Current Group Benefits Plan - Attachment 3.pdf

EMBASSY OF THE UNITED

STATES OF AMERICA

"The Embassy of the United States of America has established Group Health and Life Policy 330488 to provide Locally Employed (LE) Staff employees with supplemental health and life benefits. It reserves the right as a sovereign entity to make changes to the plan as necessary in accordance with availability of funding and United States Law. The Embassy may occasionally obtain periodic benefit surveys but has no obligation to set benefit levels equal or similar to comparator organizations, nor automatically assume coverage of benefits removed from the Canadian provincial health care plans."

Great-West Life is a leading Canadian life and health insurer. Great-West Life's financial security advisors work with our clients from coast to coast to help them secure their financial future. We provide a wide range of retirement savings and income plans; as well as life, disability and critical illness insurance for individuals and families. As a leading provider of employee benefits in Canada, we offer effective benefit solutions for large and small employee groups.

Great-West Life Online

Information and details on Great-West Life's corporate profile, our products and services, investor information, news releases and contact information can all be found at our website www.greatwestlife.com.

Great-West Life’s Toll-Free Number

To contact a customer service representative at Great-West Life for assistance with your medical and dental coverage, please call 1-866-289-5675.

This booklet describes the principal features of the group benefit plan sponsored by your employer, but Group Policy No. GH.330488 issued by Great-West Life is the governing document. If there are variations between the information in the booklet and the provisions of the policy, the policy will prevail.

This booklet contains important information and should be kept in a safe place known to you and your family.

The Plan is underwritten by

Protecting Your Personal Information

At Great-West Life, we recognize and respect the importance of privacy. When you apply for coverage or benefits, we establish a confidential file of personal information. We limit access to personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law.

We use the personal information to administer the group benefit plan under which you are covered. This includes many tasks, such as:

• determining your eligibility for coverage under the plan

• enrolling you for coverage

• assessing your claims and providing you with payment

• managing your claims

• verifying and auditing eligibility and claims

• underwriting activities, such as determining the cost of the plan, and analyzing the design options of the plan

• preparing regulatory reports, such as tax slips

We may exchange personal information with your health care providers, your plan administrator, other insurance or reinsurance companies, administrators of government benefits or other benefit programs, other organizations, or service providers working with us when necessary to administer the plan.

All claims under this plan are submitted through you as plan member. We may exchange personal information about claims with you and a person acting on your behalf when necessary to confirm eligibility and to mutually manage the claims.

The personal information in your file will be kept in the offices of Great-West Life or in the offices of an organization authorized by us. You may request to review or correct the personal information in your file. A request to review or correct your file should be made in writing and may be sent to any of Great- West Life’s offices or to our head office at:

The Great-West Life Assurance Company Attn: Group Compliance P.O. Box 6000 Winnipeg, MB R3C 3A5

Claims submissions should not be sent to this address. Please use the address on the claim form or contact your plan administrator for details.

For more information about our privacy guidelines, please ask for Great-West Life’s Privacy Guidelines brochure.

TABLE OF CONTENTS

TABLE OF CONTENTS

Embassy of the United States of America

BENEFIT DESCRIPTION

Life Insurance Reductions Long Term Disability Hospital Pay Direct Drugs Medi-Pack Dental Dental 1 and Dental 2 Dental 3 Survivor Extension Changes In Coverage Terminations of Benefits

YOUR ELIGIBILITY

Commencement of Your Coverage

YOUR ELIGIBLE DEPENDENTS

Commencement of Your Dependent's Insurance

GENERAL HEALTH EXCLUSIONS

TERMINATION OF INSURANCE

YOUR LIFE INSURANCE BENEFIT

Waiver of Premium Extension of Benefits Conversion of Your Life Insurance

LONG TERM DISABILITY BENEFIT

Definition of Disability Waiver of Premium Rehabilitation Provision Integration of Benefits Exclusions Extension of Benefits How to Submit a Claim

HOSPITAL BENEFIT

Exclusion Extension of Benefits How to Submit a Claim

PAY-DIRECT DRUG BENEFIT (PLAN 88)¸

Eligible Charges Maintenance Drugs Lost Or Stolen Cards

MEDI-PACK BENEFIT

Nursing Care

DENTAL BENEFIT

DEFINITIONS

THIRD PARTY LIABILITY

PHYSICAL EXAMINATION AND AUTOPSY

LEGAL ACTION

GROUP INSURANCE PLAN FOR EMPLOYEES OF

EMBASSY OF THE UNITED STATES OF AMERICA

Group Life & Health Insurance Policy

GH 330488

The following outlines the benefits available from July 1st, 2007.

BENEFIT DESCRIPTION

Life Insurance

100% of annual earnings plus $2,000 to a maximum of $125,000.

Any amount of Life Insurance which is not an integral multiple of $1,000 will be rounded to the next $1,000.

Reductions

On the February 1st, coincident with or next following age 65, Life Insurance will reduce 50%. This benefit will further reduce 25% on the February 1st, coincident with or next following age 70.

Long Term Disability

70% of monthly earnings to a maximum of $7,000.

Amounts over $5,000 require satisfactory evidence of insurability.

Any amount which is not an integral multiple of $1.00 will be rounded to the next $1.00.

Benefit payments are taxable.

Benefits are paid monthly in arrears after an elimination period of the later of expiration of sick leave or 140 days and terminate on the earlier of your cessation of disability, death, or attainment of age 65.

Hospital

Hospital accommodation is the difference between the public ward allowance under the Provincial Hospital Plan and the semi-private room rate in a Licensed Hospital.

