Basic Health Care Provision

The Basic Health Care Provision is available to Plan members with Comprehensive Coverage. It provides health care protection (excluding hospital services) equivalent, as far as possible, to that available to individuals living in Canada and covered under a provincial or territorial health insurance plan.

This provision offers reimbursement for reasonable and customary charges for those health care expenses covered under the Ontario Health Insurance Plan (OHIP). The maximum amount payable for the services covered is three (3) times the amount payable under OHIP. Eligible expenses are reimbursed at 100% up to the maximum amount payable, and there is no co-payment.

Eligible expenses

The eligible expenses include:

• Services of a physician, which include:
  • Services performed by a physician in the participant’s home, in the physician’s office or clinic, or in a hospital (as long as the physician is not employed by the hospital)
  • Diagnosis and treatment of illness and injury
  • Treatment of fractures and dislocations
  • One annual health examination
  • Surgery, including surgery performed by a Doctor of podiatric medicine (DPM) when performed in the USA
  • Administration of anaesthetics
  • X-rays for diagnostic and treatment purposes
  • Obstetrical care, including prenatal and postnatal care
  • Laboratory services and clinical pathology when ordered by and performed under the direction of a physician
• Services of an optometrist
• Services of a physiotherapist
• Services of a chiropractor, osteopath, or podiatrist
• Ambulance services

Exclusions

No benefit is payable for:

• Expenses identified in the General Exclusions and Limitations of the Plan
• Services performed by a physician who is a salaried employee of a hospital.
  • Note: An employee posted outside of Canada who has Comprehensive Coverage may be reimbursed for the hospital services under the Hospital (outside Canada) Provision. The Hospital (outside Canada) Provision does not apply to pensioners with Comprehensive Coverage.