Medical Coverage
This page outlines your extended health care covered expenses, limitations and exclusions.
The cost of the retiree plan is fully paid for by the participating members. Premiums are adjusted annually on May 1st.
Policy details, premiums and alternative options for coverage with other providers can be found by visiting Policy Administration.
What type of expenses does the EHC plan cover?
The plan covers expenses that are medically necessary in relation to the nature and severity of the illness.
Similar to most plans, payment is limited to what is considered reasonable and customary in Ontario, regardless of where you incur the expense. In order to determine what is reasonable and customary, Sunlife uses guidelines published by professional associations governing the suppliers or service providers.
In cases where there is no such guideline, you will be reimbursed according to Sun Life’s experience. If an expense is not eligible under the EHC plan, you are responsible for its cost.
TMU is proud to offer a comprehensive and robust benefit plan, but 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 call Sun Life at 1-800-361-6212.
Is there an upper limit to my reimbursement under the medical plan?
The plan covers eligible expenses up to an unlimited overall lifetime maximum, but some eligible expenses are subject to maximums or limitations.
See Specifics of Coverage for information about individual limits, and Ineligible expenses, limitations and exclusions 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.
Covered services and supplies
The plan reimburses 80% of the following expenses, unless otherwise stated after the $25 annual deductible has been paid.
Please note the benefit year runs from January 1 to December 31.
Description of services:
- licensed ambulance for emergency service
Maximums and limitations:
- to the nearest hospital equipped to provide the required treatment
Description of services:
- coverage for the CA 125 blood test for ovarian cancer and the PSA blood test for prostate cancer
Description of services:
- 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 an accidental blow to the mouth
Maximums and limitations:
- services must be received within 12 months of the accident
- payment will not exceed the amount for the procedure in the current provincial General Practitioner Dental Association Fee Guide in your province of residence
Description of services:
- insulin and test strips
- colostomy supplies
- continuous glucose monitor (CGM) receivers, transmitters or sensors for persons diagnosed with Type 1 diabetes, up to a maximum of $4,000 per person per year
- a doctor’s note confirming the diagnosis is required.
Maximums and limitations:
- 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 (OADP) for glucometers, insulin and insulin pump supplies
- cost of services paid after the OADP has paid maximum benefits
Descriptions of services:
- charges for semi-private or private room accommodation in an acute care hospital, less the OHIP-paid ward charges
Maximums and limitations:
- OHIP pays for ward accommodation
- charges for semi-private covered at 100%
- charges for private room cost over and above the semi-private rate are covered at 80%
- deductible does not apply
Maximums and limitations:
- must be ordered by a doctor and must be primarily for rehabilitation and not custodial care, up to the hospital's semi-private room rate or private room rate less OHIP paid ward charges
- OHIP pays for ward accommodation
- charges for semi-private covered at 100%
- charges for private room cost over and above the semi-private rate covered at 80%
- deductible does not apply
Descriptions of services:
Covered medically necessary equipment and supplies includes the following if prescribed by a doctor:
- medically necessary equipment rented (or purchased at insurer's approval) that meets the person's basic needs
- 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
- external mammary prostheses if required as a result of surgery
- wigs - required as a result of an illness or medical treatment of an illness when ordered by a doctor. Maximum $500 per lifetime.
Maximums and limitations:
- 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
Description of services
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
Maximum and limitations
- 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 (e.g. 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.
For more details, visit the travel emergency medical coverage.
Descriptions of services:
The following paramedical practitioners are covered:
- physiotherapist
- psychologist, psychotherapist or social worker
- speech therapist
- massage therapist
Maximums and limitations:
- practitioners 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
- maximum reimbursement per person is 20 treatments per benefit year (subject to reasonable and customary limits)
- If there is medical evidence to support physiotherapy treatment beyond 20 visits, Sun Life will adjudicate on an exception basis.
- psychologist, psychotherapist or social worker
- maximum per person: $3500 per year
- speech therapist
- must be prescribed by a doctor
- maximum per person: $200 per year for speech therapist
- massage therapy
- maximum reimbursement per person is 20 treatments per benefit year
- must be prescribed by a doctor
Check the Sun Life provider delisting
Sun Life regularly audits healthcare service providers. Sometimes the review of their claiming and administrative practices results in the provider being “delisted,” meaning their services are no longer covered. If you receive healthcare services or supplies from a delisted provider, Sun Life will not reimburse you for your expenses. You can still choose to obtain services from the delisted provider, however, your claim will be denied.
To view the delisted providers, log in to mysunlife.ca (external link) and select the message for delisted providers under "Please read". For more information, or help logging into mysunlife.ca (external link) , contact Sun Life directly at 1-800-361-6212
Reasonable and customary limits
Please contact Sun Life at 1-800-361-6212 for current reasonable and customary limits.
Descriptions of services:
- 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)
Maximums and limitations:
- 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
Ineligible expenses, limitations and exclusions
What expenses are not covered by the EHC?
Payment is not made for:
- 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 Insurer not to be and eligible expenses (e.g. orthopaedic mattresses, exercise equipment, air-conditioning or air-purifying equipment, whirlpools, humidifiers etc.)
- any portion of the services or supplies over the reasonable and customary charges in the locality where they are provided.
TMU 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.