Dental Plan

Subject: Pensioners' Dental Services Plan - RULES

Date: Thu, 7 Sep 2000 07:24:29 -0400

Treasury Board Rules for the Dental Plan Pensioners' Dental Services Plan - RULES

August 2000

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RULE 1. Definitions

1(1) In these rules, unless the context requires otherwise, "Accidental Dental Injury" (lÚsion dentaire accidentelle) means an unexpected and unforeseen injury to the dental and contiguous structures of natural teeth which is a result of an event that occurs by chance, but excludes an injury associated with such normal acts as cleaning, chewing and eating;

"Administrator" (administrateur) means the organization or organizations

selected to execute certain administrative functions required for the

operation of the Plan;

"Category of Coverage" (catÚgorie de protection) means one of the Categories

of Coverage set out in Rule 3(2).

"Child" (enfant) means the person who is an unmarried Child of a Member or

of the Member's Spouse or of the Member Common Law Partner, including an

adopted Child, a step-Child and a foster Child in respect of whom the Member

stands in loco parentis, provided such person is

(a) under 21 years of age; or

(b) under 25 years of age and enrolled in an accredited school, college

or university on a full-time basis; or

self-sustaining employment by reason of mental or physical impairment, and

is primarily dependant upon the Eligible Pensioner for support and

maintenance, and provided that the Child

(i) is a person to whom the above description applies on the

date the Eligible Pensioner becomes eligible for coverage, or

(ii) was covered as a dependant under this Plan immediately

prior to his or her 21st birthday, or

(iii) was covered under this Plan as a dependant while enrolled

full-time at school, college or university between the ages of 21

and 25.

"Children's Coverage" (protection des enfants) means coverage for eligible

Children;

"Common Law Partner" (conjoint de fait) means the person designated by the

Member for the purposes of Rule 4 with whom the Member is cohabiting in a

conjugal relationship, having so cohabited for a continuous period of at

least one (1) year;

"Coverage as a Common Law Partner" (protection du conjoint de fait) means

coverage as the Common Law Partner of a Member;

"Dental Hygienist" (hygiÚniste dentaire) means a person duly certified or

licensed to perform the service rendered and shall include a dental

assistant and any other similarly qualified person;

"Dental Mechanic" (mÚcanicien-dentiste) means a person

(a) who is duly qualified to perform the service rendered and shall

include a dental therapist, dentist, denturist, denturologist and any other

similarly qualified person, and

(b) who practices in a province, state or country in which he or she is

legally permitted to deal directly with the public;

"Dentist" or "Oral Surgeon" (dentiste ou chirurgien-dentiste) means a person

licensed to practice dentistry by the appropriate governmental licensing

authority, provided that such person renders a service within the scope of

his or her license;

"Effective Date of the Plan" or "Effective Date" (date d'entrÚe en vigueur

du rÚgime ou date d'effet) means January 1, 2001.

"Eligible Child" (enfant admissible) means a Child of the Member or of the

Member's Spouse or of the MemberÆs Common Law Partner but excludes any such

Child who is a Member of the Plan;

"Eligible Common Law Partner" (conjoint de fait admissible) means the Common

Law Partner of the Member but excludes any such common law partner who is a

Member of the Plan;

"Eligible Family Member" (membre de la famille admissible) means either the

Eligible Spouse or the Eligible Common Law Partner and/or the Eligible

child(ren);

"Eligible Pensioner" (pensionnÚ admissible) means a person who satisfies the

requirements of Rule 2;

"Eligible Spouse" (conjoint admissible) means the Spouse of the Member but

excludes any such Spouse who is a Member of the Plan;

"Member" (participant) means an Eligible Pensioner covered under the

PensionersÆ Dental Services Plan;

"Minister" (ministre) means the President of the Treasury Board;

"Necessary Dental Treatment" (traitement dentaire nÚcessaire) means a

treatment rendered for the prevention of dental disease or dental defect or

for the correction of dental disease, dental defect or accidental dental

injury, provided such treatment is consistent with generally accepted dental

practice;

"Plan" (rÚgime) means the PensionersÆ Dental Services Plan established by

the Treasury Board of Canada on February 24, 2000, as amended from time to

time;

"Prescribed Form" (forme prescrite) means any form prescribed for the

purposes of this Plan and approved by the Minister;

"Reasonable and Customary Charges" (frais raisonnables et habituels) means

charges for services and supplies with respect to a necessary dental

treatment, of the level usually furnished in the absence of insurance for

cases of the nature and severity of the case being treated and which are in

accordance with representative fees and prices in the area where the

treatment is rendered;

"Rules" (rÞglement) means the rules of the PensionersÆ Dental Services Plan

with any amendments to them in force from time to time;

"Spousal Coverage" (protection du conjoint) means coverage as a Spouse of a

Member;

"Spouse" (conjoint) means the person designated by the Member for the

purposes of Rule 4, who is legally married to the Member;

"Time Unit" (unitÚ de temps) with respect to a dental treatment means a

fifteen (15) minute interval or any portion of a fifteen (15) minute

interval;

"Treatment Plan" (plan de traitement) means a written report, in a form

supplied or approved by the Administrator, prepared by the attending

practitioner as the result of the examination of the patient and providing

the following:

(a) the recommended necessary dental treatment for the correction of any

dental disease, defect or accidental dental injur,

(b) the period during which such recommended treatment is to be rendered,

and

appliance;

"VeteransÆ Coverage" (protection des anciens combattants) means continuing

dental care treatment provided to veterans of military service through the

Department of Veterans Affairs.

