Miscellaneous Expense Benefit

To be eligible, the expenses must be the reasonable and customary charges and must be prescribed by a physician, unless otherwise specified.

Durable equipment

New medical products and devices are constantly appearing on the market. However, not all items are eligible for reimbursement under the Plan. You should contact Sun Life before purchasing any new durable equipment to confirm whether the item is covered.

The Plan covers the rental or purchase (at Sun Life’s discretion) of cost-effective durable equipment that is:

  • manufactured specifically for medical use,
  • for use in the patient's private residence,
  • approved by the Administrator for cost effectiveness and clinical value,
  • designated as medically necessary.

Reimbursement related to durable equipment will be limited to the cost of non-motorised equipment unless medically proven that the patient requires motorised equipment.

Durable equipment used for care

Eligible expenses include but are not limited to:

Devices for physical movement
Lifts or hoists

Limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible lift/hoist repairs incurred prior to purchase.

Walkers

Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible walker repair expenses incurred during the previous 5 years.

Wheelchairs Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible wheelchair repairs incurred during the previous 5 years (for dependent children, the 60-month maximum may not apply if purchase or replacement is medically necessary).

 

Devices for support and resting
Hospital beds

Limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible hospital bed repairs incurred prior to purchase.

Wheelchair cushions (e.g. Roho cushions)

Limited to one every 12 months and a maximum eligible expense of cost less all eligible wheelchair cushion repairs incurred during the previous 12 months.

Therapeutic mattresses

Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible therapeutic mattress repairs incurred during the previous five years.

 

Devices for monitoring
Apnea monitors

Limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible apnea monitor repairs incurred prior to purchase.

Enuresis monitors

Limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible enuresis monitor repairs incurred prior to purchase.

 

Durable equipment used for treatment

Eligible expenses include but are not limited to:

Devices for mechanical and therapeutic support
Transcutaneous electric stimulators (TENS)

Limited to one every 10 years and a maximum eligible expense equal to cost less all eligible TENS repairs incurred during the previous 10 years.

Traction kits

Limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible traction kit repairs incurred prior to purchase.

Infusion pumps Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible infusion pump repairs incurred during the previous 5 years.
Extremity pumps (lymphapress) Limited to one in a lifetime and an eligible expense equal to cost less all eligible extremity pump repairs incurred prior to purchase.

 

Devices for aerotherapeutic support
CPAPs, BiPAPs and related dental appliances (where a CPAP or BiPAP cannot be tolerated)

Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible CPAP, BiPAP or dental appliance repairs incurred during the previous 5 years.

Servicing fees, repairs and replacement parts for CPAP and BiPAP machines

$300 per calendar year

Does not include expenses for cleaning supplies or warranties

Purchases must be made on or after October 1, 2014, to be eligible.

Compressors

Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible compressor repairs incurred during the previous 5 years.

Maximists Limited to one every 5 years and a maximum eligible expense equal to cost less all eligible maximist repairs incurred during the previous 5 years.

 

Ambulance transportation

Ambulance transportation
Ground ambulance

Licensed ground ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation, where medically necessary.

Air ambulance Emergency air ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation.

 

Diabetes treatment supplies

Diabetes treatment supplies
Needles, syringes, chemical diagnostic aids

Needles, syringes, and chemical diagnostic aids for the treatment of diabetes, except needles and syringes are not eligible for the 36-month period following the date of purchase of an insulin jet injector device.

Insulin jet injector devices One insulin jet injector device for insulin dependent diabetics, limited to a maximum eligible expense of $760 during a 36-month period.
Insulin pumps Insulin pumps and associated equipment for insulin dependent diabetics, when prescribed for a patient by a physician associated with a recognised centre for the treatment of diabetes at a university teaching centre in Canada, excluding repair or replacement during the 60-month period following the date of purchase of such equipment.
Blood glucose monitors Blood glucose monitors for insulin dependent diabetics, and for non-insulin dependent diabetics if legally blind or colour blind, excluding repair or replacement during the 60-month period following the date of purchase of such equipment.

 

Hearing aids

Hearing aids
Hearing aids

Hearing aids and repairs to them, excluding batteries, limited to the maximum eligible expense of $1,000, less of the cost of all eligible hearing aid claims made in the previous 5 years.

The initial purchase of hearing aids if required as a direct result of surgery or an accident where the purchase is made within six months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six-month time limit may be extended if, as determined by the Administrator, the purchase could not have been made within the time frame specified.

 

Other miscellaneous expenses

Other miscellaneous expenses
Artificial limbs

Temporary artificial limbs.

Permanent artificial limbs, to replace temporary artificial limbs, and replacements thereof but not within:

  • 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
  • 12 months of the last purchase in the case of a dependant 21 years of age or less,
unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis.
Braces

Braces, including repairs, which contain either metal or hard plastic, excluding dental braces and braces used primarily for athletic use.

Breast prostheses Breast prostheses following mastectomy and a replacement provided 24 months have elapsed since the last purchase.
Burn apparel Elasticised apparel for burn victims.
Incontinence supplies

Catheters and drainage bags for incontinent, paraplegic or quadriplegic patients.

Medical supplies

Trusses, crutches, splints, casts and cervical collars.

Colostomy, ileostomy and tracheostomy supplies.

Bandages and surgical dressings required for the treatment of an open wound or ulcer.

Orthopaedic brassieres Orthopaedic brassieres, limited to a maximum eligible expense of $200 in a calendar year.
Orthopaedic shoes

Orthopaedic shoes, which are an integral part of a brace or are specially constructed for the patient, including modifications to such shoes, provided the shoes or modification is prescribed in writing by a physician or podiatrist, limited to a maximum eligible expense in any one calendar year of $150.

The prescription is valid for one year.

Orthotics

Orthotics and repairs to them, prescribed in writing by a physician or podiatrist, limited to one pair in a calendar year.

The prescription is valid for three years.

Oxygen Oxygen and its administration.
Penile implants Penile prosthesis implants.
Support hose Elasticised support stockings manufactured to individual patient specifications or having a minimum compression of 30 millimetres.
Wigs Wigs, when the patient is suffering from total hair loss as the result of an illness, limited to a maximum eligible expense of $1,000 every five years.

 

Exclusions:

No benefit is payable for:

  • Items purchased primarily for athletic use;
  • Ambulance services for a medical evacution considered eligible under the out-of-province benefit;
  • Expenses incurred under any of the conditions listed under General Exclusions and Limitations;
  • Durable equipment that is:
    • An accessory to an eligible device;
    • A modification to the patient's home (bar, ramp, mat, elevator, etc.);
    • Used for diagnostic or monitoring purposes (unless specifically provided under Eligible Expenses);
    • An implant (unless specifically provided under Eligible Expenses);
    • Bathroom safety equipment;
    • An air conditioner;
  • Ongoing supplies associated with durable equipment;
  • Durable equipment that is used to prevent illness, disease or injury;
  • Devices for a treatment considered to be experimental;
  • The portion of charges covered by a provincial/territorial health insurance plan or program, regardless of whether the member is a participant of the plan or program.