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Health insurance in Canada is a product that many Canadians rely on when injured or seriously ill. Many have health insurance through their employment while others need to purchase health insurance or supplement their coverage when their employer does not provide health care benefits. Health insurance provides for loss of income or increased expenses from an illness or injury.

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What does health insurance cover in Canada?

Health insurance generally falls into the following categories:

Disability Income Benefits

Disability income benefit covers lost income and additional business expenses due to illness or injury

Medical Expense Benefits

Medical expense benefit covers the cost of eligible services and products not covered by a provincial government health program

Lump-Sum Health Insurance Benefits

Lump-sum benefits are payable if an insured suffers accidental death or dismemberment, or is diagnosed with a critical illness

A Comprehensive Guide to Health Insurance in Canada

Health Insurance – Components of the Policy

Health insurance policies include the following components:

  1. Insuring agreement: the life insurance company agrees to indemnify you according to policy terms
  2. Schedule: this includes the name of the insurance company, name of the insured, policy number, policy effective date, expiry or renewal date, insured’s smoking status, total premium and benefits covered
  3. Definitions: important definitions to note
  4. General provisions: include currency provision, assignment provision, renewable provision, grace period provision, reinstatement provision, incontestability provision, misstatement of age or “gender” provision, preexisting condition provision and payment of claims provision
  5. Exclusions: statuary exclusions and conditions

Where do I buy health insurance in Canada?

Health insurance in Canada can come from many sources and/or different insurance products.

Health insurance can be obtained through the following:

  • Directly purchasing an individual health insurance policy
  • Group insurance purchased by your employer
  • Directly from an employer, but administered through an insurance company (Administrative Service Plan)
  • Association Plans are offered through professional associations and business groups. An example would be Alumni groups, the Chamber of Commerce or Boards of Trade.
  • Special Purpose Plans such as Critical Illness, Travel Health, Car Insurance, Dismemberment Insurance or Life Insurance policies cover disability in certain circumstances
  • Government Programs such as Workers Compensation, Employment Insurance, Canadian Pension Plan or Quebec Pension Plan

Health Insurance Policy Renewal Provisions

Health insurance policy renewal provisions differ according to policy wording and the agreement you have with the health insurance company. The provisions outline the circumstances wherein the insurance company can increase your premium, refuse to renew your policy or even cancel your health insurance policy.

There are generally, five health insurance renewal categories that affect the premium rate differently:

Cancelable Health Insurance Renewal Provision:

The health insurer can cancel the policy at any time, providing sufficient notice to you. Any premiums owing to you would be reimbursed.

Optionally Renewable Health Insurance Provision:

The insurance company can increase premiums and limit coverage under certain circumstances. The health insurance company can cancel you or not renew your policy for any reason.

Conditionally Renewable Health Insurance Provision:

The Insurance Company can decide not to renew your policy at the anniversary date, but only for specific reasons not related to your health.  An example would be employment status.

Guaranteed Renewable Health Insurance Provision:

The insurance company cannot cancel or elect not to renew your health insurance policy for the rest of your life or up to a selected age.  Premiums can be increased under certain circumstances.

Non-cancelable: the insurance policy cannot be canceled or non-renewed up to a select age.  The insurer cannot increase premium rates under any circumstances.

Grace Period in Health Insurance:

A grace period in health insurance allows you to pay your premium after the premium payment due date, without penalty or lapsing coverage. The grace period is a set time frame, usually 30 days, wherein your payment becomes due.

Reinstatement Provision in Health Insurance:

The reinstatement provision in health insurance specifies the conditions under which your health insurance provider reinstates a lapsed policy.  Any outstanding premium would need to be paid along with a reinstatement application. The Insurance Company can decide to decline or accept reinstatement.

Incontestability Clause in Health Insurance:

The incontestability clause provision essentially means that a health insurance policy cannot be lapsed or canceled due to material misrepresentation after a set period, usually a minimum of two years.

Pre-existing Condition Health Insurance Canada:

The pre-existing condition provision states that the insurance company will not pay any benefits for a pre-existing condition, not disclosed in the initial health insurance application, during the first two years that the policy is in force.

Payment of Health Insurance Claims Provision:

The payment of health insurance claims provision outlines the beneficiary. If the insured dies the benefit would be payable to the insured’s estate or other beneficiaries.

Disability Health Insurance

Disability insurance in Canada was originally sold as an insurance floater attached to a life insurance policy. Today disability insurance policies are sold as individual insurance policies.

What is disability health insurance?

The definition of disability insurance is a type of health insurance designed to provide income replacement if you’re unable to work due to illness or accidental injury.   Disability insurance can also provide coverage for special types of business expenses that incur while rehabilitating from injury or illness.

How long does disability health insurance last?

Disability insurance can last up to the prescribed benefit period. There are normally two stages of benefit periods with disability insurance: short term and long term.

Short-term disability can last anywhere from 6 months to a year, depending on the disability insurance provider. This can be an individual disability policy, group disability, or government disability programs.

