|
Plan details
for the first 12 months of coverage
Plan details
after the first 12 months of coverage.
Plan
Details For The First 12 Months of Coverage
Services shown below will be
eligible if they are usual, reasonable and customary, and are medically
necessary for the treatment of an illness or injury. (Note: payment is
made to patient only, not the dentist.)
DENTAL
- You have no deductible
($ Nil).
- Your overall Dental maximum
is unlimited.
- Your co-insurance is 70%
for Basic Services, 70% for Comprehensive Basic Services.
- Basic Services cover: recalls
1 every 9 months, other exams and full mouth x-rays once every 3 years.
- Comprehensive Basic covers
denture relines 1 every 3 years.
- Applicable lab, drug and
other expenses are eligible to a maximum of 40% of the professional
fee.
- Your eligible claims are
reimbursed at the level stated above and in accordance with the Current
Provincial Dental Association Fee Guide for General Practitioners.
BASIC SERVICES
- Recalls include exams,
bitewing x-rays, cleanings and fluoride treatments.
- Complete, general or comprehensive
oral exams, full mouth x-rays and panoramic x-rays.
- Basic restorations including
fillings and inlays.
- Extractions and surgical
services including general anesthetics and intravenous sedation.
COMPREHENSIVE BASIC SERVICES
- Endodontic treatment including
root canal therapy.
- Periodontal treatment including
scaling and/or root planing.
- Standard denture services
including relining and rebasing of dentures plus denture adjustments
after 3 months from installation.
General Information
LIMITED BENEFIT CLAUSE
Green Shield will determine the amount of benefits payable, giving consideration
to limited procedures, services or courses of treatment that may be performed
to accomplish the desired result. The attending physician/dentist and
the patient have the option of which procedure to use, although payment
for the procedure may be based on the "limited treatment" principle.
The Limited Benefit Clause is a financial limitation and not intended
as a comment regarding any treatment recommended or preformed by a physician/dentist.
PREDETERMINATION
If the cost of any proposed treatment is expected to exceed $300.00, submit
to Green Shield a detailed treatment plan from your provider before your
treatment begins. If a description of the procedures to be performed and
an estimate of the charges are not submitted in advance, Green Shield
reserves the right to make a determination of benefits payable, taking
into account alternate procedures, services or course of treatment, based
on accepted standards of medical/dental practice.
GENERAL OVERALL EXCLUSIONS
Eligible Services do not include and reimbursement will not be made when
we are aware of or have been apprised of:
1. Services or supplies received
as a result of disease, illness or injury due to any of:
- intentionally self-inflicted
injury while sane or insane
- an act of war, declared
or undeclared
- participation in a riot
or civil commotion
- committing a criminal offence
2. Failure to keep a scheduled
appointment with a licensed medical/dental practitioner.
3. Services or supplies which
are cosmetic in nature.
4. The completion of any claim
forms and/or insurance reports.
5. Services or supplies which do not meet accepted standards of medical/dental/opthalmic
practice, including charges for services or supplies which are experimental
in nature.
6. Services or supplies normally
paid through any provincial government health plan, Workers' compensation
Board, the Assistive Devices Program or any other Government Agency, or
which would have been payable under such a plan had proper application
for coverage been made, or had proper and timely claims submission been
made.
7. Services or supplies from
any governmental agency which are obtained without cost by compliance
with laws or regulations enacted by a federal, provincial, municipal or
other governmental body.
8. Services or supplies which
are not recommended or approved by the attending physician/dentist.
9. Services or supplies that
you are not obligated to pay for or for which no charge would be made
in the absence of benefit coverage.
10. Services or supplies which
are legally prohibited by the government from coverage.
11. The replacement of lost,
missing or stolen items, or items which are damaged due to negligence.
12. Services or supplies which
arise out of an automobile accident, and you are entitled to benefits
under the no fault benefit schedule of your automobile insurance policy,
or under an applicable Insurance Act.
CO-ORDINATION OF BENEFITS (COB)
Where you or your dependants have coverage with more than one carrier,
claims shall be coordinated so that reimbursement from all coverages shall
not exceed 100% of the actual claim. Ask for our COB brochure for information
on how your family can receive this service
SUBROGATION
Green Shield retains the right to subrogation if benefits have or should
have been paid or provided by a third party. In cases of third party liability,
you must advise your lawyer of these rights.
GROUP CONVERSION PACKAGE
If your group coverage terminates you are eligible to continue coverage
on an individual basis. You must apply within 60 days after the date your
group benefits have been terminated.
ADDITIONAL BENEFITS
Showing your Green Shield plan identification card will allow you to receive
a discount of 33% off the regular prices at "The Bay Optical"
and "Zellers Vision Centre" and up to 30% off "Sears Optical"
stores for most purchases.
Back to top
Plan
Details After The First 12 Months of Coverage
Services shown
below will be eligible if they are usual, reasonable and customary, and
are medically necessary for the treatment of an illness or injury. (Note:
payment is made to patient only, not the dentist.)
