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Medical Insurance

There are two options under the College Health Insurance Plan (C-HIP): the Basic Plan and the Comprehensive Plan. Please check with your school advisor to find out which Plan applies to you.

Basic Plan

A long list of medical-related expenses are covered under the Basic Plan, including doctor’s services, hospital accommodation, eye examinations, paramedical services, ambulance services and emergency dental services. Prescription drugs are only covered when administered as an in-patient at a hospital. Please see plan booket.

Comprehensive Plan

The Comprehensive Plan includes coverage for prescription drugs.

C-HIP provides coverage up to a lifetime maximum of $2,000,000 per covered person. Reimbursement of benefits will be made only upon the submission of verification from the hospital, attending physician or surgeon that the services claimed were rendered. The following services are provided, when medically necessary, for treatment of an illness or injury, subject to the exclusions and conditions of coverage.

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Hospital Services

Medically necessary expenses normally charged by a hospital on an in-patient or out-patient basis for medical treatment. Coverage includes the cost of:

A covered person must notify Sun Life 48 hours prior to any surgery, invasive or major diagnostic procedures, unless a delay would result in a life-threatening risk. Failure to do so will result in a payment of only 80% of the eligible medical expenses.

Psychiatric Hospitalization
Expenses for the medical treatment of psychiatric disorders are covered up to a lifetime maximum of $25,000 per covered person for in-patient and out-patient hospital services.

A preferred provider network of hospitals is available. Please contact your school administrator for further details or visit the C-HIP website at www.c-hip.ca for a list of preferred provider network of hospitals. Sun Life must be notified by all service providers upon admission to determine the eligible medical expense.

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Physicians’ Services

Medically necessary services of a physician provided in hospital, home visits or during clinical visits. Services of an anaesthetist, if recommended by a physician, are also covered.

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Diagnostic Laboratory And X-Ray Services

Diagnostic laboratory tests and x-rays that are medically necessary when ordered by the attending physician during an emergency. Exclusion: Magnetic resonance imaging (MRI), cardiac catheterization, computerized axial tomography (CAT) scans, sonograms or ultrasounds and biopsies, unless approved by Sun Life.

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Ambulance Services

When there is an emergency, transportation in a licensed air and/or ground ambulance that takes a covered person to the nearest hospital for medical treatment, up to the maximum amount charged by the provincial health care plan.

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Emergency Services Outside Of Province Or Canada

Emergency services due to illness or injury that occur within 45 days of the date the covered person left his/her province of residence. The covered person must return to his/her province of residence for a period of 24 hours before becoming eligible for another 45 days of coverage. A covered person must notify Sun Life within 48 hours of admission to hospital, unless a delay would result in a life-threatening risk. Failure to do so may limit reimbursement of eligible medical expenses. If a covered person has an emergency while travelling outside of Canada, coverage is limited to the amounts covered by the provincial health insurance plan for emergency out of Canada benefits in the province where the covered person resides.

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Medical Appliances and Services

Charges for the following medical appliances and services, when prescribed by the attending physician, up to an overall maximum of $1,000 per covered person in a plan year:

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Annual Medical Examination

Charges for one visit per plan year with a physician for a general check-up, up to a maximum of $150 per visit.

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Family Transportation

Reasonable and customary charges for a round-trip economy class flight for an immediate family member, up to a maximum of $2,500 in a plan year when either:

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Living Expenses for Immediate Family Members

When an immediate family member is approved for the Family Transportation benefit, reasonable and customary charges for meals and accommodations, when provided by commercial establishments, are covered up to $150 a day and a maximum of $1,500 in a plan year. Appropriate receipts must be submitted to Sun Life for review.

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Testing for Sexually Transmitted Diseases (STD)

Charges for testing for sexually transmitted diseases (STD), up to a maximum of $100 per covered person in a plan year.

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Private Tutorial Services

Charges for the services of a qualified private teacher or tutor, if the covered person is hospitalized for at least 30 consecutive days as an in-patient due to illness or injury, up to $25 per hour and a maximum of $500 in a plan year.

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Trauma Counselling

If the covered person suffers a covered loss of single or double dismemberment, or sight of one or both eyes, or single dismemberment and loss of sight in one eye within 90 days from the date of an accident, Sun Life will pay up to six sessions of trauma counselling.

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Maternity Care

Medical expenses related to pregnancy and/or childbirth, if the pregnancy begins while covered under this plan, or within 30 days prior to the date coverage begins. Coverage must remain in effect for the full term of the pregnancy.

If the pregnancy began while covered in the plan year immediately preceding the current plan year, Maternity care may continue into the current plan year if at any time since the pregnancy began:

Coverage includes, but is not limited to, expenses for caesarean section, spontaneous or non-induced terminations of pregnancy. Expenses for induced terminations are also covered when the attending physician determines that the pregnancy constitutes a life-threatening risk and provides Sun Life with satisfactory medical evidence. Well-baby expenses for a newborn child are covered up to a maximum of $150. All expenses must be incurred in Canada. Any pregnancy related expenses incurred outside of Canada are not covered. The maximum amount for Maternity care is $25,000 per plan year.

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Oncology Treatment

Charges for Oncology treatments as an in-patient or out-patient are covered up to a lifetime maximum of $25,000 per covered person.

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Prescription Drugs (Reimbursed At 80%) - Comprehensive Plan only

Sun Life will cover the cost of the following drugs that are prescribed by a physician, dentist or other professional legally authorized to prescribe drugs, and dispensed by a pharmacist, for out-patient use to treat an illness or injury, up to a maximum of $10,000 in a plan year.

