Definitions

Accident means any event due to sudden and unforeseeable external causes that inflict bodily injuries certified by a physician, directly and independently of any other cause. It does not mean any form of disease or degenerative process, an inguinal, femoral, umbilical or incisional hernia, or any infection other than an infection of a visible, external cut or wound accidentally sustained.

Actively at Work for benefits provided by Desjardins and AIG means, on the date in question, reporting for work at the usual place of employment with the employer able to perform all of the member’s regular duties for the scheduled number of hours for that day. They are also referred to as active employment.

Actively at Work for benefits provided by Pacific Blue Cross means a member is attending their usual place of employment with the employer, is performing all the normal and customary duties for a full working day or shift, or is on vacation or statutory holiday or a regular non-working day and is capable of being at work. It does not mean

1) working less than the required minimum number of hours per week specified in the summary of benefits or
2) employment not at the usual place of employment or business unless at a location the business requires the member to travel. Also referred to as actively employed or active employment.

Age means the insured person’s age on his last birthday when stated or calculated or when an event referred to under the policy occurs.

Annual Maximum means the maximum amount any one individual may receive per year under an insurance contract.

Benefit means the amount payable by the benefits provider to the insurance policy holder, assignee or beneficiary when a loss covered by the policy occurs. A benefit can also be a payment made to reimburse the member for health costs.

Benefits Provider means the organization responsible for adjudicating and providing the benefits a member is eligible for through the PEBT Benefits Program. Each benefit has a specified benefits provider identified in the summary of benefits under the My Benefits section of this website.

Common-Law Marriage means two persons of the opposite or same sex who have been cohabiting and residing with each other for a continuous period of time specified in the summary of benefits and whose spousal relationship has been publicly recognized.

Continuing Medical Care means the treatment a member receives. It must be accepted by the medical profession as an effective, appropriate, and essential treatment in the diagnosis or care of a specific illness or injury. It must be reasonable, considered standard practice and provided or prescribed by a physician or, when the benefits provider deems necessary, by a specialist in the appropriate field. Such care is not limited to examination and tests and must be provided at the frequency required for the specific Illness or injury.

Conversion means that an individual has the right to convert their group insurance coverage to an individual plan without presenting evidence of insurability if converted within the time frame outlined for applicable benefits.

Co-ordination of Benefits means a policy to determine how benefits will be calculated and paid if you are insured under several group contracts insuring the same event.

Core LTD Program means the long-term disability benefits program adopted by the Trustees as set out pursuant to the Trust Agreement.

Date of Disability means the initial date of the member’s total disability.

Deductible means the initial portion of the eligible expenses, which you must pay before the benefits provider will reimburse charges for any eligible expense. If the eligible expenses incurred in any calendar year do not exceed the deductible, any portion incurred during the last three months of that calendar year may be applied to the deductible for the next calendar year.

Dentist means a doctor of dentistry who is duly qualified and licensed to practice dentistry in the area where the service is provided. For the purposes of this summary, dentist may also mean dental specialist, denturist, or dental hygienist, depending on the services each may provide.

Dependent means any of the following persons for whom coverage is provided under this plan:

• one spouse of the member, as defined in the summary of benefits
• any unmarried child, stepchild, legally adopted child, or legal ward (but not a foster child), as defined in the summary of benefits

Disability means, during the elimination period and for 24 months after that exclusive of periods of active employment between successive periods of disability, which are considered one period of disability under the contract, the complete inability of a member because of illness or injury, to perform their regular duties and thereafter means the complete inability due to the same illness or injury to perform the duties of any remunerated function or work for which he is reasonably fitted by training and experience, which pays at least 60 % of the member’s pre-disability earnings and disability has a corresponding meaning.

Disability Management Program means a program established or approved by the benefits provider for the rehabilitation of a totally disabled member to enable the member to return to suitable productive employment.

Duplicate coverage means that you (and your dependents) are eligible to claim certain benefits under multiple plans.

Earnings as specified in the summary of benefits .

Elimination Period means the period of time indicated in the summary of benefits of disability, exclusive of periods of active employment between successive periods of disability, which are considered one period of disability under the contract, that must be completed before Core LTD Benefits (and Other LTD Benefits where applicable) commence under the Core LTD Program (or Other LTD Program, where applicable).

Employer means any companies listed on the policyholder’s application for the policy or specified in the summary of benefits .

