Definitions
The following definitions apply to the ELCIC Group Benefits Plan.
Accident is an unexpected or unforeseen happening or event involving an external force, causing loss or injury, independently of all other causes.
Actively at Work means at work, for the usual schedule, for an Employer at the Employee’s usual place of work. On weekends or holidays, or when on vacation, an Employee is deemed to be Actively at Work if he was Actively at Work on his last normal working day or on his last scheduled shift.
Adherence use Drug, service or supply in accordance with the terms for which it was prescribed.
Advisory Body Manulife Financial approved external experts that may provide Manulife Financial with recommendations, applying a Pharma-co-economic or cost effectiveness evaluation.
Annual Enrollment Date the date each year on which the Employee is permitted to make changes to his flexible benefits coverage.
Benefit Percentage (Co-insurance) the percentage of Covered Expenses which is payable by Manulife Financial.
Birth the complete live delivery of a child from its mother.
Child an Employee’s or Spouse’s natural or legally adopted child, or stepchild, who
(a) is dependent on the Employee or the Spouse for financial support;
(b) is a child of a Surviving Spouse who was insured under the Policy at the time of the Employee’s death;
(c) is unmarried;
(d) is not employed on a full-time basis;
(e) is not eligible for insurance as an employee under this or any other group policy; and
(f) is either under 21 years of age, or, if a full-time student at an accredited school, college or university, under 25 years of age.
A newborn child shall become insured from the moment of birth, including stillbirth.
A child insured under the Manulife Financial Policy who is incapacitated due to a mental or physical disability on the date the child reaches the age when the child would otherwise cease to be an eligible Dependent.
A child is considered incapacitated if the child is incapable of engaging in any substantially gainful activity and is dependent on the Employee for support, maintenance and care, due to a mental or physical disability.
Manulife Financial may require written proof of the Dependent’s condition as often as may reasonably be necessary.
A stepchild must be living with the Employee to be an eligible Dependent.
Dentist a doctor of dentistry, licensed to practice dentistry in the place where services are provided.
Dependent a plan member’s Spouse or Child who is insured under the Provincial Plan.
Disability or Disabled is the state of being Totally Disabled.
Disease Management Programs is an approach to healthcare that teaches patients how to manage a chronic disease. A system of coordinated healthcare interventions and communications for patients with conditions in which patient self-care efforts are significant in the management of their condition.
Drug is a medication that has been approved for use by Health Canada and has a Drug Identification Number.
Drug Dispensing Fee of the total prescription drug cost, that portion charged for the pharmacist’s professional services for filling a prescription.
Drug Dispensing Fee Maximum the maximum amount that is covered under this Policy for a Drug Dispensing Fee.
Due Diligence is a process employed by Manulife Financial to assess new Drugs, existing Drugs with new indications, services or supplies to determine eligibility under the Policy. This process may use Pharma-co-economics, cost effectiveness analysis reference information from existing Federal or Provincial formularies, recognized clinical practice guidelines, or an Advisory Body.
Earnings fare the Employee’s regular salary or wage plus bonuses, overtime pay, vacation pay and housing allowance or equity paid. Note that the FMV of rent for a parsonage is not included in the life and disability insurance benefit coverage.
For the purposes of determining the amount of an Employee’s benefit at the time of claim, an Employee’s Earning will be the amount reported by the Policyholder to Manulife Financial and for which premiums have been paid.
Employee a person who:
a) is directly employed by the Employer and has met eligibility criteria.
b) is compensated for services by the Employer; and
c) is residing in Canada.
For the purposes of the Benefits which continue beyond retirement, the term Employee also means Retiree.
Employer shall mean the Policyholder and any of the following that have executed a subscription agreement with the Policyholder: ELCIC, member congregations of ELCIC, colleges, seminaries and other entities associated with ELCIC, and organizations which employ Rostered Employees and any not-for-profit faith based body corporate and affiliated corporation of such faith based body corporate.
Exclusive Distribution are Manulife Financial approved vendors.
Experimental or Investigational is not approved as an effective, appropriate and essential treatment of an illness or injury.
Hospital is a legally licensed institution which is operated for the care and treatment of sick and injured persons as in-patients, and which:
a) is eligible to receive payments under a provincial hospital plan;
b) provides organized facilities for diagnosis, major surgery, or rehabilitation;
c) provides 24-hour nursing service by registered nurses, and has a Physician in regular attendance;
d) is not primarily operated as a nursing home or a place for rest, or for the care and treatment of the aged, the blind or deaf; and
e) is not primarily operated as a place for the care and treatment of alcoholics, drug addicts, or the mentally ill, unless the institution is eligible to receive payments under a provincial hospital plan.
For the purpose of this Policy, the chronic beds of a Hospital are not considered to be part of that Hospital.
Immediate Family Member is a person who is (a) the Employee; (b) the Employee’s Spouse or child; (c) the Employee’s or Spouse’s parent, or (d) the Employee’s or Spouse’s brother or sister.
Indefinite Lay-Off is a period during which the Employee is laid off work and which there is no fixed recall date.
Interchangeable Drug includes but is not limited to:
a) a generic equivalent to the brand name Drug deemed to be interchangeable by law where the Drug is dispensed;
b) a Drug that contains the same active ingredient that has not been deemed interchangeable in the province where the Drug is dispensed; but has been identified as interchangeable by Manulife Financial.
