With the start of the summer vacation season, a number of plan members will undoubtedly spend some of their vacation traveling outside Ontario and outside Canada. Many of these plan members will have medical conditions that they effectively keep under control with medications or other therapies. This will mean that for the purpose of their out of country travel insurance, they will be deemed to have at least one pre-existing medical condition.
As a result, these members will need to take extra precautions when traveling outside Canada. At a minimum, they should fully familiarize themselves with the out of country pre-existing condition provision contained in their group health policy, prior to their scheduled trip.
In most group insurance plans providing for out of country emergency treatment, the terms of the policy will specifically exclude emergency treatment directly or indirectly related to a pre-existing medical condition. This can mean that a claim will not be considered eligible for reimbursement unless the members pre-existing medical condition was deemed ‘stable’ by a consulting physician, prior to the start of their trip.
This does not mean that ‘pre-existing medical conditions’ are never insurable, it does however mean that plan members who suffer from a medical condition(s) in which they received or sought treatment or consultation in the period directly proceeding their trip outside of Canada, should make sure that clearance to travel is obtained and documented by their attending physician.
Although it is not necessary to obtain a medical certificate from one’s doctor, if there is any concern on the part of the insured member, they should at least ask their physician whether traveling outside Canada is advisable.
The wording used by each Insurer varies, but the key element in most policies is the same; to be eligible for coverage when traveling abroad, an insured member should ensure that their condition is ‘stable’, prior to their departure.
Some Insurers have specifically defined what they consider to be a stable medical condition. For example, Equitable Life defines a stable condition as one that did not require a new treatment, new medication or change in dosing, frequency or type of medication required to treat the condition. They further add that there should be no new symptoms or test results suggesting additional deterioration of the condition.
Generally, out of country coverage is only available for ‘emergency services’ required when traveling abroad. Non-emergency services are therefore not covered. Should an insured member need a physician for routine care or a medical checkup, it would be advisable to do so, prior to departure.
It the case of an unforeseen complication related to a pre-existing condition, the complication would normally be eligible for reimbursement based on reasonable person assumptions. This means that an insured member who travels abroad while on the waiting list for a hip replacement, would likely be covered for medical services
related to their hip if they accidentally slipped and further injured or aggravated the hip, requiring emergency hip replacement surgery abroad.
If however, that same member traveled abroad and fractured their hip while skydiving, reimbursement for those related medical expenses might be declined by the Insurer on the basis that a reasonable person would have concluded that engaging in such activity would likely have caused further damage to the injured hip.