Critical Illness

ELIGIBILITY

Who is eligible?

If you have been hired as a permanent employee to work at least 40% of a regular work week, you are entitled to coverage for you, your spouse and dependents.

Your spouse is defined as someone to whom you are married legally or common law (defined as having lived with your partner for 12 months or more; the 12 month cohabitation period is waived in the event a child is born of such relationship).  This includes a spouse of the same sex.

Your dependent child is defined as an employee’s or spouse’s child who:

• is either under age 21 or under age 26 and a full-time student at an accredited school, college, or university; and
• is unmarried (legally or common law); and
• is not employed on a full-time basis; and
• is not eligible for benefits as an employee under this or any other group plan.
• A child who is incapable of employment due to a mental or physical condition that occurred before reaching the maximum age will continue to be covered if approved by the insurance company.

When will coverage begin?

Critical Illness Insurance coverage for you, and/or your spouse and/or your dependents starts the date your employer receives your application.

You must be actively at work on the coverage effective date in order for coverage to become effective.

When will coverage end?

Your Critical Illness coverage ends when you are no longer eligible, retire, reach age 70, or employment is terminated, whichever comes first.

Coverage for your spouse ends when they no longer meet the definition of spouse, you reach age 70, your spouse reaches age 70, your employment is terminated, or at your retirement, whichever comes first.

Coverage for your dependent children ends when they no longer meet the definition of dependent child, you reach age 70, your employment is terminated or at your retirement, whichever comes first.

Coverage ends when a claim is paid.

COVERAGE FOR YOU AND/OR YOUR SPOUSE

What is covered?

Critical Illness coverage is available for you and/or your spouse in units of $5,000, with a minimum of $10,000 and a maximum of $150,000. Proof of good health is not required for the first $25,000, but you must provide proof of good health and be approved by the insurer for all amounts greater than $25,000.
*Pre-existing condition applies to the $25,000

The Critical Illness benefit is payable if one of the following conditions is diagnosed (restrictions apply).

• Alzheimer’s Disease
• Aortic Surgery
• Benign Brain Tumor
• Blindness
• Cancer (Life-Threatening)
• Coma
• Coronary Artery Bypass Surgery
• Deafness
• Heart Attack
• Heart Valve Replacement
• Kidney Failure
• Loss of Limbs
• Loss of Speech
• Major Organ Failure and On Waiting List for Transplant
• Major Organ Transplant
• Motor Neuron Disease
• Multiple Sclerosis
• Occupational HIV Infection
• Paralysis
• Parkinson’s Disease
• Severe Burns
• Stroke (Cerebrovascular Accident)

For definitions of eligible Critical Illness conditions, see Appendix A in the quick print attachment.

If while insured for this benefit you are diagnosed with one of the covered illnesses and you survive for a period of 30 days (survival period) from the date of diagnosis, the benefit will become payable.  Written notice of claim must be given to the insurance provider within 90 days after date of diagnosis.

What are the exceptions for adult coverage?

The employee must be actively at work on the coverage effective date in order for coverage to become effective.

Unless you and/or your spouse submit a medical questionnaire and are approved for coverage by the insurer, Critical Illness benefits are not payable for conditions resulting directly or indirectly from a pre-existing condition within the first 24 months of coverage.

*A pre-existing condition is defined as an illness or injury for which the Insured person has exhibited signs or symptoms, received medical treatment, care or services (including diagnostic measurements), consulted a physician or has been prescribed medication; or where treatment would have been sought by a prudent individual during the 24 months prior to the effective date of coverage or the latest date of reinstatement for this Benefit.

In addition to pre-existing conditions, benefits are not payable for the diagnosis of any life-threatening cancer or benign brain tumour made within the first 90 days of coverage.

Exclusions:
No benefits are payable related to:

• Self-inflicted injuries or illnesses whether the insured is sane or insane
• Abuse of addictive substances, including but not limited to legal and illegal drugs and alcohol
• War, insurrection, the hostile actions of any armed forces or participation in a riot or civil commotion
• The committing of or the attempt to commit an assault or criminal offence
• Injuries sustained while operating a motor vehicle, either while under the influence of any intoxicant or if the insured blood contained more than 80 milligrams of alcohol per 100 milliliters of blood at the time of the injury
• Intentionally taking a poisonous substance or inhaling toxic gases or fumes
• Any specific exclusion relating to any given condition, as more particularly set out in covered critical illness conditions appendix.

