PolicyMe Health and Dental Insurance Product Summary
Official Product Name:
PolicyMe Health and Dental Insurance
Insurer:
Securian Canada
1400-25 Sheppard Avenue West
Toronto, ON, Canada, M2N 6S6
Email: service@canadianpremier.ca
Phone (Toll-free): 1-855-883-6176
Website: https://securiancanada.ca/
AMF Client Number: 2000829775
AMF Website: http://lautorite.qc.ca/en
Distributor:
PolicyMe Corp.
1300-207 Queens Quay W, Suite 400, Toronto,
ON M5J 1A7
AMF Client Number: 3002916818
General Inquiries: info@policyme.com
Phone: 1-866-999-7457
Website: www.policyme.com
What is this product:
Health and dental insurance serves as a vital safeguard for your well-being. This type of insurance coverage is designed to provide financial assistance in times of medical need and supplement the coverage provided by your provincial or territorial Government Health Insurance Plan. Health insurance ensures that you can access necessary medical care without the burden of exorbitant costs, offering protection against unexpected illnesses or injuries. Dental insurance, on the other hand, supports your oral health by covering expenses related to dental treatments and procedures. With health and dental insurance, you gain the peace of mind that comes from knowing you have a financial safety net to navigate the complexities of medical expenses.
How do I apply?
You may apply for PolicyMe Health and Dental Insurance by submitting an online application directly on PolicyMe’s website, which you can access at www.policyme.com. All aspects of the application will be done completely online, unless you choose to complete it over the phone with a licensed advisor. All further communication will be done via email, text, or calls. Depending on the plan you apply for, you may be required to answer health and lifestyle questions as part of the application and you may need to complete a nurse visit or other medical requirements, if deemed necessary during the underwriting process.
1. Product Details
The below table has an overview of the PolicyMe Health & Dental Insurance product:
2. Product Benefits
Please note that the below section is a condensed summary of all the possible benefits offered in the PolicyMe Health and Dental Insurance product. The specific benefits, associated coverage maximums and limitations vary across all plans. All plan terms and conditions should be referenced in the original policy documents (i.e. Schedule of Benefits).
2.1. Prescription Drug Benefit
This benefit covers prescribed drugs with a legal prescription requirement, a Drug Identification Number (DIN), approval through our process, and dispensing by a licensed pharmacist. Some non-prescription drugs may be covered if they have a DIN, approval, and are dispensed by a pharmacist. The benefit also includes coverage for copayments and deductibles under the provincial/territorial Government Health Insurance Plan.
2.2. Dental Benefit
This benefit covers basic services including diagnostic, preventative, and restorative care such as exams, cleanings, fillings, and basic oral surgeries. Comprehensive services encompass endodontic and periodontal treatments, as well as standard denture services. Major services include crowns, bridges, and dentures. Orthodontic services aim to straighten teeth and correct bites, with benefits only applicable during the coverage period.
2.3. Vision Benefit
This benefit covers prescription eyeglasses (including lenses and frames), prescription contact lenses, laser eye surgery, and optometric eye examinations.
2.4. Extended Health Benefits
Extended Health Benefits include:
- Accidental Dental Benefits: Covers dental care for natural teeth due to an accidental direct blow to the mouth.
- Ambulance Transportation Benefits: Covers the cost of licensed ambulance services for emergency situations.
- Hearing Aid Benefits: Covers the cost of hearing aids.
- Home Support Service Benefits: Covers services provided by registered nurses, practical nurses, personal support workers, or occupational therapists.
- Medical Items and Equipment Benefits: Covers prescribed items such as aids for daily living, casts and braces, incontinence/ostomy supplies, compression stockings, diabetic equipment, custom footwear, mobility aids, standard prosthetics, respiratory/cardiology equipment, and sterile surgical bandages.
- Diagnostic Services Benefits: Covers charges for diagnostic services not covered by the Government Health Insurance Plan, including CAT scans, ultrasound scans, MRI, laboratory tests, PSA test, CA 125 test, and audiologist services.
- Professional Services and Registered Therapists Benefits: Covers services provided by licensed and registered practitioners such as acupuncturists, chiropractors, clinical counsellors, osteopaths, naturopaths, foot care specialists, physiotherapists, marriage and family therapists, massage therapists, dietitians, psychologists, psychotherapists, social workers, and speech therapists.
- Hospital Accommodations Benefits: Covers the additional cost of semi-private or private room accommodations in public general hospitals, convalescent or rehabilitation hospitals, or convalescent/rehabilitation wings within 14 days of discharge from a public general hospital. It addresses the difference between Reasonable and Customary daily room charges and standard or ward rates during a hospital stay.
2.5. Cancellations
If you cancel within 30 days of the Effective Date, you will receive a full refund of any premiums you have paid minus any claims that have been paid or are payable to you. If the claims that we have paid are greater than the premiums paid, you must pay us the difference right away.
You will not be charged any cancellation fees or penalties.
