LBMAO Portal

Coverage Details

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Life

Basic Life Insurance

You have access to Basic Life Insurance products that provide a wide range of innovative, flexible solutions to meet the needs of each Plan Member. This low-cost coverage helps Plan Members plan for the financial security of their beneficiaries and manage the economic consequences of an unexpected loss.

Common Basic Life Insurance plan designs include:

Life Insurance based on a multiple of salary
Life Insurance based on a flat amount
Life Insurance based on Plan Member class

A specific plan can be designed to meet the requirements of each participating group.

Some of the highlights of Basic Life Insurance plans are:

Custom tailored plans available with generous guaranteed issue amounts
Coverage can be converted to an individual Life Insurance policy (regardless of health condition) if a Plan Member terminates his or her relationship with the Plan Sponsor

Optional Life Insurance

Each Plan Member may have different life insurance needs above the amount offered for Basic Life Insurance. Optional Life Insurance allows a Plan Member to purchase additional life insurance through payroll deductions. The cost of this coverage is considerably less than to purchase individual insurance outside of a group plan. Medical evidence of insurability is required for this benefit.

Optional Life Insurance is available with the following plan features:

Coverage can be purchased for both the Plan Member and/or their spouse (if applicable)
Coverage is available in units of $10,000 up to a maximum of $500,000
There are no minimum participation requirements, which is a valuable feature if only a few Plan Members wish to purchase the additional coverage
If coverage is transferred from an existing group plan, all coverage levels will be matched – with no medical requirements. Proof of coverage with previous insurer will be required

Dependent Life Insurance

While Basic and Optional Life Insurance cover Plan Members, the loss of a spouse or child can also result in unexpected expenses or financial burden. Dependent Group Life Insurance is an affordable benefit option that can provide the financial assistance Plan Members need to help them through this difficult time.

Coverage is available up to $5,000 for the spouse and $2,500 for each child
Coverage can be converted for a spouse if Plan Member leaves the organization

Insurance Rates

Rates for the Basic Life Insurance and Dependent Life Insurance are based on the specific demographic features of each insured group.

The volume purchasing arrangement available to you allows for very competitive Life Insurance rates.

Rates for Optional Life Insurance are based on the age and smoking status of the Plan Member and/or spouse. Each rate represents the monthly cost to purchase $10,000 of optional coverage:

Age	Smoker	Non-Smoker
Under age 35	$0.90	$0.60
35-39	$1.20	$0.70
40-44	$2.10	$1.20
45-49	$3.60	$1.90
50-54	$5.70	$3.00
55-59	$9.20	$5.50
60-64	$12.80	$7.60

For example, the cost for a 38 year old non-smoking Plan Member to purchase $50,000 of Optional Life Insurance would be $50,000 X $.70 / $10,000 = $3.50 per month.

Disability

Short Term Disability Insurance

Short Term Disability or Weekly Indemnity insurance, as it is often called, provides Plan Members with protection against short term loss of income due to injury or illness. Your group plan offers Short Term Disability insurance at affordable group rates.

Short Term Disability Insurance can be formulated to match the needs of each participating member Group. Some of the more common features of a Short Term Disability program include:

Benefit payments begin on the 1st day of disability for accident or 8th day for sickness
Maximum benefit duration is typically 17 weeks or 26 weeks
Benefit amounts typically range from 60-70% of weekly income

Short Term Disability Insurance Rates

Rates for Short Term Disability Insurance are based on each group’s own demographic content and financial experience.

The volume purchasing arrangement available through the group plan enables members to obtain competitive rates for this benefit.

Long Term Disability Insurance

The Long Term Disability program provides income replacement and protection against long term loss of income due to injury or illness.

Participating groups can design their own Long Term Disability plan and determine the level of income replacement offered to Plan Members. Benefits typically commence after 17 weeks of disability, or at the expiration of the Short Term Disability plan, where applicable.

The tax status of the LTD benefit is determined by whoever pays the premium. If the Plan Member pays 100% of the premium, the benefit does not attract income tax if they become disabled. When the plan sponsor pays the premium (or any portion of the premium) the benefit is taxable when collected.

Common features of the Long Term Disability program include:

Continuation of benefits until age 65 or earlier recovery
Flexibility in plan design
Generous overall monthly maximum benefits
Worker’s Compensation, no-fault auto insurance, group retirement or pension plan and primary CPP/QPP benefits are direct offsets

Long Term Disability Insurance Rates

Rates for Long Term Disability Insurance considers both the demographic and financial results of the entire LTD pool and your individual group.

By joining the Long Term Disability program, member organizations are able to obtain cost-effective, flexible protection for their Plan Members.

