Bodycam Footage: Niagara Falls
- A recreational or impromptu excursion in a car, usually at long distances from one's home... ”(https://en.wiktionary.org/wiki/road_trip)
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The uses of RentAFriend.com are endless. And be assured, the service is strictly platonic, solely for friendship purposes. If you’re looking for love or romance, look elsewhere.
Relevant Background on Niagara Parkway Road: “The Niagara Parkway, formerly known as Niagara Boulevard and historically as the Niagara Road, is a scenic road in the province of Ontario that travels on the Canadian side of the Niagara River from the town of Fort Erie to Niagara-on-the-Lake. The portion north of Table Rock in the city of Niagara Falls is designated as an Ontario Scenic Highway. Niagara Boulevard originally referred only to the section from Fort Erie to Chippawa.
The Niagara Parkway begins at Fort Erie in the south. It passes through several villages along the river before passing through the tourist district of Niagara Falls. North of the city it provides access to several attractions, including the Whirlpool Rapids, Butterfly Conservatory, and Brock's Monument at Queenston Heights. The route ends at Fort George, southeast of the urban centre of Niagara-on-the-Lake.
Construction on the modern Niagara Parkway began in 1908; it was completed from Lake Erie to Lake Ontario in 1931 as a scenic road with gardens and manicured lawns throughout its length. The parkway was referred to by Sir Winston Churchill, having been driven down it, as "the prettiest Sunday afternoon drive in the world."...The Niagara Parkway is a two-lane minor arterial road with a 60 km/h (37 mph) speed limit for the majority of its length, although the section from Hiram Street to Upper Rapids Boulevard in Niagara Falls is a four lane divided road signed at 40 km/h (25 mph). It is 55 km (34 mi) in length, crossing the entire Niagara Peninsula between Lake Erie and Lake Ontario.[3][4] The route falls under the jurisdiction of the Niagara Parks Commission, an agency of the Government of Ontario, for most of its length. However, the section from Hiram Street to Glenview Avenue belongs to the City of Niagara Falls.[5] Despite this, it is still signed as part of the Niagara Parkway.[3] The Niagara River Recreation Trail, a mixed-use pedestrian and cycling path, follows 53 km (33 mi) of the length of the parkway between Niagara-on-the-Lake and Fort Erie.[2]
The parkway begins at the old Fort Erie, south of the Peace Bridge, where it is known as Lakeshore Road and connects with the Queen Elizabeth Way (QEW) and the former Highway 3. East of the Mather Circle, the road becomes known as Niagara Parkway and proceeds north through downtown Fort Erie, beneath the International Railway Bridge. It gradually curves to the east opposite the southern shore of Grand Island. Houses line the southern side of the parkway along this section. The road curves back northward as it crosses the Black Creek and passes through a sparsely populated stretch. It passes the Willoughby Historical Museum followed by the Legends on the Niagara Golf Course. Shortly thereafter, it enters the City of Niagara Falls and meets the Welland River. Traffic is diverted west to cross the river at Portage Road, where it then resumes on the Niagara Parkway at King's Bridge Park....The Niagara Parkway travels alongside the Upper Rapids and passes adjacent to Horseshoe Falls.[4] It crosses through Queen Victoria Park and enters downtown Niagara Falls, where it is known as River Road north of Clifton Hill. The parkway passes below the Rainbow Bridge; side streets provide access to Highway 420, but River Road itself does not meet it. As the road progresses north, it passes beneath the Whirlpool Rapids Bridge before wrapping around the Whirlpool Rapids. At Victoria Avenue, River Road becomes the Niagara Parkway again.[6] The parkway passes the Butterfly Conservatory and crosses the Sir Adam Beck Hydroelectric Power Stations.[3] Shortly thereafter, it passes by the Niagara Floral Clock, one of the largest floral clocks in the world with a diameter of 12.2 m (40 ft).[4] It passes beneath Highway 405 at the Lewiston–Queenston Bridge; the Parkway's interchange with Highway 405 was removed by December 2006....North of the bridge, the route descends the Niagara Escarpment near Brock's Monument, a column which commemorates the death of Sir Isaac Brock during the Battle of Queenston Heights. At the bottom of the escarpment, the route passes the village of Queenston.[8] The parkway meanders north, parallel to the river, with houses lining the western side. Approaching the town of Niagara-on-the-Lake, the road becomes known as Queen's Parade. It diverges from the river and travels northwest towards the town, ending at Fort George..” (https://en.wikipedia.org/wiki/Niagara_Parkway)
***
Relevant Material: “Sir Adam Beck Hydroelectric Generating Stations are two hydroelectric generating stations in Niagara Falls, Ontario, Canada. Sir Adam Beck Generating Station I, Sir Adam Beck Generating Station II and the Sir Adam Beck Pump Generating Station are all owned by Ontario Power Generation. Following the development of several smaller generating stations around Niagara Falls in the late 19th and early 20th centuries, the Province of Ontario authorized the construction of the first major publicly owned generating station in the province.[2] At the time it was built, it was the largest hydroelectric generating station in the world.
The stations divert water from the Niagara and Welland rivers above Niagara Falls which is then released into the lower portion of the Niagara River, and together produce up to 1,962 MW (2,631,000 hp)....The open cut Chippawa-Queenston Power Canal diverts water from the Welland River to the stations. Upstream of the International Control Dam are three tunnel intakes which run under Niagara Falls, Ontario, and surface 2 km (1.2 mi) upstream of the Sir Adam Beck Generating Stations. All three tunnel intakes are upstream of the Control Dam, however one of the three tunnels is unseen, under the water, located directly in front of the Control Dam, Control Tower. The open cut canal and the tunnel canal cross at the "Cross Over" where there is a third channel feeding the 174 MW pump generating station 43°08′40″N 79°03′36″W which pumps water up into the man-made reservoir at night and generates electricity during the day, feeding the water back to the Sir Adam Beck Generating Complex.[7]
The International Control Dam, operated by Ontario Power Generation, controls the water diversions from the Niagara River and dispatches the water between the New York Power Authority and Ontario Power Generation in accordance with the terms of the 1950 Niagara Treaty....” (https://en.wikipedia.org/wiki/Sir_Adam_Beck_Hydroelectric_Generating_Stations)
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Relevant Material: “The Lewiston–Queenston Bridge, also known as the Queenston–Lewiston Bridge, is an arch bridge that crosses the Niagara River gorge just south of the Niagara Escarpment. The bridge was officially opened on November 1, 1962. It is an international bridge between the United States and Canada. It connects Interstate 190 in the town of Lewiston, New York to Highway 405 in the community of Queenston, Ontario. The Lewiston–Queenston Bridge is architecturally similar to the Rainbow Bridge at nearby Niagara Falls.
Customs plazas are located on both ends of the bridge, with tolls only being charged on entering Canada ($5.00 USD or $6.50 CAD per passenger automobile). The bridge accepts E-ZPass electronic toll collection and houses the second Canadian E-ZPass collection facility, after the nearby Peace Bridge. Also, two duty-free stores are located between the two plazas.
The bridge permits no pedestrians, but licensed taxi service is permitted.[5] The Lewiston–Queenston Bridge lacks expedited border clearance facilities for NEXUS and FAST card holders traveling from the United States into Canada, but does have a NEXUS lane for travel into the United States.
Gantries have lights indicating the direction of traffic as the lanes are reversible. Speed limit is posted in kilometres and miles per hour (15 mph or 24 km/h limit) along the bridge. Canadian and United States flags fly at the midpoint on the south side of the bridge.
The crossing is the fourth-busiest on the Canada–United States border, with delays of up to two hours.[citation needed] It is on the most direct route connecting the US Interstate system to Toronto and Detroit.[6] Canada replaced its border inspection facilities in 2011. The United States announced plans in 2016 to spend US$50 million to upgrade the primary inspection facilities.[7] Construction was completed in 2022. Both facilities are open 24 hours per day, 365 days per year. All commercial vehicles crossing between the US and Canada at the Niagara River must use this crossing...” (https://en.wikipedia.org/wiki/Lewiston%E2%80%93Queenston_Bridge)
***
Relevant Material: “Niagara Falls (/naɪˈæɡərə/) is a group of three waterfalls at the southern end of Niagara Gorge, spanning the border between the province of Ontario in Canada and the state of New York in the United States. The largest of the three is Horseshoe Falls, which straddles the international border of the two countries.[1] It is also known as the Canadian Falls.[2] The smaller American Falls and Bridal Veil Falls lie within the United States. Bridal Veil Falls is separated from Horseshoe Falls by Goat Island and from American Falls by Luna Island, with both islands situated in New York.
Formed by the Niagara River, which drains Lake Erie into Lake Ontario, the combined falls have the highest flow rate of any waterfall in North America that has a vertical drop of more than 50 m (160 ft). During peak daytime tourist hours, more than 168,000 m3 (5.9 million cu ft) of water goes over the crest of the falls every minute.[3] Horseshoe Falls is the most powerful waterfall in North America, as measured by flow rate.[4] Niagara Falls is famed for its beauty and is a valuable source of hydroelectric power. Balancing recreational, commercial, and industrial uses has been a challenge for the stewards of the falls since the 19th century.
Niagara Falls is 27 km (17 mi) northwest of Buffalo, New York, and 69 km (43 mi) southeast of Toronto, between the twin cities of Niagara Falls, Ontario, and Niagara Falls, New York. Niagara Falls was formed when glaciers receded at the end of the Wisconsin glaciation (the last ice age), and water from the newly formed Great Lakes carved a path over and through the Niagara Escarpment en route to the Atlantic Ocean... The features that became Niagara Falls were created by the Wisconsin glaciation about 10,000 years ago.[11] The retreat of the ice sheet left behind a large amount of meltwater (see Lake Algonquin, Lake Chicago, Glacial Lake Iroquois, and Champlain Sea) that filled up the basins that the glaciers had carved, thus creating the Great Lakes as we know them today.[12][13] Scientists posit there is an old valley, St David's Buried Gorge, buried by glacial drift, at the approximate location of the present Welland Canal..
When the ice melted, the upper Great Lakes emptied into the Niagara River, which followed the rearranged topography across the Niagara Escarpment. In time, the river cut a gorge through the north-facing cliff, or cuesta.[14] Because of the interactions of three major rock formations, the rocky bed did not erode evenly. The caprock formation is composed of hard, erosion-resistant limestone and dolomite of the Lockport Formation (Middle Silurian). That hard layer of stone eroded more slowly than the underlying materials.[14] Immediately below the caprock lies the weaker, softer, sloping Rochester Formation (Lower Silurian). This formation is composed mainly of shale, though it has some thin limestone layers. It also contains ancient fossils. In time, the river eroded the soft layer that supported the hard layers, undercutting the hard caprock, which gave way in great chunks. This process repeated countless times, eventually carving out the falls. Submerged in the river in the lower valley, hidden from view, is the Queenston Formation (Upper Ordovician), which is composed of shales and fine sandstones. All three formations were laid down in an ancient sea, their differences of character deriving from changing conditions within that sea.
About 10,900 years ago, the Niagara Falls was between present-day Queenston, Ontario, and Lewiston, New York, but erosion of the crest caused the falls to retreat approximately 6.8 miles (10.9 km) southward.[15] The shape of Horseshoe Falls has changed through the process of erosion, evolving from a small arch to a horseshoe bend to the present day V-shape.[16] Just upstream from the falls' current location, Goat Island splits the course of the Niagara River, resulting in the separation of Horseshoe Falls to the west from the American and Bridal Veil Falls to the east. Engineering has slowed erosion and recession..”(https://en.wikipedia.org/wiki/Niagara_Falls)
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Relevant Background: “Average residential sale price is expected to increase by 3.5% 2024, while the number of sales transactions is expected to increase by 4.5 per cent. In 2024, the top three most desirable neighbourhoods in
***
Relevant Material: “The average rent for an apartment in Niagara Falls is $932. The cost of rent varies depending on several factors, including location, size, and quality..The average size for a Niagara Falls, NY apartment is 881 square feet, but this number varies greatly depending on unit type, with cheap and luxury alternatives for houses and apartments alike. Studio apartments are the smallest and most affordable, 1-bedroom apartments are closer to the average, while 2-bedroom apartments and 3-bedroom apartments offer a more generous square footage....” (https://www.rentcafe.com/average-rent-market-trends/us/ny/niagara-falls/)
***
- Injuries – both unintentional and violence-related – take the lives of 4.4 million people around the world each year and constitute nearly 8% of all deaths.
- For people age 5-29 years, 3 of the top 5 causes of death are injury-related, namely road traffic injuries, homicide and suicide.
- Injuries and violence are responsible for an estimated 10% of all years lived with disability.
- Injuries and violence place a massive burden on national economies, costing countries billions of US dollars each year in health care, lost productivity and law enforcement...” (Injuries and violence (who.int))***
- ***
- Relevant Stats: “
- Drowning is the third leading cause of unintentional injury death worldwide, accounting for 7% of all injury-related deaths.
- There are an estimated 236 000 annual drowning deaths worldwide.
- Global estimates may significantly underestimate the actual public health problem related to drowning.
- Children, males and individuals with increased access to water are most at risk of drowning....” (Drowning (who.int))
***Relevant stats relevant to hypothermia: “More than 5 million people die each year globally because of excessively hot or cold conditions, a 20-year study has found – and heat-related deaths are on the rise...” (Extreme temperatures kill 5 million people a year with heat-related deaths rising, study finds | Extreme weather | The Guardian)***Relevant stats on boating accidents: “Boating deaths in Canada have been decreasing. During 2000 (the most recent year for which national data are available), there were 147 boating fatalities - a new low. During 1996-2000, 888 people died in boating incidents, down by 17% from the previous five years (1991-1995)...Half of Canadian boating deaths occur on lakes (53%). Oceans (23%) and rivers/streams (22%) account for the balance.By region, one-quarter (28%) of Canadian boating fatalities occurred in Ontario during 1996-2000; 21% in British Columbia; 18% in Quebec; 17% in Atlantic Canada; 13% in the Prairie provinces; and 3% in the northern territories.
Powerboats are the most prevalent pleasure craft and account for more than half of all Canadian boating deaths. Small open powerboats under 5½ metres (18 feet) in length are more often involved than larger powerboats. Canoes are the second-most involved craft. The absolute number of personal watercraft fatalities is low. However the water-related death rate for PWCs, at 11 deaths a year per 100,000 boats, is higher than for powerboats at six deaths a year per 100,000 boats, and higher than unpowered craft (e.g. canoes, sailboats and rowboats) at 2 to 5 deaths a year per 100,000 boats.
From 1996 to 2000 in Canada, 85% of those who died boating were not wearing personal-flotation devices, and alcohol was involved in 38% of fatalities...” (Canadian Boating Statistics | Pat's Boating in Canada (ncf.ca))
***
Relevant Stats on Vacation and Investment Properties: “Airbnb has over 7 million active listings in over 220 countries...394 million ‘nights and experiences’ were booked on Airbnb around the world in 2022. Airbnb has had over 1.5 billion guest arrivals since it started in 2007….typical host in the U.S. earns $14,000 per year from Airbnb…” (https://www.rubyhome.com/blog/airbnb-stats/)a. Travel & Health
Travel health Insurance - Common Clauses
Health
a) Pre-existing conditions;
b) Sporting activity exclusions;
c) Excess Hospital, medical and extended care for Canadian Travellers;
d) Regular hospital coverage for visitors to Canada;
e) Accident dental treatment;
f) Emergency Transportation
g) Travel of a family member
Death or disability
Funeral Expense;
Repatriation;
Death benefits - accident (ground or Air);
Disability and loss of sight benefits – accident
Travel Health Insurance - Other coverages
Trip cancellation or interruption (usually standalone);
Baggage and other possessions (Standalone)
Return of automobile;
Delay of return travel;
Child care attendant;
Collision waver for rental vehicles;
Pet return (often restricted to dog or cat)
Flight Insurance (usually standalone)
Skill 2: Client Service and Sales skills
Outline:
Manage new and existing clients. Analyze and review risk and provide ongoing service.
Description
Brokers must possess intermediate level understanding of techniques to review and evaluate the risks and need of each travel health Insurance client. Brokers must have Intermediate level ability to negotiate with Insurers and use their rate manuals.
Brokers must have intermediate level knowledge of office procedures in order to process data and information accurately and quickly. They must have intermediate level ability to organize their daily schedules to permit client service work to be undertaken regularly and promptly, including Insurance policy maintenance and claims processing.
