GENERAL INFORMATION
OUR COMMITMENT TO PRIVACY
The Green Shield Canada Privacy Code balances the privacy rights of
our group and benefit plan participants, and our employees, with the
legitimate information requirements to provide customer service and
to meet our human resource requirements. It consists of the following key principles:
1. We ask for your personal information for the following purposes:
- To establish your identification
- To provide you and/or your dependants with the applicable benefit coverage
- To protect you and us from error and fraud
- To provide ongoing services
When you enrolled in your group benefit plan as a plan participant, your personal information was obtained and used only with your consent. We obtained your consent before we:
- Provided benefit coverage
- Offered you other Green Shield Canada services
- Obtained, used or disclosed to other persons, information about you unless we were obliged to do so by law or to protect our interests
- Used your personal information in any way we did not tell you about previously
Consent can be implied or inferred from certain actions. For our existing group and benefit plan participants, we will continue to use and disclose your personal information previously collected in accordance with our current privacy code, unless you inform us otherwise and will infer that consent has been obtained by your continued use.
3. Withdrawal of ConsentYou can withdraw your consent any time after you've given it to us, provided there are no legal or regulatory requirements to prevent this.
If you don't consent to certain uses of personal information, or if you withdraw your consent, we will no longer be able to administer your benefit coverage. If so, we will explain the situation to you to help you with your decision.
For further information on our privacy policies and procedures, please refer to the Green Shield Canada web site at www.greenshield.ca
LIMITED BENEFIT CLAUSE
Green Shield will determine the amount of benefits payable, giving consideration to limited procedures, services, or courses of treatment. 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 performed 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
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/ophthalmic practice, including charges for services or supplies which are experimental in nature.
6. Services or supplies normally paid through any provincial government health plan, Workplace Safety & Insurance 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. Any eligible service that relates to treatment of injuries arising out of a motor vehicle accident.
CO-ORDINATION OF BENEFITS (COB)
Where you or your dependents 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
Any participant who will no longer be eligible under the Member Benefits Trust plan and who will lose their group benefits may enroll in the Green Shield Group Conversion Program.
Dependent children who are no longer eligible for benefits under their parents Green Shield group benefits program may also enroll in the Green Shield Group Conversion Program.
Call (416) 601-0429 in the Toronto area or toll-free at 1 800 667-0429 for an information package. You must apply within 60 days of termination of your benefits from your Green Shield group program.
June 1, 2010