Critical Illness
Insurance

Serious illness can have life-changing consequences – not only for your health, but also for your finances. Critical illness insurance provides the comfort and security of a tax-free, lump-sum payment with no restrictions on how it is spent.

You are covered for 25 life-changing illnesses

  • Aortic Surgery
  • Aplastic Anemia
  • Bacterial Meningitis
  • Benign Brain Tumour
  • Blindness
  • Cancer
  • Coma
  • Coronary Artery Bypass Surgery
  • Deafness
  • Dementia, including Alzheimer's Disease
  • Heart Attack
  • Heart Valve Replacement or Repair
  • Kidney Failure
  • Loss of Independent Existence
  • Loss of Limbs
  • Loss of Speech
  • Major Organ Failure on Waiting List
  • Major Organ Transplant
  • Motor Neuron Disease
  • Multiple Sclerosis
  • Occupational HIV Infection
  • Paralysis
  • Parkinson’s Disease and Specified Atypical Parkinsonian Disorders
  • Severe Burns
  • Stroke
View the full definitions of covered conditions

Critical Illness Definitions

These are the 2013 Critical Illness Benchmark Definitions published by the Canadian Life and Health Insurance Association (CLHIA).  If you are insured under a Special Markets Solutions group critical illness insurance plan, please refer to your Insurance Benefits Summary or booklet wording for the definitions currently in force under your group insurance plan.

 

 

Aortic Surgery

 

Aortic Surgery means the undergoing of surgery for disease of the aorta requiring excision and surgical replacement of any part of the diseased aorta with a graft. Aorta means the thoracic and abdominal aorta but not its branches. The Surgery must be determined to be medically necessary by a Specialist.

 

Exclusion: No benefit will be payable under this condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

 

 

Aplastic Anemia

 

Aplastic Anemia means a definite Diagnosis of a chronic persistent bone marrow failure, confirmed by biopsy, which results in anemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following:

 

• marrow stimulating agents;

• immunosuppressive agents;

• bone marrow transplantation.

 

The Diagnosis of Aplastic Anemia must be made by a Specialist.

 

 

Bacterial Meningitis

 

Bacterial Meningitis means a definite Diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of Diagnosis. The Diagnosis of Bacterial Meningitis must be made by a Specialist.

 

Exclusion: No benefit will be payable under this condition for viral meningitis.

 

 

Benign Brain Tumour

 

Benign Brain Tumour means a definite Diagnosis of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgical or radiation treatment or cause Irreversible objective neurological deficit(s). The Diagnosis of Benign Brain Tumour must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition if, within the first 90 days following the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

 

• signs, symptoms or investigations that lead to a Diagnosis of Benign Brain Tumour (covered or excluded under the Policy), regardless of when the Diagnosis is made; or

• a Diagnosis of Benign Brain Tumour (covered or excluded under the Policy).

 

Medical Information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Benign Brain Tumour or any Critical Illness caused by any Benign Brain Tumour or its treatment.

 

No benefit will be payable under this condition for pituitary adenomas less than 10mm.

 

 

Blindness

 

Blindness means a definite Diagnosis of the total and Irreversible loss of vision in both eyes, evidenced by:

 

• the corrected visual acuity being 20/200 or less in both eyes; or

• the field of vision being less than 20 degrees in both eyes.

 

The Diagnosis of Blindness must be made by a Specialist.

 

 

Cancer (Life-Threatening)

 

Cancer (Life-Threatening) means a definite Diagnosis of a tumour, which must be characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Types of cancer include carcinoma, melanoma, leukemia, lymphoma, and sarcoma. The Diagnosis of Cancer (Life Threatening) must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition if, within the first 90 days following the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

 

• signs, symptoms or investigations that lead to a Diagnosis of cancer (covered or excluded under the Policy), regardless of when the Diagnosis is made; or

• a Diagnosis of cancer (covered or excluded under the Policy).

 

Medical Information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Cancer (Life Threatening) or any Critical Illness caused by any cancer or its treatment.

 

No benefit will be payable for the following:

 

• lesions described as benign, pre-malignant, uncertain, borderline, non-invasive, carcinoma in-situ (Tis), or tumours classified as Ta;

• malignant melanoma skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;

• any non-melanoma skin cancer, without lymph node or distant metastasis;

• prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;

• papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis;

• chronic lymphocytic leukemia classified less than Rai stage 1; or

• malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than AJCC Stage 2.

 

For purposes of the Policy, the terms Tis, Ta, T1a, T1b, T1 and AJCC Stage 2 are to be applied as defined in the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th Edition, 2010.