Skill 3: Risk Management skill
Outline: Identify and assess exposures of travellers and recommend methods to manage the risks associated with travel.
Description: Brokers must have intermediate level knowledge and understanding of how to identify exposures of Canadians travelling out of province/country and of foreigners travelling to and within Canada.
Brokers must have advanced level ability to identify activity exposures of travellers, including frequency and duration of trips. In particular, planned undertaking of hazardous sports or recreation during trips must be determined.
Brokers must have advanced level knowledge and understanding for the financial exposures of Canadians travelling outside the province/country and of foreigners travelling to and within Canada.
Advanced level knowledge is required to assess those exposures and quantify them. Brokers must then be able to select the Insurer offering the coverage required by clients and help clients complete the application.
Brokers must have Advanced level knowledge and understanding to advise travellers of the appropriate Insurance response to their needs. This also entails clear expectations of terms and limitations, including the procedures to be followed in order to make a claim under a policy. Advanced level skill is required to keep up-to-date on changes to industry travel policy forms and wordings.
Prescribed medication changes, other than to generic brand, must not have occurred within the 12-month period immediately preceding each departure date or the applicant's effective date. Length of time may vary with different carriers.
Definitions:
Definitions may vary amongst Insurers; the following is intended to provide a basic understanding.
Accident:
Unintentional, sudden and unforeseeable event due exclusively to an external cause inflicting, directly and independently of all other causes, bodily harm.
Activate (Activations)
Selection of, and payment of the appropriate premium for, the Multi Trip Annual Plan, Single trip annual plan, and/or any top up Extension coverage by the client.
Carrier
The Insurer underwriting the risk
Change of prescribed Medication
Medication dosage or frequency being reduced, increased, stopped and/or new medications being prescribed and or taken by applicant (Insured)
A change of prescribed medication will be considered for coverage when supported in writing by the applicant (insured's) Physician when
1. The active ingredient or dosage of the medication remains the same or is decreased due to improvement of the medical condition, or
2. Newly developed Drugs introduced to the market are prescribed where a definite improvement in the applicant's condition is anticipated
3. Prescribed Medication changes, other than to a generic brand, must not have occurred within the twelve month period (12 month) period immediately preceding each departure date or the applicant's effective date. Length of time may vary with different carriers.
Common Carrier
A public land, Air, or water conveyance licensed to carry passengers for hire.
Company
The Insuring company
Critical
In danger of death or life threatening
Deductible
The amount that the applicant must pay before any benefits are payable by the company. A deductible, if chosen, is retroactive to the first day of the applicant's trip and applies to each unrelated medical emergency that leads to an eligible claim.
Departure Date
The earlier of the date the applicant
a) Boards of the ticketed transportation, or
b) Leaves Canada on an insured trip, unless the applicant requested coverage to begin on the date the applicant leaves his/her province/territory of residence.
Departure point
The location where the applicant departs from their province or territory of residence.
Dependant (s)
Any unmarried children residing at home, who are at least 15 days of age, but under 19, and who are living with and dependant upon the pplicant for their sole means of support.
Effective date
For the multi-trip annual plan, means the date indicated on the applicant's confirmation letter, when the application and the required premium are received by the company or its representative. If the coverage is purchased after the applicant's departure date, emergency sickness related benefits shall become effective 48 hours after the date and time the required is received by the company.
For the policy, means the date this policy is issued to the applicant and as indicated on the applicant's confirmation letter.
For Top up- Extension, means the date immediately following the termination date of the applicant's existing emergency travel health Insurance coverage.
Elective treatment
Medical Treatment, surgery or any other procedure scheduled by the applicant's physician to occur at a future date.
Emergency
An unexpected or unforeseeable sickness or injury that requires immediate non-discretionary medical attention, treatment or care.
Extended Family:
The applicant's spouse, the applicant's children, their spouse's, the applicant's parent's or guardian(s), the applicant's in -laws, brother, sister's, grandparents and grand children.
Government Health Insurance plan
The ministry in each province overseas a health Insurance plan for its residents. Each province has its own regulatory fee guides and may refer to the plan by different names ; e.g., In Ontario, It is called Ontario Health Insurance plan (OHIP)
Hospital
A facility equipped to perform surgery and which regularly treats patients on a medical emergency in patient and out patient basis and is identified and licensed as a hispital in the area where the hospital services are performed. In no event, shall this include a nursing, home, a rest home, convalescent home, rehabilitation center or home for the aged.
Injury
Sudden body harm that is directly caused by an accident during an Insured trip, and that is independent of sickness and all other causes.
Insured
A person or persons named on the application form and confirmation letter for whom insurance coverage is in effect for this policy.
Insured Trip
A trip on which the applicant is travelling outside Canada (or the insured's province/territory of residence, if requested) for which coverage is in effect under a Multi-trip annual plan, a single trip daily plan or a top up extension coverage the applicant has activated for that trip. Coverage on a trip begins on the Insured's departure date and ends on earlier of the date the Insured returns to the province, or the number of days of coverage under the plan purchased.
Medical Director
The medical doctor acting on behalf of the company.
Medical Emergency
An unexpected and unforeseeable sickness or injury, which requires immediate non-discretionary medical attention, treatment or care.
Medical Stable and Controlled
Medical treatment must not have been recommended, or required, or obtained, or symptoms must not have appeared or changed and there is no change of prescribed medication (see definition)
Medical Treatment
Medical Advice, Investigation, Consultation, care, service, diagnosis, or prescription rendered by a physician for the Insured's sickness or injury.
Multi-trip Annual Plan
Coverage for an unlimited number of Insured's trip of duration of 30, 60, 90, or 120 days within a continuous 365 - day period commencing from the effective date.
Ontario Health Insurance plan - OHIP
A health Insurance plan for all Ontario residents which the Ontario government oversees and administrates. This plan covers the basic health providers and services as outlined by the applicable health act.
Physician
Medical director or person, other than a relative, who is legally qualified and licensed to practice medicine or perform surgery in the location where services are performed.
Policy period
The Period between the effective and termination date covered by the policy.
Preexisting Medical Condition
Sickness, injury, or medical condition, or any medical condition directly or indirectly related thereto, which existed on or prior to the effective date or any departure date.
Reasonable and Customary
Costs that are customarily charged for covered benefits and that are not in excess of the standard fee for the geographical area where the charges are incurred for the comparable medical treatment, services or supplies for a similar sickness or injury
Representative
The financial Institution, agent or other location where payment arrangements have been accepted by the company
Sickness
Illness or disease
Single Trip Daily plan (per Trip)
A fixed number of days of coverage equal to the total length of the Insured's trip, including the Insured's departure date and return date.
Terminal Prognosis
A clinical assessment performed by a licensed physician who determines that an existing medical condition, sickness or injury is expected to result in the Insured's premature death within a specified time, commonly twelve months following any departure date.
Termination Date
For an Insured's trip, means the date any activated coverage ends, being the earlier of the date that the insured returns to their province of residence or the number of days coverage the Insured purchased under the Insured's multi-trip annual plan option, Single trip daily plan, or top up extension coverage for that trip.
For the policy, means 364 days after the effective date for the policy.
Third Party administrator (TPA)
An organization that processes Insurance claims for a separate entity. This can be viewed as outsourcing the administration of the claims processing, since the TPA is performing a task traditionally handled by the company provicing the Insurance.
Travelling Companion
Any person, up to a specified number of persons, including the Insured, who is sharing prepaid accommodation and/or transportation arrangements with the Insured.
Unstable condition
A sickness or injury that would cause an ordinarily prudent person to expect to need medical treatment or investigation following departure.
Vehicle
A private passenger automobile, station wagon, or mini-van defined as a vehicle manufactured and designed a transport a maximum of seven passengers and used exclusively for the transportation of passengers, or a trailer either owned or rented by the Insured. Vehicles also include motor homes and camper units. Motor home means a self-propelled vehicle containing living quarters that are an integral part of the vehicle and are not removable. Camper Unit means a specifically constructed unit for living purposes mounted on or removable from a vehicle.
You or yours
Means Each Insured
Risk Management & Product types
Foreign destinations have always had a wide appeal to the members of the world community and to Canadians in particular. All travel attract various common and other more uncommon risks. Every destination has a certain associated risks - and some may even be considered too high risk to be eligible for travel Insurance - each method of travel attracts unique risks that need to be Insured against.
In this section, we look at:
a) Types of travel risks;
b) Broad categories of travel Insurance Products; and
c) Types of private plans in detail
In the next section, we look at details of typical coverages in private plans
Travel Risks
Medical risks
Travellers are faced with many risks that may result in financial loss to themselves or members of their families, in the event of sickness, accident or death.
In remote areas of the world, even if western style healthcare were available, the services of a hospital or clinic would cost between $3000 and $5000 US per day.
Enormous increase in foreign healthcare costs and cutbacks in government coverage have resulted in ever-increasing premiums. In an effort to moderate these increases , the carriers have included large deductibles, more exclusion and in some cases very restrictive underwriting practices. Personal claim deductibles now vary in size from $100 to $25000. One company has a $100,000 deductible, which reduces the premium by 80%. In this particular case, it is used as a top up for federal retirement travel benefit. These many changes have resulted in an increased risk to the travelling public. Now in addition, to the concern of lack of coverage, is the risk that the coverage is not broad enough or that benefits may run out due to the exclusions and maximums.
Non- Medical Risks
The traveller could also be faced with costs related to the following:
a) Loss of baggage or other personal possessions;
b) Delays in arriving at, or returning from, a trip;
c) The disability of others such as travel companions, or their trip interruption, resulting from an early or late return from a trip.
d) Automobile Return
e) Rental Vehicle damage
f) Child care
g) Pet return
h) Flight accident
i) Common Carrier travel accident
j) Return of deceased insured
k) Emergency dental
l) Return of Insured to destination
Advising the client of the risk
Cautious travellers, before leaving home, are now faced with a bewildering array of plans and coverages from more than 50 different Insurers. The traveller's individual situation and needs will dictate which plan is required. The Broker's skill and knowledge provides the necessary insight for travellers to make educated decisions to minimize risk.
A large part of your value as a professional advisor will be in how well you keep abreast with the policy changes and innovations that are constantly advanced by the carriers. Professionalism should be composed of equal parts, knowledge, skill and ethical practice.
Product Types - All providers
A wide spectrum of travel Insurance coverage is available under the following:
1. Provincial government health Insurance plans (GHIP), with coverage varying from one province to another.
See Appendix A for provincial and territorial GHIP residency requirements and for details of Ontario's out of country coverage.
See Appendix B for typical benefits provided under the provincial and territorial GHIP's. Individuals who incur health costs while out of the country would be reimbursed at the listed lower amounts.
2. Group Insurance plans (if available), which usually provide out of province/country coverage that pays in excess of what is covered, or which may not be covered at all, by government plans. These private group plan have limitations, exclusions, and maximums that must be examined carefully.
See Appendix C for typical benefits provided under group Insurance plans.
3. Private Travel plans, (Individually purchased travel health Insurance), which often include benefits not available through either government or group plans. Private plans are also referred to as personal plans.
Private travel health Insurance is designed to supplement the coverage that the traveller requires in addition to their GHIP. The government health act prohibits private carriers from competing with the government plan. The private carriers can provide coverage only when the government plan has
a) Been exhausted and ceases to pay; and/or
b) Does not provide coverage
The most typical private travel plans are classified by duration, purpose, and by whether travel is outbound (commonly four types) or inbound for visitors to Canada. Plan coverages also vary according to whether or not travellers are covered by their provincial health care plan.
Product Types - Private plans
Four broad categories of private travel Insurance cover risks associated with outbound travel. A fifth type covers risks associated with Inbound travel to Canada, and can be standalone or incorporated in to the one of the first four types.
Different travel health Insurance providers may classify their products in other ways; e.g., medical only, comprehensive packages covering medical and non-medical risks; single trip versus annual plan coverage, various standalone coverages etc. You will need to become familiar with each provider's products in order to advise your client knowledgeably.
This text primarily deals with travellers who are outbound but coverage for various inbound travellers is described briefly. The travel Health Blueprint at the end of this section is a useful guide for determining which product an insured needs.
Out bound Travel Insurance
Short term or one trip coverage
Short term trips are those taken by Canadians who are travelling for a relatively short period for up to 90 days. Short term coverage extends coverage offered under the GHIP plan and offer certain benefits that are not normally included in government plans.
Example of wording for single trip coverage
Short term trips are those taken by Canadians who are travelling for a relatively short period for up to 90 days. Short term coverage extends coverage offered under GHIP plan and offer certain benefits not normally included in government plans
Long-Term One-Trip coverage
Long term trips usually refer to those taken by Canadians who vacation outside Canada for an extended time that does not exceed the coverage time frame specified by the provincial GHIP. In ontario, OHIP currently has a limit of 212 days, after which the coverage is cancelled. (See Appendix A)
For many long-term travellers, split residency has become part of their lifestyle. It is common, for example, to describe our long term winter travellers as snow birds, defined as Canadians aged 55+ (now also sometimes known as zoomers) who spend 31+ consecutive nights outside Canada. While the travel pattern's of today's retirees are changing, snow birds still account for a sizeable market - it is estimated that their trips account for over $86 million in premiums spent on over 690,000 trips in 2006 and these figures are growing as the baby boomers mature.
Frequent travellers Annual plan
Frequent travel whether for business, pleasure or caregiving to elderly parents, for example, is a way of life for many people. Business travel has become a routine for many. This type of travel incurs special risks that need to be examined and properly insured. As its name implies, this is an annual; coevrage for frquent trips. It is identical to short term plans but is paid for on an annual basis. The plan offers a variety of durations, 3-90 days being common but limits the numebr of days contracted. The traveller is covered for any number of trips in the one-year period.
Expatriate Insurance
This plan requires that the person must not be Insured or eligible for benefits under a Canadian government health Insurance plan. The person must be either: i) A Canadian citizen residing outside of Canada; ii) A canadian citizen returning to reside in Canada and awaiting coverage under a government health Insurance plan, or; iii) A non-Canadian citizen residing outside their country of origin while employed by a Canadian company. Coverage is world wide.
The Canadian government recognizes that certain types of extended stays warrant special consideration. Missionaries, diplomats, health care specialists, students and certain other individuals who are out of Canada for extended absences, may receive preferential treatment and can apply for, and have, their GHIP coverage extended and topped up for years. Those with GHIP coverage would also require a traditional travel Insurance plan. Other travellers who are away for extended periods and whose GHIP coverage expires are exposed to all health care costs. Expatriate Insurance therefore becomes effective after GHIP coverage expires, and coevrs health costs from the first dollar. Generally, contracts can be renewed annually as required.
Inbound Insurance
Inbound Insurance is for travellers arriving in Canada. This includes international workers, professionals who are here on a time limited work basis, visitors, landed immigrants, refugees and students who come to Canada for higher level of education. Inbound Insurance provides beenfits for a new sickness or accident incurred while covered. In bound insurance contracts cover health costs from the first dollar. Contracts covering inbound travellers include various restrictions and limitations depending on the carrier. For exmaple, overall policy maximums can vary between $10,000 and $2,000,000. Inbound travel Insurance is available only to individuals who are not covered by GHIP coverage. The following regulations refer to the waiting periods for government coverage for various categories of visitors to Canada, and may vary from province to province.
Landed Immigrant
The effective date of coverage varies between one and three months. In Ontario, coverage becomes effective three months after the date of arrival in the province with Immigrant status, or three months after the immigrant status is acquired if the traveller arrived without Immigrant status.
Refugee
Coverage is effective immediately from the date of arrival in the province for convention refugees. Claimant refugees are covered under the federal government.
International Students
eligibility varied from province to province. In Ontario, International students are not eligible for coverage.
International Workers
Coverage is effective on the day of arrival, provided that the applicant has a minimum of a three-month visa. Family coverage is available if a correct visa is approved by Immigration Canada.
Visitors to Canada
Visitors to Canada are not eligible for any government Insurance plan coverage.
Inbound Insurance policies will not automatically cover preexisting conditions and are subject to an elimination period or a stability period for Visitors to Canada; for other inbound travellers, coevrage varies by carrier.
Coverages
Coverage Overview
The number of companies offering travel Insurance has increased tremendously in the last several decades. In the early 1990's only seven carriers offered competitive coverages; this has now increased to over 50 providers. For a listing of current travel Insurance providers, refer to the travel health Insurance Association of Canada (THIA) website, http://thiaonline.com. THIA member companies who are members of the Canadian Life and health Insurance Association (CLHIA) would also be covered under Assuris, the life Insurance Industry's consumer protection plan.
