Blue Choice Balance - Kanetix.ca · Kidney failure, kidney transplant Gastrointestinal disorders :...

Blue Choice

®

BalanceHealth Care Plan

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WHY BLUE CHOICE®

BALANCE?

COMPREHENSIVE COVERAGE

Blue Choice® Balance Health Care coverage allows you all of the benefits of a comprehensive health plan for only dollars a day.

Coverage includes:

◆ Extended Health Care

◆ Dental Care

◆ Prescription Drugs

◆ Out-of-Country Travel

◆ Accidental Death and Loss of Use

OPTIONAL COVERAGE

◆ Hospital Coverage


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THE BLUE CROSSASSISTANCE PROGRAM

INCLUDED IN ALL BLUE CROSS HEALTH PLANS

Enrolment into a Blue Cross health plan automatically grants you access to the exclusive Blue Cross Assistance Program.

This members only program offers access to Consultants and Support Services, Information and Prevention Services and exclusive Member Discounts.

This program provides you with:

◆ Home Support Services, following a hospital stay of two or more nights (including after childbirth), and includes coverage for medication delivery, domestic help and tutoring services

◆ Access to legal advice and consultations

◆ And more...

As a part of this program, you also have access to exclusive offers and services through our renowned partners.

Upon enrolment, you will receive a booklet detailing the benefits of the program along with details about our Blue Advantage discount program that offers you discounts on products and services across Canada.*

Blue Cross Assistance. Another unique and valuable feature of your Blue Cross health care plan.

*Some conditions apply. Details in your Assistance Program booklet.


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BLUE CHOICE BALANCEBENEFIT DETAILS

All maximums are per covered person.

EXTENDED HEALTH CARE

80% reimbursement for the following benefits:

◆ Ambulance Services

◆ Hearing Aids

◆ up to $300 every 5 calendar years, subject to a 3 month waiting period

◆ Orthopaedic Shoes

◆ up to $200 per calendar year

◆ Prostheses & Accessories

◆ up to $2,500 per calendar year

◆ Nursing Services and Home Care ◆ up to $2,500 per calendar year

◆ Purchase or Rental of Equipment

& Diabetic Supplies (includes standard electric wheelchairs, crutches etc.)


◆ Surgical Stockings

◆ up to $100 per calendar year

Covered at 100%

◆ Accidental Dental


PARAMEDICAL COVERAGE

100% reimbursement for the following benefits:

◆ Registered Therapists and Specialists

Benefits are payable only after the yearly OHIP maximums have been reached.

REGISTERED THERAPISTS

AND SPECIALISTS

INITIAL

VISIT

PER

VISIT

MAX.

NUMBER

Psychologist $80 $65 20

Speech Therapist $65 $45 12

Massage Therapist* $20 $20 20

Chiropodist /Podiatrist $20 $20 25

Naturopath $20 $20 25

Physiotherapist $20 $20 25

Osteopath $20 $20 25

Acupuncturist $20 $20 25

Chiropractor $20 $20 25

* A written recommendation by a physician is required


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◆ Vision Care Coverage

◆ up to $100 per 2 calendar years, subject to a 3 month waiting period.

◆ Optometry Exams – up to $50 per 2 calendar years for individuals between 20 and under 65 years of age.

◆ Includes laser eye surgery

◆ Prescription Drugs1

◆ Benefits are pro-rated in the first year ◆ No deductible ◆ Pay Direct Drug Card ◆ 70% coverage – up to $5,000 per calendar year ◆ Available only to persons under 65 years old. The benefit terminates on the 65th birthday.

