A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information.
The plan covers reasonable and customary charges for the following services and supplies. All covered services and supplies must represent reasonable treatment. Treatment is considered reasonable if it is accepted by the Canadian medical profession, it is proven to be effective, and it is of a form, intensity, frequency and duration essential to the diagnosis or management of the disease or injury.
You are covered for only the healthcare benefits that apply to the level that you are in as shown in the Benefit Summary.
- Your healthcare coverage terminates when you no longer qualify for healthcare coverage through the plan.
- Ambulance transportation to the nearest centre where adequate treatment is available
- Semi-private room and board in a hospital or the government authorized co-payment for accommodation in a nursing home is covered when provided in Canada and the treatment received is acute, convalescent or palliative care.
- Acute care is active intervention required to diagnose or manage a condition that would otherwise deteriorate.
- Convalescent care is active treatment or rehabilitation for a condition that will significantly improve as a result of the care and follows a 3-day confinement for acute care.
- Palliative care is treatment for the relief of pain in the final stages of a terminal condition.
Semi-private room and board in an out-of-province hospital is covered when the treatment received is acute, convalescent or palliative care. For out-of-province accommodation, any difference between the hospital's standard ward rate and the government authorized allowance in your home province is also covered.
The plan also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province.
Residences established primarily for senior citizens or which provide personal rather than medical care are not covered.
- Home nursing services of a registered nurse, a midwife, a registered practical nurse if you are a resident of Ontario or a licensed practical nurse if you are a resident of any other province, when services are provided in Canada. No benefits are paid for services provided by a member of your family or for services which do not require the specific skills of a registered or practical nurse
You should apply for a pre-care assessment before home nursing begins
- Drugs and drug supplies described below when prescribed by a physician or other person entitled by law to prescribe them, and provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the out-of-country emergency care provision.
- Drugs which require a written prescription according to the Food and Drugs Act, Canada or provincial legislation in effect where the drug is dispensed, including oral contraceptives
- Injectable drugs including vitamins, insulins, vacines and allergy extracts. Syringes for self-administered injections are also covered when medically necessary
- Disposable needles for use with non-disposable insulin injection devices, lancets and test strips
- Extemporaneous preparations or compounds if one of the ingredients is a covered drug
- Certain other drugs that do not require a prescription by law may be covered. If you have any questions, contact your plan administrator before incurring the expense.
Canada Life can limit the covered expense to the cost of the lowest priced interchangeable drug.
For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan.
- Rental or, at Canada Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a physician including dental sleep apnea appliances.
- Orthopedic equipment, including braces, cervical collars, casts, splints external electrospinal stimulators for the correction of scoliosis, non-union bone stimulators, prone standers
- Custom-made foot orthotics, when prescribed by a chiropractor
- Custom-fitted orthopedic shoes, including modifications to orthopedic footwear, when attached to and form part of a splint, when prescribed by a chiropractor
- Hearing aids, including batteries, tubing and ear molds provided at the time of purchase, when prescribed by a physician
- Diabetic supplies prescribed by a physician: Novolin-pens or similar insulin injection devices using a needle, blood-letting devices including platforms but not lancets. Lancets are covered under prescription drugs
- Continuous Glucose Monitors and Flash Glucose Monitors prescribed by a physician - prior authorization by Canada Life is required
- Diagnostic x-rays and lab tests, when coverage is not available under your provincial government plan
- Out-of-hospital services of a qualified acupuncturist
- Out-of-hospital services of a qualified audiologist
- Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor
- Out-of-hospital services of a qualified Christian Science Practitioner
- Out-of-hospital treatment of nutritional disorders by a registered dietician
- Out-of-hospital services of a registered massage therapist
- Out-of-hospital services of a licensed naturopath
- Out-of-hospital services of a licensed osteopath, including diagnostic x-rays
- Out-of-hospital treatment of movement disorders by a licensed physiotherapist or a qualified athletic therapist
- Out-of-hospital treatment of movement disorders by a qualified occupational therapist
- Out-of-hospital treatment of foot disorders, including diagnostic x-rays, by a licensed podiatrist
- Out-of-hospital services of a qualified chiropodist
- Out-of-hospital treatment by a registered psychologist or qualified social worker
- Out-of-hospital treatment by a registered psychoanalyst (for Quebec residents only)
- Out-of-hospital treatment of speech impairments by a qualified speech therapist or speech language pathologist
- Out-of-hospital treatment by a registered clinical counselor (for BC residents only)
- Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist, and coverage is not available under your provincial government plan
- Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician
- Laser eye surgery required to correct vision when performed by a licensed ophthalmologist
For information on available discounts on eyewear and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit.
Medical Travel In Canada
The plan will pay for the following expenses if you are referred away from home by your physician for treatment by another physician within your own province or elsewhere in Canada and the round trip distance is 1,000 kilometres or more.