Distribution Channel
The products are distributed through a network of intermediaries or channels.
a) Travel Agents (Responsible for the most sales);
b) Banks and other financial Institutions
c) Life Insurance Agents;
d) General Insurance Brokers;
e) Licensed Financial planners;
f) Travel health Insurance Sites on the Internet;
g) Affinity Associations;
h) Cruise or other tour organizations, and airlines
Other channels offering travel Insurance include credit card companies and group employee benefit plans
Some companies use only their own distribution network while others use a variety of marketing sources.
Typical Outbound Travel Health Insurance Benefits
Types, Amounts, and wordings of travel Insurance benefits may vary from company to company. The following is intended to provide a general explaination.
Note that the following describes typical benefits for most outbound Insurance coverages, with the exception of Expatriate Insurance, which by its nature may contain unique benefits. It, for example, will not include coverage for excess hospital or medical benefits. Similary, inbound Insurance coverages would not cover the excess or extended benefits described below.
To protect the consumer, contracts must be compared in terms of the following:
a) Benefits;
b) Benefits descriptions;
c) Limitations, exclusions, and maximums;
d) General Provisions;
e) Premium Costs (least Important)
All coverages are prefaced by the caution that the company will pay the reasonable and customary charges for the costs incurred outside the country of residence. It also states that benefits will be paid for charges in excess of amount allowed and/or paid for by any government health Insurance plan (GHIP). The maximum aggregate limit will also be stated. Most insurance providers have stringent rules about written permission from their medical doctor, written direction from the attending physician and copies of receipts for all expenditures.
Excess Hospital
This benefit pays for public ward, semi-private, or private ward hospital accommodation, when directed by the doctor in charge. All other hospital services and supplies for the emergency in excess of what GHIP pays are also included. The limit allowed by OHIP (as of 2008) is $400 per day. All charges in excess of this amount are the responsibility of the patient. Travel health Insurance will pay this excess, within the limitations of the contract.
Excess Medical
This benefit pays charges in excess of what GHIP pays, which are incurred by an insured for services of a legally qualified physician or surgeon who is licensed to practice medicine in the local area where the services are performed.
Extended Health care
Coverage may include the following:
1. Private duty nursing services by a registered nurse up to a stated maximum;
2. Prescribed medication;
3. X-Ray and laboratory Fees;
4. Local Ambulance Services;
5. Appliances and related services such as for wheel chair rental, crutches, and braces;
6. Paramedical Practitioner services, such as chiropractor, osteopath, chiropodist or physiotherapist. In some contracts, a maximum overall dollar value may be stated for each of these practitioners.
Out of pocket expenses
This benefit provides reimbursement of additional out of pocket expenses when an insured is hospitalized (e.g., telephone and television rental charges) up to a daily maximum and an overall dollar maximum. Minimum stay requirements are stated. Additional uses for the allowable "out of pocket expenses" are found in the "transportation of family members" benefit.
Child care attendant
This benefit reimburses costs for a child care attendant (non-relative) to care for the children who were accompanying the Insured in the event the Insured is hospitalized. The benefit will be paid after a minimum hospital stay requirement, and will pay up to a stated maximum.
Emergency Air Ambulance
If the attending physician recommends (in writing) that you must return to your province or country of residence for immediate medical attention following an emergency, the Insurance company will pay the cost of an Air Ambulance, if the patient is unable to return on a regular flight. The Insurance company must approve this in writing and a stated maximum will apply.
Trip Cancellation, Interruption or Delay
Travellers frequently experience unavoidable situations that affect their plans in one of three ways:
1. Personal or family situation such as death or sudden medical emergency that necessitates the cancellation of the trip;
2. An emergency involving family members at home that occurs after the commencement of the trip, requiring the Insured to interrupt the trip to return home early;
3. A situation that delays the scheduled return home, or delays the traveller's departure.
These delays are considered to be outside the Insured's control, and may lead to delays or missed flights and connections.
The coverage is generally broad enough to cover not only the insured traveller, but also members of the immediate or extended family. In addition, this coverage usually extends to a travelling companion or business associate.
Other circumstances include:
a) Being called to Jury duty;
b) Being subpoenaed;
c) Being quarantined (at the Insured's residence) ;
d) Medical Emergency;
e) Death
Note: Non-medical benefits are not always included in the trip cancellation insurance.
Benefits of trip cancellation Insurance
The following benefits insure the risk outlined in the three situations described above.
1. Prior to the start of the trip: The insured is forced to cancel due to emergency, or to the death of the Insured and/or a family member of the Insured's extended family, travelling companion, or the business associate with whom the insured is travelling. The benefit will pay
a) The non-refundable portion of any prepaid transportation such as air, rail or cruise ship, or
b) The non-refundable portion of any of the unused, prepaid travel arrangements.
This would include:
a) Hotel;
b) Meals;
c) Airplane fare; and
d) Other scheduled expenses arranged prior to departure.
Some travel health plans stipulate "after you leave home" and therefore do not cover cancellation prior to departure.
2. Interrupted Trip Benefits
Apply to a trip already in progress. If an occurrence prohibits the Insured from completing the trip as scheduled, the benefit will return:
a) Any non-refundable portion of any unused prepaid accommodation; and/or
b) The extra cost to change the return ticket to a one-way economy fare by regular scheduled transportation back to the departure point or to the group's next destination
3. Delayed Departure Benefits will cover the scheduled benefits as in (2) above if the departure is delayed due to an emergency.
Delayed Departure causes include:
** Severe weather conditions;
** Mechanical Breakdowns;
** An accident involving land transportation to your departure point
Trip cancellation Insurance is most often sold as an integral benefit to completely round out a travel health Insurance benefit for both domestic and foreign travel.
Other Benefits:
Other less typical benefits include the following:
Pet Return
Provides funds up to a stated maximum for return of an accompanying pet, usually limited to a cat or dog
Rental Car Collision
Provides funds up to stated maximum for damage to a vehicle rented from a commercial rental agency
Automobile return
Provides funds to a stated maximum to return a personal vehicle (land or water) to the home destination, due to a covered sickness or injury.
Flight Accident
Insured may choose amongst several levels of coverage; e.g., $200,000 to $500,000 for death and loss of limb(s), sight, etc. , due to an aircraft accident whether in flight including but not limited to on the airport premises before boardingor immediately after alighting from an aircraft.
Limitations and Exclusions
The study of travel Insurance would not be complete without examining the exclusions and limitations section
Exclusions and limitations prevent undue selection against the carrier and the premium paying consumer, and limit the exposure to normal travel risks. Benefits may vary slightly, but the real challenge lies in comparing the different companies policy wordings.
Typical Exclusions in Outbound Travel Insurance
Note: As mentioned in explaining typical benefits, the following describes typical exclusions for most outbound Insurance coverages, with the exception of Expatriate Insurance, which by its nature may contain unique exclusions. Similarly inbound Insurance coverages would contain varioud different exclusions
1. Any sickness or injury that occurs while the policy is not in effect, or during a trip or part of the trip that is not an insured trip, or for trip arrangements for which no premium was paid before departure.
2. Sickness or injury: which does not relate directly to an emergency, including general assessments or check ups, experimental drugs, preventative medicines or vaccines, elective treatment, elective or cosmetic surgery in any form, or treatment that can be delayed until return to the Insured's country of residence.
3. Expenses due to early or delayed return home, when caused by a situation that, before leaving, was aware would make it unlikely to complete the trip as booked.
4. Expenses due to trip delay or interruption: When the purpose of the trip is to visit a person who is ill, and the medical condition of the ill person worsens or death occurs, causing a delay or interruption to the Insured.
5. Hospital or medical treatment: Where the policy is sought specifically for the purpose of obtaining such treatment, whether or not recommended by a physician. This would include the borth of a child whole travelling, prenatal care or complications of a pregnancy ro child birth within eight weeks of expected delivery date.
6. Pregnancy, Child Birth, Miscarriage, or any complications due to pregnancy occurring within eight weeks of the expected delivery date is a common limitation to coverage during pregnancy. This would include the birth of a child while travelling, prenatal care, or complications of the pregnancy or child birth. Some policies totally exclude any costs related to pregnancy.
7. Suicide or self inflicted Injury: Or attempt thereat whether sane or insane, insanity, mental or emotional disorders (anxiety, depression) unless hospitalized, abuse of medication, drugs or intoxicants , or treatment of same, or accidents related thereto. This exclusion would encompass expenses incurred because the Insured failed to follow prescribed therapies or treatment.
8. Civil disorders, war or acts of war (whether war be declared or not). Action of foreign enemies or wilful exposure to peril, except in an attempt to save a human life.
9. Air Travel: Other than as a passenger in a commercial aircraft licensed to carry passengers for hire
10. Continuing medical treatment: If the insured is medically fit to return to their country of residence following treatment of a critical sickness or injury.
11. Sporting Activity Exclusions: Any costs incurred due to an injury as a result of participation as a paid professional in a sactioned competitive sport, or as a result of hand-gliding rock climbing, mountaineering, parachuting, para-sailing, skydiving, bungee jumping, snorkelling, scuba diving, cave exploration, or motorized speed or racing contests will not be covered. The sport activities exclusions may differ with different insurers.
12. Certain destinations may be excluded due to political unrest, or other circumstances.
13. Pre-existing conditions: This is undoubtedly the most often referenced limitation and exclusion clause. Because of its importance, it is discussed in detail in the section that follows.
Pre-existing conditions
Of all the limitations and exclusions that exist, none are more referenced and restrictive than "pre-ex" There are many variations, but all focus on the question, "What happened to you medically in the preceding days, months and sometimes years, prior to leaving on this trip?'
Typical Pre-ex question
What medical history, occurrence, or symptoms have you experienced prior to the date of application?
Remember that last year's medical occurrence may become this year's pre-existing condition. Worse still is the situation involving another's company's benefits.
Consider the following: Company A issues a policy providing coverage for 60 days, and the insured incurs a medical condition during those sixty days. Company B has issued a top up policy with a 60 day elimination. Company B declares the occurrencea pre-ex, even though it is the same trip and the insured has not yet made it home. A second consideration complicates the issue. A clear - cut situation would reflect symptoms for which the ill or injured person would consult a medical authority and receive a diagnosis. However, would this situation be considered a pre-ex if the symptoms were not acted on immediately? The cosensus is "YES" if a "person" experiencing such symptoms, whether or not the condition was deteriorating. An additional consideration concerns medicines or treatment prescribed to the applicant whether or not the applicant had acted on it. To further complicate the issue, a change in the prescription dosage, or type (increase or decrease) would also activate the pre-existing condition. The pre-existing period may extend from three, six, or nine months, or up to one full year prior to the date of issue. The company may include the 48 hours after purchasing the policy in the pre-existing period. In most policies, any medical condition that occurs prior to departure will trigger the pre-existing clause and it is up to applicant to provide any information regarding medical changes right up to their date of departure; otherwise, the policy may not be valid. The only remedy may be full disclosure to underwriting, asking either for elimination of the pre-ex clause or a weighted offer. The response could also be denial of issue, limitation of benefits, or caps on expenditures.
Examples of pre-existing condition wording
1. Any medical pre-existing condition which existed, or caused symptoms, or was treated or investigated, whether or not it was deteriorating, or for which medication was changed in type or dosage, on or prior to departure date.
2. Any pre-existing condition that is unstable in the three months before the traveller leaves home, or before the date policy coverage starts.
In some instances, the carrier provides for another method to eliminate the exclusion. This may take the form of
a) Underwriting
b) A top up requiring additional premiums; or
c) A departure date within a prescribed time limit of policy purchase.
Brokers, to receive full and open disclosure from their clients and to conduct their own due diligence, must realize that diagnosis is not necessary to define pre-existing conditions. It asks only if the symptoms existed. The fact that abnormal symptoms existed prior to the purchase of the policy, or that any symptoms or signs of illness or disease were known to the insured prior to the effective date of policy is sufficient. Once this occurs, it is up to the Insurer to determine the extent of the risks and the maount of premium required.
Insuring agreement
Each contract contains a statement known as the Insuring agreement. This is a broad statement of the benefits and the purpose of the policy. This statement is then augmented by the benefits and restricted by exclusions and limitations.
An example of an Insuring agreement
In consideration for the application of Insurance and the payment of the appropriate premium for the plan and coverage option you select, and subject to What is covered and what is not covered, the company will pay reasonable and customary charges up to the amounts specified below, which are in excess of any deductible amounts, for expenses incurred as a result of a medical emergency while on an insured trip. Under this policy, only medical emergencies which are unexpected or unforseeable and not related to pre-existing conditions are covered, unless you have been underwritten and received approval to have pre-existing medical conditions covered. Under this policy, only medical conditions that are unexpected and unforeseeable, and not related to Pre-existing medical conditions are covered, unless you have been underwritten and received approval to have pre-existing medical conditions covered.
The Insuring clause becomes effective after the application has been completed, signed and forwarded with the appropriate premium.
Extension of Coverage
Extension of Coverage falls in to two categories:
1. Voluntary decision to remain at the trip destination past the original intended date of return (or termination date)
2. An involuntary extension past the date of return, for reasons beyond the control of Insured person.
Voluntary extension
Some plans provide no extension of benefits past the date of termination (or return date). If the Insured is out of Canada. Others may provide extension (or top up) while the Insured is at their destination, provided there has been no change in their medical condition that may result in a claim. Conditions may include a requirement that a request be made before a minimum period prior to the planned date of return, a minimum extension period(eg. four to seven days), and a minimum premium.
Some contracts require that extension requests not exceed a maximum number of days; eg., 212 days in Ontario. A requirement may be that no extension will be granted if the request is made beyond 12 months after the Insured originally left home.
Involuntary Extension
This generally results from a medical condition that causes a delayed return. Other conditions may also apply.
This extension may be offered to
1. The insured only
2. A member of Insured's family
3. A travelling companion
Trip interruption coverage usually outlines the involuntary extensions and details the circumstances under which extensions will be granted and length of time allowed.
Example:
An automatic extension of up to 72 hours may be granted without extra premium, if the Insured trip is delayed due to circumstances beyond their control, such as
a) An emergency involving the Insured
b) A delay to the Insured's common carrier
c) Extreme weather causing hazardous travelling conditions
d) Other situations that may be submitted for consideration
Coordination of benefits with other Insurance plans
The benefits in a private plan will pay in excess of the GHIP of the Insured's home province. Benefits are also coordinated with other existing plans held by the Insured; eg. Benefits will not be paid under current policy if the other coverage would have paid, had the current policy not been in effect. The travel health policy becomes, in effect, 2nd payor.
Coordination of benefits is intended to ensure that benefits payable under all policies do not exceed 100% of all eligible expenses incurred.
Other Coverages would include, but not limited to:
a) Home owner's Insurance
b) Tenant's Insurance
c) Multi-risk Insurance
d) Extended Health care (Group or personal plans)
e) Auto Insurance Benefits;
f) Credit Card Policy
If an insured receives payment from a second insurer that should have been from a first Insurer, the second Insurer is entitled, under the subrogation clause, to recover their costs from the first Insurer.
Example of subrogation clause
If the Insured acquires the right of action against any individual, firm, or corporation, for a covered loss, for which payment has been made uner this policy, this right of claim must be transferred to the Insurer upon their request, so that they can recover expenses paid.
Applications and Underwriting
Applications forms vary widely from company to company, but all attempt to elicit the same information. Some are simple -- most are not! - but they do have some similarities. They provide for a full and open disclosure of the past (pre-existing) and present health of the applicant, to allow complete and accurate underwriting of the risk.
Application Forms - Outbound Insurance
As noted earlier with respect to benefits and exclusions, expatriate and inbound Insurance applications would differ significantly. The following describes a typical application for outbound travellers, exclusing expatriate Insurance.
All applications need to show the time exposure involved in the trip. It may list an effective date and/or date of departure, and termination date (completion date).
The only exception would be for top up or add- on benefits added to existing coverage. The effective date then would be the date of termination of the existing coverage. If the policy is an instant issue, the effective date will be the date written.
The effective date provides not only the time and date from which all coverage commences, but also a start point from which all pre-existing health conditions are measured.
All applications are designed in sections to supply the following information:
1. Name (In Quebec, maiden name must be provided);
2. Age;
3. Residence Address;
4. Date and point of departure;
5. Destination and date of return (or Termination of coverage);
6. Single, Couple or family coverage, and names of those to be covered;
7. Existing Supplemental Insurance
Section 1: Policy Coverage
This section determines who is to be covered under the policy. There may be a primary Insured and a dependant's section that would list the spouse and any dependant children travelling with the Insured.
