- In order for a member to be eligible for Basic Critical Illness coverage they must be currently participating in the NLTA Group Insurance Program.
- Subject to eligibility guidelines, NLTA members and employees residing in Canada are eligible to participate in this option.
- A 24 month pre-existing conditions clause applies.
- No benefit payable for cancer or benign brain tumor if symptoms or problems that give rise to the diagnosis of these conditions appear within the first 90 days of coverage or reinstatement of coverage.
- Member must survive at least 30 days after the date the diagnosis was made by a licensed physician.
- Coverage ceases upon retirement or attainment of age 65 on the date on which the underwriter pays a benefit for a covered critical illness/condition.
- Spousal/Dependent coverage is not available under this Option but is available under option CS/CC – Voluntary Critical Illness.
- Any NLTA member/employee may choose to remove him/herself from this option by contacting the Plan Administrator, Johnson Inc., to complete an Opting Out form. Subsequent to opting out or allowing coverage to lapse or terminate, should a teacher wish to rejoin this plan, an application will be required providing medical evidence of insurability to the insurance carrier.
Pre-existing Conditions Limitations Clause
It is important to note that this Critical Illness benefit has a 24-month Pre- existing Conditions Limitations clause. This limitation states that “no benefit is payable for an illness or pre-existing condition for which the participant has received care, treatment or services, consulted a physician, or taken medication that was prescribed to him/her, in the 24 months prior to the effective date of coverage, unless the illness in question was diagnosed at least 24 months after the effective date of the insurance of the participant, subject to other applicable provisions of this policy.”
Restrictions, Exclusions and Limitations
- No benefit is payable for any Critical Illness resulting directly or indirectly from any of the following:
- intentionally self-inflicted injury, voluntary exposure to an Illness or attempted suicide while sane or insane;
- war, whether declared or not, active service in the armed forces of any country or participation in a riot, insurrection or civil commotion;
- committing or attempting to commit a criminal offence;
- alcohol abuse;
- the use of any medication, narcotic, intoxicant or any other harmful substance, except when prescribed or recommended by a Physician.
- No benefit is payable for the following:
- an Illness or pre-existing condition for which the Participant has received care, treatment or services, consulted a Physician or taken medication that was prescribed to him, in the 24 months prior to the effective date of coverage, unless the Illness in question was diagnosed at least 24 months after the effective date of the insurance of the Participant, subject to other applicable provisions of this policy;
- paralysis, paraplegia, hemiplegia, or quadriplegia resulting directly or indirectly from the practice of one or more of the following activities: amateur or professional boxing, bungee jumping, cliff diving, mountainclimbing, car racing or speed races on land or water, parachuting, or underwater activities;
- transient cerebral ischemia;
- all types of parkinsonism other than idiopathic and degenerative Parkinson’s disease;
- non-surgical techniques such as balloon angioplasty or the correction of an occlusion using laser treatment or any other non-bypass technique;
- organic brain syndromes and psychiatric disorders other than Alzheimer’s disease;
- lesser acute coronary syndromes including unstable angina and acute coronary insufficiency.
- Restrictions, exclusions, and limitations related to cancer diagnosis. This Benefit does not apply when cancer is diagnosed within 90 days of the effective date of coverage or last reinstatement of coverage or when the medical symptoms or problems giving rise to the diagnosis of cancer appeared during this initial 90-day period. In addition, no benefit is payable for the following forms of cancer:
- early prostate cancer, diagnosed as T1A N0 M0 and T1B N0M0 or equivalent staging;
- non-invasive cancer in situ;
- precancerous lesions, benign tumours or polyps;
- any tumour that develops in a person who is HIV seropositive;
- any skin cancer other than invasive malignant melanoma greater than 0.75 mm.
- Restrictions, exclusions, and limitations related to diagnosis of HIV infection. Benefits are payable provided that the following conditions are met:
- the Insured Person (or the Policyholder) must inform the Insurer of any Accident or injury that could result in HIV infection within 14 days of the event;
- within 14 days of the Accident or injury, the Insured Person must undergo blood tests confirming that he is HIV seronegative;
- an HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;
- the accidental injury must have been reported, investigated, and documented in accordance with workplace legislation and regulations;
- the Insurer may require that all blood samples taken be provided so they can be analyzed by an independent lab and may request any other blood test that it deems appropriate;
- if an HIV vaccine becomes available, no benefits will be paid to an Insured Person who has an Accident or is injured on the job and who previously refused to be vaccinated. In addition, no benefits will be payable if a cure for HIV became available prior to the Accident or injury giving rise to the claim. HIV infections resulting from any cause not related to the Insured Person’s work, such as sexual activity or drug use, are not covered under this Benefit.
Termination of Benefits
- Basic Critical Illness insurance has no waiver of premium clause. Member must continue paying the applicable premium when on an approved leave of absense.
- After a lump-sum benefit has been paid, the Basic Critical Illness coverage terminates and no additional premiums are payable.
- The plan member’s coverage will terminate for the Basic $10,000 benefit on the earliest of:
- Retirement or the plan member’s 65th birthday
- Termination of Policy or eligibility of coverage
- The date on which the insurance company pays a benefit for a covered critical illness under your group contract
Notice and Proof of Claim
Before settling any claim under this Benefit, the Insurer will require satisfactory written proof of the existence of the relevant Illness and of the Participant’s eligibility for benefits at the time the diagnosis was made.
A written initial notice of claim must be submitted to the Insurer within 30 days of the event.
The Insurer reserves the right to verify the diagnosis with the attending Physician(s) and to require any Participant who has submitted a claim to be examined at the Insurer’s expense.
Proof of claim related to an accident or injury that may result in HIV infection.
A written notice of claim must be submitted to the Insurer within 14 days of the Accident or injury.
The Insured Person (or the Policyholder) must notify the Insurer of the Accident or injury, which will then be investigated and a report produced in accordance with the established procedures for the occupation in question.
Your group contract includes a conversion privilege clause that allows you and your spouse to convert your group Critical Illness insurance to an individual contract when your group coverage ends or if you decide to terminate your group benefits. This individual Critical Illness insurance will terminate when you turn 70. To avail of the Conversion Privilege, you must contact the insurance company within 31 days of the termination of your Critical Illness benefit.
Schedule of Benefits
The Basic Critical Illness coverage provides a benefit of $10,000 to NLTA Members and staff who are under age 65, actively at work, and currently participating in the NLTA Group Insurance Program.