Canadian Association of Occupational Therapists (CAOT) INSURANCE PLAN

Transcription

1 Canadian Association of Occupational Therapists (CAOT) INSURANCE PLAN Term Life Insurance Long Term Disability Insurance Critical Illness Insurance Extended Health Care and Dental Care Insurance Accidental Death and Dismemberment Insurance Professional Overhead Expense Insurance

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3 A comprehensive insurance plan for all CAOT members CAOT s Insurance Plan is designed to protect your income, a business you might establish and ultimately, your lifestyle, in the event the unexpected happens. The plan combines the flexibility of an individual plan with the cost advantage of a group plan while offering a full array of protection benefits. Customize your plan with: Term Life Insurance Long Term Disability (LTD) Insurance Critical Illness (CI) Insurance Extended Health Care (EHC) and Dental Insurance Accidental Death & Dismemberment (AD&D) Insurance Professional Overhead Expense (POE) Insurance Protection for yourself and your family at a glance Insurance Term Life Long Term Disability (LTD) Critical Illness (CI) Extended Health Care (EHC) and Dental Care** Who is eligible? This plan has been developed exclusively for members of CAOT. You are eligible to apply for coverage if you are: a CAOT member in good standing with the association, under age 65 (age 75 for Extended Health Care and Dental Care, age 61 for Accidental Death and Dismemberment Insurance and age 60 for Professional Overhead Expense Insurance), a resident of Canada, and actively at work for at least 25 hours a week. Evidence of good health All coverage is subject to medical underwriting. You will need to provide evidence of good health by completing a medical questionnaire. In the case of Long Term Disability Insurance, you will also be required to provide answers to financial and employment questions. Coverage available for Member, spouse and dependent children (spouse and dependent are only eligible to apply if the Member applies) Member only Member and spouse (member must have CI to obtain spouse coverage) Single, couple* or family (members must be covered under provincial health insurance) Accidental Death and Dismemberment Professional Overhead Expense Single or family (member must have Term Life Insurance) Member only (must have LTD insurance) * Couple coverage covers a CAOT member and their spouse. ** Quebec residents must also have and continue to have health and drug coverage through a group benefit plan or through Régie de l assurance maladie du Québec (RAMQ). A person not covered under a group benefit plan or through RAMQ, is not eligible for coverage under this policy. Spouse means your spouse by marriage or under any other formal union recognized by law; or a person of the opposite sex or of the same sex who is publicly represented as your spouse for a period of at least 12 months. You can only cover one spouse at a time. Discontinuance of cohabitation terminates the eligibility of a common-law spouse. Dependent children means you or your spouse s children (other than a foster child) who are not married or in any other formal union recognized by law, and are under the age of 21 (age 25 if a full-time student), as long as the child is entirely dependent on you for financial support including if a child becomes handicapped before the limiting age. We will continue coverage as long as the child is incapable of financial self-support because of a physical or mental disability and the child depends on you for financial support, and is not married nor in any other formal union recognized by law. A dependent child may only be insured by one member covered under the plan. 3

4 Term Life Insurance Term Life Insurance Consider how your family would cope if you passed away and were no longer here to take care of them. The economic realities would soon set in: bills, mortgage payments, taxes and funeral expenses, not to mention everyday living expenses. CAOT s Term Life Insurance plan offers affordable rates so you can help protect your family s financial future. Coverage Coverage is available in units of $25,000 with a minimum of $50,000 and a maximum of $1 million. If you apply for coverage, you can also apply for coverage for: your spouse; and your dependent children ($10,000/ child for all eligible children). Waiver of premium If you become totally disabled before you reach age 65, your Term Life Insurance coverage and your dependent child s Term Life Insurance coverage may continue without the payment of premiums as long as you are totally disabled. For the purposes of Term Life Insurance coverage, you will be considered totally disabled if you are prevented by illness from performing any occupation you are or may become reasonably qualified for by education, training or experience. You must be totally disabled for 180 days. Conversion If your Term Life Insurance, or your spouse s Term Life Insurance coverage ends for any reason other than your request, you or your spouse may apply to convert the coverage to an individual Term Life policy with Sun Life without providing proof of good health at the time of application. The request must be made within 31 days of the end of the Term Life Insurance coverage and prior to age 65. Living benefit If you or your insured spouse are terminally ill and expected to die within 12 months or less, you may receive an advance of up to 50% of the Term Life Insurance benefit up to a maximum of $50,000, subject to approval by Sun Life. Exclusions No benefits are payable for a death which occurs before insurance under this benefit has been in effect continuously for two years with respect to the deceased, if death results directly or indirectly from suicide, or self-destruction while sane or insane. If the Term Life Insurance is subject to more than one effective date due to additional amounts having been applied for on the deceased, the two-year period will run separately from each effective date. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada. All claims must be approved by Sun Life Financial. 4

