Benefits - Basic and Select Plans
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Benefits are payable for the following costs:
1. Hospital
The insurer agrees to pay
for semi-private hospital accommodation and for reasonable and
customary costs for services and supplies necessary for the care of
the insured during confinement as a resident in-patient.
2. Medical
The insurer agrees to pay for:
a) The
services of a legally licensed physician, surgeon, anaesthetist or
registered graduate nurse (all of whom are not related by blood or marriage to
the insured).
b) The
services of a legally licensed physiotherapist (who is not related by blood or
marriage to the insured) when ordered by the attending physician
as treatment for a covered sickness or injury. Not to exceed
$1,000 for out-patient treatment. Must be pre-approved by TIC.
c) The
services of a legally licensed doctor of chiropractic (who is no related by
blood or marriage to the insured) for treatment of a covered sickness
or injury. Not to exceed $1,000. Must be pre-approved by TIC.
d) The
services of a legally licensed podiatrist or osteopath (who is not related by
blood or marriage to the insured) for treatment of a covered sickness
or injury. Not to exceed $1,000 in total. Must be pre-approved by TIC.
e) Diagnostics,
lab tests and/or x-ray examinations as ordered by a physician for the
purpose of diagnosis.
f)
The use of a licensed local air, land, or sea ambulance (including
mountain or sea evacuation), to the nearest hospital, when reasonable
and necessary.
g) Rental
of wheelchair, crutches or hospital-type bed, not exceeding the purchase price;
and the cost of splints, trusses, braces or other approved prosthetic
appliances. Must be pre-approved by TIC.
h) Private
duty nursing services of a registered nurse or registered medical attendant
(who is not related by blood or marriage to the insured). Must be
pre-approved by TIC.
i)
Out-patient services provided by a hospital.
j)
Drugs or medications that require a physician’s written
prescription, not exceeding a 90-day supply per insured unless
hospitalized as an in-patient. Prescription drugs or medications are covered in
full when the insured is hospitalized.
3. Return
of Deceased
In the event of death due to a
covered sickness or injury, up to $10,000 will be reimbursed for
costs incurred to return the insured in a standard transportation
container, to their country of origin, or up to $4,000 for cremation or
burial at the place of death.
4. Accidental
Dental
Up to $3,000 will be reimbursed
for treatment or services to whole or sound natural teeth (including capped or
crowned teeth) which are damaged as a result of an accidental blow to
the face. To be eligible for reimbursement, the costs for such dental services
must be incurred within 90 days after the date of the injury, and be
completed during the period of coverage. Treatment must be performed by
a legally qualified dentist or oral surgeon.
5. Dental
Emergencies
Up to $500 will be reimbursed for
the immediate relief of acute dental pain caused by other than a blow to the
face. Dental conditions for which the insured has previously received
treatment or advice are not covered.
Treatment relating to any dental
claim must begin within 48 hours from the onset of the emergency and
must be completed within the period of coverage and prior to the insured’s
return to their country of origin.
6. Dentist
(in hospital)
Up to $500 will be reimbursed for
dental surgical procedures where the underlying condition is not caused by an accident
and which are medically required to be performed in a hospital.
7. Act
of Terrorism
When an act of terrorism directly or indirectly
causes a loss that would otherwise be payable under this plan, subject to all
other policy limits, coverage will be provided as follows:
a) As
a result of any one or a series of acts of terrorism occurring within a
72-hour period, the aggregate limit payable shall be limited to CAD $2.5
million for all eligible insurance policies issued and administered by TIC,
including this policy.
b) As
a result of any one or a series of acts of terrorism occurring in any
calendar year, the aggregate limit payable shall be limited to CAD $5
million for all eligible policies issued and administered by TIC, including
this policy.
The amounts payable for each eligible claim under (a) and
(b) above, are in excess of all other sources of recovery and shall be reduced
on a pro rata basis, so that the total amount paid for all such claims shall
not exceed the respective aggregate limit which will be paid after the
end of the calendar year and after completing the adjudication of all claims
relating to act(s) of terrorism.
8. Emergency
Transportation
The insurer agrees to transport
the insured to their country of origin when necessary
continuing medical care is required and is not covered under this policy,
according to exclusion EXP10 3. Any emergency transportation such as air
ambulance, one-way economy airfare, stretcher and/or a medical attendant must
be approved and arranged by TIC.
9. Return
Home
When approved and arranged by
TIC, up to $3,000 will be paid for the additional cost of one-way economy
transportation by the most direct route to the insured’s country of origin
if the insured is permanently unable to perform basic activities of
daily life as the result of a covered sickness or injury or if
the insured requires long-term chronic care. This benefit also includes
one additional insured family member.
