Personal Health Insurance (PHI)

While the policy is in effect

A claim must be received 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 PHI 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 PHI.

After the policy ends:

A claim must be received by us within 3 months of the date the 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. The client pays 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 pay benefits when we receive proof you have incurred an eligible expense. The amount is determined by:

1. applying the reimbursement percentage, and
2. then applying the maximums.

How we calculate the amount we'll pay

This is how we calculate the amount we'll pay:

1. We confirm all expenses you submit are eligible for reimbursement. We determine if there are any limitations which are described in the applicable provisions. If any of the expenses aren't eligible, we subtract that expense from the total amount you are claiming.
2. For each eligible expense, we compare:
   • the amount you are claiming,
   • the customary charge for the expense, and
   • the maximum amount the client can claim as described on the plan summaries pages.

The reimbursement is based on the lowest of these three amounts.

General exclusions

When we will not pay (exclusions)
We will not pay for:

• expenses that we are not legally allowed to pay,
• for services or items that we consider cosmetic,
• for services or items that we consider experimental,
• for delivery, transportation and administration charges,
• for services and products that are self-prescribed or are rendered or prescribed by a person who is ordinarily a resident in the insured person’s home or who is related to the insured person by blood or marriage,
• for services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program, except as described in Integration with government programs unless explicitly listed as covered under this benefit,
• services or supplies that are not usually provided to treat an illness, including experimental or investigational treatments. Experimental or investigational treatments mean treatments that are not approved by Health Canada or other government regulatory body for the general public,
• for services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada), and
• elective (non-emergency) medical treatment or surgery which is received or performed out of the province where they the insured person lives.

We will not pay benefits when the claim is for an illness resulting from:

• hostile action of any armed forces, insurrection or participation in a riot or civil commotion, and
• participation in a criminal offence

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:

• medically necessary,
• incurred due to an emergency which occurs during the first 60 days of travelling outside the province in which the insured person lives. The 60-day travel period starts on the first day of departure from the province where the insured person lives,
• incurred as a result of emergency treatment of an illness or injury which occurs outside the province in which the insured person lives, and
• for an insured person who is under the age of 80. This coverage ends on the insured person's 80th birthday.

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:

• under age 65, they become eligible for another 60 days of coverage when they return to the province where they live for 24 hours.
• 65 or older, they become eligible for another 60 days of coverage when they return to the province where they live for 20 consecutive days.

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:

• under 65, the first trip is covered because it is within the first 60 days of travel. The second trip is covered because they have returned for more than 24 hours so they are eligible for another 60 days of coverage which begins the day they leave on the February 2nd trip.
• 65 or older, the first trip is covered because it is within the first 60 days of travel. The second trip is covered because it is within 60 days from January 1. The two trips plus the two days in between is less than 60 days so both trips will be covered under the same 60-day emergency travel medical coverage, and the remaining days of coverage expire 18 days later. The insured person will be eligible for another 60 days of emergency travel medical coverage once they have returned to their province for 20 days.

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:

• under 65, they have met the requirement to return to their province for 24 hours and are eligible for another 60 days of coverage starting April 20th.
• 65 or older, they have not met the required eligibility period and coverage ends on April 29th. They are only covered for the first trip of 40 days and 10 days of the second trip. The insured person did not return to their province for the required 20 days and is only eligible for emergency travel medical coverage for the first 10 days of the 50 days of travel.

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:

• physician and hospital referrals,
• ongoing monitoring of medical treatment if an insured person is hospitalized,
• coordination of transportation arrangements via ground or air ambulance if it is medically necessary to return an insured person to Canada or transfer them to another hospital that is equipped to provide the required treatment,
• payment assistance for hospital and medical expenses,
• legal referrals,
• a telephone interpretation service, and
• a message service for insured persons; messages will be held up to 15 days.

