How to accurately administer your company’s benefit plan
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This guide is specially designed for benefit plan administrators.Its purpose is to help you administer your benefit plan with ease and accuracy. 

We recommend that you refer to your group insurance policy booklets for a comprehensive description of the types of benefits offered under your plan.

Because your time is valuable and getting the answers to employees’ questions can be complicated, we urge you to contact us directly for more complicated situations. 

We welcome your feedback about this Manual. Please tell us what was useful and areas where we could improve by sending an e-mail to the Client Relations Manager at Beneplan.

Beneplan is your benefit third party administrator. Beneplan also acts as your liaison with the carriers that administer and insure your plan. 

The Co-operators is Beneplan’s strategic partner. They are a carrier of both pooled benefits and experience rated benefits Pooled benefits include Basic Life Insurance, Accidental Death and Dismemberment, Dependent Life Insurance and Optional Life Insurance. Experience rated benefits include extended health care and dental coverage.

Green Shield is Beneplan’s strategic partner. They are the main carrier administering and insuring your benefit plan. Green Shield provides administration and claims adjudication for benefits.Beneplan deals with other insurance companies such as The Co-operators, RBC Insurance and AIG for specialized benefits such as LTD and AD&D.

Beneplan Inc. Privacy Policy

Beneplan Inc. will adhere to the provisions and principles of  all Canadian privacy laws.

Beneplan Inc. is committed to protecting the privacy, confidentiality, security and accuracy of the personal information we have collected and will collect from you. We will disclose only the necessary personal information to other insurers for the purpose of facilitating eligibility for benefits and for claims adjudication purposes. 

Beneplan Inc. collects personal information from employees using enrollment, claim and other forms.These forms will have a declaration as to the purpose of collecting the personal information. The forms will contain consent that we may use the collected information for any purpose not consented to.

Beneplan Inc. collects limited personal information from you for the specific purpose of administering the group benefits plan, including:

Beneplan Inc. will disclose to the individual member all the information we have on record for that member at the written request of the member. The individual may challenge and amend the information on hand. Beneplan Inc. reserves the right to request proof for some or all the personal information provide by a member.

Beneplan Inc. reserves the right to withhold or refuse to provide information to any party, with the exception of the individual whose information is being requested, if we believe disclosure may breach PIPEDA.

Any person on whom we keep information may advise us in writing to cease to use the information on the individual, and to destroy such information.Such person shall bear full responsibility for the consequences of his/her request. 

Beneplan Inc. will keep abreast of privacy legislation and developments and will amend our policies accordingly. 

This brochure is deemed to be our notification to you of our Privacy Policy.We will proceed with implementing our Privacy Policy as it applies to you.Please notify us immediately if there is anything in our Privacy Policy that you object to.

Beneplan Inc. will maintain, keep and archive the information collected on individuals in the course of administering benefit plans for a minimum period of five years, but not longer than six years. Beneplan Inc. will destroy the information both electronic and in paper form in a manner that ensures that the information cannot be used in any form by others.

Administration - How do I ….

Generally, claims are paid by Green Shield. All employee data is managed by Beneplan, who also produce the monthly billings. The Data is transferred to Green Shield’s system frequently to enable them to pay claims.

You, as the administrator need to inform Beneplan of any new hires, changes and terminations. You can log on the Beneplan website www.beneplan.ca to view your employees’ data. You will be provided with a user ID and password to enter Beneplan’s website. Please change your password as soon as you get it and guard it to ensure the safety of your group’s confidential information.

It is strongly recommended that you enroll new employees as soon as they are hired; let Beneplan track their effective date.

Please avoid enrolling employees or their dependents late!

Employees are eligible to enroll if they satisfy the following: 

Employee’s dependents are eligible to enroll if they satisfy the following:

Enrollment forms are customized to your company by Beneplan .Beneplan will provide forms for your use. These forms are also available in the forms section of this guide. The enrollment form is also available in a secure online format:

Please make sure to have the employee complete and sign the enrollment form to apply for group insurance coverage. 

The employer must submit the form (within 31 days of satisfying employee/dependent’s eligibility requirements) to Beneplan Administration.

To waive the waiting period, the employee must have had previous benefit coverage within six months prior to the hire date, specifically life coverage. The “Application to Waive the Waiting Period” form must be completed by the employee and submitted to Beneplan Administration. This form can be found in the Forms section at the end of this guide.

The form should be filled out with clear block letters.

Under the Employee section of the form, it is important to fill in the division and class the employee will be classified under.

The employee should fill in the type of coverage desired, i.e. Single, Family or Opt-out. An Opt-out employee is an individual who has coverage through his/her spouse with another benefit plan, and does not wish to have coverage under your plan.

An employee whose spouse has coverage with his/her employer, may participate in your plan provided he/she agrees to co-ordination of benefits between the two plans.

In case of Family coverage, the employee must list the names, gender and dates of birth of the spouse and the children if applicable (in the following order year, month and day).

In the case of children above the age of 21 or if the child is handicapped and dependent upon the member, the member must complete the section at the extreme right-hand column of the dependent’s section.

For the Opt-out option, the employee must complete the information needed under the Opt out section indicating the spouse’s insurance company and policy number.

The hire and effective dates should be filled out in the following sequence: year, month and day. The hire date is the first day worked.

It is important to state clearly the earnings amount and to specify whether it is on hourly, weekly, monthly or yearly basis. 

Under the Beneficiary section, the employee must indicate the full name/s of the beneficiary/s appointed, the relationship and the percentage they are entitled to.

Under the Co-ordination of Benefits (COB) section, the employee must list the name of the spouse’s insurance company and policy number, if applicable.

Under the declaration section the employee and the employer must sign the enrollment form making sure of the accuracy of the information. 

Should you need any further clarification on how to fill in the form, please feel free to contact Beneplan’s Administration team by email at admin@beneplan.ca .

Employees must enroll in the Plan as soon as they satisfy their waiting period. If they fail to apply within 30 days of meeting the eligibility period, they are deemed to be late applicants and must go through the late applicant process. 

The late applicant process requires the employee and his/her dependents complete and submit a “Group Health Evidence Form”. The original form must be submitted to Beneplan for submission and approval by the insurance carrier. Additional medical information may be requested after the form is reviewed and any charges for this information are the employee’s responsibility. It is possible that some or all of the requested benefits are declined (temporarily or permanently).

To obtain coverage, the employee must complete the Optional Life application form and submit the original to Beneplan, who will then forward to the carrier for approval. The related form can be found under the Forms section of the binder.

When an employee is being dispatched by your company to another country for an extended period, you will need to consider obtaining expatriate coverage for the employee and his/her family (if applicable). 

Provincial health plans are not interrupted when a Canadian travels out of the country for 180 days or less. It is possible to obtain an extension from your Provincial health plan under some circumstances. 

However Provincial health plans do not pay for many items like drugs and dental. Also note that neither Provincial health plans nor your Out–of-country coverage will pay for routine items like doctors’ visits etc. Out-of-country coverage only covers “emergency” occurrences only. 

Please contact Beneplan to discuss covering any employees that may be dispatched out of the country for extended periods of time.

To ensure that coverage is kept up to date for the employee and his/her dependents, it is vital to educate the employees they must advise the employer or plan administrator of any changes. This includes:

Plan administrators need to ensure that changes in salary are reported to Beneplan as soon as they become effective if applicable to the volume of the benefit(s), such as life insurance or LTD coverage amounts.

It is important to include the main reasons for any changes made. Changes reported more than 31 days after the date of change may require health evidence of insurability. Following is a sample of the Beneplan Group Insurance Change Form.