Health

Health Insurance

Comprehensive Health Insurance is an important part of any benefits package. Participating groups are able to provide their Plan Members with quality Health Insurance with flexible plan designs.

Available features of the program include:

Hospital accommodation at the semi-private or private level
Prescription Drug coverage
Vision Care
Paramedical Practitioner coverage
Out-of-Country Travel Insurance and Assistance

Health Insurance Rates

Rates for Health Insurance can vary based on the amount of coverage provided and any cost sharing features that are introduced. The program allows for a wide variety of combinations of benefit levels, deductibles, dispensing fee or coinsurance levels in order to meet the needs of each group.

The flexibility of the program in combination with the volume-purchasing arrangement creates Health Insurance rates that are affordable for any size group.

Dental

Dental Insurance

Dental care is one of the most desired and valued benefits available to Plan Members.

The program offers dental care based on a ‘building block’ approach:

Basic and Preventative Plan. This includes regular dental check-ups, cleanings, extractions and fillings. Endodontic treatment (root canal) and periodontal treatment (gum disease) can be covered at the basic level as well
Major Restorative Care may be added; this covers crowns and bridgework
Orthodontic coverage is available

Dental Insurance Rates

Plans can be designed with various deductibles or levels of coinsurance. Annual maximums can also be placed on different coverage levels.

Groups can design a plan to include:

Coinsurance for Major Restorative and Orthodontic Care
Annual maximum for Major Restorative Care
Annual deductible for Dental Insurance

Each plan design feature will create different pricing options for each member group. The program allows for high quality dental coverage at an affordable cost.

Accidental Death & Dismemberment (AD&D)

Accidental Death & Dismemberment (AD&D)

AD&D Insurance acts as an added form of protection should a Plan Member suffer a severe accident causing death or a specific loss as identified in the insurer’s Loss Schedule.

Coverage for AD&D Insurance is available to match the level of the Basic Life Insurance.

AD&D benefits are payable in addition to Life Insurance should an accident result in death (“double indemnity”).

Examples of covered losses include:

Life
Both hands or both feet
Sight of both eyes
One hand and one foot
One hand or one foot and sight of one eye
One arm or one leg
Sight of one eye
Thumb and index finger of one hand
Speech or hearing in both ears
Hearing in one ear
Use of both arms, both hands or both legs
Use of one arm or one leg
Use of one hand or one foot
After 365 days of continuous paralysis
- Quadriplegia (Total paralysis of upper and lowers limbs)
- Paraplegia (Total paralysis of both lower limbs)
- Hemiplegia (Total paralysis of one side of body)

Administrative Procedures

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Group Benefits Eligibility

Eligibility Rules: who qualifies and when?

A new Plan Member becomes eligible for coverage in accordance with the waiting periods outlined in the benefit summary pages for his or her classification.

To be eligible, the Plan Member must:

Be in an eligible class
Work the minimum number of hours per week
Have completed the waiting period
Be "actively at work" when he or she becomes eligible for coverage

Additional Provisions Spousal Eligibility

A Plan Member may cover only one spouse at a time:

A legal spouse An estranged spouse (separated) An ex-spouse (divorced) A Common-Law spouse: A Common-Law spouse is eligible for coverage under this agreement when living together in a conjugal relationship with the Plan Member continuously for a period of not less than one year.

Dependent Children

Generally, Dependent Children are eligible for coverage up to the end of the year following their 21st birthday or to the end of the year following their 25th birthday, if enroled and in full-time attendance at an accredited college or university. Children over 21 years of age may qualify for coverage if they are dependent upon the covered Plan Member by reason of a mental or physical disability. Eligibility of Unmarried Dependent Children

Dependent Children are eligible for benefits up to the age restrictions noted on the benefit summary pages provided they are not married (or living in a Common-Law relationship) and they are financially dependent on the Plan Member or the Plan Member's spouse. Dependent Children are automatically terminated upon reaching the age restrictions outlined in the Benefit Summaries. Eligibility for Over-Age Dependent Children - Student

An over-age Dependent Child is eligible for benefits provided he or she is enroled and in full-time attendance at an accredited college or university on a full-time basis. Full-time attendance means more than ten hours of classroom instruction per week.

Eligibility of Over-Age Dependent Children – Physically or Mentally Disabled A mentally or physically disabled dependent may be covered provided the dependent is incapable of self-sustaining employment and is wholly dependent upon the Plan Member or the spouse for support and maintenance. At the time of enrolment, the Plan Member should indicate any applicable information regarding a dependent's disabled status. Please note the insurer may require additional information at a later date to verify a dependent's status. If required, the insurer will request the additional information directly from the Plan Member. If a dependent becomes disabled at a later date, please contact HUB International for more information.

