"A Program Provided By"
A Program Provided By HEALTH AND DENTAL BENEFIT PLAN September 1, 2009 – August 31, 2010 This Booklet contains important information and should be kept for future reference. WELCOME TO ALL ELIGIBLE STUDENTS The Board of Trustees of The Campus Trust (“The Trust”) and Mount Saint Vincent Students’ Union are pleased to sponsor the Benefit Plan (“the Plan”) outlined in this booklet. All benefits are reimbursed directly from The Campus Trust, with the exception of Accidental Death and Dismemberment, which is provided by ACE INA under Group Policy No. 102526 and the Out-of-Province/Canada Travel Medical Emergency Insurance, which is provided by Expert Travel Financial Services (ETFS) under Policy No. 30724825. This booklet provides you with a description of the benefits to which you are entitled under the Plan and an explanation of the rules regarding eligibility and the procedures to follow when submitting a claim. The benefits described here may be revised from time to time or discontinued. The information contained in this booklet does not create or confer any contractual or other rights. All claims are considered, and paid, in accordance with the rules of the Plan and the insurance contracts. The MSVU Students’ Union, together with the Board of Trustees of The Campus Trust, and the appropriate insurer has the full authority to resolve all questions related to the provisions of the Plan. Your identification number, name, gender and date of birth are used by The Campus Trust to determine your eligibility for benefits, and are used only for this purpose while you are a member of the Mount Saint Vincent University Students’ Union Benefit Plan. Without the use of this information you are still covered for benefits, however, your claims may not be adjudicated. This personal information is stored with the utmost attention to security and deployed sparingly to fulfill the requirements of the Plan and the law. For further information on the use of this information or to revoke the use of this information, contact The Campus Trust. Claims for reimbursement, claims enquiries, or for more information regarding details of your benefit plan, please contact the Administrator at: The Campus Trust 1st Floor, Beothuck Building 20 Crosbie Place St. John’s, NL A1B 3Y8 Telephone: 1-800-563-1930 or (709) 754-6633 Questions you may have regarding details of the Plan are to be submitted to: Mount Saint Vincent University Students’ Union 166 Bedford Highway, Rosaria Centre Halifax, NS B3M 2J6 Telephone: (902) 457-6532 www.mountstudents.ca Deadline dates for adding dependents are as follows: September 30, 2009 Deadline dates for opting out with proof of alternative coverage are as follows: September 30, 2009 TABLE OF CONTENTS GENERAL INFORMATION Eligibility…………………………………………………………………………. 1 Dependent Eligibility…………………………………………………………… 1 Termination of Coverage ……………………………………………………… 2 Waiving Entitlement to Participate (Opting-Out)……………………………. 2 Co-ordination of Benefits………………………………………………..……. 2 Provincial Health Insurance Plan……………………………………………. 3 SCHEDULES Health Care Benefit Schedule……………………………………………….. 4 Dental Care Benefit Schedule…………………………………………………. 5 Out-of-Province/Canada Travel Emergency Insurance…………………….. 5 Accidental Death and Dismemberment Benefit Schedule…………………. 5 DETAIL DESCRIPTION OF BENEFITS Health Care Benefits……………………………………………………………. 6 Dental Care Benefits……………………………………………………………. 11 Out-of-Province/Canada Travel Emergency Insurance……………………….. 17 Accidental Death and Dismemberment Benefit………………………………. 18 SUBMITTING A CLAIM Extended Health and Dental Care…..………………………………….…………. 21 Proof of Loss………………………………………………………………..………. 21 Pay-Direct………………………………………………………………………..………. 21 Other Claims……………………………………………………………….………... 21 GENERAL INFORMATION Eligibility To be eligible for coverage you must be: enrolled as a full time undergraduate student at Mount Saint Vincent University; under the age of 65; and covered under a Provincial Health Insurance Plan. Members will become eligible for a 12-month term of coverage commencing September 1. Members enrolling after September 1 of each year will be eligible for the balance of the student year. Late registrants will not be eligible for the plan. Student Year means a period of twelve (12) consecutive months or less, beginning September 01 and ending August 31 of the following year. Dependant Eligibility To be eligible for coverage your dependant must be covered under a Provincial Health Insurance Plan. Your dependant becomes eligible for coverage when you become eligible or, if acquired later, upon becoming your dependant; if you have made written request for dependent coverage and have paid the applicable fees. You must be covered in order for your dependants to be covered. Your eligible dependants include: Spouse to whom you are legally married or with whom you have cohabited for at least one continuous year and publicly represented as your spouse; Dependant Children are children who are either natural or legally adopted or stepchildren or other children, living with you on a full-time basis; and • over 31 days old and are no longer confined to hospital after birth; or • under the age of 21 and depend on you for support while living in a parent-child relationship; or, • children over the age of 21 and under the age of 25 who are in full-time attendance at an accredited educational institution (documentation must be provided each year to verify full-time attendance at an accredited educational institution); or • unmarried dependant children over the limiting age (described above) who have been identified as disabled and where proof has been submitted to the Administrator and/or the Insurance Company, within 31 days after the date and annually thereafter, that the child: . is incapable of self-sustaining employment by reason of mental or physical disability and is chiefly dependent on you for support and maintenance; and became so disable prior to age 21 or 25 if regularly in attendance at a full-time accredited educational institution. Coverage for your dependents who are confined in a hospital because of illness or injury on the date of eligibility, will not become effective until the date such dependent is no longer confined. All new dependents must be added to your coverage within 31 days of becoming your dependent. 