Common Terms

The following common terms are used in the benefit pages.

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Accident

An accident is a bodily injury that occurs solely as a direct result of a violent, sudden, and unexpected action from an outside source.

Actively at Work

A member is actively at work when he or she is working regularly in a permanent manner at the employer’s place of business or at any other place designated for the performance of a specific job-related task.

Benefit Percentage Payable (Co-Insurance)

The percentage of covered expenses that is payable by the benefit providers.

Co-Insurance (Benefit Percentage)

The percentage of covered expenses that is payable by the benefit providers.

Covered Expenses

Expenses that are eligible for reimbursement by the benefit provider under the terms of your extended health care or dental care benefits.

Deductible

The amount of covered expenses that must be incurred and paid by you or your dependents before benefits are payable by the benefit providers.

Dependent

Your spouse or child who is insured under a provincial plan.

Spouse – your legal spouse or a person continuously living with you in a role like that of a marriage partner for at least one year. Child – your natural or adopted child or stepchild who is:

• unmarried;
• under age 22, or under age 25 if a full-time student;
• not employed on a full-time basis;
• not eligible for insurance as a plan member under this or any other group benefit program;
• a child who is older than the age at which insurance would normally terminate and who is incapacitated will be an eligible dependent;
• a child is considered incapacitated if he or she is incapable of engaging in any substantially gainful activity and is dependent on the plan member for support, maintenance, and care due to a mental or physical handicap;
• the benefit providers may require written proof of the child’s condition as often as may reasonably be necessary;
• a stepchild must be living with you to be eligible.

Disability (Total)

A state of continuous incapacity, resulting from illness or accidental injury, which prevents you from performing:

• your own occupation – essential duties of your regular employment during the period specified under long term disability without regard to the availability of such occupation;
• any occupation – afterward, any remunerated function or work for which you are or may become reasonably fitted by training, education, or experience.

Disability will only be recognized as long as you are not receiving any remuneration arising either directly or indirectly from any employment, except under a rehabilitation program approved by the benefit provider.

For disability to be acknowledged, your condition must require both regular and continuous medical care actually given by an appropriate specialist or therapist and considered satisfactory by the benefit provider.

The availability of work will not be considered by the benefit provider in assessing your disability.

If you must hold a government permit or licence to perform the duties of your job, you will not be considered totally disabled solely because your permit or licence has been withdrawn or not renewed.

Where there is a dispute over the nature and extent of your disability and/or the appropriateness of the care and treatment being provided to you, the benefit provider may require an examination by an independent expert.

Drug

Medications that have been approved for use by the federal government of Canada and have a drug identification number (DIN).

Earnings

Your regular rate of pay from your employer (prior to deductions), including regular bonuses and regular overtime pay. Earnings may include other income as agreed to in writing by the CLAC Health and Welfare Trust Fund and the benefit provider.

If you are being paid on a commission basis, your earnings will be as reported on your T4/T4A form for the previous year. If you have less than one year of service with your employer, your earnings will include an average of the total commissions paid over your actual period of employment.

For the purposes of determining the amount of your benefit at the time of claim, your earnings will be:

• the amount reported by the CLAC Health and Welfare Trust Fund to the benefit provider and for which premiums have been paid.

Experimental or investigational not approved or broadly accepted and not recognized by the Canadian medical profession as an effective, appropriate, and essential treatment of a sickness or injury, in accordance with Canadian medical standards.

Illness

An illness is a bodily injury, disease, mental infirmity, or sickness. Any surgery needed to donate a body part to another person which causes total disability is an illness.

Immediate Family Member (Private Duty Nursing only)

You, your spouse and child, your parent and your spouse’s parent, your brother or sister, and your spouse’s brother or sister.

Licensed, Certified, Registered

The status of a person who legally engages in practice by virtue of a license or certificate issued by the appropriate authority, in the place where the service is provided.

Life-Sustaining Drugs

Drugs that are necessary for the survival of the patient.

Loss

Hands and feet: actual severance through or above the wrist or ankle joint. Eyes: entire and irrecoverable loss of sight. Leg or arm: actual severance through or above the knee or elbow joint. Thumb and fingers: actual severance through or above the metacarpophalangeal joints. Speech and hearing: entire and irrecoverable loss. Toes: actual severance through or above the metatarsophalangeal joints. Loss of use of: must be total, irrecoverable, and be continuous for 12 months after which the benefit is payable, provided the nerve damage is determined to be permanent.

Medically Necessary

Broadly accepted and recognized by the Canadian medical profession as effective, appropriate, and essential in the treatment of a sickness or injury, in accordance with Canadian medical standards.

Pre-Existing Condition

Any injury or illness (whether diagnosed or not), for which the member received medical treatment or services, or took prescribed drugs or medicine with 90 days prior to becoming insured, which causes total disability within the first 12 months of becoming insured for long term disability coverage.

Provincial Plan

Any plan that provides hospital, medical, or dental benefits established by the government in the province where the insured person lives and which is governed by the Canada Health Act.

Qualifying Period

A period of continuous and total disability (starting with the first day of total disability) that you must complete in order to qualify for disability benefits.

Reasonable and Customary

Within the usual range of charges being made by others of similar standing in the area in which the charge is incurred when providing the same or comparable services or supplies.

Subrogation

If your disability is caused by another person and you have a legal right to recover damages, the benefit provider will request that you complete a subrogation reimbursement agreement when you submit your disability claim.

On settlement or judgement of your legal action, you will be required to reimburse the benefit provider those amounts you recover that, when added to the disability benefits that the benefit provider paid to you, exceed 100 percent of lost income.

Take-home Pay (Net Earnings)

Your earnings, less deductions for federal and provincial income tax, employment insurance, and the Canada or Quebec pension plans.

Tax Status of Disability Benefits

The tax position of any payments you receive under this benefit program depends on whether you or your employer pays the cost of the benefit.

If your employer pays a portion or all of the cost, then any disability benefit payments you receive will be taxable.

If you pay the full cost of the benefit, then any disability benefit payments you receive will be non-taxable.

Note: Where applicable, 15 percent of the benefit amount will be withheld for income tax purposes.

Travelling Companion (Out of Province/Canada only)

Any person who has prepaid accommodation and/or transportation with the covered person (maximum four persons, including the covered person).

Waiting Period

The period of continuous employment with your employer that you must complete before you are eligible for group benefits.

Ward

A hospital room with three or more beds that provides standard accommodation for patients.