as tax slips We may exchange personal information with your health care providers, your plan administrator, any insurance or reinsurance companies, administrators of government benefits or other benefit programs, other organizations, or service providers working with us or the above when relevant and necessary to administer the plan. As plan member, you are responsible for the claims submitted. We may exchange personal information with you or a person acting on your behalf when relevant and necessary to confirm coverage and to manage the claims submitted. You may request access or correction of the personal information in your file. A request for access or correction should be made in writing and may be sent to any of Great-West Life's offices or to our head office. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), write to Great-West Life's Chief Compliance Officer or refer to www.greatwestlife.com. TABLE OF CONTENTS
Benefit Summary Commencement and Termination of Coverage Dependent Coverage Beneficiary Designation Preferred Vision Services (PVS) Coordination of Benefits Diagnostic and Treatment Support Services (Best Doctors® Service)
Benefit Summary
This summary must be read together with the benefits described in
this booklet.


Healthcare
Covered expenses will not exceed customary charges
$100 each calendar year $100 each calendar year The individual and family deductibles do not apply to Chronic Care, Global Medical Assistance, Visioncare, In-Canada Prescription Drugs, In-Canada Hospital and Accidental Dental Injury expenses Reimbursement Levels Global Medical Assistance, In-Canada Prescription Drug, Visioncare, Chronic Care, Accidental Dental Injury, and In-Canada Hospital Expenses Out-of-Country Care Expenses - Emergency Care - Non-Emergency Care All Other Expenses 80% of the first $1,000 of paid expenses each calendar year and 100% of the remainder Basic Expense Maximums Hospital Semi-private Home Nursing Care $15,000 each calendar year 120 days each calendar year In-Canada Prescription Drugs Smoking Cessation Products $1,000 lifetime $20,000 lifetime $600 every 4 years Custom-fitted Orthopedic Shoes and Custom-made Foot Orthotics $500 every 12 months Myoelectric Arms $10,000 per prosthesis External Breast Prosthesis 1 every 12 months Surgical Brassieres 2 every 12 months Mechanical or Hydraulic Patient Lifters $2,000 per lifter once every 5 years Outdoor Wheelchair Ramps Blood-glucose Monitoring Machines 1 every 4 years Transcutaneous Nerve Stimulators Extremity Pumps for Lymphedema Custom-made Compression Hose 4 pairs each calendar year Wigs for Cancer Patients Intrauterine Devices (IUDs) 1 every 24 months Paramedical Expense Maximums $100 each calendar year $200 each calendar year, excluding x-rays Massage Therapists $1,000 each calendar year $200 each calendar year Physiotherapists $1,000 each calendar year $200 each calendar year Speech Therapists $100 each calendar year Visioncare Expense Maximums Eye Examinations 1 every 24 months to a maximum of $50 every 24 months Glasses, Contact Lenses and Laser Eye Surgery $350 every 24 months Out-of-Country Care Maximums - Emergency Care Expenses - Non-Emergency Care Expenses $50,000 each calendar year Lifetime Healthcare Maximum
Dentalcare
Covered expenses will not exceed customary charges
The dental fee guide in effect on the date treatment is rendered for the province in which treatment is rendered Reimbursement Levels Orthodontic Coverage Basic and Major Treatment $3,500 each calendar year Orthodontic Treatment COMMENCEMENT AND TERMINATION OF COVERAGE
You are eligible to participate in the plan on the first day of the month following your completion of the probationary period.  You and your dependents will be covered as soon as you become You may waive health and/or dental coverage if you are already covered for these benefits under your spouse's plan. If you lose spousal coverage you must apply for coverage under this plan. If you do not apply within 31 days of loss of such coverage, or you were previously declined for coverage by Great-West Life, you and your dependents may be required to provide evidence of insurability acceptable to Great-West Life to be covered for health benefits, and may be declined for or offered limited dental benefits.  You must be actively at work when coverage takes effect, otherwise the coverage will not be effective until you return to work. Increases in your benefits while you are covered by this plan will not become effective unless you are actively at work.  Temporary and seasonal employees, and part-time employees who work less than 15 hours per week may not join the plan. Your coverage terminates when your employment ends, you are no longer eligible, or the policy terminates, whichever is earliest.  Your dependents' coverage terminates when your insurance terminates or your dependent no longer qualifies, whichever is earlier.  When your coverage terminates, you may be entitled to an extension of benefits under the plan. Your employer will provide you with details.