Survivor Benefits

In the event that the Plan Member dies while covered under this agreement, the level of health and dental benefits provided to that Plan Member will continue to cover survivors until the earlier:

24 months not to exceed the date of the second anniversary of death; or,
The date on which the spouse remarries or the Plan Member's children are no longer eligible for coverage (i.e., age 21 or age 25, if enroled and in full-time attendance at an accredited college or university or over if they are dependent upon the Plan Member by reason of a mental or physical disability).

Billing Process

The billing administration is performed by LifeWorks (formerly Morneau Shepell).

Each group will receive an invoice for the benefits during the month prior to the coverage month. For example, invoices for July’s coverage will be mailed in late June. Payment is due on the 1st of the month for that coverage month.

All cheques for monthly premiums must be made payable to
“LifeWorks -C/O T9659 – PO Box 9659, STN A – Toronto, ON M5W 1P8” and cheques must be submitted with the stub of the invoice. Without the invoice stub, payments made by cheque, cannot be allocated.

If you remit premiums using PAD the funds are withdrawn from your bank account on the 4th of each month. Credit card payments are processed on the 1st of each month.

If you need a request from to access our on-line administration system or would like to pay your premiums by pre-authorized debit or credit card, please contact the Benefits Administration Centre at LifeWorks at 1-866-432-8427.

All additions, changes, and terminations must be made on the Plan Member Enrolment Form or the Notice of Change Form, as applicable. To ensure that Plan Member changes are reflected on your next monthly premium statement, please provide notification to HUB International prior to the 12th of the month. The forms may either be emailed or faxed to your nearest HUB International office. Changes received after the 12th of the month will be reflected on the following month’s premium statement.

Premiums become payable on the first of the month coincident with or next following the eligibility date. For example, if the Plan Member’s effective date is February 10th, the Plan Member becomes eligible to submit claims on the 10th but premium payments do not start until March 1st. If the Plan Member’s effective date is February 1st (rather than February 10th) then the eligibility date would be February 1st and premium payments would also start on February 1st. Plan member who are no longer eligible for coverage are terminated from the group benefits plan on the first of the month coincident with or next following their termination date and premiums are not pro-rated. Plan Administrator must notify HUB International of Plan Member terminations within 60 days.

Adding/Changing Plan Member's Coverage

Adding or Deleting Dependents

Plan Administrator completes Sections 1, 2 and 11 of the Change Form by indicating the Plan Member's ID, name, effective date of change etc. and signs the form

Plan Member completes applicable information in Section 11 and 12 of the Change Form and signs the form

Return a copy to:

Admin Solutions Vancouver
LifeWorks
400 – 411 Dunsmuir Street
Vancouver, BC V6B 1X4

You can also fax to 1.877.464.0109 or scan and email to [email protected]

Retain the original for your files

Loss of Spousal Coverage

If health and dental benefits are initially waived by a Plan Member because he or she had comparable coverage under a spousal plan, and his or her spouse subsequently loses coverage, the Plan Member has 31 days in which to apply for benefits under your program. If application is not made within 31 days, he or she would then be considered a “late applicant” and would have to submit Evidence of Insurability before the insurer would accept the Plan Member onto the plan.

Within 31 days:

Plan Administrator completes Sections 1 and 3 to of the Change Form by indicating the Plan Member's identification number, name, effective date of change etc.
Plan Member completes Sections 2, 11 and 13 the Change Form
Fax or scan and email a copy of this form to the Benefits Administration Centre at LifeWorks.
Retain the original for your files

After 31 days:

Plan Administrator completes Sections 1 and 3 to of the Change Form by indicating the Plan Member's identification number, name, effective date of change etc.
Plan Member completes Sections 2, 11 and 13 the Change Form
Have the Plan Member complete Canada Life’s Evidence of Insurability form

Submit the original signed Evidence of Insurability Form and a photocopy of the Notice of Change Form to Canada Life.

Note: The employee does not have coverage until you receive confirmation. You will receive a letter advising you of the insurance company’s decision (approval or declination).

Please provide the employee with an Employee Booklet.

Gain of Spousal Coverage

A Plan Member can waive his or her right to health and dental benefits under the program if comparable spousal coverage is available.

Plan Administrator must complete Section 1, 2 and 4 of the Enrolment Form.

Both the Plan Member and Plan Administrator must sign the Form in Section 6.

Changing Beneficiary, Name, Address, Employment Status, Or Birth Date (Correction)

Plan Administrator completes Section 1 of the Change Form by indicating the Plan Member's , name, effective date of change etc.

