Dental Care Insurance Questions
What types of dental coverage does our plan provide?
The Dental insurance benefit plan provides 100% coverage for basic dental expenses with no deductible. Furthermore, there is no annual maximum for dental expenses. Our present insurance carrier pays on a one-year lag to the Ontario Dental Association (O.D.A.) fee schedule.
- Basic dental procedures are covered at 100% for the insured person and their covered dependents:
- Cleaning & scaling
- Fluoride treatment
- Oral surgery
- Rebasing & relining of dentures
- Space maintainers and retainers
- Major restorative dental work is covered at 50% of the O.D.A. fee schedule (with a one-year lag). Major restorative work has a $2,000 per calendar year maximum. The following procedures are considered major restorative work:
- Orthodontic services are dental services for any corrective work on irregularities of the teeth. Orthodontic treatment and orthodontic appliances (braces, retainers, etc.) are covered at 50% of cost, based upon the O.D.A. fee schedule (one year lag) and have a $2,000 lifetime maximum, for dependents under the age of 18.
Please note that if extensive restorative dental work is required (over $300) employees should ask their dentist for an estimate. The estimate should show the procedure codes, the teeth involved, and the proposed professional fees. The estimate will be returned to the employee, along with a statement telling them the benefits payable. Therefore, both the employee and the dentist will know how much the employee's financial involvement will be before treatment begins.
How often are we covered for regular dental check-ups?
Oral examinations are covered once every nine consecutive months.
What is a fee guide?
Dental fee guides are established and published by provincial dental associations. In Ontario this is The Ontario Dental Association.The guide serves as a reference for dental practitioners to develop fee structures that are fair and reasonable for the patient and the practitioner. Insurers use these guides to provide consistent charges within provinces, and to help in the management of their dental plans.
My dentist told me that I need a crown. Is that covered by my dental plan?
X-rays are required to determine eligibility of crowns. If you want, ask your dentist to submit a pre-treatment plan and the appropriate x-rays in order for Great West Life to determine if the recommended work is indeed eligible for coverage.
General Benefit Questions
The cheque I received from Great-West Life is lower than I expected. What should I do?
You may contact Great-West Life directly by going to the Great-West Life GroupNet for plan members web site at Great-West Life or by phone at 1-800-957-9777. To inquire about your claim you will require the following information:
- Your name
- Your identification number
- Our group number which is 163087
- The name of the person (dependent) you are inquiring about. Please note if you are inquiring about a claim for yourself, state that the claim is for you.
My spouse has benefits through his/her employer. I'm covered under his/her plan and he/she is covered under my plan. To which plan should I submit my claims?
This is called Coordination of Benefits (COB). Payment of an eligible benefit is coordinated between your plan and your spouse’s and pro-rated so the total coverage amount available doesn’t exceed 100% of allowable expenses.
The following steps will help you submit a COB claim.
- To determine which insurer pays a claim, you and your spouse must submit claims to your own plan first. Children claims must be submitted to the plan of the parent with the earlier birth date in the calendar year.
- Take photocopies of your claim and receipts.
- Submit your claim to your insurer based on the above criteria.
- Once you receive your cheque and statement, complete a new claim form with the coordinating plan numbers (yours and your spouse’s). Attach the statement received with photocopies of your original claim and receipts.
- Submit this information to the coordinating plan (your spouse’s).
- If your spouse’s benefits are also with Great-West Life, submit your claim form indicating both plan numbers. Great-West Life will look after coordinating between the plans. You will receive two separate cheques.
Whom do I contact if there are changes to those covered under my drug plan?
Notify your Benefits Administrator, the Director, Human Resources and Employee Relations, of new dependents, changes in your marital status, etc. The Benefits Administrator will notify Great-West Life, and ensure the records are updated. You can also update your personal information on the member site. Visit Great-West Life to change your personal information.
Assure Health, who performs the on-line adjudication of drug claims, will update its records within 48 hours of the update being processed on Great-West Life’s system.
Where do I obtain claim forms and guidelines on how to complete them?
I lost my receipt for recent dental work I had done. Can I submit a photocopy I took of it?
No. Before Great-West Life can process a claim, they need the original receipt and a signed claim form.
What is a dependent?
