Group Health Insurance Benefits

Group health insurance benefits are highly valued by employees. Group health insurance benefits share a major role with government sponsored health care to ensure Canadians have access to proper care when they need it. OHIP in Ontario is often wrongly assumed to cover its residents for everything. Private group health insurance benefits build on the minimum universal standard of care provided by provincial/territorial health plans, covering those medical products and services that the government does not.

Private group health insurance benefits generally do not make payments toward expenses covered by government plans; though, in some cases private plans cover those services once the government coverage is first exhausted.

As governments continue to reduce and eliminate services not mandated by the Canada Health Act, they are in turn shifting the cost and responsibility to private insurance plans.

Group health insurance benefits reimburse the Insured and/or their dependents for certain medical expenses specified in their group contract. Typically, they are both listed under the extended health care section of a policy.

Group health insurance benefits provide protection against financial losses due to sickness or injury and cover routine expenses and large catastrophic claims; depending on the level of coverage elected.

Group Health Insurance Benefits

Major Medical:

As each plan is typically custom designed for a specific group, the coverage will vary. Group health insurance benefits have a wide range, below is a non-exhaustive list of many of the major-medical benefits typically available through a group health insurance benefits plan:

  • Hospital coverage
  • Paramedical services
    • Psychologists
    • Social workers
    • Massage therapists
    • Speech therapists
    • Physiotherapists
    • Naturopaths
    • Acupuncturists
    • Audiologists
    • Dieticians
    • Occupational therapists
    • Osteopaths
    • Chiropractors
    • Podiatrists
    • Chiropodists
  • Out of province and out of country emergency medical coverage
  • Travel assistance
  • Diabetic supplies
  • Vision care
    • Eyeglasses
    • Contact lenses
    • Laser eye correction surgery
    • Eye exams
  • Private duty nursing
  • Ambulance ground and/or air
  • Accidental dental
  • Wigs following chemotherapy
  • Medical equipment
    • Wheelchairs
    • Casts
    • Splints
    • Trusses
    • Braces
    • Crutches
    • Breast prostheses
    • Surgical brassieres
    • Artificial limbs and eyes
    • Surgical stockings
    • Orthotics
    • Custom-made orthopaedic shoes
    • Hearing aids
    • Oxygen, plasma blood transfusions
    • Blood glucose monitors
    • Colostomy supplies

How group health insurance benefits are reimbursed is determined by the plan design which is based on factors such as the deductible, coinsurance and benefit maximums.

Deductibles:

A deductible is the amount that a covered person must pay before the insurer will provide reimbursement of the expenses in excess of that deductible. Typically, if there is a deductible for a group health insurance plan, it is satisfied on an annual basis and is normally based on individual or a family status. For example, $25 per individual and $50 per family. Calendar year deductibles however are typically not changed for long periods of time, and it is argued that their effect on premium savings is eroded as inflation and utilization increase over time (deductible erosion).

Coinsurance:

Coinsurance is the percentage of eligible expenses (after the deductible is satisfied) eligible for reimbursement under a group health insurance benefits plan. The coinsurance percentage typically ranges from 50% to 100%, in increments of 10%. For example, in a plan with 80% coinsurance, the employee pays 20%.

Benefit Maximum:

This is the maximum amount of benefits that will be paid to any one person covered by the plan. Benefits maximums can be per visit (paramedical), per year (orthotics), every two years (vision), every five years (hearing aids), per lifetime (out of country) or a combined maximum for a group of services such as for all medical supplies or all paramedical services.

Survivor Benefits:

Group benefits plans may allow for the continuation of health benefits for dependents of a covered employee following his or her death. The survivor benefit will typically be available for up to two years with specific eligibility requirements and conditions.