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Commencement, amendment and termination of coverage
Contributions
Available coverage
Hospital (outside Canada) provision
Summary of maximum eligible expenses
Plan provisions
The purpose of this booklet is to provide you with a description of the benefits you are entitled to as a participant of the Public Service Health Care Plan (PSHCP). It is a convenient reference document that outlines the services and products eligible for reimbursement under the terms of the Plan. It also summarizes the key provisions that govern the Plan.
The information contained in this booklet describes the coverage and the Plan provisions, as they exist on July 1, 2001. The Plan may be amended from time to time. Members will receive written official notification of changes to the Plan. Please keep any future Plan change notices with this booklet.
Certain words and terms have a specific meaning in the context of the Plan. These words are italicized whenever they appear in the text, and are defined in the Glossary at the back of the booklet.
This booklet is not a substitute for the Plan Document. The complete terms and conditions of the Plan, as amended from time to time, are set out in the PSHCP Plan Document, Plan number 55555.
You can consult the Plan Document at any time through the Internet on the Treasury Board of Canada website. To obtain the Internet address, or if you do not have access to the Internet, please refer to the For more information section at the end of this booklet.
The purpose of the PSHCP is to reimburse Plan participants for all or part of costs they have incurred for eligible services and products, as identified in the Plan Document, only after they have taken advantage of benefits provided by their provincial/territorial health insurance plan or other third party sources of health care expense assistance to which the participant has a legal right. Unless otherwise specified in the Plan Document, all eligible services and products must be prescribed by a physician or a dentist who is licensed, or otherwise authorised in accordance with the applicable law, to practice in the jurisdiction in which the prescription is made.
The PSHCP reimburses eligible expenses on a reasonable and customary basis to ensure that the level of charges are within reason in the geographic area where the expense is incurred, subject to limitations which are identified in the Plan Document.
The PSHCP is a private health care plan established for the benefit of federal Public Service employees, members of the Canadian Forces and the Royal Canadian Mounted Police, members of Parliament, federal judges, employees of a number of designated agencies and corporations, and persons receiving pension benefits based on service in one of these capacities. |
The PSHCP is managed through a Trust having Trustees appointed by the three PSHCP parties.
The Plan is operated on a self-insured basis, which essentially means that the Plan assumes full liability for the payment of all costs related to the operation of the Plan, including the payment of claims.
The PSHCP is funded through contributions from the Treasury Board of Canada, participating employers, and the Plan members in accordance with the Trust Agreement which took effect April 1, 2000, between the Bargaining Agents of the National Joint Council, the Federal Superannuates National Association, and the Treasury Board of Canada (known as the PSHCP parties).
Administrator
The Administrator, Sun Life Assurance Company of Canada, is responsible for the consistent adjudication and payment of eligible claims in accordance with the Plan Document and for providing services as specified in the Administrative services only contract.
The PSHCP applies to Public Service employees, members of the Canadian Forces (CF), members of the Royal Canadian Mounted Police (RCMP), pensioners, and their respective dependants. In the case of the members of the CF and the RCMP, coverage is limited to their eligible dependants.
In general, membership in the Plan is optional. If you are eligible and wish to join the PSHCP or make a change to your coverage, you must complete and submit an application to your Personnel or Pension office. This requirement applies even if you are not required to make a monthly contribution.
When your application to join the Plan has been approved, you will be issued a benefit card showing your Certificate Number and the level of coverage you have chosen. A new benefit card will be issued whenever you amend your coverage.
If you have questions concerning your eligibility, your dependants' eligibility, and your effective date of coverage, or if you wish to obtain the appropriate forms, you should contact your Personnel or Pension office.
If you apply within 60 days of becoming eligible, coverage is effective the first of the month following the month your Personnel or Pension office receives your completed application form.
If you do not apply for coverage within 60 days of becoming eligible, the requested coverage will take effect on the first day of the fourth month following the month your Personnel or Pension office receives your completed application.
