seCUREme GLOSSARY

Accident: Any sudden and unforeseen event occurring during the policy term, resulting in bodily Injury, the cause or one of the causes of which is external to the victim’s own body and occurs beyond the victim’s control.

Basic Earnings of an Employee: For the purposes of seCUREme  coverage, is the member’s gross earnings or salary including any bonus, or overtime but not including incentive pay.

Basic Earnings of an Owner/Operator: For the purposes of seCUREme  coverage is 75% of 50% of prior average gross business revenue or 75% of prior average net earned income ÷ 12. Gross business revenue does not include cost of goods or wages paid to employees.

Basic Earnings of a Contract Driver: For the purposes of seCUREme  coverage, is 75% of prior average gross business revenue ÷ 12. Gross business revenue does not include cost of goods or wages paid to employees.

Basic Earnings of a Commissionable Salesperson: For the purposes of seCUREme  coverage is defined as the average of the last 2 (two) year’s earnings as declared on their T1 General Income Tax Return.

Benefits: Any covered expenses/services that the Insurer will pay under the seCUREme  policy.

Benefit Maximum: The maximum dollar amount that each benefit will reimburse an insured during a seCUREme  policy year as determined by your seCUREme  Schedule of Benefits.

Chronic Condition: Wherever used for the purposes of seCUREme  coverage means any Injury or Sickness which requires medical attention, monitoring, or treatment for a period exceeding 90 consecutive days.

Continuous Total Disability: Must result from an Injury or Sickness and commence within 30 days after the date of Accident, means the Insured Person’s complete inability during the first 27 months thereof to perform the substantial and material duties of his occupation.

Couple Coverage: For the purposes of seCUREme , coverage that includes the primary Insured Person and an eligible spouse OR eligible Dependent child.

Day Patient: A patient who occupies a Hospital bed or is charged for a Hospital bed.

Deductible: For the purposes of seCUREme  coverage, the deductible shall refer to the dollar amount for which the Insured Person is liable, before any remaining eligible expenses are reimbursed under seCUREme  policy. Expenses eligible to be applied towards satisfying the Deductible are defined as the expenses eligible under the CORE Benefit plan that seCUREme  is attached to. Such eligible expenses could include but are not limited to: Prescription medications requiring a written prescription by a Physician or Dentist and filled by a licensed Pharmacist, Dentistry, Hospital Expenses, Paramedicals, and Private Duty Nursing which is provided as an Out-patient.

Dentist: A practitioner who holds a Doctor of Dentistry degree and is legally registered and licensed to practice dentistry in the country where services within the scope of their license are provided. Dentistry

Dental Fee Guide:

  • Each provincial Dental Association annually establishes a Dental Fee Guide which is used as a basis for determining dental costs. Up until recently, the Alberta Dental Association (ADA) had not published a dental fee guide since 1997. The insurance industry and the ADA have worked Paramedicals together to develop a new Insurance Industry Reimbursement Guide that reflects current reasonable and customary fees.
  • This suggested guide/document outlines over 1,400 dental codes and code descriptors related to specific elements of dental treatment. It also provides suggested fees that serve as a guide only.
  • Many dental plan carriers will base plan coverage on fees and codes within this guide. In some cases, the coverage is based on previous year’s guides (going back a year or more).
    The suggested fee guide serves as a guide only; dentists are not required to follow the guide or any fee schedule. Dentists may use it as a reference to determine a fee for their dental services, as a communication guide to outline treatment options to discuss with their patient and to assist in billing patients’ plans.

Dependent:

  • The spouse or common law spouse (including same sex) of an Insured Person (but excluding those legally separated), and under the age of 70.
  • Unmarried children, step-children, foster children and legally adopted children,whoaredependentontheInsured Personforsupport,providedthat suchchildrenarenotlessthan15days oldandundertheageof19yearsold (orundertheageof25yearsoldprovided itcanbeproventhatthechildis continuing infull-timeeducation).
  • Unmarried children, step-children, foster children and legally adopted children, who are dependent on the Insured Person for support due to physical or mental Disability.

Diagnostic Services: Laboratory tests and x-ray services, radiographs and nuclear medicine procedures used to diagnose and treat medical conditions.

 

Disability: The inability to perform the principal duties of any occupation in relation to your education, skills, training and experience.

Effective Date: The date on which the seCUREme coverage under your policy begins.

 

Emergency: A sudden and unexpected turn of events or change of condition which requires immediate medical treatment and which first manifests itself while this policy is in force as to the Insured person.

Family Coverage: Coverage that includes the primary Insured Person and more than 1 dependent as defined by the seCUREme policy.

Grandfathering: “a clause creating an exemption based on circumstances previously existing”

  • seCUREme has “removed” or “exempted” the Pre-Existing Condition Clause/Requirement for all members that are currently insured under an existing Health Risk Services provided Benefit Plan.
  • For Brokers, seCUREme will “remove” or “exempt” the Pre-Existing Condition Clause/Requirement for Groups of 5 employees or more that are currently insured under an existing Benefit Plan with verification of coverage.

Health Risk Services Inc.: The Third Party Administrator and Claims Administrator appointed by the Insurer – Anahita Insurance Corporation.