The employer must submit the form (within 31 days of satisfying employee/dependent’s eligibility requirements) to Beneplan Administration.
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There are various scenarios when employees’ coverage is terminated; care must be exercised when terminating employees’ coverage. In this section we discuss the process you need to follow when terminating employees’ coverage under the various scenarios:

Employee quits/resigns with notice

If the employee quits, or resigns and works out to the end of the notice period, then the termination date would be the last day worked.

The employee is being fired for cause 

Simply terminate the coverage on the day the employee is fired. 

Voluntary leave of absence

In this case, the company may choose to suspend or extend benefits during the absence. If the company chooses to extend benefits, the company must apply for a Letter of Agreement (LOA).

Company Lay off – the layoff expected to be less than 13 weeks

The Employment Standards Act (ESA) states that companies that lay employees off temporarily (up to 13 weeks), are not deemed to have terminated these employees; In this case, the company may choose to suspend benefits during such layoff or may choose to extend benefits during the layoff. If the company chooses to extend such coverage, the company must apply for a Letter of Agreement (LOA).

Company Lay off – the layoff expected to be less than 13 weeks - Continued

All benefits, with the exception of short/long-term disability and out-of-country coverage can be continued, for a period of up to one year. This must be documented by the way of LOA.

The company must recall such employees within the 13 weeks. In the event the company does not recall such employees within the thirteen weeks, the company must terminate and provide termination pay pursuant to the Employment Standard Act (ESA).

Company Layoff – the layoff expected to be more than 13 weeks

The Employment Standards Act (ESA) states that companies that lay employees off for longer than 13 weeks, the employees are not deemed terminated if the company extends all their benefits. In this case the company must apply for a Letter of Agreement (LOA).

All benefits, except for short/long-term disability and out-of-country coverage can be continued, for a period of up to one year. This must be documented by the way of LOA.

The Employee is terminated – Benefits during the notice period 

The Employment Standard Act (ESA) requires that all benefits, including disabilities, must continue, whether the employee is actively working or not, for the number of weeks, set out by the “Employment Standards Act (ESA):

​For Ontario:

3 months or more; less than 1 year (1 week)

1 year or more; less than 2 years (2 weeks)

3 years or more; less than 4 years (3 weeks)

4 years or more; less than 5 years (4 weeks)

5 years or more; less than 6 years (5 weeks)

6 years or more; less than 7 years (6 weeks)

7 years or more; less than 8 years (7 weeks)

8 years or more (8 weeks)

​For Quebec:

3 months or more; less than 1 year (1 week)

1 year or more; less than 5 years (2 weeks)

5 years or more; less than 10 years (4 weeks)

10 years or more (8 weeks)

In the above case, no LOA is required.

​Severance 

Extension of benefits beyond the “Notice Period” requires legal documentation between the employer and the insurance carrier. This is done by providing the last day worked, the end of notice period date (if applicable) and the benefits extension date- and must be done preferably before the employees’ last day worked – but no more than 30 days thereafter. All benefits would be extended, with the exclusion of any disabilities (short or long) and out-of-country coverage (on health).So in brief the employer must inform Beneplan if they wish to extend benefits beyond the termination date or notice period. Benefits which are to be extended will be up to, but no more than one year beyond the last day worked. An LOA is required in this case.

Survivor Benefits (if applicable)

In the event of an Employee's death, the coverage for an insured dependent with respect to extended health care and dental benefits will continue for the number of years (usually 2) as indicated in the plan booklet, provided this policy and the employer’s extended health care and dental benefits remain in force under this policy and the dependent does not become eligible for benefits under any other group insurance plan as either an employee or dependent and the dependent remains eligible as defined in this policy. Premiums are required for the extension of the dependents coverage and must be paid entirely by the employer.

Compassionate Leave (Family Medical Leave)

Under the Employment Standards Act the employee is eligible to family medical leave up to eight weeks job-protected leave. The coverage will be extended for all benefits in effect prior to the leave. Employers must continue paying their share of benefits premiums.

Pregnancy/Maternity/Paternity Leave

Under the Employment Standards Act where an employee takes maternity/paternity leave, the employer must keep all of the benefits that were in force prior to the leave. If premiums for WI and LTD are paid during maternity/parental leave and the employee becomes disabled while on leave, then benefit payments would commence when the employee would normally have returned to work provided the elimination period is up and the medical evidence supports the disability as defined in the policy.If premiums are not paid, there would be no disability coverage. No letter of agreement is required here. 

Emergency Leave

 Under the Employment Standards Act if the employee is entitled to personal emergency leave then the employee will be on an unpaid, job-protected leave of up to 10 days each calendar year. The employer must continue benefits while an employee is on personal leave.

Vacation Periods Extended

If the employee on vacation (either in or out of country) and the employer decides to allow the employee to extend the employee’s vacation, then coverage for all benefits would continue to be in force. No letter of agreement is required here. Provided the vacation extension is lesser than the vacation time the employee is entitled to.

Sick Leave 

Under the Employment Standards Act if the employee is on sick leave or short term disability then he/she have the right to continue to take part in all benefit plans.

In all cases where benefits are continued or must be continued, the employer must continue to pay its share of the premiums and the employee must also continue to pay his/her share. If the employee refused to pay their share then the employer has the right to terminate the employee’s coverage.

 
​While on Long Term Disability (LTD) - No premium for LTD

In case an LTD claim is approved or in case of total disability of an employee as a result of accident, sickness or disease where no LTD coverage is available, the employee maybe eligible for premium waivers of life, AD&D and/or DGL if covered. 

Your employer should have a benefit coverage policy that allows the disabled employee to continue health and dental benefit for a particular period of time as spelled out in the policy. 

Applying for Life Insurance Conversion 

Within 31 days of group life insurance termination, the employee may obtain an individual policy with The Co-operators without providing evidence of good health. The policy could be in the following forms: a permanent traditional policy, a term to age 65 plans or a one year non-renewable, non-convertible term plan. The employee has to make direct contact with The Co-operators if he/she seeks to have life conversion after termination. 

Premium Billings 

At Beneplan, premium billings are done once every month, and there are two types of rates:

Please refer to a sample of our billing on the next page. 

Retail sales or provincial tax is the tax applicable to group benefit programs; RST is 8% in Ontario, 9% in Quebec and nil in all other provinces. Group premiums are not subject to GST. 

Page 1 is a letter from Beneplan that highlights the total amount that is payable for the monthly premiums.

 
​Page 2 breaks down the total volume by carrier and confirms any adjustments if applicable

 
​Page 3 breaks down each benefit per employee including taxes

It is advisable that employees keep a copy of their claim in case of lost mail, etc. 

Claims will be paid in accordance to the policy/booklet. 

Employees may log on to the Green Shield website to view their claims. Each employee will be provided with a login ID and password which they should change as soon as they obtain it and guard well. 

Each employee will be provided with a “drug card” which has all the necessary information the employee needs to:

​In this section we will be covering claims for the following:

Accidental Death and Dismemberment (AD&D), Life Insurance, Long Term Disability (LTD), Critical Illness (CI), Dependant Group Life (DGL), Optional Life and Waiver of Life Premium claims (If Applicable) 

Beneplan does not adjudicate claims for these benefits but will help you and facilitate by providing the insurance forms. The employee, employer and doctor must complete the relevant forms and send them back to Beneplan. Beneplan then checks the forms, adds supporting documentation and forwards them to the insurers. Once the claim is approved by the insurer, Beneplan adjusts the billings accordingly  .Claim forms can be found on The Co operators Website.

When an LTD claim is approved or in the case of total disability of an employee as a result of accident or sickness where no LTD coverage is available, the employee may be eligible for premium waivers of life, AD&D and/or DGL if covered. 

