Extended Health Care Insurance- Plan details

 

Plan details

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Available in all provinces, unless otherwise noted.

(Please note: all annual, calendar year or lifetime maximums are per insured person.)

Plan Details
Coverage
  • Available to residents of Canada who are insured under the government health care plan in their province or territory of residence
  • Available to individuals for single person coverage
  • Available to couples or families for multi-person coverage
  • Available to age 69 (you must be 18 years of age or older to apply)
  • Once issued, the plan is renewable each year for life

Plan types

 

There are three types of plans to choose from:

  • Basic plan - our most economical plan for basic coverage
  • Standard plan - coverage for the same health expenses as Basic but at higher levels. Also with semi-private hospital, vision and emergency travel medical coverage
  • Enhanced plan - the broadest and most comprehensive level of coverage, including orthodontics and restorative dental coverage
Prescription drugs*

Basic plan

  • $750 annual maximum
  • 60% reimbursement
  • Excludes fertility drugs and contraceptives
  • Up to $5.00 paid towards dispensing fee

 

Standard plan

  • $100,000 annual maximum
  • 70% reimbursement on first $7,000 of eligible expenses ($4,900 paid expenses)
  • 100% reimbursement on next $93,000 of eligible expenses
  • Excludes fertility drugs and contraceptives

Enhanced plan

  • $100,000 annual maximum
  • 80% reimbursement on first $5,000 of eligible expenses ($4,000 paid expenses)
  • 100% reimbursement on next $95,000 of eligible expenses
  • Includes contraceptives (oral only)
  • Excludes fertility drugs

All three plans include:

  • Pay Direct drug card (except in Quebec)
  • No deductible
  • Smoking cessation medication ($250 lifetime maximum)

Extended health provision

 

Basic plan

  • 60% reimbursement
  • No deductible
  • $25 maximum per visit, up to $250 per calendar year, per practitioner+
  • Accidental dental ($2,000 per fracture or injury)
  • Licensed ground or emergency air ambulance services
  • Hearing aids ($400 every five years)
  • Medical services and equipment of $2,500 per year for a combined lifetime maximum of $20,000. See list of medical services and equipment below:
  • Wigs and/or hair pieces ($100 maximum per calendar year)
  • Orthopedic shoes and orthotics ($150 maximum per calendar year)
  • Blood glucose monitor ($150 every five years)
  • Splints, crutches, braces and/or casts
  • Wheelchairs ($1,000 lifetime maximum)
  • Walkers and traction kits
  • In-home nursing**
  • Hospital bed
  • Prosthetic appliances

Standard plan

  • 100% reimbursement
  • No deductible
  • Up to $300 per calendar year, per practitioner+
  • Accidental dental ($2,000 per fracture or injury)
  • Licensed ground or emergency air ambulance services
  • Hearing aids ($400 every five years)
  • In-home nursing** up to $5,000 per year and $25,000 lifetime maximum

Enhanced plan

  • 100% reimbursement
  • No deductible
  • Up to $400 per calendar year, per practitioner+
  • Accidental dental ($2,000 per fracture or injury)
  • Licensed ground or emergency air ambulance services
  • Hearing aids ($500 every five years)
  • In-home nursing** up to $10,000 per year and $30,000 lifetime maximum

Standard and Enhanced plans include:

  • Medical equipment of $5,000 per year. See list of medical equipment below:
  • Wigs and/or hair pieces ($500 lifetime maximum)
  • Orthopedic shoes and orthotics ($200 annual maximum)
  • Blood glucose monitor ($300 every five years)
  • Splints and crutches ($500 maximum per calendar year)
  • Braces and casts
  • Wheelchairs ($4,000 lifetime maximum), walkers, traction kits
  • Hospital bed ($1,500 lifetime maximum)
  • Prosthetic appliances
  • Breast prothesis ($200 maximum per calendar year)

+Practitioners include:

acupuncturists, chiropractors, naturopaths, osteopaths, physiotherapists, podiatrists/chiropodists, psychologists, registered massage therapists and speech therapists

Dental - preventive

 

Basic plan

  • 60% reimbursement
  • $500 per calendar year

Standard plan

  • 70% reimbursement
  • $750 per calendar year

Enhanced plan

  • 80% reimbursement
  • $750 per calendar year

All three plans include:

  • Exams, diagnosis, tests, x-rays, lab exams
  • Fillings, scaling and routine extractions
  • Space maintainers for children under 12 years of age
  • Pit and fissure sealant for children under 19 years of age
  • Nine-month recall visits
  • A three-month waiting period before coverage begins

