Purchasing Health Insurance: Five Questions to Ask

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Even though you receive health insurance coverage through your provincial plan, there are products and services that aren’t covered. Individual health insurance can supplement your provincial coverage and protect you and your family from unexpected medical expenses. But after you’ve made the decision to buy additional insurance, where do you start?

Whether you’re purchasing health insurance for the first time or you’ve had a plan before, here are five questions to ask during your search for the coverage that is right for you, your family and your budget.

Are you Eligible?

You won’t be eligible for all the plans available on the market. Some offer guaranteed acceptance, while others provide coverage only if you meet certain criteria. There are plans that determine eligibility based on your current health and medical history, others that only accept members who are coming off a group health plan, and some that restrict coverage based on the individual’s age. Before you spend too much time looking into a particular plan, find out if you are eligible for it.

And there is one more important factor. To qualify for health insurance, you must be covered under your province of residence’s healthcare plan. Read this for more information: Why do I need provincial coverage to qualify for health insurance?

What are the exclusions on your health insurance?

Chances are, you’re not going to find a plan that covers all of the products and services you might need. When purchasing health insurance, take the time to learn what is and isn’t covered. Typically, you will find that plans cover certain services, partially cover others and exclude some altogether. Look at the plans you’re considering to find out if they exclude services you will use. If so, continue searching for a plan that covers the services you need, so you have adequate protection.

In addition to maximums and limitations on what is (and is not) covered by a health plan, benefits are not usually payable for:

  • Charges which are payable under your government health insurance plan or drug manufacturer’s assistance program;
  • Charges or services for aesthetic or cosmetic purposes, except for reconstructive surgery to tissue damaged by disease or injury;
  • Charges for drugs, tests, services, treatments or supplies which are experimental or not medically necessary, or charges to complete claim forms or for missed appointments;
  • Charges in excess of usual, reasonable and customary charges that are typical where you live;
  • Services, equipment and supplies provided in a chronic care, transition ward or psychiatric hospital or institution or long term care facility;
  • Duplicate or replacement prosthetic devices or durable medical equipment, unless the existing item is worn out or changes because of the patient’s condition;
  • Charges for services or supplies due to sickness or injuries resulting from war or participation in any civil commotion or riot or while serving in the armed forces; intentionally self-inflicted injury or injury while committing or attempting to commit a criminal offence.
  • Drugs, medicines, services or supplies which have been self-prescribed, or prescribed by or for family members.

How Much Does it Cost?

Think you can take a look at the monthly premium (the amount you must pay every month to maintain coverage) and know how much a Canada health insurance plan will cost? Think again. There are several different costs associated with purchasing health insurance, and the premium is only the first. In addition to the premium, many plans have copayments/coinsurancewhich is the amount you must pay for services rendered. Be sure to factor in these costs when determining whether or not you can afford a plan.

For more details see Factors that influence the cost of health insurance

How Much Does the Plan Pay for Covered Services?

Most insurance plans will not pay an unlimited amount for your treatment. Once you have reached the plan maximum (which may be based on a calendar or benefit year) for a particular service, the insurance company will stop paying. You will be responsible for any additional costs you incur until your new calendar or benefit year begins. For example, if a plan pays a maximum of $5,000 for prescription drug coverage, you will be responsible for all payments over that amount. Some plans also have lifetime maximums. If you reach the lifetime maximum, you will be responsible for all the costs you incur over the maximum for as long as you are a policyholder. Take a look at the maximums to ensure they’re not too low before purchasing health insurance.

Dental insurance maximums are sometimes difficult to understand. Read this article for more information How do my dental insurance maximums work?

Does it Cover Pre-Existing Conditions?

If you have a medical condition that requires ongoing treatment, it’s critical to find out whether the plans you’re considering cover pre-existing conditions. Some do, and some don’t. If you have a pre-existing condition and your plan does not cover treatment related to pre-existing conditions, you may be responsible for paying for all of the services necessary to treat it.

If you think a health condition you have may be an important factor in your choice of coverage, read this article to learn more Health insurance with a pre-existing-condition

Still have questions?

Click here to browse all of SBIS’s resources with great articles on health, dental and travel insurance. And for personal assistance, call us today at 1-800-667-0429. We’re open from Monday to Friday, 8:45 a.m. to 4:45 p.m. ET. At SBIS, we are always here to help.


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