1(2) In these Rules, unless the context requires otherwise, where

reference is made to a clause without anything in the context that a clause

of some other Rule is intended to be referred to, the reference shall be

deemed to be a reference to a clause of the Rule in which the reference is

made.

RULE 2. Eligibility

2(1) Any person who

(a) on December 31, 2000, is in receipt of a pension, annuity or annual

allowance pursuant to any of the following:

(i) The Public Service Superannuation Act;

(ii) The Members of Parliament Retiring Allowances Act;

(iii) The Judges Act;

(iv) The Canadian Forces Superannuation Act;

(v) The Defence Services Pension Continuation Act;

(vi) The Royal Canadian Mounted Police Superannuation Act;

(vii) The Royal Canadian Mounted Police Pension Continuation Act;

(viii) The Governor GeneralÆs Act;

(ix) The Lieutenant Governors Superannuation Act;

(x) The Diplomatic Service (Special) Superannuation Act;

(xi) The Special Retirement Arrangements Act and

(xii) Any other Act of the Parliament of Canada providing for

the payment of a pension or annuity as designated by the Treasury

Board; or

(b) on or after January 1, 2001, commences receipt of a pension, annuity

or annual allowance pursuant to:

(i) The Public Service Superannuation Act as a result of

(A) retirement from a federal department or from an

agency or entity listed in Schedule 1;

(B) having been entitled to a deferred annuity on

December 31, 2000;

or,

(D) the death of a Member employed in or retired from

a federal department or agency or entity listed in

Schedule 1;

(ii) The Members of Parliament Retiring Allowances Act;

(iii) The Judges Act;

(iv) The Canadian Forces Superannuation Act;

(v) The Defence Services Pension Continuation Act;

(vi) The Royal Canadian Mounted Police Superannuation Act;

(vii) The Royal Canadian Mounted Police Pension Continuation

Act;

(viii) The Governor GeneralÆs Act;

(ix) The Lieutenant Governors Superannuation Act;

(x) The Diplomatic Service (Special) Superannuation Act;

(xi) The Special Retirement Arrangements Act; and

(xii) Any other Act of the Parliament of Canada providing for

the payment of a pension or annuity as designated by the Treasury

Board;

is eligible to apply for membership in the Plan.

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RULE 3. Membership

Application for Membership

3(1) An Eligible Pensioner

(a) described in Rule 2(1)(a) may apply for membership under the Plan by

completing the prescribed application form and sending it to the

Administrator within the 90 day period immediately preceding the Effective

Date;

(b) described in Rule 2(1)(b) may apply for membership under the Plan by

completing the prescribed application form and sending it to the

Administrator within 60 days of the effective date of the Eligible

PensionerÆs pension entitlement or within 60 days of confirmation of the

Eligible PensionerÆs pension entitlement by the appropriate pension

authority, whichever is later.

Category of Coverage

3(2) In making application for membership, the Eligible Pensioner will

select one of three Categories of Coverage:

I Eligible Pensioner only

II Eligible Pensioner and one Eligible Family Member

III Eligible Pensioner and more than one Eligible Family Member

Effective Date of Membership

3(3) If an Eligible Pensioner makes application for membership

(a) in accordance with Rule 3(1)(a), membership will be effective on the

Effective Date;

(b) in accordance with Rule 3(1)(b), membership will be effective on the

later of

(i) the effective date of the Eligible PensionerÆs pension

entitlement; and,

(ii) the date on which coverage as an Eligible Spouse or

Eligible Common Law Partner or Eligible Child ceased; or

first day of the second month following the date on which the Administrator

receives an application in the Prescribed Form.

Late Applications for Membership

3(4) An Eligible Pensioner who makes application for membership after the

period set out in Rule 3(1) can become a Member only if the Minister is

satisfied that the Eligible Pensioner was prevented from making application

within the prescribed period and authorizes membership from a specified

date.

Deferred Membership

3(5) Notwithstanding Rules 3(1) and 3(4), an Eligible Pensioner may defer

making application for membership if the Eligible Pensioner has coverage

under another dental plan or has VeteransÆ Coverage.

An Eligible Pensioner who wishes to defer application for membership must,

within the time period prescribed in Rule 3(1), so notify the Administrator

in writing in the Prescribed Form and provide proof of that other coverage

to the satisfaction of the Administrator.

The Eligible Pensioner may subsequently make application for membership

under the Plan by completing the prescribed application form and sending it

to the Administrator no later than 60 days following the termination of the

Eligible PensionerÆs coverage under the other dental plan or VeteransÆ

Coverage.