If this benefit is part of your plan and is administered and adjudicated by Beneplan, Beneplan supplies the claim forms to be completed and submitted back for review and approval if qualified. If approved payment is made on a weekly basis according to the employer’s plan. Claim forms can be found below.

Paramedical is part of Extended Health Care (EHC). Claims for Paramedical services must be approved by Beneplan before the actual service takes place. Beneplan provides pre-approval forms to be filled out by the claimant, his doctor and the paramedical provider. The link can be found below. 

When Beneplan adjudicates paramedical services, the doctor must provide a “prognosis” that necessitates the service; the provider must provide a treatment proposal including cost. If the service is “medically necessary” in the opinion of Beneplan adjudicators, then the benefit is approved.

In the case where paramedical is administered and adjusted by Green Shield, all claims must be submitted to the insurers for review and payment. Claims are typically submitted online to Green Shield at:

In some cases (refer to the plan booklet), a doctor’s prescription is required and must be submitted with the claim. 

Most medical services and devices are payable if they are “medically necessary” and they require a doctor’s prescription. It is strongly suggested that a prescription is obtained and submitted with the claim; otherwise the claim may not be paid. The claim form must be completed accurately and thoroughly; original receipts and the doctor’s prescription must accompany the claim. All forms are available at the end of this guide.

The employee must present his/her drug card (when applicable) to the pharmacist every time to pay for their prescribed drugs. The drug cards are issued by Green Shield. The employee is required to pay a co-payment amount (if applicable) per prescription as indicated in his/her schedule of benefits.

Please refer to your employee’s plan to check the details of coverage.

In the case of the above, nothing can be done

To overcome these concerns the employee and the pharmacy must contact Green Shield at directly at  1-888-711-1119. 

Hospital stays are covered if the stay starts while the covered person is insured under the extended health care benefit. It is also provided for the difference between the approved hospital’s standard ward rate and the hospital accommodation shown in the employee’s plan booklet, provided that accommodation was specifically elected in writing by the covered person. 

To submit a claim, the employee usually provides the drug card, pays up front to hospital and gets reimbursed. In some cases, reimbursement is not made promptly but rather, the hospital presents a “hospital expense questionnaire” asking the employee to complete with more information to justify payment. 

Out of Country emergency care is provided for the covered employee for the first 90 days of travel whether he/she is travelling for vacation, business or education. Please notify your employees on the importance of taking with them the emergency medical Travel Assistance ID card whenever they travel outside Canada as this card lists important telephone numbers that the employee may need. Moreover, remind your employees that in case of any medical emergency that arises while out of country, the employee must notify the emergency medical travel 

Contact assistance service as soon as possible and within 48 hours of admission to a hospital. Failing to do so will reduce the benefits to be paid. 

The group number and account number is per the benefit structure listed earlier in this Guide. The certificate number is the employee’s certificate number as per the Health card.

If the employee or any of their dependents incur eligible expenses while insured, a dental claim must be filled completely and accurately and signed by the employee. It is strongly suggested that dental claims are submitted to Green Shield not later than ninety (90) days after the date of procedures. Dental claims can be submitted to Green Shield by the plan holder here:
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Dental claims may be submitted electronically to Green Shield if the dentist has the ability to do so. Furthermore, employees may assign their dental claims to their dentist (if the dentist agrees) by signing the assignment section of the dental claim. In this case Green Shield pays the dentist directly the amount eligible, and if any, the employee pays his dentist the amount not paid.

Please refer to your employee’s booklet to check the details of coverage: “Dental Care Benefits” section.

It is important to note here that NO dental claim will be accepted or processed if submitted after 12 months of service date.

Typical problems encountered are related to the following:

To overcome these concerns the employee and the dental office must contact Green Shield directly at 1-888-711-1119 to handle such problems. 

This includes charges for the purchase of lenses, frames or contact lenses that are required to correct vision when prescribed and dispensed by a licensed optometrist, optician or ophthalmologist. The maximum benefit payable is indicated in the plan booklet. To make a claim the employee will make the purchase of lenses, frames and pay up front then submit the claim to Green Shield online:
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Canada’s Retirement Income System 

Canada’s retirement income system has three levels:
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If you meet certain residency requirements, you’ll be entitled to a modest monthly pension once you reach age 65. The Guaranteed Income Supplement (GIS) is an additional monthly benefit for low-income OAS pensioners. A Spouses Allowance may also be available to the spouse of a GIS recipient.
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It provides you with a monthly retirement pension as early as age 60 if you have paid into it. The CPP also offers disability, survivor and death benefits. Quebec has a similar plan, called the Quebec Pension Plan (QPP).
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Old Age Security & Guaranteed Income Supplement 

Website: www.hrsdc.gc.ca/en/isp/oas/oastoc.shtmlb 

The Old Age Security (OAS) is Canada’s largest public pension program and became effective in 1952. It provides a modest monthly pension to most people, starting at age 65. If you have been a resident of Canada for 20 years or more after your 18th birthday you will be entitled to a full pension. A minimum of 10 years of residence after age 18 is required to be entitled to a partial pension. 

The maximum monthly OAS pension can be calculated here:

https://www.canada.ca/en/services/benefits/publicpensions/cpp/old-age-security/benefit-amount.html

This amount is adjusted for inflation quarterly, in April, July and October, to reflect the increase in cost of living. The Government of Canada pays OAS benefits from general tax revenues. 

The Guaranteed Income Supplement (GIS) program became effective January 1, 1967. Any low-income person who receives the Old Age Security pension and meets certain residency criteria is eligible for the GIS. The GIS monthly benefit varies in relation to income and marital status. It is also adjusted quarterly for inflation. 

An Allowance may be provided to the spouse (age 60 to 64) of a GIS recipient if the couple’s income is within certain limits. There are residency requirements applicable to the spouse. If the GIS recipient dies, the low-income surviving spouse (age 60 to 64) may be eligible for an Allowance for the Survivor. This benefit is also adjusted quarterly for inflation. The allowance terminates when the spouse reaches age 65 or remarries. 

None of the above benefits are automatic and an application must be made to receive them.

Canada Website: www.hrsdc.gc.ca/en/isp/cpp/cpptoc.shtml

The Canada Pension Plan (CPP) came into effect on January 1, 1966. The CPP is a contributory, earnings-related social insurance program. It ensures a measure of protection to a contributor and their family against loss of income due to retirement, disability or death. The CPP operates throughout Canada although the province of Quebec has its own similar program, the Quebec Pension Plan (QPP). 

Quebec Website: www.rrq.gouv.qc.ca/en 

Participation in these plans is mandatory for all employees and self-employed persons aged 18 to 70 whose earnings exceed the Year’s Basic Exemption (YBE). 

The contribution rate to both the CPP and QPP is equal to 9.9% of earnings, in excess of the basic exemption, up to the Year’s Maximum Pensionable Earnings (YMPE). The employee and employer share this contribution and each pays 4.95%. A self-employed person must pay the whole contribution rate. 

A person who has contributed to CPP is eligible for a retirement pension. QPP requires contributions for at least one year to be eligible. 

In general, the retirement pension replaces about 25% of the earnings on which the contributor paid into the CPP. The exact amount depends on how much, and for how long, the person contributed.

Pension benefits are normally payable at age 65. However, a contributor may elect to receive a retirement pension as early as age 60 or as late as age 70. If either early or deferred retirement benefits are elected the amount of pension is reduced or increased by 0.5% for each month (6% for each year) between the date the benefits actually commence and age 65. Once a person starts to receive their CPP pension they can continue to work, if desired, without affecting the amount of their pension. However, they can no longer contribute to the plan. 

Phased retirement refers to an arrangement in which a person who is within 10 years of normal retirement age is working part-time and accruing pension benefits while simultaneously receiving partial pension payments. 

The CPP does not offer an option for phased retirement. 

