What the Plan covers
What does the Plan cover in Canada?
What does the Plan cover in the event of an emergency outside my province of residence?
What does the Plan NOT cover?
How can I verify if an expense is covered or not?
Does coverage under the Plan change if the government plans change?

 


What does the Plan cover in Canada?

QPAT's Health Plan covers the reasonable and customary charges for the eligible expenses listed below, provided they were:

• incurred in Canada due to accidental injury, illness, or pregnancy;
• incurred while the insured person is covered under the Plan; and
• for most expenses, prescribed by a physician.



Eligible expenses
Drugs 
Hospitalization
Rehabilitation or convalescent home
Rehabilitation for alcoholism or another drug addiction
Paramedical care
Vision care
Transportation services (other than ambulance) for remote areas in Canada
Other medical expenses

 

Drugs in Canada

Reimbursement
For 2010: 80% of the first $5,200 in eligible drug expenses per family; this amount is indexed by $200 on January 1 of each year.

100% reimbursement for the rest of the calendar year, once your eligible drug expenses reach the maximum in that year.
Subject to deductible
Maximum per insured person
None
Important notes
The Plan covers only drugs and medicine requiring a written prescription and a valid DIN (Drug Identification Number).

The Plan also covers certain over-the-counter drugs and medication that are not accessible to the public and are directly controlled by the pharmacist (cardiotropic drugs, bronchial dilators, insulin and diabetes tests).

If you live in Quebec, once you reach age 65, you will automatically be covered under the government's universal drug plan for most drugs. Click here for details.

Hospitalization in Canada

Reimbursement

100% of the difference between:

   
• the cost of a semiprivate hospital room; and
   
• the amount reimbursed by government plans for such room
Subject to deductible
No
Maximum per insured person
None; coverage is provided for an unlimited stay in the hospital.

Rehabilitation or convalescent home in Canada

Reimbursement

100% for the daily cost of room and board in a rehabilitation or convalescent home prescribed by a physician
Subject to deductible
No
Maximum per insured person
Up to the semiprivate room rate

No limit as to the number of days
Important note

The home must be duly authorized by an appropriate government body.

The facility must be under the supervision of a physician or registered nurse.

The patient must be receiving curative treatment.

Rehabilitation in Canada (or for U.S.) for alcoholism or another drug addiction

Reimbursement

100% for the daily cost of room and board in a recognized clinic, located in Canada or the United States, specializing in rehabilitation for alcoholism and other drug addiction where the patient actually receives curative treatment, as prescribed by a physician

Subject to the maximum amount indicated below
Subject to deductible
Maximum per insured person

Up to $175 Canadian per day, 35 days per treatment program

One treatment program in a lifetime
Important notes

The clinic must be run by a physician and under the constant supervision of a registered nurse.

This benefit applies only to the Plan participant, not to eligible dependents.

Paramedical care in Canada

Reimbursement

50% for a psychologist, psychiatrist, psychoanalyst, social worker or orientation counsellor

80% for a speech therapist, audiologist or occupational therapist

100% for a physiotherapist, physical rehabilitation therapist, chiropractor, osteopath, podiatrist (chiropodist) or acupuncturist

Subject to the maximum amounts indicated below
Subject to deductible
Maximum per insured person

Psychologist, psychiatrist, psychoanalyst, social worker and orientation counsellor (50%)

 Combined maximum of $1,000 per calendar year for all these professionals
Speech therapist, audiologist and occupational therapist (80%) One treatment per day
Physiotherapist and physician rehabilitation therapist (100%) $35 per visit and one treatment per day
Chiropractor, osteopath, podiatrist (chiropodist) and acupuncturist (100%)

$20 per visit
$30 per X-ray
One treatment per day

Combined maximum of $300 for all these professionals
Important notes

Paramedical care must be given by a person duly authorized by the responsible provincial or federal organization to practice this profession in accordance with the rules of the profession.

A physician's recommendation is not required for these services.

Vision care in Canada

Reimbursement

100% for:

   
• Eyeglasses (frame and corrective lenses), excluding sunglasses or safety glasses
   
• Contact lenses

Subject to the maximum amounts indicated below
Subject to deductible
Maximum per insured person

$100 for eyeglasses or contact lenses per 24 consecutive months

No maximum applies for eyeglasses or contact lenses when:

   
• prescribed for a keratoconus (conical cornea) or as a result of surgery;
   
• satisfactory correction of vision cannot be obtained with eyeglasses; and
   
• the lenses are purchased within 12 months following the surgery.

