HomeMy WebLinkAbout1570A By-Law to authorize the Corporation of the Township of Clarke to enter into a contract for Medical and Surgical Services to the Municipal Employees with regard to By-Law No. 1569 of this Municipality.
WHEREAS the Council of the Township of Clarke
deem it expedient to enter into a contract on behalf of
their employees towards the cost of a Plan for Medical
and Surgical Services or payment thereof for employees or
any class thereof and their wives or husbands and children
with the Durham County Co-operative Medical Services;
NOW THEREFORE the Council of the Township of
Clarke ENACTS AS FOLLOWS:
1. The Corporation shall enter into a
contract for Medical and Surgical
Services with the Durham County
Co-Operative Medical Services,
2. Contract No 1-A- Group dated April 1, 1967
as set forth in Schedule "A" is hereby
declared to be and to form part of this
By-Law.
Read a first and second time this 7 day of November 1967.
Reeve
~`_
Clerk
Read a third time and finally passed this ~ day of
November X967•
Reeve
SEAL _ e6
Clerk
Y
t
t
ct� rt
t
OWN BERM
Y
GENERAL CONDITIONS AND DEFINITIONS
On applying for membership, the applicant. agrees that the
form of application as completed and signed by him forms part of
this contract and any error or omission therein may, at the sole dis-
cretion of the Co-Operative, void this contract ab initio.
BENEFITS:
The benefits to which a member and his dependants listed
herein shall be entitled will be determined by the plan or plans for
which his application is accepted, which will be indicated by the aer-
ie's letters of the plan or plans included in the serial number of the
certificate issued to the member.
(a) On applying for membership in the Co-Operative the mem-
ber agrees that any hospital or dootar maY furnish to the Co-Oper-
a~tive any and all information, records and copies of records not con-
trary to law, and available, relating to the diagnosis, treatment, or
services rendered to him or his dependants, and the complete history
of the hospitalization, surgical or medical treatment rendered to
him or his dependants, and the member further agrees, that the Co-
operative shall not be liable to him for any act or omission of any
hospital, doctor, or other professional persor-s to which he or his de-
pendan~ts may seek admission to or treatment from or of the servants,
agents or employees of such hospital or professional persons.
(b) Tn the event of any dispute as to the amount payable here-
under the Co-0perative shall have the righht to refer the question to
an independent physician and his decision as to the amount payable
under the tariff, or, where the tariff is not applicable, his decision
as to a proper charge for the services rendered shall be final and
conclusive.
(c) En the event the Co-Operative makes any payment for or
on behalf of a member or any dependent for any claim in respect of
which the member or dependent may have a right to recover damages
against a third person, the Co-Operative shall to the extent of its
expenditure for such services, shave a hen for such amount upon the
amount recoverable or recovered from such third ,person, and the
member and each dependant each hereby irrevocably appoints the Co-
operative his attorney to demand, collect and receive from such
third person and further instructs any solicitor or attorney or any
person acting on behalf of the member or dependant to pay the Co-
operative out of the monies recovered from such third person the
full amount of its aforesaid expenditures. If the member or depend-
ant fails or neglects to commence and prosecute an action for the re-
covery of damages against such third pertson when requested by the
Co-Operative to do so, the Co-operative may commence and prosecute
such action in the name of the member or dependant and may com-
promise and settle the same in its sole discretion and shall have a
lien upon the amount so recovered to the extent of its full expendi-
ture for services together with its cost for such action, and the mem-
ber and dependant each hereby irrevocably appoints the Co-opera-
tive his attorney for the aforesaid purposes.
TERMINATION:
The Co-Operative shall have the right to terminate this con-
tract ar any renewal at the end of six months from the effective date
of this contract or the renewal (whichever is applicable) upon giving
to the member one month's prior notice in writing of its intention
to do so. Such notice may be mailed to the last address of the mem-
ber as shown on the records of the Co-Operative by prepaid post and
shall be deemed to have been given on the date on which the letter
would reach the member's address in the ordinary cwurse of the
mail. In the event of su-h cancellation, the member shall be entitled
to a pro-rata refund of the premium paid.
(a) If the member named in th>1s contract is an unmarried
woman and marries or if such member is a married woman living
separate from her husband and she resumes co-habitation with her
husband this contract shall terminate on the sixtieth day after such
marriage or resumption or co-habitation unless within that time the
member applies for, and the Co-Operative consents to the addition of
her husband as a dependant, in which event the member sfiall pay
the family rate. If the contract is terminated in accordance with this
provision the Co-Operatic a will refund to her the unearned portion
of any subscription rate paid by her.