◆ Dental Care2

◆ Benefits are pro-rated in the first year ◆ No deductible ◆ 70% reimbursement – for basic dental services ◆ $500 per person per calendar year maximum ◆ 9 month recall exams ◆ Coverage is paid in accordance with the current Ontario Dental Association Fee schedule

◆ Out-of-Country Travel3

◆ Unlimited number of trips less than 15 days ◆ Up to $5,000,000 in coverage ◆ 100% reimbursement ◆ Available top-up extension insurance

◆ Accidental Death & Loss of Use

Maximum payable amount:

◆ $25,000 per adult ◆ $5,000 per child ◆ Non-taxable benefit ◆ Terminates at age 75

OPTIONAL COVERAGE

◆ Hospital4

◆ Private or semi-private room ◆ $200 per day for hospital room ◆ 100% reimbursement ◆ 90 days per year maximum

QUESTIONS? CALL US: 1-800-873-2583WE ARE HAPPY TO HELP!


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IMPORTANT NOTICE

1 Prescription DrugsIn the first calendar year, the maximum reimbursement allowed will be reduced based on the number of months remaining in the calendar year, beginning with the month immediately following the effective date. ($5,000 x number of months remaining in year / 12 = maximum reimbursement)

2 Dental CoverageIn the first calendar year, the maximum reimbursement allowed will be reduced based on the number of months remaining in the calendar year, beginning with the month immediately following the effective date. ($500 x number of months remaining in year / 12 = maximum reimbursement)

3 Exclusions relating to pre-existing conditions for Out-of-Country Travel Coverage

For individuals 60 years of age and under:

During the three months prior to the departure date of any trip, any illness, injury or condition related to a medical condition for which the Insured:

◆ consulted a physician (other than for a regular checkup); or ◆ was hospitalized; or ◆ was prescribed or received a new treatment; or ◆ received a change in an existing treatment; or ◆ was prescribed or had taken a new medication; or ◆ received a change in existing medication (including usage or dosage)

For individuals 61 years of age or over:

During the six months prior to the departure date of any trip, any illness, or condition related to one of the medical conditions listed below for which the Insured:

◆ consulted a physician (other than for a regular checkup); or ◆ was hospitalized; or ◆ was prescribed or received a treatment; or ◆ was prescribed or had taken a medication for:

◆ Cardiovascular disorders: heart attack, angina, arrhythmia, pacemaker, defibrillator, heart failure, bypass, angioplasty, valvulopathy or valve replacement, aortic aneurysm, heart transplant, peripheral vascular disease

◆ Chronic obstructive pulmonary disorders: asthma, emphysema, chronic bronchitis, lung transplant

◆ Neurological disorders: stroke, transient cerebral ischemia (TCI) ◆ Insulin-dependent diabetes: diabetes treated with injected insulin ◆ Kidney failure, kidney transplant

◆ Gastrointestinal disorders: cirrhosis, hepatitis, ulcer, internal bleeding, liver transplant, surgery for bowel obstruction

◆ Cancer or malignant tumour

During the six months prior to the departure date of any trip, any other illness, injury or condition related to a medical condition for which the Insured:

◆ consulted a physician (other than for a regular checkup); or ◆ was hospitalized, or; ◆ was prescribed or received a new treatment; or ◆ received a change in an existing treatment; or ◆ was prescribed or had taken a new medication; or ◆ received a change in existing medication (including usage or dosage)

4 Hospital CoverageBenefits for Hospital Coverage as a result of conditions arising from pregnancy are available only after eight (8) months of continuous coverage.


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This is not a contract.Actual terms and conditions are detailed in the policy provided by Ontario Blue Cross. It contains important information concerning details, terms, conditions and limitations. Please read your description of benefits carefully upon receipt.

HOW DO I ENROLL FORBLUE CHOICE BALANCE?

Determine your monthly rate by referring to the enclosed rate card. You may contact our call centre and they can process your application over the phone, or once you have determined your rate, you may enroll online at www.on.bluecross.ca or complete the attached application and mail it in the return envelope. Please ensure that all of your personal information is correct.

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® Registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Canassurance Hospital Service Association carrying on business as Blue Cross.

®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.10O

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FOR MORE INFORMATION ON BLUE CROSS PRODUCTS, CONTACT US TODAY!