An “insured dependent” means your spouse or unmarried child except for:
- a person who is in the military or like forces anywhere;
- a person who lives outside Canada or the United States;
- a child who is 21 years of age or older who is not a registered student and in full-time attendance at an accredited college or university;
- a child who is 27 years of age or older who is a registered student and in full-time attendance at an accredited college or university
- designates a husband or wife in law or in common law and shall include a same-sex common law partner of a Member (with whom the member has continuously cohabited in a spousal relationship, for at least one year if neither party is married to any other person). A Member can designate only one spouse at any given time
- a child who is supported solely by you and permanently living in the home of which you are the head;
- a child who is legally adopted;
- a stepchild who lives in your home, and
- a child who is 26 years of age or younger and is a registered student in full-time attendance at an accredited college or university
- A child will be considered a child from the moment of live birth.
My wife does not have any benefits through her work. If something should happen to me is she still covered through my benefit plan?
If you die while insured under this Plan, benefits on account of your eligible Insured Dependents will be continued, without premium payment, for 30 months after your date of death, but in no event beyond the termination date of the Group Policy.
I just found a receipt for a prescription that I forgot to submit that is six months old. Is it too late to submit it?
Proof of claim must be made on the earlier of 12 months after the date on which the expense is incurred or three months after the date of cancellation of the insurance. This applies to dental, vision and health care expenses.
Health Care Insurance Questions
Am I covered if I need to see a chiropractor, physiotherapist, or massage therapist?
Our plan covers these expenses and others (naturopath, psychologist, speech therapist, etc.), if the practitioners are registered with the appropriate provincial association in which they are practicing. Evidence of these practitioners’ credentials and their appropriate registration numbers are needed on your claim submission. A letter of referral, for these paraprofessional services, is required from your doctor.
My on-line adjudication claim was recently rejected at my pharmacy. Something about a wrong birth day. What does birth date have to do with my claim being accepted?
While your pharmacist can contact Assure’s Help Desk to rectify most card problems, it’s critical that both parties have on file your correct birth date and those of your dependents. The pharmacist needs the correct dates to access your coverage information, and Assure needs the dates to identify eligible claims.
Please make sure that both your pharmacist and plan administrator have not only the correct dates, but also the same ones.
Are orthotics covered by our benefit plan?
Yes they are, provided you have a referral from a Doctor or Podiatrist. For custom built orthopedic shoes the charges are reduced by the cost of ordinary shoes ($80), and orthopedic modifications to shoes
I want to see an Acupuncturist. Is this a covered benefit?
Can reimbursement for my chiropractic and physiotherapy treatments be sent directly to those who perform the service?
These paramedical practitioners fall under supplemental health care providers, and Great-West Life can’t make direct payment to these types of providers.
I need a brace to help a recently twisted ankle heal. Is it covered?
For most durable equipment (e.g. a wheelchair), nursing services, braces and dental accidents, Great-West Life requires your physician to complete a medical questionnaire before they can determine eligibility of these benefits.
You can obtain a questionnaire for your doctor by contacting Great-West Life's information centre.
What level of coverage do we have for hospital rooms?
Private coverage and semi-private when private is not available
Does our insurance cover the services of a Psychologist?
The services of a registered or licensed Psychologist are covered and are included in the $300 maximum combined paramedical per year.
A referral from a Doctor is required. If short term counselling is required, you may want to look into the services provided through our Employee Assistance Plan (EAP). Brochures are available in Human Resources.
The EAP provides 24 hours per day services. The EAP number is 1-877-2345 EAP (327).
My son needs to see a speech therapist, is that covered?
Speech therapy is covered to a maximum of $300 per year combined paramedical. A referral from a doctor is required.
Life Insurance Questions
I am trying to decide if I should purchase additional life insurance. What level of coverage do I have through Nipissing University?
Employee Life Insurance:
|to a maximum of
|to a maximum of
|to a maximum of
Dependent Life Insurance:
In the event of the death of an insured person, the insurer will pay the amount of insurance on the life of such person. The dependent life insurance benefit is paid in the event of the death of an insured dependent of an insured person.