5 Long Term Disability (LTD) Insurance Long Term Disability (LTD) Insurance Your ability to earn an income is one of your most important assets. What would happen if you couldn t work due to illness or injury? Would you be able to continue covering your living expenses if you weren t receiving a paycheque? You can help protect your professional income with CAOT s Long Term Disability (LTD) Insurance. It s designed to help replace your lost income to help you pay those bills that don t stop coming when you stop working. Coverage Only CAOT members are eligible to apply. The minimum benefit is $1,000 per month. Coverage can be purchased in units of $100 to a maximum coverage of $5,000 per month. The amount of coverage that you can apply for depends on your net annual earned income (see the income ratio guide page 6). You must be under 65 years of age and work a minimum of 25 hours a week in order to be eligible for coverage. Maximum benefit period Disability benefits are payable to age 65. Elimination periods The elimination period is the amount of time you must be totally disabled before LTD Insurance benefits become payable. Generally, the longer the elimination period, the lower the premium. You can choose a 30-day, 90-day or 180-day elimination period. Definition of Total Disability During the elimination period and for the first 24 months, you are considered totally disabled if illness or injury prevents you from performing the essential duties of your regular occupation, you are under the regular care of a physician and you are not gainfully employed elsewhere. After 24 months, you are considered totally disabled if illness or injury prevents you from working at any occupation for which you are qualified by education, training or experience, you are under the regular care of a physician and are not gainfully employed elsewhere. Partial Disability Benefit If, immediately following a period of total disability during which benefits were paid, you return to gainful employment which is under the supervision of a physician, and is approved by Sun Life, you may qualify for a partial disability benefit. The benefit is equal to the monthly total disability benefit reduced by: 50% of the net earnings from gainful employment, and any other amount payable to you that is listed in the Integration of Benefits provision. Waiver of premium Your LTD premiums will be waived if you are continuously disabled for 90 days, you have not reached age 65 and you are receiving disability benefits. Monthly benefit payout The amount of disability benefits payable will be the amount for which you are insured on the date you become disabled, reduced by any benefit payable as a result of your disability under any other income sources, including CPP/QPP; Workers Compensation and automobile insurance benefits; payment or income from any employer, retirement benefits, or disability benefits under any other association, group or individual insurance plans; but only to the extent necessary so that total income from all sources does not exceed 100% of your average monthly pre-disability earned income. 5

6 Long Term Disability (LTD) Insurance Income ratio guide You may select a monthly LTD Insurance benefit starting at $1,000 per month to a maximum as shown in the chart, depending upon your net annual earned income. Exclusions No benefits are payable for claims resulting directly or indirectly from any of the following: intentionally self-inflicted injuries while sane or self-inflicted injury while insane; voluntary participation in a riot or act of civil disobedience; declared or undeclared war, insurrection or rebellion; committing or attempting to commit a criminal offense; normal pregnancy and/or childbirth; during any period of imprisonment; travel or flight in any aircraft if you have any duties on or related to such aircraft or flight, or if you are flying in the course of any aviation training, instruction, testing or armed manoeuvres. Income ratio guide Annual income Monthly benefit amount $18,000 - $23,999 $1,000 $24,000 - $30,999 $1,400 $31,000 - $35,999 $1,700 $36,000 - $44,999 $2,000 $45,000 - $59,999 $2,400 $60,000 - $71,999 $3,000 $72,000 - $83,999 $3,400 $84,000 - $95,999 $3,800 $96,000 - $109,999 $4,200 $110,000 - $119,999 $4,600 $120,000 - $129,999 $4,800 $130,000 + $5,000 The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada. All claims must be approved by Sun Life Financial. 6