Pay Direct Drugs

Your deductible per prescription is $2.00 plus the dispensing fee with 80% reimbursement.

For you and your dependents living in the province of Quebec, your drug coverage as provided by this benefit provision will comply with the current rules and regulations of the Régie de l'assurance-maladie du Québec (RAMQ).

In addition to drugs covered by this benefit provision, the drug coverage provided under the RAMQ formulary is automatically included.

Medi-Pack

Your deductible per calendar year, is $25 for single coverage and $50 for family coverage.

Reimbursement is 100% of covered charges for all Out-of-Country Treatment with all other benefits reimbursed at 80% of covered charges.

Out-of-Country Treatment is limited to a lifetime maximum of $30,000 for Early Retirees.

Vision Care maximum is $250.00 in any two consecutive calendar years.

Dental

Great-West Life will pay on the basis of each year's Dental Association suggested Schedule of Fees for General Practitioners as of the 1st of the month following the month in which Great-West Life receives the new Schedule.

Your deductible per calendar year, is $25 for single coverage and $50 for family coverage.

Dental 1 and Dental 2

Reimbursement is 100% of Insured Charges. Annual maximum is $1,500.

Dental 3

Reimbursement is 50% of Insured Charges. Annual maximum is $1,500.

Survivor Extension

In the case of your death, Hospital, Pay Direct Drugs, Medi-Pack and Dental coverage will be extended to your eligible dependents until the 2nd anniversary of your death. Coverage for your spouse will be extended until the 2nd anniversary of your death or he/she remarries, which ever occurs first

Changes In Coverage

Changes in coverage due to reclassification, dependency status or gross salary will take effect on the first day of the month coincident with or next following the date of the change. You must be actively at work in order for your insurance to increase. In order for the change in benefit to occur, Great-West Life must also be properly notified by the Employer.

Terminations of Benefits

All benefits terminate at age 65.

Benefits for Early Retired Employees in the province or Nova Scotia, Ontario and British Columbia terminate on the attainment of age 65.

Benefits for Early Retired Employees in the province Québec, Manitoba and Alberta terminate on the attainment of age 69.

Note: The only Benefits applicable to Early Retired Employees are the Hospital, Pay Direct Drugs and Medi-Pack Benefits.

At age 65, if you are living in the Province of Quebec you can choose to have basic prescription drug coverage under the Régie de l'assurance-maladie du Québec (RAMQ), rather than this plan. If you make this choice, basic prescription drug coverage will no longer be available under this plan unless you cease to live in the Province of Quebec. This choice is irrevocable. You are considered to have made this choice if you have not advised your employer otherwise by the end of the 60-day period immediately following the date you first became eligible for basic prescription drug coverage under the Régie de l'assurance-maladie du Québec (RAMQ).

YOUR ELIGIBILITY

You are eligible to be insured from the first day of the month coincident with or next following 3 months of continuous employment. This is provided you work at least 20 hours per week on a regular basis.

Commencement of Your Coverage

You automatically become covered on your eligibility date, provided you have completed an application and are actively at work.

If you are not Actively at Work on the date your coverage should commence, you will become covered when you return to work.

If you are a resident of the province of Quebec, any benefit which offers drug insurance will not require approved evidence of your good health.

YOUR ELIGIBLE DEPENDENTS

Dependents eligible for benefits are either your spouse or common-law spouse and each unmarried child, step-child or common-law child who is under 22 years of age or under 26 years of age if attending an accredited educational institute, college or university on a full-time basis. Anyone who is in full-time service in any naval, military or air force will not be eligible as dependents.

The attainment of any maximum age specified above will not terminate the coverage on your dependent child if at the time your child is incapable of self-support due to mental retardation or physical handicap and relies upon you for support and maintenance.

Commencement of Your Dependent's Insurance

Your dependent's insurance will commence on the same date as your insurance if you request dependent coverage on your application.

If you do not request dependent coverage when you become insured and later want such coverage, you must complete an application.

If your dependent is a resident of the province of Quebec, any benefit which offers drug insurance will not require approved evidence of their good health.

Once you have dependent coverage, an additional child will automatically become insured on the date the child qualifies as your dependent. Notification is required if additional dependents are acquired.

If your dependent other than a new-born is confined in a hospital when coverage should commence, coverage will not begin until your dependent's discharge.

You must complete a new application if you wish to add or change a legally married or common-law spouse.

GENERAL HEALTH EXCLUSIONS

No amount of benefit will be payable for any charge that resulted either directly or indirectly from, or was in any manner or degree associated with, or occasioned by, any one or more of the following:

a) intentionally self-inflicted injury while sane or insane,

b) war, insurrection or hostilities of any kind whether or not you or your dependent were a participant in such action,

c) participation in a riot or civil commotion,

d) committing or attempting to commit a criminal offence or provoking an assault.

Additional exclusions are found under the respective Benefit Descriptions in this booklet.

TERMINATION OF INSURANCE

You are no longer insured from the date your employment terminates or the policy terminates. Insurance may terminate on the last day of the month that follows the month you began a temporary lay-off. Insurance terminates the day before you enter service in any naval, military or air force.

For benefits on termination see Conversion of Your Life Insurance under your Life Insurance Benefit and Extension of Benefits on termination of employment following the health benefit description.

YOUR LIFE INSURANCE BENEFIT

Your named beneficiary will be paid a lump sum amount in the case of your death. You may appoint one or more beneficiaries or change your appointment at any time by completing a Change in Beneficiary Form obtained from your employer. Any amount of coverage for which there is no beneficiary will be payable to your estate.

