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Ryerson University
For the purposes of the Business Travel Accident Plan and the Voluntary Accident Insurance Plan, an accident is a sudden, unforeseen, and unexpected event that happens by chance and arises from a source that is external to the insured person. It must be the direct cause of the loss or the loss of use and be independent of illness, disease, or other bodily malfunction. You are considered actively at work on any day on which you are physically and mentally fit to perform all the usual and customary duties of your occupation with Ryerson. This includes a scheduled working day when you are not present at work but you are capable of working (i.e., you are not in hospital or disabled or ill), or a day when you are not scheduled to work if, on your last scheduled working day you were actively at work. This is one method of paying for benefit coverage. The plan sponsor reimburses the insurance company for all claims paid, plus administration fees & taxes. If the liability or risk can be reasonably measured and cash flow fluctuation is not an issue, than the sponsor is only paying for what has been utilized. The risk to the sponsor is for a catastrophic claim in the tens of thousands of dollars. At Ryerson, the medical and dental benefits are paid for on an ASO basis. Your basic annual earnings include your current salary from Ryerson. It excludes any bonus, commission, overtime, or incentive pay you may receive. A beneficiary refers to the person who will receive the loss of life benefit from a benefits plan if you die (e.g., the lump sum from a life insurance plan or the loss of life benefit under an accident insurance plan). Under the Voluntary Accident Insurance Plan, if you have not named a beneficiary, the first surviving person(s) in the list below will receive your loss of life benefit, in the following order:
  • Your spouse;
  • In equal shares to your children;
  • In equal shares to your parents;
  • In equal shares to your siblings;
  • To your estate.
You would receive any accident insurance benefits other than the loss of life benefit.
The benefit year is January 1 to December 31, inclusive. A calendar year is January 1 to December 31, inclusive. See dependent child If your spouse has group benefits coverage with another insurance company, or with Ryerson University through Sun Life Financial, benefits are coordinated between the two insurance plans. Details on coordination of benefits can be found on the HR website. The deductible is the amount you pay out of pocket before the plan begins paying for covered expenses. The deductible is $25/year excluding hospital expenses. Coverage for dental expenses. There is no provincial plan for dental expenses. The plan is an ASO arrangement with Sun Life and Ryerson pays 100% of the costs. Dependent children may be insured under the Ryerson benefits program for medical and dental benefits and voluntary accident insurance. The term dependent child means an unmarried child
  • who is under 21 years of age and depends on you for support; or
  • who is under 25 years of age, depends on you for support, and is attending an institution of higher learning* as a full-time student; or
  • who is any age (if covered before age 21, or before age 25 if a student) and who is permanently mentally or physically disabled and incapable of self-support.**
Stepchildren and legally adopted children are eligible if they depend on you for support. Children of a common-law spouse are eligible during the time that coverage for the spouse is in effect and if the children depend on you for support.
* You must provide confirmation of the child's enrollment in full-time studies at an educational institution recognized by the Canada Revenue Agency, to the Human Resources Benefits Unit.
** You must obtain and complete a Disabled Dependent Questionnaire from Sun Life for any dependent child(ren) who is/are permanently mentally or physically disabled.
Your dependents include your spouse and dependent children as defined elsewhere in this glossary. The amount that the pharmacist charges to dispense a prescription drug. A doctor is a person who is licensed as a medical doctor or a doctor of osteopathy under the laws of the jurisdiction where treatment is given and who is qualified to provide the medical treatment. Doctor does not include a family member of the insured person, a social worker, a physiotherapist, or a chiropractor. Under the Voluntary Accident Insurance Plan the term domestic partner means a person
  • who is at least 18 years of age,
  • who has been in a committed relationship with you throughout the past 12 months,
  • who has been your sole spousal equivalent,
  • who has lived in the same household as you, and
  • who intends to continue the relationship described above indefinitely.
Extended Health Care. Designed to complement provincial health plans (OHIP/UHIP). Coverage for many medical expenses above what is provided by OHIP/UHIP. The plan is an ASO arrangement with Sun Life and Ryerson pays 100% of the costs. In the Long Term Disability Plan policy, this term refers to a "waiting period” before LTD benefits can begin and usually coincides with the period of time during which Sick Leave benefits are payable, although there are some exceptions. The elimination period begins with the first full day of total disability and ends
  • after a period of total disability of 66 working days, or
  • on the last day that a benefit under any loss of income or salary continuance plan is payable, if earlier.
If your total disability starts while you are on strike; temporary layoff; an approved leave of absence without pay; or a period of absence recognized as the normal non-work period if you are working a reduced workload or partial year; the elimination period begins on the date you would have normally been scheduled to return to work.
If you are considered to be a reduced workload or partial year employee, and your total disability starts while you are actively at work and continues until the date recognized as the non-work period, the elimination period will be suspended, if not yet completed, and will restart on the date you would have normally been scheduled to return to work.
If your total disability starts while you are on an approved leave of absence with pay, the elimination period begins on the date you become totally disabled.
In the case of pregnancy, the elimination period starts on the earlier of the date pregnancy terminates and the date the employee is totally disabled.