Long-term disability usually begins when the short-term disability insurance benefit period ends. This could be from EI insurance, Sick leave from your employer, or an individual disability insurance policy.

What is covered by disability health insurance?

Disability insurance covers you for lost income and expenses resulting from full or partial disability. Some disability insurance also covers rehabilitation costs and non-illness or injury and conditions such as pregnancy and childbirth.

What is the definition of a disability in health insurance?

The definition of disability in disability, health insurance is based on your eligibility to qualify as “totally disabled”. To receive disability insurance benefits you need to fit the definition of “total disability”. “Total Disability” under most disability insurance contracts is characterized in three ways:

  • Own Occupation – a disability where you’re not able to perform the essential duties of your occupation. This type of policy tends to be the most expensive and flexible. Professionals, such as doctors, lawyers, surgeons, dentists, etc. are usually the types of occupations that insurance companies will accept for a policy with this definition of disability.  Even if the insured can perform the duties of any other suitable job, benefits would continue to be paid and remain qualified as totally disabled.
  • Regular Occupation – very similar to “own occupation” with the exception that the insured cannot be performing duties in any other occupation. The policyholder has the option to collect benefits and not work, or work in any other occupation and have the benefit reduced or eliminated. However, the policyholder is not forced to take employment in any other occupation if able to do so.
  • Any Occupation – eligibility for benefits hinges on your inability to do work in any occupation. This type of disability insurance policy tends to be the lowest in cost.

What’s a presumptive disability in health insurance?

The presumptive disability clause in health insurance forces the insurance policy to respond without a “waiting period”. The presumptive disability clause protects an insured from having to self-insure medical expenses, should the injury or illness be serious enough that total disability is automatically diagnosed. An example would be total blindness, loss of hearing, or the loss of use of any appendage.

What is the waiting period for disability health insurance?

The “waiting period” in disability insurance is a time frame that must elapse before benefits from disability insurance are paid out.  Even if you meet the definition of a qualifying disability and are entitled to benefits the waiting period has to expire first.

The “waiting period” is very similar to an insurance deductible, in that, you’re self-insuring the initial portion of the loss or disability. The purpose of the waiting period is to discourage frivolous or superfluous claims and reduce administration costs, from the perspective of the insurance company.

From a policyholder’s point of view, a waiting period is a way of reducing initial expenses for the insurer and thereby lowering the insurance premium. The longer the waiting period for disability insurance is, the lower the premium will be. Again, think of the “waiting period” as a form of deductible.

How long is the waiting period for disability health insurance?

The “waiting period” for disability insurance depends on the definition that each insurance company places on that term. Typically, the waiting period is between 30 days to six months, but the most common waiting period is 90 days.

Some insurers define the “waiting period” as a set number of consecutive days that must elapse before any benefit is payable to the policyholder.

Some insurers will use an aggregate amount of time, or cumulative time, as to not penalize the policyholder for attempting to return to work, but not able to remain working. The cumulative number of days to satisfy the ‘waiting period”, is split up between the period before and after the attempted return to work, to satisfy the “waiting period.”

Types of disability health insurance:

  • The main sources for disability insurance come from:
  • Individual policies
  • Group policy usually through employment
  • Government programs, employment insurance or Canadian Pension Plan (CPP) or Quebec Pension Plan (QPP).
  • Special Purpose Plans
  • Association Plans

Individual Disability Insurance – having an individual disability insurance policy can have advantages over other forms of disability insurance.  The biggest benefit to individual disability policies is that it follows wherever you go.  You don’t have to rely on your employer, governmental or special purpose disability plan.

Individual disability insurance comes in three different types of plans:

  1. Non-cancelable Disability Insurance: also known as “non-cancelable guaranteed renewable”, cannot be canceled or have the insurance premium increased throughout the disability insurance policy period.
  2. Guaranteed Renewable Disability Insurance: the insurance company must renew your policy and can increase your premium in a particular class or category, but cannot raise individual premiums.
  3. Commercial Disability Insurance: the insurance company can elect to refuse or renew your disability insurance policy based on claim frequency or severity.

Disability Health Insurance Exclusions

Disability Insurance exclusions are specific situations where insurance coverage would not be triggered. Some examples include the following:

  • Intentionally self-inflicted injuries or illness
  • Injuries or illness resulting from war or any act of war
  • Injuries or illness resultant from illegal activities
  • Income losses from normal childbirth and pregnancy

Every disability insurance policy is different, along with the exclusions set out in the policy. It’s important to know exactly what is covered and what is not, so a careful reading of the policy wordings and the help of a licensed life and health insurance broker or agent is crucial.

Accidental Death and Dismemberment Insurance

Accidental death and dismemberment insurance pays a lump sum benefit should you decease or become dismembered in an accident. AD&D policies can be added to as an insurance floater or rider or can be sold as a standalone insurance policy.

AD&D policies can be considered a low-cost alternative to health insurance as the protection that accidental death and dismemberment policies offer is limited. A benefit is only payable if the insured suffers dismemberment or death.