Waiver of Premium

Coverage on your life will continue if you become totally disabled for at least 6 consecutive months. You must become disabled while covered before your 65th birthday. No premium payments will be required as of the date of disability.

This coverage will terminate with conversion privileges on your 65th birthday.

Totally Disabled means your complete inability to engage in any gainful occupation for which you are reasonably fitted by education, training or experience. Great-West Life must receive initial proof that you are totally disabled no later than 12 months after the date of disability. You will also be deemed to be Totally Disabled while your claim is admitted under a Group Long Term Disability Income Benefit with Great-West Life.

Extension of Benefits

The termination of the policy will not affect the continuation of your coverage under the Waiver of Premium provision.

Conversion of Your Life Insurance

You may convert your Group Life Coverage to an Individual Life Policy upon termination of your employment, or termination of the policy. Evidence of good health is not required. The individual policy will be one of the standard life insurance conversion forms available by Great-west Life or any of its affiliates.

However it may only be selected by an individual who has not attained his 65th birthday. For limits on the amount of coverage that may be selected please see your employer. It may not include any provision for disability, accidental death or other special benefit.

An application and the first premium due for the individual policy must be received by Great-West Life within 31 days after the termination of your group coverage. In the case of your death during this 31 day period, the amount of coverage, subject to any limits, will be paid to your named beneficiary.

LONG TERM DISABILITY BENEFIT

You will be paid a monthly amount based on your pre-disability monthly income after the elimination period of the later of expiration of sick leave or 140 days if you become disabled while insured.

Benefits are paid only if you are under the continuing care of a legally licensed physician or surgeon. For a disability arising from any medical condition, you must be receiving appropriate treatment as agreed upon by Great-West Life and your treating physician. We reserve the right to seek and accept an independent medical opinion from a physician specialized in the treatment of the medical condition.

No benefits will be paid during the Elimination Period. If you cease to be totally disabled, return to work and within six months again become totally disabled from the same or related cause, the Elimination Period is not applicable again.

If, however, you return to work for more than six months, the Elimination Period is again applicable.

Definition of Disability

Disabled and Disability means your complete inability due to injury, disease, illness, pregnancy or mental disorder to perform the substantial duties of your regular occupation during the first 24 months of payment. Thereafter, it means your complete inability to engage in any and every gainful occupation for which you are reasonably fitted by education, training or experience, without consideration to the availability of such occupation.

If you engage in any business or occupation except in a rehabilitation program approved by Great-West Life, you will be deemed to no longer be disabled.

Waiver of Premium

Great-West Life will waive the premium payments while you are receiving benefits from the date of disability.

Rehabilitation Provision

With the consent of Great-West Life, you may engage in rehabilitative employment. In such cases, the monthly benefit payable will be reduced

1. by 50% of the income received from the rehabilitative employment, or

2. to the extent necessary so that you are not receiving in total more than

100% of what you were earning prior to disability.

You may not be on rehabilitative employment for more than 24 months.

Integration of Benefits

The monthly benefit provided by this plan will be reduced by the amount you are entitled to receive from the Workers' Compensation Act and the Canada/Quebec Pension Plan. The amount deducted will not include any additional amount payable due to the marital status, or child benefits to which any member of your family younger than 18 years of age is entitled to apply for and receive as a result of your disability or any cost of living increases.

If you receive a disability income from another source (except from an individual insurance policy) benefits under this plan will be reduced so that the total benefits received, with or without income from another source, will not exceed 80% of your pre-disability earnings.

Exclusions

The following exclusions are in addition to those described in the General Health Exclusions. No benefits will be paid with respect to the disability

e) during the period which you are on leave of absence, including Pregnancy

Leave of Absence. If you become disabled while on leave of absence, the leave of absence will be deemed to end on the day before the date on which you are scheduled to return to work.

f) during any period while you are permanently or temporarily outside of

Canada or the United States. If you become disabled, your disability will be deemed to commence on the date you return to Canada or the United States.

Extension of Benefits

If you are disabled at the time of termination of employment or cancellation of the plan, your payments will continue to be paid for that one period of disability, provided you are entitled to this benefit.

How to Submit a Claim

Claim Forms are available from your employer. This form must be completed in full and submitted immediately but no later than 90 days after the elimination period. It is in your best interest to submit your claim as soon as possible since it helps to ensure prompt payment.

If the Group Insurance Policy terminates, no payment will be made for any claim unless proof is submitted within 90 days of the termination date.

HOSPITAL BENEFIT

You will be paid the difference between the public ward allowance under the Provincial Hospital Plan and the semi-private charge for each day you or your dependent is confined in a Licensed Hospital due to injury, disease, illness, mental disorder or pregnancy.

Exclusion

This exclusion is in addition to those described under General Health Exclusions:

a) any cause which entitles you or your dependent to apply for and receive indemnity or compensation under any Workers' Compensation Act.

Extension of Benefits

If you or your dependent are disabled at the time of termination of your employment, hospital charges as a result of such disability will continue to be paid up to 90 days, provided the benefit remains in force.

How to Submit a Claim

Claim Forms are available from your employer. This form must be completed in full and submitted within 180 days after the end of the calendar year in which the claim was incurred.

PAY-DIRECT DRUG BENEFIT (PLAN 88)¸

The Drug Coverage on your group is being administered by Assure Health Inc.

Any eligible drug charge will be paid if:

1. it is medically necessary.