Section 2: Date of Birth
The date of birth is required for most applications, and last age is commonly used to calculate the premium. The premium may be based on exact age, or more likely on five -year age bands (e.g., 40-44, 45-49, 50-54, etc)
Section 3: Home Address
Applicants are required to provide their home address in their province of residence
Section 4: Dat and point of departure
This section may look simple but can have complications. Consider the following:
1. Are the effective date and departure date two separate dates or the same date? Is the date the coverage is required the same as the date the applicant will leave the country of residence, or will they already be at their destination (i.e., is the plan topping up or adding on to an existing plan)?
2. Point of departure may be meaningless if the Insured is already at his/her destination when this coverage ceases.
3. If the Insured has to return home in response to a home emergency, and then leave the country to continue their scheduled trip, coverage would cease upon re-entry and would become effective again only when they depart.
Section 5: Destinations and Date of return (Termination of coverage)
Destinations may be one location (Vacation location) or a series of locations (cruise or tour). Generally speaking, the first location to be reached will be listed as the destination. The date of return may also differ from the termination date of the plan. Some coverage applies only to a set period, e.g., 30-90 days. The applicant, however, may be away longer and may insure the balance with a top up plan or decide to leave the remainder uninsured. Either way, it is important to the underwriter to know the exact terms of coverage and the dates to which they apply.
Section 6: Covered Individuals
Many families travel together, but occasionally people travelling together may not be family, but may be friends or travelling companions. Families receive reduction in premiums but non-related travelling companions do not!
Section 7: Existing Supplemental Insurance
Frequently, associations or affinity groups will provide travel health Insurance for a limited duration. It is important that the traveller disclose this pre-existing coverage. Some companies will not provide top up Insurance and some require this add-on Insurance to be written prior to leaving the home province. A few companies will issue after the termination date when the applicant is at their destination, but all companies will want to know the original company's coverage and duration.
Broker Identification
1. Name and Telephone Number;
2. Broker Code
Additional Information
This section seeks to disclose other pertinent details such as:
a) Smoker and Non-smoker status
b) Date of last medical and health status;
c) Provincial health card number;
d) Deductibles (If any);
e) Additional non-medical benefits (Riders and options)
Pre-existing Conditions
Most companies today provide a comprehensive medical questionnaire that may be required when pre-existing conditions have been disclosed. The applications may be rejected entirely or the applicant may be offered one of the following:
a) Coverage subject to paying additional premiums
b) Coverage allowing for one or two conditions;
c) Co-Insurance or a limitation on coverage;
d) Elimination of coverage of all pre-existing conditions, in which case coverage applies only for medical conditions or accidents that are new or not previously experienced and that originate after the trip commences.
To underwrite any pre-existing condition, the client and the broker must have sufficient time before the client's departure date to obtain the necessary information, including medical reports, if required. Clients who request coverage only days before departure will not have the advantage of having the pre-existing condition (S) underwritten. As a broker, you should encourage and educate your clients to apply for coverage well in advance of their departure dates to allow for a proper underwriting analysis.
Premium Calculation
Each plan has standard coverage that requires a basic premium calculation. This is followed by options that will increase or decrease the premium. Some examples are:
a. Excess flight coverage above the minimum offered in the plan;
b) Single, couple or family coverage, which require different premiums;
c. Coverage including both departure and return day;
d. Good health reductions, if available;
e. Non-Smoker reductions;
f. Deductibles, if any;
g. Coverage for pre-existing conditions that require an additional premium charge. The contract may offer this surcharge, OR if only one or tow of the pre-existing conditions apply, may offer full coverage subject to additional premiums;
h. In Quebec only, certain additional coverages that are required (with an extra premium charge)
Companies may offer deductibles as a method of reducing the premium. The percentage of premium reduction corresponds to the size of the deductible. This may be in the form of a straight dollar value reduction, or of a separate policy offer.
Co-Insurance and deductibles are used not only as a method of reducing premiums, but may also be used as a provision by claims administrators when some failure to comply with plan requirement occurs. An example would be an applicant's failure to notify the claims administrator immediately (or within 24 or 48 hours) of the commencement of the medical emergency, in which case the Insurer could void the contract or revert to larger deductibles.
Each consideration should be calculated before completing the application. For example, should a husband or wife who are travelling together or returning separately have two policies or one? It may not matter, or it may to their advantage to have two separate contracts. Over a certain age (55-60) , it may be mandatory to issue separate policies.
Underwriting Pre-existing conditions
Due to the tremendous impact of pre-existing conditions on claim costs, the applicant may be required to complete a medical questionnaire after a preliminary disclosure of an existing medical condition (or symptom and/or separate treatment). This form will seek to determine the existence and extent of a pre-existing condition (S).
Medical questions have long been the primary method life and health Insurance companies use to determine the degree of risk. Many of the travel health Insurance udnerwriters are now using this method as well. For these travel Insurers, the initial defence has been the disclosure of pre-existing conditions.
A current alternative is to channel the risk in to plans with restricted benefits. When an applicant indicates a medical condition, the application itself can divert the applicant to the restricted plan. The application form is divided in to sections which develop the dollowing information in addition to the general information described earlier, such as name, address, date of birth, provincial health card number, etc.
The application form is divided in to sections which develop the following information in addition to the general information described earlier, such as name, address, date of birth, provincial health card number, etc.
Physicians’ Information
1. Name, Address and telephone number;
2. Date of last visit;
3. reason and results
Medical Condition
This is a general statement of health Impairments, followed by a detailed listing of diseases and illnesses. The applicant will be required to list medication dosage and medical status when the last symptom, treatment ot mediaction change had taken place.
Additional Information frequently requested would include
1. Details of any surgery;
2. Future treatment or medical recommendation, not yet fulfilled;
3. Smoker status
Declaration or Release Statement
This statement, which must be signed and dated, may be found on the underwriting questionnaire or application. It's purpose is to provide full disclosure to enable accurate underwriting.
a) It verifies that the statements made by the applicant (S) are, to the best of their knowledge, true and fully disclosed.
b) It verifies the questionnaire forms part of their application.
c) It verifies that the health status changes between the date signed and the date of departure, the Insured will notify the company. This may be negated, i.e., this rule does not apply, if the time to departure is short (two weeks or less).
d) It authorizes the release of all medical information held by doctors and other medical providers.
e) It acknowledges that if at the time of claim, it is discovered that any question was not answered truthfully, accurately, and completely, it will result in the rejection of the claim (non-payment of the claim). In this event, the policy becomes null and void, and all premiums will be refunded. In effect, this acknowledgement gives notice of penalty provided for fraudulent intent, without stating it.
No broker is to be party to underwriting at the time of claim due to lack of true information at the time of issue. All brokers and licensed intermidiaries are responsible for assissting in ensuring that all required information is provided to the Insurance company.
Claims Administration
The very nature of travel health Insurance guarantees that a certain percentage of policies issued will result in claims. These claims can develop within weeks or even days of the effective date. It is important that the broker's understand and assist, however possible, in the claims process.
The broker's most important task, however is to explain the coverage to the applicant at the time of purchase.
Procedure at time of claim
The following is a basic outline of claims procedures.
Most Insurance carriers provide (and insist that it be used immediately) a communication system for their travelling insureds who find themselves in a traumatic health or other emergency situation. The first and foremost function of the entire system is the restoration of the health of the Insured or, failing that, the arresting and stabilizing of the situation that caused the emergency. A secondary purpose is the orderly and timely payment of the resulting charges.
The Hotline
Toll free 1-800 service numbers
Emergency response: (Managed Health care services)
The first step is the use of a hotline or the emergency response telephone number usually located somewhere on your policy documentation or wallet card to notify the Insurance carrier. For Insured's covered by two, three or more Insurers, the Canadian Life and health Association (CLHIA) has put together a protocol for multicarrier claims management and payments.
The basic premise is that the first Insurer called provides case management and claims payments. After the GHIP payments, the insurers are assessed for payments for all claims according to the terms of their contracts. The protocol provides for an orderly coordination of claims payments.
The 24-hour WORLDWIDE EMERGENCY assistance hotline will:
a) Assist Insured in obtaining emergency medical care;
b) Direct Insured to the nearest appropriate physician or medical facility, and if possible, to a contracted facility (which will often offer discounts), to meet the Insured's needs;
c) Contact friends or relatives on Insured's behalf;
d) Contact the health care provider to outline the terms of Insured's Insurance policy and payment arrangements;
e) Case manage and monitor progress daily;
f) Arrange appropriate transportation home and accompanying medical staff if required
The actual claims process is quite complex, Once the claim has been accepted, the claim(s) will proceed as shown on the claims management flow chart at the end of this section. However, before it is accepted or declined, it must follow a critical path for evaluation and adjudication.
The notification of the claim can come from one or several sources:
a) Broker/Agent;
b) Insured/Family;
c) Medical Provider
It will be processed and completed by the hotline or mail system, but if required, the Insured will be directed to a managed care unit that is part of the health Maintenance organization (HMO). Many of the providers and services have been prearranged and/or contracted. Note that this terminology applies primarily to claims occurring in the United States. "The language of Managed care" in Appendix D provides more detail on this aspect of the US system. Outside the US, the Insured would be directed to an appropriate healthcare facility. At this point, the claims administrator takes full control of the medical solution, surgery, or other required treatment in coordination of the medical facility and the personnel. They may also contact the policy holder's personal doctor and family for additional consultation. The billings will be directed to an assessor who adjudicates the statements, and makes critical decision on whether to pay or decline based on a strict interpretation of the policy, with particular attention to exclusions and pre-existing conditions. The assessor may request additional information before making the decision. Most declines are open to appeal on additional information not previously reported.
Cost reductions and Containments
Costs will be contained by avoiding a lengthy hospital stay and reducing time in the hospital prior to the repatriation charge. The costs of the claim are controlled and prearranged through the following techniques or services.
Managed Care Unit
* Physicians on call;
* Pre-admission management
* Surgical options;
* Air Evacuations
Cost Containment Unit
* Utilization and coding review
* Reasonable and Customary charges
* Expanding preferred provider Organizations network (PPO)
Pre pricing
* Clinics, hospitals, physicians are managed through PPO's;
* Hospitals issue Usual and Customary rates (UCR)
* UCR rates can be repriced and significantly discounted
* Physician's bill may be discounted up to 40%
* Hospital Bills may be discounted by up to 10% after the fact
Claims Assessment
A claims assessor reviews the claim and pays, declines, or defers it for further review, subject to additional information
A claim is paid: if all relevant information has been received and policy mandates payment on the submitted claim.
A claim is declined if the medical or other situation does not meet the policy requirements.
A claim is subject to further review if factors do not permit a pay or decline decision. These factors may include;
a) Insufficient Information
* Possible appearance of fraud, misrepresentation or other legal complication;
* Possible errors and excesses in submitted invoices.
Claims adjudication
Terms and conditions are established to determine the nature of claims payout. Discretion in the adjudication process increases the risk of claims payout. Subrogation may substantially reduce claims pay out.
Claims Adjusting
* Review for non-payment, in whole or in part;
* Review medical reports for pre-existing conditions;
* Review for fraud and Misrepresentation, etc.
* Administer in accordance with established discounting relationships (PPO's)
* Administer for retrospective discounts (quick pays, etc)
Subrogation
Initial primary responsibility falls with the provincial GHIP for payment of a claim. As noted earlier, subrogation can occur when more than on Insurer's coverages makes them liable for the claim. The primary Insurer is allowed to collect (subrogate ) from the second carrier (s) with Insurance polcieis in effect at the time.
Audits
Audits of hospital invoices for substantial amounts ($50,000) almost always result in a reduced billing.
Claims procedures and payments have the potential of either major assistance or major frustration to the Insured. Denial of payment can result in financial hardship or, in some cases, bankruptcy. The best protection is to provide full disclosure at time of writing the application.
Claims Management Flowchart
Insured experiences travel health emergency - Call the hotline - Managed care Unit - Assessor reviews and decides - Decline the claim - pay full or partial - Defer: Request more information from provider, broker/agent, and/or insured
Broker Responsibility
To be responsible broker involves much more than product knowledge. To be regarded as competent professionals requires a constant updating of knowledge and practice of the art of full disclosure to both our clients and our underwriters. As in many other professions, the responsibilities of the broker have greatly increased. New regulations, continuing education requirements, and a determination by the Insurers to know all the facts prior to the issue, have all combined to strengthen the facilitator - adivsor role of the broker. This, together with the Insurer's unwillingness to pay claims when faced with non-disclosure of pre-existing conditions or other prejudicial information, requires more from the broker than simply completing the application. The first of the professional skills that are required is the "know of your client" rule. Brokers must remember that they don't make medical prognoses and that symptoms that appear of no consequence in the "pre-app chat" can highly significant at claims time.
Sales & Service
Providing effective sales and service involves the following:
** Selecting the carrier (See Travel Health Insurance Checklist, page 14-53);
** Completing the application (See Broker Checklist, Page 14-54);
** Calculating the premium;
** Analyzing the client's needs (See client profile, page 14-55);
** Determining the client's medical condition.
Selecting the proper Carrier
Selection of the proper carrier requires due diligence and involves the following two steps
Research the market
Each Insurance carrier has an Insuring philosophy and type of coverage that they market. A careful reading of the sales material may not fully prepare you to deal with the public. When in doubt, request further descriptions of coverage and insuring clauses from the companies. Sample wordings are available on the Internet from many companies.
Understand the Key areas
Sales Brochures from different providers will all offer attractive approaches to the products. The benefits will appear to have similar protection. It is only when you compare the exclusions, limitations and definitions that the true coverage become apparent. Benefits that appear broad may have restricted maximums. Always compare the pre-existing conditions. Determine which of the carriers offers the maximum coverage at the most reasonable price. Price and commissions payable are not necessarily the deciding factors in determining which company(ies) you wish to offer to the consumer. Due to the enormity of the claim exposure, the broadest, most comprehensive benefit description will often be the deciding factor in the sale.
Completing the application
The previous section dealt extensively with the application form. It is of the utmost importance that this form (some complex and some simple) be filled out in its entirety with full and adequate disclosure. Adding to the complexity of the application form is the variety of plans and options that are available to your client.
The better you understand your client’s history and travel plans, including his or her destination, the better you are able to inform the underwriter. This will also facilitate a quick policy issue.
Calculating the premium
Calculating the premium may or may not be as easy as it first appears.
The following questions must taken in to consideration:
a) Is this a short-term, Long-term, Expatriate, Frequent Traveller, or Inbound policy?
b) Are premiums charged by the attained age or by age bands? Is it age restricted?
c) What is the duration of the travel time?
d) What additional options have been chosen?
e) Are there any pre-existing conditions or is health history clear?
f) Are there any special rates for cruises and tours?
g) Are there deductibles and/or co-insurance>?
h) Are there special rates for individually underwritten plans?
i) Is tax payable on any of the optional non-medical benefits>?
All companies maintain toll-free telephone numbers that are available to applicants and agents to request additional information or confirm rates.
Analyzing the Client's needs
Each type of traveller, and indeed each individual traveller, has unique needs that require examination prior to commitment by completing the applciation.
For ease of examination, we will present them in the following categories:
a) Type of Traveller;
b) Trip Duration
c) Destination
d) Analyzing Existing Coverage;
e) Uncovering prior medical history
Type of Traveller
As previously mentioned, travel health Insurance falls in to fairly well-defined categories of travel outside Canada.
a) short term (One-trip)
b) Long Term (One trip)
c) Expatriate Coverage
d) Offered both inside and outside Canada;
e) Frequent Travellers
Trip Duration
Trip duration is important because statistics show that the longer the Insured is away from home, the greater the risk of substantial claim.
Rates therefore favour short-term durations and costs increase substantially as the period away lengthens.
Destination
Destination has always had an effect on the premium rates and the validity of the contract. Costs to destinations where western style medical care is available and where the area enjoys political stability will less than to a country with less than desirable medical care, political unrest and any medical outbreak. No coverage is available if foreign affairs has issued a warning to avoid any specific country.
Analyzing Existing coverage
Travellers need to integrate or at least be aware of coverage that protects them
** Most group Insurance plans already offer "out of Canada" health coverage as well as travel emergency options. Benefits in their out of canada Insurance are similar to what the plan covers within canada.
** Credit cards often offer coverage that is automatic with a card purchase or is available with a check off selection
** Certain travel clubs, affinity groups and business organizations have travel benefits which may simply require an application.
