Medical Insurance

There are two options under the International Student Medical Plan (ISMP): the Basic Plan and the Comprehensive Plan. Please check with your school advisor to find out which Plan applies to you.

Basic Plan

A long list of medical-related expenses are covered under the Basic Plan, including doctor’s services, hospital accommodation, vision care, paramedical services, ambulance services and extensive emergency dental services. Prescription drugs are only covered when admitted to a hospital and prescribed by the attending physician.

Comprehensive Plan

In addition to the medical expenses covered by the Basic Plan, the Comprehensive Plan includes coverage for prescription drugs. It reimburses plan members 100% for their eligible prescription drug expenses, ambulance services, extensive emergency dental services, and preventative vaccinations.

If a student becomes ill or needs medical attention, the ISMP relieves the added stress of finding the right care. Administrators are provided with a list of preferred health care providers in Canada to share with students when they need a referral to a hospital or doctor.

The plan provides coverage up to a maximum of $500,000 per Insured Person, per 12 consecutive months. Reimbursement will be determined in accordance with the terms, conditions and allowances provided under the Provincial Health Insurance Plan Schedule of Benefits in effect on the date the charges are incurred.

Reimbursement of benefits will be made only upon the submission of verification from the hospital, attending physician or surgeon that the services claimed were rendered. The services outlined in this section are provided, when medically necessary, for treatment of an illness or injury, subject to the exclusions and conditions of coverage. Refer to the specific sections for details about coverage. Certain maximums and restrictions may apply.

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Hospital Services

• emergency room services and out-patient charges;
• standard ward accommodation, to a maximum of 2.5 times the hospital’s interprovincial rates. However, the first four days of an emergency confinement will be paid at 100% of the actual charge;
• semi-private room accommodation;
• private room accommodation when certified as medically necessary in writing by the attending physician;
• meals which form part of the hospital accommodation;
• nursing services, when provided by the hospital;
• laboratory and x-ray diagnostic procedures;
• use of operating and delivery rooms, anaesthetic and surgical supplies, use of radiotherapy facilities and respiratory equipment, use of home renal dialysis equipment or home hyperalimentation equipment, including supplies and medications available from the hospital and prescribed by a staff physician of that hospital;
• services rendered by any person paid by the hospital;
• services for occupational therapy, physiotherapy, speech therapy and diet counselling when prescribed by a physician and provided in an approved Canadian hospital;
• for elective surgical procedures, the Insured Person’s physician or surgeon must submit a treatment plan with complete details, in advance of receiving the treatment, in order to determine the extent of coverage provided by the plan.

Psychiatric Hospitalization
If under the contract Emergency Hospitalization is required for psychiatric treatmens, benefits are payable to a lifetime maximum of 30 days.

A preferred provider network of hospitals is available throughout Canada. Please contact your school administrator for further details.

Cowan must be notified by all service providers upon admission to determine the eligible medical expense.

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Physicians’ Services

Payment will be limited to 100% of the amount payable according to the schedule established by the Medical Association of the Insured Person’s province of residence.

• physicians’ services in the home, at the physicians’ office, at the hospital or any other institution;
• diagnosis and treatment of an illness or injury, and treatment of fractures and dislocations;
• surgery, including the administration of anaesthetics;
• obstetrical care, including pre and post-natal costs will only be covered when the onset of pregnancy commences up to 90 days prior to the effective date of coverage;
• one annual health examination;
• elective surgical procedures (the Insured Person’s physician or surgeon must submit a treatment plan with complete details, in advance of receiving the treatment, in order to determine the extent of coverage provided by the plan).

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Diagnostic Laboratory And X-Ray Services

• x-rays for diagnostic and treatment purposes;
• laboratory services and clinical pathology, when ordered by a physician and performed in an approved laboratory.

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Ambulance Services

Reasonable and customary charges for emergency ground ambulance and, with prior approval, medically necessary in-province air ambulance service to the nearest available hospital when confirmed as having been essential by a physician or by a designated hospital official. Reimbursement for both air and ground ambulance service will be limited to the maximum specified in the Provincial Health Insurance Plan Schedule of Benefits. The user fee is an eligible expense.

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Vision Benefit

Charges for an eye examination by a licensed medical doctor, ophthalmologist or optometrist for each Insured Person, once per 12 consecutive months.

Reimbursement is limited to the reasonable and customary expense as determined by Manulife Financial.

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Paramedical Services

Charges for treatment by a physiotherapist, chiropractor, osteopath or podiatrist will be paid up to a maximum of $500 per 12 consecutive months per category of practitioner.

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Emergency Services Outside Of Province Or Canada

Benefits are payable only when the services are obtained due to an emergency illness or accident or when medical evidence is provided in advance and approved by Manulife Financial, when that treatment is not available in the Insured Person’s province of residence.