1 GENERAL INFORMATION Termination Of Coverage Coverage for you and your dependents will terminate at the end of the 12-month term for which you are covered, but not beyond the earliest of, the date: you cease to be a member of an eligible class (except for the period between the end of the academic term and the end of the 12-month term for which you are covered, or that period between the end of your academic career and the end of the 12-month term for which you are covered); you attain the age of 65; premium payments cease; or this plan is discontinued. Coverage for your dependents will terminate on the date such dependents cease to be eligible. Waiving Entitlement to Participate (Opting-Out) If you are already covered under an extended health and/or dental plan (this does not mean your Provincial Health Insurance such as MSI) you may choose to opt out of the health or dental plan, and have your fees reassessed. You should know that your student health and dental plan includes benefits specifically designed for student needs. You may find it to your advantage to remain enrolled in both this and your other plan in order to increase your total coverage by coordinating the benefits of the two plans. For details about this option, contact the MSVU Students’ Union office or see “Co- ordination of Benefits” in this booklet. If you choose to exclude yourself from the MSVU Plan, you must complete the required form, either online at www.sbta.ca or at the Students’ Union Offices in the Rosaria Center. You must demonstrate that you have coverage by presenting a copy of your current policy or membership card clearly showing the name of the insurance company and the policy number, in person to the Health Plan Administrator during the distribution period set by MSVU Students’ Union. Co-ordination of Benefits If a student is eligible for health care and/or dental care benefits under another plan, reimbursement from the plan will be limited so that the combined payment does not exceed 100% of the charges claimed. Similarly, where two students are married or living in a marriage- like relationship, the total amount of reimbursement, for a particular claim, will not exceed 100% of the charges incurred. If a person covered under this plan is also covered under another plan, benefits under all plans are adjusted so as to limit the combined payment to 100% of the total allowable expense. The manner in which this is done is to determine which plan pays first (to determine where to submit the claim first) and which plan(s) pays next. The plan that does not have a coordination of benefits provision pays before the plan that does (most, if not all, benefit plans have such a provision). 2 GENERAL INFORMATION Co-ordination of Benefits (cont’d) The plan that covers the person: pays before the plan that covers the person as a dependent; and as the parent of the dependent child, whose birthday occurs first during the calendar year, pays first. If priority cannot be established in the above manner, the benefits shall be prorated between or amongst the plans in proportion to the amounts that would have been paid under each plan had there been coverage by just that plan. To implement this provision, the Plan Administrator may: subject to the consent of the covered person, if required by law, obtain from or release to any other person, corporation or organization any information deemed to be needed; or pay to or recover from any other person, corporation or organization any excess payment; any payment so made will be deemed to be benefits paid and, to the extent of such payments, will fully discharge the Campus Trust from all liability under this plan. Payment Made From Wrong Plan Whenever a reimbursement, which should have been made from the Plan, is made from any other plan, the Trustees will have the right, exercisable alone and in their sole discretion, to reimburse the organization, which made the payment. The amount of the reimbursement will be equal to any amount the Trustees determine to be warranted, in order to satisfy the intent of this Section. Amounts paid will be deemed to be a reimbursement made from the Plan and, to the extent of such payment, the Trustees will be fully discharged from liability under the Plan. Whenever reimbursement has been made by the Trustees, at any time, in excess of the maximum amount necessary at that time to satisfy the intent of this Section, the Trustees will have the right to recover such excess. The excess may be recovered from any person to whom such payments were made or any insurance company or any other organization, as determined by the Trustees. Provincial Health Plan This Plan supplements your Provincial Health Plan, it does not replace it. You must have coverage with a Provincial Health Plan, in order to be an eligible member of this Plan. 3 SCHEDULES HEALTH CARE BENEFITS SCHEDULE Student Year Deductible Nil Contraceptives 80% Prescription Drugs 80% Psychologist 80% Percentage Payable for All Other Covered Charges 100% Ambulance Unlimited Contraceptives $300 per student year Dental Care for Accidental Injury Unlimited Durable Medical Equipment and Supplies Unlimited Blood Glucose Monitor $500 per student year Insulin Pump $500 per lifetime Elastic Stockings 2 Pairs per student year Respiratory Equipment $1,500 per student year Wheelchair Repairs $250.00 per lifetime Foot Care Orthopedic Shoes including repairs, $150 per student year/ Arch supports, Molds or Orthotics Referral Required Health Practitioners Chiropractor, Naturopath, Osteopath, $40 per visit to a Maximum of Podiatrist/Chiropodist $500 per practitioner Physiotherapist,* Speech* and Massage* Therapist Psychologist* $300 per student year *Referral Required Hearing Care $500 every 60 months Out-of-Hospital Nursing $25,000 per student year Prescription Drugs $5,000 per student year Tutorial Expenses (provided by ACE INA) $15 per hour up to $1000 per disability Vision Care Eye Examination Once every 24 months Eyewear-Non-Participating Provider $100 every 24 months Eyewear-Participating Preferred Provider $125 every 24 months 4 SCHEDULES DENTAL CARE BENEFITS SCHEDULE Benefit Maximum $700.00 per student year Student Year Deductible Nil Percentage Payable Diagnostic and Preventative 100% Minor Restorative 80% Periodontal – Root Planing 80% Endodontic & Periodontics 50% Denture Maintenance 80% Minor Oral Surgery 80% Major Oral Surgery 10% Impacted Wisdom Teeth 75% Anesthesia 80% Fee Guide Payments will be based on the Current Nova Scotia Dental Association Suggested Fee Guide for Dental Services provided by General Practitioners. OUT-OF-PROVINCE/CANADA TRAVEL MEDICAL EMERGENCY INSURANCE This benefit is provided by Expert Travel Financial Services (ETFS) Overall Maximum $5,000,000 per lifetime ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT SCHEDULE This benefit is provided by ACE INA insurance Company Classification Amount All eligible active students See Schedule of Loss under age 65: 5 DESCRIPTION OF HEALTH CARE BENEFITS If you have fulfilled the requirements for eligibility, you and any eligible dependants, under age 65 (that you have enrolled) have health care coverage under this Plan. There is no yearly deductible. Covered Charges are reasonable and customary charges for needed medical care, services or supplies, as described below, and received while the person is covered, for either an illness or injury that is non-occupational or related to pregnancy. Benefit Maximum is the total amount of coverage allotted for reimbursement in a student year. 1. Ambulance Charges in excess of the amount payable under the covered person’s Provincial Health Plan for professional licensed ambulance service, including air or rail ambulance service subject to prior approval of the Administrator, to transport the covered person: from the place of injury (or where illness struck) to the nearest hospital where treatment is available; directly from the first hospital where treatment is given to the nearest hospital for needed specialized treatment not available at the first hospital; or from a hospital to a convalescent / rehabilitation hospital. 2. Contraceptives Contraceptives, up to the Benefit Maximum, require a physician’s prescription and must be dispensed by a pharmacist and contain medicinal content. 3. Dental Care for Accidental Injury Charges, up to the Benefit Maximum of $1,000 per injury, for care or services by a licensed dentist for the repair of sound natural teeth* when required for a non- occupational accidental injury external to the mouth (and not by an object placed in or on the mouth or self-inflicted), which occurs while the person is covered. Benefits shall be paid in accordance with the Nova Scotia Dental Association Fee Guide for General Practitioners, in effect at the time of treatment. Treatment must commence within 90 days following the date of the accident, and the care or services must be completed within one year from such date. No amount shall be payable for charges incurred after the termination date, or after the person's coverage terminates. The attending dentist must submit a letter indicating that the treatment is the result of an accident, and outline the course of treatment and the resulting cost. *Sound natural teeth: Teeth must be healthy, non-diseased and not heavily restored. When an accident occurs to existing dentures, crowns, or bridgework, it does not qualify for accidental dental coverage because they are not natural teeth. 6 DESCRIPTION OF HEALTH CARE BENEFITS 4. Durable Medical Equipment and Supplies Charges for supplies and the rental of, at The Campus Trust's option, the purchase of durable medical equipment of the type and model adequate for the covered person’s medical needs based on the nature and severity of the disability, such as, but not limited to: hospital beds, canes, wheelchairs, crutches, walkers and trusses; custom-made rigid or semi-rigid braces for back, neck, arm or leg and non-dental prostheses such as artificial limbs and eyes; including replacement if required because of a change in physical condition; respiratory equipment, including oxygen up to the Benefit Maximum; kidney dialysis equipment; contact lenses or glasses following cataract surgery splints, casts, catheters, and hypodermic needles; elastic stockings up to the Benefit Maximum; blood glucose monitor up to the Benefit Maximum; Insulin Pump for diabetics up to the Benefit Maximum; and Wheelchair repairs, up to the Benefit Maximum but excluding personal comfort, convenience, exercise, safety, self-help or environmental control items, or items which may also be used for non-medical reasons, such as, but not limited to: heating pads or lamps, communication aids, air conditioners or cleaners, and whirlpool baths or saunas. Before incurring any major expenses you should submit details to The Campus Trust to determine to what extent benefits are payable. In any event, a letter will be required from a licensed doctor (M.D.) describing the nature of the disability and the type, medical need and estimated duration of any required durable medical equipment. 