Online: www.on.bluecross.ca

or, by phone in the Toronto area:416 626-1447

or, toll free, elsewhere in Ontario:1 800 USE-BLUE

(1-800-873-2583)

185 The West MallSuite 610P.O. Box 2005Etobicoke, Ontario M9C 5P1


MONTHLY RATE CHARTS

Blue Choice

®

BalanceHealth Care Plan

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EFFECTIVE APRIL 1ST, 2019

BLUE CHOICE® BALANCE

HEALTH CARE PLAN

WITHOUT HOSPITAL($)

AGE INDIVIDUAL COUPLE* FAMILY*SINGLE PARENT

16-24 103.30 175.62 289.26 185.95

25-39 103.30 175.62 289.26 185.95

40-44 103.30 175.62 289.26 185.95

45-54 117.90 200.43 330.12 212.22

55-64 151.83 258.11 425.13 273.31

65-69 93.23 158.49 362.23 176.29

70-74 94.94 161.40 366.79 176.29

75+ 85.83 145.90 366.79 176.29

WITH HOSPITAL($)

AGE INDIVIDUAL COUPLE* FAMILY*SINGLE PARENT

16-24 111.72 189.94 312.84 201.11

25-39 111.72 189.94 312.84 201.11

40-44 111.72 189.94 312.84 201.11

45-54 130.67 222.15 365.89 235.21

55-64 170.06 289.10 476.18 306.12

65-69 135.95 231.12 475.88 249.35

70-74 137.66 234.03 480.44 249.35

75+ 145.67 247.62 480.44 249.35

* Couple and family rates indicated are based on two individuals in the same age category. To determine couple rates for individuals in different age brackets, please add both individual rates and multiply by 0.85.

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Online: www.on.bluecross.ca

or, by phone in the Toronto area: 416 626-1447

or, toll free, elsewhere in Ontario: 1 800 USE-BLUE (1-800-873-2583)

185 The West Mall, Suite 610, P.O. Box 2005, Etobicoke, Ontario M9C 5P1

FOR MORE INFORMATION ON BLUE CROSS PRODUCTS, CONTACT US TODAY!

® Registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Canassurance Hospital Service Association carrying on business as Blue Cross.

®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.0

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a) Select a Plan: Health Benefits

b) Choose the type of Protection:

Single

Couple Family Single Parent

1. COVERAGE SELECTIONPLEASE MAKE SELECTIONS FOR A & B

Instructions:1. Print in ink, or type information.2. Complete all parts of the application, including all questions & details.3. Missing information will delay the processing of your application.4. Remember to sign and date your application.5. Original application required.6. Please complete all unshaded areas. Blue Choice® Balance Health Care Plan

Application Form

2. PERSONAL INFORMATIONPRIMARY INSURED

Last Name

First Name

Date of Birth Day Month Year Age

Address No. Street Apt.

City Province Postal Code

Telephone Daytime ( ) Evening ( ) E-mail Address

Should we require further information to process your application, may we phone you during business hours? Yes No Most convenient time: _______________

Language

English French

Sex

M F

PLEASE COMPLETE INFORMATION FOR EACH APPLICANT. MINIMUM APPLICANT AGE IS 16 YEARS.

Sex Date of Birth Height Weight

Last Name First Name Relationship Day Month Year Age (in./cm) (lb/kg)

Applicant

Spouse

Children

M F

M F

M F

M F

M F

Please proceed to the reverse side of the application.01ONT0279A (04-19)

3. MEDICAL INFORMATION – based on your medical history, you may be declined or excluded for specific benefits.PROVINCIAL HEALTH COVERA GE – Please initial beside response

Do you and your Spouse and/or Dependents have valid OHIP Cards? Yes ______Initial No ______Initial

Important: Please note you must have a valid OHIP Card to apply for coverage. Eligibility for this contract is extended only to residents of Ontario who hold a valid Ontario Health Insurance Plan Card; no other person may be an insured hereunder, even if premium has been accepted by Ontario Blue Cross.

