Elective Treatment includes treatment or surgery:
- not immediately required for the relief of acute pain and suffering;
- which medically could be delayed until the Covered Person’s return to his or her province of residence;
- which the Covered Person elects to have rendered or performed outside his or her province of residence following emergency treatment for, or diagnosis of, a medical condition which would not prevent the Covered Person from returning to his or her province of residence to receive such treatment or surgery.
Eligible Medical Expense means the reasonable and customary charge for a service or supply which is ordered by a Physician, is medically necessary for the treatment of a Covered Person’s medical emergency, and is listed in the “Eligible Medical Expenses” section of this coverage.
Medical Emergency occurs when a Covered Person requires immediate medical attention while a Covered Person is travelling outside his or her province of residence due or related to:
- a sudden, unexpected injury which occurs or a new medical condition which begins while a Covered Person is travelling outside his or her province of residence; or
- a previously identified medical condition that was stable, but not diagnosed as terminal or prescribed for palliative care, at the time of departure from his or her province of residence.
Medically Necessary means any care, service, supply or other matter which is ordered to be provided to a Covered Person by a Physician or Health Care Professional and which the Insurer determines is:
- appropriate and consistent with the symptoms and findings or diagnosis and treatment of the Covered Person’s illness or Injury;
- provided in accordance with generally accepted medical practice on a national basis;
- the most appropriate supply or level of service which can be provided on a cost effective basis.
The fact that the Covered Person’s attending Physician prescribes the service or supplies does not automatically mean such services or supplies are Medically Necessary and covered by the Contract.
Stable means that the Covered Person:
- has not in the last 90 days before the departure date:
- been under treatment or evaluation for new symptoms or conditions uncovered in a medical examination; or
- experienced a worsening or increased frequency of existing symptoms or examination findings related to the medical condition, disease or illness - diagnosed or undiagnosed - if the Covered Person has been seen by a medical professional in relation to the symptoms; or
- been prescribed or recommended a change in treatment or medication related to the medical condition by a Physician or other medical professional, not including regular changes in medication that are made as part of an ongoing treatment or a reduction in medication due to an improvement in the medical condition; or
- been admitted to or treated at a hospital for the medical condition; or
- did not have future non-routine tests, investigation or new treatment planned for a previously identified medical condition or future medical appointment planned with respect to an undiagnosed medical condition.
Travelling Companion means any person who has prepaid accommodation and/or transportation with the Covered Person. The Insurer will only consider a maximum of 4 persons in a group of Travelling Companions, including the Covered Person.
Vehicle means a passenger automobile, motorcycle, motor home, or truck with a gross vehicle weight of less than 8,000 pounds (3,630 kg), provided such vehicle is not licensed to carry passengers for hire. Note: This definition applies only to Deluxe Travel.
EMERGENCY AND PAYMENT ASSISTANCE
Emergency Help Line: In the event of a Medical Emergency while travelling outside the province of residence, call the travel assistance centre. The toll-free numbers are listed on the benefits card and are available 24 hours a day, 7 days a week.
IF A COVERED PERSON IS HOSPITALIZED, THE TRAVEL ASSISTANCE CENTRE MUST BE CONTACTED WITHIN 24 HOURS OF ADMISSION*. FAILURE TO CONTACT THE TRAVEL ASSISTANCE CENTRE WILL RESULT IN DENIAL OF THE CLAIM. If it is not possible to reverse the charge or call toll-free, the Insurer will pay the cost of the telephone call.
*In the case of an incapacitating or acute sickness or Injury which prevents the Covered Person or a Travelling Companion from contacting the travel assistance centre or arranging for the travel assistance centre to be contacted within 24 hours, the claim will still be considered provided the travel assistance centre is called as soon as reasonably possible.
When contacting the travel assistance centre, the Covered Person must be able to provide his or her provincial health insurance plan number, the Insurer Contract number, his or her certificate number, and the travel assistance centre identifier number which applies for this Coverage.
For Contract inquiries, please call OTIP Benefits Services at 1-866-783-6847.
- Coverage is available only to Residents of Canada who are covered by a provincial health insurance plan while they are travelling outside their province of residence.
- Coverage is limited to a maximum of 95 consecutive days per trip, beginning on and including the date of departure, and the total reimbursement amount per trip for all eligible expenses will not exceed $2,000,000 per Covered Person.
- The availability, quality or results of any medical Treatment, transport or other services, or the failure of the Covered Person to obtain medical Treatment or other services, is not the responsibility of OTIP, the Insurer or the travel assistance centre.
- To be eligible, the Hospital or medical benefits covered must have been provided at the nearest appropriate facility capable of providing adequate service at the time the Medical Emergency occurred.
