|

Slb-benefits.ca

BENEFIT DETAILS

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
Visit our website atfor:
 information and details on Great-West Life's corporate profile and our products and services
 investor information
 news releases
 contact information
 claim forms and the ability to submit certain claims online
Great-West Life Online Services for Plan Members
As a Great-West Life plan member, you can also register for GroupNet™ for Plan Members at
www.greatwestlife.com. To access this service, click on the GroupNet for Plan Members link. Follow
the instructions to register. Make sure to have your plan and ID numbers available before accessing the
website.
This service enables you to access the following and much more, within a user friendly environment twenty-four hours a day, seven days a week:  your benefit details and claims history  personalized claim forms and cards  online claim submission for many of your claims, as outlined in the Healthcare, Dentalcare and Health Care Spending Account sections of this booklet  extensive health and wellness content Using our GroupNet Mobile app, you can access certain features of GroupNet for Plan Members to:  submit many of your claims online – part of our industry-leading GroupNet online services  access personalized coverage information about benefits, claims and more – quickly and easily, any  view card information  locate the nearest provider who has access to Provider eClaims, through a built-in GPS mapping tool
In addition, by using GroupNet Text, you can get immediate information that is specific to your benefits.
GroupNet Text allows you to use your mobile device to access detailed plan information, including:
 plan and member identification numbers
 coverage details (details available depend on your plan design)
 reimbursement amounts
 benefit maximums, balances and more
You can sign up for GroupNet Text on GroupNet for Plan Members under the Your Profile tab.
To use GroupNet Text, go to GroupNet for Plan Members and select the Your Profile tab, then text
certain keywords to 204-289-1667. You will receive an instant text back providing information on your
coverage. For a complete list of keywords, text Help. For a brief description of the type of information that
a keyword provides, text Help along with the specific keyword.
Compatibility of GroupNet Text may vary by mobile device or operating system.
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 1-800-957-9777.
 for assistance with your Health Care Spending Account, please call 1-877-883-7072.

This booklet describes the principal features of the group benefit plan sponsored by your employer, but
Group Policy Nos. 164696 and 164697 and Plan Document No. 58211 and 58436 issued by
Great-West Life and Policy Nos. AB5015901 and OE50015901 issued to your employer by ACE INA Life
Insurance are the governing documents. If there are variations between the information in the booklet and
the provisions of the policies or plan document, the policies or plan document will prevail.
This booklet contains important information and should be kept in a safe place known to you and your
family.
The Plan is administered by

Access to Documents
You have the right, upon request, to obtain a copy of the policy, your application and any written
statements or other records you have provided to Great-West Life as evidence of insurability, subject to
certain limitations.
Legal Actions
Every action or proceeding against an insurer for the recovery of insurance money payable under the
contract is absolutely barred unless commenced within the time set out in the Insurance Act or other
applicable legislation (e.g. Limitations Act, 2002 in Ontario, Quebec Civil Code).
Appeals
You have the right to appeal a denial of all or part of the insurance or benefits described in the contract as
long as you do so within one year of the initial denial of the insurance or a benefit. An appeal must be in
writing and must include your reasons for believing the denial to be incorrect.
Benefit Limitation for Overpayment
If benefits are paid that were not payable under the policy, you are responsible for repayment within 30
days after Great-West Life sends you a notice of the overpayment, or within a longer period if agreed to in
writing by Great-West Life. If you fail to fulfil this responsibility, no further benefits are payable under the
policy until the overpayment is recovered. This does not limit Great-West Life's right to use other legal
means to recover the overpayment.

Protecting Your Personal Information

At Great-West Life, we recognize and respect the importance of privacy. Personal information about you
is kept in a confidential file at the offices of Great-West Life or the offices of an organization authorized by
Great-West Life. Great-West Life may use service providers located within or outside Canada. 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. Your personal information may be subject to disclosure to those authorized under
applicable law within or outside Canada.
We use the personal information to administer the group benefits plan under which you are covered. This
includes many tasks, such as:
 determining your eligibility for coverage under the plan  enrolling you for coverage  investigating and assessing your claims and providing you with payment  managing your claims  verifying and auditing eligibility and claims  creating and maintaining records concerning our relationship  underwriting activities, such as determining the cost of the plan, and analyzing the design options of  preparing regulatory reports, such as tax slips Your employer has an agreement with Great-West Life in which your employer has financial responsibility for some or all of the benefits in the plan and we process claims on your employer's behalf. We may exchange personal information with your health care providers, your plan administrator, any insurance or reinsurance companies, administrators of government benefits or other benefit programs, other organizations, or service providers working with us or the above when relevant and necessary to administer the plan.
As plan member, you are responsible for the claims submitted. We may exchange personal information
with you and a person acting on your behalf when relevant and necessary to confirm coverage and to
manage the claims submitted.
You may request access or correction of the personal information in your file. A request for access or
correction should be made in writing and may be sent to any of Great-West Life's offices or to our head
office.
For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and
practices (including with respect to service providers), write to Great-West Life's Chief Compliance Officer
or refer to www.greatwestlife.com.
Liability for Benefits

Your employer has entered into an agreement with The Great-West Life Assurance Company whereby
your employer will have full liability for Healthcare (excluding Global Medical Assistance) and Dentalcare
benefits outlined in this booklet. This means your employer has agreed to fund these benefits and they
are, therefore, uninsured. All claims will, however, be processed by Great-West Life.
TABLE OF CONTENTS

Benefit Summary
This summary must be read together with the benefits described in this booklet.

Employee Basic Life Insurance
2 X annual earnings to a maximum of $750,000, reducing by 50% at age 65
Dependent Basic Life Insurance


Optional Life Insurance
Employee and Spouse Available in $25,000 units to a maximum of $500,000, subject to approval of evidence of insurability If you are covered under this plan as both an employee and a spouse, you are limited to the $500,000 maximum Available in $5,000 units to a maximum of $25,000 Employee Basic Accidental Death
and Dismemberment Insurance
(Underwritten by
ACE INA Life Insurance)
See benefit description
Voluntary Accidental Death
and Dismemberment Insurance
(Underwritten by
ACE INA Life Insurance)
See benefit description