Survivor Benefits

If you die while your coverage is still in force, the health and dental
benefits for your dependents will be continued for a period of 2 years or
until they no longer qualify, whichever happens first.
DEPENDENT COVERAGE
Dependent means:  Your spouse, legal or common-law.  Your unmarried children under age 21, or under age 25 if they are full-time students. Children under age 21 are not covered if they are working more than 30 hours a week, unless they are full-time students. Children who are incapable of supporting themselves because of physical or mental disorder are covered without age limit if the disorder begins before they turn 21, or while they are students under 25, and the disorder has been continuous since that time. BENEFICIARY DESIGNATION
You may make, alter, or revoke a designation of beneficiary as permitted by law. You should review any beneficiary designation made under this policy from time to time to ensure that it reflects your current intentions. You may change the designation by completing a form available from your employer. HEALTHCARE

A deductible may be applied before you are reimbursed. All expenses
will be reimbursed at the level shown in the Benefit Summary. Benefits
may be subject to plan maximums and frequency limits. Check the
Benefit Summary for this information.
The plan covers customary charges for the following services and
supplies. All covered services and supplies must represent reasonable
treatment. Treatment is considered reasonable if it is accepted by the
Canadian medical profession, it is proven to be effective, and it is of a
form, intensity, frequency and duration essential to diagnosis or
management of the disease or injury.
Covered Expenses
 Ambulance transportation to the nearest centre where adequate
treatment is available  Semi-private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's standard ward rate and the government authorized allowance in your home province is covered. The plan also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province.  Convalescent care for a condition that will significantly improve as a result of the care and follows a 3-day confinement for acute care  The government authorized co-payment for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered.  Home nursing services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, when services are provided in Canada, but only if the patient requires the specific skills of a trained nurse You should apply for a pre-care assessment before home nursing begins  Chronic care, provided in a hospital, nursing home or for home nursing care in Canada, for a condition where improvement or deterioration is unlikely within the next 12 months  Drugs and drug supplies described below when prescribed by a physician or other person entitled by law to prescribe them, and provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the out-of-country care provision. Drugs which require a written prescription according to the Food and Drugs Act, Canada or provincial legislation in effect where the drug is dispensed, including oral contraceptives Injectable drugs including vitamins, insulins and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with non-disposable insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by law may be covered. If you have any questions, contact your plan administrator before incurring the expense. Unless the prescriber has prescribed a drug by its brand name and has specified in writing that the product is not to be interchanged, the plan will cover only the cost of the lowest priced equivalent generic drug. For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan.  Rental or, at Great-West Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a physician  Custom-made foot orthotics and custom-fitted orthopedic shoes, including modifications to orthopedic footwear, when prescribed by a physician  Hearing aids, including batteries, tubing and ear molds provided at the time of purchase, when prescribed by a physician  Diabetic supplies, including insulin, syringes, Novolin pens, testing supplies and insulin infusion sets, when prescribed by a physician  Blood-glucose monitoring machines prescribed by a physician  Diagnostic x-rays and lab tests, when coverage is not available under your provincial government plan  Treatment of injury to sound natural teeth. Treatment must start within 60 days after the accident unless delayed by a medical condition A sound tooth is any tooth that did not require restorative treatment immediately before the accident. A natural tooth is any tooth that has not been artificially replaced No benefits are paid for: accidental damage to dentures dental treatment completed more than 12 months after the accident orthodontic diagnostic services or treatment  Out-of-hospital services of a qualified acupuncturist  Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor  Out-of-hospital services of a qualified massage therapist  Out-of-hospital services of a licensed naturopath  Out-of-hospital treatment of movement disorders by a licensed  Out-of-hospital treatment of foot disorders, including diagnostic x-rays, by a licensed podiatrist  Out-of-hospital treatment of speech impairments by a qualified speech therapist
Visioncare
 Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist, and coverage is not available under your provincial government plan  Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician  Laser eye surgery required to correct vision when performed by a licensed ophthalmologist For information on available discounts on eyewear and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit.
