Checking your Coverage
Understanding your Policy
Insurance and benefit plans vary in what they offer and how much they cover. There are more than 100,000 different plans offered in Canada under different insurers. One person’s plan can look very different to the next person’s – even if it is from the same insurance company.
Read your policy or the information booklet you may have received from your employer. You may be registered with the insurer’s member website and you can review it on-line. If the information is not readily available or if you have questions – speak to your HR department at work, your manager, or your insurance advisor.
Individual vs Group Benefit Plans
It is important to understand the difference between having your own individual health benefits plan, that you purchased, and benefits through a group plan.
A group plan is something offered by an employer, union, or association. It is offered as an incentive or a way to bring insurance and benefits to a group of people in the interest of keeping them well. The insurer designs the plan for the needs of the plan sponsor – the employer, union or association – NOT the individual. The insurer is accountable to the sponsor and makes decisions about coverage that are in the interest of that sponsor – decisions that balance keeping the plan affordable and keeping the group healthy. Some sponsors are involved in coverage decisions, some are not and leave it to the discretion of the insurance company or plan administrator. You do not have a say in the terms of coverage.
This is different from an individual policy that you have taken out yourself. The accountability is to you and the terms of the contract. You have more control over the terms and how the plan is designed. Usually, however, individually paid plans are more limited in coverage as an individual can only afford to purchase a limited amount of protection on their own.
Some insurance policies and benefits packages have exclusions. On individual policies and some smaller group plans, you may face limitations in coverage because of a “pre-existing” medical condition that occurred before you received the policy. Some plans are designed to not cover certain services, drugs, or treatments. Keep in mind that insurance doesn’t cover everything. Policies are developed to manage risk and expenditures to either the individual or the plan sponsor. Read your policies and understand if there are any conditions that may exclude you from making a claim or that will impact a claim. It is important to know what your plan covers and what it doesn’t cover. This will help you better understand if there are additional resources you need to get in place ahead of time.
Plan Maximums and Limits
Many health benefits plans now carry a limit on how much they will cover. This is done to control expenditures. A plan might limit the amount you can claim on a certain type of item (e.g. prescription drugs, massage therapy, counselling) per item, per year, and/or per lifetime. Some plans also limit the quantity of items you can receive like prosthetic devices or certain drugs. You may not be made aware of every limit on every item, but it is important to understand the dollar limits of your plan. The cost of prescription drugs and other supportive items can quickly escalate and understanding your plan limitations will help you determine ahead of time if you need to supplement with additional funds or provincial plan options.
Keeping Insurance While on Leave from Your Job
If you have a group insurance and benefits package through an employer or union, you may be told you need to cover the employer/union’s part of the premium payment while you are off work. That means the amount you pay for your insurance each month will go up. This occurs because the offer of insurance and benefits by your employer/union is done in the interest of keeping you supported while at work. If you are off work, you are given the option of keeping the policy(ies) but needing to assume responsibility for maintaining it.
For many people, paying more for insurance and benefits at a time when income is decreasing is overwhelming. Understand the risk of suspending insurance or benefits before you cancel them. You may be offered the same insurance package when you return to work, or you may be re-assessed, and the extent of your coverage might be re-negotiated based on your medical condition. Speak to your HR department, union lead or manager and determine your options carefully before making decisions to continue or suspend your insurance and benefits package.