Treasury Board of Canada Secretariat
Public Service Health Care Plan for Pensioners
|Hospital||means a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury on an in-patient basis, with 24-hour services by registered nurses and physicians. This includes legally licensed hospitals providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care.|
means a doctor of medicine (M.D.) legally licensed to practice medicine.
To be eligible, the expenses must be medically necessary for the treatment of disease or injury and be prescribed by a physician, unless otherwise specified.
Eligible expenses are the reasonable and customary charges for the items of expense listed below:
* unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis at an earlier date
Reimbursement will be limited to the cost of non-motorized equipment unless medically proven that the patient requires motorized equipment; and
No benefit is payable for:
For pensioners residing in Canada, certain other expenses as described below are eligible where they are incurred outside the participants province of residence, either in another province or outside Canada, and where those expenses exceed the amount covered under the pensioners provincial health plan. Reimbursement may be made only if such coverage is not expressly prohibited by law, and is subject to the limits set out in Appendix A.
Refer to the Extended Health Care Benefit for definitions.
In addition to the aforementioned Extended Health Care benefits, certain expenses are also eligible (up to the limit set out in Appendix A) and are reimbursed at 100 per cent with no annual deductible, when they are incurred for emergency treatment of an injury or disease suffered by the participant while travelling outside the province of residence, where such treatment commenced not more than 40 days from the participants date of departure from the province of residence (where treatment continues beyond the 40-day period, related expenses will be covered).
The Travel Benefit covers expenses for:
A 24-hour toll-free "help-line" service is available, which you may call to obtain assistance for:
transportation arrangements to the nearest hospital that provides the
appropriate care, or back to Canada;
medical referrals, consultation and monitoring;
a telephone interpretation service;
a message service for family and business associates; messages are held for up to 15 days; and
advance payment on behalf of members and covered dependants for hospital and medical expenses.
The "help-line" telephone number FOR TRAVEL-RELATED EMERGENCIES is:
|In Canada or the United States||1-800-667-2883 (toll-free)|
|All other countries||(519) 742-1342 (call collect)|
The following expenses are eligible (up to the limit set out in Appendix A) and are reimbursed at 80 per cent after the annual deductible is met, when the treatment or services are not offered in the province of residence and are incurred following written referral by the attending physician in the province of residence of the participant:
No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.
The benefit is applicable only to those pensioners who are eligible to join the Health Care Plan, and who reside outside Canada and are not covered under a provincial health plan. This benefit provides reimbursement for reasonable and customary charges for those health care expenses (excluding hospital services) which are covered under the provincial health insurance plan of the province of Ontario. The co-payment and deductible amount do not apply under this benefit.
Refer to the Extended Health Care Benefit for definitions.
Some of the more significant covered services are:
The maximum payable for any covered service is equivalent to a multiple of the amount which is payable under the provincial health insurance plan of the province of Ontario. The multiple is specified in Appendix A.
* These benefits are in addition to benefits that may be available under the Extended Health Care Benefit.
In addition to reviewing the general description of eligible expenses above, you should note the exclusions and limitations set out in Appendix B.
This benefit provides reimbursement for reasonable and customary charges, up to specified amounts, for each day of hospital confinement for the cost of hospital room and board charges other than standard ward charges (i.e., semi-private or private accommodation), whether the pensioner is residing in Canada or abroad. There is a maximum amount which may be payable under this benefit for each day of confinement, depending on the benefit level you have chosen. The levels are shown in Appendix A. All members of the Health Care Plan are automatically covered for Level l.
You should ensure that the benefit level which you have chosen is adequate for your own personal needs, taking into consideration the daily charges levied for preferred hospital accommodation in your area of residence. You may contact your pension office if you wish to apply to upgrade or reduce your level of coverage.
Please note that this benefit will not necessarily cover you for the full costs of semi-private or private hospital accommodation, since that will depend on whether the level of your coverage under the Health Care Plan is sufficient to cover the actual charges you are required to pay. You will be responsible for paying any difference between the actual charges by a hospital and the maximum amount payable under the level of coverage you have chosen.