2. it is reasonable and customary.

3. payment is not prohibited by a Government Sponsored plan in your Province or Territory of residence.

Eligible Charges

This is a generic drug plan. The ingredient cost of the lowest priced interchangeable product will be paid unless the prescription written is for a brand name that is directed by the prescriber as not interchangeable. The prescription must bear the notation "DO NOT PRODUCT SELECT", "NO SUB", or " NO SUBSTITUTION" on the actual script in the prescriber's own handwriting in order to be eligible for payment.

Medications, prescribed in writing by a Physician or Dentist bearing a Drug Identification Number on their labels, listed as prescription requiring in Federal or Provincial Drug Schedules and some other non- prescription requiring drugs are covered. Included are injectible drugs, injectible vitamins, insulins, allergy extracts, oral contraceptives, extemporaneous preparations or compounds and disposable needles, disposable syringes, lancets and testing materials for monitoring diabetes and drugs in the following categories:

Antimalarials Fibrinolytics Fluorides, single entity Iron salts, single entity

Nitroglycerin Potassium Replacements Thyroid agents Topical enzymatic debriding agents

Note: Drug cards cannot be used to purchase fertility drugs. These claims must be submitted directly to Great-West Life.

Maintenance Drugs

Any single purchase of drugs or medicines which would be considered reasonable and customary to be consumed or used within a 34 day period, or with respect to maintenance drugs, a 100 day period.

Antiasthmatics Antibiotics for acne Anticoagulants Anticonvulsants Antihypertensives Antiparkinson Antituberculosis

Cardiacagents Estrogens Glaucoma Hypoglycemics Oral Contraceptives Potassium Replacements Thyroid agents

Charges incurred for the following are not covered whether or not they have been prescribed for medical reasons.

1. Atomizers, appliances, prosthetic devices, colostomy supplies, first aid kits or equipment, electronic diagnostic monitoring or testing equipment, non-disposable insulin delivery devices, delivery of extension devices for inhaled medications, spring loaded devices used to hold lancets, alcohol, alcohol swabs, disinfectants, cotton, bandages or supplies and accessories for the above.

2. Oral vitamins, minerals, dietary supplements, infant formulas or injectible total parenteral nutrition solutions whether or not prescribed for a medical reason, except where Federal or Provincial law requires a prescription for their sale.

3. Diaphragms, condoms, contraceptive jellies/foams/sponges/ suppositories, intrauterine devices, contraceptive implants or appliances normally used for contraception, whether or not prescribed for a medical reason.

4. Proprietary medicines which

a. are registered under Division 10 of the Food and Drug Act, Canada, and

b. bear a General Public (GP) number on their label.

5. Prescriptions dispensed by a physician, clinic, dentist or in any non-accredited hospital pharmacy, or for treatment as an inpatient or outpatient in any hospital, including emergency status and investigational status drugs, unless otherwise approved by Great-West Life.

6. All preventative immunization vaccines and toxoids.

7. All homoeopathic preparations.

8. Items deemed cosmetic (even if a prescription is legally required). e.g.

topical minoxidil, sunscreens etc.

9. Any medication which the insured is eligible to receive under a Provincial

Drug Benefit Plan.

10. Fertility drugs, other than those dispensed for 6 menstrual cycles per lifetime.

11. Nicotine resin containing products.

12. Supplies for recreation or sports whether or not Medically Necessary.

Exclusion

This exclusion is in addition to those described under General Health Exclusions:

e) any cause which entitles you or your dependent to apply for and receive indemnity or compensation under any Workers' Compensation Act.

Lost Or Stolen Cards

Lost or stolen cards should be reported immediately, in writing, to the servicing Great-West Life Regional office. Upon receipt of written notice, a replacement card will automatically be issued with a new issue number. In most cases, the pharmacist will not honour the lost or stolen card because the name on the prescription will be different from that on the card. However, if you notify Great-West Life immediately it will greatly reduce the risk of fraudulent claims being paid.

MEDI-PACK BENEFIT

You will be paid for any of the charges incurred by you or your dependent provided that the charge meets all of the following conditions.

1. It is medically necessary.

2. It is reasonable and customary.

3. It is recommended and authorized by a physician or surgeon legally licensed to practise medicine.

4. Payment is not prohibited by the Government Sponsored plan in your province of residence.

5. It is not more than the difference between the actual cost of the charge and the amount you are entitled to apply for and receive under any Government Sponsored plan in your province of residence.

Nursing Care

The services of a registered nurse or registered nursing assistant at your residence up to an individual maximum of $5,000 per calendar year.

From January 1st coincident with or next following you or your dependent's 65th birthday, the maximum payable is $25,000 lifetime.

Note: The services will not be considered as eligible expenses while you or your dependent are residing in a nursing home, home for the aged, rest home or any other facility providing similar care, or confined in a Licensed Hospital.

Payment will not be made for services which are for custodial care and do not require the skill of a registered nurse or registered nursing assistant.

The services will not be considered as eligible expenses if the RN or RNA is normally resident in your home.

Hospital Expenses & Supplies

Charges incurred in the Canadian Province or Territory in which you or your dependent are resident for (i) services furnished by a Licensed Hospital and (ii) supplies which are obtained from an out-patient department of a Licensed Hospital or a surgical supply company, while you or your dependent are not confined to the Hospital.

Ambulance

Licensed ambulance or other emergency service used to transport you or your dependent from the place where injury, disease, illness, pregnancy or mental disorder is suffered to the nearest hospital where adequate treatment can be rendered, from one hospital to another, and from a hospital to your residence.