** Lastly, all GHIP's offer some limited out of Canada benefits. See appendix A for details of out of Canada coverage provided by Ontario And Appendix B for typical GHIP benefits provided by all provincial governments and territories.
Appendix A: Provincial/Territorial Residency requirements and OHIP Out of country Coverage.
If you have a valid provincial health card you are entitled to certain benefits when outside Canada. But because coverage for out-of-country health care services is limited, you should purchase supplementary Insurance. When planning a trip outside Canada, get all the facts about your health coverage first - and get extra health Insurance before you leave. Remember, one day in American hospital can cost as much as $5000 per day up to $10,000 for specialized care.
Provincial Residency requirements
Most provinces and territories require residents to reside within their province for a specified number of days (in most cases - 183 days - approximately six months) in order to maintain their provincial health Insurance Coverage. If this requirement is met, the resident or the Insurer on behalf of the resident would be eligible to claim against applicable GHIP plan for a percentage of medical costs in curred either out of province, or out of canada.
Note: Residency requirement periods may differ from the period an insured is allowed to be outside of Canada and still qualify for out of country coverage.
a) Province
Newfoundland and labrador
Annual requirement: 4 months
Flexibility in Application: None
b) Nova scotia
Annual requirement: 183 days: Short absences permitted beyond 183 days.
C) Prince Edward Island:
183 days: Short absences within the country permitted beyond 183 days
d) New Brunswick:
183 days: Short absences permitted beyond 183 days
e) Quebec: 182 days
Trips up to 21 days do not count against the 182 days
f) Ontario
153 days
A 30-day grace period will be permitted
g) Manitoba: 183 days
Year long absences are permitted every 3 years
h) Saskatchewan:
Short absences within the country permitted beyond 183 days
I) Alberta: 183 days
Short absences within the country permitted beyond 183 days
j) British Columbia: 183 days
Short absences within the country permitted beyond 183 days
k) Yukon: 183 days
Short absences within the country permitted beyond 183 days
l) NWT: 183 days
Short absences within the country permitted beyond 183 days
m) NWT: 183 days
Short absences within the country permitted beyond 183 days
n) Nunavut: 183 days
Short absences within the country permitted beyond 183 days
Temporary residency requirement exemptions for Ontario Residents
Ontario Residents are already allowed to receive continuous OHIP coverage while out of the country, once in a life time, for up to:
a) Duration of academic or education program (unlimited)
b) 5 years for employment or duration of missionary assignments on behalf of an Ontario Employee for specific voluntary service outside Canada (unlimited)
c) 2 years for vacation or other reasons
Without exemptions, a person whose residency had lapsed would have to live in Ontario for three months again before becoming eligible for OHIP benefits.
Out of country costs that OHIP covers
The maximum time allowed outside Ontario is 212 days. Claims will not be paid after that time limit unless you have notified OHIP in advance and have received approval for the additional time.
For people travelling outside Canada, OHIP covers only emergency health services. If you travel out of country for elective medical services that are available in Ontario and/or can be planned ahead of time, you are not covered.
Emergency health services are those given in connection with an acute, unexpected condition, illness, disease or injury that arises outside Canada and requires immediate treatment.
As of September 2008, you are injured or become ill while travelling outside Canada, OHIP will pay for emergency health services as follows:
a) If you receive emergency care from a physician or other eligible health care provider, OHIP will pay only as much as that service would cost in Ontario;
b) Emergency inpatient hospital services eligible for OHIP coverage will be paid up to a maximum of $400 a day or the amount billed, whichever is less;
** Up to $400 for complex hospital care, such as surgery or coronary, neonatal, pediatric or intensive care;
** Up to $200 for less intensive medical care
** Emergency outpatient service, with the exception of dialysis, will be paid to a maximum of $50 for all out-patient services provided on any one day. Out of country dialysis treatment will be paid at a rate of $210 (Canadian) per treatment.
** OHIP will cover services only in hospitals or other health care facilities that are licensed by local governments
** For out of country services, the health care facilities must routinely perform both complex medical and complex surgical procedures. For outpatient services, they must routinely perform either complex medical or surgical services
** For outpatient services, they must routinely perform either complex or medical surgical services.
Reimbursement For emergency care outside Canada
If you should have purchased supplementary Insurance, check with your insurance carrier about how you should submit your bills. Otherwise, send your itemized bill to your nearest OHIP office within 12 months of receiving treatment. With the bill, send:
1) Details of your treatments;
2) Your original receipts for payment;
3) your name and current Ontario Address;
4) Your health number.
To avoid delays, do not hold your bills and receipts until your return to Ontario. Mail them to your insurance carrier or the ministry as soon as you receive them.
Payment for out of country health services with prior approval
OHIP will pay in full for health services outside of Canada if:
** The patient gets written authorization from the ministry of health and long-term care before the treatment is given; and
** The treatment is generally accepted in Ontario; and
* The treatment or equivalent procedure is not performed in Ontario, or
* The treatment is performed in Ontario but it is necessary that the person travels outside Canada to avoid a delay that would result in death or medically significant irreversible tissue damage
In order to obtain consideration for full funding of treatment outside Canada, your Ontario physicain must apply to the ministry for prior approval while you are in Ontario, before you receive out- of country treatment
Appendix B: Provincial/Territorial Health Insurance Benefits
The Canadian Life and health association Inc. provides current contact information (telephone and email addresses) for each province, at http://www.clhia/.ca/domino/html/clhia/CLHIA_LP4W_LND_Webbstation.nsf/resources/Consumer+Brochures/$file/Brochure_Guide_To_Travel_ENG.pdf
The detailed coverage information for each province and territory in the chart that follows the Ontario coverage information is current as of September 2008, and is provided by TIC Travel Insurance Coordinators. Claims for out of province or out of country costs incurred would be paid- if approved - at the provincial or territory rates applicable to the Individual's province or territory of residence.
Typical Ontario Benefits while in Canada
Note: This information is subject to change according to the Health Insurance Act.
Physician's services
** Provided that your doctor is licensed to practice medicine in Ontario, your health card allows you to receive Insured, medically necessary services, including diagnostic services and treatment
** The law does not allow doctors to bill extra for medical services covered by the provincial plan
Hospital Services
The ministry of health will pay for a bed in a standard ward in hospital, the nursing care that you need there, all diagnostic services (laboratory, X-Rays, ECG, etc) any drugs your doctor orders (but not the drugs that you take home), and operating room and anaesthetic facilities. The ministry does not pay the extra cost of a semi private or private room. In recent years the services and supplies have been greatly curtailed.
Other Health care services
The ministry pays only part of the costs for and office visit to a podiatrist, chiropractor, or osteopath. For example, the Ministry pays a chiropactor a maximum amount per person, per visit, per year. These health care providers may charge an extra amount over and above the ministry payment. Usually they will advice patients of this practice before providing a service.
Physiotherapy services
Physiotherapy treatment is free of charge when received in hospitals, and most hospitals have a physiotherapist on staff. Some physiciansemploy a physiotherapist and can provide services payable by the ministry. A limited number of private physiotherapists have been approved for ministry payment, byt the Ministry does not cover the services of most private clinics.
Optometry services
The cost of eye examinations, contact lenses or eye glasses is not covered.
Dental Services
The Ministry pays for a limited number of surgical-dental procedures, but only when they are done in a licensed hospital. The hospitalization must be medically necessary, and prior approval must be obtained from the Ministry.
The Ministry does not pay for dental services in a dentist's office, whether it is in a hospital or any other facility, with the exception of children born with cleft lip and/or palate.
Medical Laboratory services
The cost of Insured services by a private medical laboratory is covered if the lab is licensed in Ontario and tests are ordered by a physician.
Other Ministry services and programs from which you may benefit, subject to specific program criteria, include:
a) Ambulance services
b) Assistive Devices program
c) Chronic Hospital care
d) Home care program
e) Northern Health Travel grant program
f) Nursing homes and homes for the aged
Typical Provincial/Territory Benefits while outside of Canada
Note: Rates are subject to change from time to time
1
a) Province: BC;
b) Provincial Health Insurance plan (In patient): Physicians, labs and x-rays, emergency hospital services, with prior approval will pay up to BC rates for services available within the province and 100% of the services unavailable in the province
c) Maximum: BC rates $75/day for adult and $41 / newborn infant
d) Provincial Health Insurance plan (Out Patient): Physicians charges, Out patient coverage (Emergency Room), (All ancillar charges should be submitted)
e) Maximum (BC rates - No coverage except $293 for dialysis)
2
a) Province: Alberta
b) Provincial Health Insurance plan (In patient): Physician Charges, Emergency hospitalization, Extra $100 a day with blue cross optimum plan
c) Maximum: $100/day; Provincial Health Insurance plan (Out patient): Physicians charges, Out patient coverage, allowance for CAT scan ($190) and MRI ($645)
d) Maximum: Alta Rates: $50/day
3. a) Province: Saskatchewan
b) Physician's charges, Emergency Hospitalization, For services unavailable in Saskatchewan, 100% coverage if referral and prior approval
c) Maximum: Alta Rates $100/day
d) Provincial Health Insurance plan (Outpatient): Physician charges, Out patient coverage, Allowance for CAT scan ($190) and MRI ($645)
e) Maximum: Alta Rates: $50/day
4. a) Province: Manitoba
b) Provincial Health Insurance plan (In patient): Physician and Hospital Charges, Emergency Hospitalization based on bed capacity: ** 1-100 ($280 a day) beds, 101 - 500 beds ($365 a day), 501 beds and more ($570 a day) , Referrals: Greater of $75% of actual charge and: 1- 100 beds ($349 a day), 101-500 beds ($491 a day), 501 beds and more ($1043 a day)
c) Maximum: As stated above
d) Provincial Health Insurance plan (Out patient): Physician Charges, Out patient coverage, For referrals, greater of 75% of actual charge and $100
e) Maximum: Manitoba Rates: $100/day
5. a) Province: Ontario
b) Provincial health Insurance plan (In - patient) Physician charges, Emergency Hospitalization - Intensive medical care, Emergency Hospitalization - Less Intensive Medical care, For services unavailable in Ontario, prior approval is required for full reimbursement
c) Ontario rates ($400 a day and $200 a day)
d) Provincial Health Insurance plan (Out patient): Physician's charges, Out-patient coverage, dialysis treatment ($210)
e) Ontario Rates: $50/day
6.a) Province: Quebec
b) Provincial Health Insurance plan: Physician charges, Emergency hospital charges, For service not available in Canada, referrals from two physicians are needed for 100% coverage
c) Maximum: $100/day
d) Provincial Health Insurance plan (Out patient): Physician charges, Out patient coverage, Dialysis treatment ($220)
e) Maximum: Quebec Rates - $50/day
7. Province: New Brunswick
b) Provincial Health Insurance plan (In patient): Physician charges, Emergency hospital services including X-rays, Standard Ward, Where services are unavailable, prior approval is required.
c) Maximum: $100/day
d) Provincial Health Insurance plan (Out patient): Physician charges and out patient coverage
e) Maximum: $50/day
8. Province: Nova scotia
a) Provincial Health Insurance plan: Emergency hospital service rates based on average of Halifax metro hospitals, 100% coverage for referrals with prior approval
b) Maximum: Nova scotia Rates: $525/day
c) Provincial Health Insurance plan (Out patient) Physician's charges, Out patient coverage (incl. labs, radiology, MRI)
d) Maximum: NS rates and No coverage
9. PEI:
a) Provincial Health Insurance plan (In patient): Physician's charges, Emergency Hospital services, 100% coverage for services unavailable in province or Canada.
b) Maximum: PEI rates: $990/day
c) Provincial Health Insurance plan: Out patient: Physicians charges, out patient coverage, 100% coverage for services available in province or Canada
d) Maximum: PEI rates - $169/day
10. New found land:
a) Physician's charges, Emergency Hospitalization in a community hospital ($350 a day), Emergency Hospitalization in a Specialized hospital ($465 a day)
b) Provincial Health Insurance plan (Out patient): Physician's charges, out patient coverage, Dialysis
c) Maximum: Newfoundland rates ($62/day, $220/treatment)
11. a) Province: Yukon:
b) Maximum: Yukon rates: $1297/day
c) Provincial Health Insurance plan: Physician's charges and out patient coverage
d) Yukon rates: $110 a day maximum
12. a) Province: NWT
b) Physician's charges, Emergency Hospital services, Prior approval required for services not available in Canada, 100% coverage
c) Prior approval required for services not available in Canada, 100% coverage; Maximum: $1269 a day, Physician charges and Out patient coverage
d) Maximum: $231/day
Appendix C: Typical Group Insurance Benefits
The following examples are for illustration purposes only. Actual benefits are outlined by contract.
Extended Health care
May include in a calendar year deductible ($50/$100) and/or a co-Insurance factor (80%). The co Insurance factor would be applied to all claims except semi-private hospital and eye care. Benefit and overall life time maximums may vary from carrier to carrier.
Coverage:
a) Hospitals: Semi private or private
b) Convalescent Hospital: Daily Limit of $50/day for a maximum period of 120 days
c) Out of Canada/Province: Provide the same benefits and services as inside the province or residence, usually subject to an overall maximum.
d) Prescription Drugs: A comprehensive list of prescription drugs
e) Paramedicals: Fee for service charge of chiropactor, pediatrists, osteopaths, naturopaths, speech therapists, clinical psychologists, and masseurs. Annual Maximum - $500
f) Nursing care: Registered Nursing services - $10,000 maximum
g) Hearing Aids: $500 in a five year period
h) Ambulance: In the event of no-government run services
i) Services and Appliances: Braces, supports, crutches, and splints, as directed by the doctor
j) Accidental Death benefits: Coverage will include the services of a dentist ro a dental surgeon for a repair of natural teeth, as a result of an accidental direct blow to the mouth
Group Travel Emergency Coverage
Provides a world access operation centre reached by a 1-800 telephone number from anywhere in the world
Benefits may include travel emergencies for
Referrals to a physician, dentist, or medical facility for medical emergencies;
** Medical transportation to the nearest appropriate medical facility;
** Frequent contact with patient, attending physician, personal physician, and family;
** In the event of a death outside the province of residence, the return of the remains to a maximum of $5000 (or similar limit)
Financial Assistance
** Cash deposits for doctors and hospital authorities;
** Personal cash advances from credit cards or family, to post bail and pay legal fees. Legal referrals are also included;
** Return of rental vehicles (Maximum benefit of $1000)
Family Benefits
** Escorted return of minor children;
** If scheduled flight has been missed due to a medical emergency, the benefit will pay for economy class transportation;
** Will pay for the round trip economy class transportation for a family member to attend the ill family member. Out of pocket expenses to a maximum of $150 per day are included
The group Travel Provider will use a case Manager(Third Party) in the same way that Individual providers utilize administrators
Group Travel Health Insurance
Typical travel health Insurance benefits for emergency treatment only
a) 1-800 Emergency response telephone access;
b) Medical referrals to physicians, dentists or facility;
c) Return Home, Medivac (Air Ambulance) or commercial Air;
d) On-site Hospital Payment;
e) Repatriation of the deceased
They typically do not include the following benefits
a) Return of the dependent children;
b) Trip delay;
c) Visit by family member;
d) Return of vehicle or pet;
e) Legal referrals;
f) Lost documents and ticket replacements
Note Limitations
** Length of travel - limited to 60 continuous days;
** Designated countries
** Company is not responsible for any medical or legal advice given ;
** Company is not liable for negligent or wrongful acts of practitioners
Appendix C: Typical Group Insurance Benefits
The following examples are for illustration purposes only. Actual benefits are outlined by the contract.
Extended Health care
May include a calendar year deductible ($50/$100) and/or a co-Insurance factor (80%). The co-Insurance factor would be applied to claims presented except semi-private hospital and eye care. Benefit and overall life time maximums may vary from carrier to carrier.
Coverage Descriptions
a) Hospital: Semi private or private
b) Convalescent hospital: Daily limit of $50 per day for a maximum period of 120 days
c) Out of Canada/Province: Provide the same benefits and services as inside the province of residence, usually subject to an overall maximum
d) Prescription Drugs: A comprehensive list of prescription drugs
e) Paramedicals: Fee for service charge of chiropactor , podiatrist, osteopaths, naturopaths, speech therapist, clinical psychologists, and masseurs. Annual maximum is $500.
f) Nursing care: Registered nursing services - $10,000 maximum
g) Hearing Aids: $500 in a 5 year period
h) Ambulance: In the event of no government-run services
i) Services and appliances: Braces, Supports, crutches, and splints, as directed by the doctor
j) Accidental death Benefits: Coverage will include the services of a dentist or dental surgeon for the repair of natural teeth as a result of an accidental direct blow to the mouth
Benefits may include travel emergencies for:
a) Referrals to a physician, dentist, or medical facility for medical emergencies;
b) Medical transportation to the nearest appropriate medical facility;
c) Frequent contact with patient, attending physician, personal physician, and family;
d) In the event of death outside the province of residence , the return of the remains to a maximum of $5000 or similar limit.
