
© Sun Life Assurance Company of Canada. All rights reserved.
Target Client profiles:
HCC is an ideal solution for those leaving a group benefits plan, clients who are retiring, have recently been laid off or are leaving a job to start their own business.
Selling features:
Provides affordable coverage for day-to-day health expenses and unexpected medical emergencies that aren't covered by provincial plans. Dental benefits are optional on some plans. No medical information is required.
We will only reimburse medical expenses that are not covered by the insured person's provincial health care plan.
Benefit |
Reimbursement |
Maximum per person |
---|---|---|
Drug | 80% | $500 in a calendar year |
Extended health | 80% | Described in the Extended health provision |
Vision | 100% |
$150 every two calendar years |
Semi-private hospital room | 50% of reasonable & customary charges | $5,000 in a calendar year |
Preventive dental | 80% | $700 in a calendar year |
Drug
Lifetime maximum
The amount we will reimburse for each insured person over the lifetime of this policy is limited to $250,000 in total for the following eligible expenses:
We will only reimburse medical expenses that are not covered by the insured person's provincial health care plan.
Benefit |
Reimbursement |
Maximum per person |
---|---|---|
Drug | 80% | $1,300 in a calendar year |
Extended health | 100% |
Described in the Extended health provision |
Vision | 100% |
$200 every two calendar years |
Emergency travel medical coverage | 100% |
60 days per trip $1,000,000 lifetime |
Semi-private hospital room | 85% of reasonable & customary charges | Described in a Semi-private hospital room provision |
In Quebec
Lifetime maximum
The amount we will reimburse for each insured person over the lifetime of this policy is limited to $250,000 in total for the following eligible expenses:
Benefit |
Reimbursement |
Maximum per person |
---|---|---|
Drug | 80% | $1,300 in a calendar year |
Extended health | 100% |
Described in the Extended health provision |
Vision | 100% |
$200 every two calendar years |
Emergency travel medical coverage | 100% |
60 days per trip $1,000,000 lifetime |
Semi-private hospital room | 85% of reasonable & customary charges | Described in a Semi-private hospital room provision |
Optional benefits | ||
Preventive dental | 80% | combined $700 per calendar year |
Restorative dental | 50% |
In Quebec:
Waiting period - Dental: An insured person becomes eligible for the restorative dental coverage one year after the effective date of this policy.
Dental benefit - anaesthesia and laboratory charges: When an insured person incurs anaesthesia and laboratory charges, these charges will only be reimbursed if incurred while receiving eligible dental services. The reimbursement for the anaesthesia and laboratory charges is limited to the reimbursement percentage of the services they were performed with.
Lifetime maximum
The amount we will reimburse for each insured person over the lifetime of this policy is limited to $250,000 in total for the following eligible expenses:
We will only reimburse medical expenses that are not covered by the insured person's provincial health care plan.
Benefit |
Reimbursement |
Maximum per person |
---|---|---|
Drug | 80% | $2,600 in a calendar year |
Extended health | 100% |
Described in the Extended health provision |
Vision | 100% |
$300 every two calendar years |
Emergency travel medical coverage | 100% |
60 days per trip $1,000,000 lifetime |
Semi-private hospital room | 85% of reasonable & customary charges | Described in a Semi-private hospital room provision |
In Quebec
Lifetime maximum
The amount we will reimburse for each insured person over the lifetime of this policy is limited to $250,000 in total for the following eligible expenses:
Benefit |
Reimbursement |
Maximum per person |
---|---|---|
Drug | 80% | $2,600 in a calendar year |
Extended health | 100% |
Described in the Extended health provision |
Vision | 100% |
$300 every two calendar years |
Emergency travel medical coverage | 100% |
60 days per trip $1,000,000 lifetime |
Semi-private hospital room | 85% of reasonable & customary charges | Described in a Semi-private hospital room provision |
Optional benefits | ||
Preventive dental | 80% | $750 in the first calendar year, $1,000 in subsequent calendar years (combined with Preventive dental) |
Restorative dental | 50% |
In Quebec
Waiting period - Dental: An insured person becomes eligible for the restorative dental coverage one year after the effective date of this policy.
