USC - PurpleCARE - Opt-Out Form

Student Health & Wellness!mystudentplan is a benefits plan for students and can provide coverage for prescription drugs, vision care, dental care, mental health counseling, and more. The plan is designed to supplement provincial health insurance and provide additional access to medical services.

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Are you covered by a comparable plan? Do you wish to cover your dependents? Or have you opted out of the plan and wish to be re-enrolled? Eligible Students may submit their online forms.

Health and Dental Opt-Out Application

Fall 2024 deadline to submit applications
Monday, September 23^rd, 2024, 11:30 PM

Each fall term, students may opt-out of the Student Plan by the applicable fall deadline if they are covered by a comparable Health Plan from parents, spouse, work, government, or band and do not wish to Coordinate Benefits.

Things to consider when thinking of opting out:

A parents' insurance plan will stop covering you if you are a part-time student over the age of 21 or a full-time student over the age of 25.
You can coordinate 2 benefit plans and increase your coverage up to 100%! Find out more Coordination of Benefits
What is in the best interest of my overall health & wellbeing?
Does my existing coverage meet all my needs?
The only time you can get back on this student plan is at the start of next fall term OR within 30 days of losing your alternate coverage.

Proof of comparable coverage

You are required to provide proof of your comparable extended health coverage by attaching documentation displaying the policy information when you are completing the online form.

Confirmation of coverage must show the name of the insurance company providing the coverage and the policy number. Acceptable forms of confirmation of coverage are:

Copy of a Plan Card (front and back images).
Confirmation letter from the employer or insurance company with a current date.
Webpage print out with a visible current date.

Important notes:

Ontario Health Insurance Plan (OHIP), University Health Insurance Plan (UHIP), or the Student Plan is not acceptable as comparable insurance coverage.
Students with comparable coverage can choose to opt out of health.
The comparable coverage accepted could be from parents, spouse, work, government, or band. To be considered a comparable health plan, the alternate coverage must include prescriptions, vision, paramedical practitioners, counselling, and more.
If you upload any dental, Life, or AD&D insurance documents as proof, the opt-out request will be denied, and a new form must be submitted before the deadline providing the required proof.
Approval of the Students opt-out will result in the plan fee being refunded according to the school's policy.
All eligible students who previously opted-out of the Plan will be automatically re-enrolled into the plan every Fall term. If you wish to keep your waiver active, you must apply to opt-out again and provide the proper documentation every year.
NO EXCEPTIONS will be made if the deadline is missed. It is the student's responsibility to pay the plan's mandatory fees, should they miss the applicable opt-out deadline.
Once you complete the opt-out form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting an opt-out request.

Steps to Submitting a Health and Dental Opt-Out Application:

1 Student Information

Complete this section below providing true and correct information. Click NEXT.

2 Health Plan Opt-Out

Scroll down and check yes/no if you wish to opt-out of the health portion of the student plan. Provide the alternate insurance company name and policy number. Click NEXT.

3 Dental Plan Opt-Out

Scroll and check yes/no if you wish to opt out of the dental portion of the student plan. Click NEXT.

4 Proof of coverage

Upload the proper proof of your comparable extended health coverage by attaching documentation displaying the policy information. Click NEXT.

5 Read and Agree to the Terms and Conditions

Click on the checkbox to indicate that you agree to the Terms and Conditions agreement. Click SUBMIT to finish your application.

6 Confirmation email

Check your email and verify if you have received the confirmation email.
If you do not receive this email, you must resubmit the form.

7 Application status

You will receive an email with the status of your application within 4 business days.

Add donotreply@gallivan.ca to your address book. Please do not reply to this email.

Questions? Please contact your Benefit Plan Office: healthdental@westernusc.ca

Health and Dental Opt-Out Form

Please complete all information on the opt out form and we will process your application as soon as we can.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Required Direct Deposit Information

Please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

Fall Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by September 23^rd, 2024 at 11:30 PM

Plan Card Generator
Generate your Plan Card and use it where direct billing to Canada Life is available.

Prescription Search Tool
Find out if your prescription drugs are covered by the student plan.

Plan Claims
Learn more about submitting online or manual claims to Canada Life to get your refund.

USC Benefits Plan Office

Email: healthdental@westernusc.ca
Address: University Community Centre
Room #320
1151 Richmond St
London, Ontario N6A 2K5

General Inquiries Line

Monday to Friday from 8:00am to 7:00pm EST

Phone: 1-877-746-5566 Ext. 7249

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Health and Dental Opt-Out Application

Things to consider when thinking of opting out:

Proof of comparable coverage

Steps to Submitting a Health and Dental Opt-Out Application:

Health and Dental Opt-Out Form

The fall 2023 opt-out deadline is closed.

Health and Dental Opt-Out Form

Student Information

Required Direct Deposit Information

USC Benefits Plan Office

General Inquiries Line

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