Termination of Membership

3(6) A MemberÆs coverage terminates on the earliest of:

(a) (i) the date of the MemberÆs death or

(ii) the first of the second month following the month in which

the Member ceases to be an Eligible Pensioner for reason other

than the MemberÆs death;

(b) the first of the second month following the date on which the

Administrator receives a termination notice in the Prescribed Form from the

Member; and

Plan for the Public Service of Canada as an "eligible employee" as defined

in that plan, becomes entitled to dental services as a member of the

Canadian Forces or the RCMP, or receives VeteransÆ Coverage and the Member

provides proof of that other coverage to the satisfaction of the

Administrator.

Re-instatement of Membership

3(7) A Member whose membership has terminated in accordance with

Rule 3(6)(c) may apply to re-instate membership under the PensionersÆ Dental

Services Plan within 60 days of the date on which the conditions described

in Rule 3(6)(c) no longer apply and the Eligible PensionerÆs application

will be treated as a new application and will be subject to the eligibility

rules which apply at the time.

Two-Year Restriction

3(8) Notwithstanding Rule 3(6)(b), no Member may voluntarily terminate

membership under the Plan before having been a Member for two complete

calendar years.

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RULE 4. Coverage of a Spouse or Common Law Partner

Eligibility for Coverage of a Spouse or Common Law Partner

4(1) Subject to Rule 4(2) a Member becomes eligible to cover a Spouse or

Common Law Partner under this Plan on the later of:

(a) the date the Eligible Pensioner becomes covered as a Member of this

Plan, and

(b) the first date the Member acquires an Eligible Spouse or Eligible

Common Law Partner

If a Member ceases to have an Eligible Spouse or Eligible Common Law

Partner, the Member shall again become eligible to cover a spouse or common

law partner on any subsequent date on which the Member again acquires an

Eligible Spouse or Eligible Common Law Partner.

Termination of Eligibility for Coverage of a Spouse or Common Law Partner

4(2) A MemberÆs eligibility for Coverage of a Spouse or Common Law

Partner terminates on the earlier of:

(a) the date on which the MemberÆs coverage terminates; and,

(b) the date on which the Member no longer has an Eligible Spouse or

Eligible Common Law Partner.

Effective date of Spouse's or Common Law PartnerÆs Coverage

4(3) The coverage of a MemberÆs Eligible Spouse or Eligible Common Law

Partner is effective on

(a) the Effective Date, if the Eligible Pensioner applied for coverage as

a Member in accordance with Rule 3(1)(a) and selected the appropriate

Category of Coverage;

(b) the effective date of the Eligible PensionerÆs pension entitlement if

the Eligible Pensioner applied for coverage as a Member in accordance with

Rule 3(1)(b) and selected the appropriate Category of Coverage; and

Administrator receives an application in the Prescribed Form from the Member

in which the Member amends the Category of Coverage to cover the Eligible

Spouse or Eligible Common Law Partner, if the Administrator receives the

application form within 60 days of the date the Spouse or Common Law Partner

becomes eligible and provided that the pensioner is an Eligible Pensioner

and the Spouse or Common Law Partner is an Eligible Spouse or an Eligible

Common Law Partner on that date.

Deferred Coverage

4(4) Notwithstanding Rule 4(3), a Member may defer covering an Eligible

Spouse or an Eligible Common Law Partner if the Eligible Spouse or Eligible

Common Law Partner has coverage under another dental plan or VeteransÆ

Coverage.

A Member who wishes to defer application for SpouseÆs or Common Law

PartnerÆs coverage must, within the time period prescribed in Rule 4(3)(c),

so notify the Administrator in writing in the Prescribed Form and provide

proof of that other coverage to the satisfaction of the Administrator.

The Member may make application for SpouseÆs or Common Law PartnerÆs

coverage under the Plan by completing an application in the Prescribed Form

and sending it to the Administrator no later than 60 days following the

termination of the SpouseÆs or Common Law PartnerÆs coverage under the other

dental plan or VeteransÆ Coverage.

Termination of a Spouse's or Common Law PartnerÆs Coverage

4(5) A SpouseÆs or Common Law PartnerÆs coverage under this Plan

terminates on the earliest of

(a) the date on which the Spouse or Common Law Partner no longer

qualifies as an Eligible Spouse or Eligible Common Law Partner under this

Plan;

(b) the date on which the coverage of the Member ceases;

under the Dental Care Plan for the Public Service of Canada as an "eligible

employee" as defined in that plan, becomes entitled to dental services as a

member of the Canadian Forces or the RCMP, or receives VeteransÆ Coverage

and the Member provides proof of that other coverage to the satisfaction of

the Administrator; and

(d) the first of the second month following the date on which the

Administrator receives a request in the Prescribed Form from the Member to

terminate a SpouseÆs or Common Law PartnerÆs coverage.

4(6) A Member whose SpouseÆs or Common Law PartnerÆs coverage has

terminated in accordance with Rule 4(5)(c) may apply to re-instate that

coverage under the PensionersÆ Dental Services Plan within 60 days of the

date on which the conditions described in Rule 4(5)(c) no longer apply and

the MemberÆs application to re-instate the SpouseÆs or Common Law PartnerÆs

coverage will be treated as a new application and will be subject to the

eligibility rules which apply at the time.