Global Medical Assistance Program
This program provides medical assistance through a worldwide
communications network which operates 24 hours a day. The network
locates medical services and obtains Great-West Life's approval of
covered services, when required as a result of a medical emergency
arising while you or your dependent is travelling for vacation, business or
education. Coverage for travel within Canada is limited to emergencies
arising more than 500 kilometres from home. You must be covered by
the government health plan in your home province to be eligible for
global medical assistance benefits. The following services are covered,
subject to Great-West Life's prior approval:
 On-site hospital payment when required for admission, to a maximum of $1,000  If suitable local care is not available, medical evacuation to the nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation will be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment When services are covered under this provision, they are not covered under other provisions described in this booklet  Transportation and lodging for one family member joining a patient hospitalized for more than 7 days while travelling alone. Benefits will be paid for moderate quality lodgings up to $1,500 and for a round trip economy class ticket  If you or a dependent is hospitalized while travelling with a companion, extra costs for moderate quality lodgings for the companion when the return trip is delayed due to your or your dependent's medical condition, to a maximum of $1,500  The cost of comparable return transportation home for you or a dependent and one travelling companion if prearranged, prepaid return transportation is missed because you or your dependent is hospitalized. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation  In case of death, preparation and transportation of the deceased  Return transportation home for minor children travelling with you or a dependent who are left unaccompanied because of your or your dependent's hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary  Costs of returning your or your dependent's vehicle home or to the nearest rental agency when illness or injury prevents you or your dependent from driving, to a maximum of $1,000. Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home Benefits payable for moderate quality accommodation include telephone expenses as well as taxicab and car rental charges. Meal expenses are not covered.
Out-Of-Country Care
 Emergency care outside Canada is covered if it is required as a
result of a medical emergency arising while you or your dependent is temporarily outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province. A medical emergency is either a sudden, unexpected injury, or a sudden, unexpected illness or acute episode of disease that could not have been reasonably anticipated based on the patient's prior medical condition. Emergency care is covered medical treatment that is provided as a result of and immediately following a medical emergency. If the patient's condition permits a return to Canada, benefits are limited to the lesser of: the amount payable under this plan for continued treatment outside Canada, and the amount payable under this plan for comparable treatment in Canada plus the cost of return transportation. No benefits are paid for: any further medical care related to a medical emergency after the initial acute phase of treatment. This includes non-emergency continued management of the condition originally treated as an emergency any subsequent and related episodes during the same absence from Canada expenses related to pregnancy and delivery, including infant care: after the 34th week of pregnancy, or at any time during the pregnancy if the patient's medical history indicates a higher than normal risk of an early delivery or complications. expenses incurred more than 6 months after the date of departure from Canada. If you or your dependent is hospital confined at the end of the 6 month period, benefits will be extended to the end of the confinement  Non-emergency care outside Canada is covered for you and your
it is required as a result of a referral from your usual Canadian physician it is not available in any Canadian province and must be obtained elsewhere for reasons other than waiting lists or scheduling difficulties you are covered by the government health plan in your home province for a portion of the cost, and a pre-authorization of benefits is approved by Great-West Life before you leave Canada for treatment. No benefits will be paid for: investigational or experimental treatment transportation or accommodation charges. The plan covers the following services and supplies when related to out-of-country care:  treatment by a physician  diagnostic x-ray and laboratory services  hospital accommodation in a standard or semi-private ward or intensive care unit, if the confinement begins while you or your dependent is covered  medical supplies provided during a covered hospital confinement  paramedical services provided during a covered hospital  hospital out-patient services and supplies  medical supplies provided out-of-hospital if they would have been covered in Canada  out-of-hospital of a professional nurse  for emergency care only: ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available dental accident treatment if it would have been covered in Canada.
