Chapter 11 - Travel Health Insurance

Common non-medical risks travellers may face

Child care expenses

Trip cancellation

Medivac to home

Pet return

Return of deceased insured

GHIP’s when outside of Canada

Some provincial/territorial health insurance plans may cover some costs of emergency health services incurred while abroad

Residency requirements for an OHIP card

Ontario is their primary home

Be physically in Ontario for 153 days in any 12-month period

• Out of Ontario for more than 212 days in any 12m period leads to OHIP cancellation (unless applied for exception)

Be physically in Ontario for at least 153 days of the first 183 days after you began living in ON

OHIP coverage for travel within Canada

OHIP covers costs of travellers within Canada for physician and public hospital services

OHIP extends coverage for first 3 months for OHIP holders when moving to a new province

Will not pay for non-medical expenses like medically relevant transportation

OHIP coverage for travel outside Canada

OHIP will reimburse a portion of medical costs from outside Canada (called Travelers program)

Two kinds of out-of-country services that OHIP may somewhat fund:

• out-of-country emergency health services

• prior-approved out-of-country health services

Requirements for Travelers program

Ontarians qualify for the Travelers program if they: have a valid OHIP card, meet physical presence requirements

Treatment or service must meet criteria:

• must be medically necessary

• must be provided at a licensed hospital or health facility

• must be for an illness, disease, condition, injury that is:

  • acute and unexpected, not pre-existing, requires immediate treatment

What the Travelers program covers

For doctor services, OHIP will pay the lesser of:

• the actual amount billed by doctor who treated the insured

• rates listed in and paid to Ontario physicians in the Ontario schedule of benefits for physicians

For emergency outpatient services, OHIP will pay the lesser of:

• up to $50 per day

• amount billed by the hospital

For emergency inpatient services, OHIP will pay up to:

• $400 per day for services provided in: operating room, coronary care, ICU, neonatal/pediatric unit

• $200 per day for lower levels of care

Doctor recommended care outside Canada

OHIP will cover if there is pre-approved written approval from the Ministry of Health

To obtain funding form OHIP, the treatment must:

• be performed at a hospital or licensed health facility

• not be experimental or research

• be generally accepted as appropriate treatment

• not be performed in Ontario, or is performed in Ontario but delays could be fatal

Non-medical expenses like travel, accommodation, meals are not covered

Kidney dialysis while outside Canada

OHIP provides an exception for patients who require kidney dialysis while traveling outside Canada

OHIP will reimburse a max of $210 per treatment with no max number of treatments

Other sources of emergency THI coverage

Credit card companies - usually only premium cards (excludes pre-existing conditions, limit on trip length, sports injuries, most have a max age of 65)

Employee group benefits - usually similar restrictions as above

OAP 1, AB - only within US and Canada as stated on OAP 1 (only auto accidents)

• Insurer will deduct any collateral benefit payments from the compensation payable to insured

Collateral benefits

Financial aid that a person receives for an accident that is not from the third party or their insurer

(Disability plans, workers' compensation, or government benefits.)

THI is provided to travellers by a partnership of 3 parties

Distributors - intermediaries that market the THI products (credit card companies, travel agents, financial planners, etc.)

Underwriters - carriers who actually indemnify the insured in case of a claim

Third-Party administrator - contracted party that handles the claim management and return the insured to health and/or Canada

Inbound THI

THI for travelers coming into Canada

There are also inbound policies for non-travelers to Canada like foreign workers or students

Outbound THI

Single trip plans - covers fixed number of days for a trip

Frequent traveller plans - covers any number of short term trips in one year

Trip lengths and total travel days are limited

THI coverage - Emergency medical services and extended health care benefits

Includes: direct payment to hospital/doctors, ambulance services, lab fees, appliance (wheelchair, crutches), outpatient services, out-of-pocket expenses, child care attendants, air ambulance where necessary

THI coverage - Trip cancellation, interruption, delay

Generally covers an accident or illness of: insured, members of immediate or extended family, a travelling companion or business associate

Cancellation: if the trip must be cancelled prior to departure due to death/serious injury, returning non-refundable portion of trip

Interruption: if the trip is interrupted part-way through, returning non-refundable portion

Delay: if trip is delayed due to emergency (weather, mechanical breakdown)

Other misc coverages may be added - pet return, rental car collision, automobile return

Extension of THI coverage periods

Voluntary extension - must declare that there has been no change in health

Involuntary extension - insured is not medically capable of returning

Automatic extension of 72 hours without extra premium if reason is medical, weather

THI exclusions

Most common:

• Travel advisories: political instability, natural disaster, heath emergencies

• Sports injuries: scuba, bungee jumping, free soloing, rodeo, aircraft able to carry less than 6

• Pre-existing medical conditions: medically recognized complication/condition, change in health where the insured consulted a physician, was hospitalized, prescribed a new medication

Formal diagnosis is not required to constitute ‘pre-existing’ as the existence of abnormal symptoms is enough

Some insurers may void all coverage if the pre-existing condition is not disclosed

Other common exclusions of THI

Sickness or injury:

• occurring outside policy term

• resulting from non-compliance of medical treatment

• which does not relate to an emergency

Non emergency hospital or emergency treatment

Continuing medical treatment

Pregnancy, childbirth, miscarriage

• pregnancy complications

• birth while travelling

Suicide/self-inflicted injury

Illegal or negligent act

Air travel with seating of 6 or less

Civil disorders

Expenses due to: early/delayed return home when the insured knew of the potential risk of this before the trip, or a trip where the insured visits someone sick and it worsens or death occurs

Coordination of benefits with other plans

Co-ordination of benefits clause is to ensure that the insured is only being compensated to 100% of loss, not anymore, upholding indemnity

THI benefits are generally paid in excess of OHIP’s policy

THI is usually second payor

Insurers can recover costs given to you if there is a mistake in property portion being paid by them

Coordination of benefits with a negligent party’s insurer

THI policies have a subrogation clause so the THI insurer may recover costs from a negligent third party

THI application process

Eligibility questionnaire, additional pre-existing medical condition questionnaire if necessary

Online, over phone, through broker

UW may decide to approve, decline, or approve with limited benefits or capped amounts payable

Medical questionnaire

Date of application

Applicant’s agreement, understanding, authorization

Claims management of THI’s

Toll-free service numbers to report claims

TP admins will help with assisting in obtaining care, contact family for insured, contact health care provider to outline coverage of insured, arrange transportation

Claims assessment of THI’s

Claims assessor reviews the claim and pays/declines/defers for further review

Deferral to pay may be due to insufficient info, possible fraud, possible errors in invoices

THI’s subrogation of other carriers

If the insured has other plans that cover the accident as well, the THI insurer is allowed to collect funds from the secondary insurance policies

Questions to ask when broking THI

Inbound or outbound

Type of trip

Trip duration/frequency

Applicant’s age

Travel companions

Pre-existing conditions

Sports/activities during the trip