5. Foot Care Charges covered up to the Benefit Maximum for orthopedic shoes including repairs, arch supports, molds and orthotics, when recommended by a licensed doctor (M.D.). 7 DESCRIPTION OF HEALTH CARE BENEFITS 6. Health Practitioners Charges, including x-ray charges, up to the Benefit Maximum by a practitioner who is registered and legally practicing within the scope of his license as: a chiropractor, naturopath, osteopath and podiatrist or chiropodist (podiatrist and chiropodist have a combined maximum) physiotherapist, massage therapist or speech therapist when prescribed by a licensed doctor (MD) as to duration and type psychology when prescribed by licensed doctor (MD) as to duration and type No amount will be paid for any visit for which any amount is payable under the covered person’s Provincial Health Insurance Plan, unless permitted by law. Participating Preferred Provider: LifeMark Physiotherapy 2nd Floor Assisi Hall Tel: 902-457-6471 email@example.com www.lifemark.ca The Campus Trust has negotiated a discount for services rendered. LifeMark Physiotherapy will direct bill to The Campus Trust. 7. Hearing Care Charges, up to the Benefit Maximum, for hearing aids excluding batteries when recommended by an otolaryngologist. 8. Prescription Drugs Please be advised that every September 1, Pay-Direct access will be suspended until mid-October to allow for the eligibility list to be determined and uploaded. Any prescription drugs required during this time should be purchased by the student and the claim submitted to The Campus Trust at the address on the claim form for reimbursement. In order to assist your pharmacist with your first original pay-direct claim, you can pick up a paper card from The Plan Administrator or print a paper card online at www.mountstudents.ca. After your initial first pay-direct claim, you should be able to give the pharmacist your student identification number only. The Drug Plan covers a list of eligible drugs, professionally compiled to address the needs of students. This Student Managed Drug Formulary is designed to help reduce the cost of the Plan while maintaining comprehensive quality care and benefits. You may search for a particular drug at www.sbta.ca. Follow the link to Product & Services and then the link to Student Drug Coverage then enter Drug Identification Number (DIN) or Drug Name. 8 DESCRIPTION OF HEALTH CARE BENEFITS Prescription Drugs (cont’d) This plan covers up to a 34 day supply of therapeutic (acute) drugs, and up to a 100 day supply for maintenance drugs. Eligible drugs include those within the following general categories, when prescribed by a licensed doctor (M.D.) or licensed dentist or another professional, authorized by provincial legislation to prescribe drugs, and dispensed by a registered pharmacist or licensed doctor (MD): eligible drugs which by law require a prescription for purchase; and compound mixtures where one of the ingredients is an eligible item. Coverage is limited to the cost of the lowest priced item in the applicable generic category that can be legally used to fill the prescription and is limited to a maximum of a 100-day supply unless prior approval is obtained from The Campus Trust. The only drugs not legally requiring a prescription which will be reimbursed if accompanied by a receipt from the pharmacist are: insulin; diabetic supplies: insulin syringes and needles; diagnostic reagents specific to the diagnosis and monitoring of diabetes; lancets; injectable vitamins; and serums and vaccines if required for a specific program of study - Authorization required – see the Health Plan Administrator Specifically excluded from coverage, whether legally requiring a prescription or not, are: all smoking cessation products; fertility drugs; prescription mouthwashes; hair loss and hair growth agents; vitamins (other than injectible); dietary foods / supplements; common household products such as, but not limited to, soap and toothpaste; oral drugs for the treatment of erectile dysfunction. . 9 DESCRIPTION OF HEALTH CARE BENEFITS 9. Vision Care Examinations Charges for eye examinations including refractions by an ophthalmologist or optometrist, registered and legally practicing within the scope of his or her license up to the Benefit Maximum of one visit every 24-month period. No amount will be reimbursed for eye examinations, including refractions, covered by the provincial health insurance plan. Eyewear At a Non-Participating provider of your choice ( $100 Maximum/24 Months) Charges for lenses and frames, contact lenses, and repairs necessary for the correction of vision when prescribed by an ophthalmologist or optometrist, up to the Benefit Maximum of $100 once every 24-month period, for the member and each eligible dependant at a non-participating provider. At a Participating Preferred Provider ( $125 Maximum/24 Months) Charges for lenses and frames, contact lenses, when prescribed by an ophthalmologist or optometrist, up to the Benefit Maximum of $125 once every 24-month period, for the member and each eligible dependant at a participating preferred provider. Limitations of Health Care Benefits No amount will be paid for care, services or supplies: if the payment is prohibited by law; that a covered person may obtain as a benefit under any governmental plan or law; or for which no charge would have been made in the absence of this coverage. No amount will be paid for any charge incurred that results from or is contributed to by: war, whether declared or not; insurrection, rebellion or participation in a riot or civil commotion; purposely self-inflicted injury; or the covered person’s commission of, or attempt to commit, an assault or a criminal offence. 