How do I make a claim?

Essentially, there are three ways to initiate claims under your insurance coverage:

1. Pay-Direct Billing (or Electronic Claims) by the health service provider (most often pharmacists and dentists; however, increasing numbers of chiropractors, optometrists and other paramedical professionals are equipping themselves to offer this service). 

• Present your completed Green Shield Health Card to your health service provider.  Have either your "Outline of Benefits" handy, or your Students' Union Members' Handbook (page 48, Benefits Summary). 

Billing the insurance company directly by the health service provider for the insured portion of the procedure or item is the most favorable method, as it saves students paying the full amount up-front, and eliminates the need for filing claims and waiting for reimbursement. Almost all pharmacies and dental offices are set up to offer this service.

If a pharmacist or dentist prefers not to use this method, and cash flow is an issue, students might consider shopping around for a more accommodating health professional, such as those found in the Student Dental Discount Network provided by Green Shield (www.greenshield.ca/studentcentre - see download below for list of participating dentists).

2. Out-of-Pocket Claims by Mail. In cases where your dentist, pharmacist or other health care provider does not offer a "pay-direct billing" option, students will need to pay the expense out-of-pocket and then make a claim for reimbursement by mail. 

• Claim forms are available for this purpose at both Students' Union offices and at www.greenshield.ca/studentcentre
• For dental claims, the dentist is required to complete and verify either a "Standard" or "Green Shield" Dental Claim form.
• For most other expenses, a "General Claim" form will need to be submitted with original receipts. 

When making claims by mail, students must ensure their claim form is completed correctly, using their name as registered with the college, including their birth date, and their full Green Shield Subscriber ID (see "Green Shield Health Card" above). Green Shield customer service staff (at 1.888.711.1119) and Students' Union staff should be called upon if assistance is required completing claim forms.

3. Pre-Approval by Insurance Company. Usually dental accidents, prosthetics and medical equipment, and medical expenses while out-of-province. In these cases, direct contact with Green Shield is required.

How do I check the status of my claim?

All students in the plan (except for first-time enrollees in their 'hold' period) may inquire into the status of their claims or the extent of their coverage by contacting Green Shield directly at 1-888-711-1119, or by registering an account at www.greenshield.ca/studentcentre using your Green Shield Subscriber ID (see above sections).

How long do I have to submit a claim?

IMPORTANT CLAIMS DEADLINE:

Claims for expenses covered by this insurance will only be accepted by Green Shield Canada up to one year from the date of purchase of the eligible health service or medical item in question. 

 

Limited Benefit Clause:

Green Shield will determine the amount of benefits payable, giving consideration to limited procedures, services, or courses of treatment that may be performed to accomplish the desired result. The attending physician or dentist and the patient have the option of which procedure to use, although payment for the procedure may be based on the "limited treatment" principle. The Limited Benefit Clause is a financial limitation and not intended as a comment regarding any treatment recommended or performed by a physician or dentist.

Predetermination:

If the cost of any proposed treatment is expected to exceed $300.00, submit to Green Shield a detailed treatment plan from your provider before your treatment begins. If a description of the procedures to be performed and an estimate of the charges are not submitted in advance, Green Shield reserves the right to make a determination of benefits payable, taking into account alternate procedures, services or course of treatment, based on accepted standards of medical and/or dental practice.

General Overall Exclusions:

Eligible Services do not include and reimbursement will not be made when we are aware of or have been apprised of:

1. Services or supplies received as a result of disease, illness or injury due to any of the following:
- intentionally self-inflicted injury while sane or insane
- an act of war, declared or undeclared
- participation in a riot or civil commotion
- committing a criminal offence

2. Failure to keep a scheduled appointment with a licensed medical or dental practitioner.

3. Services or supplies that are cosmetic in nature.

4. The completion of any claim forms and/or insurance reports.

5. Services or supplies which do not meet accepted standards of medical, dental, or ophthalmic practice, including charges for services or supplies which are experimental in nature.

6. Services or supplies normally paid through any provincial government health plan, workplace safety and/or insurance board, 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.

7. Services or supplies 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.

8. Services or supplies that are not recommended or approved by the attending physician or dentist.

9. Services or supplies that you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage.

10. Services or supplies that are legally prohibited by the government from coverage.

11. The replacement of lost, missing or stolen items, or items which are damaged due to negligence.

12. Any eligible service that relates to treatment of injuries arising out of a motor vehicle accident.

Coordination Of Benefits:

Where you or your dependents have coverage with more than one carrier, claims shall be coordinated so that reimbursement from all plans shall not exceed 100% of the actual claim. For information on how to do this, visit one of your Students' Union offices where staff will assist you.

Subrogation:

Green Shield retains the right to subrogation if benefits have or should have been paid or provided by a third party. In cases of third party liability, you must advise your lawyer of these rights.

Group Conversion Package:

Any student who will be terminating coverage where there is an active Green Shield group benefits program in force and who will lose their group benefits may enrol in the Green Shield Group Conversion Program.
Dependent children who are no longer eligible for benefits under their parents Green Shield group benefits program may also enrol in the Green Shield Group Conversion Program.
Call 416-601-0429 in the Toronto area or toll-free at 1-800-667-0429 for an information package. You must apply within 60 days of termination of your benefits from your Green Shield group program.