PRODUCTS -  3. CATASTROPHIC / STOP LOSS COVERAGE
 
 
 

This is insurance that protects plan members in the event of catastrophic expenses resulting from a disastrous health event. Often treatment for these medical conditions can result in health care claims that are not covered by government health plans and yet may be in the ten’s of thousands of dollars. For example, a plan member may contract a disease that requires thousands of dollars a month in medication or the care of a private nurse.
  
     
 
 
 

The coverage is provided after eligible claims are incurred of more than $10,000 per individual or family member per calendar year. Costs incurred to pay for procedures that are not medically necessary will not be included in determining whether $10,000 in expenses has been incurred.
  
     
 
 
 

This policy covers eligible medical expenses such as drugs, private duty nursing, or paramedical services that are not paid by provincial government health care. It is not intended to reimburse elective procedures such as plastic surgery that may be covered under an AccertaChoice Plan.
  
     
 
 
 

All healthcare claims incurred by the individual are submitted to Expert Travel Financial Security (E.T.F.S.) Inc. They will be adjudicated based upon the eligibility as defined in the master contract. This policy includes specific internal deductibles such as $500/year for each paramedical service. These specific deductibles are described in the insurance policy. All eligible claims totalling more than the deductible of $10,000 plus the various internal deductibles will be reimbursed by the carrier ROYAL/SUN ALLIANCE.
 
     
 
 
 


Many insurance policies exclude claims resulting from illness that existed at the time the insurance was purchased. These illnesses are called pre-existing conditions. Accerta’s Catastrophic Loss/Stop Loss policy does not exclude coverage for pre-existing conditions. It does pay reduced benefits, however, for claims arising from a pre-existing condition. To determine potential coverage the costs of treatment for the pre-existing condition incurred by the participant (subscriber or dependant) in the previous year are considered. For example, if the participant had $7,500 in eligible healthcare expenses in the previous year, stop loss available in such a situation is limited to a maximum pay out of $3,300. The formula showing how this reduction is calculated is set out in the insurance policy.

Very Reasonable Annual Premium. For details, please contact MedEx Benefits Consultants.

  

 

 

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