(b) In the event of a default being made by the member in
payment of his subscription rates when due (time being of the es-
sence) his membership shall be forfeited automatically and the
member shall not have any further benefits, rights or privileges
hereunder.
BENEFITS NOT ASSIGNABLE
None of the benefits payable to the member or his dependants
under this contract shall be assigned and in the event of the mem-
ber or his dependants attempting to assign the same or aiding or
attempting to aid any unauthorized person to obtain benefits here-
under, the liability of the Co-Operative shall be at an end and neith-
er the member nor his dependants shall be entitled to any further
benefits hereunder.
ADDING OR WITHDRAWING DEPENDANTS
A member desiring to add or withdraw a dependant may do
so at the beginning of a membership year provided that before a de•
pendant is added he first furnishes the Co-Operative with such in•
formation regarding such person as it may require and the Co-Oper•
alive agrees to the addition. A spouse may be added within sixty
days after the marriage during a membership year, and a new born
infant may be added during a membership year on written notice to
the Co-operative. Upon the addition of a dependant the member;
shall pay any additional subscription rate that may be applicable.
TREATMENT OUTSIDE OF ONTARIO
In the event of a member or dependant being treated outside
Ontario by a duly qualified physician, surgeon or medical practionei
licensed to practice medicine in the jurisdiction in which he is to
Gated, the Co-0perative agrees to pay for such treatment to the sazne
extent and subject to the same conditions as it would pay for such
services in Ontario but at a rate not exceeding what it would pay
for the same services in Ontario, providing the Co-0perative is noti~
fled in writing promptly following treatment and satisfactory evi•
dente of the treatment is furnished to the Co-0perative by the mem•
her and the professional person involved.
REINSTATEMENT
The Co-0perative at its option and upon application of any
member, may reinstate any membership which may have been for
feite>d and determined under the terms thereof, upon such .condition:
and upon payment of such charges as the Co-Operative may in any
instance decide; provided always that the acceptance by the Co-0p
erative of any payment for the subscription rates after forfeiture o~
determination shall not revive the membership until the Co-0perative
has agreed in writing to revive it.
RULES AND REGULATIONS
The Co-Operative may from time to time, adopt such rules one
regulations not inconsistent with the terms of this contract as are
reasonably necessary to facilitate payment of premiums. Such rule:
and regulation will be available foa• inspection to members and de
pendants at all reasonable business hours at the office of the Co
Operative and the contents thereof shall be binding on the parties
hereto in the same manner as if fully set forth in this contraM.
In construing this contract the words member, claimant one
dependant and the personal pronoun "he" or "his" relating theret<
and used therewith shall be read and construed as the number ant
gender of the party or parties referred to in each case may require
and the number of the verb agreeing therewith shall be construes
as agreeing with the said word or pronoun so substituted.
COMPLETE AGREEMENT
The mem+bes•'s application, this contract •with these terms ant
conditions and the aforesaid rwe-s and regulations constitute the en
lire agreement between the parties hereto. No employee of the Co
Operative is authorized to vary or change any term of it.
MEMBERSHIP
The person named in the certificate, when complying with the
terms and conditions of this contract is a member of DURHAM
COUNTY CO-OPERATIVE MEDICAL SERVICES.
ADDED BENEFITS
The Co-0perative may at any and all times when it deems i
reasonable and proper make any additions to the benefits availabeE
to the member and his dependants under the terms thereof and i
may when it deems it advisable withdraw or alter any of such ad
ditional benefits.
DEFINITIONS
The following words and expressions wherever used in this
contract shall, unless the contract otherwise indicates, have thf
meanings respectively set apposite such words or expressions.
(a) "Co-Operative" means Durham County Co-Operative Modica
Services.
(b) Member" means the person described as such in the applica
lion for this contract but shall not include the dependants.
(c) "Claimant". The person for wnose iimess or injury the mem
her is entitled to the benefits of prepaid medical or surgical treat
went.
(d) "Effective Date" shall mean the effective date of the mem
per's contract imprinted on the reverse side of this agreement.
(e) "Renewal Date" shall mean the date or dates on which the
member's contract is determined and imprinted on the revers
side of this agreement.
