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Submitting Claims

Pay-Direct Drugs

Note: All adjudication is provided by Co-operators.

This plan is made available as part of the benefit package through The Co-operators. The plan allows employees to pay only their portion of the drug cost directly to the pharmacist. The rest of the cost is billed directly to the plan. This eliminates the need for employees to pay the full cost of the prescription and then submit a claim form to The Co-operators for reimbursement.

If, for any reason, the employee’s pay-direct drug card was not used at the point of sale, simply have the employee complete the Extended Health Care Claim Form and attach the original receipt(s). Please send the claim form along with the receipt directly to the Co-operators.

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Health and Vision Care Claims

  1. Plan Members have the option to submit claims online through Benefits Now(R) for Plan Member or through the Benefits Now Mobile App for iPhone and Android(TM)
  2. or
  1. The Co-operators provides an Extended Health Care Claim Form for all non-drug health claims (e.g., paramedical practitioners, supplies, services etc.)
  2. Employee completes and signs Parts 1 and 2 of this form
  3. Employee attaches original receipts when submitting a claim (photocopies are not accepted)
  4. Employee may submit claims directly to The Co-operators Note: For orthotics and certain paramedical practitioners, an authorization from a physician is required – please refer to the employee handbook for additional details.

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Dental Claims

  1. Plan Members have the option to submit claims online through Benefits Now(R) for Plan Member or through the Benefits Now Mobile App for iPhone and Android(TM)
  2. or
  1. Dental claims are submitted using The Co-operators’ Dental Claim Form (a standard dental claim form available at most dental offices may also be used)
  2. Employee completes and signs this form
  3. Employee attaches original receipts when submitting a claim (photocopies are not accepted)
  4. Employee may submit claims directly to The Co-operators

Note: For any extensive course of treatment involving crowns, bridgework, etc., which may exceed $300, a detailed treatment plan must be submitted to the Insurance Company for assessment before any treatment, other than necessary emergency treatment, commences. The Covered Person will then be advised of the estimated amount payable by the Insurance Company for the Covered Dental Expense. Send estimates to The Co-operators, attention of Dental Claims Department, to determine how the expenses will be reimbursed prior to incurring the expense.

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Disability Claims

Please refer to The Co-operator’s Disability Claims Guide for complete details of the requirements of a disability claim as well as answers to some frequently asked questions.

Short Term Disability

  1. The employee must complete an Application for Short Term Disability
  2. There are three forms which must be completed for a short term disability claim:
  3. Once completed by the appropriate individuals, the employee mails all forms to The Co-operators

Note: Claims should be submitted as soon as possible after the date of disability for a short term disability claim. Benefits commence on the 15th calendar day of disability.

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Long Term Disability

  1. The employee must complete an Application for Long Term Disability. Benefits start on the 120th day of continuous disability.
  2. There are three forms that must be completed for a long term disability claim:
  3. Once completed by the appropriate individuals, the employee mails all forms to The Co-operators
  4. Claims should be submitted six to eight weeks before the end of the elimination period for a long term disability claim
  5. If the employee is eligible for WSIB benefits, the employee will receive a Worker's Compensation claim form from his/her physician

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Employee Or Spousal Life Insurance Claims

  1. In the event of the death of an insured employee or spouse, the employer and claimant complete the required statements of the Notice of death for The Co-operators Life Insurance Company
  2. For claims of $25,000 and over: submit a Proof of Death – Physician’s Statement
  3. For claims of under $25,000: a certified copy of the Funeral Director’s Statement is sufficient
  4. If the deceased was over the age of 60, a photocopy of the Birth Certificate is also required (if available)
  5. Once all completed forms and supporting documents are collected, forward them to The Co-operators

Note: Upon approval of a claim, the claim settlement cheque is sent directly to the beneficiary – the services of a lawyer are no usually required in submitting a claim for death benefits. If the beneficiary is the estate, The Co-operators will require a notarized copy of the will and the certificate of appointment of Estate Trustee.

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Total Disability Waiver Of Premium For Life Insurance Benefits

Consult your contract regarding the waiting period that is specified (e.g., the disability must be continuous for a period of nine months before a waiver claim can be submitted). Arrange to have claim forms provided to the disabled employee around the end of the waiting period.

Note: If an employee is receiving long term disability benefits with The Co-operators, a separate application will not be required.

  1. The employee must complete an Application for Long Term Disability
  2. There are three forms that must be completed for a long term disability claim:
  3. Once completed by the appropriate individuals, the employee mails all forms to The Co-operators

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Living Assistance Benefit

The living assistance program is made available as an advanced life insurance payment to help meet the expenses of terminally ill individuals who are covered by the group life insurance plan. Please refer to your employee handbook for further information regarding this benefit.

  1. The employee must complete an Application for Living Assistance
  2. The Co-operators will contact the individual’s doctor requesting medical information regarding his/her condition
  3. The decision made by The Co-operators is final and binding and cannot be appealed. However, if his/her condition worsens, he/she may re-apply

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Accidental Death Claims

  1. In the event of the accidental death of an insured employee or spouse, the employer and claimant complete the required sections of the Notice to Co-operators Life Insurance Company
  2. The claimant also completes a Claim for Accidental Death Benefit Form
  3. Accidental death claims should be submitted with the following supporting documents:
    1. A certified copy of the Funeral Director’s Statement or a Medical Examiner’s Report
    2. A copy of the police investigation report
    3. An autopsy report
    4. If the deceased was over the age of 60, a photocopy of the Birth Certificate is also required (if available)
  4. Once all completed forms and supporting documents are collected, forward them to The Co-operators

Note: The outcome of an accidental death claim will also depend on the findings of a Coroner’s Report, which The Co-operators will request from the Coroner directly. The Co-operators’ decision may take up to six months. Upon approval of a claim, the claim settlement cheque is sent directly to the beneficiary – the services of a lawyer are not usually required in submitting a claim for death benefits. If the beneficiary is the estate, The Co-operators will require a notarized copy of the will and the certificate of appointment of Estate Trustee.

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Accidental Dismemberment Claim

  1. In the event of an accidental dismemberment claim for an insured employee or spouse, the employer and claimant complete a Dismemberment Statement form
  2. There are three sections that must be completed on a Claim for Accidental Dismemberment Benefit form:
  3. Note: Please ensure that the specific loss suffered is clearly indicated.
  4. Once completed by the appropriate individuals, mail all sections of the claim to The Co-operators

Note: Settlement of accidental dismemberment claims will be sent directly to the claimant.

For further assistance regarding any aspect of a claim, please contact The Co-operators Group Client Service Team toll free at 1-800-667-8164 or email Group_Client_Services@cooperators.ca

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