This is the number related to the various divisions under the policy. Sometimes the Policy is broken up into different divisions for billing or reporting purposes. The Co-operators refer to it as “Accounts”.
Actively at work
“Actively At Work”, “Actively Employed”, “Active Work” or “Actively Working”, means an employee who is actually working at the employer’s place of business or a place where the employer’s business requires the employee to work. Employees who are absent due to scheduled vacation, weekends, statutory holidays or shift variances, maternity leave, parental leave, compassionate leave, sick leave and notice period are also deemed to be actively at work.
(AD&D) Accidental Death and Dismemberment
Coverage for death or dismemberment resulting directly from accidental causes. Benefits are provided in the event of loss of life, limbs or eyesight as a result of an accident.
AD&D Waiver of Premium
If the employee is applying for life insurance waiver of premium, then they should also apply for AD&D waiver of premium (see “Life Insurance Waiver of Premium” below).
Administrative Services Only (ASO)
A type of employee benefit plan funding that is administered by an insurance company or a third party administrator and in which the client (employer) is totally at risk for claims. In other words, ASO is self-insurance.
Brand Name Drugs
A drug protected by a patent issued to the original innovator or marketer. The patent prohibits the manufacture of the drug by other companies as long as the patent remains in effect, they are typically expensive.
Certificate / PID #
A unique number that is used to identify each employee. This number must be used in all correspondences and claims. The Co-operators refers to it as the “Personal Identification Number – PID”.
Class (Product Set ID)
A group of employees that have many characteristics of employment in common. For example, Hourly employees, Executives, etc. In benefits, a class of employees denotes a specific plan design. The Co-operators sometimes refers to a class as a “Product Set ID”, but please use “Class” in your day to day administration. Examples of Class abbreviations are CLA, CLB, CLC, CLD, CLE, etc.
Coordination of Benefits (COB)
A group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts.
The member of your plan must submit his/her claims to your policy first (the member should keep copies of the receipts and claim), once approved and processed, the employee will receive an explanation summarizing how the claim was handled. The employee then submits the explanation along with copies of the claim and receipts to his/her spouse’s carrier for further consideration of payment, if applicable.
The spouse of your member must submit his/her claims to his/her employer’s policy first (the spouse should keep copies of the receipts and claim). Once approved and processed, the spouse will receive an explanation summarizing how the claim was handled. The spouse then submits the explanation along with necessary forms and receipts to our carrier for further consideration of payment, if applicable.
For dependent children, claims must be submitted first to the carrier of the spouse whose birthday comes first in the year (not the oldest). Once approved and processed, the explanation on how the claim was handled is then submitted to the other spouse’s carrier for further consideration of payment, if applicable.
A way to pay claims that are not covered by the plan. It is typical for owners or top executives of companies to require that all their claims be paid by the company. This makes very strong tax sense since payments are tax-deductable expenses to the company, but not taxable benefits to the owner/executive. Beneplan processes such claims as follows:
- The Executive/Owner submits the claim to The Co-operators as usual and receives an EOP (Explanation of Payment) outlining what was paid and what was not.
- To have Beneplan pay the declined amounts, please send the following things to Beneplan:
- The completed Cost Plus form at back of this guide,
- The EOP from The Co-operators
- A cheque payable to “Beneplan – Cost Plus” for the total
- Beneplan will pay the Executive/Owner, remit applicable taxes, and keep 3% for their services.
A benefit designed to assist plan members who are diagnosed with a critical illness by providing funds for their discretionary use, to seek alternative treatments or to just help offset unanticipated expenses such as diminished income, home alterations or living assistance. It provides a one-time lump sum payment to plan members who are diagnosed with a covered illness and survive the 30 day waiting period.
Critical Illness Waiver Premium
If premiums for the basic life coverage are waived, the coverage premium will also be waived as long as the policy and the plan sponsor’s coverage remain in force.
The payment made to designated beneficiaries upon the death of a participating employee, i.e. life insurance or AD&D.
The natural children and legal spouse of the member. Children are eligible to be dependents if they are under 21. Children over 21 can continue to be eligible up to age 25 if they are enrolled full time in a university or a college of higher education.
Common Law Spouse and his/her children
A common-law spouse is a person whom the employee has lived with in a conjugal relationship continually for at least 12 months and publicly represented as a spouse. If the common law spouse has custody of his/her children, they are automatically eligible to be covered.
Out of Country Student
Dependants studying outside of Canada need to be fully aware that out-of-country coverage is not full coverage; it is emergency coverage only. It is important for employees that they purchase full coverage while their dependants are studying abroad.
One Spouse Only
Where an employee has more than one insurable spouse pursuant to a court order, The Co-operators will consider the other spouse a special dependent.
The employee can insure his/her child after age 21 (25 if a student) if the child is permanently incapable of supporting his or herself financially due to a medically diagnosed physical or psychiatric disorder. A “Health Evidence” form must be submitted to Beneplan Administration who will then send it to The Co-operators for approval. If approved as a handicapped child then this approval is for life as long as the employee works with his/her company. This form can be found under the ‘Forms’ section at the end of this manual.
Grandchildren and adopted children
Can be covered but only if there is a court order, declaring the member as legal guardian.
Note: Parents are never considered eligible dependants.
Dependent Group Life Insurance (DGL)
The amount of insurance for which a dependant is covered.
If premiums for the employee’s basic life insurance coverage under this policy are waived, premiums for the dependant life benefit will also be waived but only as long as the policy remains in force.
An injury which results in:
- The loss of a limb
- The loss of use of a limb
- The loss of sight
Effective Date of the group
The date on which an insurance policy goes into effect and coverage begins.
Effective Date of the employee
The date on which coverage begins for the employee and his family.