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:

• public ward accommodation and auxiliary hospital services in a general hospital,
• services of a physician,
• economy air fare to return the insured person to the province where they live for medical treatment,
• licensed ground ambulance service to the nearest hospital equipped to provide the required treatment, or to Canada as determined by us or our emergency travel assistance provider,
• emergency air ambulance service to the nearest hospital equipped to provide the required treatment, or to Canada as determined by us or our emergency travel assistance provider, when the insured person's physical condition prevents the use of another means of transportation, and
• the services and return air fare for a registered nurse when the insured person's physical condition prevents the use of another means of transportation, and the insured person requires a registered nurse during the flight.

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:

• return transportation for an insured person who is under age 16, or is handicapped, and they are left unattended because you or an insured person is hospitalized outside the province where you live. We will provide an escort to accompany them, if we or our emergency travel assistance provider determine it's necessary. The maximum payable for the return transportation is a one-way economy fare for each insured dependant who is under age 16, or who is handicapped,
• return transportation of any insured person, if their hospitalization or another insured person's hospitalization prevents them from returning home on the originally scheduled, pre-paid transportation, and they must purchase new return tickets. The extra cost of each return fare is payable to a maximum of a one-way economy fare, less any amount reimbursed for the unused return tickets,
• a visit of a spouse, parent, child, brother or sister, of the insured person when that insured person is hospitalized for more than seven days while travelling without a relative. The visit includes meals and accommodation up to a maximum of $150 per day, and round-trip economy transportation, for the person visiting. These expenses are also covered when it is necessary for one of them to identify a deceased insured person before the release of their body, and
• meals and accommodation up to a maximum of $150 per day (in total, not per person), if another insured person's trip is extended because an insured person is hospitalized.

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:

• for services that are not immediately required or which could reasonably be delayed until the insured person returns to the province where they live,
• for services relating to an illness or injury which caused the emergency, if they were received after the emergency ended,
• for services provided to the insured after the date that we or our emergency travel assistance provider, based on available medical evidence, determine that the insured person can be returned to the province where they live,
• for services received by the insured person for an illness or injury, including any complications if the insured person unreasonably refused or neglected to receive recommended medical services for that illness or injury,
• for services related to an illness or injury, including any complications or any emergency arising directly or indirectly from that illness or injury, where the trip was taken to obtain medical services for that illness or injury,
• incurred by an insured person for an emergency which occurs more than 60 days after departure from the province where they live,
  for the regular treatment of a chronic injury or illness. Emergency services do not include treatment provided as part of an established management program that existed before the insured person left their province of residence,
• due to or related to a pre-existing medical condition. A "pre-existing" medical condition is one where symptoms appeared or required medical attention, hospitalization or treatment (including changes in medication or dosage) during the nine-month period before the insured person's departure from the province where they live,
• due to pregnancy and incurred within four weeks of the insured person's expected date of delivery,
• for a child born outside of Canada until the later of their coverage effective date, or the date the child returns to Canada,
• incurred on a non-emergency or referral basis, and
• incurred under any of the conditions specified in the General exclusions section of the General provisions pages.

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;

1. Call the 24-hour help-line listed on the emergency travel medical card or have someone call on their behalf. Our emergency travel assistance provider will verify the client's private health coverage and provincial health care coverage so payments can be arranged on behalf of the insured person, their insured spouse or insured dependent.
2. An authorization form will need to be signed by the insured person, allowing our emergency travel assistance provider to recover any amount payable to provincial health care plan.
3. The insured person is responsible for expenses incurred that aren't covered under their plan or their provincial health care plan. The policy owner will need to reimburse our emergency travel assistance provider for any excess amount paid on their behalf.
4. If subsequent bills are received for these expenses, they need to be forwarded to our emergency travel assistance provider and payments will be coordinated by our emergency travel assistance provider with the provincial health care plan and Sun Life Financial.
5. Our emergency travel assistance provider  may request proof of travel (i.e. plane ticket, gas receipts, car rental receipts) to prove travel dates are within the eligible 60 days. If proof isn't provided, a claim may be denied.

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's 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.