 

For purposes of the Policy, the term Rai staging is to be applied as set out in KR Rai, A Sawitsky, EP Cronkite, AD Chanana, RN Levy and BS Pasternack: Clinical staging of chronic lymphocytic leukemia. Blood 46:219, 1975.

 

 

Coma

 

Coma means a definite Diagnosis of a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least 96 hours, and for which period the Glasgow coma score must be 4 or less. The Diagnosis of Coma must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for:

 

• a medically induced coma; or

• a coma which results directly from alcohol or drug use; or

• a diagnosis of brain death.

 

 

Coronary Artery Bypass Surgery

 

Coronary Artery Bypass Surgery means the undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s). The Surgery must be determined to be medically necessary by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

 

 

Deafness

 

Deafness means a definite Diagnosis of the total and Irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The Diagnosis of Deafness must be made by a Specialist.

 

 

Dementia, including Alzheimer’s Disease

 

Dementia, including Alzheimer’s Disease means a definite Diagnosis of dementia, which must be characterized by a progressive deterioration of memory and at least one of the following areas of cognitive function:

 

• aphasia (a disorder of speech)

• aphraxia (difficulty performing familiar tasks);

• agnosia (difficulty recognizing objects); or

• disturbance in executive functioning (e.g. inability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior), which is affecting daily life.

 

The Insured Employee must exhibit

 

• Dementia of at least moderate severity, which must be evidenced by a Mini Mental State Exam of 20/30 or less, or equivalent score on another generally medically accepted test or tests of cognitive function; and

• Evidence of progressive worsening in cognitive and daily functioning either by serial cognitive tests or by history over at least a 6 month period.

 

The Diagnosis of Dementia, including Alzheimer’s Disease must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for affective or schizophrenic disorders, or delirium.

 

For purposes of the Policy, reference to the Mini Mental State Exam is to Folstein MF, Folstein SE, McHugh PR, J Psychiatr Res. 1975;12(3):189.

 

 

Heart Attack

 

Heart Attack means a definite Diagnosis of the death of heart muscle due to obstruction of blood flow, that results in a rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:

 

• heart attack symptoms

• new electrocardiogram (ECG) changes consistent with a heart attack

• development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.

 

The Diagnosis of Heart Attack must be made by a Specialist.

 

Exclusions: No benefit will be payable under this covered condition for:

 

• elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or

• ECG changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition as described above.

 

 

Heart Valve Replacement or Repair

 

Heart Valve Replacement or Repair means the undergoing of Surgery to replace any heart valve with either a natural or mechanical valve or to repair heart valve defects or abnormalities. The Surgery must be determined to be medically necessary by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for angioplasty, inter-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

 

Kidney Failure

Kidney Failure means a definite Diagnosis of chronic Irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated. The Diagnosis of Kidney Failure must be made by a Specialist.

 

Loss of Independent Existence

Loss of Independent Existence means a definite Diagnosis of the total inability to perform, by oneself, at least 2 of the following 6 Activities of Daily Living for a continuous period of at least 90 days with no reasonable chance of recovery. The Diagnosis of Loss of Independent Existence must be made by a Specialist.

 

Activities of Daily Living are:

 

bathing – the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of assistive devices;

dressing – the ability to put on and remove necessary clothing, braces, artificial limbs or other surgical appliances with or without the aid of assistive devices;

toileting – the ability to get on and off the toilet and maintain personal hygiene with or without the aid of assistive devices;

bladder and bowel continence – the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained;

transferring – the ability to move in and out of a bed, chair or wheelchair, with or without the aid of assistive devices; and

feeding – the ability to consume food or drink that already has been prepared and made available, with or without the use of assistive devices.

Loss of Limbs

Loss of Limbs means a definite Diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation. The Diagnosis of Loss of Limbs must be made by a Specialist.

 

Loss of Speech

Loss of Speech means a definite Diagnosis of the total and Irreversible loss of the ability to speak as a result of physical injury or disease, for a period of at least 180 days. The Diagnosis of Loss of Speech must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for all psychiatric related causes.

 

Major Organ Failure on Waiting List

Major Organ Failure on Waiting List means a definite Diagnosis of the Irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under Major Organ Failure on Waiting List, the Insured Employee must become enrolled as the recipient in a recognized transplant center in Canada or the United States of America that performs the required form of transplant Surgery. For the purpose of the Survival Period, the Date of Diagnosis is the date of the Insured Employee’s enrolment in the transplant centre. The Diagnosis of the major organ failure must be made by a Specialist.