If you claim the $100 maximum for a given period of 24 consecutive months, you cannot submit a claim for contact lenses that are medically necessary, and vice versa.
Important note

The eyeglasses or contact lenses must be prescribed by an ophthalmologist or an optometrist.

Transportation services (other than ambulance) for remote areas in Canada

Reimbursement

100% for travelling expenses, NOT INCLUDING ambulance service, for insured persons in remote areas who have to undergo medical treatment that cannot be performed in their region
Subject to deductible
Maximum per insured person

$50 per day, maximum $500 per calendar year for travelling expenses in remote areas
Important note This eligible expense must be prescribed by a physician.

Other medical expenses in Canada

Laboratory
Tests
Reimbur-sement

 Laboratory analyses, electrocardiograms, electroencephalograms, radiation treatments and X-rays performed in a commercial establishment 50% first
$500

75% next $1,500
Other
Reimbur-sement

80% of the reasonable and customary charges for the items listed below, subject to the maximum amounts also indicated below

All of these eligible expenses (except dental care) must be prescribed by a physician.
Subject to deductible
Maximum per insured person

Ambulance services (licensed) by air, road or train, and for emergency transportation only

The ambulance can take the insured person either:

   
• to the nearest hospital equipped to provide the required treatment; or
   
• from the hospital, when the physical condition of the insured person precludes the use of any other means of transportation.
No maximum
Artificial limbs and eyes, or external prostheses, if the loss occurred while insured No maximum
Blood and blood plasma No maximum
  Blood glucose monitor purchased for insured persons with diabetes who have an insulin-dependent medical condition One glucometer or reflectometer device in a lifetime
  Breast prostheses (purchase) Up to $300 per
24 months
  Crutches (purchase or rental)

The purchase of crutches requires prior approval from Industrial Alliance.

 No maximum
  Dental care that is:
   
• required as a result of accidental injury to whole, healthy and natural teeth;
   
• provided by a dentist out of hospital while the insurance is in force; and
   
• in accordance with the normal suggested fee for a general practitioner.

All other dental expenses are excluded.

 No maximum, except that the insured person must receive care within 6 months of the accident
  Hearing aids (initial purchase, replacement or repair of hearing aids or any related devices) and the professional services given by a hearing aid acoustician following the purchase, provided they have been prescribed by a physician, audiologist or speech therapist

Batteries are not covered.

No maximum

Note: If you expect the total cost for hearing aids to exceed $1,000, you must obtain the Industrial Alliance's authorization BEFORE incurring such costs.
  Hernial belts, corsets, splints and casts (purchase) No maximum
  Hospital bed (excluding electric beds), rental or purchase

The purchase of a hospital bed requires prior approval from Industrial Alliance.

 No maximum
  Nursing care (services rendered outside a health care facility by a registered nurse or nurse's aide who is unrelated to the insured person and who does not ordinarily reside with the latter) Up to $500 per day, maximum $10,000 per calendar year
  Orthopedic shoes No maximum
  Orthopedic appliances (purchase or rental) other than orthopedic shoes, podiatric apparatus, eyeglasses, contact lenses, and hearing aids, which are obtained from a recognized establishment or laboratory and which are required as a result of a bodily injury or illness

The purchase of orthopedic appliances requires prior approval from Industrial Alliance.

 No maximum
  Oxygen and rental of equipment necessary for its administration No maximum
  Respiratory assistance devices (purchase or rental)

The purchase of respiratory assistance devices requires prior approval from Industrial Alliance.

 No maximum
  Sclerosing injections that are medically necessary Up to $20 per visit
  Support hose (medical elastic stockings) of medium or high compression (more than 20 mm/Hg) purchased due to a venous or lymphatic system deficiency Up to 3 pairs per calendar year
  Therapeutic appliances (purchase or rental) and maintenance, adjustment and replacement expenses for these appliances

Monitoring devices such as dextrometers, stethoscopes, sphygmomanometers or other devices of similar nature are not covered.

The purchase of therapeutic appliances requires prior approval from Industrial Alliance.

 Up to $10,000 in a lifetime
  Wheelchair (non-motorized) purchase or rental

The purchase of a wheelchair requires prior approval from Industrial Alliance.

