Glossary

Brain death

Irreversible unconsciousness with total loss of brain function and complete absence of electrical activity of the brain, even though the heart is still beating.

Child/children

Your natural, legally adopted, step or other eligible child* who meets all of the following requirements:

• unmarried,
• not cohabiting in a conjugal relationship with another individual,
• totally dependent on you for support and maintenance,
• one of the following ages:
  • under age 21,
  • under age 26 if a full-time student at an accredited post-secondary institution**,
  • of any age if physically or mentally disabled, but otherwise qualifies under this definition, provided they became disabled while covered by the plan and you provide satisfactory proof that your child is incapable of self-support as a result of the disability***,
• living in Canada, unless a full-time student elsewhere, and
• not in the armed forces (except for optional and dependent life insurance coverage).

Civil Service employees

Dentist

A doctor of dental surgery or a doctor of dental medicine licensed to practice and prescribe in the area where services are rendered.

Dependents

Your eligible spouse and children.

Earnings

For permanent employees, earnings will be based on gross earnings, excluding bonuses, overtime and commissions.

For permanent part-time CUPE Health PEI, UPSE Health PEI and UPSE Civil Service employees, earnings for LTD benefits will be based on regular earnings for the previous calendar year. However, earnings will never be less than the employment guarantee.

For long-term disability benefits for any other permanent part-time Health PEI IUOE or PEINU employees, and life insurance benefits for permanent part-time or temporary part-time Civil Service employees, earnings will be based on guaranteed earnings.

Health PEI employees

You are part of Health PEI if you belong to any of the following groups:

• Canadian Union of Public Employees (CUPE)
• Excluded employees/physicians
• International Union of Operating Engineers (IUOE)
• Non-union, non-excluded employees
• Prince Edward Island Nurses Union (PEINU)
• Prince Edward Island Union of Public Sector Employees (UPSE)

You may join the PSGIP if you are:

• a permanent full-time employee working at least 30 hours per week,
• a permanent part-time employee working less than the fully prescribed hours of work on a recurring and regularly scheduled basis,
• a temporary UPSE, IUOE, PEINU or excluded employee hired for 12 months or more.

Note: If you are a casual UPSE employee and you had coverage before August 1, 1995, you may continue your coverage in effect on August 1, 1995. However, you are not eligible for any additional benefits.

Hospital

A facility that is licensed to provide active treatment for sick or injured patients. It does not include rehabilitation hospital, mental institution, convalescent hospital or home, an institution used primarily for treatment of a specific illness or disease, a nursing home, a chronic care facility, a home for the aged, a rest home or any other facility that provides similar care. Beds set aside for chronic care in a hospital are not covered.

Regarding accidental injury or death benefits

For in-hospital confinement monthly income, hospital means a legally constituted establishment that meets all of the following conditions:

• operates primarily for the reception, care and treatment of sick, ailing or injured persons as inpatients,
• provides 24-hour service by registered or graduate nurses,
• has a staff of one or more licensed physicians available at all times,
• provides organized facilities for diagnosis and surgical facilities, and
• is not primarily a clinic, nursing home or convalescent home or similar establishment nor, other than incidentally, a place for alcoholics or drug addicts.

Immediate family

“Immediate family” refers to a spouse (or common-law spouse), parents, grandparents, children over age 18, brothers or sisters.

Irreversible

Irreversible means the condition cannot be improved by medical or surgical treatment at the time of diagnosis. The medical or surgical treatment need not be undertaken if it would involve an undue risk to the health of the person.

Life event

Qualifying life event includes:

• A change in your marital status, either a marriage or common-law relationship, or a divorce or separation,
• The birth or adoption of a child,
• The death of a dependent, or
• The loss of benefits coverage under a spousal program.

If you experience a life event, you have 31 days to register the event and make your benefit changes.

Medically necessary

A service or supply provided or prescribed by a health care professional to prevent, diagnose, or treat an injury, disease, or disability that is:

• consistent with the treatment of symptom(s) or diagnosed injury, disease, or disability,
• not primarily prescribed or provided for convenience,
• the most appropriate, safe, and cost-effective service or supply, and
• generally recognized as accepted medical practice.