Charges for the fare of one attendant to accompany you or your dependent if transportation is not provided by a licensed ambulance service.

Preferred Vision Services (PVS) Discount

Our partnership with Preferred Vision Services will allow you and your dependents to save up to 20% on the purchase of eyewear. You will receive the PVS discount when purchasing eyeglasses or contact lenses from a member of the extensive PVS network of retail optical stores. Simply by showing your wallet certificate or travel assist card at a member store, you will receive the PVS discount on your purchase. To determine the nearest participating practitioner, you can call the PVS information center toll-free at 1-800-668- 6444.

Aids, Services & Supplies

Purchase of braces, crutches, artificial limbs or eyes and prosthetic devices approved by Great-West Life.

An initial pair of frames and one corrective prosthetic lense, for each eye, that is prescribed after cataract surgery.

An initial breast prosthesis following a mastectomy plus a replacement every two calendar years and two surgical brassieres per calendar year.

Rental of a wheelchair, hospital bed or other approved durable equipment for temporary therapeutic use. This equipment may be purchased subject to Great- West Life's approval prior to the purchase.

Oxygen.

Custom made Orthopaedic shoes or orthotics prescribed by a podiatrist or physician up to a maximum of one pair per calendar year.

Two pairs of surgical stockings per calendar year.

Wigs and hairpieces purchased as a result of chemotherapy up to a lifetime maximum of $100.00. We will also reimburse up to $250.00 lifetime for wigs purchased due to TOTAL hair loss from a disease called Alopecia Totalis.

Accidental Dental

Charges by a legally licensed dentist for dental treatment of injuries to natural teeth, or replacement of natural teeth, for accidents suffered by you or your dependent while insured under this benefit.

The charge will be subject to all of the following conditions:

- the treatment is necessitated by a direct accidental blow to the mouth and not by an object or food placed wittingly or unwittingly in the mouth

- the accidental blow occurs while the person is insured

- the treatment is received within twelve months after the accidental blow

- the treatment is the least expensive that will provide a professionally adequate treatment

- no payment will be made for any part of the charge which exceeds the amount shown for the treatment in the current Dental Association Schedule of Fees for General Practitioners in your province of residence.

- if treatment is to be received more than 90 days after the accidental blow, a treatment plan must be submitted to Great-West Life within 90 days of the accident.

Emergency Treatment

The following Emergency treatment required by you or your dependent while temporarily absent from your Province or Territory of residence because of business or vacation and not for health reasons. There is a maximum of $1,000,000 for an Emergency for you and each of your dependents under this Emergency Treatment section and the Travel Assistance Benefit. This limitation is not applicable to in-Canada emergency health care benefits. When emergency treatment for a condition is completed, any ongoing treatment related to that condition is not covered.

We will cover the first 60 days of a trip. This limitation is not applicable to in- Canada emergency health care benefits.

Room and board in a Hospital up to the hospital's standard ward rate for each day of confinement.

Hospital services and supplies furnished by a Hospital.

Diagnosis and treatment by a physician or surgeon legally licensed to practise medicine.

In the event of a medical emergency, you or someone acting on your behalf must contact the Travel Assistance Centre prior to seeking medical treatment. If it is not reasonably possible for you to contact the Travel Assistance Centre prior to seeking medical treatment due to the nature of the medical emergency, you must contact the Travel Assistance Centre as soon as possible. Failure to contact the Travel Assistance Centre as described will result in a reduction of benefits in the case of hospitalization of 40% of eligible costs. All costs for such emergency will be limited to your emergency out-of-country coverage and Travel Assistance coverage maximum or $25,000, whichever is less. This limitation is not applicable to in-Canada emergency health care benefits.

If a physician or the Travel Assistance provider recommends you or your dependents be moved to a different facility at the destination, and you choose not to go, eligible costs for emergency coverage and Travel Assistance coverage will in the case of hospitalization be reduced by 40% of eligible costs. All costs for such emergency will be limited to your emergency out-of-country coverage and Travel Assistance coverage maximum or $25,000, whichever is less. This limitation is not applicable to in-Canada emergency health care benefits.

If a physician or the Travel Assistance provider recommends you or your dependent return to your home province, and you choose not to go, emergency coverage and Travel Assistance coverage will end.

"Hospital" means an institution having diagnostic facilities that provides active, chronic care or emergency treatment with physicians and registered nurses in attendance 24 hours a day and is licensed by the appropriate governmental authority. It does not include an institution providing convalescent care, a nursing home for the aged, a rest home or any other facility providing similar care.

Note: If you are travelling and require medical care, please contact the Travel

Assistance Centre using the telephone number on the Travel Assistance card.

We will not pay for any costs resulting directly or indirectly:

(a) from an accident occurring while you or your dependent were operating a vehicle, vessel or aircraft, if you or your dependent:

i) were impaired by drugs or alcohol, or

ii) had a blood alcohol level higher than 80 milligrams of alcohol per

100 millilitres of blood.

(b) from the abuse of illegal substances.

Travelling outside Canada while pregnant: We will not cover any pregnancy related costs which are incurred outside of Canada within nine weeks of the expected delivery date. Costs associated with a child born outside of Canada within nine weeks of the expected delivery date, or after the expected delivery date, are not covered.

Referral Benefit

Charges for the following services provided in Canada and the United States but outside your Province or Territory of residence if they are not available in your Province or Territory of residence and are performed on the written referral of a physician or surgeon regularly attending you or your dependents in your Province or Territory of residence.

