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Claims

How do I claim eligible expenses?

The Administrator will send you a new personalized claim form every time you submit a claim. If you do not have a personalized claim form and need to obtain a standard form, click here.

Attach your original bills and receipts to a claim form and provide full details of the services rendered or purchases made. Please keep copies of your receipts for your records, as receipts are not returned to Plan members once the claims have been processed.

For the assessment of a claim, the Administrator may require itemised hospital, drug, or equipment bills, or dental bills and an itemised statement completed by the physician or other practitioner who attended the participant or other information the Administrator considers necessary before processing the claim. Proof of claim is at the claimant's expense.

The Administrator will reimburse a member when proof is received that a participant has incurred eligible expenses. The amount reimbursed is subject to the provisions of the Plan and to the application of the annual deductible and co-payment, whenever applicable.

To determine the amount payable, the total eligible expenses claimed are adjusted as follows:

• the eligible expense maximums are applied, then
  
• the deductible, which must be satisfied each calendar year, is subtracted, and finally
  
• the co-payment is subtracted.
  

For expenses incurred under Supplementary coverage

If you live in the National Capital Region and you wish to drop off a completed claim form in person, the Sun Life claims office is located at 99 Bank Street (between Queen and Albert) in Ottawa. A drop box is located on level B-1. The reception area is open from 8:30 am to 4:30 p.m., Monday to Friday and is located on the 3rd floor, should a member wish to discuss an issue with a service representative.

For expenses incurred under Comprehensive coverage

Plan members living or working in the United States may call World Access toll-free at 1-800-363-1835.

Plan members outside Canada in countries other than the United States who are unable to call directly may call the World Access claims line in Canada, collect, at 519-742-1691. The claims line is open from 8:30 a.m. to 4:00 p.m. (EST), Monday to Friday.

Claims to provincial/territorial programs

If you are entitled to benefits under a provincial/territorial plan and you are also covered under the PSHCP, you must first submit your claim to the provincial/territorial authorities. Once your claim has been processed, you may claim the remaining expenses, if eligible, from the PSHCP.

What can I do if I disagree with a claims decision made by the Administrator?

If you do not agree with a decision of the Administrator and wish a review of your case, a submission may be made to the Administration Authority. The Administration Authority has the discretion to reach a decision that embodies due consideration for individual circumstances and Plan provisions. You should endeavour to exhaust all avenues of review with the Administrator before submitting an appeal to the Administration Authority. The Administration Authority reserves the right to refuse to reconsider their decision on an appeal. The appeal process is the final review level under the PSHCP.

An appeal must be submitted within one year of the Administrator's mailing of an Explanation of benefits regarding the claim.

What happens if my spouse also has health care coverage under the PSHCP or another plan?

Co-ordination of benefits is a provision designed to eliminate duplicate payments and to provide the sequence in which coverage will apply when a Plan participant is covered under two or more benefit plans. The Canadian Life and Health Insurance Association (CLHIA) benefit co-ordination guidelines, as amended from time to time, which are recognised by the majority of insurance companies, have been adopted for the PSHCP. If unresolved by such guidelines, the co-ordination of benefits provision will be in accordance with the rules made by the Administration Authority.

If a participant is covered under another plan or under the PSHCP as a covered dependant, payment of benefits under this Plan will be determined as follows:

• If the other plan does not contain a co-ordination of benefits clause, payment under the other plan must be made before the Administrator will pay under this Provision.
  
• If a dental accident occurs, health plans with dental accident coverage must pay benefits before dental plans.
  
• If the other plan does contain a co-ordination of benefits clause, priority of payment will be attributed in the following order:

Where the claim is in respect of a PSHCP member

• the plan where the person is covered as a member,
  
• if a person is covered under two plans, priority goes to:
  
  • the plan where the member is a full-time employee,
    
  • the plan where the member is a part-time employee,
    
  • the plan where the member is a pensioner.

  
  
  

Where the claim is in respect of a spouse

• the plan where the spouse is covered as an employee or pensioner.

Where the claim is in respect of a dependant child

• the plan of the parent with the earlier birth date (month/day) in the calendar year,
  
• the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date,
  
• in situations where parents are separated/divorced, then the following order applies:
  • the plan of the parent with custody of the dependant child,
    
  • the plan of the spouse of the parent with custody of the dependant child,
    
  • the plan of the parent not having custody of the dependant child,
    
  • the plan of the spouse of the parent not having custody of the dependant child.
    

If priority cannot be established in the above manner, the benefits will be prorated in proportion to the amount that would have been paid under each plan had there been coverage by only that plan.

Following payment under another plan, the amount of benefit payable under the PSHCP will not exceed the total amount of eligible expenses incurred less the amount paid by the other plan.

What is the deadline for submitting claims?

A claim must be received by the Administrator within 12 months following the calendar year in which the expense is incurred. Claims will not be accepted after the 12-month deadline, unless the late claim is the result of unavoidable circumstances such as medical or psychological incapacity. Failure to submit a claim within 12 months following the calendar year in which the expense is incurred will not invalidate the claim, if in the Administrator's opinion, it was not reasonably possible to submit the claim within the time, provided the claim is submitted within 18 months following the calendar year in which the expense was incurred.

What is the group policy number?

The PSHCP Plan number is 55555.

Can I assign my expense reimbursement to my health care provider?

No. If your service provider submits a claim directly to the Plan, the Administrator will decline the claim and return it to the member with a request for the member to re-submit the claim directly to the Plan. You may wish to discuss payment options with your provider.

This does not apply to claims submitted directly for hospital, out-of-province and drug expenses.

Where do I call if I have a question about a claim?