You may request to cancel your policy by sending an email to advisor@policyme.com with your policy number.
2.6. Renewals
PolicyMe Health and Dental Insurance is a renewable product. This policy will auto-renew on a yearly basis, unless you tell us you wish to cancel. You can cancel at any time, without fees or penalties.
3. Product Exclusions & Limitations
3.1. Standard Exclusions
PolicyMe Health and Dental Insurance has the industry-standard exclusion for all policies where the insurer would not pay out any benefit which are in any way related to any of the following:
- expenses that are excluded from the Covered Person’s coverage because of an individual exclusion as stated in the Getting Started document, if applicable,
- an act or accident of war (declared or undeclared), due to any type of military conflict, act of terrorism or while serving in the armed forces of any country,
- the commission or attempted commission of a criminal offence or illegal act,
- failing to keep a scheduled appointment with a legally qualified Health Practitioner or Dental Practitioner,
- charges for translating or completing any claims forms, insurance reports or medical reports for any reason,
- a sickness, injury or other loss suffered where payment under this policy is not permissible by law,
- expenses for which a non-profit association, insurance carrier, third-party administrator or someone other than us makes a payment on your behalf,
- services provided by a Health Practitioner whose license has been suspended or revoked by the relevant regulatory or professional association,
- expenses that are solely for recreational or sporting activities that are not Medically Necessary for regular activities,
- expenses that are primarily for cosmetic or aesthetic purposes, or to correct congenital malformations,
- expenses incurred from services or supplies that are provided by an immediate family member who is related to you by birth, adoption or marriage, or by a practitioner who normally lives in your home; or are provided in a facility that you own or are employed through,
- delivery and transportation charges,
- charges that are provided for free from any government agency by complying with government laws or regulations or would normally have been paid through a government health insurance plan, Workplace Safety and Insurance Board or tribunal, the Assistive Devices Program or any other government agency if you made a proper application for coverage and proper and timely claims submission, regardless of any waiting list,
- expenses occurred outside Canada and/or your province/territory of residence
- expenses from a Health Practitioner who has opted out of a provincial/territorial Government Health Insurance Plan that would have otherwise been paid,
- administrative services or other fees charged by a Service Provider other than those directly related to the delivery of the service or supply,
- expenses that occur prior to the effective date of this Policy,
- charges, services, supplies or treatment that are not generally recognized by the medical profession in Canada as appropriate, effective, or required for the treatment of an Accident, injury or illness in accordance with Canadian medical standards.
3.2. Misstatement
If any Covered Persons’ date of birth or province has been misstated, your premiums will be adjusted to the amount that would have been charged based on their correct age or province. If you would have been ineligible for coverage had the correct information been provided at the time coverage became effective, this policy is void and we will return all of the premiums paid.
If you, intentionally or unintentionally, misrepresent, hide or fail to give us information when you are making a claim, we can choose to not pay the claim. If we have already paid it, you must pay us back any amounts we have paid to you. Under certain circumstances, we may terminate your policy and you will have to pay us back. If we investigate you for fraud, you must provide (at your own cost) all information that we need to investigate your claim.
We may need to conduct a claims assessment, which may require you to complete a medical questionnaire or provide us with additional medical information. You are responsible for the costs you incur for collecting this information.
If you applied for a fully underwritten policy and failed to disclose a Material Fact that may have resulted in an individual exclusion being applied to your policy at the time of issuance, we may update your benefits to apply the appropriate individual exclusions to this policy.
You must provide us with satisfactory proof of identity, age or other eligibility-related information for any Covered Person on this policy if we ask you.
4. How to make a claim
Many claims for prescription drugs, dental services and vision care can be submitted directly by your health care provider and processed automatically. You can also submit claims through your PolicyMe account for health and dental insurance.
When submitting a claim, you must always give the Member Identification Number for the Covered Person who has received the benefit. You will find your Member Identification Number on the front of your PolicyMe Benefits Card. You should include these Member Identification Numbers on all claims and correspondence with us.
You may need to include copies of the original itemized paid receipts. We do not accept cash receipts or credit card receipts on their own as proof of payment. We reserve the right to ask you for supplementary claims information. If you do not respond to our requests, we may deny your claim.
If you intentionally omit, misrepresent or falsify information relating to a claim, this may constitute claims fraud. It is a criminal offence to submit a fraudulent claim and we may report it to the relevant law enforcement and regulatory agencies. We may also terminate your coverage under this policy.
When we are identified as a secondary carrier, you must submit the original Explanation of Benefits statement from the primary carrier along with a copy of the claim form to receive any balances that you are owed.
We must receive your claim within 12 months from the date the charge for the eligible benefit was incurred.
4.1. Submitting Pre-Authorization Forms
Some benefits require you to submit a Pre-Authorization Form to us and receive our approval prior to you being able to proceed with a service or supply or get a claim reimbursed for a benefit.