7 Critical Illness (CI) Insurance Critical Illness (CI) Insurance Medical advances are improving the probability of survival from a critical illness, but that survival is often followed by a lengthy and costly recovery. Have you considered the financial impact a critical illness would have on you and your family? Critical Illness Insurance complements your disability, life and health benefits. It pays a one-time benefit if you are diagnosed with one of the 11 covered critical illnesses and you survive the waiting period.* This plan is designed to help give you peace of mind and help provide financial security so you can focus on what matters most recovering on your terms. Critical Illness Insurance: is paid in a lump-sum which you can spend any way you like. can help you with daily expenses to maintain your lifestyle. is paid to you regardless of whether or not you are able to work. gives you financial freedom to seek alternative treatment options. helps cover costs not covered by your provincial health plan. Coverage Member and spouse: Coverage is available in units of $25,000 with a minimum of $25,000 and a maximum of $250,000. The benefit is payable on the first insured condition only and then coverage terminates. Covered illnesses** Blindness Cancer (life-threatening) Coronary artery bypass surgery Deafness Heart attack Kidney failure Loss of independent existence Major organ transplant Multiple sclerosis Paralysis Stroke (cerebrovascular accident) ** For complete Definitions please visit Best Doctors services With Group Critical Illness Insurance coverage partnering with Best Doctors, as an insured member you can now receive financial relief as well as access to medical services to help assist you in your recovery. Best Doctors connects seriously ill individuals and their treating physicians with medical specialists from around the world to help verify the diagnosis and best treatment options, without you ever having to leave your home. As an insured member, your spouse and dependent children also have access to Best Doctors should they be diagnosed with a serious illness. All representations about the services of Best Doctors are those of Best Doctors Inc., and not Sun Life Assurance Company of Canada. Sun Life cannot guarantee the availability of the Best Doctors services, and reserves the right to cancel Best Doctors at any time. BEST DOCTORS and other trademarks shown are trademarks of Best Doctors, Inc. and are used under license. Exclusions Benefits are not paid for claims resulting directly or indirectly from: intentionally self-inflicted injuries or attempted suicide, while sane or insane; the hostile action of any armed forces, insurrection or participation in a riot or civil commotion; participation in a criminal offence; the use of illegal or illicit drugs or substances, misuse of drugs or alcohol; the death of the insured during the required survival period. Additional provisions, exclusions and limitations may apply, including a 12 month pre-existing condition clause and 90-day cancer waiting period. *Diagnosis of a critical illness must occur after the effective date of coverage, you must complete a survival period (usually 30 days) and your claim must be approved by Sun Life Assurance Company of Canada. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada. All claims must be approved by Sun Life Financial. 7

8 Extended Health Care (EHC) and Dental Insurance Extended Health Care (EHC) and Dental Insurance Extended Health Care Insurance coverage is available to help cover a number of important medical expenses that may not be paid by provincial health insurance plans. Choose a plan with Dental Care to help cover routine and unexpected dental care costs. As an added convenience, you can access your claims/benefit information with your mobile device or online at mysunlife.ca. Coverage Single, couple or family coverage is available. Couple coverage covers you and your spouse. A complete list of all eligible expenses and exclusions is available on our website ( To be eligible, member must be covered under provincial health insurance. Quebec residents must also have and continue to have health and drug coverage through a group benefit plan or through Régie de l assurance maladie du Québec (RAMQ). A person not covered under a group benefit plan or through RAMQ, is not eligible for coverage under this policy. Coordination of benefits If you are covered for EHC or Dental Care under this plan and another plan, your benefits will be coordinated with CAOT following insurance industry standards. However, if you and your spouse are both active members of the same association, coordination of benefits does not apply. Basic Plan Benefit Drug Extended health Reimbursement 70% up to $750 per covered person in a plan year. Fully reimbursed up to $6.50 dispensing fee. 70% subject to limits outlined in the benefit below. Paramedical Services We will pay for the services performed by the following practitioners: acupuncturist, audiologist, occupational therapist, physiotherapist, psychologist, registered massage therapist, or speech language pathologist. The amount we pay is limited to $350 in a plan year for each practitioner and up to $600 in a plan year for the services of all practitioners combined. Accidental Dental The amount we pay is limited to $2,000 per fracture or injury. Ambulance We will pay for licensed ground or emergency air ambulance service to the nearest hospital equipped to provide the required treatment. Hearing Aids We will pay for hearing aids and repairs to them, limited to $350 per each five year period. 8

9 Extended Health Care (EHC) and Dental Insurance Basic Plan Benefit Extended health Vision Lifetime maximum Reimbursement Private Duty Nurse Your treatment must require the level of expertise of a nurse, limited to a plan year maximum of $2,500 and a lifetime maximum of $10,000. Medical Services and Equipment We will pay for the following provincially funded services and equipment, limited to a combined plan year maximum of $1,000 and a combined lifetime maximum of $20,000. We will pay for: - artificial limbs or other prosthetic appliances, - walkers, if we have approved either its purchase or rental, - braces, provided they are not solely for athletic use, - wheel chair (limited to a lifetime maximum of $1,000), - wigs and hairpieces (limited to a maximum of $100 per plan year), - custom made orthopaedic shoes, orthopaedic modifications to shoes, and orthotics. They must be prescribed by a physician, podiatrist, chiropodist or chiropractor. The amount we pay is limited to $250 in a plan year. 100%, $50 per 24 months for eye-exam; (one every 12 months for an insured person under 18 years of age). $100,000 per covered person. Standard Plan Benefit Reimbursement Drug 70% on first $1,000 ($700) and 80% on next $5,375 ($4,300). Total coverage: $5,000 ($700+$4,300) per plan year. Fully reimbursed up to $6.50 dispensing fee. Extended health 80% subject to limits outlined in the benefit below. Paramedical Services We will pay for the services performed by the following practitioners: acupuncturist, audiologist, occupational therapist, physiotherapist, psychologist, registered massage therapist, or speech language pathologist. The amount we pay is limited to $480 in a plan year for each practitioner and up to $800 in a plan year for the services of all practitioners combined. Accidental Dental The amount we pay is limited to $2,500 per fracture or injury. Ambulance We will pay for licensed ground or emergency air ambulance service to the nearest hospital equipped to provide the required treatment. Hearing Aids We will pay for hearing aids and repairs to them, limited to $400 per each five year period. Private Duty Nurse Your treatment must require the level of expertise of a nurse, limited to a plan year maximum of $5,000 and a lifetime maximum of $15,000. 9