If you cease to be employed and receive an immediate recognized ongoing pension benefit, coverage continues automatically. You must, however, authorize in writing that the required deductions will be taken from your pension cheque.
If you wish to amend your coverage from single to family coverage as a result of acquiring a dependant and you submit your application form within 60 days of acquiring your new dependant, coverage will become effective on the date of acquiring your dependant.
If you do not apply to upgrade your coverage from single to family within 60 days of acquiring a dependant, the requested coverage will take effect on the first day of the fourth month following the month your Personnel or Pension office receives your completed application.
An increase to the level of coverage under the Hospital provision will be effective on the first day of the fourth month following the month your Personnel or Pension office receives your completed application form, unless you are applying to increase your coverage coincident with an application to reduce your PSHCP coverage from family to single.
The three-month waiting period does not apply when the application is received within 60 days of:
A member ceases to be eligible on the date of:
A member who wishes to cancel their PSHCP coverage must put their request in writing to the designated officer. Deductions will cease no later than two months following the date notification was received by the designated officer. Coverage will continue for one month following the month that the last deduction was made.
A retroactive cancellation cannot be authorised.
Employees who cancel their coverage at any time while on leave without pay, will not be allowed to reinstate their coverage until they return to duty, at which time a three‑month waiting period will apply.
When cancelling a dependant's coverage, the dependant's coverage ceases no later than two months following the date that the application is received by the designated officer. The deductions at the lower rate start the month prior to the effective date of the new coverage.
Except in case of death of a dependant or of a designated officer not ceasing deductions within two months of receiving an application, no contributions will be refunded when the member cancels their dependant's coverage.
When a member ceases to be an eligible employee or an eligible pensioner, if a contribution is deducted in the month during which the member ceases to be eligible, coverage of the member and their dependant(s) will continue until the end of the following month.
In the case of a dependant's death, the contributions are adjusted effective the month of death of the dependant, provided the application is received by the designated officer within 60 days of death. If the application is received after 60 days, contributions are adjusted effective the first of the month following receipt of the application by the designated officer.
The PSHCP is supported through contributions from the Treasury Board of Canada, participating employers and Plan members.
Monthly contributions from members, where applicable, are payable one month in advance of the effective date of coverage. They are deducted from salary or a recognized pension, survivor's or children's benefit, as authorized in writing by the member.
Whenever changes are made to the contribution rates, you will be informed by your Personnel or Pension office. You should periodically ensure that the correct monthly contributions are being deducted from your salary or pension.
Active members who proceed on authorized leave without pay (LWOP) or on seasonal lay-off may continue their coverage and that of their dependants by paying the required contributions, in advance, to their Personnel office by cheque or money order made payable to the Receiver General for Canada. Members must contact their Personnel office, before proceeding on leave, regarding the requirement to make contributions for continued coverage.
This coverage is intended for eligible participants who are covered under a provincial/territorial health insurance plan. In general, the PSHCP supplements the coverage provided under the provincial/territorial plan in the member's province/territory of residence.
This coverage consists of the:
This coverage is intended for members and their eligible dependants who are residing with the member outside Canada and who are not covered under a provincial/territorial health insurance plan or in a non-government hospital insurance plan. A person covered under Comprehensive coverage will continue to be covered under this benefit after their return to Canada until such time as they become eligible to be insured under a provincial/territorial health insurance plan.
This coverage consists of the:
Please note, employees who reside outside Canada (e.g. USA) but work inCanada, are not entitled to comprehensive coverage.
If you are a member of this category, you are required by your employer to be covered for Comprehensive coverage. If your dependants are residing with you outside Canada, you are also required to obtain Comprehensive coverage for those dependants.
Coverage is also available, on a voluntary basis, for certain persons other than your dependants who reside with you and are financially dependent upon you. You should consult your Personnel office if you are interested in these benefits.
You may also opt to upgrade your coverage and apply for additional hospital coverage under Level II or Level III of the Hospital provision.