Plan Member completes section 12 and signs the Change Form

Correction to date of birth is accepted only with accompanied proof of age documentation

For Beneficiary Changes, the Plan Member must sign and date the form to validate the change – keep this original form in the Plan Member’s personnel file. In the event of a claim, the original form is required by the insurance carrier.

Mail to:

Admin Solutions Vancouver
LifeWorks
400– 411 Dunsmuir Street
Vancouver, BC V6B 1X4

Fax to 1.877.464.0109; or
Scan and email to [email protected]

Note: It is important to keep a Plan Member’s beneficiary designation up-to-date as the insurance carrier will pay life benefit proceeds to the last named beneficiary only (as indicated on the employee’s original signed Enrolment or Notice of Change Form.)

Changing Salary

Plan Administrator completes Sections 1, 2 and 4 of the Change Form by indicating the Plan Member’s name, effective date of change, and current and new annual salaries. Salary changes should be reported as they occur.

Return a copy to:

Admin Solutions Vancouver
LifeWorks
400 – 411 Dunsmuir Street
Vancouver, BC V6B 1X4

You can also fax to 1.877.464.0109 or scan and email to [email protected]

Retain the original for your files

To ensure that this change is made on your next monthly premium statement, submit it to LifeWorks prior to the 12th of the month

Terminating Employee Coverage

Terminating Employment

Plan Administrator completes Section 1, 2 and 3 of the Change Form

Return a copy to:

Admin Solutions Vancouver
LifeWorks, 400 – 411
Dunsmuir Street, Vancouver, BC V6B 1X4

or (Fax) 1.877.464.0109 or scan and email to [email protected]
Retain the original for your files. We recommend that you keep the application for a period of one year following the termination date

Converting Benefits

When a Plan Member’s employment terminates due to retirement, severance, etc., he or she should be advised that all or part of his or her life insurance may be converted to an individual policy without medical evidence, provided an application is made within 31 days of his or her formal termination date. The Plan Member is also eligible to convert his or her extended health and/or dental care benefits to an individual policy within 31 days of termination under the group plan. Please note that the individual policies will not have coverage equivalent to that of the group plan.

The conversion form can be found on the carrier website or can be requested from the LifeWorks office at [email protected]
or 1-866-432-8427.

It is very important that you inform the terminating (or retiring) Plan Member of his or her right to convert benefits. After receiving the forms, the carrier(s) will contact the Plan Member directly to explain the options available, and the associated costs of coverage.

Applying for Optional Coverage

Applying for Optional Life and Optional Spousal Life Insurance

Under most group insurance programs, a Plan Member is eligible to apply for optional life and optional spousal Life Insurance.

OPTIONAL LIFE INSURANCE

The Plan Administrator must complete sections 1 – 3 of the Canada Life Evidence of Insurability form. The Plan Member must then complete the remainder of the form. Take a photocopy of the application for your records once the Plan Administrator section is complete.

The Plan Member should mail the original signed to Canada Life for approval along with the Optional Life Application Form. Since Optional Life requires medical underwriting, the Plan Member and/or his/her spouse may be asked to provide additional medical information and/or testing by the insurance company.

Mail to:

The Canada Life Assurance Company
Group Medical Underwriting
PO Box 6000
Winnipeg MB R3C 3A5

Email: [email protected]

TTY LINE 1.800.855.0511
(available for the deaf or hard of hearing)

Note: Optional Life is NOT approved until the Plan Member is notified in writing from Canada Life. You will receive a letter advising you of the insurer’s decision (approval or declination) and the new coverage will be added to your billing statement by HUB International.

Optional Accidental Death & Dismemberment Insurance

Plan Member must complete an Application for Optional AD&D Insurance. Take a photocopy of the application for your records once the Plan Administrator section is complete. The Plan Member should mail the original signed to Canada Life for processing.

Submitting a Claim

Health Claims

Prescription Drugs

Most transactions will occur at the point of sale (i.e., pharmacy).

Prescription drug claims that are purchased at the point-of-sale using the Plan Member’s pay-direct drug card (if applicable to your plan) are submitted directly to the insurance company and the Plan Member is not required to pay out-of-pocket. Any portion of the claim not reimbursed because of plan limitations (e.g., coinsurance amounts, deductibles, etc.) is the responsibility of the claimant.

If, for any reason, the Plan Member’s pay-direct drug card was not used at the point of sale, simply have the Plan Member complete the insurer’s drug claim form and attach the original receipt(s). Plan Member may submit claims directly to the insurer.

Other Health Claims (e.g., vision care, health professional services, prostheses, etc.)

Have the Plan Member complete the appropriate claim form and attach the original receipt(s). Plan Member may submit claims directly to the insurer.

Authorization from a physician is required for certain paramedical practitioners - please refer to the master contract for additional details.