(f) "Contract Year" means the period of time from noon Stand
and Time on the effective date of this agreement to noon Standarc
Time on the annivemsary date thereat in the next year.
lg) "Surgical Treatment" shall mean any cutting or operative fro
cedure and the treatment of fractures, dislocations, burns, bruises
lacerations and contusions.
(h) "Dependant" shall mean the member's spouse and his or hey
unmarried children under the age of 19 years to whom the member
stand in loco parentis residing with the member and for whom tha
member or his spouse is entitled to a deduction for income tax
purposes under the Income Tax Act, provided such spouse and
children are named in the member's application. or added thereto
by endorsement and not subsequently withdrawn. Any such child
on marrying or at the end of the month in which he attains his
nineteenth birthday or on ceasing to qualify as a dependant of
his parents under the Tncome Tax Act whichever shall happen first
shall thereupon cease to be included in the term- "Dependant" and
thereafter shall not be entitled to benefit under this contract.
EXTENDED MEDICAL PLAN -SERIES 'EM'
BENEFI[Tl5:
In consideration of the payments agreed to be made by the
nember, the Co-Operative agrees to pay for the member and his de-
iendants subject to the exceptions, conditions and limitations herein
butained, the following:
(1) The professional charges of a physician, surgeon or gen-
:ral practitioner licensed to practice medicine in Ontario for home
uid office visits, subsequent to the effective date of this contract and
luring its currency at the scale of rates recommended in the General
>ection of the Ontario Medical Association Tariff of Fees (l~B Rey
hint). !Yb % 7 J
(2) Up to but not exceeding 20 injection treat~naents in all for
ill uersons eligible undo ~ this contract during any one contract year
n accordance with the said recommended rates;
(3) All of the items classified as benefits and subject to all of
he conditions, exceptions and limitations therein contained for
which the Co-Operative nos agreed to pay under the provisions of
he Surgical plan, Series "S" herein;
(4) One health examination for each person entitled to bene-
fits under this plan in each yearn after the expiry of the first con-
ract year, provided that no person is entitled to such an examina-
ion who has been a claimant for medical care hereunder in the pre-
:eding contract year whereby he required the services of a licensed
nedical practitioner on more than one occasion;
(5) Examinations of the eyes for correction of vision, by any
nechanicai device, of the member or nis dependants made by a reg-
stered ophthalmologist or a registered optometrist provided that
ucu examinations are not mane during the first contract year in
unich the member is entitled to the benefits of this plan and further
provided that after the first of sucn examinations of a claimant the
;o-Operative will not pay for any ftrrtner such examination for that
:laimant until 24 montna have elapsed since the date of the previous
examination.
1 ivIAXIMUM LIMITS
The Co-Operative shall not be liable for more than $200.00 per
ierson in each contract year for all benefits herein except those
provided in pazagraph I (4) hereof.
II EXCEPTIONS
Benefits in this plan will not include the following:
(a) Dental treatment or dental services of any kind.
(b) Drugs, medicine or any correekive appliance including-glasses.
(c) The treatment of tuberculosis, mental illness, brain injury, al-
oholism, epilepsy or drug addiction, when claimant is confined to
peciai institutions for treatment.
V LIMITATIONS OF LL~BILITY
The Co-Operative will not be liable for the cost of pro-
essional or other services under this contract unletss an account
or such service is received by it within 60 days of the last day of
he month in which such service was completed. Accounts received
fter the expiration of the said 60 days, if otherwise payable by the
:o-Operative will be paid at a discount of 10% for each period of 30
ays or any portion thereof elapsing between the end of the said
0 day period and the receipt of the account by the Co-0perative.
SURGICAL PLAN -SERIES 'S'
• tariff;
4. The treatment of fractures and dislocations in accordance
with the said recommended rates;
5. The breakrrrent for burns and lacerations;
6. The services of an anaesthetist, exclusive of the administra-
tion of caudal anaesthesia for childbirth unless the member is en-
titled thereto under the next succeeding clause;
7. Where the member has complied with the conditions herein
set out including the required waiting period, the professional charg-
es of a physician, surgeon or general practitioner for obstetrical care
in accordance with the said recommended rates, provided however
that obstetrical care wi;l include prenatal, postnatal and all treat-
ment required during confinement and delivery.