10 Extended Health Care (EHC) and Dental Insurance Standard Plan Benefit Extended health Vision Emergency travel medical coverage Semi-private hospital room Lifetime maximum Reimbursement Medical Services and Equipment We will pay for the following provincially funded services and equipment, limited to a combined plan year maximum of $1,500 and a combined lifetime maximum of $20,000. We will pay for: - artificial limbs or other prosthetic appliances, - breast prosthesis are limited to $200 in a plan year, - walkers, if we have approved either its purchase or rental, - wheel chair (limited to a lifetime maximum of $1,000), - hospital bed (limited to a lifetime maximum of $1,000), - wigs and hairpieces (limited to a lifetime maximum of $500), and - custom made orthopaedic shoes, orthopaedic modifications to shoes, and orthotics. They must be prescribed by a physician, podiatrist, chiropodist or chiropractor. The amount we pay is limited to $250 in a plan year. 100%, $50 per 24 months for eye-exam; (one every 12 months for an insured person under 18 years of age). 100% up to $150 every two plan years for laser eye surgery, eyeglasses, prescription sunglasses and contact lenses and repairs. One year waiting period for vision claims other than eye exams. 100%; maximum duration of 15 days per trip. Unstable pre-existing medical conditions that existed during the nine-month period prior to your trip are not covered. 80% up to $200 per day of hospitalization and up to a plan year maximum of $5,000. $300,000 per covered person. $3,000,000 lifetime maximum per covered person for Emergency travel medical coverage. Standard Plus Plan Benefit Reimbursement Drug 70% on first $800 ($560) and 80% on next $3,675 ($2,940). Total coverage: $3,500 ($560 + $2,940) per plan year. Fully reimbursed up to $6.50 dispensing fee. Extended health 80% subject to limits outlined in the benefit below. Paramedical Services We will pay for the services performed by the following practitioners: acupuncturist, audiologist, occupational therapist, physiotherapist, psychologist, registered massage therapist, or speech language pathologist. The amount we pay is limited to $480 in a plan year for each practitioner and up to $800 in a plan year for the services of all practitioners combined. Accidental Dental The amount we pay is limited to $2,500 per fracture or injury. Ambulance We will pay for licensed ground or emergency air ambulance service to the nearest hospital equipped to provide the required treatment. 10

11 Standard Plus Plan Benefit Extended health Vision Emergency travel medical coverage Semi-private hospital room Preventive Dental Lifetime maximum Reimbursement Extended Health Care (EHC) and Dental Insurance Hearing Aids We will pay for hearing aids and repairs to them, limited to $450 per each five year period. Private Duty Nurse Your treatment must require the level of expertise of a nurse, limited to a plan year maximum of $5,000 and a lifetime maximum of $15,000. Medical Services and Equipment We will pay for the following provincially funded services and equipment, limited to a combined plan year maximum of $1,500 and a combined lifetime maximum of $20,000. We will pay for: - artificial limbs or other prosthetic appliances, - breast prosthesis are limited to $200 in a plan year, - walkers, if we have approved either its purchase or rental, - wheel chair (limited to a lifetime maximum of $1,000), - hospital bed (limited to a lifetime maximum of $1,000), - wigs and hairpieces (limited to a lifetime maximum of $500), and - custom made orthopaedic shoes, orthopaedic modifications to shoes, and orthotics. They must be prescribed by a physician, podiatrist, chiropodist or chiropractor. The amount we pay is limited to $250 in a plan year. 100%, $50 per 24 months for eye-exam; (one every 12 months for an insured person under 18 years of age). 100% up to $150 every two plan years for laser eye surgery, eyeglasses, prescription sunglasses and contact lenses and repairs. One year waiting period for vision claims other than eye exams. 100%; maximum duration of 20 days per trip. Unstable pre-existing medical conditions that existed during the nine-month period prior to your trip are not covered. 80% up to $200 per day of hospitalization and up to a plan year maximum of $5, % up to a maximum of $750 per plan year. We will pay for the following Preventive procedures: oral examinations, x-rays, polishing (cleaning of teeth) and topical fluoride treatment (once every nine months), space maintainers for missing primary teeth (for insured persons under 12 years, fillings-amalgam, composite, acrylic, or the equivalent of these fillings, routine extractions, and scaling and root planing (not to exceed eight time units per year). Three month waiting period. $300,000 per covered person. $3,000,000 lifetime maximum per covered person for Emergency travel medical coverage. 11