 

Major Organ Transplant

Major Organ Transplant means a definite Diagnosis of the Irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under Major Organ Transplant, the Insured Person must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The Diagnosis of the major organ failure must be made by a Specialist.

 

Motor Neuron Disease

Motor Neuron Disease means a definite Diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy, or pseudo bulbar palsy, and limited to these conditions. The Diagnosis of Motor Neuron Disease must be made by a Specialist.

 

Multiple Sclerosis

Multiple Sclerosis means a definite Diagnosis of one of the following:

 

two or more separate clinical attacks, confirmed by a magnetic resonance imaging (MRI) of the nervous system, showing multiple lesions of demyelination; or,

well-defined neurological abnormalities lasting more than 6 months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination; or,

a single attack, confirmed by repeated MRI imaging of the nervous system, which shows multiple lesions of demyelination which have developed at intervals at least one month apart.

The Diagnosis of Multiple Sclerosis must be made by a Specialist.

 

Occupational HIV Infection

Occupational HIV Infection means a definite Diagnosis of infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the Insured Person’s normal occupation, which exposed the person to HIV contaminated body fluids.

 

The accidental injury leading to the infection must have occurred after the later of the Issue Date or latest Reinstatement Date of such Insured Person’s coverage.

 

Payment under this condition requires satisfaction of all of the following:

 

a) The accidental injury must be reported to the Company within 14 days of the accidental injury;

 

b) A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative;

 

c) A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;

 

d) All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America;

 

e) The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines.

 

The Diagnosis of Occupational HIV Infection must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition if:

 

the Insured Person has elected not to take any available licensed vaccine offering protection against HIV; or,

a licensed cure for HIV infection has become available prior to the accidental injury; or

HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

Paralysis

Paralysis means a definite Diagnosis of the total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event. The Diagnosis of Paralysis must be made by a Specialist.

 

Parkinson’s Disease and Specified Atypical Parkinsonian Disorders

Parkinson’s Disease and Specified Atypical Parkinsonian Disorders means a definite Diagnosis of either a) Parkinson’s Disease or b) Specified Atypical Parkinsonian Disorders, as defined below.

 

a) Parkinson’s Disease means a definite Diagnosis of primary Parkinson’s disease, a permanent neurological condition which must be characterized by bradykinesia (slowness of movement) and at least one of the following: muscular rigidity or rest tremor. The Insured Person must exhibit objective signs of progressive deterioration in function for at least one year, for which the treating neurologist has recommended dopaminergic medication or other generally medically accepted equivalent treatment for Parkinson’s Disease.

 

b) Specified Atypical Parkinson’s Disorders means a definite Diagnosis of progressive supranuclear palsy, corticobasal degeneration, or multiple system atrophy.

 

The Diagnosis of Parkinson’s Disease or a Specified Atypical Parkinsonian Disorder must be made by a Specialist.

 

Exclusions: No benefit will be payable for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders if, within the first year following the later of the Issue Date or the latest Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

 

signs, symptoms or investigations that lead to a Diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of parkinsonism, regardless of when the Diagnosis is made; or

a Diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of Parkinsonism.

Medical information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or its treatment.

 

No benefit will be payable under Parkinson’s Disease and Specified Atypical Parkinsonian Disorders for any other type of Parkinsonism.

 

Severe Burns

Severe Burns means a definite Diagnosis of third-degree burns over at least 20% of the body surface. The Diagnosis of Severe Burns must be made by a Specialist.

 

Stroke

Stroke (Cerebrovascular Accident) means a definite Diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with:

 

acute onset of new neurological symptoms, and

new objective neurological deficits on clinical examination,

persisting for more than 30 days following the Date of Diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing. The Diagnosis of Stroke must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for:

 

Transient Ischaemic Attacks; or

Intracerebral vascular events due to trauma; or

Lacunar infarcts which do not meet the definition of stroke as described above.

 

AdvanceCare Benefit Conditions

“AdvanceCare Benefit Conditions” are medical conditions for which an AdvanceCare Benefit is paid under the Group Policy with respect to an Insured Employee or Insured Spouse. These are coronary angioplasty or Early Stage Cancer as defined in this document.

 

Coronary angioplasty means the undergoing of an interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood.

 

The procedure must be determined to be medically necessary by a Specialist.

 

“Early Stage Cancer” refers to one of the following conditions:

 

malignant melanoma skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;

any non-melanoma skin cancer, without lymph node or distant metastasis;

prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;

papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis;

chronic lymphocytic leukemia classified less than Rai stage 1;

malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than AJCC Stage 2; or

Ductal Carcinoma in situ of the Breast

The Diagnosis of an Early Stage Cancer must be made by a Specialist.