Long Term Disability
Income Benefits
The waiting period starts The waiting period starts The waiting period starts on the first scheduled on the first scheduled on the first scheduled working day after you working day after you working day after you become disabled or the become disabled or the become disabled or the first day of hospital first day of hospital first day of hospital confinement, whichever confinement, whichever confinement, whichever is earliest, and lasts, if is earliest, and lasts, if is earliest, and lasts, if disability is continuous disability is continuous disability is continuous 60% of the first $3,000 65% of the first $7,500 of 65% of the first $7,500 of of your monthly earnings your monthly earnings your monthly earnings plus 50% of the next $4,000 plus 45% of the remainder to a maximum remainder to a maximum remainder to a maximum benefit of $15,000 or benefit of $15,000 or benefit of $15,000 or 85% of your pre-disability 85% of your pre-disability pre-disability take-home whichever is less whichever is less pay, whichever is less Inflation Protection Equal to the increase in the CPI, to a maximum
Healthcare
(Not available to
contract employees)
Covered expenses will not exceed customary charges
Lifetime Healthcare Maximum (In Canada) Reimbursement Level In-Canada Prescription Drug Expenses - Drugs purchased in An amount equal to the An amount equal to the An amount equal to the dispensing fee portion dispensing fee portion dispensing fee portion of the drug charge of the drug charge of the drug charge - Drugs purchased outside of Quebec  drugs purchased Wholesale Canada Limited or one of its affiliates using the prescription drug identification  drugs purchased purchased without An amount equal to the An amount equal to the An amount equal to the prescription drug dispensing fee portion dispensing fee portion dispensing fee portion identification card of the drug charge of the drug charge of the drug charge Reimbursement Level Expense Maximums $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar Massage Therapists $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar Physiotherapists $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar Psychologists/Social $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar Speech Therapists $500 maximum per $500 maximum per $1,000 maximum per practitioner each practitioner each practitioner each calendar year to a calendar year to a calendar year to a combined maximum of combined maximum of combined maximum of $1,500 each calendar $1,500 each calendar $1,500 each calendar Other Medical Supplies Reimbursement Level Expense Maximums Semi-private room Semi-private room Home Nursing Care $25,000 lifetime $25,000 lifetime $25,000 lifetime In-Canada Prescription Smoking Cessation $500 every 5 years $500 every 5 years $500 every 5 years Orthopedic Shoes and Custom-made Foot $150 every 12 months $150 every 12 months $150 every 12 months Myoelectric Arms $10,000 per prosthesis $10,000 per prosthesis $10,000 per prosthesis 1 every 12 months 1 every 12 months 1 every 12 months Surgical Brassieres 2 every 12 months 2 every 12 months 2 every 12 months Mechanical or Hydraulic $2,000 per lifter once $2,000 per lifter once $2,000 per lifter once Outdoor Wheelchair Monitoring Machines Transcutaneous Nerve Extremity Pumps for Compression Hose $250 each calendar $250 each calendar $250 each calendar Accidental Dental Injury Reimbursement Level Expense Maximums Glasses, Contact Lenses, Laser Eye Surgery and Eye Exams $150 every 24 months $350 every 24 months Global Medical
Assistance
Reimbursement Level
Emergency Care
Reimbursement Level
Lifetime Maximum
Dentalcare
(Not available to
contract employees)
Covered expenses will not exceed customary charges
The dental fee guide in effect in your province of The dental fee guide in residence on the date treatment is rendered effect in your province of residence on the date treatment is rendered plus another 20% for Reimbursement Levels Orthodontic Coverage for children age 6 to 18 when treatment starts Orthodontic Treatment All Other Treatment $1,500 each calendar $2,000 each calendar $3,000 each calendar
Healthcare Spending Account
See benefit description
Wellness Spending Account
See benefit description
Information About Your Flex Plan
 Option changes take effect each January 1, unless the change results from a change in family status.
If it does, the option change will take effect on the date the application for the change is made, as long as it is made within 31 days of the status change. Otherwise, the change will not take effect until the following January 1. Note: If you choose option 3 dental coverage, you are locked in at that level for 2 years. These
restrictions are waived if you are changing options because of a family status change.
 If you experience a change in family status during a plan year that affects your coverage needs, you may make changes to your benefit options that directly relate to your status change without waiting for the next January 1 re-enrollment period. Any of the following is considered a change in family status: acquiring your first dependent (spouse or child) acquiring a spouse if you have child coverage only acquiring your first child (birth, adoption or step-child) if you have spouse coverage only involuntary loss of similar coverage through your spouse's group benefit program (for example, because of a change in your spouse's employment status) death of your spouse or only child your spouse or only child ceasing to qualify for coverage (for example, through divorce or your child's attainment of a limiting age – see Dependent Coverage in this booklet) Note: See your administrator for details no later than 31 days after a change in family status occurs.
Certain conditions apply.
COMMENCEMENT AND TERMINATION OF COVERAGE
You are eligible to participate in the plan on the date your employment begins.  You and your dependents will be covered as soon as you become eligible. You may waive health coverage if you are already covered for this benefit under your spouse's plan. If you lose spousal coverage you must apply for coverage under this plan. If you do not apply within 31 days of loss of such coverage, or you were previously declined for coverage by Great-West Life, you and your dependents may be required to provide evidence of good health acceptable to Great-West Life to be covered for health benefits.  You must be actively at work when coverage takes effect, otherwise the coverage will not be effective until you return to work. Increases in your benefits while you are covered by this plan will not become effective unless you are actively at work.  Temporary, contract, seasonal employees and part-time employees who work less than 20 hours per week may not join the plan. Your coverage terminates when your employment ends, you are no longer eligible, or the plan terminates, whichever is earliest.  Your dependents' coverage terminates when your coverage terminates or your dependent no longer qualifies, whichever is earlier.  When your coverage terminates, you may be entitled to an extension of benefits under the plan. Your employer will provide you with details.
Survivor Benefits

If you die while your coverage is still in force, the health and dental benefits for your dependents will be
continued for a period of 2 years or until they no longer qualify, whichever happens first.
DEPENDENT COVERAGE
Dependent means:  Your spouse, legal or common-law. A common-law spouse is a person who has been living with you in a conjugal relationship for at least 6 months or, if you are a Quebec resident, until the earlier birth or adoption of a child of the relationship.  Your unmarried children under age 21, or under age 25 if they are full-time students. Note: If you are a Quebec resident, full-time students are covered for prescription drug benefits until
age 26.
Children under age 21 are not covered if they are working more than 30 hours a week, unless they are full-time students. Children who are incapable of supporting themselves because of physical or mental disorder are covered without age limit if the disorder begins before they turn 21, or while they are students under 25, and the disorder has been continuous since that time. BENEFICIARY DESIGNATION
You may make, alter, or revoke a designation of beneficiary as permitted by law. You should review any beneficiary designation made under this policy from time to time to ensure that it reflects your current intentions. You may change the designation by completing a form available from your employer. EMPLOYEE BASIC LIFE INSURANCE
On your death, Great-West Life will pay your life insurance benefits to your named beneficiary. If you have not named a beneficiary or there is no surviving beneficiary at the time of your death, payment will be made to your estate. Your employer will explain the claim requirements to your beneficiary.  Your life insurance terminates when you reach age 70 or when you retire, whichever comes first.  If you become disabled while insured, Great-West Life may waive the premiums on your life insurance after the waiting period, throughout the benefit period. The waiting period is the same as the waiting period under the long term disability income benefit. A benefit period is the period of time after the waiting period during which you satisfy the disability definition under the long term disability income benefit. A benefit period will not continue past your 65th birthday.  If any or all of your insurance terminates on or before your 65th birthday, you may be eligible to apply for an individual conversion policy without providing proof of your insurability. You must apply and pay the first premium no later than 31 days after your group insurance terminates. See your employer for details. DEPENDENT BASIC LIFE INSURANCE
If one of your dependents dies, Great-West Life will pay you the dependent life insurance benefit. Your employer will explain the claim requirements.  Your dependent life insurance terminates when you reach age 70, when you no longer have eligible dependents or when you retire, whichever comes first.  If you are disabled and the premiums for your employee life insurance are waived, your dependent life insurance will also continue without premium payment until your own coverage terminates or your dependents no longer qualify.  If your spouse's insurance terminates on or before his or her 65th birthday, he or she may be eligible for an individual conversion policy without providing proof of insurability. You or your spouse must apply and pay the first premium no later than 31 days after the group insurance terminates. See your employer for details. OPTIONAL LIFE INSURANCE

Optional Life Insurance allows you to choose additional coverage for yourself and your spouse. Check the
Benefit Summary for the amount of Optional Life Insurance available. When you apply for Optional Life
Insurance, you must provide proof of insurability, and the application must be approved by Great-West
Life. If you or your spouse dies within two years after applying for Optional Life Insurance, Great-West
Life has the right to verify any medical information you or your spouse provided. If any inconsistencies
are discovered, the claim will be denied and any premiums paid will be refunded.
To cover your child, you must apply for coverage within 31 days of becoming eligible. Within the first 31
days, evidence of insurability is not required for your child. If you apply for Child Optional Life coverage
after 31 days of the child's birth, medical evidence satisfactory to Great-West Life on behalf of your child
will be required before coverage takes effect.
On your death, Great-West Life will pay your life insurance to your named beneficiary. If you have not
named a beneficiary or there is no surviving beneficiary at the time of your death, payment will be made
to your estate. Your employer will explain the claim requirements. If your spouse dies you will be paid the
amount for which he or she was insured.
 If you are approved for waiver of premium on your basic life insurance, any optional life insurance for you, your spouse and your dependent children will also continue without premium payment as long as your basic life insurance continues but not beyond the date your optional insurance would otherwise terminate.  If your or your spouse's optional life insurance terminates, you or your spouse may be eligible to apply for an individual conversion policy without providing proof of insurability. You must apply and pay the first premium no later than 31 days after your group insurance terminates. See your employer for details.  Your optional life insurance terminates when you reach age 70, or when you retire, whichever comes first. Your spouse's coverage terminates at the same time, or when he or she reaches age 70 or is no longer your spouse, whichever comes first. Your children's coverage terminates at the same time, or when they are no longer eligible dependents, whichever comes first. Limitation
No benefit is paid for suicide within the first two years of initial or increased optional life coverage. In such
a situation, Great-West Life refunds the premiums that have been received. This limitation does not apply
to coverage for a dependent child.
EMPLOYEE BASIC ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
(Underwritten by ACE INA Life Insurance)
Policy No. AB50015901
Two times annual earnings to a maximum of $750,000, reducing by 50% at age 65. You are automatically the beneficiary of any accidental death and dismemberment insurance if you suffer an eligible accidental injury. You may name a beneficiary for your accidental death and dismemberment insurance should you die an accidental death. You may change that beneficiary at any time by completing a form available from your employer. On your death, your employer will explain the claim requirements to your beneficiary. ACE INA Life Insurance will pay your life insurance benefits to your beneficiary. Note that your accidental death and dismemberment insurance terminates when you reach age 70. You will be eligible for insurance if you are an active permanent full-time or part-time employee of the Policyholder and under age 70, that works a minimum of 20 hours per week. VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
(Underwritten by ACE INA Life Insurance)
Policy No. OE50015901
Employee and Spouse Available in $25,000 units to a maximum of $500,000. Available in $5,000 units to a maximum of $25,000.
Voluntary Accidental Death and Dismemberment Insurance allows you to choose additional coverage for
yourself, your spouse and your children. Check the Benefit Summary for the amount of Voluntary
Accidental Death and Dismemberment available.
Family Plan Coverage
Under the Family Plan, you can insure:
 your spouse, (legally married or domestic partner for a minimum of 6 months) under age 70, and
 your unmarried, dependent children, including step, foster or legally adopted children, to age 21 or to age 25 (26 for Extended Health Care benefit for Quebec residents only) if the child is a full-time student and dependent on you for support and maintenance,  mentally or physically challenged children, provided that they are incapable of self-sustaining employment and are dependent upon you for support and maintenance.
Schedule of Losses

