Individual health and dental

Who is individual health and dental insurance for?

It is for a person paying for their own coverage rather than receiving it through work. Edge Benefits names four situations: the self-employed, people between jobs, employees whose workplace plan leaves gaps, and small-business owners with at least three non-related employees.

The common thread is that no employer is carrying the cost or setting the terms. A plan owned by the individual stays in place through a change of job, a move between contracts, or a period of self-employment, because nothing about it depends on who signs the pay cheque.

Eligibility runs from age 18 to 69 at the point of issue, and coverage continues to age 75. Applicants outside that band are not eligible for this product, and a licensed advisor at Sutherland Insurance can look at what else is available.

What does the base plan cover?

The base plan pays 70 per cent of prescription drug costs, to $400 in the first year and $500 in each year after. Professional and therapist services are covered to $1,000 a year combined, medical services to $2,000 per person per year, and accidental dental to $3,000 per person per year.

Medical items and home support start at $1,500 and rise each year to $4,000 by the fourth year. Emergency medical travel is included at 15 days per trip, with a maximum of $5,000,000 per person per year.

Two categories are not in the base plan at all: vision care and hearing aids. Both are available, but only by adding the health upgrade described below. Reading the base list on its own therefore understates what the product can cover and overstates what it covers as bought.

What do the optional upgrades add?

The health upgrade raises professional services to $1,500 a year, medical services to $3,000, accidental dental to $10,000, and medical items and home support to $10,000 combined. It also introduces vision and hearing benefits, which the base plan does not carry.

Vision on the upgrade pays $250 every 24 months toward eyeglasses, contact lenses or laser surgery, and $65 per person every 24 months toward an eye examination. Hearing aids are covered at $500 every 36 months.

The drug upgrade is priced and assessed separately. It raises reimbursement from 70 to 90 per cent, and the annual maximum from $400 to $1,000 in the first year, $1,500 in the second, and $2,000 from the third year onward.

How does the dental plan work?

Base dental pays 70 per cent to a maximum of $450 per person per year. The dental upgrade pays 80 per cent, to $1,000 in the first year and $1,250 in each year after. A one-month waiting period applies from the coverage effective date.

That waiting period is waived for people enrolling through a small-business arrangement. For everyone else it means a claim in the first month is not payable, which is worth knowing before booking treatment around a start date.

Health cover is not available as a stand-alone product without dental. An applicant interested only in prescription drug coverage will still be taking a dental plan alongside it, and the two maximums run separately.

What does guaranteed issue mean on this plan?

Most of the coverage options are guaranteed to issue regardless of pre-existing conditions, which means acceptance does not depend on answering medical questions. The optional drug upgrade is the one component that is underwritten.

For an applicant who has been declined elsewhere, or who expects a medical history to be the obstacle, that distinction is the important one on the page. The base health plan, the health upgrade, the base dental plan and the dental upgrade are all guaranteed issue.

Approval on the underwritten drug upgrade typically takes a few weeks, against the same-session approval available on the guaranteed-issue components.

How are premiums set, and why do they change?

Premiums are determined by the insured person's age and province of residence. Edge Benefits states that they are not affected by medical background, which follows from most of the plan being guaranteed issue.

Rates are reviewed annually. Edge Benefits attributes changes to the claims experience of all its policyholders together with other market factors, rather than to an individual's own claims, so a claim made in one year does not, by itself, set the following year's premium.

A multi-product discount is available where this plan is combined with other Edge Benefits coverage. Sutherland Insurance can confirm which combinations qualify before an application is submitted.

How is a plan applied for, and when does it start?

Enrolment is completed entirely online, and approval on the guaranteed-issue components is quick. Health coverage takes effect on the first of the month following approval, and the policy itself is issued within days or weeks.

Because the effective date lands on the first of a month rather than on the day of approval, an application approved mid-month waits until the following month for coverage to begin. Dental adds its one-month waiting period on top of that effective date.

Applying through Sutherland Insurance changes none of that timing. What it changes is that a licensed broker reads the request, and remains available afterwards if a claim raises a question.

What is worth checking before applying?

Four things: whether vision and hearing matter enough to warrant the health upgrade, how the drug maximums compare with current prescription costs, that the dental waiting period is understood, and whether provincial rules apply.

Quebec is the notable provincial exception. Prescription drug coverage is not available there unless the RAMQ Top Up product is selected, because provincial rules require residents to hold drug coverage through RAMQ or a private plan.

Every figure on this page is an annual maximum rather than an estimate of what a plan will pay. What a given household actually claims depends on prescriptions, treatment and the plan selected, which is the conversation to have with an advisor rather than a number to read off a page.

Sources

• Edge Benefits: Health and Dental Insurance
• Government of Ontario: What OHIP covers