Common use of ACCIDENTAL DENTAL Clause in Contracts

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪ dental treatment for injuries to natural teeth ▪ replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪ Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪ Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪ Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed.

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪  dental treatment for injuries to natural teeth ▪  replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- non-payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪  Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪  Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪  Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed. PARAMEDICAL SERVICES  Physiotherapist - up to a maximum of $1,000 per calendar year.  Clinical Psychologist – up to a maximum of $1,500 per calendar year (2013); Up to a maximum of $1,750.00 per calendar year January 1, 2014.  Speech Therapist - up to a maximum of $1,500.00 per calendar year.  Chiropractor - $50.00 per visit to a maximum of $500.00 per calendar year. (new Jan 2013) -$40.00 per visit to a maximum of $500.00 per calendar year (Jan 1, 2011 – Dec 31, 2012) Windsor Police Association Revised January 15, 2013  Registered Massage Therapy (medical referral required) - $50 per visit to a maximum of $500 per calendar year. Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada. Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt. PRIVATE DUTY NURSING Services of a registered nurse (R.N.) in the home only on a full or part shift basis up to a maximum of $5,000.00 every 3 years. In addition; on or after the first day of the calendar year accompanying with or following next your 65th birthday, the maximum reimbursement is $5,000.00 less any expenses incurred in the 3 previous consecutive calendar years. The services must require the expertise of an R.N. only and must be certified medically necessary by the attending physician. Eligible Services do not include and reimbursement will not be made for:  charges in excess of the fee level set by the largest nursing registry in your province of residence  agency fees, commissions or overtime fees  charges by a registered nurse who is related to you by birth or marriage, and/or who normally resides in your home  charges for a registered nursing assistant, a practical nurse, homemaker, or any person who is not a registered nurse  services which are custodial and/or services which do not require the skill level of a registered nurse  charges incurred while confined in a hospital, LTC Facility, home for the aged, rest home or retirement home A Pre-Authorization Form for Private Duty Nursing must be completed by the attending physician and submitted to Green Shield Canada. Failure to comply may result in non-payment. PROSTHETIC APPLIANCES AND DURABLE MEDICAL EQUIPMENT When your attending physician provides Green Shield with a written description of the required medical equipment, as well as the reason for use and/or the diagnosis. Eligible Services include standard external prostheses which replace all or part of a body organ or the functions of a permanently inoperative or a malfunctioning body organ. Also included are the replacement, repair, fittings and adjustments of such devices. Eligible Services include but are not limited to the following:  Aids for daily living: hospital style beds (electric and manual) including rails and mattress, bedpan, standard commode (portable toilet shower, stationary, wheeled), decubitus supplies (sheep skin, foot cradle, dressings, mattress pad), IV stand, mattress (alternating pressure), patient lift, trapeze, urinal.  Braces, diabetic, footwear: braces (legs, arms, neck or back), catheterization supplies, ostomy supplies. Stock item orthopaedic boots or shoes and custom made boots or shoes when prescribed by an orthopaedic surgeon or a podiatrist up to a combined maximum of one pair of shoes every 12 months. Adjustments and/or repairs to stock item orthopaedic footwear or orthopaedic footwear eligible once every 12 months. Orthopaedic shoes as an integral part of a brace. Custom made foot orthotics eligible once every 12 months and subject to a $50 co-payment.  Medical services: blood and blood products, diagnostic tests and x-rays, dialysis equipment, laboratory tests.  Mobility aids: cane, crutch, walker, wheelchair (manual or electric, including scooter).

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while occurredwhile coverage was in force, and received within 3 years of an accident for: ▪ dental treatment for injuries to natural teeth ▪ replacement of replacementof natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will Reimbursementwill be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- non-payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪ PRIVATECOVERAGE Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪ Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪ Reimbursement for Reimbursementfor the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or hospitalor a convalescent or convalescentor rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed. COVERAGE Private Room Hospital, reimbursement for the difference in cost between semi-private accommodation and a private room (not a suite) in a public general hospital.

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪ dental treatment for injuries to natural teeth ▪ replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- non-payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪ Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪ Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪ Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed.