When the plan refers to a health care professional, it means a person who is legally licensed to practice their profession where services are rendered, and includes physicians, pharmacists, dentists, and other professionals as approved by the plan.

Nurse practitioner

A nurse practitioner of medicine who is legally licensed to prescribe drugs and administer medical treatment within the scope of their license.

Permanently and totally disabled

Under AD&D, permanent and total disabled means that after 365 days from the date of an accident you are completely and irreversibly unable to perform at least two of the six Activities of Daily Living without assistance from another person, as deemed by a Physician and as supported by objective medical evidence.

Activities of Daily Living mean the following:

• Bathing: Washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower.
• Dressing: Putting on and taking off all items of clothing and any required braces, fasteners or artificial limbs.
• Transferring: Moving into or out of a bed, chair or wheelchair.
• Toileting: Getting to and from the toilet, getting on and off the toilet, and performing related personal hygiene.
• Continence: Ability to maintain control of bowel and bladder function; or, when not able to maintain control of bowel or bladder function, the ability to perform related personal hygiene (including caring for catheter or colostomy bag).
• Eating: Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table).

Pharmacist

A pharmacist who is legally licensed to prescribe drugs within the scope of their license.

Physician

A doctor of medicine who is legally licensed to prescribe drugs, administer medical treatment, and perform surgery within the scope of their license.

Professional counsellor

A therapist or counsellor who is licensed, registered or certified to provide the applicable treatment or counselling.

Proof of good health

Medical questionnaire that you must complete to show the status of your health. Depending on your answers, Canada Life can require a medical examination and any other information.

Reasonable and customary

Canada Life reimburses expenses based on Reasonable and Customary charges. Generally this is the lowest of the following:

• Representative pricing in the area where the treatment is provided.
• Prices shown in the applicable professional association fee guide and the maximum prices established by law.

Specialist

A specialist is a licensed and certified medical practitioner who has been trained in the specific area of medicine relevant to the covered critical illness condition for which benefit is being claimed. Specialists include, but are not limited to, cardiologists, neurologists, nephrologists, oncologists, ophthalmologists, burn specialists and internists. The specialist must not be the Group Policyholder, the insured, or a relative or business associate of the Group Policyholder or the insured.

Spouse

The person to whom you are legally married, or the person of the same or opposite sex with whom you have been living in a common-law relationship for at least 12 months.

Also note:

• Your spouse must live in Canada, unless they are a full-time student elsewhere.
• The plan does not cover any spouse in the armed forces (except for optional and dependent life insurance coverage).
• The plan covers only one spouse at a time.

Temporary employee

An employee in the unclassified division engaged to perform specific duties for a specified time period because of:

• a leave of absence of a classified employee through sickness, accident, vacation or other approved leave of absence,
• a vacancy in a classified position while an employing authority is determining whether or not a position is to be filled, or
• the initiation of a special project including an extra workload.

Note: If you are a temporary employee and you have a break in service greater than 28 days, you must fulfil a new waiting period.

Totally disabled/total disability

Under LTD coverage, totally disabled means:

During the qualifying period and the following 24 months of disability, illness or injury must render you physically or mentally incapable of performing the essential duties of your normal occupation. If during this period another occupation becomes available for which you are qualified, and you are mentally and physically able to perform the essential duties of this job, you must accept it. Otherwise, benefits will end.

After the qualifying period and the following 24 months of disability, illness or injury must render you physically or mentally incapable of being gainfully employed for:

• any occupation for which you are or may become qualified by education, training or experience, and
• any occupation that pays 75% or more of the current monthly earnings for your normal occupation.

Usual cost

The usual cost of covered services and supplies that are medically necessary to treat an illness, injury or pregnancy.

The plan will only cover:

• the amount that is usually charged for the service or supplies in the area in which the charge is made,
• services and supplies that are needed to diagnose or treat an illness, injury or pregnancy and that are recognized by the Canadian Medical Association as effective and appropriate and based on accepted standards of the Canadian health care,
• services and supplies that the plan is legally allowed by the government to cover. The plan will not cover services or supplies that are covered by the government plan in the insured person’s home province,
• charges for services and supplies that are incurred while the person is insured,
• charges for services and supplies for the least expensive treatment that is medically adequate.