If you are a member of this category, you are eligible for coverage provided under the Comprehensive coverage provision. If you apply for benefits, you will be covered automatically under the Extended health provision (except for the Out‑of‑province benefit), the Basic health care provision, Level I coverage under the Hospital provision, and the Hospital expense (outside Canada).
You may also opt to upgrade your coverage and apply for additional hospital coverage under Level II or Level III of the Hospital provision.
The Hospital expense (outside Canada) benefit, which covers standard ward hospital charges and certain other in-house hospital expenses, is not available to pensioners residing outside Canada. If you require coverage for hospital expenses in addition to the coverage provided under the Hospital provision, which provides reimbursement for hospital room and board charges other than standard ward charges, you must make personal arrangements to obtain coverage through some other source. |
As a pensioner residing outside Canada without provincial/territorial health plan coverage, you may wish to apply for the benefits provided by the Comprehensive coverage. If you apply for benefits, you will be covered automatically under the Extended health provision (except for the Out‑of‑province benefit), the Basic health care provision and for Level 1 coverage under the Hospital provision. It is important to note that the Hospital expense (outside Canada) provision is not available to pensioners residing outside Canada.
You may also opt to upgrade your coverage and apply for additional hospital coverage under Level II or Level III of the Hospital provision.
The coverage to which you are entitled depends on where you reside and whether you are covered by a government health insurance plan.
As an employee or dependant of members of the CF or the RCMP who resides in Canada and is covered under a government health insurance plan… |
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You are eligible for coverage under... |
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But not... |
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As an employee or dependant of members of the CF or the RCMP who is posted outside Canada… |
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You must have coverage under… |
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You are eligible for coverage under... |
Levels II and III of the Hospital provision |
As an employee or dependant of members of the CF or the RCMP who is on loan to serve with an international organisation… |
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You are eligible for coverage under... |
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As an employee or dependant of members of the CF or the RCMP who is on an authorized educational leave without pay outside Canada… |
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You are eligible for coverage under... |
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As an employee or dependant of members of the CF or the RCMP who is on an authorized leave without pay and outside Canada (but still covered under a government health insurance plan)… |
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You are eligible for coverage under... |
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But not... |
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As a pensioner who resides in Canada and is covered under a government health insurance plan… |
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You are eligible for coverage under... |
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But not... |
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As a pensioner who resides outside Canada and is not covered under a government health insurance plan… |
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You are eligible for coverage under... |
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But not... |
Hospital expense (outside Canada) |
No benefit is payable for:
The purpose of this provision is to provide coverage for specified services and products which are not covered under provincial/territorial health insurance plans, or alternatively, in the case of members resident outside Canada, which are not covered under the Basic health care provision of the PSHCP. All members of the PSHCP are covered under this provision, except for those with Comprehensive coverage who are not eligible for the Out-of-province benefit.
The Extended health provision is comprised of the following benefits:
Some of the aforementioned benefits may be subject to reasonable and customary charges, and to certain limits as specified in the Summary of maximum eligible expenses. All are subject to deductible and co-payment except for the Emergency benefit while travelling and the Emergency travel assistance services.
Before incurring an expense |
In some cases, it is advisable that you first contact the Administrator before purchasing certain expensive medical equipment or treatments. In these cases, the Administrator may confirm the eligibility of the expense or explain the specific information required to later process the claim. For example, if you plan to incur expenses for the following benefits, you should consider first contacting the Administrator:
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To be eligible, expenses must be:
Eligible expenses are:
No benefit is payable for:
Eligible expenses are the reasonable and customary charges for the following items:
unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis.
No benefit is payable for:
Eligible expenses for the services of a medical practitioner include only those services that are within their area of expertise and require the skills and qualifications of such a medical practitioner. In addition, in accordance with provincial/territorial regulations, the medical practitioner must be registered, licensed, or certified to practise in the jurisdiction where the services are rendered.
Eligible expenses are the reasonable and customary charges for:
No benefit is payable for:
To be eligible, the expenses must be:
Eligible expenses are:
unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis,
Reimbursement related to durable equipment will be limited to the cost of non-motorised equipment unless medically proven that the patient requires motorised equipment.