1. Room and board in a Licensed Hospital up to the hospital's standard ward rate for each day that you or your dependents are confined in the hospital.

2. Hospital services and supplies furnished by a Licensed Hospital.

3. Diagnosis and treatment by a physician or surgeon legally licensed to practise medicine.

Full details of the services to be provided must be submitted by the referring doctor to, and approved in advance by, Great-West Life. The maximum amount payable under this provision with respect to you or your dependents during your lifetime will be $10,000.

Diagnostic Test

Diagnostic tests, radium treatments and X-ray examinations, excluding dental X-rays, that are incurred in the Canadian Province or Territory in which you or your dependent are resident.

Speech Therapy

The services of a qualified speech therapist, up to an individual maximum of $1,000 per calendar year.

Clinical Psychology

The services of a legally licensed clinical psychologist, up to an individual maximum of $1,000 per calendar year.

Hearing Aids

The purchase of hearing aids and repairs, excluding batteries, up to an individual maximum of $500 in four consecutive years.

Travel Assistance Benefit

The following services with respect to a medical or personal Emergency required by you or your dependent while temporarily absent from your Province or Territory of residence because of business or vacation and not for health reasons. When emergency treatment for a condition is completed, any ongoing treatment related to that condition is not covered.

We will cover the first 60 days of a trip. This limitation is not applicable to in- Canada emergency health care benefits

- on the spot medical assistance

- emergency medical payments

- telephone interpretation service

- medical evacuation

- assistance with lost documents or luggage

- return of dependent children or a travelling companion

- visit of a family member

- transmission and retention of urgent messages

- help to locate Embassy or Consulate services

- assistance in the event of death to transport the remains

- return of a vehicle to your home or nearest rental agency

Note: For specific details, please refer to your Great-West Life Travel

Assistance brochure.

We will not pay for any costs resulting directly or indirectly:

(a) from an accident occurring while you or your dependent were operating a vehicle, vessel or aircraft, if you or your dependent:

i) were impaired by drugs or alcohol, or

ii) had a blood alcohol level higher than 80 milligrams of alcohol per

100 millilitres of blood.

(b) from the abuse of illegal substances.

Please contact the Travel Assistance Centre using the telephone number on the Travel Assistance card.

Travelling outside Canada while pregnant: We will not cover any pregnancy related costs which are incurred outside of Canada within nine weeks of the expected delivery date. Costs associated with a child born outside of Canada within nine weeks of the expected delivery date, or after the expected delivery date, are not covered.

Vision Care

Vision Benefit maximum is $250.00 in any two consecutive calendar years.

Prescription eye glasses or contact lenses and the fittings of such eyewear or laser eye surgery performed by a licensed ophthalmologist for the purpose of correcting vision.

An eye examination (including eye refractions) in two consecutive calendar years.

Note: All charges must be recommended or approved by a legally licensed physician, surgeon, optometrist or ophthalmologist.

Paramedical Services

The maximum amount payable per classification of practitioner is $500.00 in any calendar year.

Laboratory tests and X-ray examinations recommended or approved by a legally licensed chiropractor, osteopath, chiropodist or podiatrist.

The services of any of these legally licensed classification of practitioners:

- Physiotherapists

- Chiropractors

- Osteopaths

- Chiropodists or Podiatrists

- Naturopaths

- Masseurs

- Acupuncturists

Note: The maximum charge for each treatment will be as determined by the Schedule of Fees approved by the Association of which the practitioner is a member, and where there is no approved Schedule of Fees, an amount as determined by Great-West Life.

If you live in Ontario, no payment for podiatrists expenses will be made until you or your dependent reach the annual OHIP maximum for such services.

Exclusions

These exclusions are in addition to those described under General Health Exclusions:

e) any cause which entitles you or your dependent to apply for and receive indemnity or compensation under the Workers' Compensation Act,

f) an examination by, or the services of, a physician or surgeon, if required solely for the use of a third party,

g) any treatment to correct temporomandibular joint dysfunction,

h) any service or treatment which you or your dependent would receive without being charged.

Extension of Benefits

If you or your dependent are disabled at the time of termination of your employment, Medi-Pack charges as a result of such disability will continue to be paid up to 90 days provided the benefit remains in force.

How to Submit a Claim

Claim Forms are available from your employer. This form must be completed in full and submitted with the original bills within 180 days after the end of the calendar year in which the claim was incurred.

Note: To ensure prompt claims service, any receipts for drugs should include:

• your name or your dependent's name receiving the service or treatment

• the date and the type of each service or treatment

• the charge for each date

• the prescription numbers for prescribed drugs and medicine

• the name of the drug or the medicine

There are special rules for claiming the costs of emergency treatment outside of your home province.

For all medical expenses, you must contact the Travel Assistance provider at the time of the emergency. This will enable the Travel Assistance provider to co-ordinate payment directly with the hospital and/or medical provider involved. In addition, with your approval the Travel Assistance provider will co-ordinate payment with your Provincial Health Care plan.

If a medical provider or hospital bills you directly, send the bill along with your claim form to the Travel Assistance provider.

DENTAL BENEFIT

If you or your dependent require any insured treatments or services, you will be reimbursed for such charges but only to the extent:

a) that they are the least expensive service, supply or method of treatment which Great-West Life determines will produce a professionally adequate result,

b) that if the charge exceeds the least expensive service, Great-West Life may provide payment based on the cost of alternative services which are defined in this provision as eligible charges,

c) that the treatment for it has been performed, recommended or approved by a legally licensed dentist or denturist,

d) that Great-West Life is not prohibited from paying it by any applicable law of the jurisdiction where you reside at the time the charge is incurred.