Dental Claims

Most Dental claims are submitted at the point-of-sale and are submitted directly to the insurance company by the Dental Office. Any portion of the claim not reimbursed because of plan limitations (e.g. coinsurance amounts, deductibles, maximums, etc.) is the responsibility of the claimant). Your insurer also provides a claim form for any claims not submitted directly by the dentist.

For any extensive course of treatment involving crowns, bridgework, etc., which may exceed $300, we recommend the Plan Member ask his/her dentist to complete a cost estimate before the work is completed. Send the estimate to the insurer’s claim department to determine how the expenses will be reimbursed.

Before incurring any large dental expenses, or beginning any orthodontic treatment, the dental service provider should complete a treatment plan and submit it to the insurer. The insurer will calculate the benefits payable for the proposed treatment, so the Plan Member will know in advance the approximate portion of the cost they will have to pay.

Online Claim Submission

Register for GreenShield Plan Member Online Services: You may also submit certain claims online or through GreenShield’s mobile app.

Registration is quick and easy. Visit http://greenshield.ca/register. You’ll just need your GSC ID number (from your ID card) and a registration key.

Disability Claims

Short Term Disability

There are three forms that need to be completed for a Short Term Disability claim:

Employee Statement and Consent Form.
Attending Physician Statement.
Employer’s Statement.

Long Term Disability

There are three forms that need to be completed for a Long Term Disability claim:

Employee’s Statement and Consent Form.
Attending Physician’s Statement
Employer’s Statement

To submit claims online, click here. You have the option of submitting paper or electronic claims. Please follow the instructions on the Canada Life site. There is a guide available for paper submissions on the site.

It’s best to submit online, but you have options if you can’t.

You can mail or fax your forms to your local Disability Management Services Office – If you have questions about submitting online, call us at 1-855-755-6729.

Note the following:

Claims must be submitted six to eight weeks before the end of the elimination period (for long term disability) and as soon as possible after the date of disability for short term disability claims. Please refer to your benefit summary for the applicable elimination periods for both long and short term disability benefits.
When a disabled Plan Member returns to work (whether the claim was for short or long term disability), please advise HUB International as soon as possible.
If the Plan Member is Eligible for Worker's Compensation (WSIB) Benefits, he/she will receive a Worker's Compensation claim form from their employer.

Life and Dependent Life Claims

The beneficiary must complete the Group Life Claimant Statement
The plan sponsor must complete the applicable sections of the Group Life Employer Statement
The attending physician will need to complete the Attending Physician’s Certificate of Death
Once all forms are completed by the appropriate individuals, they should be forwarded to Canada Life head office or emailed to [email protected] along with the Plan Member's original enrolment Form

Accidental Death & Dismemberment Claim

Please contact HUB International for assistance with an Accidental Death or Accidental Dismemberment claim.

General Information

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Frequently Asked Questions

Becoming a member

Q: How do I become eligible for participation in the LBMAO Group Insurance Program?
A: Participation in the LBMAO Group Insurance Program is an exclusive membership privilege offered by LBMAO. Interested LBMAO members or prospective members should contact HUB International.

Billing

Q: When is my premium payment due?
A: Payment is due the first business day of the billing month (i.e. January 1 for January). Most invoices are mailed weeks prior to the due date.

Q: How and when do the rates change?
A: During an annual renewal of the plan, the insurance company examines the entire pool’s claims experience and other external factors such as inflation. They then determine the rate changes needed to support the claims in the coming year. We do negotiate these renewals on your behalf to ensure that they are remaining as competitive as possible. Rates also factor in age, family status, smoking status, and province of residence.

Q: When are notices of employee changes due?
A: To ensure that employee coverage changes (e.g., new hires, terminations, etc...) are added to your next premium statement, notify HUB International, using the Group Insurance Change Form, prior to the 12th of the month.

Q: Is it required that I adjust my monthly premium payment to reflect the changes I am submitting?
A: No. You can submit changes without adjusting the premium amount due. Your next invoice will indicate the credit or the back charges for the changes submitted.

Q: I have a new hire who needs to be added to the plan. Do I send the enrolment application with my premium?
A: No, the enrolment form should be sent to The Benefits Centre: [email protected] or faxed to 1-877-494-0109.

Q: Is there a waiting period that must be satisfied before new employees can be added to the group plan?
A: The program’s waiting period can be found on the benefit summary included in the Member benefit booklet Handbook.

Eligibility

Q: Who is considered a full-time student?
A: A student must be taking at least 10 credit hours at an accredited educational institution to be considered as a full-time student. An individual can be considered a full time student up to the age of 25.

Q: How many hours must an employee work to be eligible for enrolment?
A: Please refer to the benefit summary found in the Booklet for details on the minimum work week.

