General Exclusions And Limitations

No benefit is payable for:

  1. Expenses that are payable under a Workers’ Compensation Act or similar legislation, or by any government agency.

  2. Expenses for services and supplies, rendered or prescribed by a person who is ordinarily a resident in the patient’s home or who is related to the patient by blood, marriage or common-law partnership.

  3. Expenses for services or products for cosmetic purposes only, or for conditions not detrimental to health, except those required as a result of accidental injury.

  4. Expenses for services or products normally rendered without charge.

  5. Expenses for services rendered in connection with medical examinations for insurance, school, camp, association, employment, passport or similar purposes.

  6. Expenses for services provided by a physician licensed and practicing in Canada when the participant is eligible to be insured under a provincial/territorial health insurance plan (unless otherwise stated in the Plan provisions).

  7. Expenses for experimental products or treatments, for which substantial evidence provided through objective clinical testing of the product’s or treatment’s safety and effectiveness for the purpose and under the conditions of the use recommended does not exist to the Administrator’s satisfaction.

  8. Expenses for benefits which are legally prohibited by a government from coverage.

  9. The portion of charges which are payable under a provincial/territorial health insurance plan, a provincial/territorial drug plan, or any provincially/territorially sponsored program, whether or not the participant is participating in the plan or program.

  10. The portion of charges for services rendered or supplies provided in a hospital outside of Canada that would normally be payable under a provincial/territorial health or hospital insurance plan if the services or products had been rendered in a hospital in Canada. This limitation does not apply to the eligible expenses under the Hospital (outside Canada) Provision and the Extended Health Provision (Out-of-Province Benefit).

  11. The portion of charges which is the legal liability of any other party.