12 Extended Health Care (EHC) and Dental Insurance Enhanced Plan Benefit Reimbursement Drug 80% on first $3,000 ($2,400) and 90% on next $10,667 ($9,600). Total coverage: $12,000 ($2,400+$9,600) per plan year. Coinsurance applies to dispensing fees as well. Extended health 90% subject to limits outlined in the benefit below. Paramedical Services We will pay for the services performed by the following practitioners: acupuncturist, audiologist, occupational therapist, physiotherapist, psychologist, registered massage therapist, or speech language pathologist. The amount we pay is limited to $600 in a plan year for each practitioner and up to $1,000 in a plan year for the services of all practitioners combined. Accidental Dental The amount we pay is limited to $3,000 per fracture or injury. Ambulance We will pay for licensed ground or emergency air ambulance service to the nearest hospital equipped to provide the required treatment. Hearing Aids We will pay for hearing aids and repairs to them, limited to $550 per each five year period. Private Duty Nurse Your treatment must require the level of expertise of a nurse, limited to a plan year maximum of $7,500 and a lifetime maximum of $20,000. Medical Services and Equipment We will pay for the following provincially funded services and equipment, limited to a combined plan year maximum of $2,000 and a combined lifetime maximum of $20,000. We will pay for: - artificial limbs or other prosthetic appliances, - breast prosthesis are limited to $200 in a plan year, - walkers, if we have approved either its purchase or rental, - wheel chair (limited to a lifetime maximum of $1,200), - hospital bed (limited to a lifetime maximum of $1,200), - wigs and hairpieces (limited to a lifetime maximum of $500), and - custom made orthopaedic shoes, orthopaedic modifications to shoes, and orthotics, They must be prescribed by a physician, podiatrist, chiropodist or chiropractor. The amount we pay is limited to $300 in a plan year. Vision Emergency travel medical coverage 100%, $50 per 24 months for eye-exam; (one every 12 months for an insured person under 18 years of age). 100% up to $250 every two plan years for laser eye surgery, eyeglasses, prescription sunglasses and contact lenses and repairs. One year waiting periodfor vision claims other than eye exams. 100%; maximum duration of 30 days per trip. Unstable pre-existing medical conditions that existed during the nine-month period prior to your trip are not covered. 12

13 Extended Health Care (EHC) and Dental Insurance Enhanced Plan Benefit Semi-private hospital room Lifetime maximum Reimbursement 90% up to $200 per day of hospitalization and up to a plan year maximum of $5,000. $500,000 per covered person. $3,000,000 lifetime maximum per covered person for Emergency travel medical coverage. Enhanced Plus Plan Benefit Reimbursement Drug 80% on first $3,000 ($2,400) and 90% on next $10,667 ($9,600). Total coverage: $12,000 ($2,400+$9,600) per plan year. Coinsurance applies to dispensing fees as well. Extended health 90% subject to limits outlined in the benefit below. Paramedical Services We will pay for the services performed by the following practitioners: acupuncturist, audiologist, occupational therapist, physiotherapist, psychologist, registered massage therapist, or speech language pathologist. The amount we pay is limited to $600 in a plan year for each practitioner and up to $1,000 in a plan year for the services of all practitioners combined. Accidental Dental The amount we pay is limited to $3,000 per fracture or injury. Ambulance We will pay for licensed ground or emergency air ambulance service to the nearest hospital equipped to provide the required treatment. Hearing Aids We will pay for hearing aids and repairs to them, limited to $550 per each five year period. Private Duty Nurse The insured person s treatment must require the level of expertise of a nurse, limited to a plan year maximum of $7,500 and a lifetime maximum of $20,000. Medical Services and Equipment We will pay for the following provincially funded services and equipment, limited to a combined plan year maximum of $2,000 and a combined lifetime maximum of $20,000. We will pay for: - artificial limbs or other prosthetic appliances, - breast prosthesis are limited to $200 in a plan year, - walkers, if we have approved either its purchase or rental, - wheel chair (limited to a lifetime maximum of $1,200), - hospital bed (limited to a lifetime maximum of $1,200), - wigs and hairpieces (limited to a lifetime maximum of $500), and - custom made orthopaedic shoes, orthopaedic modifications to shoes, and orthotics, They must be prescribed by a physician, podiatrist, chiropodist or chiropractor. The amount we pay is limited to $300 in a plan year. 13