Dental benefit - anaesthesia and laboratory charges: When an insured person incurs anaesthesia and laboratory charges, these charges will only be reimbursed if incurred while receiving eligible dental services. The reimbursement for the anaesthesia and laboratory charges is limited to the reimbursement percentage of the services they were performed with.
Lifetime maximum
The amount we will reimburse for each insured person over the lifetime of this policy is limited to $300,000 in total for the following eligible expenses:
While the policy is in effect
A claim must be received by us within 12 months of the date that the eligible expense is incurred. An eligible expense is incurred on the date the services are received or on the date supplies are purchased or rented. If an anticipated treatment is not specifically mentioned in the contract, the client should contact us (1-877-SUN LIFE/ 1-877-786-5433) before treatment begins to confirm whether an espense will be eligible.
Claims must be submitted through the province of residence (or Régie de l'assurance-maladie du Québec (RAMQ) first as they are the first payor. Clients in Quebec should notify their pharmacy that RAMQ pays first and claims are paid under HCC once we see from the receipt what RAMQ has paid. Exception: Drugs that are not eligible under RAMQ do not fall into this process and therefore the claim should be submitted to HCC
After the policy ends
A claim must be received by us within 3 months of the date your policy ended. We will not pay for any claims received by us more than 3 months after the date your policy ended, regardless of when the eligible expense was incurred.
We may require itemized bills, attending physician statements, commercial laboratory receipts, reports, records, x-rays, study models or other information we consider necessary to assess the claim. Your client must pay any additional cost associated with providing this information.
The intentional omission, misrepresentation or falsification of information relating to any claim constitutes fraud.
Payment of benefits
We will pay benefits when we receive proof of an incurred eligible expense. We determine the amount to be paid by:
How we calculate the amount we'll pay
This is how we calculate the amount we'll pay:
The reimbursement is based on the lowest of these three amounts.
When we will not pay (General Exclusions)
We will not pay for:
We will not pay benefits when the claim is for an illness resulting from:
When your clients buy online, you'll benefit from:
At sunlife.ca your clients can manage their PHI or HCC plans online - it's easy, secure and paperless. Clients can receive fast and efficient service, as well as:
Address changes cannot be completed online. Clients can contact the PHI administration team if they need to update their address.
Please note that access to web services is available to clients only.
This free app makes it easier for PHI and HCC clients to connect - any time, anywhere. With the app, your clients can use their smartphone to:
Clients can download the my Sun Life mobile app to their smartphone from their App store.
More information about sunlife.ca web services
Clients can register online at www.sunlife.ca or by phone at 1-877-SUN-LIFE (1-877-786-5433).
Direct deposit of claims is only available to clients who have registered for web services. Here's how the direct deposit of claims will work:
If clients have technical questions about registering or need to reset a password, please have them call 1-877-SUN-LIFE (1-877-786-5433).
1For forms which require changes (such as a termination form), clients must contact the PHI administration team at 1-877-SUN-LIFE (1-877-786-5433). Changes to the plan such as an address change, adding or removing a dependant or adding or removing a benefit cannot be done on the website.
2For PHI clients with medical (non drug) exclusions, they can still see these benefits but there is a disclaimer on the website to indicate the contract will determine the level of coverage they have.
3When the payment is deposited, an email is sent to the owner informing them the claim has been processed and the owner can sign in to see the claims payment details.
The information below applies to the current series.
All plans, except for PHI Basic and HCC A include coverage for unexpected emergency medical services performed outside an insured person's home province if they occur within the first 60 days of the trip.
Emergency travel medical provision
Eligible expenses
We will cover eligible expenses up to the limit specified on the Plan summary page and those described below.
