Request a Quote

How do I Submit a Claim?

Health/dental claim

To learn how to submit a health or dental claim, please contact your insurance carrier:

  • Beneplan Inc- 1-800-387-1670
  • The Co-operators Life 1-800-667-8164
  • Green Shield Canada 1-888-711-1119

Medical emergency claim

To submit a claim for a medical emergency occurring out of your province, please contact your insurance carrier:

    • The Co-operators (Allianz)
      Toll free within Canada/U.S.A.: 1-800-995-1662
      Collect worldwide: 416-340-0049
      Toll free International: 800-842-08420 or 00-800-842-08420 (if not available, please call collect)

 

  • Green Shield Canada (Allianz)
    Calling within Canada/US: 1-800-936-6226
    Calling Internationally: +1-519-742-3556

Other claims

To submit a claim for Life InsuranceShort Term Disability / Weekly Indemnity, Long Term Disability, Accidental Death & Dismemberment, or Critical Illness, please contact Beneplan:

Adjudicated paramedical benefits

If your paramedical benefits are adjudicated through Beneplan Inc, please contact:

How to Change My Plan?

If you have any questions about altering your current plan, don’t hesitate to contact our team who will be happy to provide assistance.

Benefits Plan Care Team
1.800.387.1670
admin@beneplan.ca

Useful Information

How do I add new plan member?

Sign in using “Member Login”.
Locate the “New Member Enrollment” section.
Print, fill out, and mail us an original, physical copy of the form.
You will also notice other forms available to change family status, terminate an employee, and change salary and class.

What’s your Late Enrollment policy?

When an employee has completed their waiting period (probationary period) to become effective on the benefits plan, that employee has 30 days to send in their completed enrollment form.

If an employee has coverage through his or her spouse, the employee may opt out of the family type coverages such as Health, Drugs, Vision care and/or Dental. This employee must enroll for the insurance type benefits such as Life Insurance, Accidental Death & Dismemberment, Dependant Life, and Short or Long-Term Disability if applicable.

Also, if an employee opted out of the family type coverage (due to coverage provided through spouses plan) and the spouse loses this coverage, the employee has 30 days (from the date the spouse lost coverage) to submit their enrollment without a medical questionnaire. If the employee submits any enrollment form after the 30 days has expired, that employee would need to fill in a medical questionnaire which could result in coverage being denied.

What’s your policy for Out-of-Country Students?

When a dependant is leaving the country for educational purposes, they are entitled to the same coverage as a plan member who is leaving the country for vacation.

As outlined in the plan booklet, the member or dependant is covered for the first 60 days of their stay, after which time they are no longer covered under the plan.

The Ontario Health Insurance Plan (OHIP) can provide coverage for out-of- country students.

Beneplan suggests that Third Party, out-of-country insurance be purchased. This will ensure that the student is covered for costs above what OHIP covers. There are many companies who offer coverage plans specifically designed for students studying abroad.

For more information on the coverage provided by OHIP click here.

How do I replace a lost membership card?

Whenever the need arises for a new card, whether lost, stolen or simply a need to obtain more, contact Charles Nadon (margaret@beneplan.ca). You will need to include the name of the member as well as their Certificate number.

Definitions

Account/Division #

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 & 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.

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.

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.

Cost Plus

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.

Critical Illness

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.

Death benefit

The payment made to designated beneficiaries upon the death of a participating employee, i.e. life insurance or AD&D.

Dependants

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.

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.

Dismemberment

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.

Eligible employees

Those members of a group who have met the eligibility requirements under a group life insurance or health insurance.

Eligible expenses

Medical expenses for which a health insurance policy will provide benefits.

Eligibility period

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.

Eligible requirements

Conditions that an employee must satisfy to participate in a plan.

Employment Standards Act, hereinafter referred to as the ESA

A federal act that regulates employment law in Canada.

Enrollment

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.

Family coverage

Coverage that includes the employee, his spouse and dependants.

Fee schedule

A listing of fees or allowances for specified medical procedures, which usually represent the maximum amount the program will pay for specified procedures.

Flat benefit

A type of benefit in group insurance under which everyone is insured for the same benefit regardless of salary, position or other circumstances.

Generic drugs

Equal in therapeutic power to the brand-name originals because they contain identical active ingredients at the same doses. They are usually inexpensive.

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.

Hire date

The employee’s first day worked.

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.

No substitution

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.

Opt out

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.

Policy/Group/Contract number

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.

Pre-existing condition

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.

Reinstatement

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

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”.

Termination date

The employee’s last day worked or end of notice period (whichever is later).

Waiting period

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).