|All about C-HIP|
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|Frequently asked questions (FAQ)|
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.
Medically necessary expenses normally charged by a hospital on an in-patient or out-patient basis for medical treatment. Coverage includes the cost of:
- accommodation up to the cost of a semi-private room;
- out-patient emergency services;
- intensive care unit, delivery room and operating rooms;
- drugs and medications that are prescribed by a physician while in hospital;
- laboratory tests, x-rays and other diagnostic procedures that are performed in a hospital;
- services, devices and supplies administered by the hospital;
- services of a physician, surgeon, nurse, technical staff and any hospital employee.
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.
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.
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.
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.
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.
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.
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:
- non-dental prostheses, such as artificial limbs and eyes, up to a combined maximum of $200 per covered person in a plan year;
- oxygen, including the rental of equipment for oxygen administration, and kidney dialysis equipment, up to a combined maximum of $500 per covered person in a plan year;
- minor applicances such as crutches, casts, splints, canes, slings, trusses, braces and walkers;
- catheters, hypodermic needles;
- temporary rental of a wheelchair or hospital-type bed (rental cost must not exceed the purchase price and requires Sun Life’s preapproval);
- blood plasma, whole blood, including the administration.
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.
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:
- the covered person is hospitalized as an in-patient for seven consecutive days or more and the attending physician has requested that an immediate family member be in attendance; or
- it is necessary for an immediate family member to identify the body of a covered person before the release of the body.
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.
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.
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.
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.
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:
- there has been no lapse in coverage;
- the covered person’s coverage was not terminated by Sun Life;
- the covered person was not returned to his/her home country under the Repatriation or Return Home provisions.
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.
Charges for Oncology treatments as an in-patient or out-patient are covered up to a lifetime maximum of $25,000 per covered person.
Prescription Drugs (Reimbursed At 80%)
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.
- drugs that legally require a prescription and have a Drug Identification Number (DIN);
- injectable drugs;
- compounded preparations, provided that the principal active ingredient is an eligible expense and has a DIN;
- immunization and vaccines, up to $100 per covered person 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.
- infant formulas (milk and milk substitutes), minerals, proteins, vitamins and collagen treatments;
- food, proteins and dietary supplements, general public products and over-the-counter drugs or medicines, whether or not prescribed, natural health products, whether or not they have a Natural Product Number (NPN);
- service fees and the cost of administering injections, serums and vaccines;
- treatments for weight loss, including drugs, hair growth stimulants, smoking cessation products, any form of contraception, drugs for the treatment of infertility, drugs for sexual dysfunction and drugs used
for cosmetic purposes;
- Accutane for the treatment of acne.
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.
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:
- podiatrist or chiropodist.
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:
- belong to a regulatory body or in the absence of a regulatory body, belong to an association approved by Sun Life,
- be licensed or registered, as required by the applicable provincial regulatory body,
- have undergone appropriate training and obtained necessary credentials in support of the services or supplies rendered,
- maintain clinical records and files consistent with the reasonable practices and standards of others in their field or as may be required by a regulatory body or association,
- produce clinical records and files to Sun Life upon request and generally act in a manner that is responsive to inquiries from Sun Life, and
- not engage in administrative practices unacceptable to Sun Life. This is not an exhaustive list of qualifications. Sun Life has the sole discretion to determine whether a paramedical practitioner is qualified to render a service or provide a supply. To the extent that the qualifications listed above apply to clinics, Sun Life has the sole discretion to determine whether a clinic is qualified such that claims for services or supplies rendered at that clinic are eligible for reimbursement under this plan.
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:
- in-patient and out-patient hospital services (including emergency room charges);
- ambulance services;
- psychiatry services;
- nurses’ services and home support (including assessment charges);
- out-patient treatment programs which would be provided under the Provincial Health Insurance Plan.
(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
- Extraction of impacted wisdom teeth, when deemed medically necessary, up to a maximum of $100 per tooth in a plan year;
- relief of dental pain, that is not caused by a dental accident or impacted wisdom teeth, up to a overall maximum of $500 per covered person in a plan year.
All treatments must be completed while covered under the plan.
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.
Return Home Benefit
Sun Life reserves the right as reasonably required, to transport a covered person to his/her home country if:
- the covered person is unable to continue his/her studies due to a covered illness or injury; or
- the covered person has a serious illness requiring ongoing treatment. 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.