Hospital and medical services and travel assistance expenses must satisfy all of the following criteria to be eligible. They must be:
Emergency services covered under the emergency travel medical coverage include any reasonable medical services or supplies, including advice, treatment, medical procedures or surgery required as the result of an emergency.
When the 60 days of coverage ends
The 60 days of coverage ends, whether a claim has been made or not, when the insured person has left the province where they live and hasn't returned for the length of time needed to obtain another 60 days of coverage. The insured person must return to the province where they live for the required 24 hours or 20 consecutive day period to be eligible for another 60 days of emergency travel medical coverage.
If emergency travel medical coverage has ended and the insured person is:
Example 1
Regardless of age, if the insured person departs from the province where they live on January 1st and travels for 60 days, they will have emergency travel medical coverage for the entire 60 days. If they have not returned to their province before the 61st day, they are no longer covered. To be eligible for another 60 days they must return to their province for the time specified based on their age.
Example 2
If the insured person departs from the province where they live on January 1 and travels for 30 days, returns to their province for two days, then departs on February 2 for another 10 days, and they are:
Example 3
If the insured person departs from the province where they live on March 1st and travels for 40 days, returns to their province for 10 days, and leaves on April 20th for another 50 days, and they are:
Travel assistance services
We will provide a toll-free number which gives insured persons 24-hour access to a worldwide assistance network. For an emergency which occurs during the 60-day travel period, the network will provide the following emergency assistance services:
Emergency payment assistance
You must confirm your provincial health care coverage and coverage under the health provisions of this policy with our emergency assistance provider before receiving medically necessary services to ensure that any expenses you incur are paid. If you are not able to confirm with our emergency travel assistance provider before receiving services, you must do so as soon as is reasonably possible afterward. If you don't confirm coverage and services are received in circumstances where you could have reasonably contacted our emergency assistance provider, then we have the right to deny or limit payments for all expenses not confirmed. If we've paid for hospital and medical expenses on behalf of an insured person, you must sign an authorization form allowing us to recover the amount we've paid from the appropriate provincial health care plan.
If we've paid or have agreed to pay for expenses that require a portion to be paid by the insured person under this policy or the provincial health care plan, or are not covered under this policy, you must reimburse us for any amount payable by the insured person or not covered under these policies.
If we haven't paid for expenses incurred, we will only reimburse you when we receive proof satisfactory to us of your claim for reimbursement.
Hospital and medical services
We cover reasonable and customary charges for the following items, less the amount payable by a provincial health care plan:
The maximum lifetime amount we will pay for hospital and medical services is $1,000,000 for each insured person.
Expenses that are included as eligible expenses under other health benefits in this policy are also eligible while travelling outside Canada. These expenses are subject to the reimbursement percentages listed under the appropriate benefit in the Plan summary.
Travel assistance benefits
We cover reasonable and customary charges for the following family assistance benefits:
The combined maximum amount we will pay for family assistance benefits is $5,000 for each travel emergency.
Repatriation
If an insured person dies while outside of the province where they lived, we will arrange for the necessary authorizations and the return of the deceased to the province where they last lived. Preparation of the deceased for repatriation includes expenses for cremation at the place of death. Return of the deceased includes a basic shipping container, but excludes expenses for burial, such as burial caskets and urns.
The maximum amount we will pay for the preparation and return of the deceased is $5,000.
Vehicle return
If an insured person is unable to operate a vehicle (owned or rented) because they are being returned to Canada for medical treatment, we will pay the cost of returning the vehicle to the province where they live, or the nearest appropriate rental agency. We will also pay this benefit when the insured person dies.
The maximum amount we will pay for returning the vehicle is $1,000.
Exclusions and limitations
At the time of an emergency, the insured person or someone present with the insured person must contact our emergency travel assistance provider. All invasive and investigative procedures (including any surgery, angiogram, MRI, PET scan, CAT scan), must be pre-authorized by our emergency travel assistance provider before being performed, except in extreme circumstances where surgery is performed on an emergency basis immediately following admission to a hospital.