Limitations
Except to the extent otherwise required by law, no benefits are paid for:
 Expenses private insurers are not permitted to cover by law  Services or supplies for which a charge is made only because you have insurance coverage  The portion of the expense for services or supplies that is payable by the government health plan in your home province, whether or not you are actually covered under the government health plan  Any portion of services or supplies which you are entitled to receive, or for which you are entitled to a benefit or reimbursement, by law or under a plan that is legislated, funded, or administered in whole or in part by a government ("government plan"), without regard to whether coverage would have otherwise been available under this plan In this limitation, government plan does not include a group plan for government employees  Services or supplies that do not represent reasonable treatment  Services or supplies associated with: treatment performed only for cosmetic purposes recreation or sports rather than with other daily living activities the diagnosis or treatment of infertility, other than drugs contraception, other than oral contraceptives and intrauterine devices (IUDs)  Services or supplies not listed as covered expenses  Extra medical supplies that are spares or alternates  Services or supplies received outside Canada except as listed under Out-of-Country Care and Global Medical Assistance  Services or supplies received out-of-province in Canada unless you are covered by the government health plan in your home province and Great-West Life would have paid benefits for the same services or supplies if they had been received in your home province This limitation does not apply to Global Medical Assistance  Expenses arising from war, insurrection, or voluntary participation in  Visioncare services and supplies required by an employer as a condition of employment In addition under the prescription drug coverage, no benefits are paid for:  Atomizers, appliances, prosthetic devices, colostomy supplies, first aid supplies, diagnostic supplies or testing equipment  Non-disposable insulin delivery devices or spring loaded devices used to hold blood letting devices  Delivery or extension devices for inhaled medications  Oral vitamins, minerals, dietary supplements, homeopathic preparations, infant formulas or injectable total parenteral nutrition solutions  Diaphragms, condoms, contraceptive jellies, foams, sponges, suppositories, contraceptive implants or appliances  Any drug that does not have a drug identification number as defined by the Food and Drugs Act, Canada  Any single purchase of drugs which would not reasonably be used within 34 days. In the case of certain maintenance drugs, a 100-day supply will be covered  Drugs dispensed by a dentist or clinic or by a non-accredited hospital pharmacy  Drugs administered during treatment in an emergency room of a hospital, or as an in-patient in a hospital  Preventative immunization vaccines and toxoids  Non-injectable allergy extracts  Drugs that are considered cosmetic, such as topical minoxidil or sunscreens, whether or not prescribed for a medical reason  Drugs used to treat erectile dysfunction
How to Make a Claim
 Out-of-country claims (other than those for Global Medical Assistance expenses) should be submitted to Great-West Life as soon as possible after the expense is incurred. It is very important that you send your claims to the Great-West Life Out-of-Country Claims Department immediately as your Provincial Medical Plan has very strict time limitations. Access GroupNet for Plan Members to obtain a personalized claim form or obtain form M5432 (Statement of Claim Out-of-Country Expenses form) from your employer. Unless you are a resident of the Territories you must also obtain the Government Assignment form, and residents of British Columbia, Quebec and Newfoundland & Labrador must also obtain the Special Government Claim form. The Great-West Life Out-of-Country Claims Department will forward the appropriate government forms to your attention when required. If you are a resident of the Territories, you must submit your out-of-country claims to your territorial government for processing before submitting the claim to Great-West Life. When you receive your Explanation of Benefits back from the territory, please send the following to the Great-West Life Out-of-Country Claims Department (be sure to keep copies for your own records): - a copy of the payment from your territory a completed Statement of Claim Out-of-Country Expenses form (form M5432) all required information copies of all original receipts Residents of the provinces should complete all applicable forms, making sure all required information is included. Attach all original receipts and forward the claim to the Great-West Life Out-of-Country Claims Department. Be sure to keep a copy for your own records. The plan will pay all eligible claims including your Provincial Medical Plan portion. Your Provincial Medical Plan will then reimburse the plan for the government's share of the expenses. Out-of-country claims must be submitted within a certain time period that varies by province. For the claims submission period applicable in your province or territory or for any other questions or for assistance in completing any of the forms, please contact Great-West Life's Out-of-Country Claims Department at 1-800-957-9777.  Claims for expenses incurred in Canada, for paramedical services and visioncare, may be submitted online. To use this online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online. Claims must be submitted to Great-West Life as soon as possible, but no later than 15 months after you incur the expense. You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.  For all other Healthcare claims, access GroupNet for Plan Members to obtain a personalized claim form or obtain form M635D from your employer. Complete this form making sure it shows all required information. Attach your receipts to the claim form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 15 months after you incur the expense.  For drug claims, your employer will provide you with a prescription
drug identification card. Present your card to the pharmacist with your prescription. Before your prescription is filled, an Assure Claims check will be done. Assure Claims is a series of seven checks that are electronically done on your drug claim history for increased safety and compliance monitoring. This has been designed to improve the health and quality of life for you and your dependents. Checks done include drug interaction, therapeutic duplication and duration of therapy, allowing the pharmacist to react prior to the drug being dispensed. Depending on the outcome of the checks, the pharmacist may refuse to dispense the prescribed drug. When your coverage ends, return your direct pay drug identification card to your employer. PREFERRED VISION SERVICES (PVS)

Preferred Vision Services (PVS) is a service provided by Great-
West Life to its customers through PVS which is a preferred
provider network company.

