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  • Kwantlen Polytechnic University T h i s b o o k l e t p r o d u c e d : S e p t e m b e r 2 3 , 2 0 1 6

    Plan Contract Number: G0083242

    Group Policy Number: G0039948

    Class: C - Support Staff, Regular, Repeating Term and Posted Auxiliary

    Employee Name:

    Certificate Number:

    Welcome to Your Group Benefit Program

    Plan Document Effective Date: July 1, 2009

    Group Policy Effective Date: July 1, 2009

    This Benefit Booklet has been specifically designed with your needs in mind, providing easy access to the information you need about the benefits to which you are entitled.

    Group Benefits are important, not only for the financial assistance they provide, but for the security they provide for you and your family, especially in case of unforeseen needs.

    Your employer can answer any questions you may have about your benefits, or how to submit a claim.

    K w a n t l e n P o l y t e c h n i c U n i v e r s i t y

    This booklet produced: September 23, 2016 1

  • T a b l e o f C o n t e n t s

    2 Kwantlen Polytechnic University

    Ta ble of Con tents T a b l e o f C o n t e n t

    Ben e fit Sum mary. ......................................................................................3

    How to Use Your Ben e fit Book let. ...........................................................10

    Ex pla na tion of Com monly Used Terms...................................................12

    Why Group Ben e fits?. ...............................................................................16 Your Em ployer’s Rep re sen ta tive. ...................................................................................16 Ap ply ing for Group Ben e fits. ..........................................................................................16 Mak ing Changes. ...........................................................................................................16

    The Claims Pro cess...................................................................................17 Nam ing a Ben e fi ciary. ....................................................................................................17 How to Sub mit a Claim...................................................................................................17 Co-or di na tion of Ex tended Health Care and Den tal Care Ben e fits. ...............................17

    Who Qual i fies for Cov er age?. ..................................................................20 El i gi bil ity. ........................................................................................................................20 Med i cal Ev i dence. ..........................................................................................................20 Late Ap pli ca tion..............................................................................................................20 Late Den tal Ap pli ca tion. .................................................................................................21 Ef fec tive Date of Cov er age. ...........................................................................................21 Ter mi na tion of Cov er age................................................................................................21

    Your Group Ben e fits..................................................................................22 Em ployee Life In sur ance................................................................................................22

    Em ployee Op tional Life In sur ance. ................................................................................24

    De pend ent Op tional Life In sur ance................................................................................25

    Ex tended Health Care. ...................................................................................................26

    Den tal Care. ...................................................................................................................44

    Sur vi vor Ex tended Ben e fit..............................................................................................50

    Weekly In come (Short Term Dis abil ity). .........................................................................51

    Long Term Dis abil ity.......................................................................................................55

    Ben e fits In sured by In dus trial-Al li ance. ..................................................62

  • B e n e f i t S u m m a r y B e n e f i t S u m m a r y

    This Benefit Summary provides information about the specific benefits supplied by Manulife Financial that are part of your Group Plan.

    This version of the Benefit Summary produced: September 23, 2016

    Employee Life Insurance Employee Life

    InsuranceThe Employee Life Insurance Benefit is insured under Manulife Financial’s Policy G0039948.

    Benefit Amount - 2 times your annual earnings, to a maximum of $800,000

    Termination Age - your benefit amount terminates at age 65. Upon attainment of age 65, your coverage will continue under Classification Code CC until age 71 or retirement, whichever is earlier.

    Employee Optional Life Insurance Employee Optional Life

    InsuranceThe Employee Optional Life Insurance Benefit is insured under Manulife Financial’s Policy G0039948.

    Benefit Amount - increments of $10,000 to a maximum of $200,000

    Termination Age - your benefit amount terminates at age 65. Upon attainment of age 65, your coverage will continue under Classification Code CC until age 71 or retirement, whichever is earlier.

    Dependent Optional Life Insurance Dependent Optional

    Life InsuranceThe Dependent Optional Life Insurance Benefit is insured under Manulife Financial’s Policy G0039948.

    Benefit Amount

    - Spouse - increments of $10,000 to a maximum of $200,000

    Termination Age - your spouse’s benefit amount terminates upon your attainment of age 65 or your spouse’s attainment of age 71, whichever is earlier. Upon your attainment of age 65, coverage will continue under Classification Code CC as long as your spouse is under age 71, and will continue until the earlier of you or your spouse’s attainment of age 71, or your retirement.

    Extended Health Care Extended Health CareThe Ben e fit

    Extended Health Care -

    The BenefitAll expenses listed below are subject to Reasonable and Customary Limitations

    Overall Benefit Maximum - Unlimited

    Kwantlen Polytechnic University 3

    Ben e fit Sum mary

  • Deductible - $125 Individual, $125 Family, per calendar year Not applicable to: Vision (Eye exams)

    Benefit Percentage (Co-insurance)

    100% for - Hospital Care - Vision (Eye exams)

    80% for British Columbia Provincial Drug Formulary and 50% for Direct Drugs - Plan 3

    80% for - Medical Services & Supplies - Professional Services - Vision (other than Eye exams)

    Note:

    The Benefit Percentage for Out-of-Province/Canada Emergency Medical Treatment is

    80%.

    The Benefit Percentage for Emergency Travel Assistance is 100%.

    Termination Age - employee’s retirement.

    Brit ish Co lum bia Pro vin cial Drug For mu lary

    Extended Health Care -

    British Columbia

    Provincial Drug

    Formulary British Columbia Provincial Drug Formulary (please see applicable percentage of coverage under Benefit Percentage (Co-Insurance) section)

    Charges incurred for the following when prescribed in writing by a physician or dentist and dispensed by a licensed pharmacist.

    - Drugs - Drugs

    Charges for any drug which is listed as a benefit in the current British Columbia Provincial Drug Formulary or any drug where the patient provides confirmation of coverage with the British Columbia Specialty Drug Program government plan.

    The following expenses are not covered:

    a) charges made by a practitioner or physician to administer injectable medications;

    b) charges for drugs, biologicals and related preparations which are intended to be

    administered in Hospital on an in-patient or out-patient basis and are not intended

    for a patient’s use at home.

    4 Kwantlen Polytechnic University

    Ben e fit Sum mary

  • - Payment of Covered Expenses - Payment of Covered

    Expenses

    Payment of your covered drug expenses will be subject to any Drug Deductible, any Drug Dispensing Fee Maximum and the Co-insurance.

    Covered expenses for any prescribed drug will not exceed the price of the lowest cost generic equivalent product that can legally be used to fill the prescription, as listed in the Provincial Drug Benefit Formulary.

    If there is no generic equivalent product for the prescribed drug, the amount covered is the cost of the prescribed product.

    - No Substitution Prescriptions - No Substitution

    Prescriptions

    If your prescription contains a written direction from your physician or dentist that the prescribed drug is not to be substituted with another product and the drug is a covered expense under this benefit, the full cost of the prescribed product is covered.

    When you have a “no substitution prescription”, please ask your pharmacist to indicate this information on your receipt, when you pay for the prescription. This will help to ensure that your expenses will be reimbursed appropriately when your claim is submitted to Manulife Financial for payment.

    Payment of your covered drug expenses will be subject to any Drug De