An emergency is an acute unexpected condition, illness, disease, or injury that requires immediate assistance. An employee is a person employed by Ryerson. An employee must reside in Canada, or may temporarily reside outside Canada if on a leave of absence approved by Ryerson. Anyone who is not entitled to benefits under either a provincial health care plan (e.g., OHIP or UHIP, see definition below) or a federal government plan that provides similar benefits is not considered to be an employee for purposes of health coverage. The fee guide of the Ontario Dental Association (ODA) lists procedure codes that identify individual treatments performed by dentists in Ontario. The guide also provides a recommended fee for each treatment. Sun Life, the carrier for the Ryerson Dental Plan, refers to the current ODA fee guide to determine the maximum the Plan will pay for each dental service. In the case of laboratory fees, the Plan will reimburse 66 2/3% of the procedure fee listed in the current fee guide. A hospital is a public institution, building, or place providing treatment for or attempting to cure a person suffering from an illness and requiring continuous confinement. This includes similar places providing specialized treatment for convalescing or chronically ill persons when approved by Sun Life. This does not include nursing homes, homes for the aged, rest homes, or other places providing similar care. An illness is a bodily injury, disease, mental infirmity, or sickness. Under the Business Travel Accident Insurance Plan and the Voluntary Accident Insurance Plan, a loss is as follows:
  • Arms and legs - severance through or above elbow or knee joints.
  • Feet - severance through or above ankle joints.
  • Hand - severance through or above the knuckle joints of at least four fingers on the same hand or at least three fingers and the thumb on the same hand.
  • Thumb and index finger of the same hand - severance through or above knuckle joint of each digit.
  • Toes - severance through or above metatarsophalangeal joints.
  • Sight - entire and irrecoverable loss of sight. Remaining vision in that eye must be no better than 20/200 using a corrective aid or device, as determined by a doctor.
  • Speech and hearing - permanent, irrecoverable, and total loss, without the aid of mechanical devices, as determined by a doctor.
  • Quadriplegia, paraplegia, hemiplegia – complete and irreversible loss of all motion and all practical use of an arm or leg that is continuous for 12 months, as determined by an doctor.
If a limb, hand, foot, thumb, or index finger is later reattached, the original loss is still considered an eligible loss under the policy.
Under the Business Travel Accident Plan and the Voluntary Accident Insurance Plan, loss of use means the total and irrecoverable loss of use of a body part. For benefits to be payable, the loss of use must continue for 12 consecutive months after which the benefit for loss of use is payable, and nerve damage must be determined to be permanent afterward. A minor is someone who is less than 18 years old. This government-operated program provides health insurance for Ontarians. It pays for ward accommodation in hospitals and for most routine medical services.
Enrollment is handled directly by OHIP. Each member of your family (even children under 21 years of age) who is covered by OHIP should have his or her own individual OHIP health card.
Information about OHIP coverage and the covered services and supplies is available from the Ontario Ministry of Health and Long-Term Care.
Coverage is provided while employees are out of the province and require medical care. An emergency means an acute illness or accidental injury that requires immediate, medically necessary treatment prescribed by a doctor. Having a heart attack while vacationing in Florida would be covered; needing regular dialysis treatment would not. Ryerson has insured a portion of this benefit so that if aggregate claims exceed $40,000, the remainder of any claims are insured (i.e. does not show up on the ASO statement). A premium is the amount of money that a plan participant or an employer pays to an insurance company for a specified amount of insurance coverage. A drug that has a drug identification number (DIN) and is prescribed in writing by a doctor. A revocable beneficiary is a beneficiary designation which you have the right to change at any time without the beneficiary’s consent. The Ryerson Faculty Association represents full-time and probationary faculty, professional counselors, and librarians. Your spouse may be insured under the Ryerson benefits program for medical and dental benefits and voluntary accident insurance.
Your spouse is either
(a) the person to whom you are married by virtue of a legal marriage or under any other formal union recognized by law, or
(b) a person of the opposite sex or of the same sex who is publicly represented as your spouse and has been continually so represented for at least the previous year.*
Under the Voluntary Accident Insurance Plan, the term "spouse" also includes "domestic partner” (see other definition).
* You must complete a Declaration of Common-Law Relationship form. You may obtain this form from the Human Resources website at www.ryerson.ca/working.
For some benefits, the government determines that the Ryerson-paid premiums count as income for tax purposes. Such a benefit is called a taxable benefit because you must pay tax based on this assessed value. For example, tuition waiver and premiums for group life insurance are taxable benefits. Under the Long-Term Disability Plan, you are considered to be totally disabled (to have a total disability) for the first 36 months of benefits for RFA, or for the first 24 months of benefits for non RFA, if you are unable to perform the duties of your own occupation. After this 36-month or 24-month period, you are totally disabled if you cannot engage in any occupation for which you are reasonably suited by education, training, or experience. Coverage in the event of accidental death or dismemberment while travelling on Ryerson business. The benefit is four times your basic salary to a maximum of $500,000. Ryerson pays 100% of the premium. This plan provides coverage for international residents or Canadian residents (and their dependents) who have been out of Canada for more than six months and are hired to work in Ontario and who are not eligible for OHIP. Ryerson, along with 11 other Ontario Universities has joined to together for the purpose of pooling or sharing the risk for the life insurance plans. More members spread the risk.

