What Does My Group Benefit Plan Cover?

May 04, 2015

Picture being at your doctor’s office with a loved one finding out results of a recent blood test only to find out that your world has been turned upside down – your spouse has been diagnosed with cancer.

A myriad of questions go through your head. How are we going to cope? What about time off for my spouse? How much are we going to pay for new prescriptions? What if a wig is required after chemo? Questions become genuine concerns, not only for your family but for your pocketbook. A review of your employee benefit plan booklet, or a conversation with your human resources personnel or plan advisor could help answer these questions and alleviate some of your concerns.

For starters, many benefit plans cover visits to psychologists, social workers and perhaps clinical counsellors, which may be helpful resources during this time of distress. Prescription drugs are typically included in the extended health benefit and can cover the remaining costs of the new drugs that may be partially covered by a provincial cancer agency or through a provincial drug program.

Many plans cover the cost difference to move up from a ward room to a semi-private or private room at the hospital. Wigs for cancer patients and other post-surgery medical supplies may also be covered.

You can apply for the Employment Insurance sickness benefit. There is a two week waiting period in order for this benefit to take effect. The benefit pays 55% of your average insurable weekly earnings up to a maximum of $524 per week for up to 15 weeks. The benefit is taxable as income.

Some employers feel that EI pays out too little and/or too late, therefore, they opt to have a short term disability program in place. This benefit will become the first payor.

Check to see if your employer offers a long term disability benefit. The waiting period is approximately 120 days, which is about the duration of the short term disability or EI benefit. What this means is that the long term disability benefit could start to pay out once the short term disability or EI benefit has been exhausted. Depending on the plan design, you could receive sufficient income replacement to see you through the treatment and recovery.

Ideally, your plan has critical illness coverage. This is a lump sum benefit, payable tax-free, for those diagnosed with various life-threatening conditions, such as cancer, stroke or heart attack amongst others. This lump sum can help ease financial worries, such as paying for extra child care or home renovations to include a wheelchair ramp.

All too often, it’s not until a crisis occurs that questions are asked about what is included in your benefit plan. But it doesn’t have to be this way. Human resources teams could host a lunch and learn or send out a simple memo summarizing the benefit coverage. Employers may think this could open your plan up to higher usage but ultimately it could one day provide dividends to those employees facing new health challenges.

In times of need, particularly in the case of a catastrophic situation such as a serious illness diagnosis, you and your employees will appreciate this information sharing.

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