The amount of insurance on the life of a dependent for each employee group is as follows:
|Spouse - $15,000||Spouse - $15,000||Spouse - $15,000||None|
|Each Child - $7,500||Each Child - $7,500||Each Child - $7,500||None|
Accidental Death & Dismemberment
If a covered person is accidentally killed, 200% of their annual insurable earnings with a maximum benefit of $500,000 will be paid.
If an insured person suffers any loss of hands, arms, etc., there is a schedule of losses, which indicates what an individual would be paid. For example, if an insured person loses one leg or part of it, they would be paid 75% of their annual insurable earnings.
The A.D.& D. is $25,000 maximum for Contract employees as listed above in the Group Insurance Coverage Table.
Out of Country Medical Insurance Questions
Do I have out-of-country medical coverage?
Our claims procedure regarding emergency medical expenses incurred while travelling outside of Canada are delineated below. You will note there are two different procedures depending on the cost of hospital/medical expenses. Eligible charges for emergency services and/or supplies will be limited to the reasonable and customary charges in the area where the expenses were incurred.
Great-West Life extended health care supplements your provincial health care plan and any other medical plan you may be eligible for. Should you or your eligible dependents require emergency medical treatment while travelling outside of Canada, eligible treatment costs will be covered as follows:
Eligible Hospital/Medical Expenses Over $200
To ensure payment of these expenses:
- Call the 24 hour help line immediately.
- Within Canada and USA: 1-800-527-0218, within Mexico: 001-800-101-0061 , within United Kingdom: 0-800-252074, all other destination call collect Baltimore, USA: 1-410-453-6330
- If you are physically unable to call the help line yourself, then have a family member, travelling companion or medical personnel call for you. Simply showing your Global Medical Assistance certificate to a doctor, nurse or hospital personnel will NOT ensure payment of these expenses.
- Global Medical Assistance will verify your extended health coverage and provincial health care coverage so payments can be arranged on behalf of you or your insured dependant.
- You will be required to sign an authorization form allowing Global Medical Assistance to recover any amounts payable by the provincial health care plan.
- For expenses that require a percentage paid by you, or that are not covered under this plan or the provincial health care plan, you must reimburse us for the excess amount of the payment.
- If you receive any subsequent bills for these expenses, please forward them to Global Medical Assistance and they will coordinate payments with the provincial health care plan and Great-West Life.
If you do not call the 24 hour help line, or if a payment has not been arranged, follow the steps below even though the expense is over $200.
Eligible Hospital/Medical Expenses Under $200:
- Pay for the expense as soon as it is incurred.
- Submit your claim to the provincial health care plan for consideration
- The claim should be submitted to:
- Ontario Health Care
- 199 Larch Street, 8th floor
- Sudbury, ON
- P3E 5R1
- OHIP will return the original receipts with their reimbursement.
- Submit any unpaid amounts of your claim to Great-West Life.
- Complete a Great-West Life claim form and include the “cheque stub” received from OHIP, along with the original receipts.
In addition to your Provincial Health Insurance Plan and the Great-West Life extended health care, the University also has a travel assistance program called Globla Medical Assistance.
Out-of-Province/Out-of-Country Travel Assistance Program – Global Medical Assistance
Great-West Life’s Out-of-Province/Country Emergency and Travel Assistance Benefit is provided through Global Medical Assistance. The service offers 24 Hour Emergency Assistance, Physician and Hospital Referrals, Coverage Verification, and Assistance with
Hospital and Medical Payments. The coverage is for the first 180 days of travel.
Please note that if you will be out of province, or country, you will need to pick up the Global Medical Assistance card in the Human Resources website. You will need this card to call the 24 hour emergency assistance numbers. The telephone #’s are as follows:
- Within Canada and U.S.A. - 1-800-527-0218
- Within Mexico - 001-800-101-0061
- Within the United Kingdom - 0-800-252074
- All other Countries = 410-453-6330 – Call Collect Baltimore U.S.A.
Vision Care Insurance Questions
What is our vision coverage?
Charges for purchase or replacement of contact lenses and eye glasses (lenses and frames) – other than sunglasses, safety glasses and glasses for cosmetic and aesthetic purposes, are covered up to a maximum of $300 per individual in any period of 24 consecutive months. Appliances must be necessary for the correction of vision and are prescribed by an Optometrist or Ophthalmologist. Eye exams are also covered every 24 months, the eye exam is not included in the $300 maximum.