The QPP offers two options for phased retirement. 

A person between 60 and 65 may elect early retirement, in which case their pension is reduced, but contributions to QPP continue based on their reduced salary. Their QPP pension could be adjusted based on contributions made during the period the person was working reduced hours. 

A person between 55 and 70 may reduce their hours worked, and thus receive reduced wages, while continuing to contribute to the plan as if they were working full-time. Under this arrangement the employer must also agree to continue to contribute to the QPP as if the salary had not been reduced. Pension benefits are not payable during this period of reduced work hours. The years during which the person works a reduced number of hours are considered to have been full-time employment for the purposes of calculating the pension benefit upon retiring. 

An application must be made for CPP retirement pension benefits as they are not automatic. Application should be made at least 6 months prior to the date the contributor wishes the pension benefits to commence. 

Benefits payable upon the death of an eligible contributor include a lump sum benefit, a surviving spouse’s pension and an orphan’s pension. 

The CPP lump sum death benefit equals six months of retirement benefits to a maximum of $2,500. The QPP lump sum death benefit is a flat $2,500.

 Survivors of deceased contributors may be eligible for benefits depending upon the number of years the deceased contributed to the plan. The amount of pension payable to the surviving spouse depends on their age and other criteria as noted in the chart at the end of this section. The benefit is payable for life. Both the CPP and QPP extend benefits to same-sex common-law partners. 

Dependent children under 18 may be eligible for an orphan’s pension. CPP (not QPP) extends the benefit to age 25 if the child is attending school. 

If an employee becomes disabled and is prevented from engaging in any gainful occupation they may be eligible for CPP/QPP disability benefits. The disability must be considered severe and prolonged with an indefinite duration. However, under the QPP and employee between the ages of 60 and 64 may be entitled to a disability pension if they are unable to perform their own occupation on a regular basis. 

In order to be eligible for benefits under the CPP the employee must have earned at least 10% of the YMPE in at least 4 of the last 6 years (3 of the last 6 years if the employee has contributed for 25 or more years). Under the QPP the employee must have contributed in 2 of the last 3 years, in 5 of the last 10 years or in half of the years in the contributory period, subject to a minimum of 2 years. 

The amount of the monthly disability benefit is calculated according to a formula that includes a flat amount plus a percentage of the contributor’s average monthly earnings, to a stated maximum. The maximum benefit is adjusted each January 1st for inflation. 

Disability benefits are payable monthly from the first of the fourth month following the date of disability and are payable until age 65, at which time the Retirement Pension becomes payable. Dependent children (under 18, or 18 to 25 and full-time students under CPP) of a disabled person receive the same pension as orphans. 

Website: www.servicecanada.gc.ca/eng/sc/ei/index.shtml/?css

Old Age Security and Canada/Quebec Pension Plan benefits are an important part of retirement income but they are not intended to meet the entire retirement needs of Canadians. The third level of Canada’s retirement income system is private pensions and savings. 

The government helps Canadians save for retirement through tax assisted programs such as Registered Pension Plans (RPPs) and Registered Retirement Savings Plans (RRSPs). Contributions in these plans are tax deductible and investment income is not taxed as it is earned. The tax is paid when the funds are withdrawn from these plans or received as pension income. 

Website: https://www.canada.ca/en/services/benefits/ei.html

This federal program became effective June 27, 1971. It provides both Regular Benefits and Special Benefits. 

Regular Benefits are payable if a person is unemployed through no fault of their own, such as, a shortage of work or lay-off. The person must be available for work but is unable to find a job. 

Special Benefits are payable in situations where a person becomes sick, pregnant or is caring for a newborn or adopted child, as well as those who must care for a family member who is seriously ill with a significant risk of death. 

The EI program in Quebec provides Special Benefits only for sickness and compassionate care. Maternity and parental leave benefits are provided through Quebec’s own program called the Quebec Parental Insurance Program (QPIP). This program became effective January 1, 2006 and covers all working residents, both those earning a wage through an employer and those who are self-employed. 

To be eligible for Regular Benefits a person must work a certain number of hours during the 52-week period preceding the start of benefits. An employee must work between 420 to 700 hours, depending on the regional unemployment rate. People who are employed for the first time or those re-entering the workforce must accumulate 910 hours of insurable employment. To be eligible for Special Benefits a person must accumulate 600 hours of insurable employment. However, Quebec doesn’t have a minimum hour’s worked requirement for maternity and parental benefits. Under QPIP parents qualify for these benefits if: 

There is a 1-week elimination period during which time no benefits are payable. 

The benefit level is 55% of insurable earnings to a maximum benefit per week. A higher benefit may be available to families with a net income of less than $25,921. 

The maximum benefit period varies between 14 to 45 weeks (decreased from 50 weeks in the January 2009 federal budget) and is dependent upon the regional unemployment rate and the number of accumulated hours of employment over the preceding 52-week period. 

Claimants in receipt of Regular, Parental and Compassionate Care Leave benefits are allowed to earn, on a part-time basis. To check maximum amounts please visit:

https://www.canada.ca/en/services/benefits/ei.html

The elimination period and benefit level is the same for Regular and Special Benefits, except for the maternity and parental leave benefits in Quebec. 

Benefits are payable for a maximum of 15 weeks. 

 Benefits are payable for a maximum of 15 weeks. A woman may elect to receive benefits at any time from the 8th week preceding the expected week of delivery or from the week of delivery, if earlier, to the 17 weeks after the expected date of delivery or the week in which delivery occurs, if later. 

 Benefits are payable for a maximum of 35 weeks. A parent(s) may elect to receive benefits anytime between the week of birth or, in the case of adoption from the week of arrival at home, to 52 weeks after. Parents of hospitalized children may have up to 2 years instead of 1 year to claim parental leave benefits. Benefits are payable to either parent or may by divided between them as they wish. 

A combination of sickness, maternity and parental leave benefits can usually be received for a maximum of 50 weeks. However, the maximum duration may be extended under special circumstances. 

Website: http://www.rqap.gouv.qc.ca/Index_en.asp
​
The QPIP provides benefits to eligible workers who take maternity, paternity, parental or adoption leave. It offers parents a choice between two options: the Basic plan or the Special plan. The difference between these plans is the benefit amount and duration of payment. The recipient may choose to receive a lesser benefit amount for a longer period of time or a higher benefit for a shorter period. Parental and adoption benefits may be shared by both parents and taken simultaneously or consecutively. The choice of plan is determined by the first parent to receive benefits and can’t be changed at a later date. 

An application is submitted at the time the person wishes to start receiving benefits. Advance applications aren’t accepted. There is no waiting period and benefits start immediately. Maternity benefits may be claimed no sooner than the 16th week before the expected week of delivery; paternity and parental benefits no sooner than the week the child is born; and adoption benefits no sooner than the week the child comes into the care of one of the parents, if adopted in Quebec, or two weeks if adopted outside of Quebec. 

The weekly benefit is usually calculated as a percentage of the average weekly earnings over the prior 52 weeks. The maximum insurable earnings are $69,000 in 2014, up from $62,000 in 2009. A supplemental benefit may be provided to families with a net income of less than $25,921. Those in receipt of Paternity, Parental or Adoption benefits are allowed to earn up to 25% of their weekly benefits ($50 if the weekly benefit is less than $200) without affecting their QPIP payment. However, any income earned while in receipt of maternity benefits is deducted from the QPIP benefit amount. 

The following table shows the amount and duration of benefits for the various plans. 

Under both plans a mother could be entitled to both maternity and parental benefits for a total of 50 weeks under the Basic plan or 40 weeks under the Special plan. 