Exclusions

The following exclusions are in addition to those outlined in the General Health Exclusions:

e) any cause for which you or your dependent may apply for and receive indemnity or compensation under any Workers' Compensation Act,

f) any Group or Policyholder-Sponsored dental care or treatment,

g) any dental care or treatment for which you or your dependent are not legally obliged to pay,

h) any dental care or treatment which is principally for cosmetic purposes,

i) any appointments not kept or for the completion of claims forms,

j) any dental treatment that has as its purpose the correction of temporomandibular joint dysfunction,

k) any endodontic treatment commencing before you or your dependent became insured under this benefit,

l) replacement of mislaid, lost or stolen appliances,

m) any crowns placed on teeth that are not functionally impaired by incisal or cuspal damage,

n) any crowns, bridges or dentures for which tooth preparations were made before you or your dependent became covered under this benefit,

o) any orthodontic expenses which were incurred before your dependent became covered under this benefit.

Assignment of Benefits

We reserve the right to refuse any assignment of benefit under this provision.

Dental 1

"Pre-determination" required.

This covers the most common dental expenses:

a) examinations

b) X-rays

c) preventive services such as oral hygiene instruction, polishing, and fluoride treatments

d) extractions, including impacted teeth e) fillings

f) space maintainers for dependent children

g) diagnostic procedures

h) anaesthesia

i) consultations

Dental 1 Charges

Diagnostic

Initial Examinations

(Not more than one examination in any period of 6 consecutive months)

01101, 01102, 01103, 01201, 01301, 01401, 01501, 01601, 01701, 01801, 01901 (other than in the Province of Quebec)

01110, 01115, 01120, 01125, 01130, 01135, 01500, 01605, 01717, 01805 (in the Province of Quebec)

Recall Examinations

(Not more than 1 examination in any calendar year)

01202 (other than in the Province of Quebec)

01200 (in the Province of Quebec)

Specific Examinations

(Not more than one examination in any period of 6 consecutive months)

01204, 01302, 01402, 01502, 01602, 01702, 01703, 01802, 01902 (other than in the Province of Quebec)

01400, 01405 (in the Province of Quebec)

C215WC-10/01

Emergency Examination

01205 (other than in the Province of Quebec)

01300, 01305 (in the Province of Quebec)

Full Mouth Series (Not more than once in any period of 24 consecutive months)

02101, 02102 (other than in the Province of Quebec)

The Quebec Dental Association Suggested Fee Guide does not list codes for this procedure.

Periapical 02111 to 02125 inclusive (other than in the Province of Quebec)

02111 to 02116 inclusive (in the Province of

Occlusal 02131 to 02136 inclusive (other than in the

02131, 02132 (in the Province of Quebec)

Bitewings (Not more than twice in any calendar year)

02141 to 02146 inclusive (other than in the

02141 to 02144 (in the Province of Quebec)

Extraoral 02201 to 02204 inclusive, 02209 (other than in the Province of Quebec)

02201, 02202 (in the Province of Quebec)

Sialography 02401, 02402, 02409 (in all Provinces)

Panorex 02601 (other than in the Province of Quebec)

02600 (in the Province of Quebec)

Cephalometric 02701 to 02704 inclusive, 02709 (other than in

02701, 02702 (in the Province of Quebec)

Other X-rays 02931 to 02934 inclusive, 02939 (other than in

02920, 02929 (in the Province of Quebec)

Tests 04101, 04311 to 04313 inclusive, 04321 to 04323 inclusive, 04401, 04501, 04509 (other than in the Province of Quebec)

04100, 04302, 04311, 04312 (in the Province of

Consultations 05101 to 05104 inclusive, 05109, 05201, 05202, 05209 (other than in the Province of Quebec)

05200 (in the Province of Quebec)

Preventive

Polishing Not more than once in a calendar year with a maximum of 1 unit per recall visit) 11101, 11102, 11107, 11109 (other than in the Province of Quebec)

11100, 11200, 11300 (in the Province of

Recall Scaling (Not more than once in a calendar year with a maximum of 1 unit per recall visit) 11111 to 11117, 11119 (other than in the Province of Quebec)

Preventive Recall Packages

(Not more than once in a calendar year) 11201 to 11203 inclusive, 11301 to 11303 inclusive, 11401 to 11403 inclusive, 11501 to 11503 inclusive (other than in the Province of Quebec)

Fluoride Treatment 12101 (other than in the Province of Quebec)

12400 (in the Province of Quebec)

Oral Hygiene Instruction

(Not more than once in any period of 6 consecutive months) 13211 to 13214 inclusive, 13217, 13219, 13231, 13232, 13237, 13239, 13241, 13242, 13247, 13249 (other than in the Province of Quebec)

13200, 13210 (in the Province of Quebec)

Space Maintainers (Applicable only to the Dependent children of an

Employee under 13 years of age) 15101 to 15105 inclusive, 15201, 15202, 15301, 15302, 15401 to 15403 inclusive, 15501, 15601 to 15604 inclusive (other than in the Province of Quebec)

15100, 15110, 15111, 15120, 15200, 15210, 15400 (in the Province of Quebec)

Occlusal Equilibration

(Not more than 8 time units in any calendar year) 43311 to 43314 inclusive, 43317, 43319 (other than in the Province of Quebec)

43300, 43310 (in the Province of Quebec)