10 DESCRIPTION OF DENTAL CARE BENEFITS 1. Diagnostic and Preventative These are procedures used to treat or help prevent basic dental problems. Some of the procedures are examinations, x-rays and fillings. A) Examinations Initial or Complete Examinations A complete examination includes examination and charting of the teeth, gums and underlying bone, pulp vitality tests, recording the history of the patient's dental work and planning a treatment. One complete examination is covered per dentist in a lifetime. Recall Examinations A recall examination includes a complete examination of the teeth, gums and underlying bone, pulp vitality tests, checking occlusion and consulting with the patient. A recall examination is covered once every six months. Specific Examinations A specific examination may include an examination of the teeth or a specific tooth, gums and underlying bone, pulp vitality tests and checking occlusion. Emergency Examinations An emergency examination includes checking for pain or infection and pulp vitality tests. B) X-rays Full Mouth Series X-rays Full mouth x-rays are a series of at least 16 films including bitewings. One series is covered every 36 months. Panorex X-rays A panorex is one view of the entire mouth and is covered once every 36 months. Periapical X-rays Periapical x-rays are x-rays of single teeth. Sixteen (16) periapical x-rays are covered every 36 months. Bitewing X-rays Bitewing x-rays are used to detect decay in molar teeth. One set is covered in a student year. Bite X-rays Bite x-rays are x-rays of the chewing surface of the teeth. These x-rays show the fit between the upper and lower teeth when they are in contact. Four bite x-rays are covered in a student year. 11 DESCRIPTION OF DENTAL CARE BENEFITS C) Cavity Prevention Polishing or Cleaning Teeth Two units (30 minutes) are covered every student year as part of the insured person's Recall Package. However, there must be a twelve month period between visits. Recall Scaling Two units (30 minutes) are covered every student year as part of the Recall Package. However, there must be a twelve month period between visits. Oral Hygiene Instruction This is instruction on how to brush and floss. One instruction is covered in a lifetime. 2. Fillings These procedures may include local anaesthesia, removal of decay, pulp protection (a sedative used to protect the nerve) and bite adjustment (work done to make sure that the fit between the top and bottom teeth is correct). The cost of finishing or polishing is not covered. All restoration done to the same tooth will be covered as a single visit to the dentist. Silver Fillings A silver filling is only covered if 12 months have passed since the last restoration to the same tooth White Fillings A white filling is only covered if 12 months have passed since the last restoration to the same tooth. Sedative Fillings for Caries, Trauma and Pain Control Caries result from tooth decay. Trauma means a blow to the mouth or teeth resulting in injury. Severe wear may be considered a traumatic injury. Pain control includes temporary fillings and local anaesthesia to reduce pain before a permanent filling is installed. Sedative fillings that are applied to reduce pain are covered. This procedure includes local anaesthesia, removal of decay and/or removal of existing restoration, bite adjustment (treatment to make sure that the fit between the top and bottom teeth is correct), pulp cap (a sedative placed on an exposed nerve to reduce pain and prevent infection) and placement of a sedative filling (a sedative placed under a filling to reduce pain). 12 DESCRIPTION OF DENTAL CARE BENEFITS 3. Endodontics Pulpotomy Pulpotomy is the removal of dental pulp from the crown portion of the tooth. This procedure may include a treatment plan, anaesthesia, the treatment, appropriate x- rays, and follow-up care and must occur more than 30 days before a root canal therapy. Root Canal Therapy includes: treatment plan pulp vitality test pulpectomy (removing the diseased nerve from inside the tooth to reduce pain) tooth isolation and clinical procedure with appropriate x-rays One root canal therapy is covered per tooth in a lifetime. Retreatment procedures are not covered. If dental coverage ends during root canal therapy, we will extend coverage for 30 days to complete the root canal service. If the dental coverage is replaced by a policy with another insurer before the procedure is completed, the replacing insurer will be responsible for the cost of the entire procedure. 4. Periodontics These procedures may include local anaesthesia, surgical dressing, sutures and follow-up care for one month. Post-treatment evaluation is not covered. Displacement Dressing A displacement dressing means placing a medicated pack on inflamed gums to move gums away from the calculus (deposits on teeth that irritate gums). Desensitization Desensitization means applying fluoride to reduce sensitivity. Gingival Curettage Gingival curettage means scraping out damaged tissue inside the gums. Gingivectomy Gingivectomy means removing damaged gum tissue. Flap Surgery Flap surgery is the opening made for bone removal. Tissue Graft A tissue graft is the transfer of healthy gums to an area where the gums have receded. Periodontal - Root Planing (Tartar Removal) Root planing means the smoothing of rough tooth surfaces and removing any calcium deposits. This benefit is covered up to four units per calendar year combined with scaling. 