PVS entitles you to a discount on a wide selection of quality eyewear
and lens extras (scratch guarding, tints, etc.) when you purchase these
items from a PVS network optician or optometrist. A discount on laser
eye surgery can be obtained through an organization that is part of the
PVS network.
PVS also entitles you to a discount on hearing aids (batteries, tubing,
ear molds, etc.) when you purchase these items from a PVS network
provider.
You are eligible to receive the PVS discount through the network
whether or not you are enrolled for the healthcare coverage described in
this booklet. You can use the PVS network as often as you wish for
yourself and your dependents.
Using PVS:
 Call
PVS Information Hotline at 1-800-668-6444 or visit the
PVS Web site at www.pvs.ca for information about PVS locations
and the program
 Arrange for a fitting, an eye examination, a hearing assessment or a hearing test, if needed  Present your group benefit plan identification card, to identify your preferred status as a PVS member through Great-West Life, at the time the eyewear or the hearing aid is purchased, or at the initial consultation for laser eye surgery  Pay the reduced PVS price. If you have vision care coverage or hearing aids coverage for the product or service, obtain a receipt and submit it with a claim form to your insurance carrier in the usual manner. DENTALCARE

A deductible may be applied before you are reimbursed. All expenses
will be reimbursed at the level shown in the Benefit Summary. Benefits
may be subject to plan maximums and frequency limits. Check the
Benefit Summary for this information.
The plan covers customary charges to the extent they do not exceed the
dental fee guide level shown in the Benefit Summary. Denturist fee
guides are applicable when services are provided by a denturist. Dental
hygienist fee guides are applicable when services are provided by a
dental hygienist practising independently.
All covered services and supplies must represent reasonable treatment.
Treatment is considered reasonable if it is recognized by the Canadian
Dental Association, it is proven to be effective, and it is of a form,
frequency, and duration essential to the management of the person's
dental health. To be considered reasonable, treatment must also be
performed by a dentist or under a dentist's supervision, performed by a
dental hygienist entitled by law to practise independently, or performed
by a denturist.
Treatment Plan
 Before incurring any large dental expenses, or beginning any orthodontic treatment, ask your dental service provider to complete a treatment plan and submit it to Great-West Life. Great-West Life will calculate the benefits payable for the proposed treatment, so you will know in advance the approximate portion of the cost you will have to pay.
