Sickness, accident, and disability insurance

To print, You fall ill or you are the victim of an accident, and the costs are piling up: the ambulance, the medication, the crutches… To make matters worse, you are forced to stop working for several weeks. 

How can you protect yourself against such situations and the resulting financial problems? Health insurance, disability insurance, salary insurance, here is a little guide to understand and sort it all out.

The different categories of health and accident insurance

There are two health and accident insurance schemes: the public scheme and the private scheme.

The public plan

The federal and provincial governments have provided different basic protection in the event of illness or accident. These public insurances cover in particular the care received in a hospital, the costs of consultation with health professionals, and the cost of medication.

Here are some examples of government programs that protect in the event of illness or disability:

In Quebec:

  • the public health insurance plan of the Régie de l’assurance maladie du Québec(RAMQ);
  • the workers’ compensation program of the Commission for Standards, Equity, Health and Safety in the Workplace of Quebec(CNESST);
  • tea Retraite Québec(QPP) plan;

At the federal level:

  • Tea Employment Insurance Plan;
  • Tea Canada Pension Plan(PPC).

Attention! The remainder of this capsule does not deal with the public insurance plan any further.

The private plan

It may be advantageous to obtain private insurance since the public plan only applies in a few situations and only offers basic protection.

Private insurance can be purchased individually or offered as part of a group insurance plan in the workplace.

The protection offered by private health and accident insurance often varies from contract to contract. It covers certain expenses that are not covered by the public plan or that are only partially covered, such as:

  • medication;
  • expenses related to a hospital stay;
  • certain prostheses;
  • ambulance costs;
  • certain medical care such as physiotherapy and osteopathy.

Sickness and accident insurance can also include disability insurance, also known as salary insurance. This insurance protects you against the possibility of a loss of income caused by an accident or an illness that prevents you from working.

You can also request that your private insurance provide you with special protection in the event of “serious” illnesses, such as cancer or a heart attack.

The different steps to obtain private health and accident insurance

Choosing who will be the insured person

You can take out health and accident insurance for yourself or another person. You are then called the “policyholder” and the person chosen is called the “insured”.

If you are taking out insurance for another person, you must first obtain their written permission. However, this permission is not necessary if it is a person whose health is of interest to you. For example:

  • your partner;
  • your child or that of your spouse;
  • your grandchild or that of your spouse;
  • your father or your mother;
  • one of your grandparents;
  • a person who contributes to your support or education;
  • your attendant;
  • your staff;
  • another person whose life or health is of financial interest to you (such as a business partner) or moral interest (such as a close friend).

Choose who will receive the insurance benefit

You can choose the “beneficiaries” of the insurance, ie the person or persons who will be able to receive the insurance indemnity if the insured is the victim of an illness or an accident.

You are free to choose the person who will be the beneficiary of the insurance. You can be this beneficiary yourself. You can even choose someone who does not yet exist, such as your “future child”.

Insurers generally require that the beneficiary have some connection or interest with the insured.

Attention! If no beneficiary has been specified in the insurance contract, it is the person who concluded the contract (the “policyholder”) or his heirs who may receive the insurance indemnity.

Change the person who will receive the insurance benefit

In principle, you can change the beneficiary or beneficiaries of your health and accident insurance contract. All you have to do is notify your insurer, in writing, of your decision.

However, two situations require you to obtain the permission of the current beneficiary before making this change:

  • when a statement in the contract indicates that the “beneficiary designation is irrevocable”; Where
  • when the current beneficiary of the insurance is your married or civil union spouse unless this designation is “revocable”.

It is always possible to change a beneficiary that you have identified in your will. Then you don’t need his permission, even if you find yourself in one of the two situations mentioned above.

Declare the true state of health of the insured person

In your initial declaration of risk, you must declare the true state of health of the insured. This may therefore be your state of health or that of the person you have chosen to insure.

You must answer the insurer’s questions to the best of your knowledge and in all honesty. This means that you should not lie or avoid revealing important details, such as the fact that you are a smoker or that you have already had a heart attack.

If you do not declare the true state of health of the insured, the insurer could ask a court to cancel your health and accident insurance contract.

Attention! As soon as the contract begins to protect you, you are no longer obliged to inform the insurer if the state of health of the insured changes.

Declare the risks related to the employment of the insured person

In your initial declaration of risk, you must declare the risks linked to the insured’s employment that may have an impact on his health (this is called “occupational risk”). It can for example be the fact of working in a production line and always making the same movements.

Once the contract has started to protect you (see below), the indemnity and premium can be changed if the “occupational risk” changes for 6 months or more. It may therefore be in your interest to inform your insurer of such a change.

Declare the actual age of the insured person

In your initial declaration of risk, you must declare the actual age of the insured. It can therefore be your real age or the real age of the person you have chosen to insure.

If the age you declare is not the actual age of the insured, the insurer may adjust:

  • the amount of the insurance indemnity by establishing the ratio between the premium you have already paid and the one you should have paid according to the actual age of the insured; Where
  • the amount of the premium according to the actual age of the insured.

It is, therefore, possible that the indemnity decreases or that the amount of the premium increases according to the actual age of the insured.

The start of protection

Your health and accident insurance usually begins to protect you when you receive your “insurance policy”, ie the hard copy of your contract.

If the insurer accepts your proposal without modification and reservation, it can also give your insurance policy to one of its representatives, who must then give it to you. In this case, your insurance begins to protect you as soon as the representative receives it.

pay insurance

The sums of money that you must pay to your insurer to take advantage of accident and sickness insurance are officially called “premiums”. They vary, among other things, according to the type of insurance (disability, critical illness, etc.), the scope of the risks covered as well as the value of the indemnity and the deductible.

You must pay the premiums at the time provided for in the insurance contract. If you do not pay your premiums, the insurer may terminate your insurance contract by giving you at least 15 days written notice.

Receive insurance compensation

If an event provided for in the contract occurs, for example, an illness or an accident, the holder, the insured, or the beneficiary must:

  • within 30 days of becoming aware of the event, send a notice to the insurer to inform it; and
  • within 90 days of becoming aware of the event, send all the information he has concerning what happened. This is often a medical report or the medical file of the insured.
  • Attention! The insurance contract may provide for longer periods, which is to your advantage.

After receiving the notice and the information, the insurer has 60 days to pay the indemnity to the beneficiary.

However, if the insurance covers the loss of wages caused by a disability (an injury or illness preventing work), the insurer must pay the indemnity:

  • 30 days after receiving the notice and information; Where
  • if the contract provides for a waiting period (ie a waiting period before receiving the first benefit), 30 days after the expiry of this period.

Important! Usually, the insurance does not cover all the costs related to an illness or an accident. In addition to providing maximum amounts beyond which you will no longer be reimbursed, the contract may require you to:

  • to incur a certain amount of money before being entitled to reimbursement (this is called a “deductible”), and
  • to bear a certain percentage of the costs. For example, the insurer could limit itself to reimbursing you for 80% of the costs you have paid.

The end of protection

The health and accident insurance contract ends and ceases to protect the insured at the time provided for in the insurance contract or at the time subsequently agreed with the insurer.

It also ends if you do not pay your premiums despite the 15-day notice sent to you by the insurer.

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