 

Coverage for your children

You can also apply for up to $10,000 in coverage for your children. Children are covered for six children-specific conditions plus 22 of the adult covered conditions*.

  • Cerebral Palsy
  • Congenital Heart Disease
  • Cystic Fibrosis
  • Down Syndrome
  • Muscular Dystrophy
  • Type 1 Diabetes 

All your children are protected for one low premium rate, and children born after your initial purchase are covered without the need for medical underwriting if you apply within 180 days of their birth.

*Note that children are not eligible for Dementia including Alzheimer’s Disease, Parkinson’s Disease and Specified Atypical Parkinsonian Disorders and Loss of Independent Existence.

Additional benefits

The SISIP Financial Critical Illness Insurance Plan also offers these additional benefits:

How you use your money is up to you

Your benefit amount is tax-free, and you can spend it any way you wish. Common uses include paying off debts, home adaptation, childcare, investment, vacation, supplementing your pension, or lifestyle changes.

You are also covered for several non-life-threatening conditions

The AdvanceCare Benefit will pay 10% of the total benefit amount for coronary angioplasty and several early stage cancers. The benefit is payable for only one AdvanceCare Benefit Condition. However, payment of the AdvanceCare Benefit will not affect the benefit payment for a subsequent diagnosis* of one of the 25 covered conditions.

View full AdvanceCare Benefit definitions

Payment is not dependent on your ability to work, or your recovery

Unlike long-term disability insurance, critical illness insurance pays the benefit amount regardless of whether you are able to work while you are ill, or whether you make a full recovery.

Multiple Event Coverage

The Multiple Event Coverage benefit allows insured Members and spouses who are unfortunate enough to suffer from a separate and unrelated covered condition to claim multiple times. For complete details and illness categories, please visit specialmarkets.ia.ca/mec

Cancer recurrence

If you are diagnosed with cancer, while insured under this policy, and after 60 consecutive months of being cancer-free you are diagnosed with cancer again, the full benefit amount may be payable.

You can get assistance in arranging private medical care

Should you choose to use private medical facilities, Claims at TuGo may help you make your money go considerably further than if you personally arrange medical treatment. You can find more information at Tugo Website. Note that utilization fees may apply.

* Including signs, symptoms or investigations leading directly or indirectly to a Diagnosis of any cancer (covered or not covered under the Policy), regardless of when the Diagnosis is made

Critical Illness Definitions

25 life-changing illnesses

These are the 2013 Critical Illness Benchmark Definitions published by the Canadian Life and Health Insurance Association (CLHIA). If you are insured under a Special Markets Solutions group critical illness insurance plan, please refer to your Insurance Benefits Summary or booklet wording for the definitions currently in force under your group insurance plan.

Multiple Event Coverage

Dependent Children Critical Illness Definitions

You can apply for up to $10,000 in coverage for your children. Children are covered for six children-specific conditions plus 22 of the adult covered conditions*.

Cerebral Palsy

Cerebral Palsy means a non-progressive neurological defect characterized by spasticity and incoordination of movements.

Congenital Heart Disease

Congenital Heart Disease means a Diagnosis of one of the following heart conditions following a 30 day survival period from Diagnosis or birth, whichever comes later. The Diagnosis must be made by a qualified pediatric cardiologist and supported by appropriate cardiac imaging.

  • Atresia of any heart valve
  • Coarctation of the Aorta
  • Double Inlet Ventricle
  • Double Outlet Left Ventricle
  • Ebstein’s Anomaly
  • Eisenmenger Syndrome
  • Hypoplastic Left Heart Syndrome
  • Hypoplastic Right Ventricle
  • Single Ventricle
  • Tetralogy of Fallot
  • Total Anomalous Pulmonary Venous Connection
  • Transposition of the Great Vessels
  • Truncus Arteriosus

Exclusion: Trans-catheter procedures such as balloon valvuloplasty or percutaneous Atrial Septal Defect closure are excluded. All other congenital cardiac conditions are excluded.

Cystic Fibrosis

Cystic Fibrosis means a definitive Diagnosis of Cystic Fibrosis with evidence of chronic lung disease and pancreatic insufficiency.

Down Syndrome

Down Syndrome means a definitive Diagnosis of Down’s Syndrome supported by chromosomal evidence of Trisomy 21.

Muscular Dystrophy

Muscular Dystrophy means a definitive Diagnosis of Muscular Dystrophy, characterized by well defined neurological abnormalities, confirmed by electromyography and muscle biopsy.