No benefit is payable for:
When two or more courses of treatment for oral procedure or accidental injury are considered appropriate, the Plan will pay for the lesser of the two treatments.
Eligible expenses mean the reasonable and customary charges for the following services and oral surgical procedures performed by a dentist.
The services of a dental surgeon, and charges for dental prosthesis, required for the treatment of a fractured jaw or for the treatment of accidental injuries to natural teeth if the fracture or injury was caused by external, violent and accidental injury or blow other than an accident associated with normal acts such as cleaning, chewing and eating, provided the treatment occurred within 12 months following the accident or, in the case of a dependant child under 17 years of age, before attaining 18 years of age. A physician's prescription is not required. This time limit may be extended if, as determined by the Administrator, the treatment could not have been rendered within the time frame specified.
If a member is covered under the Public Service Dental Care Plan, the RCMP Dependants Dental Care Plan, the CF Dependants Dental Care Plan or the Pensioners' Dental Services Plan, claims for expenses for oral surgery should first be submitted to that plan. Any amount not covered by that plan may be submitted to the PSHCP. Claims for expenses for accidental injury should first be submited to the PSHCP.
No benefit is payable for:
The Out-of-province benefit consists of:
and is for members with Supplementary coverage only.
The PSHCP covers each participant for up to $100,000 (Canadian) in eligible medical expenses incurred as a result of an emergency while travelling on vacation or on business.
Eligible expenses mean the reasonable and customary charges in excess of the amount payable by a provincial/territorial health insurance plan, if they are required for emergency treatment of an injury or disease which occurs within 40 days from the date of departure from the province/territory of residence.
Eligible expenses are charges for:
The PSHCP provides a toll-free number which gives participants 24-hour access to a world-wide assistance network.
The network will provide:
To arrange for advance payment of hospital and medical expenses, the participant must sign an authorisation form allowing the Administrator to recover payment from the provincial/territorial health insurance plan. The participant must reimburse the Administrator for any payment made on their behalf which is in excess of the amount eligible for reimbursement under the provincial/territorial health insurance plan and the PSHCP.
Assistance services are not available in countries of political unrest. The list of countries, as maintained by the Administrator, will change according to world conditions.
Neither the Administrator nor the company providing the assistance network is responsible for the availability, quality or result of the medical treatment received by the participant or for the failure to obtain medical treatment.
Employees required to travel on "official travel status" for government business are covered under the Emergency benefit while travelling and the Emergency travel assistance services during the entire period of "official travel status". Although there is no time limit to be on "official travel status", the $100,000 (Canadian) benefit coverage limit still applies.
The following items of expense are eligible for reimbursement under the PSHCP provided that the services are:
Eligible expenses under this benefit will be limited to the reasonable and customary charges in excess of the amount payable by a provincial/territorial health insurance plan and to the maximum eligible expense specified in the Summary of maximum eligible expenses:
No benefit is payable for:
This provision 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 member is residing in Canada or outside Canada. There is a maximum amount which may be payable under this provision for each day of confinement, depending on the level of coverage the member has chosen. The levels are shown in the Summary of maximum of eligible expenses. All members of the PSHCP must be covered under one level of the Hospital provision. The co‑payment and deductible amount do not apply under this provision.
Eligible expenses are charges for:
No benefit is payable for:
The provision forms part of the Comprehensive coverage and is available only to members who reside outside Canada and are not covered under a provincial/territorial health insurance plan. Its purpose is to provide reimbursement for services, excluding hospital services, which are the equivalent as far as possible to those services available to individuals residing in Canada and covered under a provincial/territorial health insurance plan. The co-payment and deductible amount do not apply under this provision.
The maximum eligible expense for these services is equal to a multiple of the amount otherwise payable based on the current fee schedule in force under the Health Insurance Act 1972 of Ontario on the day when the expense is incurred. The multiple is specified in the Summary of maximum eligible expenses.
