Supplementary Medical Plan

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The Supplementary Medical Plan (Healthcare) is a non-taxable benefit designed to help cover the cost of necessary health care expenses which are not covered by OHIP.

This optional benefit provides for reimbursement of expenses which are incurred by you or your insured dependents and which, during any one calendar year, exceed the deductible amount of $25. "Calendar year" means the period from any January 1st to the following December 31st.

Monthly premiums are based on the type of coverage required.

• Insurance ceases immediately upon termination of employment except where a disability exists at termination; benefits may continue in respect of that disability in certain cases.
• Leave of Absence special provision can be made for benefits to be continued for you and your insured dependents during a temporary leave of absence of less than two years. Arrangements for premium payments must be made with Human Resources before departure.

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Covered Expenses Reimbursement will be made for the following expenses as long as they are reasonable, deemed medically necessary and authorized by a physician or surgeon legally licensed to practice medicine:

1. Charges for:

1. drugs and serums that can only be obtained through a written prescription and certain life-supporting, non-prescription drugs, approved by Great-West Life.

2. vaccines used to prevent disease.

Benefit Maximums: The maximum amount payable for drugs used to treat erectile dysfunction is $1,000 in a calendar year. Benefits for fertility drugs are limited to one period of 6 consecutive menstrual cycles in a person’s lifetime.

Exceptions (under 1 (a) above):

Charges for the following items are not covered whether or not they have been prescribed for medical reasons:

• drugs not approved for legal sale to the general public in Canada.
• vitamins, minerals, food substitutes, health foods and dietary supplements such as proteins, infant food,
• medical soaps and creams, cosmetics, shampoos, skin lotions, eye and contact-lens solutions, mouthwashes,
• cough & cold preparations, antihistamines,
• laxatives, antidiarrheals (with approved exceptions),
• products commonly considered household remedies,
• anti-smoking treatments,
• anti-obesity treatments,
• fertility drugs, other than those dispensed for one period of 6 consecutive menstrual cycles, and
• services of a registered psychologist.

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2. Charges equal to 80% of expenses for the services of a registered nurse or registered nursing assistant at your residence provided that such person does not normally live in your residence, up to a maximum of $10,000 per insured person per calendar year. However, the lifetime maximum will be $25,000 during the period from the first day of a calendar year coincident with or next following your 65th birthday until your death.

The services will not be considered as eligible charges under this provision:

• while you (or your insured dependent) are residing in a nursing home, home for the aged, rest home or any other facility providing similar care,
• if in Great-West Life's opinion they are for custodial care and do not require the skill of a registered nurse, or
• while you (or your insured dependent) are confined in a licensed hospital.

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3. Charges for services furnished by a licensed hospital and supplies prescribed by a physician or surgeon which are obtained from an out-patient department of a licensed hospital or a surgical supply company, while you (or your insured dependent) are not confined to a hospital.

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4. Charges for licensed ambulance service or other emergency service when used to transport you (or your insured dependent):

• from the place where injury, disease or illness is suffered to the nearest hospital where adequate treatment can be rendered,
• from one hospital to another hospital, and
• from a hospital to your residence.

This coverage applies only to emergency services required in Canada.

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5. Charges for the following aids, services and supplies:

• purchase of braces, crutches, artificial limbs or eyes and prosthetic devices approved by Great-West Life, maximum amount payable for each prosthesis is $10,000. Repair charges do not apply to this maximum.
• an initial breast prosthesis following a mastectomy plus a replacement every 2 calendar years and 2 surgical brassieres per calendar year,
• rental of a wheelchair, hospital bed or other approved durable equipment for temporary therapeutic use. (This equipment may be purchased subject to Great-West Life's approval prior to the purchase. If such approval is not obtained, Great-West Life will pay only the equivalent of the rental cost of the equipment.),
• oxygen and blood serum,
• reasonable and customary charges for either custom-made orthopaedic shoes or rigid inserts, as prescribed by a podiatrist or physician up to a maximum of one pair per calendar year,
• 2 pairs of surgical stockings per calendar year,
• wigs and hairpieces, up to a lifetime maximum of $100 if necessary as a result of chemotherapy, or up to a lifetime maximum of $250 if necessary as a result of total hair loss from alopecia totalis
• charges for ostomy supplies.
• chronic care provided during confinement in a hospital or nursing home in Canada with a $25.00 daily maximum.

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6. Charges by a legally licensed dentist for dental treatment of injuries to natural teeth and the replacement of natural teeth for accidents suffered by you or your insured dependent while you are insured under this provision.

• The Charge will be subject to all of the following conditions:
• the treatment is necessitated by a direct accidental blow to your (or your insured dependent’s) mouth and not by an object or food placed knowingly or unknowingly in the mouth,
• the accidental blow occurs while you are insured under this provision,
• the treatment is the least expensive that will provide professionally adequate treatment, and
• treatment is received within 12 months after the accidental blow. If treatment is to be received more than 180 days after the accidental blow, a treatment plan must be submitted to Great-West Life within 180 days of the accident.
• Workers' Compensation benefits.

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7. Charges for the services of a qualified speech therapist, up to a maximum of $1,000 per calendar year per person.

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8. Charges for the purchase of hearing aids and for repairs, up to a maximum of $500 in each period of 4 consecutive years per insured person.