Up to 6 weeks of benefits are payable for a person who has to stay away from work temporarily to provide care and support to a member of their family who is gravely ill with a significant risk of death within 6 months. The benefits payable for the compassionate care leave may be divided between 2 or more workers who make a claim for benefits in respect of the same family member. When this happens, only 1 waiting period is applied. 

EI is second payer to any employer-sponsored wage loss replacement plan. The wage loss replacement plan may be either an insured or self-insured Weekly Indemnity plan or a Paid Sick Leave Plan with accumulated sick leave credits.

The government recognizes that utilization will be less under EI when an employer plan is in place. Therefore, they offer a program which is designed to reduce the employer’s EI premiums payable if that employer provides wage loss replacement coverage that meets Human Resources and Skills Development Canada’s requirements. 

To be considered for premium reduction, a plan that provides short-term disability benefits must: 

Although the Premium Reduction Program is administered through the employer’s portion of the premiums, the savings must be passed on to the employees in some form, such as a reduced contribution rate or an improved benefit. Because EI premiums are paid by employers and employees in a ratio of 7/12 and 5/12, respectively, the savings from the premium reduction must be passed on to the employees in the same ratio. 

Service Canada publishes a comprehensive guide on this program entitled “Guide for Employers – EI Premium Reduction Program”. A copy of this guide can be downloaded at :
​www.servicecanada.gc.ca/eng/cs/prp/0200_000.shtm

Or further information on the program may be obtained by calling Service Canada in Bathurst, N.B. at their toll-free number 1-800-561-7923

Website: www.wsib.on.ca

The concept of workers’ compensation originated in Germany, Great Britain and the United States between the late 1800’s and early 1900’s. In Canada, it had its beginnings in Ontario in 1915. The creation of the workers’ compensation program was a historic event in which workers give up the right to sue for their work-related injuries, irrespective of fault, in return for guaranteed compensation for accepted claims. Employers, for their part, receive protection from lawsuits in exchange for financing the program through premiums. This system of collective liability provides fair compensation for injured workers and their families, while spreading individual costs among employers. 

Currently each of the 10 provinces and 3 territories has their own Workers’ Compensation Board/Commission (WCB). Each has their own specific requirements covering prevention, compensation and funding. Not all employers pay into workers’ compensation; this depends on 

 Each jurisdiction’s legislation. For details of a specific plan please refer to the following website: 

 www.awcbc.org/en/linkstoworkerscompensationboardscommissions.asp

This section will briefly describe the benefits available under the Workplace Safety and Insurance Board (WSIB) in Ontario. 

The WSIB is financed entirely by employer premiums. And, as in other insurance arrangement, dangerous industries with more claim costs pay higher premium rates. While the rate varies from one employer to the next, depending on the type of business and claims experience of the employer. 

The WSIB provides a variety of benefits such as: 

The WSIB also monitors the quality of health care provided to injured workers and assists in the early and safe return to work.

A temporary disability must prevent the worker from returning to work or performing the tasks involved in a suitable type of occupation. 

This benefit starts from the working day after the injury or illness occurred. The LOE benefit is equal to 85% of the worker’s take home pay, up to the maximum insurable earnings. Take-home pay is defined as earnings less deductions for income tax, CPP and EI premiums. 

Benefits are paid every two weeks until the worker recovers or reaches age 65, whichever occurs first. Each year the WSIB adjusts the LOE payments to take inflation into account. However, if the worker is still on claim after 6 years the LOE is made permanent and it may be turned into a lump sum payment. 

A lump-sum benefit is paid to a worker who suffers a permanent injury or mental impairment. The amount of the benefit is dependent upon the degree of disability and the worker’s age. 

Rehabilitation Services and Programs (Ontario) 

The WSIB pays for expenses associated with an injured worker’s re-entry into the labor market. The program is known as Labor Market Re-Entry, or LMR. 

Typical expenses for the assessment and a resulting plan include such items as: 

Exceptional expenses, if the circumstances require, may include such items as: 

Death benefits are paid in a lump sum and consist of the following: 

Spouse’s benefit based on the spouse’s age at the date of death 

Dependent Children benefit, if there is no surviving spouse 

Burial or cremation expenses (flat rate)

Transportation costs of the deceased back home for burial 

The surviving spouse receives a monthly benefit which is calculated based on the spouse’s age as at the date of death, the deceased worker’s earnings, and whether or not there are dependent children. 

Surviving dependent children are entitled to monthly payments. The amount of the benefit depends upon the number of children and their ages. The benefits are payable until they turn 19, or 30 if a student is enrolled in an educational program approved by the WSIB. A dependent child who is physically or mentally incapable of earning wages is entitled to payments regardless of age.

The federal government, ten provinces, and three territories all play key roles in the delivery of Canada’s health care system. The federal government is responsible for setting and administering the principles of the health care system, through the Canada Health Act, and for assisting in the financing. But the actual delivery of the services is a provincial/territorial responsibility. 

The Canada Health Act is federal legislation that puts in place conditions by which individual provinces and territories may receive funding for health care services. 

There are 5 main principles in the Canada Health Act: 

Public Administration: All administration of provincial health insurance must be carried out by a public authority on a non-profit basis. They also must be accountable to the province or territory, and their records and accounts are subject to audits. 

Comprehensiveness: All necessary health services, including hospital, physicians and surgical dentist, must be insured. 

Universality: All insured residents are entitled to the same level of health care. 

Portability: A resident that moves to a different province or territory is still entitled to coverage from their home province during a minimum waiting period. This also applies to residents who leave the country. 

Accessibility: All insured persons must have reasonable access to health care facilities. In addition, all physicians, hospitals, etc., must receive reasonable compensation for the services they provide. 

Health care in Canada is funded at both the federal and provincial levels. The federal government provides funding to the provinces and territories through cash and tax transfers. The provincial financing of health care is provided via taxation from both personal and corporate income taxes. Some provinces also obtain additional funds from other financial sources like sales tax and lottery proceeds.

In Manitoba, Ontario, Quebec and Newfoundland there is an employer tax based on a percentage of their gross annual payroll. The percentage varies by province and is generally a sliding scale dependent upon the size of the payroll. In Ontario the employer tax is 1.95% of the total annual payroll in excess of $400,000. 

British Columbia and Ontario also charge health premiums to supplement health funding. British Columbia charges a single, couple or family premium rate, the amount of which is based on income. Ontario charges a premium which is collected through the income tax system. The premium applies to individuals with an annual taxable income greater than $20,000, and to plan members on short or long-term disability who receive a taxable disability benefit. Both provinces either waive the premium or offer financial assistance to low-income residents. The Canada Health Act stipulates that health services cannot be denied due to financial inability to pay premiums. Alberta used to charge premiums to all residents under age 65 on the basis of single or family coverage. However, they eliminated these premiums effective January 1, 2009. 

New residents to a province must apply for health coverage. There is typically a waiting period before health coverage is granted. This can vary, but cannot exceed 3 months as part of the Canada Health Act. (The waiting period in Ontario is 3 months.) Upon being granted coverage a health card is issued which provides proof of coverage in the province or territory. 

In addition to the standard health coverage outlined in the Canada Health Act, provinces typically provide additional services. The provinces aren’t obligated to provide services not listed in the Act. Therefore, these additional services can be delisted, or restricted, as government policies change. 

The following section briefly describes the services covered under the Ontario Health Insurance Plan (OHIP). The websites below will provide details for the other provincial and territorial health plans. 