The eligible expenses include:
No benefit is payable for:
Coverage under this provision forms part of the Comprehensive coverage and is mandatory for employees and members of the CF and RCMP residing outside Canada who are not eligible to be covered under a provincial/territorial health insurance plan. It is, however, not available to pensioners. Its purpose is to provide hospital coverage protection equivalent, as far as possible, to that available to individuals resident in Canada and covered under a provincial/territorial health or hospital plan. This provision provides reimbursement for reasonable and customary charges for hospital confinement in a general hospital, a hospital of the Canadian Forces or a hospital of the armed forces of a foreign country. The co-payment and deductible amounts do not apply under this provision.
Eligible expenses are hospital charges for each day of hospitalisation in a general hospital, a hospital of the CF or the armed forces of a foreign country.
Eligible charges may include those for:
No benefit is payable for:
It is important to note that the maximum eligible expense multiplied by the applicable reimbursement percentage determines the maximum reimbursement that will be paid for a particular expense. Reimbursement under the PSHCP is made at 80 per cent of covered eligible expenses, after you have met the annual deductible unless otherwise specified.
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Maximum |
Reimbursement |
Deductible |
Extended health provision |
80% |
yes |
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Drug benefit |
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Vision care benefit |
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Medical practitioners benefit |
80% |
yes |
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Services of: |
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Miscellaneous expense benefit |
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orthopaedic shoes |
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80% |
yes |
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Durable equipment — for care |
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Devices for physical movement |
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Devices for support and resting |
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Devices for monitoring |
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Durable equipment — for treatment |
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Devices for mechanical and therapeutic support |
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80% |
yes |
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Devices for aerotherapeutic support |
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Out-of-province benefit |
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100% |
none |
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80% |
yes |
Hospital provision |
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100% |
none |
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Basic health care provision |
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100% |
none |
Length of time a prescription is valid |
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Benefit |
Duration of prescription |
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Note: Unless otherwise requested by the Administrator, all other prescriptions do not have a time limit. |
A claim must be received by the Administrator within 6 months following the calendar year in which the expense is incurred. Claims will not be accepted after the 6-month deadline, unless the late claim is the result of unavoidable circumstances such as medical or psychological incapacity. Failure to submit a claim within 6 monthsfollowing the calendar year in which the expense is incurred will not invalidate the claim, if in the Administrator's opinion, it was not reasonably possible to submit the claim within the time, provided the claim is submitted within 18 months following the calendar year in which the expense was incurred.
For the assessment of a claim, the Administrator may require itemised hospital, drug, or equipment bills, or dental bills and an itemised statement completed by the physician or other practitioner who attended the participant or other information the Administrator considers necessary before processing the claim. Proof of claim is at the claimant's expense.
Where a member does not agree with a decision of the Administrator and wishes a review of their case, a submission may be made to the Trustees. The Trustees have the discretion to reach a decision that embodies due consideration for individual circumstances and Plan provisions. Members should endeavour to exhaust all avenues of review with the Administrator before submitting an appeal to the Trustees. The Trustees reserve the right to refuse to reconsider their decision on an appeal. The appeal process is the final review level under the PSHCP.
An appeal must be submitted within one year of the Administrator's mailing of an Explanation of benefits regarding the claim.
The Administrator will reimburse a member when proof is received that a participant has incurred eligible expenses. The amount reimbursed is subject to the provisions described in the Summary of maximum eligible expenses and to the application of the annual deductible and co‑payment, whenever applicable.
To determine the amount payable, the total eligible expenses claimed are adjusted as follows:
For each calendar year, there is a minimum deductible amount; only the eligible expenses incurred during the year which exceed that deductible amount are eligible for reimbursement under the Extended health provision, except for the Emergency benefit while travelling and the Emergency travel assistance services to which no deductible applies. The annual deductible amount is $60 per person. If a member has family coverage, but only one member of the family unit incurs eligible expenses in a calendar year, the annual deductible of $60 will apply to those expenses. Where eligible expenses are incurred in a calendar year in respect of more than one member of a family unit, the combined deductible amount which must be exceeded for all members of that family unit is $100.