Q: Do all of my eligible employees have to enroll in the health insurance plan?
A: All eligible employees, unless insured with comparable coverage through a spouse, are required to enrol in the health insurance plan. Employees eligible to waive coverage must complete the Waiver of Coverage form. Contact The Benefits Centre with questions.

General Questions

Q: What is HUB International's role in all of this?
A: We are consultants who locate the best products to suit your needs as well as ensure the financial competitiveness of your programs. We are also the Third-Party Administrators (TPA) who manage and run all of the administration required of a group insurance program. We do not, however, insure the program (pay the claims) but rather work with various insurance companies on your behalf.

Definitions

In an effort to continually improve the glossary, we welcome all suggestions. If you need help with a particular word and cannot find it in the glossary, please let us know

Accidental Death & Dismemberment - A lump sum payment if the insured dies as a result of an accident or loses eyesight, hearing, or appendages (i.e. arms, legs, feet and hands).
Acupuncture - Services provided within their specialty by acupuncturists authorized to practice acupuncture in Canada or in the province where the services are provided.
Administrator - Individual or company responsible for administering the group insurance contract including the accounting and enrollment.
Adverse Selection - Persons poorer-than-average health (or health expectations) tend to apply for greater insurance coverage than do persons in average or better health.
Age Reduction - A reduction in the amount of insurance when a person reaches a certain age. See Termination age
Aggregate - When referring to a family deductible or out-of-pocket maximum, aggregate implies that the family charges may total up to the maximum, as long as one member- meets the individual amount.
Allowable Expense - Any claims that meet the criteria of the insurance policy which you are covered by.
Annual Maximum - The maximum amount any one individual may receive, per year, under an insurance contract.
Anti-selection - The selection of coverage beneficial to the employee but not beneficial to the plan itself.
Association Group Plans Health - plans designed for members of an association.
Audiology - Services provided within their specialty by audiologists authorized to practice audiology in Canada or in the province where the services are provided.

Basic Life Coverage The base (core) life insurance plan, offered either as a lump sum or in multiples of salary. If desired, additional life coverage can be added to Basic Life to increase the coverage: see Optional Life Coverage.
Beneficiary The person designated by the insured to receive Group Life and/or Accidental Death Benefits upon the death of the insured.
Benefit The amount payable by the insurance company to the holder, assignee or beneficiary of the insurance policy when a loss covered by the policy occurs.

Canada Pension Plan (CPP) - Government plan that pays a monthly pension to eligible individuals. See Offsets.
Carrier - The insurer who agrees to underwrite the group contract and provide certain types of coverage and service.
Child, Handicapped - Specific provision in contract for the continuing coverage of dependent child regardless of age, if handicapped and unable to provide for themselves.
Chiropractic - Services provided by a member the Canadian Chiropractic Association or an affiliated provincial association.
Claim - A demand by the insured person to the insurer for the payment of benefits. See Notice and Proof of Claim.
Claimant - A plan beneficiary exercising his/her right to receive benefits.
Claims Paid - Cheques paid out to claimants by the insurance company. The checks are considered Paid Claims if they either are dated within the policy year or are cleared by the banks within the policy year.
Class - A categorical listing of insurance coverage which an individual is placed into to determine eligible coverage under the policy.
Co-ordination of Benefits - A policy which will determine how benefits will be calculated if the claimant is insured under several group contracts insuring the same event.
Coinsurance - The insured and the insurer share the cost of the claim within a specified ratio. For example, the insurer pays 80%, the insured pays 20% of the claim expense. The amount paid by the Insurer is the Coinsurance, and the amount paid by the Insured is the co-pay.
Common-Law Marriage - Two persons who have been cohabiting and residing with each other for a continuous period of at least one year, and who’s spousal relationship has been publicly recognized.
Consumer Price Index - Price index produced by Statistics Canada that measures the percentage variation over time of the cost of purchasing a specific list of goods.
Consultant - A person or firm specializing in the design, sale and service of employee benefit plans.
Contributory - A portion of the premium paid by the employee is required.
Contributory Plan - A plan which requires employees to pay part of the cost for the benefit plan.
Convalescent Hospital - Facility that provides rehabilitative care and is eligible under the provincial hospital insurance legislation.
Conversion - The individual has the right to convert group insurance coverage to an individual plan without presenting evidence of insurability if converted within 31 days of termination.
Coverage - A classification of benefits provided under a group policy or the amount of insurance or benefits stated in the group policy for which an insured is eligible.

Deductible - An amount of expenses that must be paid by the insured before any benefits become payable.
Definition of Disability - See Permanent and Total Disability and Two Year Own Occupation.
Dependent - The employee's spouse or children.
Dependent Life - Life Insurance issued for the spouse and children with the employee as the beneficiary.