British Columbia

Alberta

Saskatchewan

Manitoba

Quebec

Newfoundland

Nova Scotia

New Brunswick

Prince Edward Island

Northwest Territories

Yukon

Nunavut

Website: www.health.gov.on.ca

The Ministry of Health and Long-Term Care is responsible for administering the health care system and providing services through OHIP. Insured hospital services were introduced in 1959 and insured physician’s services in 1966. They were combined under OHIP in 1972. A list of services currently provided under OHIP is as follows: 

​In Hospital Services: 

​Laboratory and X-rays: 

​Physicians Services: 

​Paramedical Practitioners: 

​Pharmacist Consultation (MedsCheck): 

Physiotherapy: 

​Homecare & Nursing 

​Eye care: 

​Dental care: 

​Ambulance: 

​Out-of-Province: 

Out-of-Country: 

OHIP allows private insurance to pay for any portion of the expense not covered under the provincial plan, with the exception of excess physician’s fees. 

​Miscellaneous Functional Equipment: 

​Drugs: 

In addition to the Ontario Health Insurance Program (OHIP), Ontario offers numerous other health programs. Some of them are: 

Website: www.health.gov.on.ca/english/public/program/adp/adp_mn.html
​
The Assistive Devices Program (ADP) helps Ontario residents who have long-term physical disabilities get needed equipment and supplies, regardless of their income, provided they have OHIP coverage. ADP covers over 8,000 separate pieces of equipment or supplies in the following categories: 

ADP pays 75% of the cost of equipment, such as wheelchairs, artificial limbs, orthopedic braces and breathing aids. ADP contributes a fixed amount for items such as hearing aids. For breast prostheses, ostomy supplies, and needles and syringes for insulin-dependent seniors, ADP pays the person an annual grant. Between 75% and 100% of the cost of oxygen and its administration is paid, depending upon various circumstances. 

Website: http://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/funded_drug.aspx
​
This program covers most of the cost of prescription drugs listed in the Ontario Drug Benefit Formulary/Comparative Drug Index (Formulary) or funded through the Exceptional Access Program. The plan covers the following residents, provided they have OHIP coverage: 

There is a deductible under the ODB plan. Single residents age 65 and over pay an annual deductible. The benefit year for ODB runs August 1st to July 31st. After the deductible the seniors pay a dispensing fee up to $6.11 for each prescription. All other ODB eligible people may be asked to pay up to $2.00 for each prescription. 

Website: http://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/fund_trillium.aspx
​
The Trillium Drug Program (TDP) was designed to assist Ontario residents who have high prescription drug costs in relation to their net household income. Eligible drugs are listed in the Formulary. However, similar to the ODB Plan, additional drugs may be eligible if approved through the ministry’s Exceptional Access Program.

Residents may register in the program if they meet the following criteria: 

There is an annual deductible under the plan which is calculated based on the net household income and household size. The deductible is paid quarterly throughout the August 1st to July 31st benefit year. New applicants entering the program throughout the benefit year pay a pro-rated deductible. After the quarterly deductible is paid there is a further $2.00 per prescription deductible. 

Website: http://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/fund_special.aspx
​
This program covers the full cost of certain out-patient drugs used in the treatment of specific conditions such as: 

To be eligible for this assistance the resident must: 

There are no deductibles or co-insurance payments required under this program. 

Website: http://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/fund_new_drug.aspx
​
The New Drug Funding Program was formally approved in May 1997. It is administered by Cancer Care Ontario, on behalf of the ministry, and provides about 75% of the overall funding for new and approved intravenous cancer drugs administered in hospitals. The Policy Advisory Committee, which is comprised of experts from various aspects of the medical profession, recommends what drugs should be funded through the NDFP and under which circumstances. The other 25% is for older drugs which were approved prior to the creation of the NDFP and is covered by the hospitals’ budgets. 

For further information on other Ontario health plans visit the Ministry of Health and Long-Term Care website at: 

 www.health.gov.on.ca

There are two basic types of benefits:

Pooled benefits are unpredictable, infrequent, and volatile and are often high in dollar amount. Life insurance, long term disability, accidental death and dismemberment and catastrophic health claims are pooled benefits. 

For groups of less than 10,000, pooled benefits cannot be projected or predicted from claims history, they are based purely on statistical probabilities taking into account factors such as age and sex. Their rate is unrelated to claims unless the group is very large (over 2500 employees). In that case, the claims history of the group plays an increasing role depending upon the size of the group. 

In rating the life insurance benefit, mortality tables become very accurate once the group goes over 10,000 lives. Insurance companies assemble large groups of people that want to insure their lives. They collect enough premiums so that they are able to pay the claims that occur in the group and realize a profit. Many insurance companies will spread the risk of larger groups by involving other insurance companies. This is called reinsurance. 

These are benefits whose rate is derived either partially or totally from their claims history. They are benefits that are expected to be claimed, they are frequent but generally small in dollar amount. Experience rated benefits usually account for 60% - 90% of the cost of a typical benefit plan. 

Experience rated benefits are also referred to as credible or pre-paid benefits. In this context, “credible” means they can be projected accurately and “prepaid” means the premium is a deposit from which expected claims will be paid. Dental, Vision and Health are experience rated benefits. These benefits are more a commodity than an item requiring insurance; they are best suited for self-insurance.

The credibility factor of a certain benefit is the degree of claims predictability of that benefit. Corporations that have stable employee populations in excess of 30 usually have 100% credibility for their Dental and Vision claims and between 80% - 90% credibility for Health and Drugs. 

Insurance companies will base their rates for experience-rated benefits almost entirely on claims projections. They determine the rates for these benefits by analyzing the group’s historic utilization trends; they accurately project the group’s usage and add their margins.

Pooled benefits are unpredictable benefits like Life Insurance, Long Term Disability, Accidental Death and Dismemberment and catastrophic health claims. These benefits are rated based on statistical probabilities taking into account factors such as age and sex. Their rate is unrelated to claims unless the group is very large (over 1000 employees). 

Insurance companies assemble large groups of people that want to insure their lives. They collect enough premiums so that they are able to pay the claims that occur in the group and realize a profit. Many insurance companies will spread the risk of larger groups by involving other insurance companies. This is called reinsurance. 

This section discusses how insurance companies set the rates for experience rated benefits such as health and dental. 

A group of employees’ and their dependents’ claims usage follows a particular trend. The group might fluctuate in number from year to year, so the trend is based on average claims per employee.

The first step is to project the claims that will be incurred in the period being rated for this group. This is done by taking a weighted average of the usage over the last few years, with the most recent having the highest weighing. 

The next step is to add expected inflation and utilization.

The last step is to add the margin that the insurance company needs to pay its overhead, commissions and profit. Insurance companies divide the projected usage rate by the TRL to produce the rates your company pays.

The Renewal Date for Pooled Benefits (ie: Life Insurance, AD&D, LTD, DGL and Stop Loss) is April 1st of each year. Beneplan will advise the rate changes in March of each year.

At renewal, pooled benefits are reassessed based on the change in the group’s average age and average gender. 

The renewal date for Co-operative Benefits (i.e.: Health and Dental) is January 1st of each year. 

Beneplan will submit a renewal report in early December of each year.

At renewal, experience rated benefits are reassessed based on the usage per employee in the most recent period. The first step is to project the claims that will be incurred in the period being rated by taking a weighted average of the usage over the last few years, with the most recent period having the highest weighing. Then expected inflation and utilization is added. Finally, the margin that the insurance company needs to pay its overhead, commissions and profit is added. For experience rated benefits, rates will increase with inflation for the respective benefit as well as with the increase in usage of your particular group. If your group’s usage rate drops in the latest period then you can expect a moderate rate increase or a rate decrease.

Your company participates in a cooperative for the health and possibly the dental benefits.

For More information please see The Beneplan Co-operative membership package below.

Account/Division #

This is the number related to the various divisions under the policy. Sometimes the Policy is broken up into different divisions for billing or reporting purposes. 

