Benefits payable due to the death of an Employee are payable to the Employee’s beneficiary or, if no such beneficiary is alive or has been designated, to the Employee’s estate. All other benefits for an Employee has previously authorized payment to be made to the person and/or corporation which has rendered services, treatment or supplies. If the Employee is not alive, these benefits are payable to such Employee’s estate.
Payment of Small Amounts
If any amount up to $2,000 is payable to a person who is not alive or who cannot give a valid discharge for such payment, Manulife Financial may pay the amount to:
a) any relative of that person; or
b) any person or institution incurring expenses for the care, maintenance or burial of that person.
Requirement of Proof
No claim for benefits will be paid until Manulife Financial receives satisfactory proof in writing that such benefits are payable under the terms of this Policy.
Manulife Financial reserves the right to request any additional information necessary, as determined by Manulife Financial, to validate the eligibility of a claim for benefits under this Policy. The Employee is responsible for any expenses incurred for obtaining this additional information.
Submission of Proof
Proof that benefits are payable must be submitted by or on behalf of the Employee and received by Manulife Financial at its Head Office for Canadian Operations or one of its Group Claims Offices within:
a) 90 days from the date of loss for claims for Life and Accidental Death and Dismemberment benefits
b) 180 days from the end of the Qualifying Period, for claims for disability benefits
c) 12 months form the date the expense was incurred, for claims for Extended Health Care and Dental Care benefits while insurance under this Policy is in force. Upon termination of a person’s insurance under this Policy, proof that Extended Health Care and Dental Care benefits are payable must be submitted within the earlier of:
i) 12 months from the date the expense was incurred
ii) 90 days from the date of termination of insurance.
Date Costs are Incurred
The expense for a service or supply is deemed to have been incurred on the date the service was performed or the supply furnished. If a procedure involves multiple appointments, the expense is deemed to be incurred on the date the procedure is completed. For supplies that have to be ordered, that expense will be deemed to be incurred on the date the supplies were paid for. Proof of receipt of the supplies is required.
If benefits are being paid or coverage continued on an insured person because of disability, Manulife Financial may require written proof that this person remains Disabled under the terms of this Policy. This proof will be required as often as may reasonably be necessary.
Examination by Manulife Financial
Manulife Financial reserves the right to have any person in respect of whom a claim is being made under this Policy submit to a medical, psychiatric, psychological, functional, education and/or vocational examination or evaluation by an examiner selected by Manulife Financial, as often as may reasonably be required. No benefits will be payable if, without reasonable cause, the insured person fails to undergo such examination. If benefits are claimed for loss of like, Manulife Financial may require that an autopsy be performed. Manulife Financial will use the results of any such examination or autopsy to determine whether benefits are payable under this Policy.
If an insured person suffers personal injury or loss for which he has a right to bring action for damages against a third party, Manulife Financial shall be subrogated to the insured person’s rights to recover damages to the extent that it may be obligated to pay benefits to the insured person. In such case, Manulife Financial will require the insured person to complete a subrogation reimbursement agreement. Manulife Financial has the right to suspend payment of benefits until the completed agreement is received.
Upon judgement or settlement for damages, the insured person shall reimburse Manulife Financial for benefits paid or payable. Unless notified to the contrary, the insured person’s solicitor shall also represent Manulife Financial’s interests in such a recovery.
Time Limit on Legal Action
No legal action against Manulife Financial may be commenced less than 60 days after proof has been filed in accordance with the above requirements. Every action or proceeding against Manulife Financial for the recovery of benefits payable under this policy is absolutely barred unless commenced within the time set out in the Insurance Act or other applicable legislation.
Co-ordination of Benefits
Manulife Financial will co-ordinate its Extended Health Care and Dental Care Benefits payable under this Policy with other Plans which also cover an insured person for similar Benefits.
Plans Co-ordinated with this Policy
For the purposes of the Co-ordination of Benefits, Plan means:
a) other group insurance programs;
b) any other arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, including any pre-payment coverage, capitation plan, franchise plan or services plan; and
c) individual travel insurance plans.