- Travelling expenses for the person requiring the treatment and one companion if recommended by the attending physician. Benefits are limited to either round trip economy class travel or automobile fuel expenses. Taxicab, car rental charges and automobile repair charges are not covered.
- Lodging expenses for the person requiring the treatment and one companion. Benefits are limited to moderate quality accommodation for the area in which the expense is incurred. Telephone and meal expenses are not covered.
Global Medical Assistance Program
This program provides medical assistance through a worldwide communications network which operates 24 hours a day. The network locates medical services and obtains Canada Life's approval of covered services, when required as a result of a medical emergency arising while you or your dependent is travelling for vacation, business or education. Coverage for travel within Canada is limited to emergencies arising more than 500 kilometres from home. You must be covered by the government health plan in your home province to be eligible for global medical assistance benefits. The following services are covered, subject to Canada Life's prior approval:
- On-site hospital payment when required for admission, to a maximum of $5,000
- If suitable local care is not available, medical evacuation to the nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation will be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment
- When services are covered under this provision, they are not covered under other provisions described in this booklet
- Transportation and lodging for one family member joining a patient hospitalized for more than 7 days while travelling alone. Benefits will be paid for moderate quality lodgings up to $1,500 and for a round trip economy class ticket
- If you or a dependent is hospitalized while travelling with a companion, extra costs for moderate quality lodgings for the companion when the return trip is delayed due to your or your dependent’s medical condition, to a maximum of $1,500
- The cost of comparable return transportation home for you or a dependent and one travelling companion if prearranged, prepaid return transportation is missed because you or your dependent is hospitalized. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation
- In case of death, preparation and transportation of the deceased home
- Return transportation home for minor children travelling with you or a dependent who are left unaccompanied because of your or your dependent’s hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary
- Costs of returning your or your dependent's vehicle home or to the nearest rental agency when illness or injury prevents you or your dependent from driving, to a maximum of $1,000. Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home
Benefits payable for moderate quality accommodation include telephone expenses as well as taxicab and car rental charges. Meal expenses are not covered.
Out-Of-Country Emergency Care
The plan covers medical expenses incurred as a result of a medical emergency arising while you or your dependent is outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province.
A medical emergency is a sudden, unexpected injury or an acute episode of disease.
- The following services and supplies are covered when related to the initial medical treatment:
- treatment by a physician
- diagnostic x-ray and laboratory services
- hospital accommodation in a standard or semi-private ward or intensive care unit, if the confinement begins while you or your dependent is covered
- medical supplies provided during a covered hospital confinement
- paramedical services provided during a covered hospital confinement
- hospital out-patient services and supplies
- medical supplies provided out-of-hospital if they would have been covered in Canada
- out-of-hospital services of a professional nurse
- ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available
If your medical condition permits you to return to Canada, benefits will be limited to the amount payable under this plan for continued treatment outside Canada or the amount payable under this plan for comparable treatment in Canada, plus return transportation, whichever is less.
- Except to the extent otherwise required by law, no benefits are paid for:
- Expenses private insurers are not permitted to cover by law
- Services or supplies for which a charge is made only because you have insurance coverage
- The portion of the expense for services or supplies that is payable by the government health plan in your home province, whether or not you are actually covered under the government health plan
- Any portion of services or supplies which you are entitled to receive, or for which you are entitled to a benefit or reimbursement, by law or under a plan that is legislated, funded, or administered in whole or in part by a government (“government plan”), without regard to whether coverage would have otherwise been available under this plan
- In this limitation, government plan does not include a group plan for government employees
- Services or supplies that do not represent reasonable and customary treatment
- Services or supplies associated with:
- treatment performed only for cosmetic purposes
- recreation or sports rather than with other daily living activities
- the diagnosis or treatment of infertility, other than prescribed drugs
- contraception, other than prescribed oral contraceptives and intrauterine devices (IUDs)
- Services or supplies not listed as covered expenses
- Extra medical supplies that are spares or alternates
- Services or supplies received outside Canada except as listed under Out-of-Country Emergency Care and Global Medical Assistance
- Services or supplies received out-of-province in Canada unless you are covered by the government health plan in your home province and Canada Life would have paid benefits for the same services or supplies if they had been received in your home province
- This limitation does not apply to Global Medical Assistance
- Expenses arising from war, insurrection, or voluntary participation in a riot
- Chronic care
- Visioncare services and supplies required by an employer as a condition of employment
In addition under the prescription drug coverage, no benefits are paid for:
- Atomizers, appliances, prosthetic devices, colostomy supplies, first aid supplies, diagnostic supplies or testing equipment note: these are covered under the healthcare plan and not the prescription drug plan
- Non-disposable insulin delivery devices or spring loaded devices used to hold blood letting devices
- Delivery or extension devices for inhaled medications
- Oral vitamins, minerals, dietary supplements, homeopathic preparations, infant formulas or injectable total parenteral nutrition solutions
- Diaphragms, condoms, contraceptive jellies, foams, sponges, suppositories, contraceptive implants or appliances
- Any drug that does not have a drug identification number as defined by the Food and Drugs Act, Canada
- Any single purchase of drugs which would not reasonably be used within 34 days. In the case of certain maintenance drugs, a 100-day supply will be covered
- Drugs dispensed by a dentist or clinic or by a non-accredited hospital pharmacy
- Drugs administered during treatment in an emergency room of a hospital, or as an in-patient in a hospital
- Non-injectable allergy extracts
- Drugs that are considered cosmetic, such as topical minoxidil or sunscreens, whether or not prescribed for a medical reason
- Drugs used to treat erectile dysfunction
- Drugs or drug supplies not listed in the Liste de medicaments published by the Régie de l'assurance-maladie du Québec in effect on the date of purchase or which are received out-of-province, when prescribed for a dependent child who is a student over age 24 and you are a resident of Quebec
Note: If you are age 65 or older and reside in Quebec, you cease to be covered under this plan for basic prescription drug coverage and are covered under the basic plan provided by the Régie de l’assurance-maladie du Québec, unless you elect to be covered under this plan as set out below.