4(7) Notwithstanding Rule 4(5)(d), no Member may terminate a SpouseÆs or

Common Law PartnerÆs coverage before the Spouse or Common Law Partner has

been covered under the Plan for two complete calendar years.

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RULE 5. Children's Coverage

Eligibility for ChildrenÆs Coverage

5(1) A Member becomes eligible for ChildrenÆs Coverage under the Plan on

the later of:

(a) the date on which the Member first acquires an Eligible Child; and,

(b) the date on which the Eligible Pensioner becomes a Member of the

Plan.

If a Member ceases to have an Eligible Child or Children, the Member shall

again become eligible for ChildrenÆs Coverage on any subsequent date on

which the Member again acquires an Eligible Child or Children.

Termination of Eligibility for Children's Coverage

5(2) A MemberÆs eligibility for ChildrenÆs Coverage terminates on the

earlier of:

(a) the date on which the Member's coverage terminates; and,

(b) the date on which the Member no longer has Eligible Children.

Effective Date of a Child's Coverage

5(3) The coverage of a MemberÆs Eligible Child or Children is effective

(a) the Effective Date, if the Eligible Pensioner applied for coverage as

a Member in accordance with Rule 3(1)(a) and selected the appropriate

Category of Coverage;

(b) the Effective Date of the Eligible PensionerÆs pension entitlement if

the Eligible Pensioner applied for coverage as a member in accordance with

Rule 3(1)(b) and selected the appropriate Category of Coverage;

Administrator receives an application in the Prescribed Form from the Member

in which the Member amends the Category of Coverage to cover the Eligible

Child, if the Administrator receives the application form:

(i) within 60 days of the date the Child becomes eligible, or

(ii) before the Child attains the age of three (3) years.

Notwithstanding the above provision, where coverage is in respect of a Child

who is covered under the Plan by the Member's Spouse or the MemberÆs Common

Law Partner, the ChildÆs coverage as the Child of the Member shall be

effective on the day the Member sends an application in the Prescribed Form

to the Administrator.

Deferred Coverage

5(4) Notwithstanding Rule 5(3), a member may defer covering an Eligible

Child if the Eligible Child has coverage under another dental plan.

A Member who wishes to defer application for ChildÆs coverage must, within

the time period prescribed in Rule 5(3)(c), so notify the Administrator in

writing in the Prescribed Form and provide proof of that other coverage to

the satisfaction of the Administrator.

The Member may make subsequent application for ChildÆs coverage under the

Plan by completing an application in the Prescribed Form and sending it to

the Administrator no later than 60 days following the termination of the

ChildÆs coverage under the other dental plan.

Termination of a Child's Coverage

5(5) No Child of a Member shall be covered under this Plan after the

earliest of:

(a) the day a Child no longer qualifies as an Eligible Child under the

Plan;

(b) the date the MemberÆs coverage ceases; and

Plan, the day on which the MemberÆs Spouse or Common Law Partner sends an

application in the Prescribed Form to the Administrator selecting the

appropriate Category of Coverage to cover the Child.

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RULE 6. Benefits

Definitions

6(1) Subject to the other provisions of the Plan, in this Rule,

(a) "covered expenses" for Members residing outside Canada means, where

permitted by law, Reasonable and Customary Charges for the eligible dental

services provided to the Member, the MemberÆs covered Spouse or Common Law

Partner and the MemberÆs covered Children;

(b) "covered expenses" for Members residing in Canada means the charges

for the eligible dental services provided to the Member, the MemberÆs

covered Spouse or the MemberÆs covered Common Law Partner and the MemberÆs

covered Children up to but not exceeding the amount shown in the relevant

fee schedules for dental practitioners and specialists where available, or

such other fee schedules as may be adopted from time to time for the

purposes of the Plan,

(i) of the province or territory where services are rendered,

where such services are rendered in Canada; or

(ii) of the province or territory of residence of the Member,

where such services are rendered outside Canada;

where "relevant fee schedule" means

(iii) other than for the province of Alberta, the schedule in

effect the previous year; and

(iv) for the province of Alberta, the 1997 Alberta schedule

increased by an inflationary factor.

the applicable eligible dental services in excess of the calendar year

deductible, which represents the amount of the benefit to which a Member is

entitled;

(d) "calendar year deductible" means, in respect of the covered expenses

incurred in the calendar year for which it is being calculated, the covered

expenses which, when accumulated in the order of their being incurred, equal

the individual deductible amount, except that not more than the combined

deductible amount shall be applied in any calendar year against the covered

expenses of a Member and all persons to whom the Member's Coverage of a

Spouse or Common Law Partner or ChildrenÆs Coverage applies.

If the first dental expenses in a calendar year is incurred in the last

quarter of the year (October-December), and the applicable deductible has

been paid, that deductible will be carried over to the following year.

Eligible Dental Services

6(2) Subject to the other provisions of the Plan, "eligible dental

services" means the dental services listed in Schedule 2 when rendered by a

dentist or dental specialist, by a dental hygienist under the direct

supervision of one of a dentist or dental specialist, or by a dental

mechanic.