Refer to the Extended Health Care Benefit for definitions.
You should note the exclusions and limitations set out in Appendix B.
|Electrologists services (when performed by an electrologist or a physician)||$20/visit|
|Nursing services||$15,000/calendar year|
|Orthopaedic shoes||$150/calendar year|
|Speech language pathologist||$500/calendar year|
|Chiropodist, massage therapist, naturopath, osteopath or podiatrist||$300/calendar year|
|Eyeglasses and contact lenses||$150 every 24-month period
($200/two-year period* effective Jan. 1993)
|Hearing aids||$500 every 60-month period|
|Wheelchairs||Replacement cost covered every 60 months|
|Wigs||$500/lifetime for members suffering from total hair loss as a result of illness or disease|
|Orthopaedic brassieres||$100/calendar year|
|Referral Benefit: specified expenses incurred out-of-province on a referral basis||$25,000/illness|
|It is important to note that the above limits refer to the amount of eligible expenses which may be covered, and not to the amounts of benefits which may be paid. Reimbursement under the Health Care Plan is made at 80 per cent of covered eligible expenses, after you have met the annual deductible.|
|Level I $60/day
Level II $100/day
Level III $150/day
|Basic Health Care Benefit**||three times the amount otherwise payable under the Health
Insurance Act 1972 of Ontario
|Travel Benefit:||$100,000/period of travel|
|Specified expenses incurred on an emergency basis while travelling outside the province of residence (Out-of-Province Benefit)**|
* Explanation of the administration of the two-year period.
** Eligible expenses under the Hospital Benefit, the Basic Health Care Benefit and the Travel Benefit, up to the limits noted above, are reimbursed at 100 per cent.
Note: Any changes to the above-noted amounts will be announced through your pension office, and you should make note of those changes for future reference.
No coverage is payable for charges in respect of
No benefit is payable
If you reside in a province which provides a program to cover expenses which are also covered under the Health Care Plan (such as prescription drugs, artificial limbs and other assistive devices), you should first submit your claim to the provincial authorities. When that claim has been processed, you may claim to the Health Care Plan for any remaining eligible expenses.
In general, if you are covered under both the Health Care Plan and another group health plan, you may claim for eligible medical expenses under both plans. However, the combined reimbursement under both plans cannot exceed the total expenses incurred. Three situations usually exist and the method of claiming is given below.
In this situation, it is likely that you are covered under one plan as a pensioner and under the other plan as an active full-time or part-time employee. A claim for your own expenses must first be submitted to the plan that covers you as a full-time employee. If your spouse and/or children are also covered under both of your health plans, then a claim for expenses which they incur must first be submitted to the plan covering you as a full-time employee.
In this situation, a claim for your own expenses must first be submitted to the Health Care Plan, and your spouse must submit a claim first to his or her own plan. Once a claim has been settled by the first plan, you and your spouse may then claim any eligible expenses to the other plan for the unpaid balance. If there are expenses for your children, and if both of you cover your children under your respective plans, then a claim for the childrens expenses must be first submitted to the plan of the parent having the earlier birthdate.
For example, if you were born in January, and your spouse was born in June, you would first claim against the Health Care Plan for the childrens expenses.
If you have incurred expenses which are eligible for reimbursement, you should complete the authorized claim form, "Summary of Expenses", completing each column with the appropriate information. Show your full name and address, including your postal code, and sign the claim form. If you omit your Personal Identification Number (found on your benefit card) or use an incorrect number, your claim will be returned to you for correction.
If both you and your spouse are covered as members under the Health Care Plan, there is no advantage for both employees to have separate coverage under the Health Care Plan. However, if you choose to do so, both of you must submit claims for your own expenses under your Personal Identification Number found on your Health Care Plan benefit card. You may not submit a claim for any unpaid balance to the Health Care Plan under your spouses Personal Identification Number.
Likewise, claims for children must be made by one member only, either yourself or your spouse, and any balance may not then be submitted under the identification number of the other member. You may be required to provide supporting documentation to the Administrator the first time you submit a claim for your impaired child who is age 21 or over.
