Top-ups and Pre-Existing Conditions

Winter 2013 CSANews Issue 85  |   Posted date : Jan 10, 2013.Back to list

Bird talk - Le Jaseur
Dear Bird Talk,

My husband and I spend four months in Florida each winter. I have 62 days' coverage through my Ontario Teachers Insurance Plan (OTIP) and top it up to 126 days with Medipac. Last winter was the first time in many years I actually had a medical problem while in Florida, but it did raise the following question for me.

What would happen in the scenario that I or my husband became ill/had an accident, a day or two before my coverage with OTIP expired. Would this medical condition then be considered a "pre-existing condition" for my Medipac coverage starting the following day and leave me with no medical coverage for this condition if needed?

Please clarify this hypothetical scenario and suggest a solution if necessary. Many thanks.

Barb M.
Bancroft, ON

Response :
Ed: This is not hypothetical. This happens all the time. To first deal with a medical emergency that happens one or two days prior to your Teachers' Plan expiry date; the Teachers' Plan is responsible for your medical treatment ‒ and bills ‒ until your emergency is resolved. If you are in hospital on your expiry date, your bills are still covered until your safe discharge, even if it is several days AFTER your expiry date. This would apply at the end of your Medipac policy, as well. If you require an air evacuation on discharge, it is probably covered but I would check with them to be certain. Medipac would not pay any bills relating to an emergency that happened prior to the effective date of our coverage, as that is the responsibility of the Teachers' Plan.

Getting a little more complex, if your emergency happened on the first day of your Teachers' Plan and you fully recovered, then any flare-up or return of that condition, or anything related to it, is almost certainly not covered by the Teachers' Plan. There is a “reoccurrence” clause in most policies that denies coverage for a return of the same condition. So, in a nutshell, if you have a claim under a policy, another claim related to that condition will not be covered. Please check with your Teachers' Plan on this, as I have not read it recently. You should also ask if they will evacuate you and your spouse if they will not provide you with full coverage. My guess is that they will not pay for an evacuation after your condition is resolved.

Now for Medipac. If you have any symptoms, conditions or treatment, you must call Medipac and advise us what happened, so that we can determine how a claim during your first 60 days of travel (under the Teachers' Plan) would affect your policy. Medipac’s doctors and nurses will determine what coverage can be provided and at what cost. If it was a simple claim, full coverage is usually granted, but an additional premium may be charged if there is a substantially increased risk and a substantial change in your health. For instance, if you had a heart attack during the first 60 days and you were originally priced for no heart attack, your premium is going up to reflect that. If our doctors come to the conclusion that you cannot be insured, I suggest that you immediately come home; they think that you are at risk! In this situation, your prior insurance company that handled your claim should pay for that evacuation. Many companies, however, will not.

The last scenario is, of course, when you have a claim under a Medipac policy. We do not have a reoccurrence clause by which coverage is automatically denied; we use our doctors to see if we can continue to cover you, and we normally can. Following the resolution of an emergency, Medipac’s doctors will again assess your risk. If we feel that the risk is too great to continue full coverage, then we will pay to bring you home. Most emergencies are successfully resolved and you just continue with your vacation.

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