To become eligible and continue to be eligible for a PHI policy, a person must be:

1. A resident of Canada, and
2. Covered under provincial or territorial health and drug health insurance,
   • Quebec residents must also have and continue to have the health and drug coverage through a group benefit plan or through the Régie de l'assurance maladie du Québec (RAMQ). If they have drug coverage with their group benefits instead of RAMQ , we need to know the carrier, the group policy and certificate number to direct claims to the group plan first. Personal health insurance is an individual plan and does not take the place of a group plan, therefore clients cannot opt out of RAMQ because they have PHI.
3. Less than 70 years of age on the PHI application date (PHI is renewable for clients who are 70 years and over), and
4. The policyholder, or related to the policyholder in one of the following ways:
   1. Legally married or in a civil union,
   2. Living with, in a conjugal relationship and represented as spouse or partner of the insured, or
   3. A child born to you, adopted by you, or is a step child who is unmarried and entirely dependent on the insured for maintenance and support and who is
      1. Under 21 years of age,
      2. Under 25 years of age and attending a college or university full time,
      3. Physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on the policyholder for maintenance and support and while eligible under 1) or 2) above.

Other requirements

• If applying as a couple or a family, the same plan and options must be chosen for everyone in order for the Client to benefit from couple rates.
• When choosing coverage, premium rates are based on age and province of residence. Use child rates if a dependent child is under the age of 21 or under 25 and in school full time.
• If your Client is under age 25 and not applying as a dependant, use single rates.
• Pregnancy and semi-private hospital coverage - If you make an application during your pregnancy, your are eligible to apply for semi-private hospital coverage. The covered length of hospital stay will be limited to 2 days. When the baby is born, simply contact us within 30 days of the birth and the baby can be added to your plan for a small, additional premium. We also require a Personal Health Insurance - Add family member (E323) form be completed.

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.

Yearly renewable rates

Rates are not guaranteed. When your Client moves into the next age band the premiums will increase at the next policy anniversary. We will review our pricing annually. If we need to increase our rates, your Client's premiums would increase at their next anniversary. Other than these two situations only a major shift in health care expenses could cause us to increase a Client's premiums.

Couple rates are charged on a per person basis - for example, if a man is over 65 and his spouse is under 65, they are charged the couple rate for their age band.

We do not offer discounts for multiple sales.

Grace period

The grace period is 10 days for the payment of premiums and is allowed for each premium except the first. During the grace period, insurance remains in force and premiums continue to be payable. We terminate the policy when payment has not been made before the end of the grace period.

Changing plan type

Your Client may apply at any time to change their existing plan type (basic, standard or enhanced) to any other plan type we offer at the time they apply for the change. They must apply by submitting a web or paper application. We will require new evidence of insurability from all insured persons. If the application is approved, the change to the plan type takes effect on the next billing date, of the original Identification Number, following approval.

Note: Waiting periods are not waived regardless of their having been met on the existing policy.

Depending on the plan, optional benefits may be available after the effective date of the policy. 

Adding an insured person

Spouse or child:

Your Client may apply to add a spouse or 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:

• Complete and sign form Personal Health Insurance - Add family member (E323) including current medical information. Fax to 1-866-487-4745.
• Call the Customer Service Centre at 1-877-SUN LIFE (1-877-786-5433) to request a form be sent to them via e-mail or mail.

For any child the Client asks us to add, we may require the Client to prove the child's relationship to the Client.

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:

1. under 21 years of age, or
2. under 25 and attending college or university full time, or
3. physically or mentally incapable of self-support  and became incapable of self-support while entirely dependent on the Client for maintenance and support while eligible under 1 or 2.

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.

• Basic plan with semi-private hospital room coverage - all Provinces
• Standard plan with semi-private hospital room coverage - all Province
• Enhanced plan with dental and semi-private hospital room coverage - all Provinces

• Tax deductions for businesses

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:

1. Logging in to the advisor site.
2. Navigate to Home > Health > Personal Health Insurance and Health Coverage Choice > Apply now links at the bottom
   Note: The Apply now links will not be visible unless you log in.

Notes:

• To receive commission, enter your name, phone number and email address in the application.
• You must maintain information of the sale in the a Client file as you normally do with all insurance sales. Please remove any direct links to the PHI or HCC application from your advisor website

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: 1800-800-4786