- When adjudicating claims, the Insurer uses a standard administrative practice to determine if the insured was Clinically Stable at the time of the incident.
- The Insurer will make benefit reimbursements, based on Reasonable and Customary Charges as determined by the Insurer, after receipt and evaluation of satisfactory claim information. Reimbursement will be made in Canadian funds based on the rate of exchange the Covered Person would be charged within the country of travel as determined by the Insurer on the advice of any Schedule One Canadian bank. No reimbursement amount will carry interest.
- Benefits described in this Coverage will be reimbursed only on receipt of certification from the attending Physician that services have been rendered and were for emergency Treatment. Costs for completion of medical certificates or documentation required for the assessment of claims are the responsibility of the Covered Person.
- The Insurer and the travel assistance centre, in consultation with the attending Physician, reserve the right to transfer the Covered Person to another Hospital or return the Covered Person to his or her province of residence. Refusal to comply with the transfer request will end the Insurer’s liability.
(Note: The immediate availability of care, Treatment or surgery on return to the province of residence is not the responsibility of OTIP, the Insurer or the travel assistance centre.)
- The provisions of the Deluxe Travel coverage are subject to change by the Insurer. However, if a change in coverage occurs, it will apply only to trips beginning on or after the effective date of the change.
The following services and supplies are available to Covered Persons who, while vacationing or travelling outside his or her province of residence for other than health reasons, incur health care expenses as a result of a Medical Emergency or require other Emergency Assistance Services as described in this coverage.
ELIGIBLE MEDICAL EXPENSES
Hospital Accommodation — Room and board (not a private room or suite) in an active treatment Hospital in excess of the amount paid by the provincial health insurance plan.
Outpatient Services provided by a Hospital.
Physicians’ Charges in excess of the amount paid by the provincial health insurance plan.
Private Duty Nursing Services — Private duty nursing services which can only be performed by a duly Licensed Registered Nurse (RN), Registered Practical Nurse (RPN), Registered Nurse Assistant (RNA) or Licensed Practical Nurse (LPN), who has completed an approved medications training program when those services are performed during or immediately following Hospitalization, provided the services are certified in writing as Medically Necessary by the attending Physician and are not performed by a relative.
Ground Ambulance Services to the nearest medical facility where adequate medical care can be provided.
Air Ambulance Services between Hospitals or for repatriation for admission to a Hospital in the Covered Person’s province of residence, at the discretion of, or when approved by the Insurer. Any unused portion of the Covered Person’s travel ticket must be surrendered to the Insurer.
(Arrangements must be made through the travel assistance centre.)
Paramedical Services — Up to $300 for charges made by a duly Licensed, Certified or Registered physiotherapist, chiropractor, chiropodist, podiatrist or osteopath (including X-rays).
Diagnostic Services — Laboratory tests and X-rays ordered by the Covered Person’s attending Physician.
Prescription Drugs — Drugs, medicines and injected sera purchased on the prescription of a Physician or Dentist and dispensed by a Licensed, Certified or Registered pharmacist. Excluded are vitamins, vitamin/mineral preparations, food supplements, general public (GP) products and over-the-counter drugs or medicines, whether prescribed or not.
Medical Appliances — The cost of splints, casts, crutches, canes, slings, trusses, walkers and/or the temporary rental of a wheelchair required as a result of a Medical Emergency which occurred outside the province of residence, when prescribed by the attending Physician and obtained outside the province of residence.
Dental Accident — Up to $2,000 for expenses incurred by a Covered Person for dental treatment to natural teeth when necessitated by a direct, external Accidental blow to the mouth and not by an object intentionally placed in the mouth. Treatment must begin within the period of coverage for that trip and be completed within 183 days following the Accident. An Accident report is required from the treating Physician or Dentist immediately following the Accident.
Relief of Dental Pain — Up to $200 for emergency Treatment to relieve dental pain, excluding root canals, provided treatment is rendered at least 200 km from the Covered Person’s province of residence.
Miscellaneous Hospital Expenses — Up to $100 during one period of Hospitalization, to cover incidental expenses. Receipts must be submitted.
EMERGENCY ASSISTANCE SERVICES
The following emergency assistance services are available to a Covered Person, provided arrangements are made through the travel assistance centre.
Assistance in locating a Physician, clinic or Hospital.
Confirmation of coverage to the Hospital or Physician.
Advance Hospital/Medical Reimbursement — An advance deposit for Hospital charges will be provided prior to emergency treatment if required. Reimbursement in full for Hospital or Physicians’ charges will also be arranged if required immediately upon discharge from care.
Medical Monitoring — Monitoring the medical condition and treatment of a Covered Person.
