Most Often Asked Questions

We are a small company… can we afford a Group Benefits Plan?

The simple answer to this question is YES. There are options available to every employer, which can be tailored to both their needs and their budget. Exploring options and costs is the first step to ensuring the health and well being of both owners and employees.

What expenses can I claim under my Group Benefits Plan, my Health Care Spending Account or my Cost Plus Account?

For a list of legally reimbursable medical and dental expenses refer to Canada Customs & Revenue Website – www.ccra-adrc.gc.ca – go into “forms & publications” – download interpretation bulletin IT519R2

When must an employee enroll into the company’s Group Benefits Plan?

All employees meeting plan eligibility, as outlined under your plan (ie. actively working X hours per week, after X months of employment) must be enrolled in a group plan within 30 days of eligibility. An employee can choose to waive health and/or dental coverage only if he/she has coverage under a spousal plan, but must be enrolled within 30 days of eligibility for all other benefits.

What if the employee is late enrolling?

If an employee is not enrolled within 30 days of eligibility, he/she is deemed a late enrollee and medical underwriting is required. This means risk of denied or decreased coverage. Employers should be vigilant about the timing of enrollments to avoid legal responsibility for providing employee coverage.

What happens when an employee’s status changes?

Changes to an employee’s status, i.e. marital, birth of a child, loss of spousal coverage, should be changed with the carrier within 30 days to avoid risk of denied or reduced coverage.

How do I change or update a beneficiary?

The employee is required to sign a beneficiary change form (provided by the carrier). As the carrier is legally bound to the named beneficiary, regardless of status changes and any presumed intention, it is extremely important that employees be reminded to update their beneficiary should their status change.

How does co-ordination of benefits work?

Individuals may enroll for family health and dental coverage under both spousal plans. Claims are submitted to their own carrier first, with any balance submitted to the spousal plan. For children, claims are submitted to the family plan of the parent with the first birthday in the year, and any unpaid balance to the other spousal plan.

How long do I have to submit claims?

All plans have a limitation period for submission of claims. Most carriers vary from 6 months to 12 months. Employees should ensure timely submission of claims, otherwise they could be denied.

I am travelling out of country – do I have coverage?

The majority of benefit plans provide up to $1million for emergency out of country claims. Anyone with a chronic condition should have their doctor’s supportive documentation that the condition is under control and he/she is medically fit to travel. If an emergency arises while out of the country, employees should immediately contact their 1-800 # for guidance. The out of country provider will assist the employee and determine the next steps, i.e. medical procedures, return to Canada, etc.

I have an overage dependent still in school. Is that student covered?

Most plans cover dependents to age 21 and from age 21 to 24 if in full time attendance at a post secondary institution. It is important for an employee to update their plan administrator of the dependent student status. Some carriers require proof, by way of a college/university receipt to continue coverage.

I have an overage student studying outside of Canada. Is that student covered?

Most plans cover dependents to age 21 and from age 21 to 24 if in full time attendance at a post secondary institution, including out of Canada. It is important for an employee to update their plan administrator regarding the dependent student status, as well as advising OHIP as OHIP will continue to be the first payor. The student should contact the out of country provider through the 1-800 # for guidance. The out of country provider will assist the student and determine the next steps, i.e. medical procedures, return to Canada, etc.

My salary has increased – do I qualify for more coverage?

All plans cap the amount of life insurance, accidental death and disability. It is imperative for the plan administrator to update salaries with the carrier to ensure employees are covered for their eligible amounts.

Our company has an employee who is not able to work – what do we do next?

All plans have an expiry date for filing of disability claims. Regardless of whether the employee might return to work, salary continuance or vacation pay, or if the claim is a long term WSIB claim, the LTD claim should be filed approximately 8 weeks into any absence.

Why…

Often there is an expectation of return to work, which does not happen
Any delay in filing the claim could result in an employee receiving no income while the claim is being processed
WSIB may deny a claim, while the carrier may approve an LTD claim
By filing an LTD claim, it triggers the waiver of the life insurance premium. i.e. Life insurance coverage continues for an employee on WSIB or LTD, with no premium payment. This is extremely important as a disabled employee may not be able to purchase individual life insurance
Simply, if the claim does not result in LTD, the carrier closes their file, but by filing in a timely manner the employee is protected.

How long is the employer required to keep a disabled employee covered for health and dental?

Benefits are required to be kept in place in accordance with Employment Standards.

Beyond that period, the employer determines how long to keep coverage in place. Although no employer wants to terminate health and dental for a disabled employee, the question simply is “how long can an employer reasonably afford to continue that coverage?” Every employer/company should have a published policy identifying how long EHC & Dental coverage will continue to a disabled employee. This normally ranges from 6 months to one year and in the case of larger employers, anywhere up to 5 years. The key is to establish the policy before the company has a disabled employee, as it is more challenging to do so after.

What is required to continue coverage through a work share program and/or a layoff?

Carriers should be contacted if employees are on reduced hours and/or wages, or short-term layoffs to determine coverage continuation or adjustment.

Can an employer offer continued benefits in a termination package or a leave of absence?

Under a group plan, employees must continue to meet the definition of eligibility (ie. actively at work for X hours per week). Coverage cannot be arbitrarily extended to an employee without permission from the carrier. Therefore, an employer should seek permission for continuation of coverage under all circumstances prior to making any commitment to an employee.

Can an employee continue to have benefits after leaving the employ of the company?

Employees have an option to convert their life insurance coverage (some carriers also offer LTD) and also apply for individual EHC and Dental when coming out of a group plan. It is the Plan Administrator’s obligation to inform the employee of this option. This is extremely important particularly if an employee has any medical issues which could result in denial of coverage on an individual basis.