If you or a covered family member suffers one of the following specific losses within one year from the
date of the accident, ACE INA Life Insurance will pay the percentage of the Benefit amount, based on the
amount stated under the Benefit amount section, however, that not more than one (the largest) of such
benefits shall be paid with respect to injuries resulting from one accident.
Percentage of Benefit Amount

Loss of Life
Loss of Both Hands or Both Feet Loss of Entire Sight of Both Eyes Loss of One Hand and One Foot Loss of One Hand and Entire Sight of One Eye Loss of One Foot and Entire Sight of One Eye Loss of Speech and Hearing Loss of Use of Both Arms, Both Hands, Both Legs or Both Feet Loss of One Arm or One Leg Loss of Use of One Arm or One Leg Loss of One Hand or One Foot Loss of Entire Sight of One Eye Loss of Use of One Hand Loss of Speech or Hearing Loss of Thumb and Index Finger of Same Hand Loss of Four Fingers of Same Hand Loss of Hearing in One Ear Loss of All Toes of Same Foot "Loss" shall mean:  with respect to hand or foot, the actual severance through or above the wrist or ankle joint  with respect to arm or leg, the actual severance through or above the elbow or knee joint  with respect to eye, the total and irrecoverable loss of sight  with respect to speech, the total and irrecoverable loss of speech which does not allow audible communication in any degree  with respect to hearing, the total and irrecoverable loss of hearing which cannot be corrected by any hearing aid or device  with respect to "Loss of Thumb and Index finger of Same Hand" or "Loss of Four Fingers of Same Hand", the actual severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand)  with regard to toes, the actual severance through or above the metatarsophalangeal joints (the joints between the toes and the foot) of the same foot If you or a covered family member suffers the complete severance of a hand, foot, arm or leg as described above, then ACE INA Life Insurance will pay the amount specified above even if the severed limb is surgically reattached, whether successful or not. "Loss" means the complete and irrecoverable paralysis, provided that the loss of function is  continuous for twelve consecutive months and  determined on evidence satisfactory to ACE INA Life Insurance to be permanent. This includes:  quadriplegia (paralysis of both upper and lower limbs)  paraplegia (paralysis of both lower limbs)  hemiplegia (total paralysis of upper and lower limbs of one side of the body)
"Loss of Use" means the total and irrecoverable loss of function of an arm, hand, foot, or leg, provided
that the loss of function is
 continuous for twelve consecutive months and
 determined on evidence satisfactory to ACE INA Life Insurance to be permanent.
"Brain Death" means irreversible unconsciousness with total loss of brain function; and complete absence
of electrical activity of the brain, even though the heart is still beating.
Quadriplegia, Paraplegia, Hemiplegia and Loss of use losses are subject to an all policies combined
maximum benefit amount of $1,500,000.
Rehabilitation Benefit
If you or a covered family member receives a payment from ACE INA as a result of an accidental injury,
ACE INA will also provide up to $15,000 for special training provided that:
 training is required as a result of the accident and to help the injured individual to become qualified to
engage in an occupation in which he/she would not have been engaged except for such injuries;  expenses are to be incurred within two years from the date of the accident;
Note that this payment is not for ordinary living, travelling or clothing expenses.
Repatriation Benefit
If you or a covered family member is in an accident that results in a loss of life more than 150 km from
your home and the death occurs within one year (365 days) of the accident, ACE INA will reimburse the
expenses associated with preparing and shipping the body for burial to a maximum of $15,000.

Family Transportation Benefit
If you or a covered family member is in an accident that results in a hospital stay more than 150 km from
your home, and requires the personal attendance of an immediate family member, as recommended in
writing by the attending physician, any travel expenses will be covered, assuming that the travel is
 by the most direct route
 via a licensed common carrier
The maximum for this benefit is $15,000.
Note that an "immediate family member" means the spouse, legal or common-law, parents, grandparents,
children over age 18, brother or sister of the hospitalized individual.
Spousal Occupational Training Benefit
If you are in an accident that results in death, the surviving spouse will receive up to $15,000 to engage in
a formal occupational training program to gain active employment in an occupation for which the surviving
spouse does not currently have sufficient qualifications.
Home Alteration and Vehicle Modification Benefit
If you or a covered family member's accident results in the need for a wheelchair you wil be covered for:
 the one-time cost of alterations to your residence to make it wheelchair accessible and habitable; and
 the one-time cost of modifications to a motor vehicle used by the insured person to make the vehicle
accessible or driveable. Note that reimbursement will be made on reasonable and necessary expenses only and the modifications must be made 365 days of the accident. Payments will only be made if:  home alterations are made by a person or persons experienced in such alterations and recommended by a recognized organization, providing support and assistance to wheelchair users; and  vehicle modifications are carried out by a person or persons with experience in such matters and modifications are approved by the provincial vehicle licensing authorities.
The maximum amount payable for both home and vehicle alterations shall be the greater of $15,000 or
10% of your Benefit Amount to a maximum of $50,000.
Day Care Benefit
If you are in an accident that results in death, your dependent child (or children) under age twelve will be
entitled to a "Day Care Benefit". The coverage amount will be the lesser of 5% of your benefit amount or
a maximum of $5,000 per year. Expenses must be:
 reasonable and customary
 come from a legally licensed day care centre on the date of the accident or within 365 days of the
The "Day Care Benefit" will be paid each year for four (4) consecutive years, but only upon receipt of satisfactory proof that your child is enrolled in a legally licensed Day Care Centre. "Dependent Child" means either a  legitimate or illegitimate child  adopted child  step-child  any child who is in a parent-child relationship with you
The child must be twelve years of age and under and dependent upon you for maintenance and support.
If, at the time of the accident, you have no dependent children under age twelve, your beneficiary will
receive an additional benefit of $2,500, either under this benefit or under the Special Education Benefit
(see below), but not both.
Special Education Benefit
If you are in an accident that results in your death, your dependent child may receive a "Special
Education Benefit" equal to 5% of your benefit amount up to $5,000 per year, for up to four years. Your
dependent child would be eligible for this benefit if, at the time of your accident, he/she:
 was in the 12th grade and subsequently enrolls as a full-time student in a post-secondary institution
within one year of your accident  was a full-time student in a post-secondary institution
The "Special Education Benefit" is payable annually for a maximum of four (4) consecutive annual
payments but only if your dependent child continues his/her education as a full-time student in an
institution of higher learning.
If, at the time of the accident, you have no dependent children that would qualify for this benefit, your
beneficiary will receive an additional benefit of $2,500, either under this benefit or under the Day Care
Benefit (see above), but not both.
This benefit is also available to you if you have purchased voluntary AD&D Family coverage and
your spouse dies an accidental death.