Attach your bills or receipts, making sure they provide full details for services rendered or purchases made. For any prescription drug claims, it is preferred that you indicate the Drug Identification Number (DIN) on the claim form.
Claims may be submitted at any time during a calendar year in which eligible expenses are incurred. Be sure to file your claim no later than six months from the end of the year in which you incurred your expenses, because the Administrator has no obligation to recognize claims received beyond that date. However, claims may be accepted for a longer period if the Administrator is satisfied that the delay was unavoidable.
The Administrator will forward to you an Explanation of Benefits with your benefit payment when your claim has been processed. Payment will be issued to you or, on receipt of signed instructions from you, may be issued to your spouse or to the provider of service.
If, on admittance to the hospital, you request a semi-private or private room, you should show the hospital admitting clerk your Health Care Plan benefit card. Most hospitals have standard claim forms which you will be asked to sign and the hospital then files a claim on your behalf. If the hospital does not use such a form, complete the "Summary of Expenses" and attach the hospital statement of charges.
All claims should be sent to the Administrator at the following address:
Sun Life of Canada
Health Claims Office
P.O. Box 9601 CSC-T
Telephone: (613) 247-5100 or 1-888-757-7427
Pensioners who require details regarding a particular claim should contact the Administrator directly at:
(613) 247-5100 (local calls) 1-888-757-7427 (toll-free)
Where a pensioner does not agree with a decision of the Administrator, and wishes a review of his or her case, a submission may be made to the Public Service Health Care Plan Board of Management. Under its terms of reference, the Board of Management has discretion to review individual cases with respect to adjudication of claims and membership.
Pensioners must ensure that all possible remedies for individual problem cases are investigated. Problem cases should be submitted to the Board of Management only when other approaches have failed to provide solutions. In addition, you should provide the Administrator with any information or medical evidence necessary for the adjudication of claims prior to submitting them to the Board of Management.
Individual cases, with the particulars of the case, may then be submitted to the Health Care Plan Board of Management at the following address:
The Secretary of the Public Service Health Care Plan Board
c/o National Joint Council
P.O. Box 1525, Station B
Customer Services Section
Supply and Services Canada
P.O. Box 5010
Moncton, New Brunswick
Office Hours For Telephone Enquiries:
IN CANADA: 8:30 a.m.- 4:00 p.m. (your local time)
LOCAL CALLS AND CALLS FROM OUTSIDE CANADA:
8:30 a.m.- 4:30 p.m. (Atlantic time)
|IN CANADA:||1-800-561-7930 (English toll-free)
1-800-561-7935 (French toll-free)
(Moncton & Shediac):
|OUTSIDE CANADA:||(506) 533-5700 (English call collect)
(506) 533-5767 (French call collect)
TDD SYSTEM CALLS (bilingual service)
(506) 533-5990 (call collect*)
* Collect calls will not be accepted if you are calling from the region served by the toll-free telephone numbers unless it is a TDD call.
PSHCP Canadian Forces Office
Directorate of Pay Services
National Defence Headquarters
LOCAL CALLS (National Capital Region): 995-5800
PENSIONERS RESIDING IN ONTARIO (other than the National Capital Area),
QUEBEC, NEW BRUNSWICK, PRINCE EDWARD ISLAND, and NOVA SCOTIA
(toll-free): 1-800-267-6542 or 1-800-267-6543
PENSIONERS RESIDING IN MANITOBA, SASKATCHEWAN, ALBERTA, BRITISH COLUMBIA, YUKON TERRITORY, NORTHWEST TERRITORIES, AND NEWFOUNDLAND (toll-free): 1-800-267-3378
Royal Canadian Mounted Police Services Section
1200 Vanier Parkway
Office Hours for Telephone Enquiries:
8:00 a.m. 4:00 p.m.
|Long Distance (toll-free):||1-800-661-7595|
Office of the Commissioner for Federal Judicial Affairs
110 OConnor Street
(613) 996-5504 (call collect)
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