If you are not able to contact our emergency travel assistance provider before receiving services, you or someone present with the insured person must do so as soon as is reasonably possible afterward. If you don't contact our emergency travel assistance provider and emergency services are received in circumstances where you could have reasonably contacted our emergency assistance provided, then we have the right to deny or limit payments for all expenses related to that emergency.
An emergency ends when the insured person is medically stable to return to the province where they live.
We will not pay the expenses:
To determine eligibility, we may require the attending physician to provide medical evidence certifying that the insured person's medical condition was stable for a minimum period of nine months before the insured person traveled outside the province where they live. "Stable" means that the attending physician has stated that he does not expect a recurrence of the same medical condition or any problems related to that condition while the insured person travels outside the province where they live.
Due to conditions such as war, political unrest, epidemics, and geographic inaccessibility, emergency assistance services may not be available in certain countries.
Neither we nor the emergency travel assistance provider providing the assistance services is responsible for the availability, quality or results of the medical treatment received by the insured person, or for the failure to obtain medical treatment.
Emergency travel medical claims
It's important that clients quickly take the following steps if they experience a medical emergency while travelling;
Clients must send their out-of-province claims for hospital or doctors' fees to our emergency travel assistance provider, before submitting to their provincial health plan Our emergency travel assistance provider address can be obtained by visiting our Sun Life Financial Plan Member Services website at www.mysunlife.ca or by calling our Sun Life Financial Customer Care centre toll-free number 1-800-361-6212.
Following these steps will speed up the refund process. Sun Life Financial and our emergency travel assistance provider coordinate the reimbursement process with most provincial plans and insurers and send a cheque to the policy owner for the eligible expenses. Our emergency travel assistance provider will ask clients to sign a form authorizing it to act on a client's behalf before the claim is processed.
Because your client has been covered by a group health plan, he or she can apply for Health Coverage Choice. There are no medical requirements, and depending on the timing of the application, no gaps in coverage.
To become eligible and to continue to be eligible for insurance, a person must be:
Other requirements
We will only reimburse medical expenses that are not covered by the insured person's provincial health care plan.
Premiums
Premiums are due on the date shown on the Policy particulars page.
Premiums vary by age and by how much provincial and territorial health plans cover. This means your premium reflects how old each insured person is and in which province they live.
We may change your premium from time to time for a variety of reasons, including our claims experience for insured persons with similar policies, and our expenses.
If we change your premium, we will give you at least 30 days written notice before the change is made.
Grace period
A ten day grace period is allowed for premium payments. During the grace period, insurance remains in force and premiums continue to be payable. If the premium has not been paid by the end of the grace period, coverage ends. Any claims for expenses incurred after the policy has ended are not eligible for payment.
the most recent rates, get a quote from our tool on www.sunlife.ca/MyFinancialPlan.
To calculate the premium for your family, use the applicable rates for the age of each insured.
If there are two adults in your family, use the couple rate for each adult's age instead of the single rate.
Child rates apply if your child is under 21 or under age 25 and attending school full time.
If your child is applying without an adult, the <44 single rates will apply.
To calculate an annual premium, multiply the monthly premium by 12.
This rate sheet is prepared for information purposes only and is not an offer to provide insurance. It does not form part of any policy that may be issued.
Policies may be issued up to age 74 and are renewable.
Adding an insured person
Child:
Your client may apply in writing to add a child as an insured person under this policy.
We will add newborn children without evidence if the client asks us to add them within 30 days of their birth.
Your client needs to contact us directly in one of these three ways to add a newborn child:
We need to know the newborn child's:
For any child the client asks us to add, we may require the client to prove the child's relationship to the client. We will also advise if they need to provide evidence of insurability for the child they want to add who is age 31 days or older.
The client may apply to add any child who is unmarried and entirely dependent on them for maintenance and support and is either born to them, adopted by them, or is a stepchild and is:
Other eligible persons:
The client may ask us to add a person to the list of insured persons. They must make this request in writing. The person must meet our eligibility requirements and give evidence of insurability satisfactory to us.