DENTAL
- You have no deductible
($ Nil).
- Your overall Dental maximum
is unlimited.
- Your co-insurance is 80%
for Basic Services, 80% for Comprehensive Basic Services, 50% for Major
Restorative Services.
- Basic Services cover: recalls
1 every 9 months, other exams and full mouth x-rays once every 3 years.
- Comprehensive Basic covers
denture relines 1 every 3 years.
- Major Restorative Services
cover dentures, crowns and bridges once every 5 years and to a maximum
of $600.00 per person per year based on effective date of the subscriber.
- Applicable lab, drug and
other expenses are eligible to a maximum of 40% of the professional
fee.
- Your eligible claims are
reimbursed at the level stated above and in accordance with the Current
Provincial Dental Association Fee Guide for General Practitioners.
BASIC SERVICES
- Recalls include exams,
bitewing x-rays, cleanings and fluoride treatments.
- Complete, general or comprehensive
oral exams, full mouth x-rays and panoramic x-rays.
- Basic restorations including
fillings and inlays.
- Extractions and surgical
services including general anesthetics and intravenous sedation.
COMPREHENSIVE BASIC SERVICES
- Endodontic treatment including
root canal therapy.
- Periodontal treatment including
scaling and/or root planing.
- Standard denture services
including relining and rebasing of dentures plus denture adjustments
after 3 months from installation.
MAJOR RESTORATIVE SERVICES
- Dentures, complete, immediate,
transitional and partial.
- Crown restorations or onlays
on natural teeth.
- Repair or recementing of
crowns, onlays and bridgework on natural teeth.
- Bridges, including pontics,
abutment retainers/crowns on natural teeth once every 5 years for the
same tooth.
General Information
LIMITED BENEFIT CLAUSE
Green Shield will determine the amount of benefits payable, giving consideration
to limited procedures, services or courses of treatment that may be performed
to accomplish the desired result. The attending physician/dentist and
the patient have the option of which procedure to use, although payment
for the procedure may be based on the "limited treatment" principle.
The Limited Benefit Clause is a financial limitation and not intended
as a comment regarding any treatment recommended or preformed by a physician/dentist.
PREDETERMINATION
If the cost of any proposed treatment is expected to exceed $300.00, submit
to Green Shield a detailed treatment plan from your provider before your
treatment begins. If a description of the procedures to be performed and
an estimate of the charges are not submitted in advance, Green Shield
reserves the right to make a determination of benefits payable, taking
into account alternate procedures, services or course of treatment, based
on accepted standards of medical/dental practice.
GENERAL OVERALL EXCLUSIONS
Eligible Services do not include and reimbursement will not be made when
we are aware of or have been apprised of:
1. Services
or supplies received as a result of disease, illness or injury due to
any of:
- intentionally self-inflicted
injury while sane or insane
- an act of war, declared
or undeclared
- participation in a riot
or civil commotion
- committing a criminal offence
2. Failure to keep a scheduled
appointment with a licensed medical/dental practitioner.
3. Services or supplies which
are cosmetic in nature.
4. The completion of any claim
forms and/or insurance reports
5. Services or supplies which
do not meet accepted standards of medical/dental/opthalmic practice, including
charges for services or supplies which are experimental in nature.
6. Services or supplies normally
paid through any provincial government health plan, Workers' compensation
Board, the Assistive Devices Program or any other Government Agency, or
which would have been payable under such a plan had proper application
for coverage been made, or had proper and timely claims submission been
made.
7. Services or supplies from
any governmental agency which are obtained without cost by compliance
with laws or regulations enacted by a federal, provincial, municipal or
other governmental body.
8. Services or supplies which
are not recommended or approved by the attending physician/dentist.
9. Services or supplies that
you are not obligated to pay for or for which no charge would be made
in the absence of benefit coverage.
10. Services or supplies which
are legally prohibited by the government from coverage.
11. The replacement of lost,
missing or stolen items, or items which are damaged due to negligence.
12. Services or supplies which
arise out of an automobile accident, and you are entitled to benefits
under the no fault benefit schedule of your automobile insurance policy,
or under an applicable Insurance Act.
CO-ORDINATION OF BENEFITS (COB)
Where you or your dependants have coverage with more than one carrier,
claims shall be co-ordinated so that reimbursement from all coverages
shall not exceed 100% of the actual claim. Ask for our COB brochure for
information on how your family can receive this service
SUBROGATION
Green Shield retains the right to subrogation if benefits have or should
have been paid or provided by a third party. In cases of third party liability,
you must advise your lawyer of these rights.
GROUP CONVERSION PACKAGE
If your group coverage terminates you are eligible to continue coverage
on an individual basis. You must apply within 60 days after the date your
group benefits have been terminated.
ADDITIONAL BENEFITS
Showing your Green Shield plan identification card will allow you to receive
a discount of 33% off the regular prices at "The Bay Optical"
and "Zellers Vision Centre" and up to 30% off "Sears Optical"
stores for most purchases.
Back to top
|