Where any province, state or country employs a coding of procedures for

individual dental treatment which is different from that of the Canadian

Dental Association, the appropriate codes of the guide of such province,

state or country for the equivalent procedure shall apply. Where it cannot

be ascertained that dental services rendered are eligible services, eligible

services shall be the alternative services defined below as eligible dental

services, as determined by the Administrator.

Specific Limitations with Respect to Major Services

6(3)

(a) The services listed in Schedule 2 dealing with the installation of

prosthodontic appliances (e.g. fixed bridge, pontics and abutments,

temporary or permanent, partial or complete dentures), constitute eligible

dental services only if they are rendered for

(i) an initial prosthodontic appliance, or

(ii) the replacement of an existing prosthodontic appliance,

including the addition of teeth to an existing appliance, if

* the replacement, or the addition of teeth is

required because at least one additional natural

tooth was extracted after the insertion of the

existing appliance, and the appliance could not

have been made serviceable. If the existing

appliance could have been made serviceable, the

expense for only that portion of the replacement

appliance which replaces the teeth extracted shall

be covered,

* the existing appliance is at least five (5) years

old and cannot be made serviceable,

* the existing appliance was temporarily installed,

provided that the replacement appliance is

installed within twelve (12) months of insertion of

the temporary appliance and that such replacement

appliance will thereafter be deemed permanent for

the purposes of this provision,

* the replacement appliance is required as a result

of the installation of an initial opposing denture

after the date the person becomes covered under the

Plan, or

* the replacement appliance is required as a result

of accidental dental injury to a natural tooth that

occurred after the date the person became covered

under the Plan.

(b) With respect to the services listed in Schedule 2 dealing with

crowns, the services for the replacement of a crown are eligible if the

existing crown is at least five (5) years old and cannot be made

serviceable.

Amount of Benefit

6(4) Subject to the other provisions of Rule 6, where a Member incurs

covered expenses in respect of a person covered by the Plan, the Member is

entitled to a benefit for all such covered expenses incurred in respect of

such covered person in any calendar year equal to the co-insurance

percentage of those covered expenses which exceeds the calendar year

deductible, up to but not exceeding the maximum reimbursement amounts for

the applicable covered expenses.

Table of Benefits

6(5) For the purpose of calculating the Member's benefit under Rule 6(4),

the co-insurance percentages, deductibles and maximum reimbursement amounts

shall be as follows:

(a) Co-insurance percentages:

(i) 50% for the following services :

* major restorative services (listed under

provision 3(ii) of Schedule 2)

* major prosthodontic services (listed under

provision 6(ii) of Schedule 2), and

* orthodontic services (listed under provisions 8(ii)

and (iii) of Schedule 2);

(ii) 90% for all other services listed in Schedule 2.

(b) Calendar year deductibles:

(i) individual deductible: $25;

(ii) combined deductible: $50.

(i) $2,500 for all benefits payable with respect to eligible

orthodontic services (listed under provision 8 of Schedule 2)

rendered to a covered person for the whole period while covered

under the Plan

(ii) $1,300 for benefits payable with respect to eligible

dental services, other than orthodontic services (referred to in

Rule 6(5)(c)(i)), rendered to a covered person in a given calendar

year.

(iii) Notwithstanding Rule 6(5)(c)(ii), the amount reimbursed

for dental expenses, excluding orthodontic services, shall not

exceed $650 in a given calendar year, if the Member, his Eligible

Spouse or Eligible Common Law Partner and Eligible Children became

covered under the plan on or after July 1 of that given year.

Treatment Plan Provision

6(6)

(a) The Member should submit a treatment plan to the Administrator for

benefit determination when the estimated cost of a course of treatment is

$300 or more.

(b) Such treatment plan is not valid if treatment does not commence

within ninety (90) days of the date on which the Member submitted it.

shall advise the Member of the estimated amount payable on the basis of the

treatment plan estimate at the time of benefit determination.

Date an Expense is Incurred

6(7)

(a) As a general rule, a covered expense is deemed to be incurred on the

date the particular service is rendered or the supply purchased. Where

multiple appointments are required for a single service, the covered

expenses shall be deemed to be incurred on the date such service is

complete.

(b) Where applicable, a procedure involving the installation of an

appliance shall be deemed to be completed on the date the appliance is

installed. However, in the case of orthodontic services, covered expenses

shall be deemed to be incurred monthly, starting with the first date the

appliance is installed, and at the same date of each subsequent month

falling during the treatment period.

not provide for specific fees with respect to the initial consultation, the

amount of covered expenses incurred for each month shall be equal to the

total amount of covered charges for the treatment divided by the number of

months in the treatment period.

(d) Where the cost estimates given in the orthodontic treatment plan

contain fees with respect to the initial consultation, the amount of covered

charges incurred for each month shall be equal to

(i) with respect to the first month of treatment, the lesser of

25% of the total amount of covered charges for the treatment and

the fees shown for the initial consultation;

(ii) with respect to subsequent months, the difference between

the total amount of covered charges for the treatment and the

covered charges for the first month û divided by the number of

subsequent months in the treatment period.

Method of Payment

6(8)

(a) Reimbursement under this Plan shall be made in a single payment for

each claim. However, in the case of orthodontic services, payments shall be

made monthly, the amount of each reimbursement being equal to the benefit

payable with respect to covered expenses incurred during such month, as

determined under Rule 6(7).