8. Hospital visits by a physician, surgeon or general practition-
er including any necessary medical treatments at the sand recom-
mended rats subject however, to the following conditions:
(a) Such hospital visits will include only one consultation, if such
is required, in any one period of hospitalizahion of the claimant;
(b) Paymenh will be made only during periods or Hospitalization,
for one call per day, and up to a limit of the first 60 days thereof
for each eligible member or dependant during any contract year.
II LIMITATIONS OF LIABILITY
The Co-Operative will not be liable for the cost of professional
"or other services under this contract unless an account for such.
service is received by it within 60 days od the last day of the month
in wnrch such service, was completed. Accounts received after the
expiration of the said 60 days, if otherwise payable by the Oo-Oper-
ative will be paid at a discount of 10% for each period of 30 days
or any portion thereof ela~plsing between the end of the said 60 day
period and the receipt of the account by the Co-Operative.
III EXCEPTIONS
Without implying any extension of the above list of services
for which the Co-Operative will be liable, the Co-Operative will not
be liable for:
(a) The treatment of injuries or illness for which treatment
is provided to the member under the Workmen's Compensatign Act
of Ontario or any other statute passed by any competent goverhment-
al authority w~hetner such statute be present>,v in force or may be
hereafter provided by which treatment is provided without expense
to the clannant.
(b) The treatment of tuberculosis, :mental illness, brain injury,
alcoholism, epilepsy or drug addiction, when claimant is confined
to special institutions for treatment.
(c) The treatment of any injury, or illness resulting from a
self-induced abortion, attempted abortion, attempted suicide or any
act ar omission contrary to the Criminal Code.
(d) hest cures, X-rays (except as in preceding paragraphs)
radium or physiotherapy, blood or blood plasma.
(e) t'ne service of blood donors.
(f) The cost of plastic operations for cosmetic or beautifying
purposes, unless required as a result of injuries covered Gy this plan.
(g) Prescriptions or drugs of any kind.
ln) Dental treatment or dental services of any kind.
IV WAITING PERIOD
Notwithstanding anything herein contained, the Co-Operative
shall not be liable for any form of care or treat~tnent for any condition
arising from pregnancy and childbirth except ectopic pregnancy,
spontaneous aoortion o~ mjscarriage when conception occurs after
the acceptance of the contract until the husband and wife have been
entitled to benefits under this contract (or the former surgical con-
tract issued by the Co-Operative) for a period of ten months immedi-
ately preceding admission to the hospital, or treatment at home,
nor for any care or treatment under this contract rendered to mem-
ber or his dependants relating to hernia or hernias (including vesi-
cal hernias); tonsils and/or adenoids, until this contract or the
former surgical contract issued by this. Co-Operative has been in
force for a continuous period of ten months.'
BENEFITS: MAJOR MEDICAL PLAN -SERIES 'M.M.'
In consideration of the payments agreed to be made by the I BENEFITS:
iember, the Co-Operative agrees to pay for k~he member and his de-
endants subject to the exceptions, conditions and limitations herein In consideration of the payments agreed to be made by the
ontained, the following• member, the Co-Operative agrees to pay for the member and his de•
1. The professional charges of a physician, surgeon or general Pendants subject to the exceptions, conditions and limitations herein
ractitioner licensed to practice medicine in Ontario for surgical contained, the following:
reatment performed on the member or his dependants, subsequent Eighty percent (80%) of the Cost of Medical Care, as defined
o the effective date of this contract and during its currency at the herein, incurred by the member during any one contract year, calcu-
cale of rates recommended in the General Section of the Ontario lated from the date of the occurrence of the first accident or the on-
fedical Association Tariff of Fees (fit) except that wher~~~Tset of the first illness subsequent to the effective date hereof and
~vo or more surgical treatments are performed on any one suoh~i~ubject to the provisions and limitations herein contained.
