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co unearnmmu PLAN Eonnsstesurs or csrmceEceuunr open ronIEteneLMeNr OCTOBER tsrt re 25th ROAGEErmrrjl N0 EXCLUSION OPPREEXISTINGZORCHRONIC corrmrrorrs N0 MEDICAL oR STATEMENT 0E HEAErEr REourRED NolciAIMFoiitiihf N0 POLICYFEE COVERAGE ro BE EFFECTIVE NOVEMBER iSTi963 50 00 QUARTERLY FAMILY PLAN QUARTERLY Sponsored by the ISIMCOE CCOPERIITIVE MEDICAL SERVICES Suite 259 Innisfil Street Barrie 2nd Floor of the Coop Store BENEFITS IO Cystoscopic and Bronchoscopic examinations II 60 hospital visits per person per contract year by attending physician when con fined to hospital for medical illness 12 One consultation for each confinement Lacerations l° hospllal for medcal illness optometrist every two years AFTER the $25 per person per contract year for Lab 13 UNLIMITED chiropractic care by mem contract has been in force one year lees ber sof the Ontario Association of Chiro I8 One health examination afterthe first $25 per person per contract year for praciors Coop members pay only $I00 year for those who have not had medi diagnostic Xrays per visit cal treatment on more than one occasion NB The total of benefits numbered 14 15 16 1718 may not exceed $20000 per person per contract year SINGLE PLAN I4 Home and office calls starts with first call 15 Up to 20 iniection treatments per contract year 16 Up to 10 osteopathic treatments at $300 per treatment per contract year I7 Eye examinations for the correction of vision by registered ophthamologist or Surgical operation Anaesthetics Maternity care Fractures Dislocations Burns EXTRA MAJOR MEDICAL lCataEttophe Sectionl In addition to the above outlined cervical which are ayeble tram the tint dollar the COOP COMMUN rTY HEALTH PLAN Includes coverage tor the Health Extras The Meier Medical Section pays 80 at the tort of the services listed below when ordered by doctor rublect to $20000 deduction per il month period the maximum payable In any IZrnonth period It $500000 Ambulance Service Prescription Drugs $300 maximum per l2month eriodi agistered nursing services In your home t$300 maximum per l2Am0nth period Physiotherapy and related services Aanionces required leg wheel chairs nttiiicial limbs etei llastlc surgery Ior cosmetic purposes it as esuli at inIUries covered by this contract ALI SURGICAL AND MEDICAL CLAIMS ARE PAID APPLICATION TO SIMCOE COOPERATIVE MEDICAL SERVICES Suite 259 lnniltil Street Barrie Name iiirthrlnte Adder List All eligible dependents below Iiierrled Spouse Sngle mmmnlo Widowed Children Christian Nnrrte enri Monihnnd Year at iiirth it ti it the elmvelnarrrni wish to enroll In tire IOOi COMMUNITY HEALTH ILAN in nunrranra wtllr lIit arms and trittrliitmtr ill litls ilrrn also wish my cligtitie dependents ilelerl Above to have the beneitie ni Iilll IIRn um tunnu Signature Enclose the applicable nmmtnt with this Ripiicnllan Single tlrrn Qrthlerly $1550 ilRll Yrary 3100 Yenrl $0200 Family Plan Quarterly 83100 iiall Yearly 00 Yenry 011400 SCHEDULE OF FEES i962 REPRINT THE COOP COMMUNITY HEALTH PLAN DOES NOT COVER Hospital services fitting or purchase of glasses dental services cos metic plastic operations except as outlined under the Malor Medical section treatment provided under the Workmens Compensation Act or any statute providing treatment at pub lic expense treatment of tuberculosis mental Illnesses nervous disorders alcoholism epil epsy drug addiction saltInduced abortion attempted abortion attempted suicide any act contrary to the Criminal Coda treatment provided by statute for member or dis char cd member of Her Malest Forces or More ant Marine rest cures blood blood plasma or the services of blood donors WAITING PERIOD Maternity Care The Co0p shall not be liable Ior any condition aris lng from pre nancy and childbirth until alter bath itusbanrll and wile have been entitled to benefits tor period at io months Immediate ly prior to admission to hospital or treatment at ome EMPLOYEE PLAN This Plan Is available to Employee Groups at live or more at Group ates ACCORDING TO THE GENERAL SECTION OF THE ONTARIO MEDICAL ASSOCIATION