Plan does not include school insurance or Provincial Plans.
How Claims are Co-ordinated
Benefits payable under this Policy will be reduced, when necessary, so that no more than 100% of eligible expenses incurred during a calendar year are jointly paid by this Policy and all Plans which come before it in the Order of Benefit Payment.
For the purposes of this provision, eligible expenses are as defined in each Policy or Plan document, before any applicable payment limitation, such as deductible, benefit percentage and maximums, are applied. An expenses is eligible only to the extent that it is Reasonable and Customary.
Order of Benefit Payment
The Order of Benefit Payment is established by applying the following rule to the various Plans which cover eligible expenses. The rules are applied from first to last until an order is established.
a) The Plan with no Co-ordination of Benefits provision in the Policy or Plan document is deemed to pay its benefits first (primary carrier).
b) If all Plans have a Co-ordination of Benefits provision, the following rules are applied to determine the Order of Benefit Payment. The rules depend on the basis on which the person is covered in the Plan.
The Plan which covers the person as an employee/member is deemed to pay its benefits before a Plan which covers that person as a dependent.
If the person is an employee/member under more than one Plan, the following order applies:
- the Plan where the person is an active full-time employee, then
- the Plan where the person is an active part-time employee, then
- the Plan where the person is a retiree.
ii) Dependent – Spouse
If a dependent spouse is also covered as an employee/member under another Plan, the Plan which covers the spouse as an employee/member is deemed to pay its benefits before the Plan which covers the spouse as as dependent.
If the souse is an employee/member under more than one Plan, the order of benefit payment is as outlined under “Employee/Member” above.
iii) Dependent – Child
If a dependent child is covered under more than one Plan, benefits are deemed to be paid first under the Plan of the parent with the earlier birthdate (month/day) in the calendar year. If both parents have the same birthdate, the Plan of the parent whose first name begins with the earlier letter in the alphabet is deemed to pay benefits first.
However, in situations where the parents of the dependent child are separated or divorced, the following order applies:
- the Plan of the parent with custody of the child, then
- the Plan of the spouse of the parent with custody of the child, then
- the Plan of the parent not having custody of the child, then
- the Plan of the spouse of the parent not having custody of the child.
Where divorced or separated parents share joint custody of the dependent child, benefits are deemed to be paid first under the Plan of the parent with the earlier birthdate (month/day) in the calendar year. If both parents have the same birthdate, the Plan of the parent whose first name begins with the earlier letter in the alphabet is deemed to pay benefits first.
c) For dental accidents, Extended Health Care Plans with accidental dental coverage determine benefits before Dental Plans.
d) If the Order of Benefits Payment cannot be established by the preceding rules, benefits will be pro-rated between or among the Plans in proportion to the amounts that would have been paid under each Plan had there been coverage by only that Plan.
Special Rules Applied
Manulife Financial will apply the following rules in co-ordination benefits under this Policy.
a) if a person does not apply for a benefit for which he is eligible under another Plan, the amount of such benefit will be estimated by Manulife Financial and assumed to be paid;
b) if only part of a Plan provides for the co-ordination of benefits, this part will be considered a separate Plan from the part which does not provide for co-ordination;
c) the Policy is considered to be a Plan in applying the rules which establish an Order of Benefit Payment;
d) when a Plan provides benefits in the form of service rather than cash payments, the Reasonable and Customary value of the service rendered is deemed to be both and eligible expense and a benefit paid; and
e) if a person is also covered under an individual travel insurance plan, benefits will be co-ordinated in accordance with the guidelines provided by the Canadian Life and Health Insurance Association.
Administration of the Provision
Manulife Financial has the right to release to or obtain from any other insurer, person or institution, information needed to administer the Co-ordination of Benefits provision in this Policy. Manulife Financial has the right to recover any payments in excess of the amount determined to be payable in accordance with this provision.