Payments for any single purchase are limited to quantities that can reasonably be used in a 30 day period. Charges in excess of the lowest priced equivalent generic product are not covered.

Sun Life will not pay for the following, even when prescribed.

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Eye Examinations

Charges for eye examinations performed by a licensed optometrist or ophthalmologist for the purpose of obtaining prescription eyewear, up to a maximum of $75 per visit once in a 24 month period.

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Paramedical Services

Charges for the services of a qualified psychologist are covered up to a maximum of $600 in a plan year for out-patient clinical visits.

Charges for the services of the following qualified paramedical practitioners are covered up to a maximum of $30 per visit and $600 per specialty per covered person in a plan year:

Qualified means a person who is a member of the appropriate governing body established by the provincial government for their profession. In the absence of a governing body, the person must be an active member of an association approved by the Company. Qualified paramedical practitioners must:

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Self-Inflicted Injuries, Suicide And Attempted Suicide Provision

Following an incident of self-inflicted injuries or attempted suicide that occurs while covered under this plan, the following expenses are reimbursed up to a lifetime maximum of $20,000 per covered person:

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Dental Services

(a) Dental Accident
Services of a dentist or dental surgeon to treat a fractured jaw or injuries to permanent natural teeth caused by an accidental blow to the mouth which occurs while covered under this plan. Treatment must take place within 90 days of the date of the accident and be completed no later than 60 days after coverage ends. Benefits will be based on the applicable Dental Association Suggested Fee Guide for General Practitioners in the province where treatment is received, up to a maximum of $2,500 per accident. The covered person must provide Sun Life with the accident report from the dentist or dental surgeon. Implants and implant-related or supported services and devices are not covered.

Pre-determination for Dental Accident

A treatment plan with complete details must be submitted in advance of receiving the treatment, unless emergency treatment is immediately required to alleviate pain, in order to determine the extent of coverage provided by the plan.

(b) Dental emergencies

All treatments must be completed while covered under the plan.

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Repatriation

If the covered person is diagnosed as terminally ill (with 12 months or less to live) and the medical condition is stable, or if the covered person dies, the plan will pay the actual cost of returning the covered person or remains by the most direct route to the air terminal nearest the covered person’s residence in his/her home country, to a maximum of $10,000 (expenses must be considered reasonable by Sun Life compared to prices generally charged for such services). Eligible expenses include economy airfare for the covered person (and stretcher, if required) and return airfare for a qualified medical attendant (if certified as necessary by the attending physician), including, if required, overnight hotel and meal expenses for the medical attendant. Coverage includes, in case of death, the reasonable and customary expenses for preparation and transportation of the remains, including cost of the casket and specialized equipment. If the covered person refuses to be transported when declared medically or mentally fit to travel, any further expenses incurred after the covered person’s refusal to be transported to his/her home country will not be covered.

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Return Home Benefit

Sun Life reserves the right as reasonably required, to transport a covered person to his/her home country if:

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Exclusions

Sun Life will not pay any claims for any of the following:

Sun Life will not pay any claims resulting from:

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Coordination Of Benefits

If you have similar benefits through any other insurer, the amount payable under this plan will be coordinated with the other plan following insurance industry standards. These standards determine which plan you should claim from first. The plan that does not contain a coordination of benefits clause is considered to be the first payer and therefore pays benefits before a plan which includes a coordination of benefits clause.

For dental accidents, health plans with dental accident coverage pay benefits before dental plans. The maximum amount that you can receive from all plans for eligible expenses is 100% of actual expenses.

Where both plans contain a coordination of benefits clause, claims must be submitted in the order described below.

Claims for a child should be submitted in the following order:

The above order applies in all situations except when parents are separated/divorced and there is no joint custody of the child, in which case the following order applies:

When you submit a claim, you have an obligation to disclose to Sun Life all other equivalent coverage that you or your dependents have.

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Claims

As a general rule, claims will be paid directly to the provider. However, in exceptional situations, the covered person may be required to pay the provider. In such cases, eligible expenses paid will be reimbursed to the covered person.

For all eligible expenses, completed claim forms, with itemized original receipts or statements (not photocopies), must be sent to:

Sun Life Assurance Company of Canada
Claims Department
P.O. Box 2015 STN Waterloo
Waterloo, ON N2J 0B1

Written proof of claim must be received by Sun Life not later than 6 months following the date the claim was incurred.

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Limitation Period

Every action or proceeding against an insurer for the recovery of insurance money payable under the plan is absolutely barred unless commenced within the time limit set out in the Insurance Act or the time set out in such other legislation as may apply to a claim, action or proceeding for insurance money.

Where or when applicable legislation permits the use of a different limitation period, no legal action or proceeding may be brought against Sun Life more than one year after the end of the time period in which the initial submission of proof of claim is required by the terms of the contract.

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Termination Of Benefits

Coverage for you and your dependents ends on the earliest of the following:

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Special Extension Of Benefits

If coverage would otherwise terminate while the covered person is hospitalized, benefits for that covered person will continue to be paid, until the earlier of:

This extension of benefits only applies to you, not your dependents.

The above summarizes the important features of the benefit plan, is prepared as information only, and does not, in itself, constitute a contract. The exact terms and conditions of the benefit plan are described in the Benefit Contract held by your educational institution.

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