Extended Health Claim
Use the Extended Health Benefits Claim form if you’ve paid for extended health expenses (prescription drugs, physiotherapy, chiropractor, vision care, etc) that are covered under the Plan and you wish to be reimbursed.
Information Needed to Complete the Form
Your personal Member information and the Group Plan number (70682) is needed to complete the form. In addition:
- original receipts,
- the name of the insured person(s),
- the relationship to the employee,
- birth date(s),
- service provided,
- service date of each claim,
- information about other benefit or insurance plans that you may be eligible to claim from.
- If you are coordinating claim’s payment with your spouse’s health plan, you should include the primary carrier’s payment statement.
Please follow the instructions on the form.
- These expenses must have been incurred by you or one of the dependents you listed on your enrolment card.
- You must attach all original receipts for reimbursement. These will not be returned. Make a copy for yourself before submitting your claim.
- Submit your claims on a regular basis to avoid delay in processing.
Completed forms should be forwarded to the Plan Administrator.
Frequently Asked Questions
What do I need to send in with the form?
You must attach all original receipts for reimbursement. These will not be returned. Make a copy for yourself before submitting your claim.
If you are coordinating claim’s payment with your spouse’s health plan, you must include the primary carrier’s payment statement and a photocopy of the original receipts.
My spouse is also a Member of a health benefits plan at work, how do I coordinate my claim with my spouse's benefits plan?
If a Member or any eligible Dependents are entitled to receive similar benefits simultaneously under the Health & Welfare Plan or any other group insurance plan (including Provincial Plans), to prevent over payment, benefits payable under this Plan would be co-ordinated with the other Plan.
For example: A Member’s wife is covered under her employer’s plan with family coverage. The Member, his spouse and their three children are all covered under both Plans. To determine which plan would be primarily responsible for the dependent children: Between the Member and the spouse, whomever’s birthday falls first in the calendar year, their plan is responsible for the initial reimbursement of benefits for the dependent children, then, any amounts that are not paid by that Plan are submitted to the other parent’s plan.
In the event that the Member’s birthday is in April and the spouses birthday is in January. The spouses plan would be primarily responsible for the spouse’s claims and the claims of the children. Any amounts not paid by the spouse’s plan can be submitted to the Member’s Plan for reimbursement. Any amounts for the Member that are not paid by the Member’s Plan can be submitted to the spouse’s plan for reimbursement.
Please see the General Information section for a description of “Coordination of Benefits”.
Other questions on completing the form should be directed to the Plan Administrator.