 No maximum
  Wigs and hairpieces following chemotherapy Up to $500 per calendar year
Important note

Although no specific maximum applies for many medical expenses listed above, reimbursement of ALL eligible medical expenses is based on reasonable and customary charges only.

What does the Plan cover in the event of an emergency outside my province of residence?

QPAT's Health Plan provides the following coverage and assistance in the event of an emergency resulting from illness or an accident:

   
• hospitalization, medical and surgical expenses outside the province of residence; and
   
• medical assistance and other services when travelling outside Canada.

If you plan on travelling, make sure you bring along your Industrial Alliance wallet card. You may also want to include, with your personal travel papers, a printout of the Plan's emergency coverage described below.


Hospitalization, medical and surgical expenses outside the province of residence

The Plan covers the following customary and reasonable expenses in case of emergency. These expenses must be incurred while the person is covered under the Plan. They also must be prescribed by a physician.

Reimbursement

100% for hospital, medical and surgical expenses outside the province of residence of the insured person, in case of emergency

Subject to the maximum amount indicated below
Subject to deductible
No
Maximum per insured person

$4 million in a lifetime
Important notes

Industrial Alliance reimburses only eligible expenses that exceed the amount paid by a provincial health insurance plan, which all insured persons must participate in.

Expenses must be incurred due to a sudden and unexpected illness or to an accident that occurred during any stay outside the province of residence, or during a stay outside of Canada that is expected to last less than 180 consecutive days.

When hospitalized outside Canada, the insured person must get in touch with the Medical Assistance Service as soon as possible. Otherwise, Industrial Alliance has the right to deny coverage for such expenses.

Industrial Alliance may request that the insured person be repatriated or treated elsewhere, unless medical reasons indicate it is unwise to do so. Repatriation must be recommended and planned by the medical assistance company. If an insured person refuses to follow a recommendation for repatriation, Industrial Alliance accepts no responsibility for expenses incurred thereafter.

Medical assistance and other services when travelling outside Canada

Through QPAT's Health Plan, you and your eligible dependents can benefit from the Medical Assistance Service. To participate, you and your insured dependents must also be covered under both QPAT's Health Plan and a government health insurance plan.

How does this service work?

Call 1 800 203-9024 in the U.S. or (514) 499-3747 (collect) elsewhere, if:

   
•
 you are on a vacation or business trip outside Canada that is expected to last less than 180 days; and
     
• you require:
     
  emergency medical assistance following an accident or illness;
     
  legal assistance; or
     
  assistance after losing your luggage or important documents.

The hotline is available 24 hours a day, seven days a week. Multilingual coordinators will put you in touch with a network of specialists to handle travel-related emergencies.

As soon as you—or your insured dependents—are aware of an incident, you must take all reasonable precautions to stop its progression and contact the Medical Assistance Service as soon as possible to indicate the circumstances and the known or presumed causes of the incident. Upon request by the Medical Assistance Service, you must provide a certificate from the attending physician explaining the probable consequences of the illness or the injuries suffered during the accident.

Below are the details on each of the services offered. Be sure to refer to certain exclusions and conditions specific to the Medical Assistance.

Most frequently used services

   
• Medical care
   
• Medical transportation.
   
• Payment of medical expenses and cash advance

Other services include:

• Cash advances
• Emergency medication
• Interpretation of a foreign language
• Key travel information
• Legal assistance
• Loss of luggage or important documents
• Meals and accommodation
• Message board
• Return of deceased
• Return of dependent children
• Return of a family member
• Return of a vehicle
•

Visit from a family member

 
Cash advances

If need be, the Medical Assistance Service will advance cash or provide payment guarantees of up to $1,000 Cdn, for you or your insured dependents to obtain the following services:

• Medical transportation;
   
• Return of dependent children;
   
• Return of a family member;
   
• Return of a vehicle;
   
• Meals and accommodation; and
   
• Visit from a family member.

You must pay back any cash advance to Industrial Alliance according to the exchange rates effective at the time of the cash advance. Industrial Alliance will withhold cash advances from any claim payments, if applicable.
Emergency medication
The Medical Assistance Service will coordinate the search for any dispatch of medication that is unavailable locally but indispensable for a treatment in progress.

