Frequently Asked Questions

In determining your need for critical illness insurance, you should consider benefits that may already be available to you through other insurance policies, such as life insurance and group health insurance. For example, the benefits offered through your employer’s group disability plan may provide appropriate and adequate coverage in the event of a critical illness. You should also consider your personal circumstances and the added financial strain that could be brought about by dealing with a serious illness or disease. Public and private health insurance plans typically do not provide coverage for day-to-day living expenses such as travel to and from treatments, home care and child care.

Generally, the younger and healthier you are, the lower the premium (cost). However, the cost varies depending on your age, medical condition, the amount of coverage, the number of illnesses covered by the policy, and the insurance company. It pays to shop around to get the best rate. When shopping for a critical illness plan, you should consider your income, financial obligations, dependents, and health care needs.

You can make a claim if a physician, licensed to practice medicine in Canada and specializing in your particular illness, diagnoses you with a critical illness or disease covered by your policy.

If you die for a reason not covered by the critical illness policy, the premiums you paid may be refunded to your named beneficiary. Some plans will return the premium or a portion of the premiums paid during the life of the policy if the policy matures and no claim has been paid.

You are entitled to collect the entire benefit even if you make a full recovery.

No. Long-term care insurance provides for personal care on a long-term basis if you need supervision or assistance with daily living activities due to a chronic illness, disabling condition or cognitive impairment. Long-term care policies generally reimburse, up to a specified limit, the expenses incurred for various types of care, such as nursing home or home health care; or they pay a pre-determined benefit amount on a daily or monthly basis.

No. Disability insurance, also known as “income replacement” insurance, provides a monthly income replacement benefit if you become disabled and can no longer perform the normal duties of your work. Generally, the benefit is limited to a percentage of your regular income and ceases once you earn an income or you no longer meet the definition of disability in the contract. Unlike critical illness insurance which provides the full policy benefit in a lump sum payment on diagnosis of a critical illness, long-term disability policies may have a waiting period from the onset of disability. Unlike critical illness benefits, long-term disability benefits may be affected by other income you receive or by your full recovery from the illness.

To obtain a regular individual policy on the open market the purchaser must warrant that he is in good health and to the best of his own knowledge is not currently HIV-positive. A general principle of insurance is that the policyholder sells risk that, to the best of his knowledge, is not higher than the stated circumstances imply. Withholding relevant circumstances or hiding them is selling something that is not what it was warranted. Analogies are insider trading using material non-public information and making fraudulent (incomplete or false) seller disclosure in a real estate transaction.

Workers’ compensation policies are not obligated to pay claims for disability that is not job-related. Insurance for such risks can be purchased, but because the risks are more inclusive, the premiums are higher.

Because most disability events are temporary, insurance coverage for them is cheaper when the policyholder agrees to wait longer before receiving payments. For example, if a policy-holder breaks a finger, it may be only 2 months before he or she is able to do his or her job again. If the policy-holder agreed to wait 60 days before receiving claim payments, then the insurer need not pay. This reduction to the insurer’s risk is reflected in the lower price that was paid to purchase coverage (lower premiums).

An auto insurance policy may include coverage for lost income during a driving-related period of disability. Often lost-income coverage is a separately-priced rider to the auto insurance policy. In this case, the policy-holder may make a claim with the auto insurance company and either (1) make a secondary claim with disability insurer, or (2) decide that the primary claim is enough and skip the second claim. Sometimes there is a pre-established priority that makes the disability insurer liable only to the extent that the auto coverage is not enough. If the injury is someone else’s fault, their liability coverage from an auto, home, or personal umbrella policy may pay for the injured person’s lost income, and therefore that person will not make a claim on his or her own policy.

It is rare for any policy to pay the full amount of the insured’s salary. Generally it pays only some percentage, such as 80%, or a flat amount, such as $1500/month, regardless of the normal salary amount. The idea behind this reduced benefit is that it is enough to protect the beneficiary from mortgage foreclosure, or to keep the beneficiary from running up huge debts during convalescence.

Most policies in the lower and middle areas of the market have a cap, for example, 5 years. More expensive policies pay until the national social insurance program takes over as the primary income source. For example, in the U.S., this is usually at the individual’s Social Security full retirement age; for most individuals, age 66. Also, in the U.S. most long term disability insurance policies require those receiving benefits to apply for Social Security disability benefits.

Most policies in the lower and middle market pay claims only if there is no job that the beneficiary can possibly do. Others, referred to as own-occ policies, pay the claim as long as the beneficiary cannot return to his or her own occupation. Own-occ policies have higher premiums than non-own-occ, because their claims risk is greater. For example, suppose that a disabled person’s normal job involves lifting heavy boxes and getting paid $4000/month. If insured is still capable of doing light assembly work at a workbench for $2000/month, a less-expensive policy provides no benefits.