Effective Date - The date a policy becomes effective. If the hour is not specified, the effective time is 12:01 a.m. on the appropriate date.
Eligible Employees - Employees who have met the requirements under the group policy for insurance.
Employee Benefit Program - A program through which various benefits are offered to employees by their employer to cover such contingencies as medical expenses, disability income, retirement and death; usually paid for wholly or in part by the employer. Such benefits frequently are referred to as "fringe benefits" because they are separate from wages and salaries.
Evidence of Insurability - Proof presented through written statements on an application form, and/or through a medical examination, that an individual is eligible for a certain type of insurance coverage.
EOB - Once a claim has been processed, the subscriber will receive an Explanation Of Benefits statement. The following information is detailed on the EOB actual charges, allowed charges, deductible and coinsurance amounts, total benefits payable and the claimant responsibility

Family - Two spouses who are legally married or living common-law, or one or two adults (legally married or living common-law) and their dependent children.

Group Insurance - Insurance issued, usually without medical examination, on a group of people under a master contract. It is usually issued to an employer for the benefit of employees. The individual members of the group hold certificates as evidence of their insurance.
Group Insurance Change Form - A form used to submit additions, changes and terminations for processing by the premium administrators.
Group Life - Insurance covering a group of employees under one life insurance policy.
Guaranteed Issue - Maximum amount of benefit that will be provided without the need for evidence of insurability.

Insured - The member who is covered by the policy.
Insurer - The insurance carrier who agrees to underwrite the group contract and provide certain types of coverage and service.
Indemnity Plan - Plan which restores or reimburses one to the extent of their loss.

LTD - Long Term Disability insurance provides income protection in the event of time lost due to sickness or accident of long term nature. Generally monthly payments commence after a specified waiting period and continue while the employee remains disabled usually up to a specified age. See Definition of Disability, Permanent and Total Disability, Period of Disability, Two Year Own Occupation and Offsets.

Massage Therapy - Services provided within their specialty by individuals authorized by a recognized provincial association to practice massage therapy. (Where such an association does not exist, individuals who, in the insurer’s opinion, have similar qualifications.)
Maximum Benefit - The maximum amount any one individual may receive under an insurance contract. See Annual Maximum.

Naturopathy - Services provided within their specialty by members of the Canadian Naturopathic Association or an affiliated provincial association.
Non-Evidence Maximum (NEM) - The maximum amount of insurance coverage one may receive before Evidence of Insurability is required.
Notice and Proof of Claim - The policy will specify time limits for giving notice, and then proof of claim. It also specifies the manner in which the proof of loss must be submitted.
Nursing Home - Facility housing (elderly) individuals who, due to a reduction in their physical or psychological autonomy, must live in a sheltered environment.

Occupational Therapy - Services provided within their specialty by occupational therapists authorized to practice occupational therapy in Canada or in the province where the services are provided.
Offsets - Reductions to one’s Long Term Disability benefit in order to offset other sources of income such as Worker’s Compensation, CPP, QPP, etc.
Old Age Security (OAS) - A federal retirement income program providing pension benefits to those 65 or older, with residence in Canada for at least 10 years.
Optional Life Coverage - Option to purchase additional life insurance over and above Basic or core life insurance coverage. Optional Life frequently requires applicants to provide additional personal information. See Evidence of Insurability.
Orthotherapy- Services provided within their specialty by orthotherapists authorized to practice orthotherapy in Canada or in the province where the services are provided.
Osteopathy - Services provided within their specialty by holders of a doctorate in osteopathy conferred by a college of osteopathy approved by the Canadian Osteopathic Association.
Out-of-Country Expenses - Expenses incurred by an insured or insured dependent for emergency services and treatment of bodily injury or disease while travelling outside Canada.
Out-of-Pocket Expenses - Those medical expenses which an insured is required to pay because they are not covered under the group contract.
Out-of-Pocket Maximum - The maximum amount of coinsurance an insured is required to pay before the plan will pay 100% .
Over-the-Counter Drug - Drug that can be purchased without a prescription.