TO BE COMPLETED BY ALL APPLICANTS:

1. Have you or any listed dependents consulted and/or received advice or treatment from a registered specialist or therapist (Chiropractor, Physiotherapist, Psychologist, Masseur etc.) during the past two years, or have you been advised to do so?

2. Have you or any listed dependents purchased, during the past two years or plan to purchase orthopaedic shoes, supplies or arch supports?

3. Have you or any listed dependent rented/purchased during the past two years or plan to rent/purchase assistive devices (artificial limbs, braces, etc.), medical equipment or supplies (walker, wheelchair, oxygen, CPAP machine, ostomy supplies etc.)?

4. Have you or any listed dependent required ambulance services or nursing care during the past two years?

5. Have you or any listed dependent consulted a physician or specialist about, been treated for or had any known indication of: heart or circulatory disorder, angina, heart attack, arrhythmia (irregular heartbeat), TIA (mini-stroke) or stroke, insulin dependent diabetes, chronic kidney or liver disease, Chronic Obstructive Pulmonary Disease (COPD) or emphysema, leukemia or cancer (excluding basal cell carcinoma), Multiple Sclerosis, Motor Neurone Disease, Alzheimer’s, Parkinson’s, senile dementia or any inheritable disorder (such as polycystic kidney disease or Huntington’s Chorea)?

Yes No

Yes No

Yes No

Yes No

Yes No

6. Please provide full details if you have answered ‘yes’ to any of the above questions.

Person’s Name Date Details – If space does not allow for a full description of the details, please use the ‘Additional Information’ section on the reverse of this application.

Health Benefits with Hospital

01ONT0279A Blue Choice Balance_ (04-19)_ REV_26_02.ai 1 19-03-29 13:1601ONT0279A Blue Choice Balance_ (04-19)_ REV_26_02.ai 1 19-03-29 13:16

8. ARE YOU OR ANY LISTED DEPENDENT CURRENTLY TAKING ANY PRESCRIPTION MEDICATION, HAVE A PRESCRIPTION FOR WHICH REFILLSARE AUTHORIZED, OR HAVE A PRESCRIPTION THAT HAS NOT BEEN FILLED AS OF YET? PLEASE PROVIDE DETAILS IF THE ANSWER IS ‘YES’.

7. TO BE COMPLETED BY ALL APPLICANTS.

Name and address of personal physician:

Date Last Consulted (DD/MM/YY):

Reason (if for check-up, what problems/symptoms did you have)?

Findings and/or treatment:

Name and address of personal physician:

Date Last Consulted (DD/MM/YY):

Reason (if for check-up, what problems/symptoms did you have)?

Findings and/or treatment:

APPLI

CANT

SPOUSE

Person’s Name Prescription Name Strength Daily Qty. Reason Cost perPresc. # of Refills/Yr.

YES NO

9. Have you or any listed dependent EVER consulted a physician or specialist, been treated for or had any indication of:Please select either YES or NO for ALL questions.

a) Heart, circulatory trouble or chest pain?

b) High blood pressure, stroke, blood disorder or elevated cholesterol?

c) Cancer, tumour or Leukemia?

d) Diabetes, Colitis or Crohn’s?

e) Respiratory or Allergy Disorder (including asthma)?

f ) Bone or joint disorder (including arthritis)?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

g) Mental, nervous or emotional disorder?

h) Stomach, intestinal, liver, kidney or bladder disorder?

i) Chronic headaches, migraines or recurrent infections?

j) Skin disorder (including acne)?

k) Alcohol or drug dependency?

l) AIDS, ARC (AIDS Related Complex) or other immunological disorder?

m) Infertility/Reproductive disorder?

n) Have you or any listed dependent been advised, treated or hospitalized for any physical impairment, condition, disease or disorder stated above?

o) Have you or any listed dependent had or currently have a referral, testing, or investigation pending or contemplated but not yet completed?