Yes. The Ministry of Health of Ontario strongly recommends that you do, whether you are absent from Canada for a few minutes or for an extended time. OHIP does not insure or pay for all out-of-country medical services. Also, the amount of funding provided by OHIP will not usually cover the full cost of any health services that you do obtain outside of Canada. You should therefore, obtain supplementary health insurance from a private insurance company to provide you with additional coverage during your absence. It is also recommended that you understand the terms and conditions of the additional insurance coverage you have purchased and the implications of any pre-existing health conditions on your insurance coverage. To obtain private insurance contact a private insurance company of your choice.

No. If you are a resident of Ontario and you are insured under OHIP, you are entitled to very limited funding for a certain range of medical services when you are travelling outside of Canada. For this reason, you are strongly advised to purchase additional health insurance every time you leave Canada and ensure that the supplementary insurance you have purchased provides adequate coverage.

OHIP will pay very limited amounts for physician services and hospital/health facility services, and only if certain conditions are satisfied. These provisions are intended and designed to provide a very limited amount of funding for the medical treatment of insured residents of Ontario if they incur an unexpected illness, disease, condition or injury while they are outside of Canada. If the illness, disease, condition or injury arises before you leave Canada, or if it is not acute or unexpected, no payment can be made. Under Ontario’s Health Insurance Act and regulations, physician services are subject to different conditions than hospital services. OHIP will pay only for insured, emergency out-of-country health services that are rendered to an insured person. To qualify as an ’emergency’ there are a number of criteria that must be satisfied. These criteria are set by regulation and include the conditions listed below that must be met:

• the treatment must be medically necessary, and
• the treatment must be performed at a licensed hospital or licensed health facility, and
• the treatment must be rendered in relation to an illness, disease, condition or injury that: is acute and unexpected, and arose outside of Canada, and requires immediate treatment.

OHIP does not cover:

• treatment that is medically unnecessary
• health services that are rendered at a facility that is not a licensed hospital or licensed health facility
• treatment that is generally accepted by the medical profession in Ontario, as being experimental, or for research or for part of a study
• treatment rendered for an illness, disease condition or injury that arose inside Canada
• ambulance services or transportation costs
• other services specifically set out in the regulations as uninsured or otherwise not listed as insured.

• The amount that OHIP pays is set by regulation. The amount paid for out-of-country health services is very limited and usually will not be sufficient to cover the full cost of the services rendered. OHIP covers only very limited amounts for hospital, health facility and physician services. You are strongly advised to purchase additional health insurance every time you leave Canada to cover any expenses in excess of the limited funding provided by OHIP. You should also ensure that you understand the amount of protection provided by your supplementary health insurance provider because the amount of coverage may vary significantly from one insurance carrier to another. You should also check with your supplementary health insurance provider to determine if there are restrictions relating to pre-existing health conditions if these health conditions were not disclosed at the time your policy was purchased.
• For physician services, OHIP will pay the actual cost billed by the out-of-country physician(s) or the cost of the same physician service(s) in Ontario, whichever is less. Physician services in Ontario are usually rendered at a significantly lower cost than those billed at out-of-country health facilities. Please note that out-of-country health facilities and physicians usually bill separately.
• For outpatient emergency room services, OHIP will pay $50 Canadian (CDN) per day.
• For inpatient services, OHIP will pay $200 CDN per day. If the services are inpatient services rendered in an operating room, coronary care unit, intensive care unit, neonatal or pediatric special care unit, then OHIP will pay at the higher rate of $400 CDN per day for hospital services.
• For outpatient dialysis services, OHIP will pay $210 CDN per day.

The “per day” rates listed above cover all hospital inpatient services including, but not limited to, accommodation, meals, prescription drugs, surgically implanted devices and nursing services. OHIP does not pay for ambulance services, transportation costs, or out-of-hospital food/accommodation/drugs or prescriptions.

You may be temporarily outside of Canada for a total of 212 days in any 12 month period and still maintain your OHIP coverage as long as your primary place of residence is still in Ontario. However, the ministry does have extended absence provisions which are outlined below.

Because the Government of Canada will help you save money if you open an RESP account through the Canada Education Savings Grant and the Canada Learning Bond. They are only available for your child if you open an RESP.

Anyone can open an RESP account for a child – parents, guardians, grandparents, other relatives or friends.

It depends. Some types of RESPs have no minimum deposit requirements, while others do. The Government of Canada will still add to your savings, no matter how little you put into your child’s RESP account.

No. You can open an RESP without having a bank account.