Sun Life will not pay any claims for any of the following:
- a pre-existing condition;
- treatment, services or supplies that are deemed to be experimental, cosmetic, not legal or not approved for use in Canada, self-prescribed, not medically necessary, elective or non-emergency;
- charges that exceed the reasonable and customary charges in the locality where the services or supplies are provided;
- eligible expenses for which a physician’s written approval is required but not provided to Sun Life;
- a pre-authorization was required but not approved by Sun Life;
- a treatment plan was required but not submitted to Sun Life.
- medical treatment when provided by an immediate family member;
- missed or cancelled appointments, delivery charges, travel to and from appointments;
- magnetic resonance imaging (MRI), cardiac catheterization, computerized axial tomography (CAT) scans, sonograms or ultrasounds and biopsies;
- medical examinations or services required solely for the use by or at the request of a third party (including immigration purposes) or consultations with a physician by telephone or e-mail;
- failure to follow or comply with the medical advice, direction, treatment or recommendation of a physician or other health care provider or travelling when advised not to do so by a physician;
- treatment or surgery in Canada, where this coverage is purchased or where the visit is undertaken specifically for the sole purpose of obtaining medical treatment or hospital services, whether or not such visit is taken on the advice of a physician;
- expenses where a charge would not normally have been incurred in the absence of this coverage or for which a covered person is not legally obligated to pay;
- expenses incurred in the covered person’s home country;
- benefits that a covered person is entitled to receive under any other plan or which would be provided without charge in the absence of coverage under this plan;
- acupuncture, dialysis, organ transplant, bone marrow transplant, the treatment of Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or conditions arising from Human Immunodeficiency Virus (HIV), Attention Deficit Hyperactivity Disorder (ADHD) or similar conditions or diagnoses;
- medical treatment which could have been reasonably delayed until the covered person’s return to his/her home country;
- expenses that contravene or are prohibited by legislation under the applicable provincial or territorial governement health insurance program in Canada;
- translation services of any kind, even when utilized in the delivery of medical services;
- transportation by ground or air ambulance where there is no emergency;
- medical treatment when the covered person has stayed outside his/her province of residence for more than 45 consecutive days.
Sun Life will not pay any claims resulting from:
- participation in any training exercises of the armed forces, militia, national guard or organized reserve corps of any country or international authority;
- declared or undeclared war, insurrection, acts of terrorism, kidnapping, hijacking, rebellion voluntary participation in a riot, protests or act of civil disobedience;
- travelling in a country that the government of Canada has placed under a travel advisory, warning travelers to either avoid non-essential travel or avoid all travel to that country;
- committing or attempting to commit a criminal offence or an illegal act;
- operating a motorized vehicle while deemed impaired by drugs or alcohol in the jurisdiction where the vehicle is operated;
- the use of illegal drugs, misuse/abuse of drugs, alcohol or other intoxicants;
- participating in:
- any professional sports or motorized speed events or contests;
- hazardous or risky activities such as parachuting, mountain climbing,
- sky diving, bungee jumping, cave exploration or hand gliding;
- scuba diving without the appropriate certification that is recognized
- in Canada or without the accompaniment of a certified instructor;
- aviation (except as a fare-paying passenger on a commercial aircraft);
- snow skiing or snowboarding outside of marked trails at supervised
- recreational facilities;
- employment when not legally permitted to work in Canada.
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 plan where the child is covered under a student health or dental plan provided through an educational institution.
- the plan of the parent with the earlier birth date (month and day) in the calendar year. For example, if your birthday is May 1, and your spouse’s birthday is June 5, you must claim under your plan first.
- the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birth date.
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:
- the plan of the parent with custody of the child.
- the plan of the spouse of the parent with custody of the child.
- the plan of the parent not having custody of the child.
When you submit a claim, you have an obligation to disclose to Sun Life all other equivalent coverage that you or your dependents have.
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
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.
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.
Termination Of Benefits
Coverage for you and your dependents ends on the earliest of the following:
- the last day of the month for which premiums have been paid;
- the Covered Person’s 65th birthday;
- the last day of the month you no longer meet the eligibility requirements;
- the last day of the month in which a dependent ceases to be an eligible dependent;
- the date the covered person permanently leaves Canada;
- the date your authorization documentation becomes invalid for any reason;
- if it is determined that there has been fraudulent use of the coverage card; or
- the last day of the month in which the covered person refuses to be transported when declared medically or mentally fit to travel under the Repatriation and Return Home benefits above.
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:
- the date the covered person is released from hospital; or
- the 31st day following termination of coverage.
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.