13 DESCRIPTION OF DENTAL CARE BENEFITS 5. Denture Maintenance Denture Adjustments Adjustments are covered and unlimited as long as the adjustments are made more than three months after the new dentures were first inserted. Denture Repairs Repairing dentures means fixing broken or damaged dentures. The insured person is covered for unlimited denture repairs. Denture Rebasing and Relining Rebasing dentures means fitting dentures with a new base. Relining dentures means adding material so that the dentures fit properly. One rebase or reline is covered every 36 months as long as the rebasing or relining is done more than three months after the dentures were first inserted. Tissue Conditioning Tissue conditioning means applying a conditioner to the alveolar ridge that ensures a proper denture fit and is covered once every 36 months. 6. Minor Oral Surgery These procedures may include local anaesthesia, appropriate x-rays, surgery and follow-up care. Extractions Extraction means removing a non-impacted tooth. Residual Root Removal Residual root removal means removing tooth roots left behind when a tooth is extracted. One root removal is covered per tooth in a lifetime. 7. Major Oral Surgery These procedures may include local anaesthesia, appropriate x-rays, surgery and follow-up care. Extractions – Surgical Extraction – surgical means removing impacted wisdom teeth. Surgical Excision This includes the removal of cysts or a foreign body. Surgical Incision This is an incision made to an infected area usually to allow drainage. Fractures The treatment of fractures of the upper or lower alveolar bone which holds the teeth in their sockets. 14 DESCRIPTION OF DENTAL CARE BENEFITS Major Oral Surgery (cont’d) Frenectomy Frenectomy involves surgery on the frenum (a thin tissue that connects the lips to the gums and the tongue to the floor of the mouth). Post Surgical Care This is treatment given by the dentist after surgery until healing is complete. 8. Anaesthesia All necessary anaesthesia during a dental procedure including: general anaesthesia (total loss of consciousness), deep sedation (where the insured person may be in and out of consciousness during a procedure), intravenous sedation (the injection of a sedative into the blood stream) and inhalation technique (sedation given using a mask). Pre-Determination of Benefits If a planned course of treatment by a licensed dentist exceeds $300.00, proposed details must first be submitted to the Administrator for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Other Dental Practitioners Dental care, services or supplies must be rendered and dispensed by a licensed dentist, except that scaling and a licensed dental hygienist may do cleaning of teeth. Charges for such care, services and supplies will be deemed to be Benefits, up to the amount shown in the practitioner’s tariff of the province where the charges are incurred. 15 DESCRIPTION OF DENTAL CARE BENEFITS Limitations of Dental Care Benefits The following are not considered eligible expenses: dental services or supplies that the insured person is eligible to claim under the Workers’ Compensation legislation any dental charges not included in the current Nova Scotia Dental Association Suggested Fee Guide for Dental Services provided by General Practitioners cosmetic procedures charges for appointments that are not kept charges for the completion of claim forms treatment to correct temporomandibular joint dysfunction (The hinge joint of the jaw is called the temporomandibular joint) any endodontic treatment which was started before the effective date of coverage the replacement of dental appliances that are lost, misplaced or stolen any treatment related to orthognathic surgery (remodelling or reconstruction of your jaw) any major restorative services procedures or supplies used in vertical dimension corrections (changing the height of the teeth) or to correct attrition problems (worn down teeth) implanting fabricated teeth or any major surgery resulting from implanting fabricated teeth any crowns, bridges or dentures for which tooth preparations were started before the effective date of coverage experimental treatment or testing orthodontic services 16 OUT-OF-PROVINCE/CANADA TRAVEL MEDICAL EMERGENCY This Benefit is provided by Expert Travel Financial Services (ETFS) As part of the Health Plan, you and your eligible dependants are covered for medical emergencies while traveling or vacationing outside your home province (Nova Scotia) for periods of not more than 90 days. The travel insurance contract summarized below describes coverage that is designed to cover losses arising from sudden and unforeseeable circumstances occurring while you are traveling outside your province or territory of residence for periods of not more than 90 days per trip. You must be covered under your provincial health insurance plan and the extended health care plan of the policyholder. This coverage has an overall maximum of $5,000,000 dollars per lifetime. It is important that you read and understand your Plan before you travel. In the event of any discrepancy between the provisions of a booklet or other document, and the provisions of the contract, the provisions of the contract shall govern. Medical assistance and claims services are provided by ETFS. For complete details of coverage please go to www.mountstudents.ca. (follow the links) to download your copy of the travel insurance booklet. Please contact the Mount Saint Vincent’s Student Union Plan Administrator to obtain your medical assistance card. In the