Definitions and exclusions

Definitions

Family
Family is defined as spouse and dependent children.

Spouse
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
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.

General exclusions

Sun Life Assurance Company of Canada will also not pay for expenses:

  • incurred, directly or indirectly caused by or associated with civil disorder or war, whether declared or not; or service in the naval, military or air force of any country, combination of countries or international organization at war, whether war is declared or not,
  • that we are not legally allowed to pay,
  • for services or items that we consider cosmetic,
  • for services or items that we consider experimental,
  • for delivery, transportation and administration charges,
  • for services and products that are self-prescribed or are rendered or prescribed by a person who is ordinarily a resident in the insured person's home or who is related to the insured person by blood or marriage,
  • for services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program unless explicitly listed as covered under this benefit,
  • for services or supplies that are not approved by Health Canada or other government regulatory body for the general public,
  • for services or supplies that are not generally recognized by the Canadian medical profession as effective, appropriate and required in the treatment of an illness in accordance with Canadian medical standards,
  • for services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada), and
  • for elective (non-emergency) medical treatment or surgery which is received or performed out of province where they live.
  • services or supplies to the extent that their costs exceed the reasonable and customary rates in the locality where the services or supplies are provided.
  • equipment that Sun Life considers ineligible (examples of this equipment are orthopaedic mattresses, exercise equipment, air-conditioning or air-purifying equipment, whirlpools, humidifiers, and equipment used to treat seasonal affective disorders).
  • services or supplies for which no charge would have been made in the absence of this coverage.

Sun Life Assurance Company of Canada will not pay benefits when the claim is for an illness or injury resulting from:

  • the hostile action of any armed forces, insurrection or participation in a riot or civil commotion.
  • Self-inflicted injury or suicide, regardless of whether you have the ability to form the requisite intent or regardless of whether you have a mental illness such that you do not know or understand the consequences your action(s).
  • participation in a criminal offence.
  • travelling to a destination where a travel advisory has been issued by the Government of Canada to "Avoid all travel" or to "Avoid non-essential travel".