The insured person is responsible for the cost of the medication unless it is covered under QPAT's Health Plan.
Interpretation of a foreign language

In case of an emergency, the Medical Assistance Service will provide you or your insured dependents with telephone interpretation services in most foreign languages.
Key travel information

Before, during and after a trip outside Canada, you can obtain key travel information related to transportation, vaccinations and precautionary measures. Simply call:

1 800 203-9024 in the U.S.
(514) 499-3747 (collect) elsewhere.

You will also find these telephone numbers on the back of your Industrial Alliance wallet card.
Legal assistance

The Medical Assistance Service will:

   
• help you find local legal aid for an accident or another cause of defence; and
   
• help you obtain a cash advance from your credit cards, family and friends, to pay for any bail or legal fees.

Loss of luggage or important documents

If your luggage or important documents are lost or stolen, the Medical Assistance Service will help you contact the appropriate authorities.
Meals and accommodation The Medical Assistance Service will reimburse expenses incurred for meals and accommodation in relation to:
   
• the return of dependent children;
   
• the return of a family member; and
   
• a visit from a family member.

These expenses are payable up to $150 Cdn per day for a maximum of seven days.

Receipts must be provided for these expenses before the Medical Assistance Service can issue a reimbursement.
Medical care The Medical Assistance Service will:
   
• upon request by the insured person, organize consultations with general practitioners or specialists to obtain the best medical care available in the area;
   
• assist with admittance to the hospital nearest to the scene of the accident or illness;
   
• assure doctors and hospitals that the Health Plan will cover the expenses;
   
• coordinate the search for any dispatch of medication that is not available locally but that is indispensable for a treatment in progress. The insured person is responsible for the cost of the medication unless it is covered under QPAT's Health Plan.

Medical transportation The Medical Assistance Service will:
   
•
 arrange for transportation or transfer of the insured person:
     
  by any appropriate means that is recommended by the attending physician and that the Medical Assistance Service agrees to;
     
  to a hospital near the scene of the accident or illness, if required by the medical emergency.
     
• organize the return of the insured person:
     
  to his or her residence or to a hospital near his or her residence after initial medical care has been provided;
     
  by an appropriate means of transportation, provided that the return is medically necessary and permissible.

The Medical Assistance Service arranges for the insured person's return using the most appropriate means of transportation: air ambulance, helicopter, commercial airline, train or ambulance.

Industrial Alliance will pay the expenses incurred for transporting or transferring the insured person as described above.
Message board

In case of an emergency, the Medical Assistance Service can relay a message, upon request, to you at your home, office, or elsewhere, or hold messages for you or for family members for 15 days.
Payment of medical expenses and cash advance The Medical Assistance Service will:
   
• make the necessary arrangements to pay any medical expenses covered under QPAT's Health Plan for emergency hospitalization and medical or surgical care outside of Canada;
   
• if need be, advance up to $10,000 Cdn for you and your covered dependents, after reaching an agreement with Industrial Alliance.

You must pay back any cash advance to Industrial Alliance as follows:

   
• in one lump sum;
   
• according to the exchange rates in effect at the time of the cash advance; and
   
• within 90 days following your return to Canada or the return of your insured dependents.

Should you fail to pay back any cash advance, Industrial Alliance reserves the right to deduct such amounts from health claims or any other claims that you or your insured dependents may make from Industrial Alliance.
Return of deceased Should an insured person die, the Medical Assistance Service will take care of all the arrangements and pay up to $5,000 Cdn for:
   
• the post-mortem expenses;
   
• the coffin; and
   
• transportation of the deceased to the place of burial in Canada.

Neither the Medical Assistance Service nor Industrial Alliance will cover funeral expenses.
Return of dependent children If you have children under age 16 who are left unattended as a result of an accident or illness while travelling abroad, the Medical Assistance Service will:
   
• organize their return; and
   
• arrange and pay for economy transportation for the children, with an escort if necessary, to their usual place of residence in Canada.

If the return tickets are still valid, only the additional cost for return transportation will be paid, after deducting the value of the tickets.
Return of a family member If a family member has lost the use of his or her airplane ticket due to an insured person's hospitalization or death, the Medical Assistance Service will:
   
• organize the return of that family member; and
   
• make the arrangements to provide economy transportation for the family member to his or her usual place of residence in Canada.

If the return ticket is still valid, only the additional cost for return transportation will be paid, after deducting the value of the ticket.
Return of a vehicle

The Medical Assistance Service will pay up to $1,000 Cdn to return the insured person's private or rental vehicle to the insured person's residence or the nearest appropriate vehicle rental location.
Visit from a family member The Medical Assistance Service will organize round-trip economy class transportation for a family member to visit an insured person if:
   
• the person is in hospital for at least seven consecutive days; and
   
• the attending physician feels that the visit would be beneficial for the patient.