(b) All benefits under this Plan, are payable to

(i) the Member;

(ii) the MemberÆs Spouse or Common Law Partner, if so directed

by the Member; or

(iii) the MemberÆs dental practitioner or specialist, if so

directed by the Member.

Extension of Benefits

6(9) Notwithstanding any other provision of the Plan,

(a) where coverage for a person is terminated, coverage for the following

services shall be extended for a period of thirty-one (31) days after the

termination date, provided the services commenced as defined below, before

such date

(i) endodontic services, where the pulp chamber is opened

before the termination date: services listed under provision 4 of

Schedule 2 for "root canal therapy";

(ii) prosthodontic services involving an appliance for which an

impression was taken before the termination date;

services listed under provision 6 of Schedule 2 for "relining and

rebasing", "addition of tooth to a removable denture", "complete

dentures" and "partial dentures";

(iii) major restorative and prosthodontic services for which a

tooth was prepared before the termination date;

major restorative services listed under provision 3 of Schedule 2

for "gold inlays", "crowns" and "other restorative services";

prosthodontic services listed under provision 6 of Schedule 2 for

"pontics", "retainers", "abutments", "retentive pins in abutments"

and "repairs of fixed appliances".

(iv) orthodontic services for which a Member was entitled to a

benefit prior to the date of termination of coverage.

Conditions for Benefit Payment

6(10)

(a) A Member entitled to a benefit under the Plan must submit to the

Administrator within fifteen (15) months of the date the expense is incurred

or deemed to be incurred under the Plan notice and proof of claim

satisfactory to the Administrator.

(b) If the Member fails to provide the notice and proof within the time

required, the claim shall not be invalid if it was not reasonably possible

for the Member to provide proof within such time, so long as the Member

provides such proof as soon as reasonably possible and in no event, except

in the case of legal incapacity, later than twenty-four (24) months after

the expense was incurred.

Co-ordination of Benefits

6(11)

(a) All covered expenses shall be subject to co-ordination of benefits as

defined in this Rule 6(11).

(b) For the application of Rule 6(11), "allowable expense" means any

reasonable and customary item of expense at least a portion of which is

covered under at least one of the plans covering the person for whom claim

is made.

person covered under this Plan for any calendar year if, for the allowable

expenses incurred in respect of such person during such year, the sum of the

benefits that would be payable under this Plan (in the absence of

Rule 6(11)) and the benefits that would be payable under all plans including

this Plan (in the absence in those plans of provisions of similar purpose to

Rule 6(11)), exceeds such allowable expenses.

(d) For any calendar year to which Rule 6(11) applies, the benefits that

would be payable under this Plan (in the absence of Rule 6(11)) for the

allowable expenses incurred in respect of such person during that calendar

year shall be reduced to the extent that the sum of the reduced benefits and

all the benefits payable for such allowable expenses under all plans

including this Plan, except as provided under Rule 6(11)(e), shall not

exceed the total of such allowable expenses. Benefits payable under another

plan include the benefits that would have been payable had a claim been made

for them.

(e) If

(i) another plan which is involved in Rule 6(11)(d) contains a

provision co-ordinating its benefits with those of this Plan and

would, according to its rules, determine its benefits after the

benefits of this Plan have been determined, and

(ii) Rule 6(11)(f) would require this Plan to determine its

benefits before such other plan,

the benefits of such other plan shall be ignored for the purpose of

determining the benefits under this Plan.

(f) For the purpose of Rule 6(11)(e),

(i) benefits shall be determined first under the plan which

covers the person for whom expenses have been incurred other than

as a Spouse or a Common Law Partner or Child or as a Child of the

person whose date of birth, excluding year of birth, is earlier in

the calendar year;

(ii) subject to Rule 6(11)(f)(iii), where Rule 6(11)(f)(i) does

not establish an order of benefit determination, or another plan

contains different rules, benefits will be pro-rated between or

amongst the plans in proportion to the amounts that would have

been paid under each plan in the absence of other coverage; and

(iii) notwithstanding Rule 6(11)(f)(ii), where the other plan

is the Public Service Health Care Plan, benefits shall be

determined first under the Public Service Health Care Plan for

allowable expenses on account of accidental dental injury and

first under this Plan for allowable expenses with respect to oral

surgery.

(g) When this provision operates to reduce the total amount of benefits

otherwise payable in respect of a person covered under this Plan during any

calendar year, each benefit that would be payable in the absence of this

Rule 6(11)(g) shall be reduced proportionately, and such reduced amount

shall be charged against any applicable maximum reimbursement amount of this

Plan.

(h) For the purpose of determining the applicability of and implementing

the terms of Rule 6(11) or of any provision of similar purpose in any other

plan, the Administrator may, without the consent of or notice to any person,

release to or obtain from any insurance company or other organisation or

person any information with respect to any person which the Administrator

deems to be necessary for such purposes. Any person claiming benefits under

this Plan shall provide the Administrator with such information as may be

necessary to implement this Rule.

Covered Expenses Limitations

6(12)

(a) Expenses incurred for the services, treatments and supplies listed in

Schedule 3 are not covered expenses.