14 Extended Health Care (EHC) and Dental Insurance Enhanced Plus Plan Benefit Vision Emergency travel medical coverage Semi-private hospital room Preventive dental Restorative dental Reimbursement 100%, $50 per 24 months for eye-exam; (one every 12 months for an insured person under 18 years of age). 100% up to $250 every two plan years for laser eye surgery, eyeglasses, prescription sunglasses and contact lenses and repairs. One year waiting period for vision claims other than eye exams. 100%; maximum duration of 30 days per trip. Unstable pre-existing medical conditions that existed during the nine-month period prior to your trip are not covered. 90% up to $200 per day of hospitalization and up to a plan year maximum of $5, % up to a maximum of $750 per plan year. We will pay for the following Preventive procedures: - oral examinations, - x-rays, - polishing (cleaning of teeth) and topical fluoride treatment (once every nine months), - space maintainers for missing primary teeth (for insured persons under 12 years), - fillings amalgam, composite, acrylic, or the equivalent of these fillings, - routine extractions, and - scaling and root planing (not to exceed eight time units per year). Three month waiting period. 50% up to a maximum of $500 per plan year. We will pay for the following Restorative procedures: - endodontics, - periodontics, - periodontal appliances (once every five years), - crowns and repairs to crowns, other than prefabricated metal restorations, - partial and complete dentures and repairs or additions to them, - rebase or reline of a partial or complete denture, - fixed bridgework and repairs to them, and - oral surgery. Six month waiting period. Orthodontic dental 60% up to a lifetime maximum of $1,500. We will pay for the following Orthodontic procedures: - interceptive, interventive or preventive orthodontic services, other than space maintainers, and - comprehensive orthodontic treatment, using a removable or fixed appliance, or combination of both. This includes diagnostic procedures, formal treatment and retention. One year waiting period. Lifetime Maximum $500,000 per covered person. $3,000,000 lifetime maximum per covered person for Emergency travel medical coverage. 14

15 Extended Health Care (EHC) and Dental Insurance Applies to all Plans Quebec residents If you have prescription drug insurance through the Régie de l assurance maladie du Québec (RAMQ), this means that your prescription drug claims must first be submitted to RAMQ. Any remaining, unpaid portion that is eligible under this policy can then be submitted to us for reimbursement. The coinsurance and deductible that an insured person must pay under their plan with the RAMQ are eligible under this policy. If you have group drug coverage and are not covered by RAMQ prescription drug insurance, your prescription drug claims must first be submitted to your group policy. Any remaining, unpaid portion that is eligible under this policy can then be submitted to us for reimbursement. If your group drug coverage is with us please contact us to co-ordinate drug benefits between your group policy and this policy. If your group drug coverage ends, you must then obtain RAMQ prescription drug insurance to remain eligible under this policy. Submit your claims on the go With Sun Life s mobile app or mysunlife.ca you can check your coverage, submit benefits claims on the go and see the money in your account usually within 48 hours. Sun Life s mobile app lets you: Submit and track medical, dental and vision claims. View full coverage details for health, drug and vision care. Use your smartphone as your drug and travel cards. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada. All claims must be approved by Sun Life Financial. 15

16 Accidental Death and Dismemberment (AD&D) Insurance Accidental Death & Dismemberment (AD&D) Insurance You can t foresee the occurrence of an accident. In the event of an accident that results in injury or death, CAOT s AD&D Insurance plan is with you all the way. It can provide financial compensation to help you and your family cope with the consequences of your injury or death. Coverage Single and family coverage is available. You must have Term Life Insurance coverage through CAOT to be eligible for AD&D Insurance. Coverage is available in units of $25,000 with a minimum of $25,000 and a maximum of $250,000. Coverage cannot exceed the amount of the member s Term Life Insurance coverage. You can insure yourself only or yourself and your family. When you select family coverage, your family will become insured as follows: If you do not have dependent children, your spouse will be insured for 50% of the benefit you have selected for yourself. If you and your spouse have dependent children, your spouse will be insured for 40% of your benefit and each dependent child, regardless of the number, will be insured for 10% of your benefit, to a maximum of $50,000 per child. If you do not have a spouse, each dependent child will be insured for 20% of your benefit up to a maximum of $50,000 per child. The amount that we will pay is a percentage of the Accidental Death and Dismemberment coverage. The percentage depends on the loss suffered. The following table shows the percentages we use to determine the payment. Table of Losses Loss of life 100% Loss of both arms or both legs 100% Loss of both hands or both feet 100% Loss of one hand and one foot 100% Loss of one hand or one foot, and entire sight of one eye 100% Loss of one arm or one leg 75% Loss of one hand or one foot 75% Loss of four fingers on the same hand 33 1/3% Loss of thumb and index finger on the same hand 33 1/3% Loss of four toes on the same foot 25% Loss of use of both arms or both legs 100% Loss of use of both hands or both feet 100% Loss of use of one arm or one leg 75% Loss of use of one hand or one foot 75% Loss of entire sight of both eyes 100% Loss of speech and loss of hearing in both ears 100% Loss of entire sight of one eye 75% Loss of speech 75% 16