Pit and Fissure Sealants

13401, 13409 (other than in the Province of

13401, 13404 (in the Province of Quebec)

Minor Restorative

Caries, Trauma and Pain Control

20111, 20119, 20121, 20129, 20131, 20139 (other than in the Province of Quebec)

20111, 20121, 20131 (in the Province of

Amalgam Restorations

21111 to 21115 inclusive, 21121 to 21125 inclusive, 21211 to 21215 inclusive, 21221 to 21225 inclusive, 21231 to 21235 inclusive, 21241 to 21245 inclusive (other than in the Province of Quebec)

21101 to 21105 inclusive, 21121 to 21125 inclusive, 21211 to 21215 inclusive, 21221 to 21225 inclusive, 21231 to 21235 inclusive, 21241 to 21245 inclusive (in the Province of Quebec)

Retentive Pins 21401 to 21405 inclusive (other than in the

21301 to 21304 inclusive (in the Province of

Stainless Steel, Plastic and Polycarbonate

(Applicable only to the Dependent children of an Employee while they are under 16 years of age) 22201, 22202, 22211, 22212, 22301, 22302, 22311, 22312, 22401, 22411, 22501, 22511 (other than in the Province of Quebec)

27403, 27413, 27421 to 27424 inclusive (in the

Tooth Coloured 23101 to 23105 inclusive, 23111 to 23115 inclusive, 23211 to 23215 inclusive, 23221 to 23225 inclusive, 23311 to 23315 inclusive, 23321 to 23325 inclusive, 23401 to 23405 inclusive, 23411 to 23415 inclusive, 23501 to 23505 inclusive, 23511 to 23515 inclusive (other

23111 to 23115 inclusive, 23118, 23211 to 23215 inclusive, 23221 to 23225 inclusive, 23311 to 23315 inclusive, 23411 to 23415 inclusive (in the Province of Quebec)

Veneer Applications

23121, 23122 (other than in the Province of

23122 (in the Province of Quebec)

Minor Surgical

Extractions 71101, 71109, 71201, 71209, 72111, 72119, 72211, 72219, 72221, 72229, 72231, 72239

71101, 71111, 72100, 72210, 72220, 72230, 72240 (in the Province of Quebec)

Residual Root Removal

72311, 72319, 72321, 72329, 72331, 72339 (other than in the Province of Quebec)

72300, 72310, 72320 (in the Province of

Additional Services

Anaesthesia (used in conjunction with an eligible dental expense) 92101, 92102, 92212 to 92219 inclusive, 92222 to 92229 inclusive, 92301 to 92309 inclusive, 92411 to 92419 inclusive, 92421 to 92429 inclusive, 92431 to 92439 inclusive, 92441 to 92449 inclusive, 92451 to 92459 inclusive (other than in the Province of

92110, 92120, 92201, 92310, 92311 (in the

Professional Visits 93111, 93112, 93119, 94101, 94102, 94301, 94302 (other than in the Province of Quebec)

93100, 94100, 94200, 94400 (in the Province of

Miscellaneous 96101, 96102, 96202 (other than in the Province of Quebec)

96101 (in the Province of Quebec)

Dental 2

"Pre-determination" required.

The services included are:

a) root canal work (endodontics)

b) treatment of gum disease (periodontics)

c) major surgery

Dental 2 Charges

Periodontics

Non-surgical 41101 to 41104, 41109, 41211 to 41214, 41219, 41221 to 41224, 41229, 41301, 41302, 41309

The maximum benefit payable will include charges for packing and post-surgical treatment.

Surgical 42111, 42201, 42311, 42321, 42331, 42339, 42411, 42421, 42431, 42441, 42511, 42521, 42531, 42541, 42551, 42561, 42571, 42581

Adjunctive Services

42611, 42621, 42711, 42719, 42721 to 42723, 42729, 42731 to 42734, 42739, 42821 to 42823, 42829, 42831 to 42833, 42839, 43111, 43211, 43221, 43231, 43241, 43251, 43261, 43271, 43279, 49101, 49102, 49109, 49211, 49219

Scaling and/or Root Planing

43411 to 43417, 43419, 43421 to 43427, 43429

Periodontal Appliances and Repair

43611, 43612, 43621 to 43623, 43629, 43631, 43632

Endodontics

Pulpotomy 32211, 32212, 32221, 32222, 32231, 32232

Pulpectomy 32311, 32312, 32315, 32321, 32322

Root Canal Therapy

33111 to 33114, 33121, 33131, 33141, 33401 to 33403

Apexification 33601 to 33604, 33611 to 33614

Periapical Services 34111 to 34113, 34121 to 34123, 34131 to

34135, 34141 to 34143, 34145, 34211 to 34215, 34221 to 34223, 34225, 34241, 34242, 34251, 34254, 34261, 34264

Root Amputation 34401, 34402, 34411, 34412

Surgery 34601 to 34603 inclusive, 34609

Other Procedures 39101, 39201, 39202, 39211, 39212, 39301 to

39303, 39309

Hemisection 34421 to 34423

Bleaching 39311 to 39313, 39319, 39411 to 39413, 39421 to 39423, 97111 to 97113, 97131 to 97133, 97139 (other than for cosmetic purposes)

Intentional Removal, Apical Filling and Reimplantation

34451 to 34453

Endosseous Treatment

39711, 39712, 39721

Emergency and Miscellaneous Procedures

39501 to 39503, 39911, 39912, 39921, 39922, 39931, 39941, 39942

Retrofi…