(b) Expenses incurred for services, treatments, and supplies that are

reimbursed pursuant to the Extension of Benefits provision of the Public

Service Dental Care Plan are not covered expenses.

RULE 7. Contributions

7(1)

(a) The cost of the Plan shall be shared on a 60% - 40% basis between the

Government of Canada and Members, respectively.

(b) Members shall pay a monthly contribution in the amount prescribed by

the Treasury Board from time to time by deduction from the MemberÆs pension

entitlement one month in advance to provide coverage for the following month

for the Category of Coverage selected by the Member.

pension or annuity is too small for the deduction to be made, the Member

will send contributions quarterly to the appropriate pension administrator.

RULE 8. General Provisions

Amendments

8(1) The Treasury Board of Canada may modify or amend the Rules and when

adding the name of an agency or entity to Schedule 1, may prescribe

conditions for that agencyÆs or entityÆs participation in the PensionersÆ

Dental Services Plan.

Instructions

8(2) The Administrator may, at any time and from time to time, issue

instructions consistent with the provisions of the Plan to provide for the

proper administration of the Plan.

Non-alienation of Benefits

8(3) No benefit under the Plan shall be subject in any manner to

anticipation, alienation, sale, transfer, assignment, pledge encumbrance or

charge, and any attempt to do so shall be void, except as specifically

provided in the Plan, nor shall any such benefit be in any manner liable for

or subject to garnishment, attachment, execution or levy, or liable for or

subject to the debts, contracts, liabilities, engagements or torts of the

person entitled to such benefit.

Beneficiaries

8(4)

(a) Any benefits unpaid at the Member's death may, at the option of the

Administrator, be paid either to the beneficiary or to the estate of such

person.

(b) If a benefit under this Plan is payable to the estate of the Member

or to a Member who is a minor or otherwise not competent to give a valid

release, the Administrator may pay such benefit to any relative by blood or

connection by marriage of the Member or to a person appearing to the

Administrator to be equitably entitled to the payment by reason of having

incurred expenses for the maintenance, care or treatment of the Member or

the Member's dependant. Any payment made by the Administrator in good faith

pursuant to this provision shall fully discharge the Plan with respect to

such payment.

Discretion

8(5) The Minister may, for any person or group of persons, make decisions

concerning the application or provisions of this Plan, notwithstanding any

provision in this Plan.

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SCHEDULE I. List of Agencies and Entities for the Purposes of Rule 2(1)(b)

Canada Investment and Savings

Canadian Food Inspection Agency

Canadian Institutes of Health Research (formerly Medical Research Council)

Canadian Nuclear Safety Commission (formerly Atomic Energy Control Board)

Canadian Polar Commission

Canadian Security Intelligence Service

Communications Security Establishment

House of Commons

Indian Oil and Gas Canada

Library of Parliament

National Energy Board

National Film Board

National Research Council of Canada

National Round Table on the Environment and the Economy

Natural Sciences and Engineering Research Council

Northern Pipeline Agency Canada

Office of the Auditor General Canada

Office of the Correctional Investigator

Office of the Secretary to the Governor General

Office of the Superintendent of Financial Institutions

Parks Canada Agency

Public Service Staff Relations Board

Security Intelligence Review Committee

Senate

Social Sciences and Humanities Research Council of Canada

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SCHEDULE 2. Eligible Dental Services

1. Diagnostic Services

(i) examination and diagnostic

* complete oral examination

* recall oral examination, once every 9 months

* specific oral examination

* emergency oral examination

* treatment planning

(ii) radiographs

* complete series of periapical films required to support a

proper course of treatment, but not more frequently than once

every 36 months

* occlusal films

* bitewings required to support a proper course of treatment,

but not more frequently than once every 9 months

* extra-oral films

* sialography, use of dyes

* panoramic film required to support a proper course of

treatment, but not more frequently than once every 36 months

* interpretation of radiographs from another source

* tomography

(iii) tests, laboratory examinations

* biopsy of oral tissue

* pulp vitality tests

2. Preventive Services

(i) routine services

* dental cleaning and polishing, up to once every 9 months

* topical application of fluoride required to support a proper

course of treatment, but not more frequently than once every

9 months

* pit and fissure sealants for covered Children prior to

reaching age 15

* caries control

* enameloplasty

* oral hygiene instructions (once per calendar year)

(ii) space maintainers (not involving movement of teeth)

3. Restorative

(i) minor restorations

* amalgam

* silicate

* acrylic or composite

* pin reinforcements for these restorations

Note: Replacement fillings for the same tooth and surface are covered only

if the existing filling is at least 24 months old.

