Prescription Drugs & Contraceptive Benefits
When injury or sickness require prescription drugs, prescribed in writing by a physician or surgeon, the Plan will pay 80% of the actual cost of such prescription drugs or medicines, up to a maximum of $2,500.00 during the policy year for:
- most prescription drugs or medicines;
- insulin injectibles;
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insulin supplies which include syringes, needles and diagnostic test strips, including continuous and flash glucometers, alcohol swabs and lancets. (Pseudo Din# 910333 must be used for all diabetic supplies);
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allergy serums;
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oral contraceptives and the patch (birth control);
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Nuva Ring (contraceptive), subject to a maximum of $178.00 per insured, per policy year;
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IUDs, subject to a maximum of $300 per insured, per policy year, limited to Mirena, Jaydess, and Kyleena brands (Effective September 1, 2018);
- vaccinations, excluding Hepatitis B (Effective September 1, 2018);
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all acne preparations excluding Accutane.
AIDS Coverage
The plan will pay up to $5,000.00 with respect to drug treatments for HIV-positive or AIDS infected students. (Special authorization required)
Diabetes
Included within the prescription reimbursement limit of $2,500.00 is the cost of Insulin (bottled and/or cartridge), syringes and pen needles, reservoirs and infusion sets for the pump. Continuous and Flash glucometers, insulin pens, alcohol swabs are also covered.
Extended Health Care
This benefit helps pay the cost of eligible medical expenses incurred by an Insured and their insured family members. An Insured will be reimbursed for eligible expenses not covered by the Provincial Medicare Plan, subject to the deductible, if any, and percentage reimbursed shown below. Payment will be made for those eligible expenses which are a) reasonable and medically necessary and b) incurred on the prior recommendation of a legally qualified physician except where otherwise indicated.
Please note that all EHC claims MUST be submitted manually using the EHC Claim Form that can be found here
ELIGIBLE EXPENSES (IN PROVINCE)
ClaimSecure will pay 100% of Vision Care eligible expenses and 80% of all other eligible expenses unless otherwise indicated. The following are the eligible expenses provided by licensed practitioners in the province the expense is incurred in.
AMBULANCE
a) A licensed ground ambulance when used to transport an Insured because of emergency or in-patient treatment i) from the place where the Insured suffers the sickness to the nearest hospital where adequate medical treatment is available, ii) from one hospital to another, or iii) from a hospital to the Insured’s residence, when an Insured’s condition warrants it.
b) Emergency transportation by a licensed air ambulance to the nearest hospital where adequate treatment is available or to another hospital when certified as essential by the attending physician. If medically necessary, in flight services of a registered nurse and the return air fare for the registered nurse will be included.
PARAMEDICAl PRACTITIONERS
80% up to a maximum of $300.00 each policy year for each type of practitioner listed below:
a) Combined services a clinical psychologist, psychotherapist (effective September 1, 2019), or speech therapist;
b) Combined services of a naturopath or a chiropractor;
c) Services of a physiotherapist and occupational therapist (effective September 1, 2019), if recommended by a physician;
d) Services of a massage therapist, if recommended by a physician;
e) Services of a registered dietician;
f) Services of an osteopath;
g) Combined services of a podiatrist or chiropodist.
ORTHOPEDIC SUPPLIES
Charges for molded arch supports, orthopedic supplies and custom made orthopedic shoes are covered at 80% to a maximum of $200.00, if recommended by a physician, podiatrist or chiropodist;
Orthopedic supplies as noted above must be dispensed by one of the following providers: othotist, pedorthist, podiatrist or chiropodist.
Orthopedic supplies must be dispensed by a different provider than the prescriber. Orthopedic supplies prescribed or dispensed by a chiropractor are not eligible.
*When submitting your claim be sure to include the following: Your major medical expense claim form, referral pre-dating treatment, original paid in full invoice, gait analysis or biomechanical exam, a description of the raw materials used in the construction of the orthotic.