The services are limited to those specified under Hospital Services, Physicians' Services, Diagnostic Laboratory and X-Ray Services, Ambulance Services, Vision Benefit and Paramedical Services. Reimbursement is limited to that which would have been paid by the Provincial Health Insurance Plan, had the Insured Person been insured thereunder.

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Nursing Homes

When the Insured Person needs regular medical supervision as well as nursing and personal care on a 24-hour basis, the plan will pay a portion of the standard ward costs in a licensed nursing home.

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Chronic Hospital Care

Chronic care is available in a hospital or approved nursing home, when prescribed by a physician, for those who have long-term illnesses or disabilities that cannot be treated at home. After 60 days, patients contribute to the cost of their room and board.

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Home Care

Health care services on a visiting basis in the Insured Person’s home when the doctor specifies that a professional health service is needed. A patient’s home situation and health condition must meet certain criteria.

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Medically Necessary Dental Care In Hospital

Dentists’ fees for the surgical removal of impacted teeth, or when hospitalization is medically necessary as determined by a medical doctor or dental surgeon and the procedures are performed in an approved hospital by a dental surgeon who is a member of the hospital’s staff. A treatment plan with complete details, must be submitted in advance of receiving the treatment, in order to determine the extent of coverage provided by the plan.

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Cleft Lip And Palate Assistance Program

Cost of specialized dental treatment for children and young people with cleft lip and palate.

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Additional Dental Services

(1)    Dental Accident

Dental care provided by a dentist to repair or replace permanent natural teeth damaged as a result of a direct external accidental blow to the mouth (and not by an object intentionally placed in the mouth) that occurs while the Insured Person is covered under this plan.

Treatment must be completed within 90 days following the date of the accident.

Benefits will be based on Dental Association Suggested Fee Guide for General Practitioners in effect in the Insured Person’s province of residence up to a maximum reimbursement of $2,500 per occurrence.

Implants and implant-related or supported services will not be covered.

Pre-determination of Dental Accident Benefits

A treatment plan with complete details, must be submitted in advance of receiving the treatment, unless emergency treatment is immediately required to alleviate pain, in order to determine the extent of coverage provided by the plan.

(2)    Wisdom Tooth Extraction

Reimbursement for the cost of extracting wisdom teeth, when performed outside a hospital, up to a lifetime maximum of $500 per Insured Person.

(3)    Treatment for Abscesses and Infections

Reimbursement for the cost of treating dental abscesses and infections up to a lifetime maximum of $500 per Insured Person. Treatment must commence at least 6 months after the Insured Person’s effective date of coverage.

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Assistive Devices Program

Cost of certain specialized aids and supplies required by disabled persons as governed by the assistive devices program of the Provincial Health Insurance Plan, with prior approval.

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Repatriation

If the Insured Person is diagnosed as terminally ill (with 12 months or less to live) and the medical condition is stable, or if the Insured Person dies, the plan will pay the actual cost of returning the Insured Person or remains by the most direct route to the air terminal nearest the Insured Person’s residence in his/her home country, to a maximum of $10,000 (expenses must be considered reasonable by the insurer compared to prices generally charged for such services). Eligible expenses include economy airfare for the Insured Person (or stretcher, if required) and return airfare for a qualified medical attendant (if certified as necessary by the attending doctor), including, if required overnight hotel and meal expenses for the medical attendant. In case of death, expenses include preparation and transportation of the remains, including cost of the casket and specialized equipment, to a $2,000 maximum within the overall $10,000 maximum.

If such terminally ill person refuses repatriation, the person will not be allowed to renew his coverage and instead, any further expenses payable under the plan will be limited to the said $10,000 maximum.

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Drugs And Medicines (Reimbursed At 100%) - Comprehensive Plan only

Charges for injected allergy sera, drugs and medicines as defined herein and listed in Manulife Financial Formulary One, which by law require the prescription of a physician, dentist or hospital. This includes extemporaneous preparations provided at least one of the ingredients is eligible as defined.

Charges for the following diabetic supplies, provided the plan administrator is given a receipt or claim form from the provider: insulin, needles, syringes and chemical testing agents.

Receipts for drugs and medicines must show:

• the name, strength and quantity of the drug or medicine
• the prescription number
• the drug identification number (DIN)

Charges for Immunization for Hepatitis A & B only, provided it is a requirement of the student’s course of studies, limited to a maximum of $150 per Insured Person.

No coverage is provided for:

• vitamins (other than injected vitamins), vitamin/mineral preparations, food supplements, patented medicines, general public (G.P.) products and over-the-counter drugs or medicines, whether or not prescribed;
• smoking cessation aids;
• oral contraceptive drugs;
• fertility drugs;
• that part of any one prescription for drugs or medicine that is in excess of a 30 day supply, unless prescribed while a hospital inpatient;
• preventive drugs (vaccinations);
• Accutane™ (acne treatment);
• Rogaine™ (hair growth stimulant).