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COVERAGE FOR YOUR DEPENDENT CHILDREN

What is covered?

Coverage is available for your dependent children.  It provides a lump sum payment of $10,000 should your child be diagnosed with one of a number of specified conditions.

Optional Critical Illness Insurance for your dependent children starts the date your employer receives the application.

In addition to the previously listed adult illnesses, the following childhood conditions are covered (restrictions apply; please see definitions for eligible conditions in the quick print attachment above.

• Autism
• Cerebral Palsy
• Congenital Heart Disease (certain conditions apply)
• Cystic Fibrosis
• Down Syndrome
• Muscular Dystrophy
• Type 1 Diabetes Mellitus

What are the exceptions to a dependents coverage?

The employee must be actively at work on the coverage effective date in order for coverage to become effective.

No critical illness benefit will be paid in relation to a child who is born within the first ten (10) months of coverage effective date and who is diagnosed with a child covered condition within those ten months.

In addition, benefits are not payable for diagnosis of any life-threatening cancer or benign brain tumour made within first 90 days of coverage.

Autism diagnosis must be before the child’s third birthday.

Exclusions:
No benefits are payable related to:

• Self-inflicted injuries or illnesses whether the insured is sane or insane
• Abuse of addictive substances, including but not limited to legal and illegal drugs and alcohol
• War, insurrection, the hostile actions of any armed forces or participation in a riot or civil commotion
• The committing of or the attempt to commit an assault or criminal offence
• Injuries sustained while operating a motor vehicle, either while under the influence of any intoxicant or if the insured blood contained more than 80 milligrams of alcohol per 100 milliliters of blood at the time of the injury
• Intentionally taking a poisonous substance or inhaling toxic gases or fumes
• Any specific exclusion relating to any given condition, as more particularly set out in covered critical illness conditions appendix.

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CLAIMING

How do I make a claim?

In the event of a claim, you must notify your employer and complete and submit the Critical Illness Notification form. The claimant (you, your spouse and/or your eligible dependents) must survive 30 days from the date of diagnosis.  Written notice of claim must be given to the insurance provider within 90 days after the date of the diagnosis.

CONTINUATION OF COVERAGE

What happens during a leave of absence?

If you take an approved paid leave of absence your deductions and coverage would continue.  Coverage can continue up to 24 months.  Coverage will not be reinstated automatically.

If you take an approved unpaid leave of absence, or a maternity or parental leave, you may continue for up to 24 months as long as you pay your required premiums.  If you choose not to continue the benefit during your leave, you may re-apply for coverage when you return to work.  Coverage will not be reinstated automatically.

If you are on an approved sick leave you may continue benefits for up to 24 months.

If you are approved for Health Association Nova Scotia Long Term Disability (LTD) benefits (after January 1, 2009), coverage continues and you do not pay premiums for as long as you are receiving the LTD benefit.

What happens to coverage when I retire?

Critical Illness coverage ceases.

Can I convert coverage?

There is no conversion option when your Critical Illness coverage ends.

HEALTH SERVICE NAVIGATOR…
A SERVICE AVAILABLE TO CRITICAL ILLNESS PLAN MEMBERS

In addition to the critical illness coverage, the insurance provider offers you, your spouse and your eligible dependents with access to Health Service Navigator (HSN), a comprehensive, integrated health information and online resource centre.

Health Service Navigator:

• Provides a resource to help you navigate the Canadian health care system
• Provides access to you and your eligible family members
• Is available even when you are not  making a critical illness claim
• Provides access to a world-class medical second opinion service.

To use the service, please visit
www.healthservicenavigator.com. Once you agree to the Terms you can access the resources available.

Health Association Nova Scotia reserves the right to review the employee benefits program and to modify, amend, discontinue, and/or make exceptions to the program. All information is subject to change. This document provides a information around the key benefits available to you under the Health Association Nova Scotia Single Group Benefits Plan. In the case of a discrepancy, the contracts will prevail. 

For Covered Critical Illness Conditions, see Appendix A