Other Related Documents

Summary of maximum eligible expenses

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.

Plan provisions

Claims

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.

Appeals

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.

Payment of benefits

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:

• the eligible expense maximums are applied, then
• the deductible, which must be satisfied each calendar year, is subtracted, and finally
• the co-payment is subtracted.

Deductible amount

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.

Co-payment

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.

Overpayments

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.

Claims to provincial/territorial programs

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

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:

• If the other plan does not contain a co-ordination of benefits clause, payment under the other plan must be made before the Administrator will pay under this Provision.
• If a dental accident occurs, health plans with dental accident coverage must pay benefits before dental plans.
• There is no co-ordination of benefits between two members of this Plan.
• If two members of this Plan are from the same family unit, a dependant child may be covered as a dependant of one member only.
• A person may not be both a member and a covered dependant under this Plan.
• If the other plan does contain a co-ordination of benefits clause, priority of payment will be attributed in the following order:

Where the claim is in respect of a PSHCP member:

• the plan where the person is covered as a member,
• if a person is covered under two plans, priority goes to:
  • the plan where the member is a full-time employee,
  • the plan where the member is a part-time employee,
  • the plan where the member is a pensioner.

Where the claim is in respect of a spouse:

• the plan where the spouse is covered as an employee or pensioner.

Where the claim is in respect of a dependant child:

• the plan of the parent with the earlier birth date (month/day) in the calendar year,
• the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date,
• in situations where parents are separated/divorced, then the following order applies:
  • the plan of the parent with custody of the dependant child,
  • the plan of the spouse of the parent with custody of the dependant child,
  • the plan of the parent not having custody of the dependant child,
  • the plan of the spouse of the parent not having custody of the 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.

For more information

About the PSHCP Trust

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.

About PSHCP claims or benefit information

If you have any questions about your PSHCP claims or benefits, please contact the Administrator, Sun Life Assurance Company of Canada, at:

• 1-888-757-7427 (toll-free in North America), or
• 247-5100 in the National Capital Region.

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:

• Monday to Friday from 7:00 a.m. to 12:00 midnight (EST), or
• Saturday from 7:00 a.m. to 8:00 p.m. (EST).

If you have Internet access, you may also visit the Administrator's website at: http://www.sunlife.ca.

About where to send your claims

Claims must be sent to the Administrator. Please mail your completed claim forms to the following address:

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:

• Suite 240, 1730 St. Laurent Boulevard (at the corner of Innes Road) in Ottawa.

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.

Claims for expenses incurred under the Comprehensive coverage provision

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:

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.

Emergency travel assistance benefit

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:

• 1-800-667-2883 in Canada and the United States, or
• call collect 519-742-1342 in all other countries.

About how to complete your claim form

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.

About the claims or coverage appeal process

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:

About your PSHCP monthly contributions and pay or pension deductions

If you have any questions concerning monthly contributions, pay or pension deductions, eligibility requirements and the like, please contact your Personnel or Pension office.

How to contact your Pension office

Public Service pensioners

• Address :
  Client Insurance Services
  Section Superannuation Directorate
  Public Works and Government Services Canada
  P.O. Box 5010
  Moncton, New Brunswick E1C 8Z5
• Office hours for telephone enquiries:
  In Canada: 8:00 a.m. - 4:00 p.m. (your local time)
• Local calls and calls from outside Canada:
  8:00 a.m. - 4.00 p.m. (Atlantic time)
• Telephone numbers:
  In Canada: 1-800-561-7930
  (English — toll-free) 1-800-561-7935
  (French — toll‑free) Local calls: 533-5800 (bilingual)
  Outside Canada: 506-533-5800 (bilingual — call collect)

TDD system calls (bilingual services)

• Local calls: 533-5990
• Long distance: 506-533-5990 (call collect*)
  
  *  Collect calls will not be accepted if you are calling from the region served 
  by the toll-free telephone numbers unless it is a TDD call.

Canadian Forces pensioners

• Address:
  PSHCP Canadian Forces Office Director, Accounts Processing, Pay and Pensions National Defence Headquarters Ottawa, Ontario K1A 0K2
• Telephone numbers:
  Local calls (National Capital Region): 995-5800
  Pensioners residing inside Canada: 1-800-267-6542
  Pensioners residing outside Canada: 613-995-5800 (call collect)

RCMP pensioners

• Address:
  Specialized Services Division (RCMP)
  2nd Floor, Wing 2200 Main Building
  120 Parkdale Avenue Ottawa, Ontario K1A 9Z9
• Office hours for telephone enquiries:
  8:00 a.m. - 4:00 p.m.
• Telephone numbers:
  Local calls: 993-9071
  Long distance: 1-800-661-7595 (toll-free)

Judges Act pensioners

• Address:
  Office of the Commissioner for
  Federal Judicial Affairs
  8th Floor 99 Metcalfe Street
  Ottawa, Ontario K1A 1E3
• Telephone numbers:
  Local calls: 996-5504
  Toll-free: 1-877-583-4266

About the Plan Document

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:

Glossary

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:

• under 21 years of age,
• under 25 years of age and attending an accredited school, college or university on a full-time basis, or
• a person over 20 or 24 years of age who was a dependant child as defined above when they became incapable of engaging in self-sustaining employment by reason of mental or physical impairment, and is primarily dependent upon the member for support and maintenance.

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:

• a person who holds an office, or position, or performs services for which the remuneration is payable out of the Consolidated Revenue Fund of Canada or by an agent of Her Majesty in right of Canada,
• a person designated by the Treasury Board of Canada as being eligible to join the Plan as listed in Schedule III of the Plan Document, as amended from time to time by the Treasury Board of Canada,
• a person who is an employee of a participating employer as listed in Schedule I of the Plan Document, as amended from time to time by the Treasury Board of Canada,
• a person who is a member of a civilian component of the forces of a state that is a party to the North Atlantic Treaty Status of Forces Agreement, 1949 who is serving in Canada.

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:

• an employee or a pensioner who has applied for and has been granted coverage under the PSHCP by a designated officer, or
• a member of the CF or the RCMP who has applied for and has been granted coverage for their dependants under the PSHCP.

member of the Canadian Forces (CF)
means a person who is:

• a member of the regular force of the CF,
• a member of the CF, other than a member of the regular force, and as an individual or as a member of a class, has been designated by the Treasury Board of Canada as a member of the CF for the purposes of the Plan,
• a member of the forces of a state that is a party to the North Atlantic Treaty Status of Forces Agreement, 1949 who is serving in Canada.

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.

Notes