TEDB NN 010 6457

Statement date: January 10, 2018

Your plan number: 0087200
000002737 Your certificate number: 216117126
CAROL CASSIDY FRIDY
Group name: WAL-MART CANADA CORP.
17 STEWART ST
OAKVILLE ON L6K 1X4
Benefit paid to: DR. ALI ASGHAR SHAHSAVAR
Cheque number: 04608444
Dentist: DR. ALI ASGHAR SHAHSAVAR

Questions?

Your dental claim statement

Internet: www.manulife.ca/planmember
Call: 1-888-330-6484
Write: Group Health Claims
PO Box 1653
Waterloo, ON N2J 4W1

Summary of your claim

Amount Benefit We made your Plan Member Secure Site
Description submitted ($) paid ($) even better! Easy navigation, user friendly
TOTAL FOR CAROL 337.00 194.40
features and a 3 step online claims process,
check it out at
CLAIM TOTAL $337.00 $194.40 www.manulife.ca/planmember .
Amount of payment: $194.40

Details of your claim

CAROL (insured)
Amount Amount Percent Benefit
Description submitted ($) eligible ($) paid paid ($) See note

Service date: January 09, 2018

Procedure: 01205, Emergency exam
100.00 100.00 90% 90.00
Procedure: 02111, One xray
28.00 28.00 90% 25.20
Procedure: 02142, Two bitewing xrays
34.00 0.00 0.00 1
Procedure: 42832, Treatment of periodontal abscess
175.00 88.00 90% 79.20 2, 3, 4
TOTAL FOR CAROL $337.00 $216.00 $194.40

Continued on back
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 Statement date: January 10, 2018
Your plan number: 0087200
Your certificate number: 216117126
Insured: CAROL CASSIDY FRIDY

Details of your claim continued

NOTES FOR CAROL
1. Your plan covers bitewing x-rays once per 9 months .
2. Your plan covers dental services up to the amount recommended by the 2018 Ontario General Practitioner Dental Association fee guide.
This service was processed on that basis.
3. We have adjudicated this service in accordance with our administrative practices based on what is considered usual time spent for this
service.
4. Your plan covers a maximum amount of $ 2000.00 per benefit period. In the current benefit period you have received benefits of $
1575.00 .

Important messages
Our records show this patient also has other coverage. Up to 100% of this claim may be paid by submitting it to the other
plan. Include this explanation of benefits with your claim.
Please ensure all claim forms are signed when submitting for payment.

Please keep this document for income tax purposes, or if coordinating benefits with another plan. This document is sufficient
for income tax purposes. If you need a replacement copy, we charge a fee.

Respecting your privacy has always been important to us. We invite you to review our privacy policy online at
www.manulife.ca, scroll to the bottom of the page and click on 'privacy policy', or call us at 1-800-268-6195.

Key terms
Following are some explanations of key terms used in this claim statement.
Amount submitted - The amount you were charged for a product or service.
Amount eligible - The portion of the amount submitted that is eligible for whole or partial reimbursement by your plan.
Percent paid (coinsurance) - The percentage of the amount eligible that your plan covers, sometimes referred to as
coinsurance. For example, if your plan covers 80% of the amount eligible, then you will not be reimbursed for the other 20%.

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