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Self-Inflicted Injuries, Suicide And Attempted Suicide Provision

Charges for the following will be limited to a lifetime maximum of $20,000 per Insured Person:

• in-patient and out-patient hospital services (including emergency room charges);
• ambulance services;
• psychiatry services;
• nursing and home support (including assessment charges);
• out-patient treatment programs that would be provided under the Provincial Health Insurance Plan.

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Return Home Benefit

The insurer reserves the right, as reasonably required, to transport an insured person to his/her country of origin if:

1. the insured is unable to continue his/her studies due to a covered sickness or injury or
2. the insured has a serious illness requiring ongoing treatment

If the insured refuses to be transported when declared medically or mentally fit to travel, any continuing costs incurred after the insured’s refusal will be limited to a $10,000 maximum.

The payment of any costs above the $10,000 limit will become the responsibility of the insured.

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Exclusions

No benefits are payable for:

• any charges above those specified in the schedule of fees of the Provincial Medical Association;
• any in-patient hospital ward charges above 2.5 times the hospital’s interprovincial rates, except in case of an emergency as previously outlined;
• hospital visits solely for the administration of drugs;
• charges for dental care (except in hospital);
• eyeglasses, artificial limbs, crutches, special braces or other such aids (unless covered by the assistive devices benefit listed under Assistive Devices Program);
• private-duty nursing fees;
• drugs, whether prescribed or not (unless administered during a hospital stay);
• transportation charges other than approved ambulance services;
• medical examinations or certificates required for applications for employment or the continuance of employment, life insurance or admission to camps, recreational activities or for immigration purposes;
• cosmetic surgery, unless medically necessary and as the direct result of an accident that occurred while the person was covered under the plan;
• acupuncture;
• prenatal classes;
• completion of forms or other documentation;
• advice by telephone;
• any health service other than those provided by approved hospitals or practitioners as specified herein;
• group examinations, immunizations or inoculations (unless requested due to special circumstances and normally covered under the Provincial Health Insurance Plan);
• charges outlined under Self-Inflicted Injuries, Suicide and Attempted Suicide Provision which are in excess of a lifetime maximum of $20,000 per Insured Person for self-inflicted injuries, suicide or attempted suicide;
• conditions resulting from participation in professional sports;
• conditions resulting from war, whether declared or not, hijacking or terrorism, riot, civil commotion or insurrection or while the Insured Person is serving in the armed forces of any country;
• charges incurred by the Insured Person for which he/she is entitled to obtain benefits or reimbursement under any other plan, or which would be provided without charge in the absence of coverage under this policy;
• the Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) or Aids Related Complex (ARC);
• charges for Oncology treatments as an inpatient or out patient are limited to $25,000 per lifetime; or
• charges for Obstetrical care, including pre and post-natal costs, if the onset of pregnancy commences more than 90 days prior to the effective date of coverage.

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Coordination Of Benefits

The Manulife Financial plan includes a Coordination of Benefits provision. If the Insured Person has similar benefits through any other insurer, the amount payable through this plan shall be coordinated as follows, so that payment from all benefit plans does not exceed 100 percent of the eligible expense. Where both spouses of a family have coverage through two benefit plans, the first payer of each spouse’s claims is their own benefit plan.

Any amount not paid by the first payer can then be submitted for consideration to the other spouse’s benefit plan (the second payer).

Claims for dependent children should be submitted first to the benefit plan of the spouse who has the earlier birthday in a calendar year, and second to the other spouse’s benefit plan. When submitting a claim to a second payer, be sure to include payment details provided by the first payer.

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Claims

As a general rule, claims will be paid directly to the provider. However, in exceptional situations, the insured person may be required to pay the provider. In such cases, eligible expenses paid will be reimbursed to the Insured Person.

For all eligible expenses, completed claim forms, with itemized original receipts or statements (not photocopies), must be sent to:

Written proof of claim must be received by Cowan
not later than six months following the date the claim was incurred.

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Termination Of Benefits

Coverage for the Insured Person and their dependents ends on the earliest of the following:

• the last day of the month for which premiums have been paid;
• the Insured Person’s 65th birthday;
• the last day of the month in which a dependent ceases to be an eligible dependent;
• the day the person permanently leaves Canada;
• if authorization documentation becomes invalid for any reason; or
• if it is determined that there has been fraudulent use of the coverage card.

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Special Extension Of Benefits

If coverage would otherwise terminate while the Insured Person is hospitalized, benefits for that Insured Person will continue to be paid, until the earlier of

• the date the Insured Person is released from hospital; or
• the 31st day following termination of coverage.

This extension of benefits only applies to the Insured Person who is an International Student, not their dependents.

The above summarizes the important features of the benefit plan, is prepared as information only, and does not, in itself, constitute a contract. The exact terms and conditions of the benefit plan are described in the Benefit Contract held by your educational institution.

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