Yes No

Yes No

Yes No

10. IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE PROVIDE DETAILS BELOW:

Question (indicate letter)

Persons Name Condition Type of Treatment Result of Treatment/Extent of Recovery

Treatment Dates

FirstDD / MM / YY

LastDD / MM / YY

Additional Information:

11. Have you or any listed dependent smoked tobacco in the last 12 months? If so, who:__________________________________________________

12. Are you or any of your listed dependents pregnant*? If yes, who:________________________________________________ Due Date___________*Benefits for Hospital Coverage as a result of conditions arising from pregnancy are available only after eight (8) months of continuous coverage.

Notice: You may be contacted for further information in order to process your application.

Yes No

Yes No


4. PAYMENT - please select only one method of payment (A, B or C)

*A. CREDIT CARD PAYMENT

*B. ANNUAL CHEQUE

MONTHLY ANNUAL Amex Master Card VISA

Card Number Expiry Date: M Y

Signature of Cardholder:

Please attach a cheque payable to ONTARIO BLUE CROSS. (monthly rate x 12)

Would you like a receipt for income tax purposes? Yes No _____________ Initial

*C. Monthly Automatic Bank Withdrawals

PRE-AUTHORIZED DEBIT (PAD) AGREEMENT

1. PAYOR INFORMATION (PLEASE PRINT)

Last and first names of depositors

Account holder name _______________________________________________________ First name _______________________________________________

Joint account holder name ___________________________________________________ First name _______________________________________________

Address ________________________ Street __________________________________________________________________ Unit _____________________

City ________________________________________________________ Province ___________________ Postal code ______________ - _______________

Telephone (______) ________-___________ Mobile (______) ________-___________ E-mail ______________________________________________________

FOR ADMINISTRATION ONLY

Contract no. ________________ Insured's name ________________

2. BANK ACCOUNT INFORMATION

Financial institution ___________________________________________________________________________________________________________________

Address ________________________ Street _____________________________________________________________________________________________

City ________________________________________________________ Province ___________________ Postal code ______________ - _______________

Institution no. Branch transit no. Account no.

4. SIGNATURE

Signature of the account holder Signature of joint account holder (if applicable)

Name ________________________________________________________ Name ________________________________________________________________

Date ___________________ Date ___________________

3. AUTHORIZATION OF PRE-AUTHORIZED DEBIT (PAD)

1. I, the undersigned, hereby authorize Blue Cross Canassurance, hereinafter called the Insurer, to debit my bank account identified above monthly, on the date indicated below or the following business day, for the sum of $__________.______, in payment of my insurance contract. If no date is entered, I understand that the date may be determined by the Insurer without giving me prior notice.

Desired withdrawal date: _________________ (excluding the 29th, 30th and 31st). I have attached a sample cheque

I authorize the Insurer to debit my bank account for a one-time amount when required for the payment of amounts owing in respect of my insurance policy, including service fees and applicable taxes. I understand that, for the purposes of this Agreement, all pre-authorized debits (PAD) withdrawn from my account are fixed or variable-amount personal PADs.

2. I understand that the amount of the PAD may be increased or decreased at a later date as a result of insurance policy endorsements, exclusions or renewal. I understand that the Insurer is required to send me prior notice of thirty (30) days only for the renewal of my policy.

3. I understand that if a PAD is returned due to insufficient funds, the Insurer may resubmit the PAD amount to my financial institution. I accept that any related service charges incurred as a result of the returned PAD will be added to the subsequent PAD.

4. I understand that I must notify the Insurer in writing of any changes to the information regarding the above-mentioned bank account at least ten (10) business days prior to a PAD.

5. I understand that I may modify the method or frequency of paym of my insurance premium by contacting the Customer Service department at 1 800 363-3958. I understand that, following a change I have requested to my insurance policy or this Agreement that changes the amount of my PAD, the Insurer is not required to notify me prior to withdrawal of the new PAD.

6. I understand that I may revoke this authorization at any time subject to providing ten (10) days’ notice in writing. To obtain a sample cancellation form or for more information on my right to cancel a PAD agreement, I may contact my financial institution or visit www.cdnpay.ca.