The lump-sum benefit that accidental death and dismemberment policies payout is called the principal sum.   Benefits payable for lesser losses are expressed as percentages or ratios.    For example, the loss of an arm may pay 50%, while the dismemberment of a finger could be a 10% payout.

International Student Health Insurance Canada

Health insurance for international students provides health insurance coverage to foreign students while studying abroad.

The need for international student health insurance stems from a lack of government-funded health insurance coverage for foreign students. Without student health insurance any cost or medical treatment while abroad would be your shoulders.

Universities and Colleges usually require that international health insurance is secured before admission to the school is granted.  This is understandable as learning institutions want to ensure that you have proper insurance coverage should something bad happen while a foreign student.

Features of international student health insurance:

Lower premiums – lower health insurance premiums for international students tend to be lower as the student demographic is younger compared to the average.

Absence of Family Coverage – this essentially makes international health insurance cheaper as only one individual is covered.

Student Health Insurance Renewal – most international students who purchase health insurance while studying abroad usually never need to renew their policy as it is set for a particular term until no longer required.

Preexisting Conditions in Health Insurance

A pre-existing condition provision in health insurance means that the insurance company will not pay a benefit relating to a medical condition that you already have before the health insurance application was filled. A pre-existing condition is an illness or injury not disclosed on the initial application.

Legislation in Canada prohibits health insurance companies from denying claims that predate the policy unless specifically excluded in the policy wordings.  However, if the pre-existing condition was not disclosed in the initial application then a claim could be denied for material misrepresentation.

Health Insurance for Small Business

Health insurance for a small business addresses the need to protect a business from financial loss or ruin should key employees, partners or owners, suffer illness or disability rendering them unable to perform their employment duties.

The loss of a key person can potentially devastate a business and the livelihood the business generates for everyone that has a stake.

Types of health insurance for small businesses include:

  • Disability Insurance
  • Critical Illness Insurance
  • Key Person Insurance
  • Partnership Insurance or buy-sell insurance

Key Person Disability Insurance:

Key person disability insurance provides coverage for the financial loss of a business due to the illness or injury of an indispensable employee or person.  Usually, the “key” person is the owner of the business, and the business is both the beneficiary and policy owner.

The amount of insurance coverage needed for key person insurance is usually estimated for loss of earned value and the projected cost of finding a replacement key person.

Benefits are payable after the waiting period or elimination period has lapsed.

Partnership Insurance or Buy-Sell insurance:

Partnership insurance or buy-sell insurance provides a lump sum payment that other owners can use to buy out a deceased or disabled owner’s share of the business.  It helps other owners from using their funds or business assets to fund the agreement.

Buy-sell insurance is most suitable for businesses with multiple owners or partners and wishes not to use their funds to finance a buyout agreement

Critical illness Health insurance:

Critical illness insurance in Canada pays a lump sum benefit if you are diagnosed with a serious or life-threatening condition covered under the insurance policy.  A 30 day waiting period is usually applied.

Critical illness insurance is very flexible which allows you to pick the method in how you receive the benefit.  The lump-sum benefit from critical illness insurance can be used for the following:

  • Generating an income
  • Payoff mortgages and other debts
  • Cover the cost of experimental medical treatment
  • To accommodate your home with assistive devices
  • Can provide financial support while in rehabilitation
  • Critical Illness insurance can be converted into long term car insurance depending on your insurance company

What is the cost of health insurance in Canada?

The cost of health insurance in Canada can be wide-ranged, due to so many variables and platforms in which to purchase the insurance coverage.

With so many health insurance plans to choose from, the health insurance market is fiercely competitive.

The price of health insurance is determined by the coverage and services you choose. It only makes sense that the more coverages and services you choose the more costly the health insurance will be.

Other factors that will increase costs are pre-existing medical or health conditions.

The best any consumer can do is shop around until you find the best coverage for the best price that suits your health insurance requirements. Speak to a licensed Life and Health insurance Broker to learn more!

Health Insurance Deductibles vs Copay vs Coinsurance

A deductible on health insurance means that you’re required to pay a stated amount before any benefits can become payable.

For example: if you have a $100 deductible on your vision care coverage, that means you would need to pay the first $100 before your health insurance company initiates coverage, and will pay over and above the deductible, subject to limitations and also restrictions, depending on the company issuing the policy and the type of the policy.

The point of having a deductible is two-fold:  helps the insurance company control administrative cost with low severity claims, and also allows the policyholder to reduce their premiums by sharing in the expense of the loss.  Having a deductible also encourages policyholders to keep their choice of medical treatments to a reasonable minimum to help control the cost of health insurance coverage.

Health Insurance Copay

A copay is a small amount the policyholder needs to pay each time a covered service is used or a purchase is made.  Example: with a $10 copay for prescription drugs and pay $10 each time a covered prescription is filled.

Health Insurance Coinsurance

A coinsurance clause in a health insurance policy means that a percentage contribution from the policyholder is required on all losses, medical expenses or claims.  For example: a 25% coinsurance for a $100 medical expense would be $75 from the insurance company, leaving 25 dollars responsible by the policyholder. Health insurance can be subject to both coinsurance and deductible.