Actively at work 

"Actively at Work", "Actively Employed", "Active Work" or “Actively Working”, means an employee who is actually working at the employer’s place of business or a place where the employer’s business requires the employee to work. Employees who are absent due to scheduled vacation, weekends, statutory holidays or shift variances, maternity leave, parental leave, compassionate leave, sick leave and notice period are also deemed to be actively at work. 

(AD&D) Accidental Death and Dismemberment 

Coverage for death or dismemberment resulting directly from accidental causes. Benefits are provided in the event of loss of life, limbs or eyesight as a result of an accident. 

AD&D Waiver of Premium

If the employee is applying for life insurance waiver of premium, then they should also apply for AD&D waiver of premium (see “Life Insurance Waiver of Premium” below).

Administrative Services Only (ASO)

A type of employee benefit plan funding that is administered by an insurance company or a third party administrator and in which the client (employer) is totally at risk for claims. In other words, ASO is self-insurance.

 Brand Name Drugs

A drug protected by a patent issued to the original innovator or marketer. The patent prohibits the manufacture of the drug by other companies as long as the patent remains in effect, they are typically expensive. 

Certificate / PID #

A unique number that is used to identify each employee. This number must be used in all correspondences and claims. 

Class (Product Set ID)

A group of employees that have many characteristics of employment in common. For example, Hourly employees, Executives, etc. In benefits, a class of employees denotes a specific plan design. Please use “Class” in your day to day administration. Examples of Class abbreviations are CLA, CLB, CLC, CLD, CLE, etc.

 Coordination of Benefits (COB)

A group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts. 

The member of your plan must submit his/her claims to your policy first (the member should keep copies of the receipts and claim), once approved and processed, the employee will receive an explanation summarizing how the claim was handled. The employee then submits the explanation along with copies of the claim and receipts to his/her spouse’s carrier for further consideration of payment, if applicable.

The spouse of your member must submit his/her claims to his/her employer’s policy first (the spouse should keep copies of the receipts and claim). Once approved and processed, the spouse will receive an explanation summarizing how the claim was handled. The spouse then submits the explanation along with necessary forms and receipts to our carrier for further consideration of payment, if applicable.

For dependent children, claims must be submitted first to the carrier of the spouse whose birthday comes first in the year (not the oldest). Once approved and processed, the explanation on how the claim was handled is then submitted to the other spouse’s carrier for further consideration of payment, if applicable.

 Cost Plus 

A way to pay claims that are not covered by the plan. It is typical for owners or top executives of companies to require that all their claims be paid by the company. This makes very strong tax sense since payments are tax-deductible expenses to the company, but not taxable benefits to the owner/executive. Beneplan processes such claims as follows:

Critical Illness

A benefit designed to assist plan members who are diagnosed with a critical illness by providing funds for their discretionary use, to seek alternative treatments or to just help offset unanticipated expenses such as diminished income, home alterations or living assistance. It provides a one-time lump sum payment to plan members who are diagnosed with a covered illness and survive the 30 day waiting period.

 Critical Illness Waiver Premium

If premiums for the basic life coverage are waived, the coverage premium will also be waived as long as the policy and the plan sponsor’s coverage remain in force.

 Death Benefit

The payment made to designated beneficiaries upon the death of a participating employee, i.e. life insurance or AD&D. 

 Dependents

The natural children and legal spouse of the member. Children are eligible to be dependents if they are under 21. Children over 21 can continue to be eligible up to age 25 if they are enrolled full time in a university or a college of higher education.

 Common Law Spouse and his/her children

A common-law spouse is a person whom the employee has lived with in a conjugal relationship continually for at least 12 months and publicly represented as a spouse. If the common law spouse has custody of his/her children, they are automatically eligible to be covered. 

Out of Country Student

Dependants studying outside of Canada need to be fully aware that out-of-country coverage is not full coverage; it is emergency coverage only. It is important for employees that they purchase full coverage while their dependants are studying abroad. 

 Handicapped

The employee can insure his/her child after age 21 (25 if a student) if the child is permanently incapable of supporting his or herself financially due to a medically diagnosed physical or psychiatric disorder. A “Health Evidence” form must be submitted to Beneplan Administration who will then send it to Green Shield for approval. If approved as a handicapped child then this approval is for life as long as the employee works with his/her company. This form can be found under the ‘Forms’ section at the end of this manual.

Incurred but Not Reported (IBNR) Reserve

The IBNR reserve is set up to cover incurred but not reported claims. Insurance companies do this to fund claims they will have to pay after the date of termination of the contract. They set this reserve very liberally to protect themselves, although there are methods to measure it more accurately. 

 Insurance companies very often price the first-year rates without regard to the IBNR i.e. They use the projected paid claims in the first year to set first year rates. This results in very competitive rates when they are bidding on a new group. 

Insurance companies build the IBNR at first renewal, which is why first renewals result in a very large increase. IBNRs are usually larger than they need to be and the insurance company usually keeps any funds left over in the reserve. 

 Inflation, Utilization & Trend

Trend is the increase (or decrease) in the rate for the benefit that is being utilized.

Trend has two parts: inflation and utilization.

Inflation is the increase in the cost of the components of the benefit year over year.

Utilization is the increase in the benefit usage due to social, educational and lifestyle reasons.

Dental inflation over the last few years has been only 3% on average. Dental utilization was very high in the eighties, is now tame in the area of 2-5% so total dental trend averaged between 5%-7% over the last few years. 

Health inflation over the last few years has been high at 10% on average; Health utilization continues to be high, in the area of 5-10%, so total health trend averaged between 15% - 20% over the last few years.

 Grandchildren and adopted children

Can be covered but only if there is a court order, declaring the member as legal guardian. 

Note: Parents are never considered eligible dependents.

 
​Dependent Group Life Insurance (DGL)

The amount of insurance for which a dependent is covered. 

If premiums for the employee’s basic life insurance coverage under this policy are waived, premiums for the dependent life benefit will also be waived but only as long as the policy remains in force. 

 Dismemberment

An injury which results in:

Effective Date of the group

The date on which an insurance policy goes into effect and coverage begins.

 Effective Date of the employee

 The date on which coverage begins for the employee and his family.

 Eligibility Period 

Usually 31 days after the effective date of the employee, when potential members of a group life or health insurance plan can still enroll without evidence of insurability.

 Eligible Requirements 

Conditions that an employee must satisfy to participate in a plan. 

 Eligible Employees

Those members of a group who have met the eligibility requirements under a group life insurance or health insurance. 

 Eligible Expenses

Medical expenses for which a health insurance policy will provide benefits.

Employment Standards Act, hereinafter referred to as the ESA

A federal act that regulates employment law in Canada. 

 Enrollment

The process by which an individual and or dependents become subscribers to health plan coverage. The enrollment is done through a completion and signing of the enrollment form, found at the back of this manual. 

 Family coverage

Coverage that includes the employee, his spouse and dependents. 

 Fee Schedule 

A listing of fees or allowances for specified medical procedures, which usually represent the maximum amount the program will pay for specified procedures.

 Flat Benefit

 A type of benefit in group insurance under which everyone is insured for the same benefit regardless of salary, position or other circumstances. 

Generic Drugs

Equal in therapeutic power to the brand-name originals because they contain identical active ingredients at the same doses. They are usually inexpensive.

 Hire date

The employee’s first day worked.

 Health Spending Account HSA

A benefit (usually for owners or top executives) that gives the member a specific amount of money that he/she can claim for procedures and services not eligible to be paid from the regular plan. It is usually a specific annual amount.

 Life Insurance Conversion

If the employee’s insurance terminates due to termination of the employee’s coverage, the employee is entitled to convert the coverage he/she had under the policy to an individual policy without going through medical underwriting. The individual life-policy will be issued if a written application (including the required first premium) is completed and received by Humania Assurance within 31 days from the date the insurance terminates.

