Menumenu button

Exclusions

Limitations and Exclusions to Extended Health Benefits

No benefit is payable for:
1) expenses for which benefits are payable under a Workers' Compensation Act or a similar statute
2) expenses incurred due to intentionally self-inflicted injuries
3) expenses incurred due to civil disorder or war, whether or not war was declared
4) expenses for services and products, rendered or prescribed by a person who ordinarily resides in the patient's home or who is related to the patient by blood or marriage
5) expenses for which benefits are payable under a government plan
6) expenses for benefits which are legally prohibited by the government from coverage
7) out-of-province expenses for elective (non-emergency) medical treatment or surgery
8) expenses for drugs which, in the insurer's opinion, are experimental
9) expenses for dietary supplements, vitamins and infant foods
10) expenses for contraceptives (other than oral)
11) drugs for the treatment of erectile dysfunction
12) expenses for drugs if they are used for the treatment of infertility
13) expenses for the services of a homemaker
14) expenses for items purchased solely for athletic use
15) dental expenses, except those specifically provided under eligible expenses for treatment of accidental injuries to natural teeth
16) utilization fees which are imposed by the Provincial Health Care Plan for the use of a service
17) expenses for the regular treatment of an injury or disease which existed before the member’s or dependant’s departure from his/her province of residence
18) any other exclusion identified in the policy contract

Limitations and Exclusions to Dental Benefits

No benefit is payable for:
1) any cause for which the insured may apply for and receive protection, exemption or compensation under any Workers’ Compensation Act
2) self-inflicted injuries while sane or insane 
3) war, insurrection or hostilities of any kind, whether or not the insured was a participant in such actions
4) participation in any riot or civil commotion 
5) committing or attempting to commit a criminal offence or provoking an assault
6) any group or policyholder sponsored dental care or treatment
7) any dental care, treatment or supplies primarily for cosmetic purposes
8) failing to keep scheduled appointments
9) file transfers, the completion of claim forms or other documentation
10) any dental treatment for the correction of temporomandibular joint dysfunction
11) expenses for treatment of root canal therapy, inlays, onlays, crowns, veneers, and bridges started prior to becoming an insured member/dependant under this plan
12) replacement of mislaid, lost or stolen appliances
13) expenses for crowns placed on a tooth not functionally impaired by incisal angle or cuspal damage
14) any charges incurred for other than metal only crowns or pontics, posterior to the second bicuspid tooth
15) expenses for full mouth reconstructions for vertical dimension correction or to repair or restore teeth damaged or worn due to attrition or vertical wear or to restore occlusion
16) any services or supplies for implantology, including tooth implantation and surgical insertion of fabricated implants
17) any dental procedure which is not listed in the descriptions of dental benefits indicated herein
18) charges that are in excess of the fees stated in the Dental Association General Dentist Fee Guide applicable to this benefit
19) where coverage for services is provided under any government plan
20) where services would be provided without charge in the absence of this policy
21) any other exclusions identified in the policy contract

Service Members


Find a Practitioner