Seat Belt Benefit
If you or a covered family member is in an automobile accident that results in a payment under the
Schedule of Losses, the Benefit amount will be increased by 10%, to a maximum of $25,000, if, at the
time of the accident, the injured individual was driving or riding in a vehicle and wearing a properly
fastened seat belt. A automobile or vehicle means a private passenger car, station wagon, van, or jeep-
type automobile.
Proof of seat belt use must be provided at the time the claim is submitted.
In-Hospital Indemnity
In the event you sustain an injury which results in a payment being made under the Schedule of Losses
of this policy, excluding the Loss of Life Benefit and the Insured Person is hospital confined as an in-
patient and is under the care of a legally qualified and registered physician or surgeon other than himself,
ACE INA Life Insurance will pay for each full month, one percent (1%) of the Insured Person's Principal
Sum, subject to a maximum benefit of $2,500, or one-thirtieth of such monthly benefit for each day of
partial month, retroactive to the 1st full day of such confinement but not to exceed 365 days in the
aggregate for each period of hospital confinement.
"Hospital" as used herein means a legally constituted establishment which meets all of the following
requirements: (1) operates primarily for the reception, care and treatment of sick, ailing or injured
persons as in-patients; (2) provides 24 hour a day nursing service by registered or graduate nurses; (3)
has a staff of one or more licensed physicians available at all times; (4) provides organized facilities for
diagnosis and surgical facilities; and (5) is not primarily a clinic, nursing home or convalescent home or
similar establishment nor, other than incidentally, a place for alcoholics or drug addicts.
"In-Patient" means a person admitted to a hospital as a resident or bed-patient and who is provided at
least one day's room and board by the hospital.

Identification Benefit
If you or a covered family member is in an accident that results in a loss of life, police or a similar
government authority may request that an immediate family member identify the body. Your AD&D
coverage will reimburse the reasonable expenses associated with:
 transportation by the most direct route to the city or town where the body is located; and
 hotel accommodation, to a maximum duration of three (3) days.
You or your family member will be reimbursed only if the body is identified as being covered under the
plan, and only up to a maximum of $15,000.
Payment will not be made for board or other ordinary living, travelling or clothing expenses. Acceptable
travel expenses include those for commercial air, rail or bus travel as well as taxi cabs.
Reimbursement for identification benefits is available by incident; for example, if the accidental death
affects two family members, one family member will be expected to travel to identify both bodies.
Bereavement Benefit
Recognizing that family members may require some professional support when dealing with the
accidental death of a family members, your coverage also includes up to six (6) sessions of grief
counselling, by a professional counselor (who is licensed, registered or certified to provide such
treatment), subject to a maximum of $1,000. Counselling must occur within one year (365 days) of the
accidental death and the expenses must be reasonable and customary.
Cosmetic Disfigurement Benefit
If you or an insured family member suffers a third-degree burn in a non-occupational accident, ACE INA
will pay a percentage of the Principal Sum depending on the area of the body which was burned
according to the following table:
Maximum allowable % for Area Burned Face, Neck, Head Either Upper Arm Torso (Front or Back) Either Lower Leg
The maximum percent of Principal Sum Payable (C) is determined by multiplying the Area Classification
(A) by the Maximum Allowable percent for Area Burned (B). In the event of a 50% surface burn, the
Maximum Allowable percent for Area Burned (B) is reduced by 50%. This table only represents the
maximum percent of the Principal Sum payable for any one accident. If the burns are in more than one
area as a result of any one accident, benefits will not exceed a maximum of $25,000.
Continuance of Coverage
Subject to the payment of premiums, your AD&D coverage will continue for up to 12 months if you are:
 temporarily absent from work due to short-term disability
 on an approved leave of absence
 on maternity or parental leave If during your leave you engage in other occupational duties during the leave or lay-off period, no benefits shall be payable for a loss that occurs while engaging in other occupational duties.
Waiver of Premium
If you are under age 65, and are receiving long-term disability payments, your AD&D premiums will be
waived until your long-term disability payments end or you reach age 65. If you return to work with
Schlumberger Canada Limited and are a member of an eligible class, your insurance may be continued
upon resumption of premium payments.
How to Make a Claim

In the event of a claim, notice must be given to ACE INA Life Insurance within 30 days from the date of
the accident and subsequent proof of claim must be submitted to ACE INA Life Insurance within 90 days
from the date of the accident.
A claim form can be obtained from your employer
LONG TERM DISABILITY (LTD) INCOME BENEFITS

The plan provides you with regular income to replace income lost because of a lengthy disability due to
disease or injury. Benefits begin after the waiting period is over and continue until you are no longer
disabled as defined by the policy or you reach age 65, whichever comes first. Check the Benefit
Summary for the benefit amount and waiting period.
 If disability is not continuous, the days you are disabled can be accumulated to satisfy the waiting period as long as no interruption is longer than 2 weeks and the disabilities arise from the same disease or injury.  LTD benefits are payable for the first 24 months following the waiting period if disease or injury prevents you from performing the essential duties of your regular occupation, and, except for any
employment under an approved rehabilitation plan, you are not employed in any occupation that is
providing you with income equal to or greater than your amount of LTD insurance under this plan, as
shown in the Benefit Summary.
 After 24 months, LTD benefits will continue only if your disability prevents you from being gainfully employed in any job. Gainful employment is work you are medically able to perform, for which you have at least the minimum qualifications, and which provides you with an income of at least 50% of your indexed monthly earnings before you became disabled.  Loss of any license required for work will not be considered in assessing disability.  After the waiting period, separate periods of disability arising from the same disease or injury are considered to be one period of disability unless they are separated by at least 6 months.  Because you pay the entire cost of LTD coverage, benefits are not taxable.  Your LTD insurance terminates when you reach age 65.
Other Income
Your LTD benefit is reduced by other income you are entitled to receive while you are disabled. Your
benefit is first reduced by:
 disability or retirement benefits you are entitled to on your own behalf under the Canada Pension Plan or Quebec Pension Plan  benefits under any Workers' Compensation Act or similar law  employer sponsored short term disability or sick leave benefits  loss of income benefits under an automobile insurance plan, to the extent permitted by law  50% of earnings received from an approved rehabilitation plan There is a further reduction of your LTD benefit if the total of the income listed below exceeds 85% of your indexed monthly take-home pay before you became disabled. If it does, your benefit is reduced by the excess amount.  your income under this plan  loss of income benefits available through legislation, except for Employment Insurance benefits and automobile insurance benefits, which you or another member of your family is entitled to on the basis of your disability  the wage loss portion of any criminal injury award  disability benefits under a plan of insurance available through an association  employment income, disability benefits, or retirement benefits related to any employment except for income from an approved rehabilitation plan, or employer sponsored short term disability or sick leave benefits (termination pay, severance benefits, and any similar termination of employment benefits, including any salary paid in lieu of notice, are included as employment income under this provision) The balance of any earnings received from an approved rehabilitation plan is not used to further reduce your LTD benefit unless that balance, together with your income from this plan and the other income listed above, would exceed your indexed monthly take-home pay before you became disabled. If it does, your benefit is reduced by the excess amount. Cost-of-living increases in the other income listed above, that take effect after the benefit period starts,
except for income from an approved rehabilitation plan, are not included.
Vocational Rehabilitation

Vocational rehabilitation involves a work related activity or training strategy that is designed to help you
return to your own job or other gainful employment, and is recommended or approved by Great-West Life.
In considering whether to recommend or approve a rehabilitation plan, Great-West Life will assess such
factors as the expected duration of disability, and the level of activity required to facilitate the earliest
possible return to work.
Medical Coordination

Medical coordination is a program, recommended or approved by Great-West Life that is designed to
facilitate medical stability and provide you with cost effective, quality care. In considering whether to
recommend or approve a medical coordination program, Great-West Life will assess such factors as the
expected duration of disability, and the level of activity required to facilitate medical stability.
Inflation Protection
If you chose inflation protection then one year after the start of your benefit period and annually after that,
the then current amount payable will be adjusted to reflect increases in the Consumer Price Index, to a
maximum increase of Equal to the increase in the CPI, to a maximum of 3% in any year in any year.
Survivor Benefit
If you die while LTD income benefits are being paid, Great-West Life will pay 3 times your monthly LTD
benefit to your named beneficiary. If you have not named a beneficiary or there is no surviving beneficiary
at the time of your death, payment will be made to your estate. Your employer will explain the claim
requirements to your beneficiary.