RETIREES (Aged 65+)
Extended Health Care Plan Details



Overview


It's inevitable – you will probably have some medical costs in the next year. While a few may be costs you expect, it may harder to plan for and pay for some others.

Despite the coverage provided by the Ontario Health Insurance Plan (OHIP), a number of services and supplies are not covered. The Sun Life Extended Health Care (EHC) plan for Ryerson post 65 Retirees can help you pay for many of these routine and unexpected medical expenses. Participating members must have provincial health coverage (OHIP) and must have commenced Ryerson Pension payments.

The cost of the plan is fully paid for by the participating members. The Plan reimburses eligible expenses at 80% unless otherwise stated, after you have paid the $25 annual deductible. If you have dependents, they're also covered under the Plan if you choose family coverage and you provide the required enrollment information. For more information about enrollment, see Eligibility & Enrollment. To add or remove dependent coverage, see Changing Personal Information.

Be aware that some expenses have limits and some are not eligible. This site describes limits on covered expenses and lists excluded expenses. To find out if a specific service or item is covered, you can also visit Sun Life's website or call Sun Life at 1-800-361-6212.


Participation in this plan is a one time only offer. The plan allows a retiree to re-elect coverage only in such circumstances where by coverage was waived in writing as a result of being covered under another insurance plan and such coverage has ceased. Proof will be required.

Cost & Tax Facts

What is the cost for the EHC Plan?