Except where otherwise stated, the Plan will reimburse the member 80% of the reasonable and customary charges incurred for an eligible service or product once the annual deductible has been satisfied, subject to the Plan's stated maximums for the service or product, as identified in the Summary of maximum eligible expenses. The co-payment is the remaining 20% of such eligible expenses paid by the member.
Administrative error: In situations where the member was reimbursed in excess of what was claimed, the Administrator is authorised to recover overpayments. The Administrator will proceed with the recovery process by advising the member of the overpayment and asking how they would like to reimburse the amount, i.e. either by cheque for the amount of the overpayment or by authorising the Administrator to deduct the overpayment from future claims. In the event the member does not acknowledge the overpayment within 30 days, the Administrator will automatically deduct the overpayment from future claims reimbursement.
Adjudication error: In situations where an adjudication error is made or an adjudication decision is reversed based on additional information, the Administrator will not recover the overpayment from the member, but will advise the member in writing that these expenses will no longer be reimbursed.
If you are entitled to benefits under a provincial/territorial plan and you are also covered under the PSHCP, you must first submit your claim to the provincial/territorial authorities. Once your claim has been processed, you may claim the remaining expenses, if eligible, from the PSHCP.
Co-ordination of benefits is a provision designed to eliminate duplicate payments and to provide the sequence in which coverage will apply when a Plan participant is covered under two or more benefit plans. The Canadian Life and Health Insurance Association (CLHIA) benefit co-ordination guidelines, as amended from time to time, which are recognised by the majority of insurance companies, have been adopted for the PSHCP or, if unresolved by such guidelines, in accordance with the rules made by the Trustees.
If a participant is covered under another plan, payment of benefits under this Plan will be determined as follows:
Where the claim is in respect of a PSHCP member:
Where the claim is in respect of a spouse:
Where the claim is in respect of a dependant child:
If priority cannot be established in the above manner, the benefits will be prorated in proportion to the amount that would have been paid under each plan had there been coverage by only that plan.
Following payment under another plan, the amount of benefit payable under the PSHCP will not exceed the total amount of eligible expenses incurred less the amount paid by the other plan.
The PSHCP Trust is an independent body that operates at arm's length from the federal government. The Trust is comprised of nine Trustees and a Chairperson who meet regularly to ensure that the interests of PSHCP members are protected. The Trustees are the fiduciaries of the PSHCP.
The Trustees have established a Secretariat to support their work and assist them in fulfilling their mandate. The Secretariat will ensure that the policies and decisions of the Trustees are implemented and effectively monitored.
If you have any questions about your PSHCP claims or benefits, please contact the Administrator, Sun Life Assurance Company of Canada, at:
Customer Service Representatives are available from 7:00 a.m. to 8:00 p.m. (EST), Monday through Friday.
If you want information about the status of your claim, you may use SunServe, the Administrator's interactive telephone system. SunServe is available at the following times:
If you have Internet access, you may also visit the Administrator's website at: http://www.sunlife.ca.
Claims must be sent to the Administrator. Please mail your completed claim forms to the following address:
Sun Life Assurance Company of Canada
Health Claims Office
PO Box 9601 CSC-T
Ottawa ON K1G 6A1
If you live in the National Capital Region and you wish to drop off a completed claim form in person, the Sun Life claims office is located at:
The reception area is open from 8:30 am to 4:30 p.m., Monday to Friday. You may also deposit your completed claim forms at any time in the "Drop box" located inside the main door of the building.
If you incur claims under the Comprehensive coverage provision of the PSHCP, you may send your claims directly to World Access Canada at the following address:
World Access Canada
Public Service Health Care Plan
P.O. Box 880
Waterloo ON N2J 4C3
Plan members living or working in the United States may call World Access toll-free at 1‑800‑363-1835.
Plan members outside Canada in countries other than the United States who are unable to call directly may call the World Access claims line collect at 519‑742‑1691. The claims line is open from 8:30 a.m. to 4:00 p.m. (EST), Monday to Friday.