Enrolment Grace Period means within four months from the coverage effective date.

Fee guide means the Canadian provincial/territorial dental fee guide that contains dental services and fees in effect on the date the dental services are performed. For Alberta, the fee guide means the current Alberta Blue Cross Usual and Customary fee guide.

Family-Related Leave means any leave of absence from work taken by a member in accordance with such provincial or federal legislation or an agreement between the member and the employer.

Fee schedule means the schedule of the Pacific Blue Cross Fee guide that contains eligible dental services, financial limits, treatment frequencies, and fees in effect on the date the dental services are performed.

Hospital for benefits provided by Pacific Blue Cross means an acute care institution which:

1. provides primarily for the diagnosis and short-term treatment of patients for a wide range of diseases or injuries and
2. may or may not have a group of beds or rooms or a separate wing or building to which patients requiring extended care are admitted and
3. if located in Canada, is recognized as a “public general hospital” and is generally not operated for profit and
4. has a staff of one or more Physicians available at all times and continuously provides 24-hour nursing services by registered nurses (RNs), and
5. is not primarily a health spa, hospice, clinic, nursing home, rest or convalescent facility, or treatment centre for substance abusers.

Hospital for benefits provided by Desjardins means any hospital designated as such by law intended for the care and treatment of sick and injured individuals. It has organized facilities for diagnosis and major surgeries, as well as 24-hour nursing service. The term does not include a nursing home, home for the aged or chronically ill, rest home, convalescent hospital, or a place for the care and treatment of alcoholism or drug abuse.

Hospitalization means:

1. to be admitted to a hospital as an in-patient for more than 18 consecutive hours; or
2. any hospital stay during which the member undergoes surgery performed by a physician and which requires local or general anesthesia, excluding any minor surgery that can be performed in a physician’s office.

Illness means any health deterioration or bodily disorder certified by a physician. For the purposes of the applicable benefits that refer to this definition, organ donations and related complications are also considered illnesses.

Immediate family means a person who is the spouse, son, daughter, father, mother, brother, sister, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law or sister-in-law of the member.

Injury means bodily injuries caused by an accident.

Insured person means the member or one of their insured dependents.

The insurer is the insurance carrier that agrees to underwrite the group contract and provide certain types of coverage and service. The insurer will be referred to as the benefits provider throughout this website.

Joint Early Intervention Services (JEIS) is a program designed to complement the LTD plan by providing proactive and timely service to plan members to facilitate their return to work in a caring, safe and timely manner.

Life event means a marriage, divorce, legal separation, birth or adoption of a child, or a change in the eligibility of a dependent.

Markup means the percentage a pharmacy charges above the manufacturer’s list price.

Maternity leave means any leave of absence from work due to pregnancy in accordance with any labour standards legislation that is applicable in the insured person’s province of residence. Maternity Leave consists of a voluntary portion and a “health-related portion.” The “health-related portion” of the maternity leave commences on the delivery date and lasts for at least six weeks (eight weeks for cesarean delivery). The person is considered to be on maternity leave during the entire period for which they receive maternity benefits under any provincial or federal legislation. If they are absent from work due to a total disability that commenced before or during pregnancy, they are considered to be on maternity leave in accordance with any provincial or federal legislation.

Maximum Benefit Period, for disability benefits, means the maximum period of time during which benefits are payable. This period is specified in the summary of benefits .

Member means a member as defined in the Trust Agreement who meets the eligibility requirements outlined in the summary of benefits.

Net Earnings means the earnings in effect immediately prior to commencement of total disability less all income taxes and contributions to the Canada/Quebec Pension Plan and Employment Insurance payable thereon.

Net Proceeds of Third-party Claim means proceeds of third-party claim less legal fees and disbursements reasonably and properly incurred by the member in prosecuting the third-party claim and any amount the member can verify to the reasonable satisfaction of the Insurer is attributable to the loss or destruction of property of the member.

Non Evidence Limit means the maximum amount of insurance the benefits provider will provide without evidence of insurability as indicated in the summary of benefits.

Non-Smoker means the Insured person has abstained from smoking any tobacco or nicotine products within the past 12 months from application for coverage.

Parental Leave means any leave of absence from work taken by a member to take care of their newborn or adopted child in accordance with such provincial or federal labour standards legislation or an agreement between the member and the employer.