(ii) major restorations

* gold foil

* gold inlays

* porcelain inlays

* retention pins, posts and cores

* crowns

* other restorative services

4. Endodontics

* pulp capping

* pulpotomy

* root canal therapy

* periapical services

* other endodontic procedures

5. Periodontics

* non surgical services

* surgical services

* post surgical treatment

* occlusal equilibration, not exceeding 8 time units every

12-month period

* scaling and root planing, not exceeding 6 time units every

calendar year; except in documented cases and with

pre-approval of a Treatment Plan, not exceeding 12 time units

every calendar year

* other periodontic services

6. Prosthodontics

(i) minor services for removable dentures

* repairs

* adjustment

* relining and rebasing, limited to once every 36 months

(ii) major

* exams, films and diagnostic casts

* addition of a tooth to a removable denture

* complete dentures

* partial dentures

* pontics (fixed bridges)

* retainers

* abutments (pontics)

* retentive pins in abutments

* repairs of fixed appliances

* other prosthodontic services

7. Oral surgery

* uncomplicated removal

* surgical removal and tooth repositioning

* alveopoplasty, gingivoplasty, stomatoplasty, osteoplasty,

tuberoplasty

* removal of excess mucosa

* surgical excision

* removal of cyst

* surgical incision

* removal of impacted teeth

* repair of soft tissue

* frenectomy, dislocations

* miscellaneous surgical services

8. Orthodontic services

(i) Diagnostic Services

* orthodontic exam

* films

* orthodontic diagnostic casts

(ii) observation and adjustment

* surgical services

* observation and adjustment

* repairs, alterations

(iii) appliances

* removable appliances

* fixed appliances

* retention appliances

* appliances to control harmful habits

9. Adjunctive General Services

* emergency services not otherwise specified

* anaesthesia in connection with oral surgery and drug

injections

* consultation

* house call, hospital call and special office visit

------------------------------------------------------------------------

SCHEDULE 3. Covered Expense Limitations for the Purposes of Rule 6(12)

(a) services and supplies, or any portion thereof, which are covered

under any provincial, territorial or other public dental, hospital or health

plan to which the person is eligible;

(b) services and supplies, or portion thereof, which are the legal

liability of any other party;

entitled without charge pursuant to any law including but not limited to

Workers' Compensation or similar law, or for which there is no cost to the

person except for the existence of insurance against such cost;

(d) services and supplies received in a hospital owned or operated by a

government, unless the person is required to pay for such services or

supplies regardless of the existence of insurance;

(e) services and supplies rendered outside Canada to persons residing in

Canada or to Children of a Member residing in Canada, which would be payable

under a provincial health, dental or hospital plan if the services had been

rendered in Canada;

(f) dental treatment involving the use of precious metals, if such

treatment could have been rendered at lower cost by means of a reasonable

substitute consistent with generally accepted dental practice, except for

that portion of expenses which would have been incurred for treatment by

means of a reasonable substitute;

(g) user fees, co-insurance charges or similar charges which are in

excess of charges payable by a governmental dental, hospital or health plan;

(h) dental treatment which is not yet approved by the Canadian Dental

Association or which, in the opinion of the Administrator, is clearly

experimental in nature;

(i) services and supplies which, in the opinion of the Administrator, are

rendered principally for cosmetic purposes including, but not limited to,

porcelain or composite facings on crowns or pontics on molar teeth;

(j) services and supplies related to the purchase, repair, modification

or replacement of a duplicate prosthodontic appliance, for any reasons;

(k) services rendered and supplies purchased prior to the date the person

became covered under this Plan;

(l) charges for an appliance or a modification of one where an impression

is made for such appliance or modification before the person became covered

under this Plan; charges for crowns, bridges and gold restorations for which

a tooth was prepared before the person became covered under this Plan;

charges for root canal therapy where the pulp chamber was opened before the

person became covered under this Plan;

(m) services and supplies rendered as a result of a congenital or

developmental malformation which is not a Class I, II, III malocclusion,

except for a Child under 19 years of age;

(n) charges for a periodontal appliance, occlusal equilibration, and

other related service as a result of a temporo-mandibular joint dysfunction

(TMJ dysfunction) or vertical dimension correction;

(o) implants, except that a benefit may be paid based on the reasonable

and customary charges for the least expensive alternative course of

treatment that is an eligible dental service under the Plan;

(p) charges for an orthodontic treatment, in respect of a Member or

Eligible Spouse or eligible Common Law Partner, where the initial appliance

was installed before the person became covered for such service under this

Plan.

------------------------------------------------------------------------

For More Information

* Call Sun Life Assurance Company of Canada at

1-888-757-7427 (toll-free) or at 247-5100 in the

National Capital Region

* Write to Sun Life Assurance Company of Canada at:

PO BOX 9805 CSC-T

Ottawa ON K1G 6M6

* Visit the Treasury Board of Canada Secretariat

Website at: http://www.tbs-sct.gc.ca

® Her Majesty the Queen in Right of Canada

Represented by the President of the Treasury Board, 2000

Catalogue No. BT22-71/2û2000

ISBN 0-662-65183û9

This document is available in alternative formats and on the Treasury Board

of Canada Secretariat Website at the following address:

http://www.tbs-sct.gc.ca

and on the HR CONNEXIONS web address:

http://www.tbs-sct.gc.ca/hr_connexions_rh

Copies of the booklet may be obtained by contacting the:

Distribution Centre

Treasury Board of Canada Secretariat

300 Laurier Avenue West

Ottawa ON K1A 0R5

Tel: 613 995-2855 Fax: 613 996-0518

Services-Publication@fin.gc.ca

TBS Distribution Centre Stock No.: TBS 006779

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