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Exclusions

Limitations and Exclusions to Extended Health Benefits
Eligible benefits do not include and reimbursement will not be made for:
1) Services or supplies received as a result of disease, illness or injury due to:
(a) intentionally self-inflicted injury while sane or insane;
(b) an act of war, declared or undeclared;
(c) participation in a riot or civil commotion; or
(d) committing a criminal offence;
2) Services or supplies provided while serving in the armed forces of any country;
3) Failure to keep a scheduled appointment with a legally qualified medical or dental practitioner;
4) The completion of any claim forms and/or insurance reports;
5) Any specific treatment or drug which:
(a) does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature, or is not considered to be effective (either medically or from a cost perspective, based on Health Canada's approved indication for use);
(b) is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
(c) will be administered in a hospital;
(d) is not dispensed by the pharmacist in accordance with the payment method shown under the Prescription Drugs Benefit; or
(e) is not being used and/or administered in accordance with Health Canada's approved indication for use, even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries; or
6) Services or supplies that:
(a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of the insurer) medical practitioner or dental practitioner as permitted by law;
(b) are legally prohibited by the government from coverage;
(c) you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than the insurer, your plan sponsor or you;
(d) are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
(e) are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
(f) are used solely for recreational or sporting activities and which are not medically necessary for regular activities;
(g) are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
(h) are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
(i) are provided by your plan sponsor and/or a practitioner employed by your plan sponsor, other than as part of an employee assistance plan;
(j) are a replacement of lost, missing or stolen items, or items that are damaged due to negligence (replacements are eligible when required due to natural wear, growth or relevant change in your medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a lesser cost and the item is still medically required);
(k) are video instructional kits, informational manuals or pamphlets;
(l) are for medical or surgical audio and visual treatment;
(m) are special or unusual procedures such as, but not limited to, orthoptics, vision training, subnormal vision aids and aniseikonic lenses;
(n) are delivery and transportation charges;
(o) are for Insulin pumps and supplies (unless otherwise covered under the plan);
(p) are for medical examinations, audiometric examinations or hearing aid evaluation tests;
(q) are batteries, unless specifically included as an eligible benefit;
(r) are a duplicate prosthetic device or appliance;
(s) are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
(t) would normally be paid through any provincial health insurance plan, Workplace Safety and Insurance Board or tribunal, the Assistive Devices Program or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
(u) were previously provided or paid for by any governmental body or agency, but which have been modified, suspended or discontinued as a result of changes in provincial health plan legislation or de-listing of any provincial health plan services or supplies;
(v) may include but are not limited to, drugs, laboratory services, diagnostic testing or any other service which is provided by and/or administered in any public or private health care clinic or like facility, medical practitioner's office or residence, where the treatment or drug does not meet the accepted standards or is not considered to be effective (either medically or from a cost perspective, based on Health Canada's approved indication for use);
(w) are provided by a medical practitioner who has opted out of any provincial health insurance plan and the provincial health insurance plan would have otherwise paid for such eligible service;
(x) relate to treatment of injuries arising out of a motor vehicle accident (Ontario);
Note: Payment of benefits for claims relating to automobile accidents for which coverage is available under a motor vehicle liability policy providing no-fault benefits will be considered only if:
i) the service or supplies being claimed is not eligible; or
ii) the financial commitment is complete (a letter from your automobile insurance carrier will be required); or
(y) are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.

Limitations and Exclusions to Dental Benefits
Eligible benefits do not include and reimbursement will not be made for:
1) Services or supplies received as a result of disease, illness or Injury due to:
(a) intentionally self-inflicted Injury while sane or insane;
(b) an act of war, declared or undeclared;
(c) participation in a riot or civil commotion; or
(d) committing a criminal offence;
2) Services or supplies provided while serving in the armed forces of any country;
3) Failure to keep a scheduled appointment with a legally qualified dental practitioner;
4) The completion of any claim forms and/or insurance reports;
5) Any dental service that is not contained in the procedure codes developed and maintained by the Canadian Dental Association, adopted by the provincial or territorial dental association of the province or territory in which the service is provided (or your province of residence if any dental service is provided outside Canada) and in effect at the time the service is provided;
6) Implants and related services;
7) Restorations necessary for wear, acid erosion, vertical dimension and/or restoring occlusion; 
8) Appliances related to treatment of myofacial pain syndrome including all diagnostic models, 
gnathological determinants, maintenance, adjustments, repairs and relines;
9) Posterior cantilever pontics/teeth and extra pontics/teeth to fill in diastemas/spaces;
10) Service and charges for sleep dentistry;
11) Diagnostic and/or intraoral repositioning appliances including maintenance, adjustments, repairs and relines related to treatment of temporomandibular joint dysfunction;
12) Any specific treatment or drug which:
(a) does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature, or is not considered to be effective (either medically or from a cost perspective, based on Health Canada's approved indication for use);
(b) is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
(c) will be administered in a hospital;
(d) is not dispensed by the pharmacist in accordance with the payment method shown under the Health Benefit Plan Prescription Drugs; or
(e) is not being used and/or administered in accordance with Health Canada's approved indication for use, even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries; or
13) Services or supplies that:
(a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of Green Shield) medical practitioner or dental practitioner as permitted by law;
(b) are legally prohibited by the government from coverage;
(c) you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage; or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than Green Shield, your plan sponsor or you;
(d) are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
(e) are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
(f) are used solely for recreational or sporting activities and which are not medically necessary for regular activities;
(g) are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
(h) are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
(i) are provided by your plan sponsor and/or a practitioner employed by your plan sponsor, other than as part of an employee assistance plan;
(j) are a replacement of lost, missing or stolen items, or items that are damaged due to negligence (replacements are eligible when required due to natural wear, growth or relevant change in your medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a lesser cost and the item is still medically required);
(k) are video instructional kits, informational manuals or pamphlets;
(l) are delivery and transportation charges;
(m) are a duplicate prosthetic device or appliance;
(n) are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
(o) would normally be paid through any provincial health insurance plan, Workplace Safety and Insurance Board or tribunal, or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
(p) relate to treatment of injuries arising out of a motor vehicle accident (Ontario);
Note: Payment of benefits for claims relating to automobile accidents for which coverage is available under a motor vehicle liability policy providing no-fault benefits will be considered only if:
i) the service or supplies being claimed is not eligible; or
ii) the financial commitment is complete (a letter from your automobile insurance carrier will be required); or
(q) are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.

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