Basic Coverage
The following expenses will be covered:
 Diagnostic services including: one complete oral examination every 36 months limited oral examinations once every 9 months, except that only one limited oral examination is covered in any 12-month period that a complete oral examination is also performed limited periodontal examinations once every 9 months complete series of x-rays every 36 months intra-oral x-rays to a maximum of 15 films every 36 months and a panoramic x-ray every 36 months. Services provided in the same 12 months as a complete series are not covered  Preventive services including: polishing and topical application of fluoride each once every 9 months scaling, limited to a maximum combined with periodontal root planing of 10 time units every 12 months A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval pit and fissure sealants on bicuspids and permanent molars every 60 months space maintainers including appliances for the control of harmful habits recontouring of teeth  Minor restorative services including: caries, trauma, and pain control amalgam and tooth-coloured fillings. Replacement fillings are covered only if the existing filling is at least 2 years old or the existing filling was not covered under this plan retentive pins and prefabricated posts for fillings prefabricated crowns for primary teeth  Endodontics. Root canal therapy for permanent teeth will be limited to one course of treatment per tooth. Repeat treatment is covered only if the original treatment fails after the first 18 months  Periodontal services including: root planing, limited to a maximum combined with preventive scaling of 10 time units every 12 months occlusal adjustment and equilibration, limited to a combined maximum of 4 time units every 12 months A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval  Denture maintenance, after the 3-month post-insertion care period, denture relines for dentures at least 6 months old, once every 36 months denture rebases for dentures at least 2 years old, once every 36 months resilient liner in relined or rebased dentures, once every 36 months denture repairs and additions and resetting of denture teeth denture adjustments, once every 12 months
Major Coverage
 Crowns. Coverage for crowns on molars is limited to the cost of metal crowns. Coverage for complicated crowns is limited to the cost of standard crowns  Onlays. Coverage for tooth-coloured onlays on molars is limited to the cost of metal onlays Replacement crowns and onlays are covered when the existing restoration is at least 5 years old and cannot be made serviceable  Standard complete dentures, standard cast or acrylic partial dentures or complete overdentures or bridgework when required to replace one or more teeth extracted while the person is covered. Overdentures and bridgework are covered only when standard complete or partial dentures are not viable treatment options. Coverage for tooth-coloured retainers and pontics on molars is limited to the cost of metal retainers and pontics. Replacement appliances are covered only when: the existing appliance is a covered temporary appliance the existing appliance is at least 5 years old and cannot be made serviceable. If the existing appliance is less than 5 years old, a replacement will still be covered if the existing appliance becomes unserviceable while the person is covered and as a result of the placement of an initial opposing appliance or the extraction of additional teeth. If additional teeth are extracted but the existing appliance can be made serviceable, coverage is limited to the replacement of the additional teeth  Denture-related surgical services for remodelling and recontouring  Denture and bridgework maintenance following the 3-month post- insertion period including: denture remakes, once every 36 months repairs to covered bridgework removal and recementation of bridgework
Orthodontic Coverage
 Orthodontics are covered for persons age 6 or over when treatment
Limitations
No benefits are paid for:
 Duplicate x-rays, custom fluoride appliances, any oral hygiene
instruction and nutritional counselling  The following endodontic services - root canal therapy for primary teeth, isolation of teeth, enlargement of pulp chambers and endosseous intra coronal implants  The following periodontal services - desensitization, topical application of antimicrobial agents, subgingival periodontal irrigation, charges for post surgical treatment and periodontal re-evaluations  The following oral surgery services - implantology, surgical movement of teeth, services performed to remodel or recontour oral tissues (other than minor alveoloplasty, gingivoplasty and stomatoplasty) and alveoloplasty or gingivoplasty performed in conjunction with extractions. Services for remodelling and recontouring oral tissues will be covered under Major Coverage  Hypnosis or acupuncture  Veneers, recontouring existing crowns, and staining porcelain  Crowns or onlays if the tooth could have been restored using other procedures. If crowns, onlays or inlays are provided, benefits will be based on coverage for fillings  Overdentures or initial bridgework if provided when standard complete or partial dentures would have been a viable treatment option. If overdentures are provided, coverage will be limited to standard complete dentures. If initial bridgework is provided, coverage will be limited to a standard cast partial denture and restoration of abutment teeth when required for purposes other than bridgework If additional bridgework is performed in the same arch within 60 months, coverage will be limited to the addition of teeth to a denture and restoration of abutment teeth when required for purposes other than bridgework Benefits will be limited to standard dentures or bridgework when equilibrated and gnathological dentures, dentures with stress breaker, precision and semi-precision attachments, dentures with swing lock connectors, partial overdentures and dentures and bridgework related to implants are provided  Expenses covered under another group plan's extension of benefits  Services or supplies covered under Healthcare. If the amount payable would be greater under this Dentalcare benefit, then benefits will be paid under Dentalcare and not Healthcare  Expenses private plans are not permitted to cover by law  Services and supplies you are entitled to without charge by law or for which a charge is made only because you have insurance coverage  Services or supplies that do not represent reasonable treatment  Treatment performed for cosmetic purposes only  Congenital defects or developmental malformations in people 19 years of age or over, except orthodontics  Temporomandibular joint disorders, vertical dimension correction or  Expenses arising from war, insurrection, or voluntary participation in
How to Make a Claim
 Claims for expenses incurred in Canada may be submitted online.