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪  dental treatment for injuries to natural teeth ▪  replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- non-payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪  Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪  Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪  Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed. PARAMEDICAL SERVICES  Physiotherapist - up to a maximum of $1,000.00 per calendar year, $1,500.00 per calendar year January 1, 2018.  Clinical Psychologist – up to a maximum of $1,750.00 per calendar year January 1, 2014; up to a maximum of $2,000.00 per calendar year January 1, 2018; up to a maximum of $2,250.00 per calendar year January 1, 2019.  Speech Therapist - up to a maximum of $1,500.00 per calendar year. Windsor Police Association Revised January 2, 2016  Chiropractor - $50.00 per visit to a maximum of $600.00 per calendar year January 2, 2016; $700.00 per calendar year January 1, 2019.  Registered Massage Therapy (medical referral required) - $50 per visit to a maximum of $600.00 per calendar year January 2, 2016; $700.00 per calendar year January 1, 2019. Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada. Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt. PRIVATE DUTY NURSING Services of a registered nurse (R.N.) in the home only on a full or part shift basis up to a maximum of $5,000.00 every 3 years. In addition; on or after the first day of the calendar year accompanying with or following next your 65th birthday, the maximum reimbursement is $5,000.00 less any expenses incurred in the 3 previous consecutive calendar years. The services must require the expertise of an R.N. only and must be certified medically necessary by the attending physician. Eligible Services do not include and reimbursement will not be made for:  charges in excess of the fee level set by the largest nursing registry in your province of residence  agency fees, commissions or overtime fees  charges by a registered nurse who is related to you by birth or marriage, and/or who normally resides in your home  charges for a registered nursing assistant, a practical nurse, homemaker, or any person who is not a registered nurse  services which are custodial and/or services which do not require the skill level of a registered nurse  charges incurred while confined in a hospital, LTC Facility, home for the aged, rest home or retirement home A Pre-Authorization Form for Private Duty Nursing must be completed by the attending physician and submitted to Green Shield Canada. Failure to comply may result in non-payment. PROSTHETIC APPLIANCES AND DURABLE MEDICAL EQUIPMENT When your attending physician provides Green Shield with a written description of the required medical equipment, as well as the reason for use and/or the diagnosis. Eligible Services include standard external prostheses which replace all or part of a body organ or the functions of a permanently inoperative or a malfunctioning body organ. Also included are the replacement, repair, fittings and adjustments of such devices. Eligible Services include but are not limited to the following:  Aids for daily living: hospital style beds (electric and manual) including rails and mattress, bedpan, standard commode (portable toilet shower, stationary, wheeled), decubitus supplies (sheep skin, foot cradle, dressings, mattress pad), IV stand, mattress (alternating pressure), patient lift, trapeze, urinal.  Braces, diabetic, footwear: braces (legs, arms, neck or back), catheterization supplies, ostomy supplies. Stock item orthopaedic boots or shoes and custom made boots or shoes when prescribed by an orthopaedic surgeon or a podiatrist up to a combined maximum of one pair of shoes every 12 months. Adjustments and/or repairs to stock item orthopaedic footwear or orthopaedic footwear eligible once every 12 months. Orthopaedic shoes as an integral part of a brace. Custom made foot orthotics eligible once every 12 months and subject to a $50 co-payment.  Diabetic Supplies: Insulin infusion pumps, lancets and insulin guns, to a maximum of $5,000.00 per calendar year January 1, 2017.  Medical services: blood and blood products, diagnostic tests and x-rays, dialysis equipment, laboratory tests.  Mobility aids: cane, crutch, walker, wheelchair (manual or electric, including scooter).