The cost of the benefit plan is fully paid for by the participating members. The university assumes no obligation to fund or subsidize the plan.

Monthly premiums for Retirees aged 65+:
Rates Effective May 1, 2014
Health $47.29 (single) $95.03 (family)


Premiums are adjusted annually each May 1st.

Some expenses are not covered by the Plan or are covered only up to a maximum reimbursement limit. See Specifics of Coverage for information about individual limits, and Excluded Expenses for a list of ineligible expenses.

How do taxes apply to the EHC Plan?

Premiums paid are an eligible medical expense for income tax purposes.


Covered Expenses

Is there an upper limit to my reimbursement under the EHC Plan?

The Plan covers eligible expenses up to an unlimited overall lifetime maximum.

However, some eligible expenses are subject to maximums or limitations. See Specifics of Coverage for information about individual limits, and Excluded Expenses for a list of ineligible expenses.

Is there a deductible?

You must pay a flat $25 deductible per benefit year, whether you have Single or Family Plan coverage. The deductible does not apply to hospital expenses.

If you incur medical expenses during the last three months of the year that are not reimbursed by the Plan because you have not yet paid the full annual deductible, Sun Life will apply those expenses against your deductible for the following year.

What coverage does the EHC Plan provide?

The table below describes your EHC Plan coverage. After you have paid the $25 deductible, eligible expenses are reimbursed at 80% unless otherwise stated, up to the limits stated. The deductible does not apply to hospital expenses.

The Plan covers expenses that are medically necessary in relation to the nature and severity of the illness. Payment is limited to what is considered reasonable and customary in Ontario, regardless of where you incur the expense. What is considered reasonable and customary is based on guidelines published by professional associations governing the suppliers or service providers. In cases where there is no such guideline, the Plan will reimburse you according to Sun Life's experience. If an expense is not eligible under the EHC Plan, you are responsible for its cost. See Excluded Expenses for a list of ineligible expenses.

If your doctor recommends a treatment, service, or medical supply that is not mentioned, call Sun Life at 1-800-361-6212. They will help you determine if the expense is covered and if it is subject to any restrictions.

Specifics of Coverage
Covered Services & Supplies Description Maximums & Limitations
Ambulance Licensed ambulance for emergency service To the nearest hospital equipped to provide the required treatment
Blood Tests Coverage for the CA 125 blood test for ovarian cancer and the PSA blood test for prostate cancer  
Dental care after an accident Services of a dentist, including charges for braces or splints, for the repair or alleviation of damage to natural teeth if the damage resulted from anaccidental blow to the mouth Services must be received within 12 months of the accident. Payment will not exceed the amount for the procedure in the current provincial Dental Association Fee Guide in your province of residence.
Diabetic supplies
  • Insulin and test strips
  • Requires a doctor's written prescription and must be dispensed by a doctor or licensed pharmacist
  • Proof of application must be provided under the Ontario Assistive Devices Program
  • Assistive Devices Program (OADP)
  • Cost of services paid after the OADP has paid maximum benefits
Hospital stay (acute care) Charges for semi-private or private room accommodation in an acute care hospital, less the OHIP-paid ward charges (deductible does not apply)
  • OHIP pays for ward accommodation.
  • Semi-private room covered at 100%
  • Private room cost over and above the semi-private rate covered at 80%
Medical equipment & supplies See list below chart. To verify current details on limitations, call Sun Life at 1-800-361-6212.
If alternate equipment is available, eligible expenses are limited to the cost of the least expensive equipment that will meet basic medical needs.
Out-of-province & out-of-country coverage Emergency: The following services are covered in the event of an emergency:
  • room and board in a hospital up to the difference between the hospital's ward rate and semi-private room rate, at 100% reimbursement or up to the difference between the hospital's semi-private rate and the private room rate, at 80% reimbursement as applicable (including where permitted by law, any admittance, coinsurance, or utilization charges)
  • other hospital services
  • out-patient services in a hospital
  • services of a doctor

Brief description and Travel Card, please see Travel Benefit and Medi-Passport.

