Summary of forms to be used by salaried employees

when submitting claims to Maritime Life

Vision care

Retired prior to August 1, 1989

 Vision care form #GS059a-6 is required for all claims.  This form is to be completed by an optometrist or optician and then forwarded to  maritime life.    A paid receipt only is not acceptable.

Retired after August 1, 1989

 Flex-account form #GB2271 is required for reimbursement of vision care expenses.  Submit completed form along with original paid receipt to maritime life. 

Dental plan

All salaried retirees

 Maritime life dental claim form #GB2269 may be used for dental claims.  In addition a "standard dental claim form" which is available at all dentist offices is also acceptable.  Completed form must include - date of service, procedure code and dentist's fee. 

Drug plan

All salaried retirees

 Claims for prescribed drugs purchased within the province are submitted directly to maritime life via on line system controlled by the dispensing pharmacist.

 To claim reimbursement for prescribed drugs purchased outside the province use pay direct claim form #GB1831.  An original receipt must accompany the completed form.

 Chiropractor claims

Retired prior to August 1, 1989

 To claim for chiropractor expenses (expenses incurred after the annual OHIP payment is exhausted) use pay direct claim form #GB1831.  The first claim must include a statement from chiropractor indicating OHIP has paid their annual maximum fee.

 Retired after August 1, 1989

 Use flex-account form #GB2271 to claim any chiropractor expenses not paid by OHIP. 

Out of province claims

All salaried retirees

 For expenses $200.00 0r less

If you incur an out of province medical expense a claim must be submitted to OHIP first.

Example:  incurred medical expense for $200.00 while out of province.

 Submit an itemized invoice along with proof of payment to  OHIP first.  OHIP  will make a payment in accordance with their schedule of fees and then forward to you along with a "statement of payment".  Complete paid direct claim form #gb1831 and forward to maritime life  along with

(1)     Copy of the itemized invoice

(2)     Copy of OHIP statement of payment

Maritime life will then pay the outstanding balance and forward to you.

 For expenses over $200.00

Note

Out of the province medical expenses in excess of $200.00 or more are normally forwarded direct to worldwide travel assistance for payment.  The procedure to follow with these type of claims is outlined in the new maritime life travel assistance brochure. 

Prosthetic appliances and durable medical equipment

All salaried retirees

 You must receive approval from maritime life before purchasing either prosthetic appliances and or durable medical equipment.  Form #GB1305 must be completed by your physician and submitted to maritime life for approval.

 Minor expenses incurred such as the cost of crutches or cane can be submitted direct to maritime life.  Submit paid receipt along with completed form #GB1305. 

Hearing aid expenses

 Those retired prior to August 1, 1989 may submit a claim once every (36) months.  Those retired after August 1, 1989 may submit a claim once every (60 months).

Hearing aid must be purchased from a "participating provider".  To obtain reimbursement of hearing aid costs, use hearing aid form #GS007a-3. 

Ambulance charges

All salaried retirees

 When  a patient is transported to the hospital by ambulance, the hospital bills OHIP direct.  However, in the province of Ontario a surcharge is imposed on all ambulance services.   The hospital will bill you direct for this amount.  In order to obtain a  refund  of the surcharge you must pay this amount in full at the hospital, obtain a receipt and forward to maritime life along with pay direct form #GB1831. 

Semi private hospital

The plan pays for full coverage for semi-private hospital.  The hospital will bill maritime life  direct for all charges.  If you choose, a private room then you will be required to pay the difference. 

All forms described here may be obtained from the benefits administrator at the location where you last worked.

Maritime Life  Phone #      416-480-6334  or 1-800-387-8904

 Maritime Life Mailing Address:  Maritime Life Assurance Company

                                                                       Attn. Group Operations-Health And Dental Claims

                                                                       3080 Yonge St., Suite 3040

                                                                        Toronto Ontario

                                                                       M4N 3P1

Identification # for all claims is your Social Insurance Number.

 Contract or control #   - retired prior to August 1, 1989       7048-20-001

 Contract  or control # - retired after August 1, 1989              7048-25-001

Revised Jan. 2001

Author: Keith Smith.

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