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.
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:
- the Injury is sustained after the effective date of an Insured Person’s coverage;
- the Company is notified of the Injury within ninety (90) days from the date of the accident;
- treatment is commenced within such ninety (90) day period;
- 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:
- Continuous Positive Airway Pressure Machine (CPAP and APA)
— supplies excluded - Intermittent Positive Pressure Breathing Machine (IPPB)
— supplies excluded - Apnea Monitors for respiratory dysrhythmias
- Mist tenets and nebulizers
- Oxygen (including cylinders and concentrators) and equipment needed for its administration
- Tracheostoma tubes
- 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.
- Canes
- Crutches
- 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:
- 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.
- Standard artificial limbs — this excludes Myoelectric limbs
- Artificial eyes including repair and replacement
- Stump socks
- Shoulder harnesses
- 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
- Splints (including splints attached to a brace) — exclusions: intra-oral splints are not covered
- Casts
- 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:
- eye exams provided by a licensed ophthalmologist or optometrist
- 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:
- prescribed vitamins;
- prescribed medications falling into Federal and Provincial Schedules and bearing a Drug Identification Number (D.I.N.) on their labels;
- all injectible drugs including serums, vaccines and injectible vitamins;
- all extemporaneous preparations or compounds;
- all needles and diagnostic tests for diabetics and testing material for glycemia;
- oral contraceptives (only if you are insured for the Enhanced Option);
-
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:
- Atomizers, appliances and prosthetic devices and first aid and/or diagnostic supplies;
- Diaphragms, condoms, contraceptive jellies, or appliances normally used for contraception whether or not such prescription is given for a medical reason;
- 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;
- Prescriptions dispensed in any physician or dentist office, unless otherwise directed;
- Prescriptions dispensed in any hospital, unless otherwise directed;
- Alcohol swabs and cotton;
- Items deemed cosmetic (even if a prescription is legally required);
- 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:
- Charges for dental services provide to an Insured Person in the first three months immediately following the effective date of Dental Care Benefits;
- Charges for services provided for cosmetic reasons only
- Charges for missed or cancelled appointments, completion of forms, communications, or any other non-treatment services
- Charges for services or supplies that are not necessary dental services nor do not meet accepted standards of dental practice
- Professional fees for an anesthetist
- Replacement of lost, stolen or broken prostheses or appliances
- Protective appliances for athletic purposes
- Implant and any dental service associated with implants
- Under this benefit, charges which are covered under any other benefit in this benefit plan
- Services covered by an Workplace Safety and insurance board unless prohibited by any Government legislation
- Services and supplies not shown in the included list of benefits
- Any claim expenses for service provided by an immediate family member
- 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
- Dental services or supplies required as a result of participation in a riot or civil disturbance
- 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:
- expenses which are payable under any Government Health Insurance Plan or legally mandated program, including workers’ compensation plans;
- 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;
- charges for medical care which is experimental or not necessary according to generally accepted standards of medical practice in Canada;
- 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;
- 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.
- 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;
- charges incurred for medical care to the extent that the applicable government jurisdiction prohibits the payment of any benefits;
- 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;
- charges incurred from any attempted suicide or self-inflicted injuries or illness while the Insured Person is sane or insane;
- 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;
- drugs, medicines, services or supplies which have been self-prescribed, or prescribed by or for family members.
- charges for which the Insured Person is entitled to indemnity or compensation under any Workplace Safety and Insurance Board (WSIB) or similar legislation;
- charges resulting from the committing of or attempt to commit a criminal offence including, without restriction, an assault;
- services or supplies received outside Canada except Vision Care Services;
- 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;
- services and supplies not shown in the included list of benefits; and
- 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.