Up to $50,000 for each child (named in one or more RESPs). Although there are no annual limits on contributions made to an RESP, the Canada Education Savings Grant will only be paid on the first $2,500 of contributions made every year. If the child has accumulated grant room, then the Canada Education Savings Grant will be paid on the first $5,000 of contributions made per year.

Every RESP is different. Some types require specific monthly contributions. Others let you put money into your RESP account whenever you want. The sooner you start to save, the sooner you’ll be earning interest, and the more your money will grow. Even savings of $5 a week can quickly add up, especially when the Government of Canada adds money to your savings.

Yes, you can. You can open an RESP at any age An RESP allows adults to earn interest on their registered education savings plan tax-free.

• While you can open a plan for a child, you can also name yourself or another adult as the definition of beneficiary.
• Please note that all children up to the age of 17 are entitled to the Canada Education Savings Grant.

• Your money grows tax-free while it is in your RESP.
• You don’t get a tax deduction for the money you put into an RESP.
• The money that your investment earns while it is in the RESP won’t be taxed until money is taken out to pay for your child’s education.
• Money paid out of the RESP as an Educational Assistance Payment is taxed in the hands of the student. Since many students have little or no other income, they can usually withdraw the money tax-free.
• The money that you have put in the RESP is returned to you, tax-free.

• You will not be taxed on the amount you contributed to the RESP, but you will have to pay taxes on the money that you earned in your plan as interest. This money is called “accumulated income”. It will be taxed at your regular income tax level, plus an additional 20 percent.
• The money that you have put into the RESP is returned to you.
• The Canada Education Savings Grant can be shared with a brother or sister if they have grant room available—otherwise, the grant must be returned to the Government of Canada.
• When you close your RESP, you will have to pay tax on the earnings in the RESP. (Although there will be earnings on the Canada Education Savings Grant, the grant must be returned to the Government of Canada.) You may be able to reduce the taxes you have to pay by transferring your accumulated income to either your or your spouse’s Registered Retirement Savings Plan. For more information, see the Accumulated Income Payments section of the Canada Revenue Agency’s Web site.
• Talk to your RESP provider to find out about any conditions that may apply to the plan if your child does not continue his or her education after high school.

Yes. A child can be named as the definition of beneficiary of more than one RESP account. However, you should be aware of the following information.

• There is a lifetime limit of $50,000 that can be contributed for each child.
• Be sure to find out if anyone else is making contributions to a plan for that child so that you don’t go over any limits when you decide how much money to put into an RESP.

There are four types of EI special benefits:

• Maternity benefits are for mothers who give birth. These benefits cover the period surrounding the child’s birth (up to 15 weeks).
• Parental benefits are for any parent (mother or father) to care for their newborn or newly adopted child or children. Either parent can receive benefits, or they can share benefits between them (up to 35 weeks).
• Sickness benefits are for people who cannot work due to injury, illness, or the need to be isolated in quarantine because they may be carrying a disease (up to 15 weeks).
• Compassionate care benefits are for people who must be away from work temporarily to provide care or support to a family member who is seriously ill with a significant risk of death (up to 6 weeks). The 6 weeks of benefits can be shared between different family members who applied and are eligible to receive them.

You can register if you operate your own business, or if you work for a corporation but cannot access EI benefits because you control more than 40% of the corporation’s voting shares. You must also be either a Canadian citizen or a permanent resident of Canada. However, some individuals who work independently and are not hired as employees cannot register for these EI special benefits for self-employed people because they are already eligible to receive benefits through the regular EI program. These individuals include:

• barbers, hairdressers, taxi drivers, and drivers of other passenger vehicles who are not hired as employees but whose employment is insurable under the EI Regulations; and
• fishers who are included as insured persons under the EI Fishing Regulations.

You have to wait 12 months after the day you register before you will be able to apply for EI special benefits. For example, if you entered into an agreement on November 13, 2012, you will be able to apply for EI special benefits as early as November 13, 2013.

You must meet the following conditions to qualify for EI special benefits:

• your registration in the EI Program for Self-Employed People must still be valid (that is, not terminated);
• you must have experienced an interruption of earnings because of: the birth of a child; the need to care for your newborn or newly adopted child or children; illness, injury, or quarantine; or the need to provide care or support to a gravely ill family member;
• you must have earned a minimum specified amount of self-employed earnings during the calendar year before the year you submit an EI claim (for claims filed in 2013, the minimum amount of 2012 income is $6,342).

Yes. If you are applying for sickness benefits, you have to provide a medical certificate as proof that you are ill, injured, or in quarantine. If you are applying for compassionate care benefits, you have to provide medical proof showing that a gravely ill family member needs your care or support. If you are applying for maternity or parental benefits, you have to provide the expected date of birth of the child and the actual birth date once it has occurred, or the official placement date in the case of adoption.