Financial Assistance
** Cash deposits for doctors and hospital authorities;
** Personal cash advances from credit cards or family, to post bail and pay legal fees. Legal referrals are also included;
** Return of rental vehicles (Maximum benefit of $1000)
Family Benefits
** Escorted return of minor children;
** If scheduled flight has been missed due to medical emergency, the benefit will pay for economy class transportation;
** Will pay for the round trip economic class transportation for a family member to attend ill family member. Out of pocket expenses to a maximum of $150 per day are included.
The group travel provider will use a case manager (Third Party) in the same way that individual providers utilize Administrators
Group travel health Insurance
Typical travel health Insurance benefits for emergency treatment only
1) 1-800 Emergency response telephone access;
2) Medical referral to physcians, dentists, or facility;
3) Return Home, Medivac (Air Ambulance) or commercial Air;
d) Onsite Hospital payment
e) Repatriation of the deceased
They typically do not include the following benefits
a) Return of dependent children
b) Trip Delay;
c) Visit by family member;
d) Return of vehicle or pet;
e) Legal referrals
f) Lost documents and ticket replacements
Note Limitations
a) Length of travel - limited to 60 continuous days;
b) Designated countries;
c) Company is not responsible for any medical or legal advice given;
d) Company is not liable for negligent or wrong ful acts of practitioners
Appendix D: The language of Managed care
Capitation: Under a capitation system, a managed care plan pays a doctor or hospital a flat monthly fee for the care of each policy provider. The provider is paid regardless of whether the patient receives services. However, the provider does not receive additional payment if cost of care exceeds the set fee
Copayment or Co-Insurance: The portion of covered health care expenses that must be met by the policy holder, in addition to the deductible. This figure is usually expressed as a percentage. For example, in a traditional 80/20 plan, the insurer pays 80% of the doctor's bill and the patient pays 20%. This 80/20 calculation is based on the insurance company's definition of what constitutes a physician's reaosnable and customary fee.
Note: Many physicians charges are higher than the reasonable and customary fee and the patient is responsible for 100% of the access amount. This is known as "balance Billing". In all HMO's, a patient 's copayment will be only $5 to $15 per visit
Credentialing: Managed care plans review a phsyician's background and current professional standing before contracting with a physician. This will usually include requiring evidence of graduation from an accredited medical school, a current state medical license, and hospital privelages in good standing. A professional liability claims history, including malpractice coverage, and an inquiry in to past actions include chemical dependency, criminal convictions and disciplinary actions.
Deductible: The amount an insured must pay, before the Insurance company begins to pay its portion of claims. The higher the deductible, the lower the cost of the health plans.
Gatekeeper: A primary physician. In a managed care plan, the gate keeper is responsible for monitoring a patient's care and deciding when specialized care or tests are needed. The term encompasses family physicians and practitioners, internists, paediatricians and sometimes obstetricians/gyanaecologists.
Health Maintenance Organization (HMO): An HMO provides members, through a network of selected physicians and hospitals, with a basic and supplemental health maintenance and treatment package in exchange for a prepaid premium. There are generally small payments, no deductibles, and no claims to file. The HMO provides no reimbursement (or a reduced amount) for non-emergency care with a physician or hospital outside of the network. There are several types of HMO's:
a) A staff Model: A type of HMO's that hires its own doctors, who usually practice under one roof and are salaried.
b) Independent Practice Association (IPA): An "HMO with walls" - in which patients choose doctors from a select list and are treated at the physician's private offices. IPA physicians are free to contract with more than one HMO at a time as well as fee for service patients.
c) Point of service plan (POS): The latest development in negotiated care, this type of HMO allows the patient to see either an in-network or out-of-network provider. However, the patient pays more for opting out of the system. In those instances, reimbursement is only 50-80% and the patient must submit a claim and has deductible and co-payment charges just as he or she would under a traditional fee-for-service Insurance policy.
d) Indemnity or Fee- for service plan: Medicine the old-fashioned way. Patients receive a bill from the doctor or hospital for each service rendered. They submit the bill to their Insurance company and the company pays for it. These plans provide maximum coice of physicians and hospitals but are the most expensive kind of plan. Critics argue that this method gives doctors an incentive to perform more, sometimes unnecessary, procedures.
e) Managed Care: A general term for organizing doctors and hospitals in to health care delivery networks with the intent of lowering costs and providing appropriate care by managing the medical care provided. HMO's were the earliest form of managed care; currently, there are many different kinds of plans.
f) Network: A selected group of physicians, hospitals, laboratories, and other health care providers who participate in a managed care plan's health delivery program. They agree to follow the plan's procedures, submit monitoring of their practices, and provide certain negotiated discounts, in exchange for a guranteed patient pool.
Out of pocket maximum: A limit on all of the Insured's out of pocket expenses (including deductible and co-payments) for treatment of illness or injury. At this maximum, the Insurance company will begin covering 100% of the charges. If you use in-network providers, your out of pocket maximum will usually be between $1000 and $2000. If you choose to go out of network, your out-of-pocket maximum could be as high as $10,000.
Preferred provider organization (PPO): A type of managed care plan in which doctors and hospitals agree to provide an Insurance company or employer with discounted rates. PPO's usually don't exercise tight management over medical care; for example, they normally don't use primary care "gate keepers" patients are reimbursed 80-100% for treatment within the PPO versus 50-70% outside of it.
Premium: The monthly fee paid by consumers to Insurance plans for coverage. It does not include deductibles or co-payments. The premium is usually shared between the employer and employee.
Utilization Review: A general term for all Insurance plans oversight of the healthcare its members receive. It includes:
a) Precertification: the plan must approve, in advance, certain medical procedures before the insurer will agree to pay for them.
b) Case management: A nurse employed by the plan coordinates your care and rehabilitation, often in your home.
c) Second Opinion reviews - the plan decides, before approving payment, whether a second opinion for a surgical procedure is necessary...
b. Personal property coverage
c. Gps tracker, satellite phone, Panic Button, Dashcam, GPS, parking sensors, go pro, Breath analyzer for alcohol, Built in vehicle features like drowsiness alert and lane keep assist
d. TFSA, credit card insurance, personal loan insurance, Line of Credit Insurance
e. Liability Coverage:
“What Liability policies Insure
The majority of liability Insurance policies share certain characteristics. This chapter focuses on features common to automobile, personal, and most business liability policies.
The Insuring Agreement
The main Insuring Agreement on most liability policies can be summarized as follows:
"The Insurer agrees to pay all sums which the Insured shall become legally obligated to pay to third partiesas compensatory to a third party. It must be caused by an occurrence; it must occur during the policy period, and it must take place in the coverage territory"
The following is a brief analysis of this insuring agreement
1. Insure Bodily Injury & Property damage
Most liability policies insure the bodily injury and property damage caused by the Insureds
i) Bodily Injury
Bodily Injury refers to physical injury sustained, and associated with external causes. For example, a person who trips over loose carpeting or one who falls through defective stairs on the Insured's premises and is injured is considered to have suffered a bodily injury.
Bodily Injury also includes injury caused by:
** Sickness or Disease
and
Death resulting from any such injury at a later date will be considered as part of the same bodily injury.
Bodily Injury - A Broad definition
The definition of body injury contained in liability policies refers to actual harm to the body resulting from the Insured's actions, work or products. The following example illustrates the extent of the coverage provided:
Body Injury:
This morning Bert was in a rush to leave his store to attend a business meeting. As he was leaving, he negligently collided with an elderly customer who had just entered the building. As a result, the customer fell to the ground, causing her to break a hip. This injury to the customer falls within the coverages provided for bodily injury.
Sickness or Disease:
Thousands of Canadian women are the victims of failed breast implants. Legal actions in the mid 1990's against Dow Chemical, the company responsible for the faulty implants, alleged sickness due to implant rupture, painful joints, Muscle pain, tremors, memory loss and diseases such as Lupus and scleroderma. Liability policies providing bodily injury coverage would respond to pay such losses.
Death resulting from any of these at any time When the deaths of others are attributed to bodily injury, sickness and disease caused by the Insured, payment will be provided under the policy. ii. Property Damage Unintentional damage to the property of others is generally covered by their liability policy. Property damage includes: ** Physical Injury to tangible property as well as resulting loss of use; It also includes the loss of use to tangible property that is not physically injured. Property Damage includes payment for loss of use of tangible property When there is a claim against the Insured for damage to tangible property, the wronged party will often incur other significant financial loss. Two years ago, the Butler's home was destroyed by a fire started by a neighbour's child. In addition to the damage caused to their dwelling, Bert and Betty incurred additional expenditures for the rental of a temporary dwelling, transportation, and to board Bowser at a local kennel. The additional costs arising out of the loss of use of their premises would be paid under the property damage coverage provided by the neighbor’s liability policy. 2. Third Party Coverage The coverage provided by all liability policies is for damage or injury caused by the insureds to third parties A third party is anyone or any entity that is not named in the policy. 3. Payment only when insured legally liable Although the insured may feel a moral obligation to the injured party, the policy will respond only when the insured is legally liable for the injury or damage caused. Negligence must be established. Determination of legal liability - A matter for the courts. Last week, Betty lost control of their lawn mower and injured two children who were playing on a sidewalk next to the Butler's premises. The issue of Betty's legal liability for damages is the matter for the courts to decide. While betty may believe that she is legally responsible, she will normally have sufficient knowledge of the law to make that determination. In fact, it may be possible that she is not legally liable or as is often the case, is legally liable for only a portion of the damages. The message here is simple - only the courts have the authority to determine one's legal liability for injury or damage caused. It does not matter if the insured, insurer, and all the lawyers in the world believe someone is legally liable. Only a decision of the courts can make it so. This does not mean that all disputes involving bodily injury or property damage will be resolved by the courts. In the majority of the cases, the insurer will agree to an out of door settlement with the plaintiff when the evidence strongly supports that decision. 4. Coverage provided on Occurrence basis Occurrence is defined by the policy as an event…" Which occurs suddenly and unexpectedly; Technically, a sudden and unusual event which can be fixed in time is an accident. Or Which occurs over a long period of time BI/PD coverage provided on an occurrence basis Liability policies insure bodily injury and property damage on an occurrence basis. This includes coverages for unexpected injury and damage which happens: i. Suddenly or ii. Over long periods of time Accident The injuries caused to the children playing on the sidewalk near the Butler's premises when betty lost control of the riding lawnmower constitute an accident. The injuries occurred unexpectedly and suddenly and can be fixed in time. Continuous or repeated exposure Last fall, the butler's neighbours installed a fireplace in their home. By November, Betty noticed a slight paint discoloration on their dwelling. She suspected this was caused by improperly vented smoke from the neighbour's chimney. After careful observation, that appeared to be the case. By March, the entire side of the Butler's home was severely discoloured. Their neighbour refused to pay for repainting the Butler's dwelling, his only comment being, "So, Sue me!" The neighbour’s liability Insurance policy will provide coverage for damage to others arising out of the "continuous or repeated exposure to substantially the same general harmful conditions" The limit stated on the policy for bodily injury and property damage liability is available for each occurrence. In other words, even if a claim has been paid, the limit stated in the policy will be available again to pay future claims. Limit of Insurance available for each occurrence. The pink flamingo lamps made and sold by the Butlers caused three major fire losses last year. The Butler's business liability policy, if written on an occurrence basis, would provide them with a limit of $1000000 insurance for body injury and property damage liability. The following describes how the Insurer dealt with each loss: Loss # 1 - February 13 Claim - $750,000 The entire amount of the claim will be paid if the butler's are legally liable for the loss. Loss #2 - June 7 Claim - $1,300,000 The insurer is obligated to pay only the first $1,000,000 of the loss, provided the Butler's are legally liable. The payment of the remaining $300,000 would be the responsibility of the Butler's. Loss #3 - September 30 Claim - $500,000 The entire amount of the claim will be paid if the butlers are legally liable for the loss After each occurrence, the entire limit of Insurance purchased by the Butler's is again available. The above example Is based on a occurrence limit only. If the policy included an aggregate limit, the total will differ. Aggregate Limits An aggregate limit is the maximum amount paid for all valid claims during the policy term. In the above example, and if the policy was written with a bodily injury and property damage limit of $1,000,000 per occurrence and an aggregate limit of $2,000,000 the losses would be paid as follows: Loss #1: Paid $750,000. The loss is within the occurrence limit and within the aggregate limit. Loss #2: Paid $1,000,000. The loss exceeded the occurrence limit and therefore is subject to the occurrence limit of $1,000,000. When this loss is paid, this would also erode the aggregate limit by $1,000,000. Therefore, at this time, $1750,000 of the aggregate limit has been paid. Loss #3: Paid $250,000 The loss is within the occurrence limit but following loss # 2, there remains only $250,000 of the aggregate limit. Split limits or separate limits of liability policies may be written with split limits as compared to an inclusive limit. An inclusive limit could be $1,000,000 inclusive. This means that whether the claim be for body injury or property damage, there is an available limit overall of $1,000,000. However, if the liability policy is issued with split limits, the policy limits could be stated as follows: $100,000/$200,000/$50,000 When the policy includes Split limits, the three limits as shown in this example are as follows: The first number, $100,000, is the limit for bodily injury per person. The second number, $200,000, is the limit in total for bodily injury for all claimants for more than one person. However, this is still subject to the limit per person of $100,000. The third number, $50,000, is the limit for property damage per occurrence. For example, if a policy includes the split limits stated above and the damages are as follows: a) $110,000 b) $80,000 c) $25,000 The policy would pay as follows: a) $100,000 for bodily injury (limit per person) b) $80,000 for bodily injury c) $20,000 for bodily injury, total limit per occurrence is $200,000, leaving $5000 not covered Split Limits are used frequently with minimum limits applicable to auto insurance in the United States 5. Coverage for compensatory damages Liability policies pay for compensatory damages only Compensatory damages are those which are intended to compensate the third party/plaintiff for the injury or damage caused by the Insured (defendant) `There are other types of damages that may also be awarded by the courts. For example, the court may order the payment of punitive or exemplary damages. These damages are intended to punish the defendants for their actions and serve to deter others from similar behaviour in the future. The payment of punitive or exemplary damages is the sole responsibility of the Insured. Duties in the event of an occurrence, Claim or action Liability Insurers place a number of obligations on Insureds in the event of occurrence, claim or action. Insureds are required to: a) Provide the Insurer with prompt notification of any occurrence, claim or action. The information to be provided includes: Time, place and circumstances of the accident; The name and the addresses of the witness and potentially injured persons. Prompt notification allows the Insurer to quickly assess the potential of a successful action against the Insured. It also gives the Insurer the opportunity to collect all the facts concerning the accident while they are still fresh in the Insured's mind. Potential liability claims against Insured required to be reported promptly. The fortress Insurance company requires that the Butler's provide prompt notification of any occurrence which may lead to a claim. Too often, Insured's will ignore this requirement for notice, believing that no claim will be made against them. Two weeks ago, an elderly customer, Mr. B. Good, tripped over an electrical extension cord which was strung across a store aisle. Bert helped him to his feet and insisted on driving him home even though Mr. Good maintained he was "all right", Bert did not inform the Fortress Insurance company of the accident. Shortly after the accident and, unknown to Bert, Mr. Good began to experience a stiffness in his left hip which made it increasingly difficult for him to get around. Finally, 12 days after the accident, he could stand the pain no longer and consulted his doctor. The Doctor advised him that he had fractured his hip which made it increasingly difficult for him to get around. Finally, 12 days after the accident, he could stand the pain no longer and consulted his doctor. The doctor advised him that he had fractured his hip and that it would require surgery. Mr. Good consulted a lawyer and was advised to bring a suit for damages against the Butlers. As a condition of coverage, Bert owed an obligation to inform the Fortress Insurance company promptly of his potential liability claim. This would have allowed the Insurer the opportunity to collect all the facts while they were still fresh in Bert's mind and to interview witnesses who were in the store at the time. The more time passes, the more details tend to be forgotten or misstated. Immediately provide the Insurer with copies of any legal documents received. When notice of legal action is received, it is responsibility of the Insured to inform the Insurer immediately and to provide copies of all legal documents received. This is known as a notice of a claim. This condition is important because it gives the Insurer the opportunity to declare it's intention to the court and to defend the action against the Insured. Authorize the Insurer to obtain records and other information Written reports filed with police, fire and other authorities may contain information valuable to the Insurer in defending the claim. This condition