CLAIMS PROCEDURES
Health Claims
The member may submit claims to the Plan Administrator, Johnson Inc . at any time up to the end of the calendar year following the year in which the expense was incurred . All claims are paid based on the date the expense was incurred .
For all Health claim benefits, when the member’s insurance terminates for any reason, written proof of claim must be submitted to the Plan Administrator, Johnson Inc ., within 90 days of the date of termination of insurance .
Direct Pay Drugs
A drug card is issued by the Plan Administrator, Johnson Inc ., to all new members, and to any member, upon request . For drug claims incurred in Newfoundland and Labrador, an eligible member may upon presentation of the drug card, obtain drugs from a pharmacy by paying only the pharmacy dispensing fee and markup . The pharmacist will bill the Plan Administrator, Johnson Inc ., for 100% of the ingredient cost of the eligible prescribed drug .
If a drug claim is not payable in the above manner, an eligible member must pay the entire purchase cost to the pharmacy and submit proof of claim to the Plan Administrator, Johnson Inc ., for reimbursement of eligible expenses .
Hospital
An expense will be incurred if the member requests semi-private or private accommodation while in hospital . Upon presentation of the drug card to the hospital, the hospital will bill the Plan Administrator, Johnson Inc ., for the eligible expenses covered under the Hospital Benefit . The member will be required to pay the hospital the remaining expenses not covered by the Plan
Eligible Expenses
Eligible expenses must be reasonable and customary and recommended as medically necessary by a physician (except for paramedical expenses listed in the “Major Medical” section) . Payment will be based on reasonable and customary charges in the area in which the treatment is rendered.
The following is a summary of the items currently eligible for payment under this Group Plan . However, should the Provincial Health Plan alter to include any of these items, coverage under this Plan will automatically adjust in accordance with the approved legislation. Eligible expenses shall not include expenses incurred for any services, treatments and supplies which are not specifically listed in the Eligible Expenses Clause of the Master Policy.