Health Benefits Plan (Dejardins)

Group Travel Insurance

The group travel insurance plan covers a wide range of benefits which may be required as a result of an accident or unexpected illness incurred outside the province or country while traveling on business or vacation (some restrictions may apply). The plan provides coverage for a period of 90 days per trip for travel within Canada and 30 days per trip for travel outside Canada. Proof of departure and return date from province of residence is required.

It is important to note that coverage is provided for emergencies only related to accidents or unexpected illness while traveling outside your province of residence. If you have an existing medical condition, the condition must be stable before traveling to have coverage for that condition. Stable means that in the last 3 months before leaving, there has been no hospitalization, no increase or modification in treatment or prescribed medication dosage or no symptom for which a reasonably prudent person would consult a physician. Stable dosage does not apply if you are a diabetic.

The insurer will pay 100% of the reasonable and customary charges (subject to any benefit maximums) for the following eligible expenses:

1. Charges of a public general hospital, less the amount allowed under the provincial government health plan for (a) room accommodation (not a suite of rooms), and (b) medically necessary in-patient and out-patient services.
2. Customary charges by physicians and surgeons for services rendered, less the amount allowed under the provincial government health plan.
3. Rental of wheelchairs, crutches and canes when required as a result of sickness or accident. This benefit will be payable only when the sickness or accident occurs outside the insured person's province of residence. Rental expenses must be incurred outside the province of residence and ordered by a physician.
4. Private duty nursing when ordered by a physician at the usual and customary fee. registered nurses providing the service must not be a relative of the patient or an employee of the hospital.
5. Charges for normal ambulance service to and from the nearest hospital able to provide the type of care essential to the patient.
6. Extra costs of return economy fare by the most direct route (air, bus, train) when an illness is such that the patient must return home and be accompanied by a qualified medical attendant (not a relative). Written authorization is required from the attending physician. If returning on a commercial aircraft, this coverage includes:
   • two economy seats by most direct route to the patient's home city in Canada, one for the covered patient and one round trip fare for a medical attendant;
   • the number of economy seats required to accommodate the covered patient if on a stretcher and one round trip fare for a medical attendant.
7. The cost of diagnostic laboratory and x-ray services, less the amount allowed under the provincial government health plan, when ordered by the attending physician.
8. The cost of services provided by Chiropractors, Osteopaths, Chiropodist/Podiatrist and Physiotherapist (not a relative) in excess of payment by a provincial government health plan, excluding charges for x-rays.
9. Charges for prescription drugs in a quantity sufficient for the period of travel. Payment of eligible drug expenses will be made only when proof of purchase is supplied in the form of an account from a pharmacist, physician or hospital located outside the insured person's province of residence, showing the name of the preparation, date of purchase, quantity, strength and total cost.
10. Charges for dental treatment to a maximum of $1,000 in all, when, as the result of accidental injury (direct accidental blow to the mouth), natural teeth have been damaged or a fractured or dislocated jaw requires setting. Such dental treatment must be rendered or reported and approved for payment by the insurer within 180 days of the accident and be supported by proper certification. When such dental treatment must be deferred because of the age of the patient, or other factors which are justified in the opinion of the insurer within 180 days of the accident, complete details of the required services from the dentist and reason for deferment.
11. An allowance of up to $500 Canadian for the cost of driving the patient's vehicle, either private or rental, by commercial agency to the patient's residence or nearest appropriate vehicle rental agency when the patient is unable to return it due to sickness or accident.
12. Up to $3,000 Canadian towards the cost of preparation and homeward transportation of the deceased (excluding the cost of a coffin) to the point of departure in Canada by the most direct route in the event of the insured person's death.
13. Up to $700 Canadian ($100 per day for seven days) per trip for extra costs of commercial accommodation and meals incurred by the insured person, or by an insured dependent remaining with you or a traveling companion. This must be verified by the attending physician and supported with receipts from commercial organizations.
14. Return economy fare by the most direct route for transportation costs (air, bus, train) when the insured person has been confined to hospital for seven days or more, or has died and the attending physician has advised the necessary attendance of a family member or close friend.
15. The services of a 24-hour emergency hotline are available to insured persons who need assistance while traveling. By telephoning the appropriate number shown on your Identification Card "Voyage Assistance" when a medical emergency occurs, coverage will be confirmed to the hospital or physician. Payment of medical expenses will be arranged or co-ordinated on behalf of the insured person.
16. The patient may call for a list of hospitals or medical facilities and arrangements will be made for:
    • advice from a qualified physician;
    • medical follow-up of the patient's condition and communication with the insured person's family;
    • return home or transfer of patient if medically permissible; and
    • transportation of a family member to the patient's bedside or to identify the deceased.
17. The patient may call to obtain:
    • An emergency response in any major language;
    • emergency assistance in contacting the family or business; and
    • referral to legal counsel.

Co-ordination of Benefits
Should similar benefits be provided by more than one section of the policy, any claim for these benefits will be assessed by insurance company in a manner which provides the greatest benefit to the participant.

Where compensation for benefits covered under this plan is available to a participant under any other prepaid health service contract or insurance policy, the amount payable under this plan shall be coordinated with such other coverages in accordance with the Canadian Life and Health Insurance Association (CLHIA) Guidelines so that the total benefits from all plans will not exceed the expenses actually incurred.

Effective April 1, 2010, Co-ordination of Benefits will be allowed between spouses insured under the Plan.

If the other plan does not contain a coordination of benefits provision, then that plan shall be considered first payer.

Limitations and Exclusions
No benefits are payable under the plan for expenses in connection with:

• Traveling outside the province of residence primarily or incidentally to seek medical advice or treatment, even if such a trip is on the recommendation of a physician;
• Elective (non-emergency) treatment or surgery;
• Benefits received from a third party;
• The abuse of medications, drugs or alcohol;
• Suicide or attempted suicide; and
• Criminal acts, wars or other hostilities.

The insurer, in consultation with the attending physician, reserves the right to return the patient to Canada. If any patient is (on medical evidence) able to return to Canada following the diagnosis of, or the emergency treatment for, a medical condition which requires continuing medical services, treatment or surgery, and the insured person elects to have such treatment or services rendered or surgery performed outside of Canada, the expense of such continuing medical services, treatment or surgery will not be covered by this plan. Coverage is available to all insured employees/retirees as long as they are insured under provincial Medicare programs.

Termination of Coverage
Your Group Health Insurance Coverage terminates on the earlier of termination of employment or on the attainment of age 75. Coverage may be continued during retirement provided you are in receipt of a pension from either the Public Service Pension Plan, the Uniformed Services Pension Plan, the Members of the House of Assembly Pension Plan, or the Provincial Court Judges' Pension Plan.
 
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