Feb.

16, 2024

TANJA OGNJENOVIC
27080 27TH AVE
ALDERGROVE, Colombie-Britannique
V4W 3E7

Predetermination of benefits

Estimate of what your plan will cover

See the message labelled Important under your claim to find out if we're still reviewing your request for a
predetermination/estimate, or if we've completed it. If we have completed it, keep in mind your provider hasn't
received a copy of it. You may want to discuss it with your provider before starting treatment.

If you submitted other expenses with your predetermination, you'll receive another statement for those
expenses.

Plan number: 50088 Date processed: Feb. 9, 2024

Member ID (or certificate number): E000113878 Total estimated amount: $0.00
Plan type: Health, Drugs, Vision & Dental

TANJA - Member

Dental
Other Estimated
Service date Service Submitted Eligible insurance Deductible Payable at amount

01 FEB 2024 Misc Dental Service $1,200.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:34

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,200.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:35

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,600.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:34

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,200.00 $0.00No Data No Data No Data $0.00

1
 Feb. 16, 2024

TANJA OGNJENOVIC
27080 27TH AVE
ALDERGROVE, Colombie-Britannique
V4W 3E7

Predetermination of benefits

Estimate of what your plan will cover

Continued from previous page

Other Estimated
Service date Service Submitted Eligible insurance Deductible Payable at amount

(99999)
Tooth code:37

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,200.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:36

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,600.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:36

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,600.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:37

Note: Your claim/predetermination has been received and is currently being reviewed.

01 FEB 2024 Misc Dental Service $1,600.00 $0.00No Data No Data No Data $0.00
(99999)
Tooth code:35

Note: Your claim/predetermination has been received and is currently being reviewed.

Total: $11,200.00 $0.00 $0.00 $0.00No Data $0.00

2
 Feb. 16, 2024

TANJA OGNJENOVIC
27080 27TH AVE
ALDERGROVE, Colombie-Britannique
V4W 3E7

Predetermination of benefits

Estimate of what your plan will cover

Continued from previous page

Note

We estimate the benefit payment for this treatment would be $0.00. This estimate is valid until Aug. 9, 2024.

Conditions that may result in a different payment amount

• The actual payment amount may be lower if your plan has an annual benefit maximum and we process
more claims for this individual before you submit the claim for treatment. To determine if your benefits may
be affected by your plan maximum, you can review your claim records, contact your plan administrator, or
check with us before proceeding.
• This amount may be higher or lower if your plan has a deductible affected by treatment date or other
claims you submit.
• This amount may not be paid if your coverage ends before the treatment date, if a dependant is no longer
eligible on the treatment date, or if the claim is submitted after the submission deadline for your plan.
• This amount may change if your dental plan changes.
• This amount may be lower if the individual is covered for this treatment under another plan.
• This amount may be reassessed if the treatment is later than the date above.

If dental services that your plan covers include lab fees, they’ll be covered at the same coinsurance rate as the
eligible dental services. When this treatment is complete, please complete and submit a dental claim form for
final assessment.

The Canada Life Assurance Company provides claim processing and adjudication services only. Benefits under
the plan are funded by the contract holder and not by The Canada Life Assurance Company.

On the web Mailing address Telephone

Visit us at our personalized secure Winnipeg Benefit Payments 1-855-644-0538

service site for plan members at P.O. Box 6040 Station Main
canadalife.com Winnipeg, Manitoba
R3C 0S2