Glossary

ACCIDENT

Any unintentional sudden, and unforeseeable event due exclusively to an external cause of a violent nature and inflicting, directly or independently of all other causes, bodily injuries.

APPLICANT

The person who initiates an application for insurance.

ATTENDING PHYSICIAN

The formal relationship of a patient and the patient’s primary doctor during hospitalization or treatment.

CALENDAR YEAR

All benefits are based on a yearly schedule that starts on January 1st of each year.

CLAIMING PERIOD

The period allowable for submission of claims as defined in the insurance policy booklet.

COORDINATION OF BENEFITS

If a covered person is entitled to similar benefits under another insurance contract, benefits can be submitted to both insurers. The amounts payable are coordinated so that the total amount of the claim does not exceed the amount of the claim.

DENTAL RECALL EXAM

A recall exam is performed yearly following an initial consultation for maintenance purposes. Recall exams often include polishing and scaling.

DEPENDENT CHILD

A dependent child is defined as a child of the contract holder, his spouse or both, over 30 days old and who is dependent on the contract holder, who is not married and who is under 21 years of age, or under 25 and attending an educational institution as a full-time student, or physically or mentally handicapped.

MAJOR DENTAL BENEFITS

Necessary dental procedures that are complex.

MEDICALLY NECESSARY

A treatment, service or supply which is generally accepted by the medical profession as essential, effective and appropriate in the care and treatment of a medical condition, sickness or injury.

OHIP

ONTARIO HEALTH INSURANCE PLAN.

OVER-THE-COUNTER DRUGS

Drugs that can be purchased without a prescription from a physician.

PAY DIRECT

A solution that allows an insurance company to bill a service provider directly.

PRE-DETERMINATION/PRELIMINARY EVALUATION

For certain anticipated claims, the insurer will request an estimate of the potential cost of the service or claim in advance to determine whether the costs can be covered under the plan.

PRE-EXISTING CONDITION

Any illness or condition for which the individual consulted a physician (other than for regular check-up), was hospitalized, was prescribed or received treatment for, or was prescribed or had taken medication for.

PRO-RATED

When benefits are pro-rated, the benefit maximum is applied proportionately to the premiums paid for that period. For example, if your contract comes into force in October and the benefit maximum is based on a yearly maximum of $1,000, the maximum amount payable would be reduced for that benefit to $249.99.

REASONABLE AND CUSTOMARY

Charges that are consistent with representative fees and prices which would normally be made in the absence of coverage.

REPATRIATION

If an insurer deems that the insured will not be able to receive appropriate medical treatment at their current location, the insurer will transport the insured back to their province of residence for care. This process is called repatriation.

RESCISSION PERIOD

The period of time a policyholder is allowed to review the individual life insurance or accident and sickness insurance contract/policy to confirm that it is consistent with what was expected when he or she applied for the policy. If the policyholder is not satisfied, this period allows the cancellation of the contract for a refund of premiums paid.

SPOUSE

The person united to the contract holder by marriage or a person who has been living permanently with the contract holder for over one year.

SUBROGATION

The right to recover costs for an injury caused by the fault or negligence of another person.

WAITING PERIOD

Period of time as stipulated in the contract which must be satisfied by continuous coverage before benefits are payable.