event of an emergency you must call ETFS immediately. The emergency telephone numbers are listed on the back of the available medical assistance card. The eligible expenses are listed below. Benefit Benefit Limit Hospital Accommodations Reasonable & Customary Costs Physician Charges Reasonable & Customary Costs Diagnostic Services Reasonable & Customary Costs Prescription Drugs 30-day supply per Prescription Ambulance Services Reasonable & Customary Costs Emergency Air Transportation Reasonable & Customary Costs Transportation to Bedside Economy Round-trip Airfare plus up to $150 per day to $3,000 per Trip for meals and accommodation Returnof Traveling Companion One-way Economy Airfare Treatment of Dental Accidents Up to $2,000 Meals and Accommodation Up to $150 per day, $3,000 per Trip Vehicle Return Up to $5,000 Return of Deceased Up to $5,000 Incidental Expenses Up to $250 This travel insurance contract summarized herein does not cover losses or expenses resulting from any medical condition for which, prior to departure, medical evidence suggests that treatment or hospitalization could be required. Additional exclusions, general provisions, and limitations apply. 17 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT This benefit is provided by ACE INA Insurance Company The word "injury" as used below means accidental bodily injury sustained by an insured person while this policy is in force, which results directly and independently of all other causes in loss covered by this policy. Schedule Of Losses If injury sustained by an insured person results in any of the following losses within 365 days of the date of accident, ACE INA Insurance Company will pay the sum listed opposite such loss. If more than one of the following losses is sustained by an insured person as the result of one accident, only one of the amounts shown below, the largest, will be paid. For Loss of: Life…………………………………………………………… $ 6,000 Both Hands or Both Feet or Sight of Both Eyes………. $18,000 One Hand and One Foot……………………………………… $18,000 Either Hand or Foot and Sight of One Eye………………… $18,000 Speech and Hearing in Both Ears…………………………... $18,000 Use of Both Hands and Both Feet………………………….. $18,000 Use of One Hand and One Foot………………….………… $18,000 Movement of Both Upper and Lower Limbs (Quadriplegia)………………………………..… $18,000 Movement of Upper and Lower Limbs of One Side of the Body (Hemiplegia)………………….…... $18,000 Movement of Both Lower Limbs ( Paraplegia)……………… $18,000 One Arm or One Leg………………………………………… $13,500 Use of One Arm or One Leg………………………………… $13,500 One Hand or One Foot or Sight of One Eye………….……… $12,000 Use of One Hand or One Foot……………………………….. $12,000 Speech or Hearing in Both Ears………………………….….. $12,000 Thumb and Index Finger of One Hand or 4 Fingers of one hand…………………………………..……... $6,000 Hearing in One Ear…………………………………………..… $3,000 The term "loss" shall mean with regard to hands and feet, actual severance through or above wrist or ankle joints; with regard to eyes, entire and irrecoverable loss of sight; with regard to the thumb and fingers, actual severance through or above the metacarpophalangeal joints; with regard to speech and hearing, entire and recoverable; with regard to arms or legs, actual severance through or above elbow or knee joints; with regard to toes, actual severance through or above the metatarsophalangeal joints; with reference to movement of limbs, complete and irreversible paralysis of such limbs. The term “loss of use” as used here, shall mean with regard to hands, arms, feet or legs, loss of the ability to perform each and every act and service that these hands, arms, feet or legs, were able to perform before the accident occurred. Such "loss of use" must commence within 365 days of the date of the accident and continue without interruption for a period of not less than 12 consecutive months. Loss of use must be total and irrecoverable and beyond remedy by surgical or other means. 18 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT Permanent Total Disability Benefit Upon due written proof submitted to the Company during the lifetime of an insured person, that injury sustained by such person prior to his or her 65th birthday resulted directly and independently of all other causes in permanent total disability (hereinafter defined): a) which commenced within 30 days of the date of the accident; and b) continued without interruption for a period of not less than 12 consecutive months and to the date such proof is submitted to the Company; and c) that such disability will be total, permanent, and continuous during such person's further lifetime; the Company will pay the applicable Principal Sum. The Applicable Principal Sum is the amount applicable to the insured person as determined in accordance with the Schedule Of Losses list on the previous page, unless such person suffered loss described in any Accidental Death and Dismemberment Benefit in the policy in consequence of the accident, in which case the applicable Principal Sum will be the amount determined in accordance with Schedule Of Losses list on the previous page, less any amount paid or payable under this policy for such loss. The term "permanent total disability" as used in this benefit, shall mean that the insured person is wholly and permanently prevented, for the remainder of his or her life, from engaging in any occupation or employment for compensation or profit for which he or she is reasonably qualified by training, education or experience. Repatriation Benefit If an insured person sustains a covered injury and subsequently suffers loss of life, payable under this policy, the Company will pay the reasonable and necessarily incurred expenses for