Limitations
No benefits are paid for:
 Disability arising from a disease or injury for which you received medical care before your insurance started. This limitation does not apply if your disability starts after you have been continuously insured for 1 year, or you have not had medical care for the disease or injury for a continuous period of 1 year ending on or after the date your insurance took effect.  Any period after you fail to participate or cooperate in a prescribed plan of medical treatment appropriate for your condition. Depending on the severity of the condition, you may be required to be under the care of a specialist. If substance abuse contributes to your disability, the treatment program must include participation in a recognized substance withdrawal program.  Any period after you fail to cooperate in applying for other disability benefits, reapplying for such benefits, or appealing decisions regarding such benefits, where considered appropriate by Great-West Life.  Any period after you fail to participate or cooperate in an approved rehabilitation plan.  Any period after you fail to participate or cooperate in a recommended medical coordination program.  Any period after you fail to participate or cooperate in a required medical or vocational assessment.  The scheduled duration of a leave of absence. This does not apply to any portion of a period of maternity leave during which you are disabled due to pregnancy.  Any period in which you are outside Canada. This exclusion does not apply during the first 30 days of an absence, or if Great-West Life pre-authorized the absence prior to your departure.  Any period of incarceration, confinement, or imprisonment by authority of law.  Disability arising from war, insurrection, or voluntary participation in a riot.
How to Make a Claim
 To submit claims online, go to/ Client Services / Forms for Group Benefits
Plan Members / Standard Claim Forms. Click Apply for Disability Income Benefits and follow the instructions provided under Online claim submission.  To submit paper claims, obtain an Employee Claim Submission Guide (form M4307B) and follow the guide's instructions. You can get this form from your employer, or online from the Great-West Life corporate website. To access the form online, go t/ Client Services / Forms for Group Benefits Plan Members / Standard Claim Forms / Apply for Disability Income Benefits. Under Paper claim submission, click Long Term Disability Income Benefits – Guide. Please ensure that your claim is submitted to Great-West Life as soon as possible, but no later than 3 months after proof of your claim has been requested. HEALTHCARE

A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level
shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check
the Benefit Summary for this information.
The plan covers customary charges for the following services and supplies. All covered services and
supplies must represent reasonable treatment. Treatment is considered reasonable if it is accepted by the
Canadian medical profession, it is proven to be effective, and it is of a form, intensity, frequency and
duration essential to diagnosis or management of the disease or injury.
You are covered for only the Healthcare benefits that apply to the option that you choose as shown in the
Benefit Summary.
Except to the extent otherwise required by law, your healthcare coverage terminates when you retire.
Covered Expenses
 Ambulance transportation to the nearest centre where adequate treatment is available  Depending on the option you choose, semi-private room or private room and board in a hospital or the government authorized co-payment for accommodation in a nursing home is covered when
provided in Canada and the treatment received is acute, convalescent or palliative care, up to the
maximum as shown in the Benefit Summary.
Acute care is active intervention required to diagnose or manage a condition that would otherwise deteriorate. Convalescent care is active treatment or rehabilitation for a condition that will significantly improve as a result of the care and follows a 3-day confinement for acute care. Palliative care is treatment for the relief of pain in the final stages of a terminal condition. Depending on the option you choose, semi-private room or private room and board in an out-of-province hospital is covered when the treatment received is acute, convalescent or palliative care. For out-of-province accommodation, any difference between the hospital's standard ward rate and the government authorized allowance in your home province is also covered. The plan also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province.  Residences established primarily for senior citizens or which provide personal rather than medical care are not covered.  Home nursing services of a registered nurse, a registered practical nurse if you are a resident of Ontario or a licensed practical nurse if you are a resident of any other province, when services are provided in Canada. No benefits are paid for services provided by a member of your family or for services which do not require the specific skills of a registered or practical nurse You should apply for a pre-care assessment before home nursing begins  Drugs and drug supplies described below when prescribed by a person entitled by law to prescribe them, dispensed by a person entitled by law to dispense them, and provided in Canada. Benefits for drugs and drug supplies provided outside Canada are payable only as provided under the out-of-country emergency care provision. Drugs which require a written prescription according to the Food and Drugs Act, Canada or provincial legislation in effect where the drug is dispensed, including contraceptive drugs and products containing a contraceptive drug Injectable drugs including vitamins, insulins and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with non-disposable insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by law may be covered. If you have any questions, contact your plan administrator before incurring the expense. The plan will also pay for preventative immunization vaccines and toxoids. Unless medical evidence is provided to the plan administrator that indicates why a drug is not to be substituted, the covered expense may be limited to the cost of the lowest priced interchangeable drug. For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan.  Rental or, at the plan's discretion, purchase of certain medical supplies (including but not limited to crutches, trusses, casts, braces, and oxygen), appliances and prosthetic devices prescribed by a physician  Custom-made foot orthotics and custom-fitted orthopedic shoes, including modifications to orthopedic footwear, when prescribed by a physician  Hearing aids, including batteries, tubing and ear molds provided at the time of purchase, when prescribed by a physician  Diabetic supplies prescribed by a physician: Novolin-pens or similar insulin injection devices using a needle, blood-letting devices including platforms but not lancets. Lancets are covered under prescription drugs  Blood-glucose monitoring machines prescribed by a physician  Diagnostic x-rays and lab tests, when coverage is not available under your provincial government  Treatment of injury to sound natural teeth. Treatment must start within 60 days after the accident unless delayed by a medical condition A sound tooth is any tooth that did not require restorative treatment immediately before the accident. A natural tooth is any tooth that has not been artificially replaced No benefits are paid for: accidental damage to dentures dental treatment completed more than 12 months after the accident orthodontic diagnostic services or treatment  Out-of-hospital services of a qualified acupuncturist  Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed  Out-of-hospital treatment of nutritional disorders by a registered dietician  Out-of-hospital services of a qualified massage therapist  Out-of-hospital services of a licensed naturopath  Out-of-hospital services of a licensed osteopath, including diagnostic x-rays  Out-of-hospital treatment of movement disorders by a licensed physiotherapist  Out-of-hospital treatment of foot disorders, including diagnostic x-rays, by a licensed podiatrist  Out-of-hospital treatment by a registered psychologist or qualified social worker  Out-of-hospital treatment of speech impairments by a qualified speech therapist
Visioncare
 Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist, and coverage is not available under your provincial government plan  Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician  Laser eye surgery required to correct vision when performed by a licensed ophthalmologist For information on available discounts on eyewear and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit.
Global Medical Assistance Program
This program provides medical assistance through a worldwide communications network which operates
24 hours a day. The network locates medical services and obtains Great-West Life's approval of covered
services, when required as a result of a medical emergency arising while you or your dependent is
travelling for vacation, business or education. Coverage for travel within Canada is limited to emergencies
arising more than 500 kilometres from home. You must be covered by the government health plan in your
home province to be eligible for global medical assistance benefits. The following services are covered,
subject to Great-West Life's prior approval:
 On-site hospital payment when required for admission, to a maximum of $1,000  If suitable local care is not available, medical evacuation to the nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation will be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment When services are covered under this provision, they are not covered under other provisions described in this booklet  Transportation and lodging for one family member joining a patient hospitalized for more than 7 days while travelling alone. Benefits will be paid for moderate quality lodgings up to $1,500 and for a round trip economy class ticket  If you or a dependent is hospitalized while travelling with a companion, extra costs for moderate quality lodgings for the companion when the return trip is delayed due to your or your dependent's medical condition, to a maximum of $1,500  The cost of comparable return transportation home for you or a dependent and one travelling companion if prearranged, prepaid return transportation is missed because you or your dependent is hospitalized. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation  In case of death, preparation and transportation of the deceased home  Return transportation home for minor children travelling with you or a dependent who are left unaccompanied because of your or your dependent's hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary  Costs of returning your or your dependent's vehicle home or to the nearest rental agency when illness or injury prevents you or your dependent from driving, to a maximum of $1,000. Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home Benefits payable for moderate quality accommodation include telephone expenses as well as taxicab and car rental charges. Meal expenses are not covered.
Out-Of-Country Emergency Care
The plan covers medical expenses incurred as a result of a medical emergency arising while you or your
dependent is outside Canada for vacation, business or education purposes. To qualify for benefits, you
must be covered by the government health plan in your home province.
A medical emergency is a sudden, unexpected injury or an acute episode of disease.
 The following services and supplies are covered when related to the initial medical treatment: treatment by a physician diagnostic x-ray and laboratory services hospital accommodation in a standard or semi-private ward or intensive care unit, if the confinement begins while you or your dependent is covered medical supplies provided during a covered hospital confinement paramedical services provided during a covered hospital confinement hospital out-patient services and supplies medical supplies provided out-of-hospital if they would have been covered in Canada out-of-hospital services of a professional nurse ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available dental accident treatment if it would have been covered in Canada If your medical condition permits you to return to Canada, benefits will be limited to the amount payable under this plan for continued treatment outside Canada or the amount payable under this plan for comparable treatment in Canada, plus return transportation, whichever is less.
Other Services and Supplies
Services or supplies that represent reasonable treatment but are not otherwise covered under this plan may be covered by the plan on such terms as the plan administrator determines.
Limitations
A claim for a service or supply that was purchased from a provider that is not approved by the plan
administrator may be declined.
The covered expense for a service or supply may be limited to that of a lower cost alternative service or
supply that represents reasonable treatment.
Except to the extent otherwise required by law, no benefits are paid for:
 Expenses private benefit plans are not permitted to cover by law  Services or supplies for which a charge is made only because you have coverage  The portion of the expense for services or supplies that is payable by the government health plan in your home province, whether or not you are actually covered under the government health plan  Any portion of services or supplies which you are entitled to receive, or for which you are entitled to a benefit or reimbursement, by law or under a plan that is legislated, funded, or administered in whole or in part by a government ("government plan"), without regard to whether coverage would have otherwise been available under this plan In this limitation, government plan does not include a group plan for government employees  Services or supplies that do not represent reasonable treatment  Services or supplies associated with: treatment performed only for cosmetic purposes recreation or sports rather than with other daily living activities the diagnosis or treatment of infertility contraception, other than contraceptive drugs and products containing a contraceptive drug  Services or supplies associated with a covered service or supply, unless specifically listed as a covered service or supply or determined by Great-West Life to be a covered service or supply  Extra medical supplies that are spares or alternates  Services or supplies received outside Canada except as listed under Out-of-Country Emergency Care and Global Medical Assistance  Services or supplies received out-of-province in Canada unless you are covered by the government health plan in your home province and Great-West Life would have paid benefits for the same services or supplies if they had been received in your home province This limitation does not apply to Global Medical Assistance  Expenses arising from war, insurrection, or voluntary participation in a riot  Chronic care  Visioncare services and supplies required by an employer as a condition of employment In addition under the prescription drug coverage, no benefits are paid for:  Atomizers, appliances, prosthetic devices, colostomy supplies, first aid supplies, diagnostic supplies or testing equipment  Non-disposable insulin delivery devices or spring loaded devices used to hold blood letting devices  Delivery or extension devices for inhaled medications  Oral vitamins, minerals, dietary supplements, homeopathic preparations, infant formulas or injectable total parenteral nutrition solutions  Diaphragms, condoms, contraceptive jellies, foams, sponges, suppositories, contraceptive implants  Any drug that does not have a drug identification number as defined by the Food and Drugs Act,  Any single purchase of drugs which would not reasonably be used within 34 days. In the case of certain maintenance drugs, a 100-day supply will be covered  Drugs administered during treatment in an emergency room of a hospital, or as an in-patient in a  Non-injectable allergy extracts  Drugs that are considered cosmetic, such as topical minoxidil or sunscreens, whether or not prescribed for a medical reason  Anti-obesity drugs  Fertility drugs, whether or not prescribed for a medical reason  Drugs used to treat erectile dysfunction  Drugs or drug supplies not listed in the Liste de médicaments published by the Régie de l'assurance- maladie du Québec in effect on the date of purchase or which are received out-of-province, when prescribed for a dependent child who is a student over age 24 and you are a resident of Quebec
Note: If you are age 65 or older and reside in Quebec, you cease to be covered under this plan for basic
prescription drug coverage and are covered under the basic plan provided by the Régie de l'assurance-
maladie du Québec, unless you elect to be covered under this plan as set out below.
A one-time election may be made to be covered under this plan. You must make this election and
communicate it to your employer by the end of the 60-day period immediately following:
 the date you reach age 65; or
 the date you become a resident of Quebec, within the meaning of the Health Insurance Act, Quebec,
if you are age 65 or over. While your election to be covered under this plan is in effect, you will be deemed not to be entitled to the basic plan provided by the Régie de l'assurance-maladie du Québec. "Basic prescription drug coverage" means the portion of drug expenses that is reimbursed by the de l'assurance-maladie du Québec.
Prior Authorization
In order to determine whether coverage is provided for certain services or supplies, the plan administrator
maintains a limited list of services and supplies that require prior authorization.
These services and supplies, including a listing of the prior authorization drugs, can be found on the
Great-West Life website as follows:

Prior authorization is intended to help ensure that a service or supply represents a reasonable treatment.
If the use of a lower cost alternative service or supply represents reasonable treatment, you or your
dependent may be required to provide medical evidence to the plan administrator why the lower cost
alternative service or supply cannot be used before coverage may be provided for the service or supply.

Health Case Management
If you or one of your dependents apply for prior authorization of certain supplies or services, the plan
administrator may contact you to participate in health case management. Health case management is a
program recommended or approved by the plan administrator that may include but is not limited to:
 consultation with you or your dependent and the attending physician to gain understanding of the treatment plan recommended by the attending physician;  comparison, with the attending physician, of the recommended treatment plan with alternatives, if any, that represent reasonable treatment;  identification to the attending physician of opportunities for education and support; and  monitoring your or your dependent's adherence to the treatment plan recommended by the person's attending physician.
In determining whether to implement health case management, the plan administrator may assess such
factors as the service or supply, the medical condition, and the existence of generally accepted medical
guidelines for objectively measuring medical effectiveness of the treatment plan recommended by the
attending physician.
Health Case Management Limitation
The payment of benefits for a service or supply may be limited, on such terms as the plan administrator
determines, where:
 the plan administrator has implemented health case management and you or your dependent do not
participate or cooperate; or  you or your dependent have not adhered to the treatment plan recommended by his attending physician with respect to the use of the service or supply.
Designated Provider Limitation
For a service or supply to which prior authorization applies or where the plan administrator has
recommended or approved health case management, the plan administrator can require that a service or
supply be purchased from or administered by a provider designated by the plan administrator, and:
 the covered expense for a service or supply that was not purchased from or administered by a provider designated by the plan administrator may be limited to the cost of the service or supply had it been purchased from or administered by the provider designated by the plan administrator; or  a claim for a service or supply that was not purchased from or administered by a provider designated by the plan administrator may be declined.
Patient Assistance Program
A patient assistance program may provide financial, educational or other assistance to you or your
dependents with respect to certain services or supplies.
If you or your dependents are eligible for a patient assistance program, you or your dependent may be
required to apply to and participate in such a program. Where financial assistance is available from a
patient assistance program the plan administrator requires participation in, the covered expense for a
service or supply may be reduced by the amount of financial assistance you or your dependent is entitled
to receive for that service or supply.