If you are eligible for EI special benefits, you can expect to receive 55% of your average weekly earnings up to a defined annual limit. In 2013, you can receive up to $501 per week, based on the maximum insurable earnings of $47,400 for that year. The amount of your benefits may decrease if you continue to work or if your business generates earnings while you are collecting EI special benefits.

If you are claiming sickness or maternity benefits, we will deduct any part-time earnings from your benefits on a dollar-for-dollar basis. If you are claiming parental or compassionate care benefits, you normally can earn either a maximum of 25% of your weekly benefit (if your weekly benefit amount is $200 or more) or a maximum of $50 (if your weekly benefit amount is less than $200) without changing the amount of EI benefits you receive for that week. We will deduct any money you earn above that amount from your benefits on a dollar-for-dollar basis. However, effective August 5, 2012 until August 1, 2015, a new pilot project is in place which changes the way earnings are deducted. Under the Working While on Claim pilot project, once you have served your waiting period, your benefits will be reduced by a rate of 50% of your earnings each week if the earnings are equal to or less than 90% of your weekly earnings that were used to calculate your benefit rate. Any earnings that exceed the 90% threshold will be deducted dollar for dollar from your benefits.

As with any insurance program, you will need to pay premiums. In 2013, for every $100 you earn, you will need to contribute $1.88 in EI premiums up to a defined maximum—the same amount that employees pay. This means the most you will pay in EI premiums for 2013 is $891.12. EI premiums are calculated based on your income tax return. For example, if you sign up for the program in 2013, your premiums will be based on your 2013 tax return.

The choice is yours: you can choose to apply for EI special benefits either as a self-employed person or as an employee. If you choose to apply as a self-employed person, we will take into account your earnings from both self-employment and employment as an employee when we calculate your weekly benefit amount, as long as your earnings from both sources are eligible. A Record of Employment will be required from your employer to show details of your eligible employment earnings. If you choose to apply as an employee, we will use only the earnings from your employment as an employee (including fishing earnings) to calculate your weekly benefit amount. We will not use any of your self-employed earnings. A Record of Employment will be required from your employer to show details of your eligible employment earnings.

By taking part in this EI program, you are registering with the Canada Employment Insurance Commission and agreeing to pay premiums on your self-employed income. If you change your mind, you have 60 days to cancel your registration. If you choose to cancel your registration within those first 60 days, you will not have to pay any premiums. After the 60-day period, you can terminate your registration at any time – as long as you have never claimed any benefits. This termination will be effective at the end of the calendar year, so you will have to pay EI premiums for the entire calendar year. Once you have claimed EI benefits, your participation in the program lasts indefinitely. You will have to pay premiums for the entire duration of your self-employed career, regardless of any change in the nature of your self-employment.

Once you register, you must wait 12 months to make a claim for EI special benefits. For example, if you registered on June 13, 2012, you could apply for EI special benefits on June 13, 2013.

Yes, it does. OHIP coverage for seniors includes this type of coverage.

OHIP pays for you to have one eye examination every 12 months. OHIP also covers any follow-up care you require before you have your next major eye examination.

The routine eye examinations for healthy adults aged 20 to 64 years are not covered. OHIP covers all medically necessary services provided by ophthalmologists.

The Ministry of Community and Social Services has established a program to ensure people receiving social assistance are covered for regular eye examinations as they have been in the past. Persons in receipt of assistance under the Ontario Disability Support Program, Ontario Works or the Family Benefits Program will receive coverage for regular eye examinations. Coverage is once every two years.

The optometrist determines patient fees. The ministry does not play a role in regulating these fees.

Yes, if you are 65 or older or 19 and under. Individuals aged 20 to 64 discharged after an overnight stay will be covered for services provided by a designated physiotherapy clinic as long as they were referred by the hospital physician who treated them.

These people will not be covered unless they are over 65 or 19 and under, a recipient of the Ontario Disability Support Program, Family Benefits or Ontario Works or if a physician has requested in-home service.

People over 65 and 19 and under, recipients of Ontario Disability Support Program, Family Benefits or Ontario Works and people whose physician has requested in-home physiotherapy services will be covered. People aged 20 to 64 discharged after an overnight stay will receive coverage for physiotherapy at a designated OHIP-insured physiotherapy clinic if the patient has been referred by the hospital physician who treated them. People aged 20 to 64 who are taken to the ER, or receive outpatient treatment such as day surgery, after they leave the hospital will not be covered. These Ontarians may have private insurance coverage for physiotherapy or may have to pay for it themselves.

People aged 20 to 64 discharged after an overnight stay will receive physiotherapy by a designated clinic as long as they were referred by the hospital physician who treated them.