Care of Children — If dependent children or grandchildren are left unattended due to the hospitalization of a Covered Person, arrangements will be made to return the children to their home. The extra costs over and above any allowance under pre-paid travel arrangements will be paid. If necessary for a qualified escort to accompany the dependent children, expenses incurred for round-trip transportation will be paid.
Repatriation — When a Covered Person’s attending Physician specifies in writing that he or she must be returned to the province of residence for immediate medical attention as a result of a Medical Emergency, the extra cost of the most economical airfare and, if necessary, the cost to accommodate a stretcher, will be covered to return the Covered Person by the most direct route to the air terminal nearest the departure point in the Covered Person’s province of residence, provided arrangements are made through the travel assistance centre. This benefit will also apply to one other Covered Person who is travelling with the patient at the time the Medical Emergency occurs.
NOTE: This benefit is only provided when the Covered Person does not have a valid open-return air ticket.
In addition, when the attending Physician or commercial airline specifies in writing that the patient must be accompanied by a qualified medical attendant (not a relative), the fee charged by the medical attendant will be covered, as well as charges for the most economical airfare and overnight hotel and meal expenses for that attendant, if necessary.
Friend/Family Hospital Visit — The most economical airfare by the most direct route will be covered for one family member or friend to visit a Covered Person confined in a Hospital as a result of a Medical Emergency. This benefit is only provided when the Covered Person has been an In-patient for at least seven days outside his or her province of residence and the attending Physician certifies in writing that the situation was serious enough to require the visit.
Identification of Deceased — The most economical airfare by the most direct route will be covered for one family member or friend to identify the deceased Covered Person in order to permit release of the body.
Return of Deceased — Up to $5,000 will be reimbursed towards the cost of preparation and transportation of a deceased Covered Person to the city of usual residence. Alternatively, up to $5,000 will be reimbursed for cremation and/or burial of the Covered Person at the place of death. In either case, the cost of a casket is excluded.
Meals and Accommodation — Up to $150 per day, to an overall maximum of $1,500 for the Contract Holder and Dependants combined, will be reimbursed towards the extra cost incurred by a Covered Person for commercial accommodation and meals when return to the province of residence is delayed beyond the planned termination date of the trip due to sickness or injury of a Covered Person or Travelling Companion. Claims must be verified by the attending Physician and supported by receipts from commercial organizations.
Vehicle Services — Up to $2,000 will be reimbursed toward the cost of driving a Covered Person’s Vehicle, either private or rental, to the province of residence or nearest appropriate Vehicle rental agency when the Covered Person is unable to do so due to sickness or injury, and there is no Travelling Companion who can do so. Medical certification is required, as well as receipts for costs incurred. If the Covered Person’s private Vehicle is stolen or rendered inoperable due to an Accident, the most economical airfare to return the Covered Person to the province of residence by the most direct route will be covered. The Insurer must be provided with an official report of the loss or Accident.
Trip Interruption/Trip Cancellation — If a Covered Person is unable to travel or to continue to travel due to one of the following:
- A Medical Emergency of the Covered Person or, if the Covered Person has already departed on the trip, a Medical Emergency of the Covered Person or Travelling Companion;
- The death or Serious Injury or Illness of a Covered Person or a member of the Covered Person’s Immediate or Extended Family;
- The death of a Covered Person’s Travelling Companion or of a member of the Immediate or Extended Family of the Travelling Companion;
- A travel advisory issued by the Government of Canada after the purchase of the travel tickets, recommending that Canadians not travel within the country originally ticketed, for a period that would include the trip;
- If the Covered Person has not yet departed on the trip, a call for jury duty, a subpoena to appear as a witness or a required appearance to be a defendant in a civil suit, during the period of the trip;
- If the Covered Person has already departed on the trip, damage to the Covered Person’s principal residence by a disaster making it uninhabitable; or
- If the Covered Person has already departed on the trip, a natural disaster at the place of destination. The Covered Person may be reimbursed for up to the amount indicated in the Schedule of Benefits per trip for unused, pre-paid, non-refundable and non-transferable expenses incurred before the scheduled departure date. In addition, the Covered Person may be eligible for a one way economy fare and the excess cost over and above any pre-paid travel arrangements, if the Covered Person returns home or joins or rejoins the trip, as the case may be. Together these expenses shall not exceed reimbursement of the amount indicated in the Schedule of Benefits. These expenses will be reimbursed only after providing, at the discretion of the travel assistance centre, any of the following:
- A statement from the Physician in attendance and the complete reason for the necessity of the cancellation, interruption or delay;
- Documentary evidence of the emergency situation which caused the cancellation, interruption or delay. In the event of a travel advisory, please provide proof of booking date as well as a copy of the travel advisory issued by the Canadian government;
- Proof that a portion of the travel arrangement costs is non-refundable and copies of receipts/unused tickets and receipts/coupons for any additional transport costs incurred.
