Accident & Sickness Insurance for Individuals (A&S)

Health insurance is available to all Canadians through provincial health plans. The services vary and have limits. Five types of individual accident & sickness insurance help cover expenses which government plans exclude:

  1. accidental death & dismemberment
  2. extended health care
  3. dental plans
  4. prescription drugs
  5. travel assistance

These plans provide lump sum reimbursement for expenses incurred, not income. So disability insurance is also useful.

Coverage is most often provided through group health plans.

Expenses from self-inflicted injuries or criminal acts are usually excluded


  • provide lump sum reimbursement (e.g., for medical expenses, treatments, prescriptions)
  • no waiting period
  • to reduce costs (which would otherwise cause premium increases), plans may have
    1. deductible
      • the amount you pay before the insurer will pay (you'd find this on your car and home insurance also)
      • can be lower for you than your family
    2. coinsurance factor
      • the percentage of the costs that you pay (e.g., 20%)

Benefit Formula

\begin{align} Benefit = (Claim - Deductible) \times (1 - Coinsurance Factor) \end{align}
  • you pay the deductible and coinsurance factor


Accidental Death & Dismemberment (AD&D)

  • lump sum if
    • death from an accident (can assign the beneficiary), or
    • qualifying multiple dismemberments
      • partial benefit available for single dismemberment
  • may be a rider on another insurance plan
  • no proof of a financial loss is required

Extended Health Care

  • also called "major medical"
  • usually covers
    • semiprivate or private hospital room
    • ambulance services
    • prescription drugs
    • private duty nursing
    • medical appliances (e.g., artificial limbs)
    • diagnostic services

Dental Plans

  • preventative endodontics (e.g., exams, x-rays, polishing, fillings, root canal)
  • restorative (e.g., crowns, inlays)
  • orthodontic (e.g., braces)
  • periodontic (e.g., teeth, bones, and gums)
  • prosthodontic (e.g., dentures, bridges, caps, veneers)

Prescription Drugs

  • may be part of an Extended Health Care plan or a separate plan
  • two types
    • reimbursement: you pay for the drugs and get reimbursed by the insurer later
    • pay direct: you use the drug insurance card and the insurer pays the pharmacy directly
  • to limit costs, plans usually include
    • deductible: annual dollar amount you must pay first (e.g., $50)
    • coinsurance: you pay a percentage of the expenses (e.g., 20%)

Travel Assistance

  • when traveling outside Canada for health care costs which provincial plans exclude
  • usually covers
    • hospital and medical costs
    • transfer to hospitals
    • transportation services
    • required travel by family members
    • repatriation (cost of returning to Canada. e.g., upon total disability or death)


Premiums Benefits
deductible as medical expenses under the medical tax credit tax-free

Contract Provisions

  • incontestable after in force continuously for two years from the later of issue, renewal or reinstatement
    • except for fraud (no time limit)
  • pre-existing conditions: free of treatment for 90 days before coverage can begin

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