health
benefits

General Information

• Definitions
• Effective Date of Coverage and Enrolment
• Late Applicants
• Identification (ID) Cards
• Claims
• Duplicate Coverage
• Coordination of Benefits
• General Exclusions
• Termination of Coverage

Allowable Enrolment Period
means,

1. within 4 months (for Extended Health & Dental benefits), or
2. within 31 days (for the Wage Indemnity benefit)

Coverage Effective Date
means the date coverage becomes effective based on

1. your date of hire, and
2. the average number of hours you work each week or each year, and,
3. the waiting period, and
4. the Allowable Enrolment Period.

Deductible
means the initial portion of the Eligible expenses, which you must pay before the Plan will reimburse charges for any Eligible expense.

Dentist
means a doctor of dentistry who is duly qualified and licensed to practice dentistry in the area where the service is provided. For the purposes of this booklet, dentist may also mean dental specialist, or denturist.

Dependent
means, subject to any age limitations included in the benefit description, any of the following persons for whom coverage is provided under this Plan:

1. one Spouse, and
2. any child, stepchild, legally adopted child, or legal ward who is unmarried, living with you, and dependent upon you up to the age of 21 or 25 if attending school on a full-time basis. Coverage will terminate at the earliest of age 25 or the end of the school year (August 31st) in which the student graduates. A dependent child will be covered to any age if such dependent is handicapped.

Duplicate coverage
means that you (and your Dependents) are eligible to claim certain benefits under more than one plan.

Spouse
means your legal spouse or a person who has been living with you in a common-law relationship for at least one full year and who is publicly represented as your spouse.

If you are eligible for coverage, you must complete an enrolment card within the Allowable Enrolment Period to ensure that your coverage starts on the correct effective date.

You should apply for Dependent coverage (when applicable):

1. on the same date you apply for your own coverage, or
2. within the Allowable Enrolment Period if you have a new Dependent.

Limitations:

1. If you are not actively at work on your Coverage Effective Date, your Coverage Effective Date will be delayed until you return to active full-time employment.
2. If the Plan Administrator does not receive your enrolment card within the required time limits, please refer to the Late Applicants section.

Coverage begins on the Coverage Effective Date shown on your identification (ID) card(s), provided that you have complied with the Plan's enrolment rules.

Should you require additional information about when your coverage starts, please contact the Plan Administrator.

If you did not apply during the Allowable Enrolment Period but request coverage later (for yourself and/or your Dependents), ask the Plan Administrator to explain the requirements for late enrolment under the Plan. Note: Different benefits may have different requirements health evidence or retroactive premium payment. In some instances, coverage may be denied.

You will be issued identification (ID) cards by the Plan Administrator.

Only you and your enrolled Dependents are entitled to use this card. Should you (or your Dependent) allow an ineligible person to use this card, your coverage may be suspended without notice.

You may be asked to substantiate that an individual you claim as a Dependent meets the definition of Dependent under the Plan.

1. All claims must be submitted in either English or French.
2. The Plan will pay eligible claims when all the required information is received within the required time limits. You are encouraged to become familiar with the time periods allowed for claiming benefits. Under the Claims sections, the claiming deadlines are fully described for each benefit. No payment will be made if your claim is received after the time limits described in this booklet.
3. Your claim may be rejected if sufficient information is not provided to enable a full assessment of the claim, or if an attempt is made, except through unintentional error, to make an excessive claim, or if a claim is made for a person who is not entitled.
4. The necessary claim forms are available from the Plan Administrator or the Union Hall.
5. The exchange rate on foreign currency is payable at the rate quoted by selected financial institutions in Vancouver, British Columbia, for the date on which the expense was paid. Fluctuations in exchange rates are not the responsibility of the Plan.

If you and your Spouse are both employed and you are both enrolled for similar benefits, Duplicate coverage is allowed.

If you are eligible for Duplicate coverage, you and your family should discuss both plans (and what portion of the benefits you pay) to determine whether it is to your advantage to enroll under more than one plan.

The Plan will pay claims based on the rules of the Canadian Life and Health Insurance Association guidelines. They are:

1. Dependent 00 is always the primary claimant. Dependent 01 (or 90 to 99) is always the secondary claimant.
2. Dependent children are always covered primarily under the parent who has the earliest birthdate in the year (month and day).
3. In situations of separation or divorce, the following order applies:
   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 not having custody of the child
   4. the plan of the Spouse of the parent in c) above
4. Total reimbursement shall never exceed 100% of the Eligible expenses.

1. The Plan will not be liable for any portion of an expense for which you or your Dependent is entitled to reimbursement:
   1. under any other group or individual benefit plan or insurance policy, or
   2. due to the legal liability of any other party.
2. In no event will benefits be payable for expenses resulting directly or indirectly from, or in any manner or degree associated with, any of the following:
   1. Intentional self-inflicted injury while sane or insane, war, whether declared or undeclared, or any act of war, or participation in a riot, insurrection, or civil commotion.
   2. Active duty in the military forces of any nation or international organization, or in any civilian noncombatant unit which serves with such forces in combat.
   3. A direct or indirect attempt at, or commission of, an indictable offense under the Criminal Code of Canada or similar law of any other country.
   4. Any injury, illness, or condition for which care is provided or may be provided or available without cost by public authorities or by a tax-supported agency, including preventive treatment and services available under any Workers Compensation Act or similar plan.

Generally, your coverage (and your Dependent coverage) terminates if you cease to be eligible due to leave of absence, age limitation or retirement, or if you terminate your employment, etc. For further details on termination of coverage, please contact the Plan Administrator.