The Emergency travel assistance benefit provides emergency medical and general travel assistance to eligible members who travel outside their province/territory of residence.
If emergency assistance is needed, a 24-hour help line is available. Multilingual coordinators can access a worldwide network of professionals who offer help with medical, legal, or other travel‑related emergencies. Call the 24‑hour toll-free number:
Attach your original bills and receipts to a claim form and provide full details of the services rendered or purchases made. Please keep copies of your receipts for your records, as receipts are not returned to Plan members once the claims have been processed.
The Administrator will send you a new personalized claim form every time you submit a claim. If you do not have a personalized claim form and need to obtain a standard PSHCP claim form, contact your Personnel or Pension office or download the form from the Treasury Board of Canada Secretariat website at: http://www.tbs-sct.gc.ca. Both the standard claim form and the claim form for Comprehensive coverage (outside Canada) are available on-line. To find the forms, click on: Policies and Publications/Human Resources Management/Insurance and Related Benefits/Health Care.
Occasionally, you might not agree with how a claim was processed by the Administrator or with the decision relating to your coverage under the PSHCP. In this case, you should discuss and explore all options with the Administrator. If this discussion and exploration fails to provide a solution, you can request a review of the disputed claim or coverage situation. If you wish to do this, send a written submission to:
PSHCP Trust
Box 1328 Station "B"
Ottawa ON K1P 5R4
If you have any questions concerning monthly contributions, pay or pension deductions, eligibility requirements and the like, please contact your Personnel or Pension office.
Public Service pensioners
TDD system calls (bilingual services)
Canadian Forces pensioners
RCMP pensioners
Judges Act pensioners
If you wish to consult the Plan Document, please visit the Treasury Board of Canada Secretariat website at: http://www.tbs-sct.gc.ca. To find the document, click on: Policies and Publications/Human Resources Management/Insurance and Related Benefits/Health Care/Public Service Health Care Plan Directive.
If you do not have access to the Internet, please communicate with the Trust Secretariat at the following address:
PSHCP Trust
Box 1328 Station "B"
Ottawa ON K1P 5R4
The following is a list of commonly used terms under the PSHCP, along with their definitions as found in the Plan Document.
Administrative services only contract
means the contract between the Trustees and the Administrator setting out the
services to be provided by the Administrator in respect of the Plan, as amended
from time to time.
Administrator
means the organisation selected to adjudicate and pay claims in accordance
with the Plan Document and/or direction from the Trustees.
calendar year
means January 1 to December 31.
chiropodist
means a person licensed by the appropriate provincial/territorial licensing
authority or in those provinces/territories where there is no licensing authority,
members of the Canadian Association of Foot Professionals, or in the absence of
such association, a person with comparable qualifications as determined by the
Administrator.
chiropractor
means a member of the Canadian Chiropractic Association or of a
provincial/territorial association affiliated with it, or in the absence of such
association, a person with comparable qualifications as determined by the
Administrator.
chronic disease
means a condition that exists beyond the usual course of an acute disease or
beyond a reasonable time for tissue damage to heal. Any condition that lasts
longer than 6 months may be considered chronic.
Compendium of pharmaceuticals and specialities or CPS
means the reference manual as amended from time to time, containing
information about products intended for human use, which is compiled annually and
produced by the Canadian Pharmacists Association for the benefit of health
professionals.
co-payment
means the proportion of eligible expenses, net of deductible, not reimbursed
by the Plan which remains the responsibility of the Plan member.
deductible
means the specific dollar amount that a member must satisfy each calendar year
before they may receive reimbursement by the Plan.
dentist
means a person licensed to practise dentistry by the provincial/territorial
licensing authority, or in the absence of such authority, a person with comparable
qualifications as determined by the Administrator.
dependant
means a member's spouse, a dependant child of a member or the dependant child
of the member's spouse.
dependant child
means the person who is an unmarried child of a member or of the member's
spouse, including an adopted child, a step-child and a foster child in respect of
whom the member stands in loco parentis, provided such person is:
designated officer
means a person designated by a deputy head to be responsible for receiving and
actioning application requests upon verification of eligibility.
durable equipment
means an eligible device that does not achieve any of its primary intended
purposes by chemical action or by being metabolised.
electrologist
means a person who, as determined by the Administrator, qualifies as a
certified electrologist.
employee
means:
family member
means a member or a covered dependant.
family unit
means a member and their covered dependants.