10. Physical
Examination
If the coverage purchased is for
a continuous 365-day period commencing from the effective date, this
benefit covers one routine annual examination by a physician up to a
maximum of $200 after this policy has been in effect for 6 consecutive months
with no lapse in coverage. (not subject to any deductible).
11. Eye
Examination
The services of a registered
optometrist for diagnostic procedures to determine the presence of any observed
abnormality in the visual system. Limited to one visit in any consecutive
12-month period of coverage.
12. Maternity
Benefit
When the expected delivery date
is more than 10 months after the effective date of this policy and there is no
lapse in coverage, TIC will pay 80% of the costs per pregnancy incurred by the
mother and the newborn as the result of pregnancy, childbirth or miscarriage,
or complications related thereto, up to a total maximum of either:
a) $5,000
for normal childbirth; or
b) $7,500
for caesarean section; or
c) $25,000
for medical complications related to childbirth.
Newborns are not covered under
this policy other than as specifically stated above. Newborns can be fully
covered at 15 days of age if a completed application is accepted by TIC or its
representative and written approval is given by TIC.
13. Psychiatrist
When referred in writing by a
physician and approved by TIC, the services of a psychiatrist are payable, up
to a maximum of one hour per week to a maximum of 10 visits in any consecutive
12-month period provided this policy has been in effect for at least 6
consecutive months with no lapse in coverage.
ADDITIONAL BENEFITS for Select Plan
Benefits are payable for the following costs:
14. Accidental
Death & Dismemberment
The insurer agrees to pay
up to the sum insured of $10,000, for loss of life, limb or sight resulting
directly from accidental injury, occurring during the period of
coverage, except while boarding, riding or alighting from an aircraft. Loss
of life, limb or sight must occur within one year from the injury.
Benefits are payable according to
the following schedule:
a) 100% of sum insured resulting
from the same accidental injury for loss of:
i.
life; or
ii.
entire sight of both eyes; or
iii.
both hands; or
iv.
both feet; or
v.
one hand and entire sight of one eye; or
vi.
one foot and entire sight of one eye.
b) 50%
of sum insured resulting from the same accidental injury for loss of:
i.
entire sight of one eye; or
ii.
one hand; or
iii.
one foot.
Loss of hand or hands, or foot or
feet means severance through or above the wrist joint or ankle joint,
respectively.
Loss of eye or eyes means total
and irrevocable loss of the entire sight.
Only one amount is payable (the
largest) if the insured suffers more than one of these losses.
Exposure and Disappearance
If the insured is exposed
to the elements or disappears as a result of an accident, a loss will be
covered if:
a) as
a result of such exposure, the insured suffers one of the losses
specified in the schedule of losses above, or
b) the
body of the insured has not been found within 52 weeks from the date of
the accident it will be presumed, subject to evidence to the contrary,
that the insured suffered loss of life.
15. Transportation
of Family or Friend
Up to $3,000 for one round-trip
economy class transportation by the most direct route, and up to $1,000 for
reasonable costs incurred after arrival by a family member or
close friend of the insured if:
a) the insured is
hospitalized due to a covered sickness or injury and the
attending physician advises the necessary attendance by such persons; or
b) local authorities legally
require the attendance of such persons to identify the insured’s remains
in the event of death due to a covered sickness or injury.
16. Attendant
Up to $50 a day, to a maximum of
$500 for an attendant (who is not related by blood or marriage to the insured)
to care for any family members (under age 18, or physically or mentally
handicapped who rely on the insured for assistance), if the insured is
hospitalized for 48 hours or more resulting from a covered sickness or injury.
This benefit is only payable when approved in advance by TIC.
17. Vaccinations
If the coverage purchased is for
a continuous 365-day period commencing from the effective date, this
benefits covers vaccinations up to a maximum of $100 annually after this policy
has been in effect for 6 consecutive months (not subject to any deductible).
EXCLUSIONS
Benefits are not payable for costs incurred due to:
EXP1 Any sickness, injury or medical condition
that exhibited symptoms for which a diagnosis need not have been made or
required any or all of: medical consultation, prescription medication,
medical treatment or hospitalization prior to the effective date.
EXP2 Any sickness for which symptoms occurred
within 48 hours of the effective date, except when the application for
this insurance is completed:
a) prior
to the insured leaving the country of origin; or
b) before
the expiry date of an existing TIC Global Expatriate Policy.
EXP3 Any sickness, injury or medical condition
for which a diagnosis need not have been made or state of health which, prior
to the effective date was such as to render expected medical
treatment or hospitalization.
EXP4 Losses while sane or insane due to: emotional,
mental or nervous disorders resulting from any cause, including but not limited
to anxiety or depression; suicide or attempted suicide; or intentional
self-inflicted injury, except as specifically provided under Benefit 13,
Psychiatrist.
