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General exclusions and limitations
Drug benefit exclusions
Vision care benefit exclusions
Medical practitioner benefit exclusions
Miscellaneous expense benefit exclusions
Dental benefit exclusions
Out-of-province benefit exclusions
Hospital benefit exclusions
Comprehensive coverage exclusions
General exclusions and limitations
No benefit is payable for:
- expenses for which benefits are payable under a Workers' Compensation Act or a similar statute or enactment, or by any government agency,
- expenses for services and supplies, rendered or prescribed by a person who is ordinarily a resident in the patient's home or who is related to the patient by blood or marriage,
- expenses for services or products for cosmetic purposes only, or for conditions not detrimental to health, except those required as a result of accidental injury,
- expenses for services or products normally rendered without charge,
- expenses for services rendered in connection with medical examinations for insurance, school, camp, association, employment, passport or similar purposes,
- expenses for services provided by a physician licensed and practising in Canada where the participant is eligible to be insured under a provincial/territorial health insurance plan, except for such services which are specifically included under the section entitled Plan provisions,
- expenses for experimental products or treatments, for which substantial evidence provided through objective clinical testing of the product's or treatment's safety and effectiveness for the purpose and under the conditions of the use recommended does not exist to the Administrator's satisfaction,
- expenses for benefits which are legally prohibited by a government from coverage,
- the portion of charges which are payable under a provincial/territorial health insurance plan, a provincial/territorial drug plan, or any provincially/territorially sponsored program, whether or not the participant is participating in the plan or program,
- the portion of charges for services rendered or supplies provided in a hospital outside of Canada, that would normally be payable under a provincial/territorial health or hospital insurance plan if the services or products had been rendered in a hospital in Canada. This limitation does not apply to the eligible expenses under the
hospital (outside Canada) provision and the Extended health provision—
out-of-province benefit,
- the portion of charges which is the legal liability of any other party.
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Drug benefit exclusions
No benefits are paid for expenses related to:
- drugs which, in the Administrator's opinion, are experimental,
- publicly advertised items or products which, in the Administrator's opinion, are household remedies,
- contraceptives, other than oral,
- vitamins (except injectables), minerals, and protein supplements, other than expenses that would
qualify for reimbursement,
- therapeutic nutrients other than those that would
qualify for reimbursement,
- diets and dietary supplements, infant foods and sugar or salt substitutes, other than expenses that would
qualify for reimbursement,
- lozenges, mouth washes, non-medicated shampoos, contact lens care products and skin cleansers, protectives or emollients,
- drugs which are used for cosmetic purposes,
- drugs which are used for a condition or conditions not recommended by the manufacturer of the drugs,
- any of the conditions listed above,
- any benefit payable under a government drug plan, whether or not the participant is participating in the Plan.
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Vision care benefit exclusions
No benefits are paid for:
- laser eye surgery to correct vision so that visual aids such as glasses or contact lenses will no longer be required. This would include but not be limited to, procedures such as eximer laser, photo refractive keratectomy (PRK), and lasik,
- expenses incurred under any of the conditions listed above.
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Medical practitioner benefit exclusions
No benefits are paid for:
- expenses incurred under any of the conditions listed above,
- expenses for surgical supplies and diagnostic aids,
- Prostatic Specific Antigen (PSA) test used for screening purposes.
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Miscellaneous expense benefit exclusions
No benefits are paid for:
- expenses for items purchased primarily for athletic use,
- expenses for ambulance services for a medical evacuation which are eligible under the
out-of-province benefit,
- expenses incurred under any of the conditions listed above,
- 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 except as
specifically provided,
- an implant, except as
specifically provided,
- bathroom safety equipment, or
- an air conditioner,
- ongoing supplies associated with durable equipment,
- durable equipment that is used to prevent illness, disease or injury,
- the use of a device for a treatment which in the Administrator's
opinion is considered to be clinically experimental,
- the portion of charges which are payable under a provincial/territorial health insurance plan, or any provincially/territorially sponsored program whether or not the participant is participating in the plan or program.
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Dental benefit exclusions
No benefits are paid for:
- expenses incurred under any of the conditions listed above,
- dental expenses, except those
specifically provided, for treatment of accidental injuries to natural teeth and oral surgical procedures.
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Out-of province benefit exclusions
No benefit is payable for:
- expenses incurred outside the participant's province/territory of residence if they are required for the emergency treatment of an injury or disease which occurred more than 40 days after the date of departure from the province/territory of residence, except as provided for members who are on
official travel status,
- expenses incurred by a participant who is temporarily or permanently residing outside Canada
- expenses for the regular treatment of an injury or disease which existed prior to the participant's departure from their province/territory of residence,
- expenses incurred under any of the conditions listed above.
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Hospital benefit exclusions
No benefit is payable for:
- expenses incurred under any of the conditions listed above,
- coinsurance charges or similar charges for hospital care which are in excess of charges payable by a provincial/territorial government health or hospital insurance plan and which are not charges made for utilisation of semi-private or private accommodation,
- personal charges such as televisions and telephones.
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Comprehensive coverage exclusions
No benefit is payable for:
- expenses incurred under any of the conditions listed above,
- physician services rendered as a salaried employee of a hospital (if you are an employee posted outside Canada, you may be reimbursed for these expenses under the
hospital (outside Canada) provision),
- co-insurance charges or similar charges for hospital care which are in excess of charges payable by a provincial/territorial government health or hospital insurance plan and which are not charges made for utilisation of semi-private or private accommodation,
- charges incurred by a person insured under a non-government group hospital insurance plan administered in a foreign country that provides Hospital expense benefits similar to those provided under the Health Insurance Act 1972 of Ontario, as amended from time to time.
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