Hospital: Any medical or surgical institution which is legally licensed in the country in which it is located and whose main activities are not those of a rehabilitation center, spa, hydro clinic, sanatorium, nursing home or home for the aged. It must be under the constant supervision of a resident Physician.

Hospital Services: Costs for accommodation, nursing, operating theatres, drugs, dressings, diagnostic procedures or any other necessary costs made by the Hospital for medical treatment.

Injury: Any harm to the body caused by an Accident resulting, directly and independently of all other causes, in the Insured Person incurring Medical Expenses.

Inpatient: A patient who occupies a Hospital bed for more than 24 hours for medical treatment and for which admission was recommended by a Physician or Surgeon.

Insured Person/You/Your: An eligible person as defined in the eligibility section of this policy.

Insurer: For the purposes of seCUREme coverage, Anahita Insurance Corporation is the Insurer and Underwriter.

Insuring Agreement: In consideration of the payment of the premium, the Insurers, agree with the policyholder to reimburse up to the limits detailed in seCUREme policy for costs incurred during the policy term subject to all the exceptions, limitations and provisions of the policy.

Medical Appliances: Minor appliances such as crutches, casts, splints, canes, slings, trusses, braces, orthotics and the temporary rental of a wheelchair when prescribed by a Physician or Surgeon.

Medical Expenses: Those medical and related expenses for which coverage is provided under the Extended Health Care Benefits section of this policy which are necessarily incurred as a result of Injury or Sickness while coverage is in force under this policy as to the Insured Person.

Medically Necessary: Any health care service or procedure that a qualified health provider would provide to a patient for the purpose of preventing, diagnosing or treating any Sickness, disease, Injury or its symptoms in a manner that is a) prescribed in accordance with generally accepted standards of care, b) clinically appropriate in terms of type, frequency, extent, site and duration, c) not primarily for the convenience of the patient and d) within the scope of practice of such practitioner.

Mental, Nervous and Emotional Disorders: Mental, Nervous and Emotional Disorders are any disorders that are listed in Chapter V (Mental and Behavioral Disorders) of the International Statistical Classification of Diseases and Related Health Problems 10th Revision by the World Health Organization (WHO).

Nurse Practitioner (NP): Is a registered nurse who is prepared, through advanced education and clinical training, to provide a wide range of Preventative and acute health care services to individuals of all ages.

Outpatient: An Insured Person who receives treatment, including Diagnostic Services at a Hospital, or other medical institution, or at a Physician’s office; where the Insured Person is not admitted or confined to a Hospital bed as an Inpatient or Day Patient.

Overall Maximum Limit: The total lifetime Benefits limit that may be claimed by an insured person. Such limit is indicated in the wording of the seCUREme policy.

Permanently and Totally Disabled: For the purposes of seCUREme coverage, means the Insured Person’s complete inability, after 27 months of Continuous Total Disability as defined in Glossary, to engage in any occupation or employment for which the Insured Person is fitted by reason of education, training or experience for the remainder of his life.

Permanent Total Disability Benefit (PTD): For the purposes of seCUREme coverage , means that after 27 months of “continuous total Disability” and if the Insured Person is then “permanently and totally disabled” as a result of a Sickness or from Injuries sustained from a work or non-work-related incident that occurred while employed and covered under seCUREme policy, the Insurer will pay a Permanent Total Disability Benefit equal to the amount specified in your policy.

Physician’s Assistant (PA): Is a medical professional who works as part of a team with a medical doctor. A PA is a graduate of an accredited PA educational program who is nationally certified and licensed to practice medicine with the supervision of a Physician.

Physician or Surgeon: A legally licensed medical practitioner recognized by the law of the country where treatment is provided and who, in rendering such treatment, is practicing within the scope of his/her licensing and training. A Physician or Surgeon must not be the Insured Person or an immediate family member of an Insured Person.

Policy Year: The Policy Term as indicated on the seCUREme cover page your policy.

Pre-existing Condition: Wherever used in the seCUREme Policy means any Injury or Sickness which requires medical attention, monitoring, or treatment for a period exceeding 90 consecutive days.

Prescription Drugs: drugs, medicines, serums and vaccines which must, by federal law or regulation in the country where incurred, be dispensed only pursuant to a prescription from a licensed Physician or Dentist. For geographical areas where there are no regulatory laws for such substances, eligibility will be determined by Canadian standards as defined by the Canadian Food and Drugs Act and Regulations.

Preventive Service: Services provided to prevent or to diagnose disease prior to the manifestation of symptoms, when performed either in conjunction with a Routine Check-up or as an isolated service.

Prosthesis: a device, external or implanted, that substitutes for, or supplements a missing or defective part of the body.

Reasonable and Customary Costs: Costs incurred for approved, eligible treatment or supplies that do not exceed the standard costs of other providers of similar standing in the same region, for the same treatment of a similar Sickness or Injury.

Sickness: Any illness or disease contracted by an Insured Person which causes the insured person to incur medical expenses.

Total Disability: “Continuous Total Disability”, which must result from an Injury or Sickness and commence within 30 days after the date of Accident, means the Insured Person’s complete inability during the first 27 months thereof to perform the substantialand material dutiesof his occupation.

Total Temporary Disability (TTD): An Insured Person is considered disabled if Sickness or Injury prevents him from performing a substantial portion of the duties he regularly performed for the before Disability started.