Transmission of urgent messages to family members or business partners.
Assistance with lost documents.
Assistance accessing legal counsel.
AUTOMATIC EXTENSION OF COVERAGE
If a Covered Person is confined in a Hospital on the date the 95 day coverage period ends, coverage will continue until discharge from the Hospital. In addition, coverage will automatically be extended to the Covered Person and any accompanying covered family members for up to 72 hours:
- Following discharge from a period of Hospitalization which extended past the end of the 95 day coverage period;
- Beyond the end of the 95 day coverage period when return to the province of residence is delayed, by order of the attending Physician, due to a covered Medical Emergency;
- Beyond the end of the 95 day coverage period when return to the province of residence is delayed:
- Due to the delay of a common carrier (airplane, bus, taxi, train) on which the Covered Person is a passenger; or
- Due to a traffic accident or mechanical failure of a private automobile en route to the departure point.
Claims must be supported by documented proof.
EXCLUSIONS (Applicable to Deluxe Travel Benefits only)
The Insurer will not pay benefits or provide emergency assistance services that relate in any way to expenses incurred:
- For care, services or supplies which are not Medically Necessary, as determined by the Insurer.
- For Elective Treatment.
- For Hospital accommodation or Treatment received in a Hospital which is not an active treatment Hospital, such as a nursing home, health spa, chronic care hospital or chronic care unit of a public Hospital.
- Outside the province of residence when the Covered Person could have been returned to the province of residence without risk to the Covered Person’s life or health, even if the treatment available in the province of residence is of lesser quality than that available elsewhere.
- For a medical condition for which, prior to departure, medical evidence would suggest that Treatment or Hospitalization could be required while on the trip.
- By a Covered Person who is travelling outside the province of residence, with intent or incidentally, to seek medical advice or Treatment, even if the trip is on the recommendation of a Physician.
- For Hospitalization or services rendered in connection with or in any way associated with:
- general health examinations for check-up purposes;
- ongoing maintenance of an existing medical condition;
- rehabilitation or ongoing care in connection with drug, alcohol or other substance abuse;
- a rest cure or travel for health reasons; or
- cosmetic treatment.
- In connection with or in any way associated with travel booked or commenced contrary to medical advice or after receipt of a terminal prognosis.
- For Hospital or medical care of either a Covered Person or a newborn Child as a result of, in connection with or in any way associated with:
- full-term birth;
- medical complications after the 26th week of pregnancy; or
- deliberate termination of pregnancy.
- For services provided by naturopaths or optometrists or for cataract surgery.
- As a result of, in connection with or in any way associated with driving a Motorized Vehicle while impaired by drugs, alcohol or toxic substances or an alcohol level of more than 80 milligrams in 100 millilitres of blood. (For the purpose of this exclusion, “Motorized Vehicle” means any form of transportation which is propelled or driven by a motor and includes, but is not restricted to, an automobile, truck, motorcycle, moped, snowmobile or boat.)
- As a result of, in connection with or in any way associated with abuse of medication, toxic substances, alcohol or the use of non-prescribed drugs.
- As a result of, in connection with or in any way associated with suicide, attempted suicide or self-inflicted injury, whether sane or insane.
- As a result of, in connection with or in any way associated with committing, or attempting to commit, a criminal act under legislation in the jurisdiction where the act was attempted or committed.
- As a result of, in connection with or in any way associated with parachuting, hang gliding, bungee jumping, mountaineering, cave exploring, participation in professional sports or any Speed Contest by a Motorized Vehicle. (For the purpose of this exclusion, “Motorized Vehicle” means any form of transportation which is propelled or driven by a motor and includes, but is not restricted to, an automobile, truck, motorcycle, moped, snowmobile or boat.)
- As a result of, in connection with or in any way associated with a flight accident unless the Covered Person is riding as a fare-paying passenger on a commercial airline or charter aircraft with a seating capacity of six people or more.
- As a result of, in connection with or in any way associated with the radioactive, toxic, explosive or other hazardous properties of nuclear materials or by-products.
- As a result of, in connection with or in any way associated with any of the following, regardless of any other cause or event contributing concurrently or in any other sequence thereto: war, invasion, acts of foreign enemies, hostilities, warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power, hijacking or any Act of Terrorism or any action taken in controlling, preventing or suppressing any of the foregoing. (For the purpose of this exclusion, “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, by any person or groups of persons, whether acting alone or on behalf of or in connection with any organization or government, committed for political, religious, ideological, or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear that has been determined by the appropriate federal authority to have been an act of terrorism.)
- As a result of, in connection with or in any way associated with service in the armed forces.
- For services or supplies to the extent to which they are available under any Government Plan, or would be available without charge if this coverage was not in effect.