authorizes the Insurer to access those records. ** Assist in Investigation, settlement or defense of the claim or action; Assist in the investigation, settlement or defense of the claim or action; Sometimes an insured knows the plaintiff and may be openly "on their side". When this happens, the Insurer may have difficulty in the following areas: Investigation When Insureds are reluctant to cooperate, the Insurer may be denied important information Settlement Insured's may actively resist any attempt by the Insurer to settle a claim out of court. This usually happens when Insured's feel they are not legally liable for injury or damage caused. This can be a source of frustration for Insurer's who are usually acting on legal advice. Defence When Insurers decide to defend an action against their Insured, they are usually convinced that there is not legal basis for the claim. In such cases, the Insured may be called upon to provide testimony. Any refusal by the Insured to do so could seriously undermine the Insurer's case. Not, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without the consent of the Insurer. The rights to investigate, defend and settle claims belongs exclusively to the Insurer. Any payments made or promised to the plaintiff by the Insured are an infringement upon those rights and are prohibited. The rights to investigate, defend and settle claims belongs exclusively to the Insurer. Any payments made or promised to the plaintiff by the Insured are an infringement upon those rights and are prohibited. The only financial obligations which can be passed on to the Insurer without its consent are those made for first aid at the time of the accident. Unless Otherwise Authorized, financial obligations assumed by Insured on behalf of the Insurer limited to those for first aid. Sometimes insureds will attempt to earn the good will of others to whom they cause injury or damage. In fact, when another customer tripped on loose carpeting in their store last Tuesday, Bert offered her $500 to "forget the whole thing". A local restaurant offered $1000 to all people who became ill after eating their "fish surprise" The Insurer will not reimburse the Insured for payment they voluntarily make to others. In fact, to do so, will be seen by the court as an admission of liability. The only monetary obligation an insured is entitled to incur on behalf of the Insurer without its consent is that directly related to the rendering of First Aid to the victim. The payment is not viewed as admission of liability but, rather, as the action expected of a responsible person when people are injured. This action also may mitigate damage incurred. Supplementary Payments The limit of Insurance provided by the policy for bodily injury and property damage is reserved for the payment of claims. The additional expenses incurred by insurers and Insureds in investigating, settling and defending a claim are provided under a separate insuring agreement entitled supplementary payments. The costs insured by this agreement include: I. Costs of defense; Actual legal cost to conduct a defense can, in a complicated action, amount to hundreds of thousands of dollars. Also, an Insurer may hire an independent adjuster to Investigate and negotiate any settlement of a claim. For many Insureds, the agreement of the Insurer to pay defense costs more than justifies the cost of purchasing liability Insurance. ii. Reasonable Expenses incurred by the Insured at the Insurer's request to assist in the investigation and defense of the claim; iii. Court Costs assessed against the Insured The court may rule that court costs be borne by either, or both the plaintiff and the defendant. iv. Interest from the date the judgement was rendered but only on the amount which is within the limit of Insurance provided by the policy. Insurer liable for payment of Interest costs from the date of the judgement. Last fall, the Butler's were found legally liable for damages in the amount of $2,000,000. The Insurer believed the court erred and took three months to decide whether to appeal the decision. Finally, the Insurer agreed to pay the claim. When the award is made by the court, the plaintiff is entitled to immediate payment. The Insurer is liable to the plaintiff for loss of interest. The interest is calculated from the date of the judgement and the Insurer is liable only for that portion provided on bodily injury and property damage limit of $1,000,000 only, and a judgement was for $2 million, the Fortress Insurance company would be required to pay interest on $1 million only. Supplementary payments are extremely important for all Insureds. They are usually not limited to any specific amount, and with most policies are provided in addition to other coverage limits in the policy. Liability policies restricted to specific activities Liability policies generally deal with specific activities and are not designed to insure all exposures faced by the Insureds. For example, a separate policy will be required for each of the Insured's personal, business, and professional liability exposures. In addition, the liability exposure associated with automobiles and aircraft is so great that they are required to be insured under their own policy. Chapter 10: Liability Insurance Policies The discussion for personal liability in this chapter is applicable to the RIBO comprehensive Homeowner, Tenant, Condominium Unit owner package policy. However, the RIBO wording also includes: Coverage I - Loss Assessment (Applicable to Condominium Unit Owner only) - RIBO - pg. 24 The Insurer agrees to pay up to 2505 of coverage A1 (unless a higher amount is stated in the declaration). The purpose of this coverage is to pay on behalf of the Insured any amount assessed by the corporation should the limits under the corporation's liability policy be inadequate or exhausted. It will not respond to any assessment made necessary by any deductible on the corporation's policy. Insuring Personal Liability - The Homeowners Forms Most individuals and businesses would be unable to withstand the financial strain a judgement for damage would impose upon them. Fortunately, insurers will agree to assume many of their exposures to financial loss. Most Insurance companies include liability coverages in the habitational property Insurance policies they sell. This eliminates the need for homeowners and tenants to purchase a separate policy for their liability exposures. The liability coverages normally provided under homeowner's forms are also designed to be used with the following habitational forms: a) Tenants Package Form; b) Mobile Homeowners Form; c) Condominium Unit Owner Forms; (with additions for loss assessment coverages for the most part, the coverages provided are the same for all forms. This discussion of personal liability is based on Section II- Liability coverage of the RIBO Comprehensive Homeowner, Tenant, Condominium Unit Owner package policy. Please refer to the provided booklet while studying this chapter. Coverages There are four coverages provided by this Section, namely: Coverage E - Personal Liability Coverage F - Voluntary Medical Payments Coverage G - Voluntary payment for damage to property Coverage H - Voluntary compensation for Residence Employees. Limits of Insurance The limit of Insurance for each of the three coverages is indicated on the coverage summary page. Insurers set their own limit for each of the three coverages is indicated on the coverage summary page. Insurers set their own limits for each coverage. For example, many of the homeowner forms issued by some insurers provide the following coverage limits: Coverage E: Personal Liability - $1 million Coverage F - Voluntary Medical payments - $1000 Coverage G: Voluntary payment for damage to property - $500 Coverage H: Voluntary Compensation for residence employees - As per schedule The limit for coverage E - Personal liability can usually be increased for an additional premium. These coverages are not subject to deductible but one may be inserted for property damage losses when the Insured has a history of frequent claims. Key Definitions i. Persons Insured (RIBO pg. 17) Persons insured by section 1- Property coverages are also insured under this section. In addition, four (4) other categories of people are insured. 1. Persons or organization legally liable for damages caused by a watercraft or an animal owned by the Insured which the policy covers. 2. Residence Employees while performing duties in connection with the ownership, use or operation of motorized vehicles and trailers covered by the policy. 3. A legal representative having temporary custody of the insured premises after the Insured's death for the liability arising out of the Insured's premises. 4. Anyone Insured by the policy who continues to reside on the premises after the Insured's death. ii) Premises Insured (RIBO pg. 17) The coverage provided by the policy insures "all premises where the person(s) named as insured in the Declarations, or his or her spouse maintains a residence, including seasonal or other residences, provided such premises are specifically described in the Declarations." Liability coverage can be extended to seasonal and other dwellings owned by the Insured. Bert's Brother Bart and his wife own two homes - a summer home in Winkler, Manitoba and another in Winnipeg where they spend their winters. Three years ago, they purchased a small cottage at Clear Lake, a popular resort. The Homeowners Forms will provide liability coverage at all three locations provided such locations are specifically described on the coverage summary page. Coverage is also provided at the following locations: "1. Premises where you are residing temporarily or which you are using temporarily, as long as you are not: a) The owner of the premises; Coverage provided for claims originating on Premises of others while Insured Temporarily residing there. Last Summer the Butlers rented a cottage for two weeks at Greenwater Lake, Saskatchewan. On their third day there, a friend who came to visit suffered a broken leg when she was knocked to the ground by Bowser, The Butler's Dog. Their friend, a water-skiing instructor, was unable to work for the entire summer and, in an attempt to recover the amount of her financial loss, sued Bert abd Betty for damages. The Homeowners Form will respond when a claim arises out of the premises of other while being temporarily used by the Insured for residential purposes. Other premises insured would include apartments, hotel rooms, camps and campgrounds anywhere in the world. ** The lessee or tenant of the premises under any agreement which is longer than 90 consecutive days." There is not coverage for claims arising out of premises which are rented or leased for more than 90 consecutive days. This coverage limitation will be important to insureds who spend three or more months away each winter and to students living away from home. In such cases, Insureds must be advised to purchased additional coverage. 2. Premises in Canada to be occupied by you as your principal residence from the date you acquire ownership or take possession but not beyond the earliest of: a) 30 consecutive days; b) The date the policy expires or is terminated; c) The date upon which specific liability Insurance is arranged for such premises." Insureds who purchase another home which is to be occupied as their principal residence are automatically insured from the date, they take possession of the home. However, coverage is for a limited time period only. For example, if the Insured's policy expires in five days, there is no coverage for such dwelling beyond five days. In the event arrangements have been made for new Insurance, the coverage provided by this policy ceases immediately. In no event shall the coverage provided by this policy exceed 30 consecutive days. "3. Individual or family cemetery plots or burial plots;" All premises owned by the Insured represent a potential liability exposure. As such, it is important that family-owned cemetery plots or burial vaults be included within definition of "premises" insured by the policy. "4. Vacant land in Canada you own or rent other than farm land;" Vacant land purchased as a future dwelling site, for investment purposes, or for other purposes, or for other reasons can expose the Insured to claims for injury or damage when people go onto that land. For example, snowmobilers crossing such land may be injured when they run in to tree stumps, rocks or fences. The coverage provided by this section extends to those premises. However, it is important to note that this additional coverage applies only to vacant land located within Canada. For example, Insureds who buy a vacant lot in Texas or Hawaii would be required to purchase additional coverage. There is no coverage for claims arising out of vacant farm land. "5. Land in Canada where an independent contractor is building a one, two or three-family residence to be occupied by you" Insureds who hire a contractor to build a one, two or three-family home which they will occupy do not have to purchase additional liability Insurance for that location during the period of construction. Liability Coverages Coverage E - Personal Liability Personal Liability coverage is designed to Insure the legal liability of Insureds in their role as private citizens while anywhere in the world. Accidental Injury or damage originating on the Insured's premises or caused while on holidays, at public meetings, or while shopping, fishing, golfing or playing ball are included within the kinds of private wrongs insured by this Insuring agreement. Liability for personal acts Insured anywhere in the world. Bert and Betty are planning a summer holiday and have narrowed their choices down to Taiwan, Greece, and China. As this Insuring Agreement provides them with personal liability coverages anywhere in the world, they will not need to purchase a separate liability policy to cover their legal liability for injury or damage to others while on their vacation. Condition of Insured's Premises a Major source of Liability Claims. The condition of the Insured's premises and the activities conducted thereon can be a major source of liability claims. Types of losses thereon can be a major source of liability claims. Types of losses for which coverage is provided by the policy include: a) Injury to postal employee caused by the Insured's dog; b) Drowning of neighbor's child in Insured's swimming pool or hot tub; c) Injury to other children who use skate board ramp on the Insured's driveway or trampoline in the Insured's yard; d) Fire damage to neighbouring property from sparks from an outdoor barbeque pit. Exclusions "We do not Insure claims made against you arising from: 1. "Liability you have assumed by contract unless your legal liability would have applied even if no contract had been in force, but we do insure claims made against you for the legal liability of other persons in relation to your premises that you have assumed under a written contract" Insureds cannot voluntarily assume the liability of others and expect their Insurer to pay for the injury or damage caused by such persons. For example, the insurer would not provide payment when the Insured agrees to assume the liability of a friend when that friend borrows the Insured's electric golf cart. However, there are two exceptions to this general rule. The Insurer agrees to make a payment: a) When the Insured would have been liable anyway; In the above example, if the golf cart is defective and injury or damage is directly due to such condition, the Insurer agrees to provide coverage in the event the Insured is judged liable. b) When the liability being assumed is related to the Insured's premises. For example, if the Insured hires a contractor to build a fence on the premises and agrees in writing to assume the liability of that contractor for unintentional injury caused to passerby or for damage to neighbouring property, the Insurer would respond in the event of a claim. 2. "damage to property owned by an Insured" It makes sense that damage caused by Insureds to owned property would be excluded. Paying for such claims would lead to abuse by Insureds. Provided the damage the Insureds caused was accidental, Section 1 would pay for this damage. 3. "damage to property if used, occupied, leased or rented by or in the care, custody or control of an Insured, except for unintentional property damage to premises owned by others, or their contents, which are using, renting or have in your custody or control caused by fire, explosion, water damage or smoke. This means smoke due to a sudden, unusual and faulty operation of any heating or cooking unit in or on the premises, but not smoke from fireplaces. Water damage has the same meaning as in Section I" This exclusion is common to all liability policies. The Insurer believes that when Insureds have control over the property of others, they are in a position to prevent its loss or damage. In these cases, separate property coverage can be purchased. No coverage for damage to property in Insured's care, custody or control The following are examples of property which may be damaged by Insureds while in their care, custody and control and for which coverage is excluded by the policy: 1. Rented or Borrowed property Last Saturday, Bert damaged the transmission in the lawnmover borrowed from a neighbour. The cost of repairs is estimated at $600. There is no coverage under this policy. This exclusion would also apply to watercraft, recreation vehicles, tools, movies and other property rented or leased from others. 2. Property Being stored for others Damage caused to clothing, sports equipment or other property being stored for a friend in the Insured's basement will not be paid under the policy even if the Insured is responsible for its loss. Note: Homeowner Forms provide coverage for the uninsured property of others (except roomers and boarders) under section 1 - Property Coverages. Any claim for damage caused to such property can be made under that section and payment will be made without regard to fault. Also, if people who leave their property in the care, custody or control of the Insured have their own Insurance, they can claim directly from their Insurer in the event of a loss. However, unlike the liability coverages provided by this policy, claims made under Section 1 - Property Coverages will be subject to the application of a deductible. Exception This exclusion does not apply to unintentional property damage to premises owned by others, or their contents which the Insured is using, renting or which is otherwise in the Insured's custody or control. Payment will be made for the following causes of loss: a) Fire; b) Explosion; c) Water Damage; d) Smoke… excluding smoke from a fireplace Limited Coverage for damage to premises in care, Custody or control of Insureds The homeowners Forms provide the following coverages for Insured's who temporarily rent or use the premises of others for habitational purposes. Payment will be made only when the Butlers are legally liable for the damage. Coverage is limited to: a) Fire: Last Summer, the Butlers were having an evening wiener roast on the premises of a cabin they rented. A spark from the opne fire caused a grass fire which burned the cabin to the ground. b) Explosion: Later that summer, friends gave the Butlers the use of their cottage for the August holiday weekend. On the first night, Bert had difficulty lighting the barbeque. Rather than turning the gas supply off and trying again later, Bert kept pushing the ignition button hoping it would start. Finally, after ten minutes of constant effort, the gas ignited. The resultant explosion tore the lid off the barbeque and hurled it through the glass patio doors of the cabin, The damage was estimated at $1250 c) Water Escape: During a weekend stay at a hotel, Betty forgot that she has left the water running in the bathroom tub, When she returned from shopping three hours later, she found that THE WATER HAD DAMAGED THE TILING AND WALL BOARD in the bathroom. The cost to repair the damage was estimated at $1750. d) Smoke: Last Summer, the Butler's attended the Calgary stampede. They rented a two-bedroom unit at the Ranch hotel. On the first night, they found the room chilly and brought in a kerosene heater they had packed with their camping gear. In each of the above examples, the policy would respond to pay the claim. 4. "Damage to personal property or fixtures as a result of work done on them by you or anyone on your behalf." No coverage for property damage arising out of work performed by Insureds Last month, Bert agreed to sand an antique table for a neighbour. He was not as careful as he should have been and caused gouges in the surface of the table which could not be repaired. The damage to the table is not covered by the policy. 