Leave of Absence is a period of absence from work for which the dates are fixed by legislation or by mutual agreement between the Employee and the Employee. Leave of absence include Maternity and Parental Leave of Absence.
Licensed, Certified or Registered is the status of a person who legally engages in practice by virtue of a license or certificate issued by the appropriate authority, in the place where the service is provided.
Life Events are considered to be one of the following:
a) change in marital status – marriage, separation (of 6 months), divorce
b) birth or adoption of a child
c) death of a Spouse or dependent child
d) gaining coverage under another plan (Spouse)
e) loss or significant change in Spouse’s benefit coverage due to loss of employment or due to discontinuation or significant alteration of Spouse’s benefit coverage
f) when a dependent is no longer eligible as they attain age 21 or 25 if a full-time student.
A Member has 31 days from a Life Event to make changes. Coverage is then retroactive to the date of the Life Event.
Life-Sustaining Drugs are non-prescription Drugs which are necessary to sustain life.
Lower Cost Alternative if two or more Drugs, supplies or services result in therapeutically similar results, or prescribing guidelines recommend alternate Drugs, supplies or services be tried first that are lower in cost, the Lower Cost Alternative will be considered.
Maternity Leave of Absence is the period of formal maternity leave to which an Employee is entitled by legislation governing the Employer, or a longer period, if the Employer’s normal practice permits.
For the purpose of this Policy, Maternity Leave of Absence will be deemed to commence on the earlier of:
a) the date fixed by mutual agreement between the Employee and the Employer; and
b) the date the child is born.
Medically Necessary accepted and recognized by the Canadian medical profession and Manulife Financial as effective, appropriate and essential treatment of a phase of an illness or injury. Manulife Financial has the right after Due Diligence has been completed to determine whether the Drug, service or supply is eligible under the Policy.
Net Earnings is the employee’s Earnings, less deductions normally made for federal and provincial income tax.
Non-Evidence Limit refers to satisfactory medical evidence that must be submitted to Manulife Financial for Benefit Amounts greater than this amount.
Parental Leave of Absence is the period of formal child care leave to which an Employee is entitled by legislation governing the Employer, or a longer period, if the Employer’s normal practice permits.
Patient Assistance Program a program that provides assistance to insured persons prescribed select Drugs, supplies or services. Manufacturers and distributors may provide Patient Assistance Programs that include financial support, along with education and training.
Pharma co economics the scientific discipline that evaluates the value of pharmaceutical drugs, clinical services or supplies. This discipline includes but is not limited to clinical evaluations, risks analysis, economic value and the cost consequences to plans. Pharmacoeconomic studies serve to guide optimal healthcare resource allocation, in a standardized and scientifically grounded manner as determined by Manulife Financial.
Physician a Doctor of Medicine licensed to practice medicine in the place where the services are provided.
Prior Authorization is a claims management feature applied to a specific list of Drugs, supplies or services to determine eligibility based on predefined clinical criteria and a Pharmacoeconomic or cost effectiveness evaluation.
Prior Plan is a previous Group Policy which insured all or some of the persons insured under this Policy, and which terminated within 31 days prior to the Effective Date of this Policy.
Provincial Plan is any plan which provides hospital, medical, or dental benefits established by the government in the province where the insured person lives.
Qualifying Period is a period of continuous Total Disability, starting with the first day of Total Disability, which must be completed by the Employee in order to qualify for benefits. The Qualifying Period is shown in the Benefit Schedule.
Reasonable and Customary – the lowest of:
- the prevailing amount charged for the same or comparable service or supply in the area in which the charge is incurred, as determined by Manulife Financial; or
- the amount shown in the applicable professional association fee guide; or
- the maximum price established by law.
Retiree is a person who was at least age 60 at termination of employment and who was an Employee of an Employer immediately prior to his termination.
Spouse means the legal spouse, or the person to whom at least one of the following situations applies:
a) they have been living with the employee, in a conjugal relationship for at least 12 continuous months. Note in this definition, 12 continuous months includes any period you were separated for less than 90 days because of a breakdown in the relationship.
b) they are the parent of your child by birth or adoption
c) they have custody and control of your child (or had custody and control immediately before the child turned 19 years of age) and your child is wholly dependent on that person for support.
Only one Spouse will be eligible for insurance under the Policy, and will be as indicated by the Employee on the applicable form for insurance under the Policy. Where this information is not contained on the Employee’s application, the person who qualifies last under this Policy’s definition of Spouse will be the eligible Spouse.
Total Disability or Totally Disabled
Restriction or lack of ability due to an illness or injury which prevents an Employee from performing the essential duties of:
a) his own occupation, during the Qualifying Period and the 2 years immediately following the Qualifying Period; and
b) any occupation for which the Employee is qualified, or may reasonably become qualified by training, education ore experience, after the 2 years specified in part a) of this provision.
The availability of work will not be considered by Manulife Financial in assessing the Employee’s Disability.
An Employee who must hold a government permit or license to perform his duties will not be considered Totally Disabled solely because such permit or license has been withdrawn or not renewed.
Vocational Plan (Vocational Rehabilitation) is a training or job placement program that is expected to facilitate a Disabled Employee’s return to his own job or other gainful employment.
Yearly Maximum Pensionable Earnings is the maximum amount of earnings of an individual that is used to determine the maximum contributionary earnings and the maximum benefits applicable under the Canada Pension Plan/Quebec Pension Plan. The Yearly Maximum Pensionable Earnings is revised annually.