Payroll Deduction - The amount taken from the employee's earnings with their consent, as contribution toward the cost of the group insurance plan.
Period of Disability - The period during which an employee is prevented from performing the usual duties of his/her occupation or employment or during which a dependent is prevented from performing the normal activities of a healthy person of the same age or sex. More than one cause (accident or sickness) may be present during or contribute to a single period of disability. See Two Year Own Occupation.
Permanent and Total Disability - A disability that will presumably last for the insured's lifetime and prevents engagement in any occupation for which the insured is reasonably fitted. See Offsets.
Physiotherapy - Services provided within their specialty by members of the Canadian Physiotherapy Association or an affiliated provincial association..
Podiatry - Services provided for foot health by individuals authorized to practice.
Pooling - The combination of all premiums, claims, expenses for certain size cases, types of coverage or excess classes in order to spread the risk.
Pre-Existing Condition - Any physical and/or mental condition or conditions that existed prior to the effective date of coverage under a contract.
Premium - The amount paid to the insurer for the insurance protection.
Prescription Drug - Drug that cannot be obtained without a prescription from a physician or dentist.
Provision - A part of a group insurance contract that explains or describes a feature, benefit, condition, requirement, etc., of the insurance protection afforded by the contract.
Psychology - Services provided within their specialty by permanently recognized psychologists whose names appear in the registry of psychologists of the province where the services are provided.

QPP Québec Pension Plan. See Offsets.
Québec Pension Plan - Government plan that pays a monthly pension to eligible individuals.

Reasonable and Customary - This term refers to limiting benefit payments to fees which are reasonable and representative for the service rendered, under the circumstances rendered, by the physician rendered.
Recurring Disability - A case where if a second disability occurs related to the first disability within a specified period of time, the second disability will be a continuation of the first disability claim.
Rehabilitation - Refers to a provision in many long-term disability (LTD) plans that enables the insured claimant to receive at least partial benefits while undergoing retraining and seeking new employment.
Rehabilitative Employment - Any occupation or work for compensation or profit approved by the Insurer and undertaken by the insured while unable to work on a full-time basis usually in conjunction with a LTD plan.
Renewal Date - The date when the insurance policy is to be reviewed for experience and the rates are adjusted.
Retention - The portion of the premium retained by the insurance company to cover expenses and provide profits.
Retirement - Permanent withdrawal from the labor force.

Salary - Base salary, excluding bonuses.
Secondary Payer - The plan that pays second when you have coverage through two benefit plans (yours and your spouse's plan). This is known as co-ordination of benefits where you can be reimbursed up to 100% (but not more) when you submit your claim to both benefit plans.
STD - Short-Term Disability benefit provided to employees who are absent from work due to illness or disability. Short Term Disability (also known as Weekly Indemnity or Sick Leave) usually has a maximum amount of time the benefit will last.
Sickness - Illness not arising from accident or injury. Usually the sickness causing disability must be contracted by the insured while the policy is in effect. Some policies require that the sickness need only manifest itself while the policy is in effect.
Single - An unmarried person with no dependent children.
Smoker - A smoker is defined as someone who has smoked cigarettes at least once in the last 12 months.
Speech Therapy - Services provided within their specialty by holders of a master’s degree in speech therapy who are a member of the Canadian Association of Speech-Language Pathologists and Audiologists or an affiliated provincial association or who satisfies the conditions for membership in this association.
Spouse - The person to whom you are lawfully married; or a person who has been cohabiting and residing with you for a continuous period of at least one year, and has been publicly represented by you as your spouse.
Subject to Insurability - A statement of proof of a person's physical condition, occupation or other factor affecting his or her acceptance for insurance is required.
Survivor Benefits - Allows dependent family members of a deceased employee to have continued coverage for a specified period; premiums are often waived during this period. See Waiver of Premium.

Term Life Insurance - Life insurance plan that terminates when employment ceases. Conversion policies are available.
Termination - An employee who terminates employment with the employer or withdraws from a group plan offered by the employer.
Termination Age - Specified age when an employee loses insurance coverage. See Age reduction.
Total Disability - Inability to perform all of the duties of one's regular occupation or the duties of any occupation for which the individual may become fitted due to education, training or experience.
Twenty-Four Hour Coverage - Insurance providing benefits for an accident or sickness incurred either on the job or off the job.
Two-Year Own Occupation - Common disability definition stating that the employee is disabled for his or her own occupation during the first two years of disability and thereafter is disabled for any occupation that is suitable by virtue of past training, education or experience.

Underwriting - The process by which an insurance company determines whether or not it will accept an application for insurance.

Voluntary - Chosen by one's own consent. Often refers to lack of minimum enrollment requirements.

Waiting Period - A period of time that must pass in order for an individual to become eligible for benefits under a group insurance policy.
Waiver - An agreement attached to a policy which exempts from coverage certain disabilities normally covered by the policy.
Waiver of Premium - A provision that under certain conditions a person's insurance will be kept in full force by the insured without further payment or premiums. It is used most often in the event of permanent and total disability.
Worker's Compensation Act - A statute imposing liability on employers to pay benefits and furnish care to employees injured and to pay benefits to dependents of employees killed, in the course of and because of their employment. See Offsets.