How to Make a Claim
 Out-of-country claims (other than those for Global Medical Assistance expenses) should be
submitted to Great-West Life as soon as possible after the expense is incurred. It is very important that you send your claims to the Great-West Life Out-of-Country Claims Department immediately as your Provincial or Territorial Medical Plan has very strict time limitations. Access GroupNet for Plan Members to obtain a personalized claim form or obtain form M5432 (Statement of Claim Out-of-Country Expenses form) from your employer. You must also obtain the Government Assignment form, and residents of British Columbia, Quebec and Newfoundland & Labrador must also obtain the Special Government Claim form. The Great-West Life Out-of-Country Claims Department will forward the appropriate government forms to your attention when required. You should complete all applicable forms, making sure all required information is included. Attach all original receipts and forward the claim to the Great-West Life Out-of-Country Claims Department. Be sure to keep a copy for your own records. The plan will pay all eligible claims including your Provincial or Territorial Medical Plan portion. Your Provincial or Territorial Medical Plan will then reimburse the plan for the government's share of the expenses. Out-of-country claims must be submitted within a certain time period that varies by province or territory. For the claims submission period applicable in your province or territory or for any other questions or for assistance in completing any of the forms, please contact Great-West Life's Out-of-Country Claims Department at 1-800-957-9777.
 Claims for expenses incurred in Canada, for paramedical services and visioncare, may be
submitted online. To use this online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online. Online claims must be submitted to Great-West Life as soon as possible, but no later than 6 months after you incur the expense. You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.  For all other Healthcare claims, access GroupNet for Plan Members to obtain a personalized claim
form or obtain form M635D from your employer. Complete this form making sure it shows all required information. Attach your receipts to the claim form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 15 months after you incur the expense.  For drug claims, your employer will provide you with a prescription drug identification card. Present
your card to the pharmacist with your prescription. Before your prescription is filled, an Assure Claims check will be done. Assure Claims is a series of seven checks that are electronically done on your drug claim history for increased safety and compliance monitoring. This has been designed to improve the health and quality of life for you and your dependents. Checks done include drug interaction, therapeutic duplication and duration of therapy, allowing the pharmacist to react prior to the drug being dispensed. Depending on the outcome of the checks, the pharmacist may refuse to dispense the prescribed drug. When your coverage ends, return your direct pay drug identification card to your employer. PREFERRED VISION SERVICES (PVS)

Preferred Vision Services (PVS) is a service provided by Great-West Life to its customers through
PVS which is a preferred provider network company.

PVS entitles you to a discount on a wide selection of quality eyewear and lens extras (scratch guarding,
tints, etc.) when you purchase these items from a PVS network optician or optometrist. A discount on
laser eye surgery can be obtained through an organization that is part of the PVS network.
PVS also entitles you to a discount on hearing aids (batteries, tubing, ear molds, etc.) when you purchase
these items from a PVS network provider.
You are eligible to receive the PVS discount through the network whether or not you are enrolled for the
healthcare coverage described in this booklet. You can use the PVS network as often as you wish for
yourself and your dependents.
Using PVS:
 Call the PVS Information Hotline at 1-800-668-6444 or visit the PVS Web site at www.pvs.ca for
information about PVS locations and the program  Arrange for a fitting, an eye examination, a hearing assessment or a hearing test, if needed  Present your group benefit plan identification card, to identify your preferred status as a PVS member through Great-West Life, at the time the eyewear or the hearing aid is purchased, or at the initial consultation for laser eye surgery  Pay the reduced PVS price. If you have vision care coverage or hearing aids coverage for the product or service, obtain a receipt and submit it with a claim form to your insurance carrier in the usual manner. DENTALCARE

A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level
shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check
the Benefit Summary for this information.
The plan covers customary charges to the extent they do not exceed the dental fee guide level shown in
the Benefit Summary. Denturist fee guides are applicable when services are provided by a denturist.
Dental hygienist fee guides are applicable when services are provided by a dental hygienist practising
independently.
All covered services and supplies must represent reasonable treatment. Treatment is considered
reasonable if it is recognized by the Canadian Dental Association, it is proven to be effective, and it is of a
form, frequency, and duration essential to the management of the person's dental health. To be
considered reasonable, treatment must also be performed by a dentist or under a dentist's supervision,
performed by a dental hygienist entitled by law to practise independently, or performed by a denturist.
You are covered for only the Dentalcare benefits that apply to the option that you choose as shown in the
Benefit Summary.
Your dentalcare coverage terminates when you retire.
Treatment Plan
 Before incurring any large dental expenses, or beginning any orthodontic treatment, ask your dental service provider to complete a treatment plan and submit it to the plan. The benefits payable for the proposed treatment will be calculated, so you will know in advance the approximate portion of the cost you will have to pay.
Basic Coverage
The following expenses will be covered:
 Diagnostic services including: one complete oral examination every 36 months limited oral examinations twice every 12 months, except that only one limited oral examination is covered in any 12-month period that a complete oral examination is also performed limited periodontal examinations twice every 12 months complete series of x-rays every 36 months intra-oral x-rays to a maximum of 15 films every 36 months and a panoramic x-ray every 36 months. Services provided in the same 12 months as a complete series are not covered  Preventive services including: polishing and topical application of fluoride each twice every 12 months scaling, limited to a maximum combined with periodontal root planing of 16 time units every 12 months A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval pit and fissure sealants on bicuspids and permanent molars for dependent children under age 19 only space maintainers including appliances for the control of harmful habits finishing restorations interproximal disking recontouring of teeth  Minor restorative services including: caries, trauma, and pain control amalgam and tooth-coloured fillings. Replacement fillings are covered only if the existing filling is at least 2 years old or the existing filling was not covered under this plan retentive pins and prefabricated posts for fillings prefabricated crowns for primary teeth  Endodontics. Root canal therapy for permanent teeth will be limited to one course of treatment per tooth. Repeat treatment is covered only if the original treatment fails after the first 18 months  Periodontal services including: root planing, limited to a maximum combined with preventive scaling of 16 time units every 12 months occlusal adjustment and equilibration, limited to a combined maximum of 4 time units every 12 months A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval  Denture maintenance, including: denture relines for dentures at least 6 months old, once every 36 months denture rebases for dentures at least 2 years old, once every 36 months resilient liner in relined or rebased dentures after the 3-month post-insertion care period has elapsed, once every 36 months  Oral surgery  Adjunctive services
Major Coverage
 Crowns. Coverage for complicated crowns is limited to the cost of standard crowns Replacement crowns and onlays are covered when the existing restoration is at least 5 years old and cannot be made serviceable  Dentures and bridgework, including overdentures and implant-retained appliances when required to replace one or more teeth extracted while the person was covered for major coverage. Replacement appliances are also covered when: the existing appliance is a covered temporary appliance the existing appliance is at least 5 years old and cannot be made serviceable. If the existing appliance is less than 5 years old, a replacement will still be covered if the existing appliance becomes unserviceable while the person is covered and as a result of the placement of an initial opposing appliance or the extraction of additional teeth. If additional teeth are extracted but the existing appliance can be made serviceable, coverage is limited to the replacement of the additional teeth  Denture-related surgical services for remodelling and recontouring oral tissues  Denture and bridgework maintenance following the 3-month post-insertion period including: denture remakes, once every 36 months denture adjustments, once every 12 months denture repairs and additions, tissue conditioning and resetting of denture teeth bridgework repairs removal and recementation of bridgework removal and reinsertion of implant-retained appliances for repair
Orthodontic Coverage
 Orthodontics are covered for children age 6 to 18 when treatment starts
Limitations
No benefits are paid for:
 Duplicate x-rays, custom fluoride appliances, any oral hygiene instruction and nutritional counselling
 The following endodontic services - root canal therapy for primary teeth, isolation of teeth,
enlargement of pulp chambers and endosseous intra coronal implants  The following periodontal services - desensitization, topical application of antimicrobial agents, subgingival periodontal irrigation, charges for post surgical treatment and periodontal re-evaluations  The following oral surgery services - surgical movement of teeth, services performed to remodel or recontour oral tissues (other than minor alveoloplasty, gingivoplasty and stomatoplasty) and alveoloplasty or gingivoplasty performed in conjunction with extractions. Services for implantology, remodelling and recontouring oral tissues will be covered under Major Coverage  Hypnosis or acupuncture  Veneers, recontouring existing crowns, and staining porcelain  Crowns or onlays if the tooth could have been restored using other procedures. If crowns, onlays or inlays are provided, benefits will be based on coverage for fillings  Expenses covered under another group plan's extension of benefits provision  Services or supplies covered under Healthcare. If the amount payable would be greater under this Dentalcare benefit, then benefits will be paid under Dentalcare and not Healthcare  Expenses private benefit plans are not permitted to cover by law  Services and supplies you are entitled to without charge by law or for which a charge is made only because you have coverage  Services or supplies that do not represent reasonable treatment  Treatment performed for cosmetic purposes only  Congenital defects or developmental malformations in people 19 years of age or over  Temporomandibular joint disorders, vertical dimension correction or myofacial pain  Expenses arising from war, insurrection, or voluntary participation in a riot
How to Make a Claim
 Claims for expenses incurred in Canada may be submitted online. Access GroupNet for Plan
Members to obtain a personalized claim form or obtain form M445D from your employer and have your dental service provider complete the form. The completed claim form will contain the information necessary to enter the claim online. To use the online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online. Online claims must be submitted to Great-West Life as soon as possible, but no later than 6 months after the dental treatment. You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.
 For all other Dentalcare claims, access GroupNet for Plan Members to obtain a personalized claim
form or obtain form M445D from your employer. Have your dental service provider complete the form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 15 months after the dental treatment. HEALTH CARE SPENDING ACCOUNT BENEFITS (HCSA)