Type 1 Diabetes

Type 1 Diabetes means a Diagnosis of type 1 mellitus, characterized by absolute insulin deficiency and continuous dependence on exogenous insulin for survival. The Diagnosis must be made by a qualified pediatrician or endocrinologist licenced and practicing in Canada or the United States of America and there must be evidence of dependence on insulin for a minimum of three months.

Questions? We’re here to help.

1-800-266-5667

specialmarkets@ia.ca

Accidental Dental Benefit

Detailed Benefits

Charges for the services of a licensed dental provider for the repair or replacement of sound natural teeth required as a result of an accidental Injury to the head or mouth by an external force or blow to the face and not by an object placed wittingly or unwittingly into the mouth, provided:

  1. the Injury is sustained after the effective date of an Insured Person’s coverage;
  2. the Company is notified of the Injury within ninety (90) days from the date of the accident;
  3. treatment is commenced within such ninety (90) day period;
  4. treatment is rendered within twelve (12) consecutive months of the date of the accident.

Accidental Dental Exclusions

Payment will be made in accordance with the Dental Association Suggested Fee Guide for General Practitioners in effect on the date of treatment for the province or territory in which the treatment is performed. No payment will be made for charges incurred after the termination date of this Policy or after the termination date of the Insured Person’s coverage under this Group Policy. Pre-determination of Accidental Dental Benefit: A written estimate must be obtained from the attending Dental Provider, containing details of the accident, pre-accident condition of the teeth, planned treatment and cost. The Company will review the estimate and advise the Insured Person as to the amount of the benefit payable. Approval must be obtained from the Company prior to commencement of treatment (except for such emergency treatment as is immediately required to alleviate pain). Alternate Benefit Provision: The Company reserves the right to take into account alternative procedures, services, courses of treatment and materials, and to provide benefits based on the least costly thereof which would produce a professionally adequate result, consistent with accepted standards of dental practice. Where a range of fees, laboratory charges or other individual considerations are included, the Company will determine the amount payable.

Ambulance Benefit

Detailed Benefits

Charges as a result of a medical emergency, for ground transportation by a professional ambulance service to the nearest Hospital or other medical facility capable of providing the required medical treatment (if not covered by the Insured Person’s Government Health Insurance Plan), up to the difference in amount between the Government Health Insurance Plan allowance and the usual, Reasonable and Customary charges for such services, as determined by the Company.

Ambulance Benefit Exclusions

Emergency transportation by air, rail or water may be considered provided pre-approval is obtained.

Diagnostic Services

Detailed Benefits

Diagnostic laboratory and x-ray procedures which are defined as diagnostic testing of blood, urine or other bodily fluids and tissues and radiographic examinations performed in the Insured Person’s province of residence are covered when coverage is not available under the Government Health Insurance Plan.

Durable Medical Equipment

Detailed Benefits

Charges incurred by an Insured Person for the purchase, lease or rental of the following, when prescribed by the attending Physician, for therapeutic use only:

  1. Continuous Positive Airway Pressure Machine (CPAP and APA)
    — supplies excluded
  2. Intermittent Positive Pressure Breathing Machine (IPPB)
    — supplies excluded
  3. Apnea Monitors for respiratory dysrhythmias
  4. Mist tenets and nebulizers
  5. Oxygen (including cylinders and concentrators) and equipment needed for its administration
  6. Tracheostoma tubes
  7. Standard Wheelchair, or where medically required electric wheelchairs. The maximum benefit is $3,000 every sixty (60) consecutive months per Insured Person. Pre-approval is required.
  8. Canes
  9. Crutches
  10. Walkers

Durable Medical Equipment Exclusions

If the aggregate amount of rental charges for equipment would exceed its purchase/lease or rental price based on the Physician’s prognosis and estimated duration of use, the Company at its option will pay the initial purchase price for the item in lieu of the rental charges.
A written estimate outlining the charges for the purchase/lease or rental of medical equipment must be obtained. Provincial assistive device program maximums will be taken into consideration where applicable. The Company will review the estimate and advise the Insured Person as to the amount of the benefit payable.
The medical equipment benefit does not include charges for the maintenance of medical equipment rented or purchased. Rental costs may not exceed the purchase price.

Hearing Aids

Detailed Benefits

Charges for new hearing aids purchased on the written prescription of a Physician, speech or hearing specialist, including the cost of repair to an existing hearing aid(s) will be covered.

Hearing Aids Exclusions

A Physician or Audiologist’s referral is required for the purchase of a hearing aid. Provincial assistive device program maximums will be taken into consideration where applicable.
Benefits are not payable for hearing tests, batteries and ear moulds.