PROSTHETIC APPLIANCES
a) Charges for artificial limbs when the loss of the limb occurs while the individual is insured under this benefit, the cost of repair is also eligible; replacement is included when required due to physiological change, but excluding myoelectric appliances;
b) Charges for artificial eyes including reimbursement for one polishing or one re-making of the artificial eye each policy year;
c) Charges for crutches, casts, splints, trusses and braces (does not include dental braces, or expense of a brace or similar device used for non therapeutic purposes or used solely for the purpose of participation in sports or other leisure activities), including replacements when medically necessary, subject to a maximum of $300.00
d) Purchase of an external breast prosthesis when required because of a total or radical mastectomy that has been performed while the individual is insured under this benefit, including the purchase of 2 surgical brassieres, to a maximum of $200.00 per individual each policy year.
MEDICAL SUPPLIES
Charges for vaccines (excluding Hepatitis B)**, compound serums, colostomy supplies, injectable drugs and varicose vein injections, if medically necessary. Such drugs or supplies must be either administered by a physician or dentist or prescribed by a physician or dentist and dispensed by a pharmacist. However, any charges for their administration will not be included.
Please note that all EHC claims MUST be submitted manually using the EHC Claim Form that can be found here
**Please note that vaccinations will now be processed under Prescription Drugs, effective September 1, 2018.
EQUIPMENT RENTAL
Charges for wheelchairs, walkers, hospital beds, traction kits which are rented for temporary therapeutic use. If, due to extended illness or disability, the need for these items will be long term, the Company, at its sole discretion, may approve the purchase of these items. Repair to a wheelchair will be included up to a lifetime maximum of $250.00.
OTHER ELIGIBLE EXPENSES
a) Charges for oxygen, blood or blood products and the equipment required for its administration;
b) Charges for treatment of a sickness by the use of radiotherapy or coagulotherapy;
c) Charges for laboratory tests done in a commercial laboratory for diagnosis of a sickness but excluding any tests performed in a physician’s office or a pharmacy.
LIMITATIONS AND EXCLUSIONS
a) expenses as a result of any injury or sickness caused by declared or undeclared war or any act thereof;
b) expenses of any kind which would not normally be charged to the Insured provided by the policy were not in effect;
c) expenses incurred from any injury or sickness sustained as a result of employment when the Insured is covered or eligible to receive benefits under the applicable Workplace Safety and Insurance Board’s legislation or similar law;
d) suicide or any attempt thereat or intentionally self-inflicted injury, regardless of mental health;
e) cosmetic medical or surgical care, other than due to an accidental bodily injury sustained while the Insured is insured under this benefit;
f) medical treatment which is experimental or investigational in nature;
g) periodic health examinations, broken appointments, physician’s costs for traveling or providing telephone advice, third-party examinations, completion of forms or medical reports, travel for health purposes;
h) services, treatment or supplies not included in this benefit;
i) expenses incurred from any injury or sickness as the result of active full-time service in the armed forces of any country;
j) expenses for optical services rendered by a Physician, Licensed, Certified or Registered optician, Licensed, Certified or Registered optometrist or a Licensed, Certified or Registered ophthalmologist employed or engaged by CommU;
k) expenses incurred by an Insured who is not covered under any Federal or Provincial Hospital or Medical Plan, or its equivalent.
Vision Care
If an Insured incurs expenses for vision care, the Company will pay reasonable and customary charges for:
a) one general optometric examination by an optometrist or ophthalmologist during any 24 consecutive months plus (b) or (c) below;
b) standard eye glass lenses and frames (single vision or bifocal as required) or contacts when prescribed by a physician or an optometrist, or replacement of existing eye glass lenses and frames to a maximum of $100.00 in any consecutive 24 months for one complete set of lenses and frames for any one Insured; or
c) contact lenses when prescribed by a physician or optometrist for severe corneal astigmatism, severe corneal scarring, Keratoconus (Conical Cornea) or Aphakia, provided that visual acuity can be improved to at least 20/40 level with contact lenses, but cannot be improved to that level with regular glasses, up to a maximum of $200.00 for one complete set of lenses for any Insured, in any 24 consecutive months. Otherwise, contact lenses are subject to the same maximum as eye glasses and frames
Accident Expense Reimbursement (excluding Varsity Athletes**)
**Varsity Athletes should refer to their copy of the Varsity Students Coverage Information booklet for their coverage terms. For specific details, Varsity Athletes should contact Matthew Moreland at the David Braley Sport Medicine & Rehabilitation Centre via morelandm@commU.ca.
