D.A. TOWNLEY  -  Plan Administrators  

health benefits




(Refer to your Identification Card and Collective Agreement for the amount of benefit.)
A percentage of your basic monthly wage or weekly equivalent will be paid to you when you are necessarily absent from work because of either accident or sickness not covered by Workers’ Compensation or similar legislation. The benefit commences from the 1st day of disability due to accident, and the 7th day of disability due to sickness, except that if, during a period of sickness disability, an employee is confined in a hospital for at least 24 consecutive hours prior to the 7th day of disability, the payment shall commence from the 1st day of hospitalization. Payments will continue as long as you are disabled and unable to work and following the prescribed treatment plan of your medical advisors, up to a maximum of 52 weeks for any continuous period of disability or upon attaining age 65, whichever is sooner. There is no limit to the number of separate periods of disability, so long as they are not due to failure to follow recommended treatment programs. Periods of disability due to the same or related causes will be considered one continuous period of disability except where you return to work and work at least 30 days between periods of disability. You must be under the care of a Physician, Surgeon, Chiropractor or other qualified Practitioner, and compliant with treatment prescribed by that
Practitioner. Failure to comply with prescribed treatment or conduct incompatible with prescribed treatment may result in discontinuation of benefits. Weekly Income claimants, whose claims are stress-related, must be directed to an Employee Family Assistance Program (EFAP). Participation in an EFAP program is mandatory for stress-related claims. This benefit is not payable during any period for which the employee is paid Employment Insurance Maternity benefits; for intentionally self-inflicted injury, while sane or insane; insurrection or war or participation in any riot. This benefit does not cover any period of disability which is due to any bodily injury or sickness for which payment is made under the Workers’ Compensation law or similar legislation, including ICBC and ICBC equivalent insurance. At the discretion of the Trustees, benefits may be payable to a Member who has a right to recover damages or benefits from any person or organization due to the same cause. Subject to approval by the Trustees, such a Member must enter into a Loan Agreement with the Plan, which states that the Member will reimburse the Plan in the amount of benefits paid out of the damages recovered. The term “damages” will include, but are not limited to, any lump sum or periodic payments received on account of past, present or future loss of income. The Plan shall be first payee of any outstanding monies owed following settlement from WCB or ICBC claims and any outstanding monies can be drawn from Long Term Disability payments, if any. In circumstances where funds are owed to the Plan, the Plan will, at a minimum, deduct 100% of any funds owed by the Plan to the Member in the form of benefits until the full debt has been repaid to the Plan. Funds owed to the Plan are expected to be repaid immediately upon the Member’s receipt of their WCB,
ICBC or equivalent payment. If a Member does not co-operate in repaying the funds owed, the file will be referred to the Plan’s legal counsel for the appropriate handling. Should the Plan be required to pursue the Member for collection of any outstanding monies, the Member will be responsible for any legal costs and administration charges incurred, associated with the Plan doing so.

Integration with Federal and Provincial Plans
Any disability income benefits which an employee becomes eligible to receive under the Canada Pension Plan or Quebec Pension Plan (primary only and not secondary) or any other disability income benefits which an employee becomes eligible to receive under any other Federal or Provincial Plan shall reduce the amount payable under this benefit to the extent that the total amount which the employee is eligible to receive from all such sources shall not exceed 85% of gross earnings at the date of commencement of his disability.

Substance Abuse Claims
An Employee is normally entitled to receive benefits only once for substance abuse-related claims under the Plan for Weekly Income and Treatment Centre costs, unless satisfactory medical evidence is provided that the Member was unable to successfully complete the treatment program due to circumstances beyond his/her control and which are not the result of a failure to follow treatment. When the Plan receives a substance abuse claim, payment will be initiated and the Member will be referred to the mandatory WORKHEALTH program through Wilson Banwell & Associates or a similar program if recommended by the insured’s treating physician. An assessment will be completed and a treatment coordinator assigned by the applicable program. With a medical referral and with the assistance of the treatment coordinator, the Member may enter a residential treatment centre or engage in other recommended treatment.Wage loss benefits will be paid for up to 7 days while a Member waits for entry into the facility, unless a longer period is necessary due to a lack of available treatment places. The Member will receive wage loss benefits for the period the Member is resident in the treatment facility or otherwise unavailable for work due to receiving treatment for substance abuse. In the normal course, this period shall not exceed 56 days unless satisfactory medical evidence is provided that a lengthier period of confinement is necessary for treatment purposes. Benefits will be paid at the regular Weekly Income benefit rate. Additionally, facility charges of the lesser
of the actual daily charge or $75.00 per day will be paid through the Extended Health Care benefit. Upon completion of the Residential Treatment Program (RTP), or other recommended treatment program, the Member is required to continue to participate in the WORKHEALTH or other applicable treatment program in order to ensure continued and successful rehabilitation. The Member may be eligible for up to 14 days of Weekly Income benefits during a transition period to accommodate work re-entry following completion of the RTP.

Guide to Obtain Benefits for Substance Abuse Treatment
The procedure for obtaining benefit coverage for treatment for substance abuse is as follows: A Member see his/her physician, who diagnoses a substance abuse problem and/or refers him/her to an appropriate specialist for diagnosis and treatment of such a problem. The physician provides medical information on theWI claim form stating that theMember is currently unavailable for work due to seeking treatment for a substance abuse problem, and provides information as to the nature of the program to which the Member has been referred. If the treatment program is other than a residential treatment program, the physician or treatment specialist must provide a satisfactory medical rationale for selecting a different treatment method. In the normal course, the Plan will only payWI benefits for the waiting period to enter the facility of up to 7 days, plus 56 days in-house treatment, unless provided with medical verification that appropriate treatment can not be completed within this time frame. Maintenance of benefits for absence from work due to substance abuse problems requires medical verification that the Member is actively pursuing treatment and is compliant with the prescribed treatment program. Benefits will normally be provided for only one period of absence from work due to substance abuse problems and treatment unless medical evidence is provided which demonstrates that unsuccessful treatment or relapse is due to circumstances beyond the Member’s control and is not the result of non-compliance with the treatment program.

Negotiated Benefit Changes
If you are on active claim for disability which commenced prior to a negotiated change in benefits, you will be eligible for the changed Weekly Income benefit on the effective date of the negotiated change for your employer.

Weekly Income Claim Procedure
In the event of a claim, refer to your employer who will have the necessary forms. It is important that you promptly report to your employer any disability which may result in a Weekly Income claim in order that the appropriate form can be completed.
Example: Claimant misses 4 days of work and sees Physician on the 5th day for an illness. Determination of eligibility commences day 5. As the waiting period for illness is 6 days with benefits payable only if still disabled on the 7th day, benefits in this example would not commence until the 11th day (day 5 plus 6 days).


Form Links

Related Links
Government of BC site for PharamCare

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