Access GroupNet for Plan Members to obtain a personalized claim form or obtain form M445D from your employer and have your dental service provider complete the form. The completed claim form will contain the information necessary to enter the claim online. To use the online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online. Claims must be submitted to Great-West Life as soon as possible, but no later than 15 months after the dental treatment. You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.  For all other Dentalcare claims, access GroupNet for Plan Members to obtain a personalized claim form or obtain form M445D from your employer. Have your dental service provider complete the form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 15 months after the dental treatment. COORDINATION OF BENEFITS
 Benefits for you or a dependent will be directly reduced by any amount payable under a government plan. If you or a dependent are entitled to benefits for the same expenses under another group plan or as both an employee and dependent under this plan or as a dependent of both parents under this plan, benefits will be co-ordinated so that the total benefits from all plans will not exceed expenses.  You and your spouse should first submit your own claims through your own group plan. Claims for dependent children should be submitted to the plan of the parent who has the earlier birth date in the calendar year (the year of birth is not considered). If you are separated or divorced, the plan which will pay benefits for your children will be determined in the following order: 1. the plan of the parent with custody of the child; 2. the plan of the spouse of the parent with custody of the child; 3. the plan of the parent without custody of the child; 4. the plan of the spouse of the parent without custody of the child You may submit a claim to the plan of the other spouse for any amount which is not paid by the first plan. DIAGNOSTIC AND TREATMENT SUPPORT SERVICES
(BEST DOCTORS® SERVICE)

This service is designed to allow you, your dependents and your
attending physician or specialists access to the expertise of world-class
specialists, resources, information and clinical guidance.
If you or your dependents are diagnosed with a serious medical
condition for which there is objective evidence, or if your physician or
you or your dependent suspect you have this condition, you can access
this service. This service is made up of a unique step-by-step process
that may help address questions or concerns about a medical condition.
This may include confirming the diagnosis and suggesting the most
effective treatment plan by drawing on a global database of up to 50,000
peer-ranked specialists.
How it works

 You or your dependent can access diagnostic and treatment support
services by calling 1-877-419-BEST (2378) toll-free.  You will be connected with a member advocate who will be dedicated to your case and will provide support through the process. The member advocate will take the necessary medical history and answer your questions. Any information provided is not shared with either your employer or the administrator of your health plan.  Based on the information and questions, the member advocate determines the optimal level of service for you or your dependent.  The member advocate may provide information, resources, guidance and advice individually tailored to meet your health needs. They can also help identify individual community supports and resources available.  If it is appropriate, the member advocate may arrange for an in- depth review of your medical file to assist in confirming the diagnosis and help develop a treatment plan. This review may include collecting, deconstructing and reconstructing medical records, pathology retesting and analyzing test results. A written report outlining the conclusions and recommendations of the specialists will be forwarded to you and your physician. On average, this process takes 6 to 8 weeks. Timeframes may vary depending on the complexity of the case and amount of medical records to collect.  If you decide to seek treatment by a different physician, the member advocate can help identify the specialist best qualified to meet your specific medical needs. Expenses incurred for travel and treatment are not covered by this service.  If you decide to seek treatment outside Canada, the member advocate can arrange referrals and can help book accommodations. The member advocate can also access hospital and physician discounts, arrange for forwarding of medical information and monitor the treatment process. Expenses incurred for travel and treatment are not covered by this service.
Note: These services are not insured services. Great-West Life is not
responsible for the provision of the services, their results, or any
treatment received or requested in connection with the services.

Source: http://www.thekettle.ca/wp-content/uploads/2012/10/Great-West-Life-Group-Benefit-Plan-Casual.pdf