Please contact the Administrator by emailing clientservices@hbmplus.ca or calling 1-519-739-1124 to obtain a copy of the Pre-Authorization Form. You can also access all Pre-Authorization Forms from your PolicyMe account for health and dental insurance.
You can submit Pre-Authorization Forms for medical equipment benefits to medical.authorization@groupinsurance.securiancanada.ca
Pre-Authorization Forms for drug benefits should be submitted to drugspecial.autho@greenshield.ca.
4.2. Overpayment of Claims
We reserve the right to recover all amounts resulting from overpaid or unsupported claims for benefits by deducting these amounts from any future claims you make or by any other legal means.
4.3. Getting Reimbursed
While this policy is in force, we will reimburse you for Reasonable and Customary Charges that you or your Dependents incur for Eligible Services/Supplies received subject to the exclusions, limitations, and conditions in the policy and subsequent amendments and counter-offer (if applicable). These must be:
- prescribed by and given under the direction of a Health Practitioner or Dental Practitioner, where required,
- Medically Necessary, in our opinion, for treating an illness or injury, taking all factors into account, and
- reasonable in the circumstances.
Benefits will be paid according to this policy after any contribution made by your provincial or territorial Government Health Insurance Plan (we will apply the standard co-pay for your plan before we reimburse you).
We will reimburse you by:
- making a direct deposit to your personal bank account, or
- mailing a cheque payable to you through Canada Post.
When we can reimburse your Service Provider, we will make a direct payment to them. We will reimburse you or your Service Provider in Canadian dollars. All dollar amounts stated in this policy are in Canadian dollars. Please note that reimbursements under this policy are only payable to the Policyholder or the Service Provider. The Policyholder cannot designate another person to be paid instead.
Claim eligibility and amounts available for reimbursement are based on plan maximums and the date that the service is received or the Eligible Services/Supplies are delivered, and not the order date or payment date. If you have not paid the premiums you owe in full at the time the Eligible Services/Supplies were provided, we will not reimburse you.
4.4. Coordination of Benefits (COB)
If you are covered for health and dental benefits under another plan in addition to this plan, and both plans permit a Coordination of Benefits (COB), your benefits under this plan will be coordinated with the other plan following industry standard guidelines developed by the Canadian Life and Health Insurance Association: the total amount payable cannot be greater than 100% of the eligible expense incurred.
Applying COB allows all benefit carriers to identify which plan is the primary payor and which is the secondary payor. We work together with other carriers or benefit plans to make sure you receive the maximum dollar value from all plans that you and your family are entitled to.
If your Spouse is covered under another plan, they must submit claims to that benefit plan first and then submit any remaining balances to this plan. Coverage under this plan will be secondary.
When your Dependent Children are covered under both your benefit plan and your Spouse’s benefit plan, you should first submit claims under the plan for the parent whose birth month and day fall earlier in the Calendar Year.
4.5. Frequently Asked Questions
4.5.1. How long will it take for a claim to be paid?
If you're submitting a claim online, it will be processed in real-time and you'll typically receive your reimbursement the following day through direct deposit. In some cases, a claim might trigger an audit at which point you may be asked to submit additional documentation within a certain timeframe.
From the time we receive your documents, it could take up to a week for us to review your claim and process your reimbursement.
If your medical provider will be submitting the claim on your behalf, it will be processed in real-time.
4.5.2. Who will pay my claim?
Securian Canada will be responsible for handling all the paperwork and paying out valid claims.
4.5.3. Does my health and dental insurance plan have any exclusions that I should know about?
Your health and dental insurance plan will have some exclusions that are common. We always recommend that our customers read what's included in their coverage carefully before accepting and paying for their policy.
4.5.4. How will my reimbursement be paid?
If you're submitting a claim online yourself, it will be reimbursed through direct deposit. In the event that are imbursement can't be made via direct deposit (e.g. if the banking details haven't yet been added to the portal or are incorrect), then you'll receive a cheque by mail.
4.5.5. How long should I hold onto my receipts?
We recommend that our customers keep the receipts of any submitted claims for at least 12 months.
5. Complaints
PolicyMe and Securian Canada are committed to providing you with the best customer experience to purchase health and dental insurance. If you are unhappy with your PolicyMe insurance and wish to makea complaint, you can do so by notifying PolicyMe in writing, either by email or letter, detailing the nature of your complaint and providing any relevant documentation.
Upon receipt of the complaint, PolicyMe will acknowledge your communication and initiate an investigation. The company will review your complaint and may request additional information if necessary. PolicyMe will aim to resolve your complaint in a timely and fair manner and provide you with a written response detailing the outcome of the investigation.
If you are not satisfied with the outcome of the investigation, you may escalate your complaint to PolicyMe at www.policyme.com/legal/complaints.
It is important to note that PolicyMe is committed to treating all complaints seriously and will work to ensure that any issues are resolved as quickly and effectively as possible.
PM-HD-02-EN-PS (03/2025)