Federal Superannuates National Association
means an association of federal retirees representing all pensioner members of
the Plan.
fee guide
for services provided by dentists, refers to charges established by the
provincial/territorial dental association in the province/territory in which the
expense is incurred or, in the absence of such association, comparable charges
considered reasonable and customary, as determined by the Administrator.
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. A hospital also is a legally licensed hospital providing
specialised 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.
massage therapist
means a person licensed by the appropriate provincial/territorial licensing
body or in the absence of a provincial/territorial licensing body, a person whose
qualifications the Administrator determines to be comparable with those required
by a licensing body.
member
means:
member of the Canadian Forces (CF)
means a person who is:
month
means the period of time from a date in one calendar month to the same date in
the following calendar month.
National Joint Council or NJC
means a consultative body established pursuant to Treasury Board Minute
T.272382B of March 1945, providing regular consultation between the
government and employee organisations certified as Bargaining Agents on common
employee issues.
naturopath
means a member of the Canadian Naturopathic Association or any
provincial/territorial association affiliated with it, or in the absence of such
association, a person with comparable qualifications as determined by the
Administrator.
nurse
means a registered nurse, registered nursing assistant, registered practical
nurse, licensed practical nurse, or certified nursing assistant who is listed on
the appropriate provincial/territorial registry and in the absence of such
registry, a nurse with comparable qualifications as determined by the
Administrator.
ophthalmologist
means a person licensed to practise ophthalmology.
optometrist
means a member of the Canadian Association of Optometrists or of a
provincial/territorial association associated with it, or in the absence of such
association, a person with comparable qualifications as determined by the
Administrator.
osteopath
means a person who holds the degree of doctor of osteopathic medicine from a
college of osteopathic medicine approved by the Canadian Osteopathic Association,
or in the absence of such association, a person with comparable qualifications as
determined by the Administrator.
participant
means a person covered under the PSHCP.
pharmacist
means a person who is licensed to practise pharmacy and whose name is listed
on the pharmacists' registry of the licensing body for the jurisdiction in which
such person is practising.
physician
means a doctor of medicine (M.D.) legally licensed to practise medicine.
physiotherapist
means a member of the Canadian Physiotherapy Association or of a
provincial/territorial association affiliated with it, or in the absence of such
association, a person with comparable qualifications as determined by the
Administrator.
podiatrist
means a person licensed by the appropriate provincial/territorial licensing
authority or in those provinces/territories where there is no licensing authority,
members of the Canadian Association of Foot Professionals, or in the absence of
such association, a person with comparable qualifications as determined by the
Administrator.
psychologist
means a permanently certified psychologist who is listed on the appropriate
provincial/territorial registry in the province/territory where the service is
rendered, or in the absence of such registry, a person with comparable
qualifications as determined by the Administrator.
reasonable and customary charges
means that amount which is usually charged to a person without coverage and
which does not exceed the general level of charges for the specific service or
product in the geographic location where the expense is incurred, as determined by
the Administrator. Published fee guides of national, provincial/territorial
associations of practitioners will be consulted for this purpose where applicable.
RCMP
means Royal Canadian Mounted Police.
speech language pathologist
means a person who holds a master's degree in speech language pathology and is
a member or is qualified to be a member of the Canadian Speech and Hearing
Association or any provincial/territorial association affiliated with it, or in
the absence of such registry, a person with comparable qualifications as
determined by the Administrator.
spouse
means the person who is legally married to the member, or a person with whom
the member has lived for a continuous period of at least one year, whom the member
has publicly represented to be their spouse and continues to live with as if that
person were their spouse, as designated by the member.