Non-Varsity Coverage:
Expenses for any of the following services or supplies if an Insured receives medical treatment within 30 days from the date of the accident and is under the regular care and attendance of a physician:
a) hospital charges for the difference between the public ward allowance under the Insured’s Provincial Hospital Plan and the semi-private accommodation charge (private accommodation charge if recommended by a physician);
b) expenses for the services of a private-duty nurse;
c)fees for the services of a physiotherapist or combined services of a chiropractor/athletic therapist when recommended by a physician, up to $600 for a physiotherapist, and up to $300 for a chiropractor/athletic therapist, per any one accident;
d) expenses for the services of a chiropodist, podiatrist, osteopath or speech therapist;
e) transportation by a licensed ambulance service or, when recommended by a physician, by any other conveyance licensed to carry passengers for hire to or from the nearest hospital which is equipped to provide the required treatment, subject to a maximum reimbursement of $1,000.00 as the result of any one accident;
f) transportation home from the hospital by a licensed ambulance service following an injury, if deemed necessary provided alternative transportation is not available or possible, subject to a maximum reimbursement of $1,000.00 as the result of any one accident;
g) miscellaneous expenses for crutches, casts, splints, trusses and braces (does not include dental braces, or expense of a brace or similar device used for non therapeutic purposes or used solely for the purpose of participation in sports or other leisure activities), but not including replacement thereof, subject to a maximum of $2,000.00 during any one policy year;
h) rental of wheelchair, respirator/ventilator, and other durable equipment for therapeutic treatment, not to exceed the purchase price prevailing at the time rental became necessary;
i) charges for x-rays.
The reasonable and customary expenses must be incurred within 3 years after the date of the accident and reimbursement under this provision is subject to a maximum of $15,000.00 as a result of any one accident.
Reimbursement made under this provision shall not duplicate payment provided by any other part payable under the policy.
Accidental Dental Expense
When injury to whole or sound teeth (capped or crowned teeth will be considered whole and sound), due to an external force or blow to the mouth and within 30 days from the date of the accident, requires treatment by a dentist or oral surgeon, the Company will pay the reasonable and necessary expenses actually incurred by the Insured within 52 weeks after the date of the accident, but not to exceed $2,000.00 as the result of any one accident.
Any payment made under this provision will be in accordance with the current Fee Guide for General Practitioners published by the Ontario Dental Association.
Tutorial and Special Telephone Expense
If injury shall, within 100 days from the date of the accident, totally disable and confine the Insured Student to his residence or hospital for a period in excess of 40 consecutive days, the Company will pay the expenses incurred from the first day the actual expense is incurred for such confinement, for the tutorial services of a qualified teacher, at a maximum rate of $20.00 per hour and in addition, will pay for labour charges, wiring and rental of communication equipment to provide a telephone tutorial service from the school to his residence or hospital. All benefits under this provision is subject to an aggregate limit of $2,000.00.
Eyeglasses and Contact Lenses Expense
If injury sustained by an Insured requires treatment by a physician and,
a) results in the breakage of eyeglasses or loss or breakage of a contact lens or lenses the Company will pay the actual cost of repair, or replacement, to a maximum of $200.00 in respect to all such replacements or repairs per policy year; or
b) results in the purchase of eyeglasses or contact lenses upon the advice of a physician, when neither of which were previously required or worn, the Company will pay the actual expense therefore, up to a maximum of $200.00 in respect to all such purchases per policy year.
Life Insurance
The MSU will provide $7,500.00 life insurance benefit from sickness (please refer to the Dread Disease benefit) or accident.
Accidental Dismemberment
When an accidental injury results in any of the following losses, occurring within 365 days, the plan will pay the amount specified for such loss as per the schedule below. Only one such loss (the greatest) shall be payable as the result of any one accident.
