Key Terms & Conditions
Insurance claims are paid via an electronic adjudication system by way of a swipe card or the completion of a claim form by the medical provider for processing. Such ‘paper claims’ will require out of pocket payment to the service provider and must be submitted within ninety (90) days of the service date, after which reimbursement is made either by direct bank transfer or cheque payment. Claim forms are to be fully completed and accompanied by original receipts. All claims must be submitted through your Credit Union.
HEALTH CARDS & CLAIMS CHEQUES
Health Cards and Claims cheques will be dispatched at your respective Credit Union. Submission of claim forms should be done at your credit union.
Please note, that the termination age remains at age 75 with the option to extend to age 99 on condition that a medical is submitted annually after age 74 years. Coverage is reduced by half at age 65 years.
ACCIDENTAL DEATH AND DISMEMBERMENT
Accidental Death and Dismemberment AD&D ceases at age 69 years.
DEFINITION OF DISABILITY
Disability means the incapacity of the insured as a result of an accident leaving member completely unable to engage in any gainful occupation.
R & C
Reasonable and Customary (R&C) charges are set at the general level of fees usually charged for similar services or materials by professionals or institutions within the community where such fees are charged.
Coordinate your benefits with NHF/JADEP.
There is a six (6) month waiting period for Hospitalization, Surgery & Major Diagnostic Services unless the service is necessaited by an emergency. There is a 9- month waiting period for maternity.
The deductible is a one-time annual payment or accumulation of payments out of pocket where there is a need to access the Major Medical benefit after exhaustion of the basic benefit. A deductible is not required for a basic benefit to be paid. All claims must be submitted to satisfy the deductible.
LIMITATIONS AND DISCLAIMER
THIS BROCHURE IS IN NO WAY INTENDED TO BE A COMPLETE EXPLANATION OF ALL CONDITIONS, TERMS, LIMITATIONS, EXCLUSIONS AND OTHER PROVISIONS OF CONTRACT. THIS BROCHURE IS FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED TO BE A CONTRACT OF INSURANCE.