7. I understand that the Insurer may cancel this Agreement upon thirty (30) days’ written notice, that such cancellation will not terminate my insurance policy and that an alternative method of payment accepted by the Insurer will replace the PAD for the payment of my premiums.

8. I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive a reimbursement for any PAD that is not authorized or is not consistent with this agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca

TYPE OF SERVICE: PERSONAL


5. IMPORTANT INFORMATION, AGREEMENT, CONSENT & PRIVACYFAILURE TO COMPLETE THIS APPLICATION IN ITS ENTIRETY WILL RESULT IN DELAYS.

Contract Effective Date: The contract will be effective on the date of approval by the insurer provided the first premium is paid in full and that no change occurred in the insurability of the person(s) to be insured since the signature of the application. 10-Day Right to Examine: You have 10 days from the effective date of your policy to examine and return it for refund of monies paid, if you are not entirely satisfied.

In applying for this coverage, I understand that Ontario Blue Cross needs to know the complete medical history of myself and of any family members. I have read over the application and certify that all questions are answered fully and correctly. I understand and agree that any injury that occurred on or before the date of this application or any sickness which appeared on or before the date of this application must be fully disclosed on this application and may not be covered. I understand and agree that it is my obligation to inform Ontario Blue Cross of any change in the health of myself and of any family members to be covered due to either injury or illness which occurs after the date of this application and prior to the effective date of the policy.

The discovery of facts known by me or by my covered dependents but not disclosed to Ontario Blue Cross could result in the denial of a claim and the cancellation or modification of the policy. I agree that this application, any supplemental information as required by Ontario Blue Cross, and the policy shall constitute the entire contract. NOTICE REGARDING PERSONAL INFORMATION: I hereby authorize Canassurance Hospital Service Association (Blue Cross) and its subsidiaries1 , to collect, use and disclose any personal information regarding myself and/or my dependent children from and to the following individuals and organizations: any licensed medical practitioner or licensed health professional, hospital, clinic or medical related facility, any other insurance company, including any reinsurance company, or any other person or organization with information relevant to my claim or coverage, and any other person or organization that provides information services or insurance services to, or that acts as an insurance intermediary for Canassurance Hospital Service Association. Ontario Blue Cross aims to ensure the greatest confidentiality possible. All of your personal information is kept in a file titled “Insurance File”. The information held by the insurer is confidential; only an employee of the insurer may consult your file, and only if justified as part of his or her job. As well, unless you object, this information may be used for personal solicitations by mail or by telephone. You may consult your file and correct the information as needed by writing to the insurer at: 185The West Mall, Suite 610, Etobicoke, ON, M9C 5P1.

I agree that no coverage is in effect unless and until my application is approved by Ontario Blue Cross.

This consent is valid for the length of time necessary for Canassurance Hospital Service Association to achieve the purposes mentioned in the Notice regarding personal information. I understand that I may withdraw this consent at any time by giving Canassurance Hospital Service Association written notice of withdrawal. I also understand that withdrawal of my consent could result in Canassurance Hospital Service Association’s inability to provide coverage or pay claims. A photocopy of this authorization is as valid as the original. For further details, please visit our Website at www.on.bluecross.ca or contact us by phone.

Dated(Day/Month/Year) Signature of Applicant: Signature of Spouse:

For Agent Use Only

Agent Name: Agent #: Telephone: Fax: Agent Signature:

*No representative is authorized to establish and/or modify a Canassurance Hospital Service Association and/or Canassurance Insurance Company contract, to determine if a person to be insured constitutes as an acceptable risk or to waive any right or requirement in the name of Canassurance Hospital Service Association and/or Canassurance Insurance Company.

For Ontario Blue Cross Use OnlyIdentification No. Underwriting Approval

Signature Date

1 Canassurance Insurance Company Inc. and CanAssistance Inc.

® Registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by the Canassurance Hospital Service Association carrying on business as Ontario Blue Cross.

®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.


Blue Choice Balance - Kanetix.ca · Kidney failure, kidney transplant Gastrointestinal disorders :...

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