Dental - restorative

 

Basic plan

  • No coverage

 

Standard plan

  • No coverage

 

Enhanced plan

  • 50% reimbursement
  • $500 annual maximum
  • One-year waiting period before coverage begins
  • Includes endodontics (root canals), periodontics, oral surgery, anaesthesia, crowns, onlays, laboratory procedures, bridges, dentures (and repairs)

Dental - orthodontics

 

Basic plan

  • No coverage

 

Standard plan

  • No coverage

 

Enhanced plan

  • 60% reimbursement
  • $1,500 lifetime maximum
  • Two-year waiting period before coverage begins

Semi-private hospital room (in Canada)

 

Basic plan

  • No coverage

 

Standard and Enhanced plans include:

  • 85% reimbursement
  • up to $200/day for an annual maximum of $5,000
  • Convalescent hospital - maximum of $20/day - 180 days per incident
  • If you are pregnant at the time of application, we will pay up to two days of hospitalization due to pregnancy

Vision care

 

Basic plan

  • No coverage

 

Standard and Enhanced plans include:

  • 100% reimbursement
  • Prescription eyeglasses, contact lenses, prescription sunglasses, laser eye surgery
  • One year waiting period
Standard plan Enhanced plan

Vision

  • Maximum $150 every two calendar years (including eye exams)

Eye examination

  • Up to $50 every two calendar years (per calendar year for dependents under age 18)

Vision

  • Maximum $200 every two calendar years (including eye exams)

Eye examination

  • Up to $50 every two calendar years (per calendar year for dependents under age 18)

Emergency travel medical

 

Basic plan

  • No coverage

 

Standard and Enhanced plans include:

  • 100% reimbursement
  • $1 million lifetime maximum
  • Up to 60-days per trip. Coverage begins when you leave your province/territory of residence
  • Available until the age of 80
  • If you have a pre-existing medical condition that existed during the nine months prior to your trip, expenses related to this condition are not included***

This chart provides the highlights, but not all the details of PHI Direct. The complete terms, conditions, exclusions and limitations governing the coverage are found in the insurance policy issued by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies.

* This plan is second payor to any government - sponsored drug plan. In Quebec, this plan will be second payor to comply with RAMQ legislation.

** In-home nursing includes RNs, RPNs, RNAs, CNAs or LPAs.

*** Emergency travel medical does not cover any pre-existing condition. A pre-existing condition is a medical condition where symptoms appeared or required medical attention, hospitalization or treatment (this includes changes in medication or dosage) during the nine-month period before you leave your province or territory. Certain provisions may apply, please read your policy carefully before you travel.

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Plan member services

Our Plan Member Services website has many features and services available to PHI plan members. You can:

  • Submit claims
  • Instruct us to deposit your claim payment directly into your bank account
  • Print personal claim forms
  • View or print details of your claims
  • Print a personalized Pay-Direct drug card 

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Eligibility

You are eligible to apply for PHI insurance if you:

  • reside in Canada
  • are over age 18, are under age 69, and
  • have provincial health coverage.
  • Your spouse is eligible to apply for PHI insurance if they:
  • reside in Canada
  • are less than 70 years of age
  • have provincial health coverage.

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Effective date

Coverage becomes effective on the first day of the month coinciding with or immediately following the date a completed application is approved by Sun Life Assurance Company of Canada provided any required statement of health has been determined to be satisfactory and full premium for the insurance has been withdrawn from your account.

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Definition of dependent child

A dependent child is a child, other than a foster child, of you or your spouse, who is not married or in any other formal union recognized by law, under age 21 (or age 25 if a full-time student and entirely dependent on you for support) or of any age if incapable of self support because of physical or mental disability.

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Statement of health

All applications are subject to a satisfactory statement of health. You (and your spouse, if applying) must complete a questionnaire outlining your medical history, which will be assessed by Sun Life Assurance Company of Canada to determine if coverage may be issued. The first time you apply for insurance for your dependent child, a statement of health is required for the child or children to be insured. Dependent children born subsequently will be covered from birth without having to provide a statement of health.

Sun Life Assurance Company of Canada reserves the right to request a medical examination or tests such as a general blood profile (including a blood test for HIV, where permitted), which will be made at no expense to you.

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This website provides the highlights but not all the details. The complete terms, conditions, exclusions and limitations governing the coverage are found in the insurance policy issued by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies.

Check our Quote & apply section to get an estimate of the cost for your insurance coverage.