A one-time election may be made to be covered under this plan. You must make this election and communicate it to your plan administrator by the end of the 60-day period immediately following:
- the date you reach age 65; or
- the date you become a resident of Quebec, within the meaning of the Health Insurance Act, Quebec, if you are age 65 or over.
While your election to be covered under this plan is in effect, you will be deemed not to be entitled to the basic plan provided by the Régie de l’assurance-maladie du Québec.
“Basic prescription drug coverage” means the portion of drug expenses that is reimbursed by the Régie de l’assurance-maladie du Québec.
How to Make a Claim
- Out-of-country claims (other than those for Global Medical Assistance expenses) should be submitted to Canada Life as soon as possible after the expense is incurred. It is very important that you send your claims to the Canada Life Out-of-Country Claims Department immediately as your Provincial Medical Plan has very strict time limitations.
Access GroupNet for Plan Members to obtain a personalized claim form or obtain form M5432 (Statement of Claim Out-of-Country Expenses form) from your plan administrator. Unless you are a resident of the Territories you must also obtain the Government Assignment form, and residents of British Columbia, Quebec and Newfoundland & Labrador must also obtain the Special Government Claim form. The Canada Life Out-of-Country Claims Department will forward the appropriate government forms to your attention when required.
If you are a resident of the Territories, you must submit your out-of-country claims to your territorial government for processing before submitting the claim to Canada Life. When you receive your Explanation of Benefits back from the territory, please send the following to the Canada Life Out-of-Country Claims Department (be sure to keep copies for your own records):
- a copy of the payment from your territory
- a completed Statement of Claim Out-of-Country Expenses form (form M5432)
- all required information
- copies of all original receipts
Residents of the provinces should complete all applicable forms, making sure all required information is included. Attach all original receipts and forward the claim to the Canada Life Out-of-Country Claims Department. Be sure to keep a copy for your own records. The plan will pay all eligible claims including your Provincial Medical Plan portion. Your Provincial Medical Plan will then reimburse the plan for the government’s share of the expenses.
Out-of-country claims must be submitted within a certain time period that varies by province. For the claims submission period applicable in your province or territory or for any other questions or for assistance in completing any of the forms, please contact Canada Life’s Out-of-Country Claims Department at 1-855-729-1839.
- Claims for expenses incurred in Canada, for paramedical services and visioncare, may be submitted online. To use this online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online.
Claims must be submitted to Canada Life as soon as possible, but no later than 12 months after you incur the expense.
You must retain your receipt for 12 months from the date you submit your claim to Canada Life as a record of the transaction, and you must submit it to Canada Life on request.
- For all other Healthcare claims, access GroupNet for Plan Members to obtain a personalized claim form or obtain claim forms from your plan administrator. Complete this form making sure it shows all required information.
Attach your receipts to the claim form and return it to the Canada Life Benefit Payment Office as soon as possible, but no later than 12 months after you incur the expense.
- For drug claims, your plan administrator will provide you with a prescription drug identification card. Present your card to the pharmacist with your prescription.
Before your prescription is filled, an Assure Claims check will be done. Assure Claims is a series of seven checks that are electronically done on your drug claim history for increased safety and compliance monitoring. This has been designed to improve the health and quality of life for you and your dependents. Checks done include drug interaction, therapeutic duplication and duration of therapy, allowing the pharmacist to react prior to the drug being dispensed. Depending on the outcome of the checks, the pharmacist may refuse to dispense the prescribed drug.
When your coverage ends, return your direct pay drug identification card to your plan administrator.