Private Duty Nursing

Detailed Benefits

Charges for the services of a Registered Nurse, Licensed Practical Nurse, or Registered Nursing Assistant when the services are determined to be Medically Necessary by the attending Physician, and are performed in the Insured Person’s home.

Private Duty Nursing Exclusions

Requests for private duty nursing services must be submitted to the Company prior to the commencement of services for pre-approval in order to determine the type of caregiver and duration of eligible services which will be approved. Services must include substantive elements of personal care in order to receive approval. The approval is subject to periodic reassessment.

The nursing provider may not be a resident of the Insured Person’s home or related to the Insured Person’s family.

Benefits are not payable for agency fees, commissions, overtime charges or amounts in excess of usual, Reasonable and Customary charges as determined by the Company or charges incurred by an Insured Person who qualifies for similar coverage under a government homecare program.

Private Prosthetic Appliances & Orthopaedic Equipment

Detailed Benefits

Charges incurred by an Insured Person for purchase of the following when prescribed by the attending Physician for therapeutic use only:

  1. External breast prosthesis where required as a result of a total or radical mastectomy. The maximum benefit is one per breast per Policy Year per Insured Person.
  2. Standard artificial limbs — this excludes Myoelectric limbs
  3. Artificial eyes including repair and replacement
  4. Stump socks
  5. Shoulder harnesses
  6. Braces which are wearable, orthopaedic appliances and must be made of rigid or semi-rigid material such as metal or hard plastic to hold parts of the body in the correct position — exclusions include elastic supports and foot orthotics and dental braces which are not considered an orthopaedic appliance
  7. Splints (including splints attached to a brace) — exclusions: intra-oral splints are not covered
  8. Casts
  9. Cervical Collars

Prosthetic Appliances & Orthopaedic Equipment Exclusions

No payment will be made for charges incurred for custom moulded orthotics, custom made orthopaedic shoes or off-the-shelf orthopaedic shoes and orthopaedic modifications.

Vision Care

Detailed Benefits

The Company will reimburse the insured Member for charges incurred by an Insured Person, subject to the Reimbursement Percentage and the Benefit Maximum.

Eligible expenses include:

  1. eye exams provided by a licensed ophthalmologist or optometrist
  2. prescription eyeglasses (lenses and/or frames) or contact lenses when prescribed by a registered, certified or licensed ophthalmologist or optometrist and dispensed by a licensed ophthalmologist, optometrist or optician.

Vision Care Exclusions

The Company will not pay benefits for:

  • safety glasses, safety goggles or prescription and non-prescription sunglasses;
  • replacement of lost, stolen or broken lenses or frames
  • duplicate or spare eyeglasses
  • intra-ocular lens implants
  • laser eye surgery
  • refractions required by a client, a government body or other third party
  • services or supplies which are not for the personal use of the Insured Person.

Hospital Benefit

Detailed Benefits

If an Insured Person is hospitalized in a Hospital as a result of illness, injury and/or pregnancy, the Company will pay for daily room charges in excess of the hospital’s standard ward rate for semi-private room or private room accommodation, up to the amount stated in the Benefits Summary Table.

If the Insured Person has only obtained standard ward accommodation, the Company will pay the daily cash amount shown in the Benefits Summary Table above, starting on the third (3rd) consecutive day of hospitalization. The date of admission to standard ward accommodation in a Hospital will be used to determine eligibility of benefits.

Hospital Benefit Exclusions

The Hospital Benefit is only available if the insured Member has selected the Combo Plan with the Enhanced Option. The benefit does not provide payment for charges incurred for convalescence care, accommodation in a private hospital, a chronic care facility, or a transition ward of a Hospital.

Prescription Drug

Detailed Benefits

The insured Member will only be reimbursed for the lowest priced substitutable drug, as provided for in the Provincial Drug Benefit Formulary. The cost of the following drugs and medicines are eligible expenses when prescribed by a physician or dentist and dispensed by a licensed pharmacist:

  1. prescribed vitamins;
  2. prescribed medications falling into Federal and Provincial Schedules and bearing a Drug Identification Number (D.I.N.) on their labels;
  3. all injectible drugs including serums, vaccines and injectible vitamins;
  4. all extemporaneous preparations or compounds;
  5. all needles and diagnostic tests for diabetics and testing material for glycemia;
  6. oral contraceptives (only if you are insured for the Enhanced Option);

  7. products containing the following drugs:

    • Acetylcysteine
    • Atopine
    • Belladonna Alkaloids
    • Benzonatate
    • Colchicine
    • Coltracine Ointment
    • Cyclopentolate
    • Edrophonium Chloride
    • Ephedrine
    • Gold and Gold Compounds
    • Haloprogin
    • Heparin
    • Homatropine
    • Hyoscine and Hyocyamus
    • Niclosamide
    • Nikethamide
    • Nitroglycerin Ointment
    • Oxtriphyiline
    • Oxytocin
    • Pilocarpine
    • Placebo
    • Potassium Perchlorate
    • Potassium Supplement
    • Prenylamine
    • Probenecid
    • Proguanil
    • Pyrimethamine
    • Silver Sulfadiazine
    • Topical Application
    • Sodium Polystyrene
    • Sulfonate
    • Topical Enzymatic
    • Debriding Agents
    • Triethanolamine Polypeptide
    • Oleate
    • Tyloxapol
    • Vasopresin

The quantity of drugs which may be dispensed for any one prescription will be limited to that amount sufficient for up to a 34-day period, except in the case of drugs for long term therapy (maintenance drugs) for which up to a 100 day supply is allowable.

Prescription Drug Exclusions

Benefits are not payable for:

  1. Atomizers, appliances and prosthetic devices and first aid and/or diagnostic supplies;
  2. Diaphragms, condoms, contraceptive jellies, or appliances normally used for contraception whether or not such prescription is given for a medical reason;
  3. Proprietary and patent medicines which are defined as products registered under Division Ten (10) of the Food and Drug Act, Canada, and which bear a General Public (G.P.) number on their label and do not also bear a Drug Identification Number (D.I.N.) on their label;
  4. Prescriptions dispensed in any physician or dentist office, unless otherwise directed;
  5. Prescriptions dispensed in any hospital, unless otherwise directed;
  6. Alcohol swabs and cotton;
  7. Items deemed cosmetic (even if a prescription is legally required);
  8. Any medication which the Insured Person is eligible to receive under various Provincial Drug Benefit Plans.

Dental Care

Detailed Benefits

Diagnostic Services

  • one complete examination every thirty-six months
  • one recall examination every nine months
  • two specific examinations every twelve consecutive months
  • two emergency examinations every twelve consecutive months
  • one complete series of radiographs or panoramic radiograph every thirty-six consecutive months
  • one bite-wing radiograph every twelve consecutive months
  • cytological tests and analyses
  • histopathological tests and analyses
  • microbiological tests and analyses
  • occlusal radiographs
  • periapical radiographs

Preventive Services

  • one fluoride treatment every nine months
  • one oral hygiene instruction per lifetime
  • one unit of polishing every nine months
  • 4 units of time per Policy Year of scaling or root planning
  • interproximal disking
  • pit and fissure sealants
  • space maintainers and maintenance of space maintainers

Minor Restorative Services

  • amalgamation restorations. Bonded amalgam restorations limited to the cost of non-bonded amalgam restorations
  • prefabricated restorations (prefabricated crowns) for primary teeth only
  • tooth coloured restorations limited to anterior and bi-cuspid teeth only. Tooth coloured restorations performed on molar teeth are limited to the cost of non-bonded amalgam restorations
  • caries, trauma and pain control
  • prefabricated posts
  • retentive pins

Minor Oral Surgical Services

  • simple alveloplasty
  • antral surgery
  • extractions and residual root removal
  • fractures
  • frenectomy
  • surgical excision, exposure and incision
  • treatment of salivary glands
  • vestibuloplasty
  • hemorrhage control

Crowns/Bridges/Denture Maintenance Services

  • one denture rebase per arch every thirty-six months
  • one denture reline per arch every thirty-six months
  • denture repair
  • recementation or repair of crowns and bridgework

Adjunctive Services

  • deep sedation
  • general anaesthesia
  • nitrous oxide
  • nitrous oxide with oral sedation
  • parenteral conscious sedation
  • therapeutic injections

Endodontic Services

  • routine initial root canal therapy. Complicated root canal therapy is limited to the cost of routine root canal therapy. Retreatment of root canal is covered only if at least thirty-six (36) consecutive months have elapsed from the date of the initial root canal therapy. There is no coverage for root canal therapy for primary teeth.
  • apexification;
  • apicoectomy;
  • pulpectomy;
  • pulpotomy;
  • retrofilling;
  • root amputation
  • bleaching of endodontically treated teeth
  • hemisection
  • isolation of endodontic tooth
  • open and drain