erson at any one time, the amount payable hereunder shall not Cost of Medical Care shall mean the aggregate charges, of
xceed the rate recommended for the principal or most expensive physicians, surgeons and general practitioners, including certified
urgical treatment performed plus one half of the rate recommended specialists, licensed • to practice medicine in Ontario, at the rates
~r the next most expensive surgical treatment performed and will hereinafter set forth for the following services when rendered to the
rclude nothing for any other surgical treatment; member or his dependants during the time this contract or any re-
l. X-rays for diagnostic purposes; newal thereof is in force as a result of illness, accidental bodily in-
3. Cystoscopic and bronchoscopic examination and other diag- jury, pregnancy, childbirth, or condition resulting therefrom, of the
ostic procedures, not requiring admission to a Hospital as a bed member and any such dependant, but does not include charges for
atient, in accordance with the rates recommended in the said O.M.A. services rendered to the member or his dependants as a result of
SERIES `11Z. M.' (Coalk3naed) vided to the tuember under the Workmen's Compensation Act o:
any illness, accident or condition resulting therefrom which origin- Ontario or any other statute passed by any competent governments
whether such statute be presently in force or may be
authorit
ated prior to the effective date of this contract;
Physicians surgeons and general practitioners services at y
hereafter provided by which treatment is provided without expensE
rates not exceeding the scale recommended by the Ontario Medical
Association in schedule of fees published in icy, 18p; and ,' P L'r' to the claimant.
(viii) Treatment for injuries or illness for which treatment is
vsuch beneditsmforba member or~d~oharged member of HerroMvia'
mein er~f l`ui
m l
bo th
di
~f
t
~
te
T ~
b
y
a
e
a
e
e
nurse who is AO
the
a mei
e
and who does not ordinarily reside in the member's home, and whose
services were ordered by the attending physician as a necessary part g
esty's Forces or the Mez'chh~ant Marine.
(tx) Any benefit provided ~to the member or his dependants under
of the patient's treatment, at rates not higher than the prevailing
rapes at the place where the services are rendered, and in no case plans S or E.M. in this contract or under any other contract issues
by this. Co-O rative, it being understood that the Co-Operative is
such benefit.
ment of an
th
a
li
t
t
b
d
h
higher than the rate for comparable services in Ontario; and
f
ll y
y
ca
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e p
up
y
o
ere
not obligated
III DEDUCTIBLE AMOUNTS:
-
i
Ambulance services from the place of injury or onset o
near to the nearest place or places for treatment; and Where +the member and his dependants are entitled to benefit:
Laboratory services, special drugs, appliances, therapy or re-
toted services administered by a registered physiotherapist .and ar- under the Surgical Plan in addition to this plan, the amount foi
which the Co-Operative is not liable will be ?,he first $100.00 of the
dered by the attending physician as necessary for treatment of any
illness or injury. cast of medical care herein.
Where the meaisber and his dependants are entitled to benefits
under the Extended Medical Plaa in addition to this Plan, the amount
II EXCEPTIONS: for which the Co-Operative is not liable will be the first $50.00 of
This plan shall not include charges for: the cost of medical care herein.
(i) Hospital Services of any kind except those set out above in this For the purpose of computing the Co-Operative's liability, the
d b
f
ll be d
t
fi
d
h
i
section. ore ap~
a
erm
ne
e
ne
e
s
cost of medical care as herein de
(ii) Dentistry or dental x-rays, eye refractions, or the fitting, or
bea
tif
in
ti
f pplying the deductible clause.
BILITY
LI
y
g
c or
u
or, cosme
purchase of glasses; and plastic surgery :
IV LIMITATIONS OF
A
purposes unless required as a result of injuries covered by this plan.
ib
t
t
d
l
i
f The Co•Operative will not be liable under this plan unless the
f hi
ti
it
i
t
h
C
-0
d
r
e
rom or con
u
t
ng
or illness resu
(ui) Treatment for injury pera
ve an
em
ze
accoun
o
s
e
o
member presents to t
,
to any atempt at suicide, while sane or insane. claim within 60 days of the end of the month is which the medical
(iv) Rest cures.
brai
injur
t
l ill
i
f
b
l
T care and services provided for herein were completed ar within 6d
tr
ar whi
h
v
ll fi
ur
f th
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a
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(v) ac
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a
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days o
alcoholism, epilepsy or drug addiction when claimant is confined to V MAXIMUM LIABILITY:
a special institution for treatment. The maximum of the Co-Operative under this .plan will be
(vi) Drugs and medications other !than those requiring written Five Thousand Dollars 05,000.00) in any contract year and during
prescriptions and dispensed by a licensed pharmacist or practising the term of this contract or any renewals thereof the maximum
physician. liability of the Co-Operative for anq one illne~ or injury of or to any
(vii) Treatment of injuries or illness for whidi treatmient is pro- one claimant will be Five Thousand Dollars, ($5.000.00).
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