Participating employer means a compulsory employer or a permitted employer as described in the Trust Agreement.

Physician (PBC) means an individual who is duly qualified and licensed to practice medicine or surgery, or both, in the area where the service is provided but excludes a physician residing with or related to you or your dependent.

Physician (Desjardins) means a legally qualified medical practitioner lawfully entitled to practice medicine in the place where he provides the medical services.

Plan Administrator means an entity appointed by the Trustees for the purpose of providing administrative services with respect to the insurance provided under this plan.

Practitioner means a person currently licensed, certified, or registered to practice a profession by the appropriate licensing, certification, or registration authority in the jurisdiction where the care or services are provided or, where no such authority exists, has a certificate of competency from the professional body which establishes standards of competence and conduct for the profession and is acting within the scope of that license. Pacific Blue Cross reserves the right to refuse the service, medical supply or equipment from the provider based on ineligibility or based on the Practitioner’s qualifications or conduct.

Pre-Disability Earnings means the average monthly earnings a member received or was entitled to receive during the 12 months immediately before the date of disability.

Pre-Existing Condition means any condition or Illness (whether diagnosed or not) for which a member was treated or attended to by a physician or for which drugs were prescribed during a period of time immediately prior to the effective date of the member’s coverage under this policy. Specific pre-existing condition information is provided within the applicable benefit sections.

Primary healthcare nurse practitioner means a person duly qualified and licensed to deliver specific healthcare services in the jurisdiction where the services are provided and acting within the scope of that license.

Proceeds of Third-party Claim means all sums of money paid by or on behalf of a third party towards the settlement of a third-party claim with or without any admission of liability or in satisfaction of a judgement of a third-party claim rendered by a court of competent jurisdiction, including any costs included in any settlement or judgement but excluding any no-fault benefits paid to the member under Part VII of the regulations under the Insurance (Motor Vehicle) Act.

Proof means written evidence sufficient to verify the circumstances of an event or to establish a fact pertinent to a member’s coverage or a claim for LTD Benefits under this policy, including the amount of a member’s pre-disability earnings. The evidence must be acceptable to the Insurer and received in a format approved for such purposes by the Insurer.

Provider means a person, group, or other entity currently licensed, certified, or registered to provide an eligible service, medical supply or equipment by the appropriate licensing, certification, or registration authority in the jurisdiction where the services or equipment are provided or, where no such authority exists, has a certificate of competency from the professional body which establishes standards of competence and conduct for the profession and is acting within the scope of that license. Pacific Blue Cross reserves the right to refuse the service, medical supply or equipment from the provider based on ineligibility or based on the provider’s qualifications or conduct.

Regular Duties means the duties that the member’s employer expects the member to perform immediately before the date of disability.

Rehabilitation Employment Program means a mandatory program established or approved by the benefits provider for rehabilitation of a disabled member to enable the member to return to suitable productive employment.

School District Benefits Administrator means the key contact person at the school district who is responsible for administering the benefits program.

Smoker means the Insured person has smoked tobacco or nicotine products within the past 12 months from application for coverage.

Termination Age means a specified age when a member is no longer eligible for coverage.

Third-party means any person, firm, partnership or corporate body that a member claims is legally liable in whole or in part for damages arising from events or circumstances the member alleges caused or contributed to total disability for which the member has applied for LTD benefits under this policy.

Third-party Claim means a claim of a member against a Third-party under all heads of damages, including, without limitation; general damages, special damages, past wage loss and future wage loss arising from events or circumstances the member alleges caused or contributed to total disability for which the member has applied for LTD benefits under this policy.

Total Disability or Totally Disabled see disability.

Trustees means the persons duly appointed to the Board of Trustees at the applicable time pursuant to the provisions of the Trust Agreement.

Waiting Period means a period of time that must pass in order for a new employee to become eligible for benefits under a group insurance policy. See the summary of benefits for details.

Waiver of Premium means a provision that, under certain conditions, a person’s insurance/benefits will be kept in full force by the benefits provider/plan without further payment of premiums.

Disclaimer:

The information contained on this website is provided for general information purposes only. Every effort has been made to ensure that this information is accurate, but this site is not a substitute for the official Plan documents, nor is it an employment contract. In the event there is a discrepancy between this website and the official Plan documents, the official Plan documents will prevail. For more information, or if you have questions about the information provided on this website please contact your School District Benefits Administrator.