For more details, please see Emergency Travel Assistance Policy.

If you require emergency medical care when travelling, the Medical Plan will cover eligible expenses not covered by OHIP, as long as the expenses are considered reasonable and customary in Canada.

Must have provincial health coverage (OHIP).

The Emergency Travel Assistance plan applies for a maximum of 180 days from the time you leave your province of residence. If you are hospitalized during this period, in-hospital service is covered until you are discharged. The maximum benefit for eligible expenses incurred outside of Canada is $1 million per person per lifetime.
Paramedical services
(Practitioner must be licensed and/or registered in his/her province for the service to be covered)
Physiotherapist
  • Therapist must not normally reside in the patient's home
  • Must be prescribed by a doctor
Psychologist and speech therapist
  • Must be prescribed by a doctor (speech therapy only)
  • Maximum per person: $200 per year for psychologist and $200 per year for speech therapist
Massage Therapy
  • Maximum reimbursement per person is 20 treatments per practitioner per benefit year (no dollar limit)
  • Only one X-ray examination per benefit year ordered by each licensed practitioner
  • Must be prescribed by a doctor
Private nursing care Services of a registered nurse (RN) or registered nursing assistant (RNA) who is licensed, registered, or certified through his/her respective organization

Services of an eligible home care worker (Victorian Order of Nurses (VON) nurse, Red Cross Homemaker, practical nurse, or home service worker)
  • To be eligible for this benefit, you must not be confined to a hospital
  • RN or RNA: Maximum of $25,000 per year
  • Eligible home care worker: Maximum of $5,000 per year if patient is not confined in a hospital
  • The nurse or home care worker may not normally reside in the patient's home
  • Sun Life pre-approval required


Covered medical equipment and supplies includes the following if prescribed by a doctor:
  • Rental or purchase for temporary therapeutic use, at the insurer's option, of a wheelchair, hospital bed, walker or other durable equipment, approved by the insurer
  • Trusses, crutches, casts, splints, or braces
  • Artificial limbs or other prosthetic appliances (excluding dental prostheses), including replacements when medically necessary. For myoelectric limbs, payment is limited to the amount otherwise paid for standard-type limbs.
  • Oxygen, plasma, and blood transfusions
  • Colostomy supplies
  • External mammary prostheses if required as a result of surgery
  • Wigs required as the result of an illness, or as the result of medical treatment of an illness, to a lifetime maximum of $500 per person


Ineligible Expenses; Limitations and Exclusions

Payment is not made for:

  • Baby foods and formula, minerals, proteins, vitamins and collagen treatments
  • Any charge for the administration of serums, vaccines and injectable drugs
  • Anti-obesity treatments including drugs, proteins and dietary or food supplements and hair growth stimulants, whether or not prescribed for medical reasons
  • Any smoking cessation products (other than Nicorette)
  • Drugs for the treatment of sexual dysfunction
  • Any portion of the expenses for which reimbursement is provided by a government plan
  • Drugs and treatment that are used for cosmetic purposes
  • Natural health products, whether or not they have a natural Product Number (NPN)
  • Drugs and treatment, and any services and supplies relating to the administration of the drug and treatment, administered in a hospital, on an in-patient or out-patient basis, or in a government-funded clinic or treatment facility
  • Drugs that are available without a prescription even if prescribed
  • Services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program except as stated in the Master Plan Document
  • Services or supplies that are not approved by Health Canada or other government regulatory body for the general public
  • Services or supplies that are not generally recognized by the Canadian medical profession as effective, appropriate and required in the treatment of an illness in accordance with Canadian medical standards
  • Services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada)
  • Expenses for services performed by a person ordinarily a resident in the patient's home or a close relative
  • Any portion of the expense for which reimbursement is made due to the legal liability of another party
  • Charges incurred for an illness due to or resulting from the hostile action of any armed forces, insurrection or participation in a riot or civil commotion
  • Charges incurred for an illness due to or resulting from any cause for which indemnity or compensation is provided under any Workers' Compensation Act, Criminal Injuries Compensation Act or similar legislation
  • Charges incurred for an illness due to or resulting from the commission or attempted commission of a criminal offence by the covered person
  • Charges incurred for an illness due to or resulting from intentionally self-inflected injuries
  • Charges incurred for an illness due to or resulting from optional services which are mainly for cosmetic purposes
  • Charges for equipment deemed by the Plan Sponsor not to be and eligible expenses (e.g. orthopaedic mattresses, exercise equipment, air-conditioning or air-purifying equipment, whirlpools, humidifiers etc.)