A Health Care Spending Account (HCSA) is like a bank account through which you may be reimbursed
for health and dental expenses up to a predetermined annual credit amount. Credits are established each
year at annual enrollment subject to available flex credits. These credits may be used to cover expenses
not covered by group health plans or to top-up expenses not fully covered by group health plans,
including deductibles and co-payment amounts. Also, since annual credits are in the form of before tax
dollars, the HCSA is a tax-effective way of paying for your health-related expenses.
Eligibility

You and your dependents are eligible for HCSA credits through your employer if you are covered for
basic health benefits under your or your spouse's group health plan. In addition to the dependents eligible
for coverage under your basic health plan, HCSA benefits are extended to any other person for whom
you are entitled to claim a medical expense tax credit under the Income Tax Act (Canada).
You may apply for HCSA benefits in conjunction with your application for group benefits within 31 days of
the date you first become eligible or at your plan's annual enrolment date. Eligibility for HCSA benefits are
subject to the availability of flex credits.
Termination

Your HCSA coverage terminates when your basic health coverage terminates, when you elect to
discontinue coverage (at any plan enrolment date) or when your employer discontinues the plan.
Your dependents' HCSA coverage terminates when your coverage terminates or when they no longer
qualify, whichever is earlier.
Covered Expenses

The Income Tax Act (Canada) governs the types of expenses that can be reimbursed under the HCSA.
Coverage is provided for those expenses that qualify for a medical expense tax credit. For a complete list
of covered expenses, contact your Canada Revenue Agency District Office and ask for Income Tax
Interpretation Bulletin IT-519R.
Benefits will be paid for 100% of covered expenses that are incurred while you and your dependents are
covered, up to a maximum annual payment equal to the credits in your HCSA. Dental expenses, other
than orthodontic expenses, are considered to be incurred when treatment is completed. Orthodontic
expenses are considered to be incurred on a periodic basis throughout the course of treatment. All other
expenses are considered to be incurred when they are received.
Credits are available for covered expenses incurred in a plan year. Any remaining credits will be carried
forward for covered expenses incurred in the following plan year. If they are not used for expenses
incurred in that plan year, they are automatically forfeited.
The maximum annual payment available under your account will consist of the amount of the credit
directed to it for the plan year plus any unused amount from the previous year.

Limitations

No benefits are paid for:
 Expenses that private benefit plans are not permitted to cover by law
 Services or supplies you are entitled to without charge by law or for which a charge is made only
because you have coverage under a private benefit plan  Any portion of the expense for services or supplies for which benefits are payable under your basic health plan, another group plan or a government plan
How to Make a Claim

The HCSA will reimburse you for the balance of the expense remaining after all other insurance plans
have paid out. You must first submit all claims to any government and private insurance plans under
which you or any eligible dependents are covered. Once you have received reimbursement for the
expense from all other plans, you may submit a claim against the HCSA.
Claims against the HCSA may be submitted on a claim form. Claims for paramedical services, visioncare
and dentalcare expenses incurred in Canada may also be submitted online.
 To submit claims using a claim form, use form M5429A or form M445D (HCSA) for dental claims, and
form M5431A or form M635D (HCSA) for all other claims  To submit claims online, you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request. Claims against the HCSA must be submitted to the Great-West Life Benefit Payment Office before the earliest of the following:  90 days after the end of the plan year in which the expenses are incurred  the date the HCSA contract terminates, if it terminates because your employer fails to make a required payment  31 days after the date the HCSA contract terminates, if it terminates for any other reason WELLNESS SPENDING ACCOUNT BENEFITS (WSA)

A Wellness Spending Account Benefits (WSA) is like a bank account through which you may be
reimbursed for programs that will help improve your wellness up to a predetermined annual credit
amount. Credits are established each year at annual enrollment subject to available flex credits. These
credits may be used to cover expenses as determined by Schlumberger.

Eligibility

You and your dependents are eligible for WSA credits through your employer if you are covered for basic
health benefits under your or your spouse's group health plan. In addition to the dependents eligible for
coverage under your basic health plan, WSA benefits are extended to any other person for whom you are
entitled to claim a medical expense tax credit under the Income Tax Act (Canada).
You may apply for WSA benefits in conjunction with your application for group benefits within 31 days of
the date you first become eligible or at your plan's annual enrolment date. Eligibility for WSA benefits are
subject to the availability of flex credits.
Termination

Your WSA coverage terminates when your basic health coverage terminates, when you elect to
discontinue coverage (at any plan enrolment date) or when your employer discontinues the plan.
Your dependents' WSA coverage terminates when your coverage terminates or when they no longer
qualify, whichever is earlier.

Covered Expenses

Covered expenses include:
1. Cholesterol and hypertension screening
2. Health assessments/screening
3. Allergy tests
4. Maternity services (e.g., prenatal classes)
5. Health education programs, such as programs to help quit smoking, reduce weight (excluding cost of
food/videotapes), or manage stress 6. Nutritional programs or counselling 7. Healthy cooking classes 8. Health education products (e.g., smoking cessation products) 9. Vitamins and supplements (including herbal) 10. Orthopaedic beds and orthopaedic pillows 11. Services of alternative health practitioners (e.g., reflexologist, herbalist, homeopath, athletic therapist, exercise physiologist, Chinese medical practitioner, shiatsu therapist, osteopathic practitioner, acupressurist and occupational therapist) 12. Exercise equipment (excluding clothing and footwear) 13. Employee paid Long Term Disability premiums 14. Registration fees for sports leagues 15. Fitness classes 16. Gym Memberships 17. Comprehensive medical examinations 18. Naturopathic medicines 19. Financial services including estate planning, tax return preparation and will preparation provided by a suitable qualified professional/professional services firm Benefits will be paid for 100% of covered expenses that are incurred while you and your dependents are covered, up to a maximum annual payment equal to the credits in your WSA. All expenses are considered to be incurred when they are received.
Credits are available for covered expenses incurred in a plan year. Any remaining credits will be carried
forward for covered expenses incurred in the following plan year. If they are not used for expenses
incurred in that plan year, they are automatically forfeited.
The maximum annual payment available under your account will consist of the amount of the credit
directed to it for the plan year plus any unused amount from the previous year.
Limitations

No benefits are paid for:
 Expenses that private benefit plans are not permitted to cover by law
 Services or supplies you are entitled to without charge by law or for which a charge is made only
because you have coverage under a private benefit plan  Any portion of the expense for services or supplies for which benefits are payable under your basic health plan, another group plan or a government plan
How to Make a Claim

The WSA will reimburse you for the balance of the expense remaining after all other insurance plans
have paid out. You must first submit all claims to any government and private insurance plans under
which you or any eligible dependents are covered. Once you have received reimbursement for the
expense from all other plans, you may submit a claim against the WSA.
Claims against the WSA may be submitted on a claim form. Claims for paramedical services, visioncare
and dentalcare expenses incurred in Canada may also be submitted online at www.greatwestlife.com.
 To submit claims using a claim form, use form M5431A or form M635D (HCSA).
 To submit claims online, you will need to be registered for GroupNet for Plan Members and signed up
for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online Please note that receipts must be in the employee's name for tax purposes. You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request. Claims against the WSA must be submitted to the Great-West Life Benefit Payment Office before the earliest of the following:  90 days after the end of the plan year in which the expenses are incurred  the date the WSA contract terminates, if it terminates because your employer fails to make a required  31 days after the date the WSA contract terminates, if it terminates for any other reason COORDINATION OF BENEFITS
 Benefits for you or a dependent will be directly reduced by any amount payable under a government plan. If you or a dependent are entitled to benefits for the same expenses under another group plan or as both an employee and dependent under this plan or as a dependent of both parents under this plan, benefits will be co-ordinated so that the total benefits from all plans will not exceed expenses.  You and your spouse should first submit your own claims through your own group plan. Claims for dependent 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 You may submit a claim to the plan of the other spouse for any amount which is not paid by the first plan.

Source: http://www.slb-benefits.ca/_assets/Canada%20Extended%20Health%20and%20Wellness%20Benefits%202016.pdf