Frequently Asked Questions - Claims Information

You should complete the appropriate claim form and attach any related supporting receipts. The following list is a quick reference guide of the claim form and corresponding number for each:

• Health Care/Vision Care Claim Form - M635D(51991)
• Dental Claim Form M445D(51991)
• Assure Card Claim Form - M6226(51991)

In the case of dental claims, your dentist will provide details on the claim form about the services rendered. Please note: Send all completed claim forms to the Great-West Life, London Office (the address is provided on the claim forms). Keep copies of ALL of your receipts as a backup in the event that your claim is lost or misplaced.

All claims must be submitted to and be received by Great-West Life within the policy year in which the claims were incurred. There is a 90-day grace period at the end of the policy year to have any outstanding claims paid. The policy year for extended health care and dental coverage for this plan is September 1 to August 31; vision care coverage is based on 24 consecutive months. A 90-day grace period is extended for outstanding claims until November 30, or for 90 days after the end of the claim period.

Great-West Life is set up to receive claims submitted electronically. If your dentist presently has the capability of submitting claims online, then this process can be followed. Otherwise, paper claims can be submitted directly to Great-West Life, London Office (the address is provided on the claim forms).

Have a pre-determination done before incurring any large dental expenses, or before beginning any orthodontic treatment. Your dentist can complete a treatment plan and submit it to Great-West Life. The benefits payable will be calculated for the proposed treatment, so you will know in advance the approximate portion of the cost you will have to pay.

Medical services provided by Licensed Speech Therapists, Physiotherapists, Psychologists, Registered Social Workers, Osteopaths, Chiropractors, Podiatrists and Registered Massage Therapists must be performed by registered practitioners. All of these services require a written referral from a qualified physician. Services provided by a Registered Christian Science Practitioner or Naturopath do not require a written referral from a qualified physician.

You are required to pay for the first 10 visits of Chiropractic Services before Great-West Life will accept a claim for reimbursement for the 11th visit on, up to the $500 maximum.

Benefits for you or a dependant will be directly reduced by any amount payable under a government plan. If you or a dependant are entitled to benefits for the same expenses under another group plan, benefits will be coordinated so that the total benefits from all plans will not exceed expenses.

1. If both members work for PETL and each have single coverage:
   • Each member can only submit his/her own claims through his/her own single plan.
2. If both members work for PETL and one member has family coverage:
   • One member has family coverage for the other member and any dependants;
   • Both members submit claims under the family plan.
3. If your spouse is covered under a different plan:
   • You and your spouse should submit your own claims through your own group plans;
   • Once your claim has been adjudicated, you may submit any outstanding balance to the other spouse’s carrier for consideration;
   • Claims for dependant children should be submitted to the plan of the parent who has the earlier birth date in the calendar year (the year of birth is not considered);
   • If you are separated or divorced, the plan which will pay benefits for your children will be determined in the following order:
   1. the plan of the parent with custody of the child;
   2. the plan of the spouse of the parent with custody of the child;
   3. the plan of the parent without custody of the child;
   4. the plan of the spouse of the parent without custody of the child.