Both Hands or Both Feet............................................................................................$ 25,000.00
Entire Sight of Both Eyes............................................................................................$ 25,000.00
One Hand and One Foot.............................................................................................$ 25,000.00
One Hand or One Foot and Entire Sight of One Eye.................................................$ 25,000.00
Speech and Hearing in Both Ears...............................................................................$ 25,000.00
Speech or hearing in Both Ears.................................................................................. $ 15,000.00
One Arm or One Leg...................................................................................................$ 15,000.00
One Hand or One Foot................................................................................................$ 10,000.00
Entire Sight of One Eye...............................................................................................$ 10,000.00
Hearing in One Ear......................................................................................................$ 5,000.00
Thumb and Index Finger of Either Hand...................................................................$ 5,000.00
Four Fingers of Either Hand.......................................................................................$ 5,000.00
All Toes of One Foot....................................................................................................$ 3,750.00
Any One Entire Finger or Entire Thumb.................................................................... $ 1,000.00
Part of Any One Finger or Thumb............................................................................... $ 150.00
One or More Entire Toes............................................................................................. $ 50.00
One Entire Phalanx of Any One Finger.......................................................................$ 50.00
Quadriplegia (complete paralysis of both upper and lower limbs).............................$ 30,000.00
Paraplegia (complete paralysis of both lower limbs)...................... ........................... $ 30,000.00
Hemiplegia (complete paralysis of upper & lower limbs of one side of the body)..... $ 30,000.00
Double Indemnity
The amount of indemnity for accidental loss of life stipulated under Accidental Death and Dismemberment Benefits shall be doubled, if such loss occurs while the Insured is riding in, boarding or alighting from any bus, streetcar, train or school vehicle owned or leased by proper school authority.
Repatriation Expense Benefit
If the Insured suffers an accidental loss of life outside of their province of residence, the plan will pay the expense of homeward carriage of the body, subject to a maximum payment of $2,000.00.
Dread Disease Benefit Care
If Poliomyelitis, Scarlet Fever, Diphtheria, Spinal Meningitis, Encephalitis, Rabies, Tetnus, Tularemia, Cancer, Typhoid, Hepatitis B, Non-A and Non-B Hepatitis, AIDS or testing HIV positive which commences while the policy is in force with respect to the Insured requires confinement in a hospital or the services of a nurse, the plan will pay for the expense actually incurred for confinement or services within three years immediately following the date the first expense is incurred, to a maximum of $10,000.00.
If such disease results in loss of life, the Company will pay a lump sum of $7,500.00 less any amount already paid for treatment for such disease. In the event that the payment made under this part exceeds $7,500.00 when loss of life occurs, no further payment will be made.
Excess Hospital/Medical Reimbursement for Out of Province
(Applicable only to Residents of Canada covered under Provincial Health Insurance Plan or its equivalent)
When by reason of injury sustained outside normal province of residence, the Company will pay the following reasonable and customary expenses actually incurred by the Insured for medical treatment not to exceed $10,000.00 as the result of any one accident:
a) services and supplies rendered by a hospital while the Insured is confined as a resident in-patient in standard ward or semi-private accommodation;
b) services of a physician or anaesthetist;
c) services of a nurse;
d) diagnostic x-ray examination by a physician;
e) transportation by a licensed ambulance; rental of crutches, splints, trusses or braces (excluding the expense of brace or similar device used for non therapeutic purposes or used solely for the purpose of participating in sports or other leisure activities).
Reimbursement under this provision shall not duplicate payment provided by any other part of the policy. Insurance commences on the date of departure of an Insured from the province of residence and terminates upon the date of return to the province of residence.
WE STRONGLY RECOMMEND that travel medical insurance be purchased if you travel outside of Ontario.
EXCLUSIONS
This section does not cover loss, fatal or non-fatal, caused by or resulting from:
- suicide or any attempt thereat or intentionally self-inflicted injury, regardless of mental health;
- declared or undeclared war or any act thereof;
- active full-time service in the armed forces of any country;
- injury sustained in consequence or riding as a passenger or otherwise in any vehicle or device for aerial navigation, other than as provided in the Limited Air Travel coverage;
- expenses of dental treatment, nor the cost of x-rays, repair or replacement or pre- existing dentures, filling or crowns, other than as provided in the Accidental Dental benefit;
- expense of repairing, supplying or replacing eyeglasses, contact lenses or prescriptions therefore, other than as provided in the Eyeglasses and Contact Lenses Expense;
- charges for massage therapy;
- sickness or disease, either as a cause or effect, other than as provided in the Dread Disease benefit;
- expenses incurred by an Insured who is not covered under any Federal or Provincial Hospital or Medical Plan, or its equivalent
- a criminal act the Insured commits or attempts to commit.
Benefits are reduced by any amount paid or payable under any other policy providing similar reimbursement expenses.