EXP5 Act of war, kidnapping, act of
terrorism caused directly or indirectly by nuclear, chemical or
biological means; riots, strike or civil commotion, unlawful visit in any
country, participation in protests, participation in armed forces activities or
a commercial sexual transaction or the commission or attempted commission of
any criminal offence, contravention of any statutory law or regulation in the
area where the loss occurred by the insured, a family member or
travelling companion.
EXP6 Any sickness, injury or medical
condition, for which a diagnosis need not have been made, for which the policy
is purchased or the trip is undertaken for the purpose of securing
medical treatment or advice.
EXP7 Loss, death or injury, if at the time of
the loss, death or injury, evidence supports the insured was
affected by, or the medical condition causing the loss was in any way
contributed to by, the use of alcohol, prohibited drugs, or any other
intoxicant; the non-compliance with a prescribed treatment or medical therapy;
or the misuse of medication.
EXP8 Any medical consultation that is elective
or related to a prior elective procedure.
EXP9 Travelling against the advice of a physician
or any loss resulting from a sickness or medical condition that was
diagnosed by a physician as terminal prior to the effective
date of this policy.
EXP10
1. For
temporary residents in Canada with coverage under a basic plan: treatment which
can be reasonably delayed until the insured returns to their country
of origin (whether or not they intend to return) by the next available
means of transportation unless approved in advance by TIC.
2. For
returning Canadians and landed immigrants awaiting coverage under a government
health insurance plan: treatment which can be reasonably delayed until the insured’s
government health insurance plan takes effect.
3. For
an insured with coverage under a basic plan: any treatment,
investigation or hospitalization which:
a) is
a continuation of or subsequent to an inpatient hospitalization; or
b) exceeds
30 days following the initial day that necessary outpatient treatment of a
covered sickness or injury began, unless approved in advance by
TIC.
EXP11 Any rehabilitation or convalescent care.
EXP12 Injury resulting from training for or
participating in speed contests usually and customarily in excess of 60 km per
hour, professional sport activities, or organized motor sport contests.
EXP13 Any loss incurred as a result of pregnancy,
abortion, miscarriage, childbirth or complications thereof, except as
specifically provided under Benefit 12, Maternity.
EXP14 Sickness or injury resulting from
a motor vehicle accident where the insured is entitled to receive
benefits pursuant to any policy or legislative plan of motor vehicle insurance.
EXP15 Cosmetic surgery unless such emergency
surgery is a result of a covered sickness or injury.
EXP16 Dental care, services or supplies, except as
specifically provided under Benefit 4 Accidental Dental, Benefit 5 Dental
Emergencies and Benefit 6 Dentist (in hospital).
EXP17 Treatment or services that contravene, or are
prohibited by, legislation under a provincial or territorial hospital/medical
plan of the province where the policy was issued.
EXP18 Naturopathic, holistic or acupuncture
treatment.
EXP19 Costs that exceed the reasonable and
customary rate for the area where the treatment or services are being
performed, or costs incurred in Canada which exceed the applicable provincial medical/dental
association schedule of fees.
EXP20 Any loss incurred in the U.S.A. if coverage is
purchased for ‘Worldwide excluding the U.S.A.’ only, except for loss due to
acute emergency hospital and other covered emergency costs
due to sickness or injury occurring during the period of
coverage while the insured is travelling in transit through the
U.S.A. for a period of up to 5 days.
EXP21 Eye glasses, contact lenses, hearing aids
and/or prescriptions for any of these items, unless required as the result of
an accidental injury.
EXP22 Any nuclear occurrence, however caused.
EXP23 Any loss resulting from an act of terrorism
while at a destination where, prior to the insured’s departure to that
destination, a statement regarding terrorism is made in the ‘Travel Report’
issued by the Canadian Department of Foreign Affairs advising or recommending
that Canadians should not travel to that destination during the period of
coverage, or any such loss if incurred more than 12 months after such
statement is made, if the statement is made at a time when the insured
is already at the destination and has coverage under the 5-year policy option.
EXP24 The purchase of:
1. medications
or drugs not approved for use by the appropriate government authority,
2. patent
or proprietary medications,
3. vitamins
or vitamin preparations,
4. drugs
or medications which can be purchased over the counter without a physician’s
written prescription,
5. acne
medications,
6. nicotine
resin products,
7. dietary
supplements or weight loss products,
8. quantities
of any drug or medications which exceed a 30-day supply within one month prior
to the policy expiry date,
9. contraceptives
prescribed for any purpose,
10. contraceptive
consultation or testing,
11. fertility drugs
or testing, or drugs, medications, or other costs paid for by any other agency,
or
12. experimental
drugs or preventative medications.