 Life Insurance Waiver of Premium

If the employee becomes very sick, with a possible result in death (stroke, heart attack, etc) then the administrator should apply for a life insurance waiver of premium. If approved, premiums for life insurance are not payable while coverage continues.

 Long Term Disability (LTD)

 LTD is a significant period of disability generally ranging from six months to life. The LTD provides a reasonable replacement of a portion of an employee’s earned income lost through serious and prolonged illness or injury during his normal work career. 

 No Substitution

 An expression that doctors may write on their prescription indicating that the pharmacist must dispense the drug prescribed and not any generic equivalent. 

 Provincial Health Insurance Plan

 It is a health plan that provides government sponsored hospital, drug, and dental or other medical care benefits for residents of the province in Canada. Each province has their own plan that covers residents of that province. Provincial plans vary in coverage and conditions of coverage from one province to another, some require premiums to be paid by residents and others do not. 

 Opt Out

Employees may decide to opt out of health and/or dental benefits (only), if they are covered under their spouse’s benefit plan. An Opt-out employee is eligible to rejoin if his/her spouse loses coverage. They need to do so within 30 days of losing the other coverage, otherwise they will be required to provide evidence of satisfactory health and may be denied coverage. Employees cannot opt out from all other benefits while the employee is actively at work.

 Out of Country/ Province Emergency Care

Out‑of‑Country Emergency care is provided for covered persons for the first 60 days of travel as a result of a medical emergency arising while the covered person is travelling outside Canada for vacation, business or education. A medical emergency means a sudden, unexpected injury or an acute episode of disease. Emergency medical care does not include medical attention for the monitoring of a stabilized condition. 

Policy/Group/Contract Number

The number that identifies the “Employer” and it should be reflected on all claim forms submitted by employees.

 Predetermination / pre-authorization / pre-estimate of cost / pre certification / pre-treatment estimate / prior authorization

An administrative procedure whereby a covered member submits a treatment plan to the carrier before treatment is initiated. The carrier reviews the treatment plan, indicating the amount that would be approved. 

Employees must complete a health or dental predetermination form if the amount is over $500. If pre-determination is not obtained prior to incurring and submitting the claim, it may be denied. 

 Pre-existing Condition

Means a sickness or injury for which the Employee sought medical investigation, diagnosis, treatment, care, medication or medical advice, or for which there were symptoms which would have caused a person to seek medical investigation, diagnosis, treatment, care, medication or medical advice within the 90 Day period immediately prior to becoming insured under this Policy. 

 Reasonable and Customary Treatment

Treatment that is generally accepted and recognized by the Canadian medical profession as effective, appropriate and essential in the treatment of the medically diagnosed condition. 

Green Shield will not pay for any service or appliance just because the member purchased it. Insurers have a “reasonable and customary” clause that declares that they will pay for the procedure or appliance if it is a reasonable and customary procedure or appliance that treats the illness. Employees are advised to submit the procedure or appliance they plan to purchase for pre-determination.

 Reinstatement

The resumption of coverage after the employee’s coverage is terminated, provided the termination is within six months of reinstatement. The re-instatement date must be the first day worked after return to work.

If an employee returns to work within 6 months of the previous termination date, then all benefits can be reinstated, without the need to re-serve the waiting period. In this case, no “Enrollment” form is required. 

If after 6 months, or in the event that the employer wishes the employee to re-serve the waiting period, then the employee would be considered “new”, requiring a new “Enrollment” to be completed.

 Short Term Disability (STD) and Short Term Disability Income Insurance

STD is a disability lasting less than six months. STD income insurance is a provision to pay benefits to a covered disabled person as long a she or she remains disabled up to a specified period. 

Single Coverage

Single coverage applies to an employee who has no dependents. In the case that a “single”, who has dependents on his effective date, wishes to include his dependents at a later date then they will be considered late applicants and must provide evidence of satisfactory health.

 Stop Loss Insurance

Contract established between a self-insured group and insurance carrier providing coverage if claims exceed specified dollar amount over a set period of time. It may apply to an entire plan or a single component. It is also called “excess loss insurance”. 

 Target Loss Ration (TLR): 

Expressed as a percentage, TLR is the percentage of premiums that the insurance company expects to pay as claims. A TLR of 80% means that of every $100 of premiums the insurance company expects to pay $80 as claims. This means the insurance company hopes to keep $20 to cover their costs and profit. That is 20% of premiums or 25% of claims.

The larger the group, the larger the TLR. A group of 20 employees is likely to have a 70% TLR, while typically a group of 40 employees would have a 75% TLR and a group of 60 employees would have a 80% TLR. The best and largest groups would have a TLR of 85%. 

A TLR of 80% really translates into a mark-up on claims of 25%.

For example: the 20% as a percent of the 80% claims is a 25% mark up on claims.

 Termination date

The employee’s last day worked or end of notice period (whichever is later). 

 Waiting Period

It is the period between employment or enrollment in a program and the date when an insured person become eligible for benefits.

 Weekly Indemnity Insurance (WI)

Also referred to as Short Term Disability (STD). 

Please notify Beneplan as soon as possible when an employee’s status is changed so that their salary or class is up-to-date. The notice can be emailed or faxed to Beneplan.

Failure to do so may result in legal and financial risk to your company. Please contact Beneplan if you would like an explanation as to how this might happen.

If an employee is making any of the following changes and change form is required. Change forms are located in the back of the binder, or online. For a traditional online form please visit:

Change forms are warranted for any of the following changes:

Once the employee has completed the form the following steps need to take place:

Send the forms to Beneplan by email or fax first, and the original form must follow by mail

If the employee(s) is been terminated, please send the following information to Beneplan by emailing, faxing, or mailing the following information:

If the company lay off employee(s), the company can choose to suspend or extend the benefits for the employee(s) during the lay off period. If the company wants to extend the benefits of the benefits, please send the following information to Beneplan by emailing, faxing, or mailing the following information:

Beneplan will prepare the Letter of Agreement (LOA) and mail it to the company. Please read and sign the LOA and mail it back to Beneplan so we can process from there.

If the company chooses to suspend the benefits, please inform Beneplan following the termination process. 

If the employee(s) take voluntary leave of absence, the company can choose to suspend or extend the benefits for the employee(s) during the leave. If the company wants to extend the benefits of the benefits, please send the following information to Beneplan by emailing, faxing or mailing:

Beneplan will prepare the Letter of Agreement (LOA) and mail it to the company. Please read and sign the LOA and mail it back to Beneplan so we can process from there.

If the company chooses to suspend the benefits, please inform Beneplan following the termination process. 

If the employee(s) take sick leave, please contact admin@beneplan.ca .

Contacting Beneplan
Please send all changes to:

admin@beneplan.ca 1-800-387-1670 x245 or x 267

Beneplan is pleased to introduce the Beneplan HR Toolkit, which is an extra assistance program (XAP) including the following embedded features for all members:

Beneplan members are now eligible to book a call with the in-house HR Advisor for support in areas such as talent acquisition, employment contracts, compensation and layoffs.

For More information please contact us by phone at 416-863-6718- Ext 268
Or

(Pharmacogenetic testing coverage based upon approval)

To Learn more or find out if you are covered contact the P3 Team below or visit them online.
Personalized Prescribing Inc: 

Or

OR

Beneplan Members have access to a full EFAP from Telus Health.

The only Employee and Family Assistance Program(EFAP) provider with a full range of flexible and confidential counselling delivery options available to you and your family members.

To learn more contact Telus Health by phone at 1 (844) 880-9142
or
 Visit them online at Telus Health One.
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For all forms please visit us online at Beneplan 

For Standard Beneplan Inc Electronic and Printable forms 

For All Co- operators Forms 

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