What does the Plan NOT cover?

The QPAT Health Plan does not cover the following expenses:

• Care and services rendered free of charge or which would be free of charge were it not for insurance coverage or which are not chargeable to the insured person.
•

Care or treatments related to fertility or infertility.
• Contribution to the cost of drugs and
pharmaceutical services (i.e., deductible, coinsurance or premium) that the insured person must pay under any provincial drug insurance plan.
• Erectile dysfunction-realted treatment or medication.
• Expenses resulting from attempted suicide or voluntary self-inflicted injury, while sane or insane.
• Expenses resulting from injury or illness caused by civil unrest, insurrection or war, whether war be declared or not, participation in a riot or active service in the armed forces of any country.
• Expenses that are or would normally be payable or reimbursable under a workers' compensation act, if a claim had been submitted.
• Eye examinations.
   
•

The following products or drugs:

     
  products for esthetic or cosmetic care;
     
  "natural" products;
     
  artificial insemination products.
     
•

Purchase of food or nutritional supplements.
     
•

Purchase or rental of any comfort or massage apparatus, and of domestic accessories that are not exclusively for medical purposes, such as whirlpool baths, air purifiers, humidifiers, air conditioners, and other similar devices.
     
•

Services, supplies, tests, or care required by a third party or received collectively.
     
•

Surgery or treatment that is not medically required and that is for cosmetic purposes or for any reason other than curative.

Note: The Health Plan will reduce all amounts payable by any benefit that:

• is payable or reimbursable under a government plan, a group plan, or an individual plan; or
• would have been payable had the person submitted a claim.

 

Special note about the Medical Assistance Service

Also, regarding medical assistance service outside Canada, the Plan does not cover the following expenses:

   
•

Expenses payable or reimbursable under a government, a group or individual plan, or which normally would have been payable if a claim had been submitted.
     
• Expenses resulting from attempted suicide or voluntary self-inflicted injury, whether the insured person is sane or insane.
     
• Expenses resulting from injury or illness caused by civil unrest, insurrection or war, whether war is declared or not, or participation in a riot.
     
• Surgery or treatment that:
     
  is not medically required and that is for cosmetic purposes or for any reason other than curative; or
     
  exceeds ordinary surgery or treatment given in accordance with normal therapeutic practice; or
     
  is given in relation to an operation or treatment of an experimental nature.
     
•

The portion of the expenses that exceeds reasonable and customary fees for the area in which treatment is provided for an illness of the same nature and severity.
     
•

Care or services rendered free of charge or that would be free of charge were it not for insurance coverage, or that are not chargeable to the insured person.
     
•

Any rest cure or travel for health reasons.

Please note that the doctors, hospitals, clinics, lawyers and other authorized practitioners or institutions to which the Medical Assistance Service directs insured persons are, for the most part, independent contractors. They act on their own behalf and are not employees, agents or subordinates of the Medical Assistance Service.

The Medical Assistance Service and Industrial Alliance are not in any way responsible for negligence or other acts or omissions by doctors, hospitals, clinics, lawyers, or other authorized practitioners or institutions.

The Medical Assistance Service will try to provide assistance in countries with security risks. However, it may not be held responsible for failure to provide medical assistance or for delays caused by strikes, civil wars, invasions, intervention by enemy powers, hostilities (whether war is declared or not), rebellions, insurrections, acts of terrorism, military operations or coups, riots or uprisings, radioactive fallout, or any other situation beyond its control.


How can I verify if an expense is covered or not?

Before you incur an expense, verify:

   
• what the Plan covers and to what extent; and
   
• the list of exclusions.

If you are still unsure, call Industrial Alliance to find out if the expense is covered. You can reach a representative at (514) 499-3800 or 1 800 363-3540.

Industrial Alliance, not QPAT, is responsible for applying the terms of the insurance policy.

 

Does coverage under the Plan change if the government plans change?

QPAT's Health Plan will reflect any applicable modifications to Quebec's Act respecting prescription drug insurance. Otherwise, changes in government plans will not affect benefits under QPAT's Health Plan, unless an agreement is signed by the authorized officers of Industrial Alliance and QPAT.