Other Major Medical Coverages

Semi-Private Hospital

Semi-Private room and board charges in excess of the charges for ward accommodations in a licensed Canadian Hospital.

Hospital

To be recognized as a hospital for insurance purposes, an institution must keep patients regularly overnight, have full therapeutic facilities for the care of the injured, sick or chronically ill and be continuously staffed by licensed physicians, who are doctors of medicine, and by registered graduate nurses. Such institution must have facilities both for diagnosis and for major surgery. The term hospital, as used in this policy, shall not include a rest home, nursing home, convalescent home, health spa, a place for custodial care, a home for the aged or an institution used primarily for the confinement or treatment of alcoholism or drug addiction, tuberculosis or mental illness.

Convalescent/Rehabilitation Hospital (within Home Province)

Daily room and board in excess of ward rate, provided the individual is admitted to the convalescent hospital immediately following a minimum 3 consecutive day confinement in a hospital. The confinement must be for the continued care of the same condition for which the patient was hospitalised. All confinements in a convalescent hospital will be considered as one period of disability unless confinements are separated by at least 90 days. Disability must commence prior to age 65.

To be recognized as a convalescent/rehabilitation hospital or licensed nursing home, for insurance purposes, an institution must have a transfer arrangement with one or more hospitals and regularly provide skilled 24 hour nursing care during the convalescent or rehabilitation stage of an injury or disease, and its charges for ward care for the individual are reimbursed under a provincial hospital plan. Unless they fully meet this definition, institutions, for rest, the aged, custodial care, drug addicts, or for the care of pulmonary tuberculosis, or mental illness do not qualify as convalescent/rehabilitation hospitals, or licensed nursing homes.

Ambulance

Service charges within Canada, including emergency air ambulance service, in excess of the amount payable under the insured person’s Provincial Health Plan and to the limits specified above. The services must be required to transport the person from the place of injury (or where illness struck) to the nearest hospital where treatment is available, or directly from that hospital to the nearest hospital for needed specialized treatment not available at the first hospital, or from hospital to a convalescent/rehabilitation hospital.

Out of Hospital Nursing

Services of a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), a Certified Nursing Assistant (C.N.A.), or a member of the Victorian Order of Nurses (V.O.N.) while the patient is not confined to a hospital. The nursing service must have been ordered by a physician as medically necessary and requiring the specialized training of a registered nurse. The nurse must not ordinarily reside in the member's home or be a member of the family. Charges for services that are mainly custodial or assist the individual with the functions of daily living are not covered.

Accidental Dental

Charges up to the amounts for necessary dental care by a licensed dentist for the prompt repair of sound natural teeth when required for a non-occupational accidental injury, external to the mouth, which occurs while insured. The dental work must be completed within 12 months of the accident to be a covered medical expense.

Foot Care

Foot Care benefits are subject to the limits specified. Charges for orthopedic shoes (including repairs) and orthotics which have been specially designed and molded for the insured individual and are required to correct a diagnosed physical impairment, provided that the following information is supplied:

• a diagnosis, including list of symptoms and the primary complaint;
• a description of the physical findings from the clinical examination;
• a brief description of the gait abnormality associated with the diagnosis; and
• confirmation that the product has been custom-made.

In order to be eligible for reimbursement, orthopedic shoes and orthotic devices must be prescribed, on an annual basis, by either a licensed physician or Chiropodist/Podiatrist, and must be dispensed by one of the following provider types: licensed physician, Chiropodist/Podiatrist, Orthotist, or Pedorthist.

Hearing Aid Benefit

Hearing Aid charges, including replacement and repairs, and excluding batteries, when provided by a certified, clinical Audiologist, up to the amount specified. The financial limit does not apply in the event of an accidental injury to the ear.

Diagnostic Laboratory and X-Ray Expenses

Diagnostic Laboratory and X-Ray Expenses not covered by any provincial health plan