Usually 31 days after the effective date of the employee, when potential members of a group life or health insurance plan can still enroll without evidence of insurability.
Conditions that an employee must satisfy to participate in a plan.
Those members of a group who have met the eligibility requirements under a group life insurance or health insurance.
Medical expenses for which a health insurance policy will provide benefits.
Employment Standards Act, hereinafter referred to as the ESA
A federal act that regulates employment law in Canada.
The process by which an individual and or dependents become subscribers to health plan coverage. The enrollment is done through a completion and signing of the enrollment form, found at the back of this manual.
Coverage that includes the employee, his spouse and dependants.
A listing of fees or allowances for specified medical procedures, which usually represent the maximum amount the program will pay for specified procedures.
A type of benefit in group insurance under which everyone is insured for the same benefit regardless of salary, position or other circumstances.
Equal in therapeutic power to the brand-name originals because they contain identical active ingredients at the same doses. They are usually inexpensive.
The employee’s first day worked.
Health Spending Account HSA
A benefit (usually for owners or top executives) that gives the member a specific amount of money that he/she can claim for procedures and services not eligible to be paid from the regular plan. It is usually a specific annual amount.
Life Insurance Conversion
If the employee’s insurance terminates due to termination of the employee’s coverage, the employee is entitled to convert the coverage he/she had under the policy to an individual policy without going through medical underwriting. The individual life-policy will be issued if a written application (including the required first premium) is completed and received by Co-operators Life at its Regina head office within 31 days from the date the insurance terminates. The individual life policy will become effective on the day following the expiration of the 31 day period.
Life Insurance Waiver of Premium
If the employee becomes very sick, with a possible result in death (stroke, heart attack, etc) then the administrator should apply for a life insurance waiver of premium. If approved, premiums for life insurance are not payable while coverage continues.
Long Term Disability (LTD)
LTD is a significant period of disability generally ranging from six months to life. The LTD provides a reasonable replacement of a portion of an employee’s earned income lost through serious and prolonged illness or injury during his normal work career.
An expression that doctors may write on their prescription indicating that the pharmacist must dispense the drug prescribed and not any generic equivalent.
Provincial Health Insurance Plan
It is a health plan that provides government sponsored hospital, drug, and dental or other medical care benefits for residents of the province in Canada. Each province has their own plan that covers residents of that province. Provincial plans vary in coverage and conditions of coverage from one province to another, some require premiums to be paid by residents and others do not.
Employees may decide to opt out of health and/or dental benefits (only), if they are covered under their spouse’s benefit plan. An Opt-out employee is eligible to rejoin if his/her spouse loses coverage. They need to do so within 30 days of losing the other coverage, otherwise they will be required to provide evidence of satisfactory health and may be denied coverage. Employees cannot opt out from all other benefits while the employee is actively at work.
Out of Country/ Province Emergency Care
Out‑of‑Country Emergency care is provided for covered persons for the first 60 days of travel as a result of a medical emergency arising while the covered person is travelling outside Canada for vacation, business or education. A medical emergency means a sudden, unexpected injury or an acute episode of disease. Emergency medical care does not include medical attention for the monitoring of a stabilized condition.
The number that identifies the “Employer” and it should be reflected on all claim forms submitted by employees.
Predetermination / pre-authorization / pre-estimate of cost / pre certification / pre-treatment estimate / prior authorization
An administrative procedure whereby a covered member submits a treatment plan to the carrier before treatment is initiated. The carrier reviews the treatment plan, indicating the amount that would be approved.
Employees must complete a health or dental predetermination form if the amount is over $500. If pre-determination is not obtained prior to incurring and submitting the claim, it may be denied.
Means a sickness or injury for which the Employee sought medical investigation, diagnosis, treatment, care, medication or medical advice, or for which there were symptoms which would have caused a person to seek medical investigation, diagnosis, treatment, care, medication or medical advice within the 90 Day period immediately prior to becoming insured under this Policy.
Reasonable and Customary Treatment
Treatment that is generally accepted and recognized by the Canadian medical profession as effective, appropriate and essential in the treatment of the medically diagnosed condition.
The Co-operators will not pay for any service or appliance just because the member purchased it. Insurers have a “reasonable and customary” clause that declares that they will pay for the procedure or appliance if it is a reasonable and customary procedure or appliance that treats the illness. Employees are advised to submit the procedure or appliance they plan to purchase for pre-determination.
The resumption of coverage after the employee’s coverage is terminated, provided the termination is within six months of reinstatement. The re-instatement date must be the first day worked after return to work.
If an employee returns to work within 6 months of the previous termination date, then all benefits can be reinstated, without the need to re-serve the waiting period. In this case, no “Enrollment” form is required.
If after 6 months, or in the event that the employer wishes the employee to re-serve the waiting period, then the employee would be considered “new”, requiring a new “Enrollment” to be completed.
Short Term Disability (STD) and Short Term Disability Income Insurance
STD is a disability lasting less than six months. STD income insurance is a provision to pay benefits to a covered disabled person as long a she or she remains disabled up to a specified period.
Single coverage applies to an employee who has no dependents. In the case that a “single”, who has dependents on his effective date, wishes to include his dependents at a later date then they will be considered late applicants and must provide evidence of satisfactory health.
Stop Loss Insurance
Contract established between a self insured group and insurance carrier providing coverage if claims exceed specified dollar amount over a set period of time. It may apply to an entire plan or a single component. It is also called “excess loss insurance”.
The employee’s last day worked or end of notice period (whichever is later).
It is the period between employment or enrollment in a program and the date when an insured person become eligible for benefits.
Weekly Indemnity Insurance (WI)
Also referred to as Short Term Disability (STD).