17 Accidental Death and Dismemberment (AD&D) Insurance Table of Losses Loss of hearing in both ears 75% Loss of hearing in one ear 25% Quadriplegia 200% Paraplegia 200% Hemiplegia 200% Spouse occupational training benefit If you die as a direct result of an accident, Sun Life will pay up to $3,000 to your spouse for occupational training for a job that your spouse was not previously qualified for. Waiver of premium If you become totally disabled before you reach age 65, your coverage may continue without the payment of premiums as long as you remain totally disabled. For the purposes of AD&D coverage, Insured Member will be considered totally disabled if they are prevented by illness from performing any occupation they are or may become reasonably qualified for by education, training or experience. You must be totally disabled for 180 days. Repatriation benefit If you die as a direct result of an accident 100 kilometres or more from home, your coverage will pay up to $10,000 for the preparation and transportation of your body for burial or cremation. Seat belt benefit If you die as a direct result of driving or riding in a motorized vehicle, Sun Life will pay an additional 10% of the amount of coverage. The seat belt must have been properly fastened at the time of the accident and be certified in the official accident report. Home and vehicle adaptation benefit If you suffer the loss of use, or loss of, both feet or both legs or suffer from hemiplegia, quadriplegia or paraplegia, Sun Life will pay an additional 10% of the amount of coverage up to $10,000 for the usual and reasonable cost of adaptations required to your residence or vehicle to allow for wheelchair accessibility. Exclusions No benefit will be paid for any loss directly or indirectly due to or resulting from one or more of the following: self-inflicted injuries, by firearm or otherwise. a drug overdose. carbon monoxide inhalation. attempted suicide or suicide while sane or insane. flying in, descending from or being exposed to any hazard related to an aircraft while receiving flying lessons. performing any duties in connection with the aircraft. being flown for a parachute jump. a member of the armed forces if the aircraft is under the control of or chartered by the armed forces. the hostile action of any armed forces, insurrection or participation in a riot or civil commotion. full-time service in the armed forces of any country. participation in a criminal offence. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada. All claims must be approved by Sun Life Financial. 17

18 Professional Overhead Expense (POE) Insurance Professional Overhead Expense (POE) Insurance Running your own practice is a great opportunity. But what if you were to become temporarily disabled or seriously ill? How would you cover those costs? That s where Professional Overhead Expense (POE) Insurance comes in. This plan will provide reimbursement for incurred expenses in the normal operation of a business, allowing you to concentrate on your recovery rather than worrying about the financial stability of your business or how you are going to pay expenses such as rent or your employees salaries. Coverage Professional Overhead Expense Insurance is available to CAOT members to cover the normal costs of running a business in the case of total disability. You must be covered under CAOT s Long Term Disability Insurance program to be eligible for POE Insurance. Coverage is available in units of $100, from a minimum of $500 to a maximum of $5,000 per month. Elimination period The elimination period is the amount of time you must be totally disabled before POE Insurance benefits become payable. You can choose a 14-day or 30-day elimination period. The elimination period can be satisfied with intermittent periods of disability from the same cause accumulated within six months. Maximum benefit period Benefits are payable for a maximum of 12 months and are not paid past the age of 65. Covered expenses The monthly POE benefit payable will be the lesser of the monthly benefit elected and the average of the covered monthly overhead expenses that you incur in the six months immediately preceding the start of total disability. The covered monthly overhead expenses consist of, but are not limited to, the following: rent, heat, water, electricity, telephone, depreciation, wages or salaries of your employees and other fixed expenses normally related to running an office. Taxes and mortgage interest payments on business premises that are owned by you and used by you in your profession (but not mortgage amortization payments), are included in covered monthly overhead expenses. Covered expenses do not include any salary, fees, drawing account, or any other remuneration for you or any other member of your profession or any person employed to perform the duties of your profession or occupation, or cost of goods, wares or merchandise of any nature, implements of occupation, payments on mortgage principal, or the cost of your automobiles. 18

19 Professional Overhead Expense (POE) Insurance Definition of total disability You are considered totally disabled if you are: unable to perform the essential duties of your regular occupation, as a result of illness or injury, and under the regular care of a physician and are not gainfully employed elsewhere. Partial disability benefit You may qualify for partial disability benefits if, immediately after a period of total disability for which you received benefits, you begin working again, under the supervision of a physician. The benefit is equal to the monthly total disability benefit reduced by: 50% of the net earnings from gainful employment, and any other amount payable to you that is listed in the Integration of Benefits provision. Waiver of premium You will not pay POE premiums if you are totally disabled for 90 days or more, have not reached 65 years of age and you are receiving total disability benefits. Integration of benefits When Professional Overhead expenses are covered under another insurance plan which provides similar coverage to the benefits provided by this benefit, Sun Life will pay only the proportional share of the eligible overhead expenses that are incurred. Exclusions No benefits are payable for claims resulting directly or indirectly from any of the following: declared or undeclared war, insurrection or rebellion; voluntary participation in a riot or act of civil disobedience; intentionally self-inflected injuries while sane or self inflicted injuries while insane; committing or attempting to commit a criminal offense; normal pregnancy and/or childbirth. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada. All claims must be approved by Sun Life Financial. 19