preparing the deceased insured person's body for burial or cremation and shipment to the place of burial provided that: a) the loss of life occurs within 365 days of the date of accident; and b) at the time of loss of life the Insured Person is at least 200 kilometers away from his or her permanent place of residence; and c) the additional benefit payable hereunder shall not exceed $5,000.00 Exclusions This policy does not apply to any loss, fatal or non-fatal, caused by or resulting from: 1. suicide, while sane or insane, or an intentionally self-inflicted injury, or 2. sickness, or disease or medical or surgical treatment thereof except pus-forming infection which shall occur through an accidental cut or wound 3. war, or any act of war, whether declared or not 4. injury sustained while serving on full time active duty in any of the armed forces (land, water or air) of any country or international authority, any premium paid to be returned by ACE INA Insurance Company pro rata for such period of full time active duty 19 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT 5. injury sustained while riding in, boarding, or alighting from, any aircraft, except while as a passenger (and not as a pilot or crew member) in, boarding or alighting from a previously tried, tested, and approved aircraft being used at the time for the transportation of passengers only, provided: a) such aircraft is operated in accordance with then existing regulations of the authority having jurisdiction over the operation of the aircraft; and b) such aircraft is not operated under the direction of any military (land, sea or air) authority other than transport aircraft operated by the Canadian Armed Forces Air Transport Command or the similar air transport service of any duly constituted government authority of any other country recognized by Canada; 6. injury sustained while an insured person is riding in, boarding or alighting from an aircraft owned, operated or leased, by or on behalf of the Policyholder or by an employer of the Insured Person if other than the Policyholder, unless a specific written agreement has been obtained from ACE INA Insurance Company. 7. committing, or attempting to commit a criminal offence, 8. if injuries are the result of operating a vehicle and your blood contained more than 80 milligrams of alcohol per 100 milliliters of blood. Making A Claim For Accidental Death and Dismemberment Insurance The insured person or their agent, or a beneficiary entitled to make a claim or their agent, shall: a) give written notice to ACE INA Insurance Company, within ninety days from the date of the accident for which the claim is made, furnish to ACE INA Insurance Company such proof of claim as is reasonably possible in the circumstances of the occurrence of the accident and the loss occasioned thereby, and b) if so required by ACE INA Insurance Company, furnish a certificate as to the cause and nature of the accident for which the claim is made and as to the duration of the disability caused thereby, from a medical practitioner legally to practice in the province. The appropriate forms can be obtained from The Campus Trust. 20 SUBMITTING A CLAIM Extended Health and Dental Care You may by written request direct that all or part of the benefits for extended health or dental insurance be paid directly to the hospital, dentist or person rendering such care. Proof of Loss Written proof stating the occurrence, character, and extent of loss must be submitted to The Campus Trust within 6 months after the date of the loss, provided the coverage has not terminated. Claims must be submitted within 6 months from the date the coverage or contract has terminated using the date of the care, services or supplies were incurred or received. Legal action to recover benefits under this plan must begin within 2 years of the date of loss. The Campus Trust has the right and opportunity to examine any person whose injury or illness is the basis of claim, when and as often as it may reasonably require during the pendency and payment period of any such claim. Pay-Direct Eligible students can purchase prescription drugs using pay-direct. You can pick up your paper pay-direct card at the Students’ Union office or print it online at www.mountstudents.ca. This paper card can be presented to a pharmacist at a participating pharmacy along with your prescription. As indicated on your card, students will have to pay 20% of the drug cost. If the pharmacist is not participating in the NexgenRx Network, or the student is purchasing prescription drugs without a Pay-Direct paper card, the student should submit the claim and receipts as described under "Other Claims". Other Claims All benefits other than those claimed under the Pay-Direct drug card are paid on a reimbursement basis. To make a claim, complete a health care claim form available from the address at the front of this booklet, or from the Students Union office, or downloaded from the college website www.mountstudents.ca. A standard dental claim form from the dentist were services are rendered is acceptable. Submit forms along with original receipts to The Campus Trust. Claims will be processed and payment will be mailed directly to the student. Some benefits have deadlines for submission – see proof of loss. The Campus Trust reserves the right and opportunity to inspect or determine the validity of any claim for which a benefit claim is made. The benefits described under this plan may be revised from time to time or discontinued. Detailed information about benefits or other provisions of the contract(s) or copies of those provisions may be obtained from the Mount Saint Vincent University Students’ Union. 21