Removing an insured person
If the client asks us in writing, we will remove an insured person from this policy. This change takes effect on the date we receive the request or the next date we deem appropriate.
Right to cancel this policy
The client may cancel this policy at any time by sending a written request to the address shown at the beginning of the policy. We must receive a minimum of 10 days advance written notice of termination. We encourage the use of form Personal Health Insurance - terminating coverage with Sun Life Assurance Company of Canada (E118) for faster service.
The following policy wording is provided solely for your convenience and reference. It is incomplete and reflects only some of the general provisions that may be found in some of our insurance policies. We periodically make changes to policy wording and therefore this incomplete sample may not duplicate the wording of any actual issued policy. It is not to be construed or interpreted in any manner as a contract or an offer to contract. The actual policy issued to any given client will govern that relationship.
printable copy:
Self-employed people are allowed a deduction for business purposes of amounts paid for their own Health Coverage Choice premiums, provided the following provisions are met.
Otherwise, the amount deductible is limited to $1,500 for the individual, $1,500 for their spouse and $750 for each child.
Arm's length employee
An arm's length employee is one that is not a family member and has no controlling interest in the business.
Q&A about tax deductions
1. If a self-employed person pays premiums for a spouse and children, are those deductible as well?
Yes, provided the conditions are met.
2. Can the premiums be included in the person's medical expense tax credit?
Where a tax deduction is claimed, no amount paid for premiums will be eligible for the medical expense tax credit.
Scenarios
Scenario 1:
After leaving her group benefit plan, Susan opens a restaurant with a partner, who is also her husband. They have 5 employees, 3 of which are her children. She has another 2 kids at home. The business is unincorporated.
She purchases the same Health Coverage Choice plan for herself ($950 in premium), her 2 kids at home and the 3 employees that are her children. For the other 2 employees, she purchases equivalent PHI coverage. Does she qualify for the tax deduction? If so, is there a maximum? What about for the kids at home?
Answer: Yes, Susan qualifies for the deduction subject to a maximum of $1,500 each for herself and her husband and $750 for each of her children.
Scenario 2:
Ken works part-time for a children's toy store as a clown. However, he is also self-employed with a picture-framing business (not incorporated). He made $20,000 in his day job, and $15,000 in his framing business. He has no employees. Is he eligible for the tax deduction?
Answer: No, Ken will not qualify since his income from other sources is in excess of $10,000.
Scenario 3:
Lisa owns an unincorporated landscaping company with 9 employees. She decides to purchase PHI for her employees and HCC for herself. She purchases the Basic PHI plan for her employees, and the Health Coverage Choice C plan with optional dental for herself, her spouse and her children. Are hers and her family's premiums tax deductible?
Answer: No, the premiums are not deductible since equivalent coverage is not provided for her employees.
As a result of a new legal framework that came into effect June 13, 2019, for clients in Quebec, the online direct sales process must be similar to working with an advisor.
The PHI and HCC web applications don’t support these requirements. We hope to update them in the future. In the meantime, an advisor’s involvement throughout the process is required and the web application must only be used as a tool in the sales process.
Quebec clients cannot directly buy PHI or HCC products using our online application. Quebec residents will be directed to work with an advisor if they need to purchase PHI or HCC.
To service a client who lives in Quebec using the web application, you must sign in to the advisor website. Access the application by:
Notes:
Reminder! Clients in Quebec must have RAMQ coverage in addition to other criteria, to be eligible to apply. Quebec residents must fill and send the Confirmation of coverage through a group benefits plan or through Régie de l'assurance maladie du Québec (RAMQ) form on their RAMQ coverage details along with the web application form.
For questions about PHI and HCC products: salesdesk@sunlife.com
For web support: 1-800-800-4SUN (4786)
Want to share this information on social media? Select the appropriate link below.
© Sun Life Assurance Company of Canada. All rights reserved.