20 When your coverage ends When your coverage ends Term Life Insurance Your coverage ends: upon termination of the Group Policy; the date you terminate coverage under the Plan; on your 75 th birthday; on the premium due date, if you fail to pay premium, subject to the grace period 1 ; the date you cease to reside in Canada; the date you die. Your spouse s and dependent s coverage ends: the date your coverage terminates under the Plan; on your spouse s 75 th birthday; the date your spouse ceases to reside in Canada; the date your spouse dies; the date your spouse or dependent is no longer eligible or no longer meets the definition. Critical Illness Insurance Your coverage ends: upon termination of the Group Policy; the date you terminate coverage under the Plan; on your 70 th birthday; on the premium due date, if you fail to pay premium, subject to the grace period 1 ; the date you cease to reside in Canada; the date you die; the date a Critical Illness benefit is paid for a covered condition which you sustain. Your spouse s coverage ends: the date your coverage terminates under the Plan; on your spouse s 70th birthday; the date your spouse ceases to reside in Canada; the date your spouse dies; the date your spouse or dependent is no longer eligible or no longer meets the definition; the date a Critical Illness benefit is paid for a covered condition which your spouse sustains. Accidental Death and Dismemberment Insurance Your coverage ends: upon termination of the Group Policy; the date you terminate coverage under the Plan; on your 70 th birthday; on the premium due date, if you fail to pay premium, subject to the grace period 1 ; the date you cease to reside in Canada; the date you die. Long Term Disability Insurance Your coverage ends: upon termination of your Group Policy; the date you terminate coverage under the Plan; on your 65 th birthday; on the premium due date, if you fail to pay premium, subject to the grace period 1 ; the date you cease to reside in Canada; the date you die. 1 After the first payment has been paid, a grace period of 31 days will be granted for the payment of an unpaid premium. During the grace period your coverage will continue in force but you will be liable to Sun Life Assurance Company of Canada for the outstanding payment. After the 31-day grace period your coverage can be terminated for non-payment of premiums. 20

21 When your coverage ends Extended Health Care and Dental Care Insurance Your coverage ends: upon termination of your Group Policy; the date you terminate coverage under the Plan; on your 75 th birthday; on the premium due date, if you fail to pay premium, subject to grace period 1 ; the date you cease to reside in Canada; the date you die. Your spouse s and dependent s coverage ends: the date your coverage terminates under the Plan; on your dependent s 75 th birthday; the date your dependent ceases to reside in Canada; the date your dependent dies; the date your spouse or dependent is no longer eligible or no longer meets the definition. Professional Overhead Expense Insurance Your coverage ends: upon termination of your Group Policy; the date you terminate coverage under the Plan; on your 65 th birthday; the date you are no longer actively at work; the date you no longer have Long Term Disability Insurance coverage; on the premium due date, if you fail to pay premium, subject to the grace period 1 ; the date you cease to reside in Canada; the date you die. 1 After the first payment has been paid, a grace period of 31 days will be granted for the payment of an unpaid premium. During the grace period your coverage will continue in force but you will be liable to Sun Life Assurance Company of Canada for the outstanding payment. After the 31-day grace period your coverage can be terminated for non-payment of premiums. 21

22 CAOT has you covered CAOT has you covered Premium rates Please refer to the current monthly premium rate sheet for Long Term Disability, Critical Illness, Term Life, Extended Health Care and Dental Care, Accidental Death and Dismemberment, and Professional Overhead Expense insurance rates. All plans except Accidental Death and Dismemberment Insurance and Dependent Term Life Insurance have rates that are on an age-banded basis, which means premiums increase as you age and move into a different age band. Rates are subject to provincial tax where applicable. Applying for coverage in the CAOT insurance plan Applying is easy. Simply visit our website (sunlife.com/caot). Plan questions: If you require assistance completing your application, or have any questions, please call Sun Life Assurance Company of Canada toll-free at , or in the Toronto area, Monday to Friday, from 8:30 a.m. 5 p.m. E.S.T. This brochure provides the highlights but not all the details of the CAOT Insurance Plan. The complete terms, conditions, exclusions and limitations governing the coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. All coverage becomes effective upon date of approval and receipt of premium payment. 22

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24 Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies, a leading international financial services organization providing a diverse range of wealth accumulation and protection products and services to individuals and corporate customers. Chartered in 1865, Sun Life Financial and its partners today have operations in key markets worldwide, including Canada, the United States, the United Kingdom, Hong Kong, the Philippines, Japan, Indonesia, India, China and Bermuda. Sun Life Financial Services of Canada Inc. trades on the Toronto (TSX), New York (NYSE) and Philippine (PSE) stock exchanges under ticker symbol SLF. AA-0002-CAOT-Brochure-02-15