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9. Charges for diabetic supplies including: insulin and insulin syringes; Novolin-Pens or similar insulin injection devices using a needle; test strips; blood letting devices

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10. Charges for the services of a qualified physiotherapist provided that such person does not normally reside in your home. Great-West Life will pay up to the following limits:

	Private Clinics	OHIP Approved
Initial visit	$55.00	$40.00
Subsequent visits	$35.00	$20.00*

*for assessment or re-assessment only, not for treatment

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11. Charges for treatment by a legally licensed chiropractor, chiropodist, osteopath, podiatrist or naturopath. Great-West Life will pay an amount equal to 50% of such medical expenses up to a maximum of $300 per practitioner per year. Where applicable, no payment can be made until the provincial plans have paid their yearly maximum.

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12. Out-of-province/country coverage: If you (or your insured dependent) are temporarily out of the province or out of the country on vacation or business, you are covered for emergency health care.

For travel within Canada there is a reciprocal agreement among provincial health care plans in all provinces except Quebec. In Quebec charges are higher than those in the other provinces, and Great-West Life will pay the amount not paid by OHIP, therefore should you require emergency medical treatment in Quebec, you need to access the MEDEX toll free line to ensure appropriate processing of claims.

When travelling outside of Canada, charges for emergency treatment will be paid at 100% if you are under age 65 and 80% if you are age 65 or over. Therefore, if your coverage level is 80% you may wish to purchase additional out-of-country insurance.

The following services are included:

• room and board in a hospital up to the hospital's standard ward rate for each day that you (or your insured dependent) are confined in the hospital,
• hospital services and supplies furnished by a hospital, and
• diagnosis and treatment by a physician or surgeon legally licensed to practise medicine.

MEDEX Assistance Corporation must be notified within 48 hours, or when reasonably possible, following an emergency. Claims may be denied or reduced if contact is not made with MEDEX Assistance Corporation within 48 hours of admission to hospital. If in the opinion of a physician or MEDEX Assistance Corporation the patient can be returned home or to another medical facility for immediate or continuing treatment and the patient chooses not to for whatever reason, the claim will be denied for payment by MEDEX.

"Emergency" means any sudden critical, unforeseen or unexpected occurrence requiring immediate medical attention and which takes place outside your province of residence while the coverage is in force. Great-West Life does not consider complications during the last 9 weeks of pregnancy as an "emergency" and does not cover out-of-province medical treatment in these cases.

"Hospital" means an institution having diagnostic facilities that provides active, chronic care or emergency treatment with physicians and registered nurses in attendance 24 hours a day and is so licensed by the appropriate governmental authority. It does not include an institution providing convalescent care, a nursing home, home for the aged, a rest home or any other facility providing similar care.

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13. Chronic Care : Chronic care is management of a condition where significant improvement or deterioration in unlikely within the next 12 months. Chronic care is covered if it starts while the person is insured under this benefit provision and it is provided in Canada. Great-West life will pay a maximum of $25 per day while being confined in a hospital or nursing home.

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14. Vision Care : A vision care benefit is being added to the Supplementary Medical plan effective May 1, 2005 for active Faculty members and July 1, 2005 for active General Staff and CUPE employee group members. Only active employees who participate in the Supplementary Medical benefit are eligible for vision care expenses.

Coverage:

• Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist;
• Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician;
• Laser eye surgery required to correct vision when performed by a licensed ophthalmologist.

Limits:

The maximum amount payable is:

• Up to $65 every 24 months per active covered person for eye examinations performed by a licensed ophthalmologist, optometrist or medical doctor;
• Up to $200 every 24 months for glasses, contact lenses, laser eye surgery for faculty association members, QUFA department employees, or other clinical (non-QUFA) faculty, and $250 every 24 months for any other employee;
• A lifetime maximum of $150 in a person's lifetime for visual training and remedial therapy performed by a licensed ophthalmologist or optometrist.

No benefits will be paid for vision care supplies required by an employer as a condition of employment.

For information on available discounts on eyewear and vision care services, refer to Preferred Vision Services.

Preferred Vision Services (PVS) entitles you to a discount on a wide selection of quality eyewear and lens extras (scratch guarding, tints, etc.) when you purchase these items from a PVS network optician or optometrist. You are eligible to receive the PVS discount through the network whether or not you are enrolled in the Queen's University supplementary medical coverage. You can use the PVS network as often as you wish to purchase eyewear for yourself and your dependents at a reduced cost.

Questions? Contact the PVS Information Hotline at 1-800-668-6444 or visit the PVS web site for information about PVS locations and the program.

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Exclusions

No amount of benefit will be payable under this provision for any charge that resulted either directly or indirectly from, or was in any manner or degree associated with, or occasioned by, any one or more of:

• any cause for which you may apply and receive indemnity or compensation under the Workplace Safety and Insurance Act or any such Act,
• intentionally self-inflicted injury,
• war, insurrection or hostilities of any kind, whether or not you were a participant in such actions,
• participating in any riot or civil commotion,
• committing or attempting to commit a criminal offence or provoking an assault,
• an examination by, or the services of, a physician or surgeon if required solely for the use of a third party,
• any treatment that has as its purpose the correction of temporomandibular joint dysfunction,
• any service or treatment which you (or your insured dependent) would receive without being charged if you were not insured under this provision, and
• cosmetic surgery.