Periodontic Services

  • periodontal appliances and maintenance limited to one (1) appliance per arch every thirty-six (36) consecutive months
  • management of oral disease
  • occlusal equilibration
  • periodontal abscess or periocoronitis
  • periodontal surgery – flap approach - osteoplasty
  • periodontal surgery – flap approach - osseous defect
  • periodontal surgery - gingival curettage
  • periodontal surgery – gingivoplasty
  • periodontal surgery – gingivectomy
  • periodontal surgery – grafts - soft tissue
  • proximal wedge

Dental Care Benefit Exclusions

In addition to the individual benefit exclusions set out in this document, benefits are not payable for:

  1. Charges for dental services provide to an Insured Person in the first three months immediately following the effective date of Dental Care Benefits;
  2. Charges for services provided for cosmetic reasons only
  3. Charges for missed or cancelled appointments, completion of forms, communications, or any other non-treatment services
  4. Charges for services or supplies that are not necessary dental services nor do not meet accepted standards of dental practice
  5. Professional fees for an anesthetist
  6. Replacement of lost, stolen or broken prostheses or appliances
  7. Protective appliances for athletic purposes
  8. Implant and any dental service associated with implants
  9. Under this benefit, charges which are covered under any other benefit in this benefit plan
  10. Services covered by an Workplace Safety and insurance board unless prohibited by any Government legislation
  11. Services and supplies not shown in the included list of benefits
  12. Any claim expenses for service provided by an immediate family member
  13. Dental services or supplies required as a result of war, terrorism, rebellion or hostilities of any kind, whether or not the Insured Person is a participant
  14. Dental services or supplies required as a result of participation in a riot or civil disturbance
  15. Dental services or supplies required due to intentional self-inflicted injury

*Important information for Quebec residents

Quebec residents must be registered under the Public Prescription Drug Insurance Plan administered by the Régie de l’assurance maladie du Québec (RAMQ), unless they are required to enroll under a private plan (usually made available through employment, professional order or professional association, or through their spouse or parents). The Extended Health and Dental Insurance being offered to alumni members will only top up the basic drug plan coverage mandated by Quebec provincial health insurance.

Please note, Quebec residents will not be able to use the Health Benefit Card for automatic reimbursement of prescription drug claims. They must submit prescription drug claims manually to iA Financial Group. If you have any questions about the Extended Health and Dental Insurance being offered, please contact an iA Financial Group Client Service Specialist by email at solutions@ia.ca or call toll free 1 (800) 266-5667.

*In addition to the individual benefit exclusions set out in this document, benefits are not payable for:

  1. expenses which are payable under any Government Health Insurance Plan or legally mandated program, including workers’ compensation plans;
  2. care, services or supplies which are for cosmetic purposes, except when in connection with reconstructive surgery to repair or replace tissue damaged by disease or bodily injury;
  3. charges for medical care which is experimental or not necessary according to generally accepted standards of medical practice in Canada;
  4. charges in excess of those deemed by iA Financial Group to be usual, Reasonable and Customary charges in the geographic region of the Insured Person’s residence;
  5. charges incurred during a period of Hospital confinement which began before the Insured Person became covered under the plan. This limitation will not apply to a child who became covered at birth.
  6. services, equipment and supplies provided in a chronic care or psychiatric hospital or institution, chronic care unit of a hospital, psychiatric unit of a hospital or when a patient is confined to a long term care facility or a transition ward of an acute hospital;
  7. charges incurred for medical care to the extent that the applicable government jurisdiction prohibits the payment of any benefits;
  8. duplicate, or replacement prosthetic appliances, devices or durable medical equipment, except where replacement is required because the existing item can no longer be made serviceable due to normal wear, or as a result of a pathological change in the patient’s condition;
  9. charges incurred from any attempted suicide or self-inflicted injuries or illness while the Insured Person is sane or insane;
  10. medical care charges resulting from riot, insurrection, war or hostilities of any kind, or any act incident thereto whether war be declared or not and whether or not the Insured Person was participating therein;
  11. drugs, medicines, services or supplies which have been self-prescribed, or prescribed by or for family members.
  12. charges for which the Insured Person is entitled to indemnity or compensation under any Workplace Safety and Insurance Board (WSIB) or similar legislation;
  13. charges resulting from the committing of or attempt to commit a criminal offence including, without restriction, an assault;
  14. services or supplies received outside Canada except Vision Care Services;
  15. charges paid under any Welfare Act, and Act respecting Workmen’s Compensation, care and services provided in municipal, provincial or federal clinics as well as charges incurred for cosmetic purposes or for treatment of mental illnesses which would normally be paid by public organizations;
  16. services and supplies not shown in the included list of benefits; and
  17. services or supplies for which an Insured Person is entitled without charge by law or for which a charge is made only because such person has insurance.