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪  dental treatment for injuries to natural teeth ▪  replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪  Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪  Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪  Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed. PARAMEDICAL SERVICES  Physiotherapist - up to a maximum of $1,000 per calendar year.  Clinical Psychologist – up to a maximum of $1,500 per calendar year (2013); Up to a maximum of $1,750.00 per calendar year January 1, 2014  Speech Therapist - up to a maximum of $1,500.00 per calendar year.  Chiropractor - $50.00 per visit to a maximum of $500.00 per calendar year. (new 2013) - $40.00 per visit to a maximum of $500.00 per calendar year (Jan 1, 2011 – Dec 31, 2012) Windsor Police Association Revised January 15, 2013  Registered Massage Therapy (medical referral required) - $50 per visit to a maximum of $500 per calendar year. Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada. Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt. PRIVATE DUTY NURSING Services of a registered nurse (R.N.) in the home only on a full or part shift basis up to a maximum of $5,000.00 every 3 years. In addition; on or after the first day of the calendar year accompanying with or following next your 65th birthday, the maximum reimbursement is $5,000.00 less any expenses incurred in the 3 previous consecutive calendar years. The services must require the expertise of an R.N. only and must be certified medically necessary by the attending physician. Eligible Services do not include and reimbursement will not be made for:  charges in excess of the fee level set by the largest nursing registry in your province of residence  agency fees, commissions or overtime fees  charges by a registered nurse who is related to you by birth or marriage, and/or who normally resides in your home  charges for a registered nursing assistant, a practical nurse, homemaker, or any person who is not a registered nurse  services which are custodial and/or services which do not require the skill level of a registered nurse  charges incurred while confined in a hospital, LTC Facility, home for the aged, rest home or retirement home A Pre-Authorization Form for Private Duty Nursing must be completed by the attending physician and submitted to Green Shield Canada. Failure to comply may result in non-payment. PROSTHETIC APPLIANCES AND DURABLE MEDICAL EQUIPMENT When your attending physician provides Green Shield with a written description of the required medical equipment, as well as the reason for use and/or the diagnosis. Eligible Services include standard external prostheses which replace all or part of a body organ or the functions of a permanently inoperative or a malfunctioning body organ. Also included are the replacement, repair, fittings and adjustments of such devices. Eligible Services include but are not limited to the following:  Aids for daily living: hospital style beds (electric and manual) including rails and mattress, bedpan, standard commode (portable toilet shower, stationary, wheeled), decubitus supplies (sheep skin, foot cradle, dressings, mattress pad), IV stand, mattress (alternating pressure), patient lift, trapeze, urinal.  Braces, diabetic, footwear: braces (legs, arms, neck or back), catheterization supplies, ostomy supplies. Stock item orthopaedic boots or shoes and custom made boots or shoes when prescribed by an orthopaedic surgeon or a podiatrist up to a combined maximum of one pair of shoes every 12 months. Adjustments and/or repairs to stock item orthopaedic footwear or orthopaedic footwear eligible once every 12 months. Orthopaedic shoes as an integral part of a brace. Custom made foot orthotics eligible once every 12 months and subject to a $50 co-payment.  Medical services: blood and blood products, diagnostic tests and x-rays, dialysis equipment, laboratory tests.  Mobility aids: cane, crutch, walker, wheelchair (manual or electric, including scooter).

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪ dental treatment for injuries to natural teeth ▪ replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- non-payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪ Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪ Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪ Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed.

ACCIDENTAL DENTAL. Services by a licensed dental practitioner for the following dental treatment resulting from directly and independently of all other causes, from bodily injury caused by accidental means which occurred while coverage was in force, and received within 3 years of an accident for: ▪ • dental treatment for injuries to natural teeth ▪ • replacement of natural teeth to a maximum of $500.00 per accident, ie. dentures, bridge, crowns Reimbursement will be made up to the fees set out in the General Practitioners Fee Guide in effect on the date of treatment. A Dental Accident Report Form and your dental x-rays must be submitted to Green Shield for prior approval. Failure to comply may result in non- non-payment. AMBULANCE TRANSPORTATION When required as the result of an accident or acute physical disability by professional land ambulance, or in acute emergency, by air ambulance. HOSPITAL ACCOMMODATION Eligible benefits will be paid at 100% based on usual, reasonable and customary charges in the area where they were received, provided your provincial government health plan has accepted or agreed to pay the xxxx or standard rate. SEMI-PRIVATE COVERAGE ▪ • Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a public general hospital when you have occupied an active treatment bed, or alternative level of care bed. ▪ • Reimbursement up to a maximum of $3.00 per day for 120 days per calendar year for the difference in cost between standard xxxx charges and semi-private accommodation in a public chronic hospital or chronic wing facility of a public general hospital when you have occupied a chronic treatment bed or in a public general hospital when you have occupied an alternate level of care semi-private bed. ▪ • Reimbursement for the difference in cost between standard xxxx charges and semi-private accommodation in a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital when you have occupied an active convalescent or rehabilitation bed. PRIVATE COVERAGE • Private Room in Hospital, reimbursement for the difference in cost between semi-private accommodation and a private room (not a suite) in a public general hospital.