 



Making Claims

How should I submit a claim for the EHC Plan?

You must submit claims within 18 months of incurring an expense. It is to your advantage to submit most claims as quickly as possible, but it is helpful if you hold claims for medical expenses until they total $50 or more.

Proof of claims includes itemized bills, reports from doctors or hospitals, and hospital records.

You may download the Extended Health Care Claim Form from either the SunLife or Ryerson HR websites or pick up a form from the reception area of Human Resources. Complete the following steps to ensure prompt processing of your claim:
  1. Complete both sides of the claim form. The signature at the bottom of the claim form must be yours, whether the claim is for yourself or one of your dependents. The claim will not be paid if the claim form is not properly completed.
  2. Make a copy of your claim form and receipts for your records. Keep in mind that some medical expenses not reimbursed by your group insurance may be eligible for a tax credit when you file your income tax return.
  3. Mail the completed form with all receipts directly to Sun Life. The mailing address is on the back of the claim form.
  4. Sun Life will mail a reimbursement cheque, if appropriate, to your home address along with an explanation of how your eligibility for payment has been determined. Or, contact Sun Life at 1-800-361-6212 to arrange a direct deposit to your bank account.
If you have questions about your coverage or the status of submitted claims, or disagree with any claim settlement, please contact Sun Life at 1-800-361-6212.

How do I submit claims if my spouse has coverage?

The purpose of insurance coverage is to help you meet actual expenses. The benefits plan has been designed so that benefits paid by all group plans combined will provide coverage up to the actual eligible expenses incurred.

If your spouse is insured under another medical plan, you must follow co-ordination of benefits (COB) procedures when you submit your claims. COB is a set of rules designed to distribute expenses for you and your dependents among health plans in a fair manner. The rules set out a specific order for submitting claims depending on who incurred the expense, so that you can obtain maximum reimbursement and so that no more than 100% of the expense is reimbursed.

For you and your spouse:
When an expense is your own, you always submit the claim to your EHC Plan first. Your spouse must always submit expenses to his or her plan first.

After the first insurer has processed the claim, you may submit any remaining eligible balance to the second person's insurer along with a copy of the Explanation of Benefits (EOB) that you received from the first insurer and copies of the receipts.

If you and your spouse both have coverage with Sun Life, complete section 2 on the claim form, including your spouse's contract and member ID numbers, and ensure your spouse signs and dates the form. Sun Life will then automatically co-ordinate the claims, which will save you the step of submitting the claim twice to the same insurer.

For your dependent children:
Expenses for children should be submitted first to the plan covering the parent with the earliest birth date in the year and then to the plan insuring the other parent for any remaining eligible balance. For example, if one parent was born in February and the other in August, the parent born in February would submit claims for any eligible children to his or her plan first. Any remaining eligible balance would be submitted to the plan covering the parent born in August.

To ensure efficient processing of claims, you and your spouse must list each other and your eligible childrenas dependents under both plans.

In the event of your death, your surviving spouse and/or eligible dependent children enrolled in the plan, are eligible for coverage for a period of six months following your date of death.


Ryerson reserves the right, at any time, to amend, change or discontinue any benefit coverage. If there is a question about coverage referred to in any portion of this benefits communication, the master contract from the insurer is the governing document.

 

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