5. "Bodily Injury to you or to any person residing in your household other than a residence employee" The law in certain provinces may allow family members living in the same household to sue each other for injuries caused by negligence of another member. The amount of judgement against the responsible party is not insured by this policy. This exclusion also applies to claims made by roomers or boarders. Exception Residence employees are normally not required to be Insured under the provincial workers' compensation plan. As a result, a residence employee who is injured on the job as a result of the Insured's negligence is entitled to take legal action against the Insured for damages. The Homeowners Forms provide coverage in such situations. HOME OWNERS FORMS cover legal liability of employers for injury to residence employees Each Summer, When Benji and Barbie are out of school, the Butlers hire a university student to "babysit" The, and, at the same time, to maintain their home and yard. Last Summer, the Butlers bought a new 15 H.P. lawnmower. The manufacturer's instructions clearly stated that the lawnmower should not be operated unless the bag to catch the grass clippings was in place. Failure to follow this procedure could result in injury to the operator and others. On her first day on the job, Julie Ann was instructed to cut the lawn. She removed the bag because she didn't think it was needed and, besides, she had not been told where to dump the clippings. On her first pass, she ran over a bone Bowser had left on the lawn, The blade of the mower broke the bone in to a number of pieces which were then propelled out of the opening where the bags should have been. One of the bone fragments pierced Julie Ann's eye and doctors were not able to save her sight. In the ensuing legal action, it was ruled that Butlers should have advised Julie Ann of the operating instructions and they were held liable for her injuries. The personal liability coverage provided by the policy would respond to pay the claim. 6. "The personal actions of a named Insured who does not reside on the premises described in the coverage summary page" There is no coverage for a person who is named on the policy but who resides elsewhere. Persons most affected by this exclusion would be named insureds who have separated or divorced. Defence, Settlement, Supplementary payments (RIBO pg. 19) As is common to liability policies, the Insurer agrees to pay all costs associated with the defence and settlement of claims, including the following specified supplementary payments, even if the claim made against the Insured is groundless or without merit. The Insurer agrees to investigate, negotiate and settle any claim if they decide it is appropriate to do so, and will pay for legal counsel of the Insured that they select. The Insurer agrees to investigate, negotiate and settle any claim if they decide it is appropriate to do so, and will pay for legal counsel of the Insured that they select. The Insurer also agrees to pay: 1. All expenses the Insurer should incur in the defence of the action 2. All costs charged against the Insured in any suit insured under section E - Personal Liability of the policy. 3. Any interest accruing after judgement on that part of the judgement which is within the limit of the liability Insurance purchased. 4. Premiums for appeal bonds required, or bonds to release property that is being held as security, up to the amount of Insurance, but the Insurer is not obliged to apply for or provide these bonds. 5. Expenses the Insured may incur for emergency medical aid following an accident or occurrence insured. 6. Reasonable expenses including loss of Income up to $100 per day that the Insured suffers at the Insurer's request. Coverage F - Voluntary Medical payments This Insuring agreement provides for the payment of medical expenses when an Insured unintentionally injures another person or if they are accidentally injured while on the Insured's premises. The types of claims for which payment will be made include surgical, dental, hospital, nursing, ambulance service and funeral expenses. The Insurer agrees to voluntarily make such payments on the Insured's behalf. In other words, there is no requirement that the Insured be legally liable for the injury before payment will be made. When payment is made, it will be: a. Limited as to amount; Limit of Insurance will be indicated on the Coverage Summary Page. While this amount may vary between Insurers, $1000 is common. ** Limited to one year from the date of the accident Payment is not provided when the Injured person is covered by a provincial worker's compensation plan, a hospitalization plan, or other private Insurance. Medical Payments provided without regard to Fault Two years ago, the Butlers invited neighbours over for a barbeque. While playing lawn darts, Bart threw a dart and struck a guest in the face. It took two operations to repair the bone damage. Two weeks ago, their friend peter came to spend the weekend. While going to the table for dinner, peter stumbled over his own feet and fell, hitting his head on the hardwood floor. An ambulance was called and peter spent the night in hospital. When released, he was more embarrassed than hurt. Medical expenses incurred by others who are unintentionally hurt by an Insured or who are accidentally injured on their premises are insured by the policy, whether the Insureds are liable or not. However, as indicated above, certain coverage limitations apply. Coverage G - Voluntary Payment for Damage to Property Under this Insuring agreement, the Insurer agrees to make a voluntary payment for property damage: ** Which has been unintentionally caused and for which the Insured would not be legally liable; The Insurer agrees to "voluntarily" pay for unintentional damage caused to property of others even when the Insured is not legally liable for such damage. Coverage G - Voluntary payments for damage to property Last weekend, the Butler's neighbours, Lilly and Red white, held a garage sale. On Friday evening before the sale, Red asked Bert for help in moving some of the heavy furniture. When they were moving a China cabinet down a set of stairs, Red went too quickly, causing Bert to drop his end of the cabinet. While there was little structural damage, the glass in both doors broke. Red estimates it will cost $50-$75 to repair the damage and believes Bert should pay. This spring, the Butler's Lawnmower was being repaired at a local shop. When repairs had still not been made after two weeks, Bert asked to borrow the Whites' mower. Red's comment at the time Bert picked up the lawnmower was simply, "Take it. It's all ready to go. That's what neighbours are for". Red had neglected to tell Bert that he had drained the oil from the motor and had not yet replaced it. After 10 minutes of use, the motor seized. Red estimates it will cost $600 to replace the motor. As far as Red is concerned, Bert should pay for the repairs. This Insuring agreement pays for unintentional direct damage caused by Insureds to property of others even though they had not been legally liable for such damage. There is, however, a limit applicable to this coverage, usually no more than $500 in each occurrence. ** Which has been intentionally caused by an Insured 12 years of age or under Most Insurance policies will not respond to pay claims for loss or damage which is deliberately caused. However, when children are involved, an exception is provided under the liability coverages provided by Home owner forms. Coverage, however, is restricted to damage intentionally caused by an insured 12 years of age or under. Insurer agrees to make voluntary payment when property damage deliberately caused by certain children. Last week, 11-year-old Benji tried out for a community baseball team. He did extremely well at the tryouts and expected to be made team captain. However, the coach's son was given that honour. As circumstances would have it, the coach and his family live just across the streets from the Butlers. When Benji came home from practice that day, he was so frustrated that he picked up a rock and deliberately threw it through the kitchen window of the coach's home. The cost of repair is estimated at $200. This insuring agreement provides for the payment of direct damage intentionally caused by an insured 12 years of age or under. The amount of Insurance available to pay losses under this Insuring agreement is limited, usually not exceeding $500 in each occurrence. Exclusions As with most Insuring agreements, certain exclusions will apply. There is no coverage for: 1. "Damage to property you or your tenants own or rent" This Insuring agreement does not cover property owned by one Insured and which is damage by another Insured. This exclusion also applies to rented property such as yard or garden equipment., movie videos and recreational equipment such as bikes and watercraft. This exclusion applies whether such property is owned or rented by the Insureds or their tenants. 2. "Damage to Property which is Insured under section 1" All Homeowner forms provide limited coverage under section 1 - Property coverage for personal property belonging to others. When the loss of that property is caused by a peril insured under section 1, it cannot be claimed under this Insuring agreement. 3. "Claims resulting from the loss of use, disappearance or theft of property." No payment will be made for property of others which has been stolen or which is claimed to have disappeared. Also, any payment for financial loss due to loss of use of property damaged by an Insured is not covered. Coverage H - Voluntary Compensation for Residence Employees Coverage E - Personal Liability provides coverage for the Insured's legal liability for injury or death of residence employees. However, when such employees are injured or killed through no fault of the Insured, there is no coverage. Coverage H - Voluntary Compensation for Residence Employees ** Is designed to provide all occasional residence employees with limited benefits in such situations. Permanent residence employees are insured only when stated on the coverage summary page. The amounts provided by this Insuring agreement are outlined in a separate schedule of benefits and include payment for: a) Loss of Life, including funeral Expenses; b) temporary total disability; c) Permanent Total Disability; d) Injury Benefits (Weekly Indemnity); e) Medical Expenses The limits payable and the duration of payments varies with each of the above categories.
These payments are made voluntarily. No suit or action is required by the injured employee: in fact, should the Injured employee bring an action against the Insured, the injured party is not entitled to voluntary payments...” (RIBO)
F. Personal Property Coverage
G. Auto Insurance: Liability, Collision, Upset, Long-term Parking and storage Coverage
"7.1.2 Coverage Options
A. Specified Perils This coverage limits payments for damages to those caused directly by the following perils: Fire; theft or attempted theft; lightning windstorm; hail, or rising water; earthquake; explosion; riot or civil disturbance; falling or forced landing of aircraft or parts of the aircraft; or the stranding, sinking burning, derailment or collision of any kind of transport in, or upon which a described automobile is being carried on land or water. B. Comprehensive coverage is an all-risks version of the specified perils coverage. Coverage under this section includes all coverages within the specified perils coverage, and adds to it the perils of falling or flying objects, missiles and vandalism. All damage to the vehicle not caused by collision of some kind is covered under the comprehensive section, unless specifically excluded. C. Collision or Upset Collision average pays for all damage suffered when the Insured automobile is involved in a collision with another object or upset which is when the vehicle tips over. Collison occurs when vehicle hits something in contact with the ground. Upset damage occurs when the only thing that the vehicle hits is the ground. Note: Collisions with animals such as dee or moose are usually paid out under comprehensive. D. All perils This option combines the coverage of collision or upset and comprehensive. The benefit to purchasing all perils coverage instead of separately purchasing collision or upset and comprehensive coverages is the inclusion of two types of theft excluded under comprehensive. All perils coverage, unlike comprehensive, does not exclude theft of the vehicle by the person who lives in the insured household. There is no exclusion for theft of the vehicle by an employee who drives or uses services or repairs the described automobile. 7.2 Loss or damage we won't cover 7.2.1 General Since Comprehensive and all perils are both all risks type policies, there are a number of exclusions applicable to these coverages. The first three exclusions listed in this section are wear and tear exclusions: Damage to tires, breakdown of any part of the automobile, and any damage consisting of or caused by rusting, corrosion, wear and tear, freezing or explosion within the engine. The next two exclusions are types of theft claims that will not be honoured. 1. Damage resulting from illegal claim of ownership, illegal disposal, or theft of automobile by anyone who has legal possession of it under a written agreement such as a mortgage or lease agreement. If the insured misses payments on his or her lease and the vehicle is repossessed, the insurer will not pay if the insured makes a theft claim of the vehicle. 2. Loss or damage resulting from a change in ownership that is agreed to, even if that change was brought about by trickery or fraud. The policy's example talks of selling the car to a stranger for a cheque at a party. If the cheque bounces, the insured cannot claim the vehicle stolen. Damage caused by radioactive contamination is excluded. Damage to contents of automobiles and trailers, other than their equipment are excluded. This section pays only for loss or damage to insured automobile. Equipment is anything provided with the automobile or trailer to be used with the vehicle, and anything that is a permanent fixture in the automobile. A scissor jack is not permanently attached to the automobile, but it would be considered equipment provided with the automobile for use with the automobile. Other examples include motor cycle helmets and child car seats. The next exclusion states the reimbursement for recorded material (CD's or cassettes) is limited to $25. Only recorded material that was actually in the playing device at the time of loss is covered. Any recorded material in the vehicle in storage cases or visor holders is considered contents of the automobile and there fore not covered. 7.2.2 Illegal Use Illegal uses of the automobile forfeit any claim for physical damage payable under the policy. The policy lists some very specific illegal uses and illegal activities which render the coverage section forfeit. 1. Any damaged caused to automobile while the Insured was operating it while intoxicated. 2. Damage caused to any action which also results in the insured being convicted of any of the following offences under the criminal code of Canada. a. Causing death by criminal negligence b. Causing bodily harm by criminal negligence c. Dangerous operation of motor vehicles; d. Failure to stop at the scene of an accident; e. Operation of the motor vehicle when impaired or with no more than 80 mg of alcohol in the blood; f. Operating a motor vehicle while disqualified from doing so; g. If the Insured uses ir allows the automobile to be used in a race, or speed test or illegal activity; h. If the Insured drives the automobile while not authorized by law; and i. If another person, with the Insured's permission, drives or operates the automobile under any of these conditions. 7.2.3 Certain thefts Not covered The policy describes the theft of the automobile by a member of the Insured's household or theft by employee of the Insured who drives or uses preairs or services the automobile. Both of these types of theft are excluded under the specified perils and comprehensive coverages. All perils coverages are not subject to these two exclusions. 7.3 The Deductible The deductible is the amount of any loss the insured agrees to pay. The deductible amount is stated in the certificate of auto Insurance. The Standard deductible in Ontario is currently $500 for collision losses and $500 for specified perils or comprehensive claims, as of June 1st 2016. There are two types of losses not subject to the deductible under these coverages; Fire losses and lightning losses. All other losses covered under this section are subject to the deductible. In the event the loss is caused by an insured peril other than fire or lightning, the insurer will pay the amount of damage minus the deductible. The policy lists a few examples of how the collision coverage integrates with the DCPD coverage for payment of damages to the Insured vehicle caused by collision with another motorist. Below is an expansion of the examples from the DCPD section of this text with the collision portion of this policy now applied to earlier situations. We will assume the standard $500 deductible also applies to the DCPD coverage for these examples. XYZ was sitting in his car, stopped at a red light when he was struck from behind by YZZ wreck less driver. In this case, yzz is considered to be 100% at fault for the accident. As such, xyz is considered to be not at fault for the accident, XYZ's automobile suffers $5000 damage due to the accident. XYZ's own insurer will pay for the cost of repairs less the $500 DCPD deductible, and will pay for temporary replacement for the transportation (rental cars, taxis, buses etc) under Direct compensation - Property damage section. XYZ who is 100% at fault for the accident, would claim for damage to his vehicle under his optional collision coverage. Assuming the damage to XYZ's car is $3000, xyz will receive $2500 from his insurer after the deductible was subtracted from the amount payable. Unlike XYZ, YZZ will not be reimbursed for temporary transportation replacement while his automobile is being repaired. There is no provision for such coverage in the loss and damage section of the policy. If xyz had purchased a separate endorsement, he may be entitled to the coverage (see OPCF 20), but the coverage must have been purchased before the accident took place. Xyz and YZZ are involved in a collision for which they are both considered to be 50% at fault. XYZ's vehicle suffers $4000 damage. YZZ's insurer, under DCPD coverage, will pay only a portion of the damage which he is not at fault for. As he is 50% at fault, it so follows that he is 50% not at fault. XYZ's DCPD will pay for 50% of the $4000 damage, or $2000. XYZ's insurer will then deduct from the amount 50% of DCPD deductible. Since the payment of the loss is partial under this coverage in this case, the application of the deductible matches the same percentage as the payment. 50% of the $500 deductible is $250, so $250 is deducted from the $2000 payment. XYZ will receive $1750 from the DCPD section. XYZ will claim for damage for which he is at fault from the collision portion of his policy. The mathematics will work the same. 50% of the damage is covered under the collision portion, so 50% of the deductible will apply in this case. Payment will be $2000 minus $250 or $1750. In total, for the $4000 loss, XYZ will recover $3500 from his insurer. The same rationale is used to determine how much XYZ will receive from her Insurer under her DCPD and Collision coverage. If XYZ suffers $2600 damage to her vehicle, Insurer will pay $1300 minus 50% of the DCPD deductible or $250 towards the damage under her DCPD coverage, and $1300 minus 50% of the $500 collision deductible or $250 under collision coverage since she is also 50% at fault for the accident. xyz will receive $1050 under the DCPD and $1050 under collision. In total, XYZ will receive $2100 from her Insurer. As you can see, if the DCPD and collision deductibles are the same, the Insured will always pay same deductible amount for any percentage of fault in a collision. 7.4 Additional Benefits There are coverages for indirect financial losses suffered concurrently with the damage to an automobile. The policy covers four such losses. 1. General Average charges General average charges occur as a result of marine law. If a boat begins to sink while on route from one port to another, the captain of the boat will order the jettisoning of cargo overboard to reduce the weight of the boat and slow the progress of sinking. In many instances, not all cargo needs to be jettisoned. Marine law states that all owners of the cargo which is saved from the loss must share in the compensation of those owners whose cargo was thrown overboard. The cost of the lost cargo is divided amongst all owners of the cargo which survived. The assessed portion of damage each cargo owner has to pay is referred to as general average charge. It is the sacrifice of few in these cases that ensures the well being of the majority of the shipment. If the Insured's vehicle is on a ferryboat between Vancouver and the island and the boat starts to sink, the cars at the back of the ferry will be jettisoned to reduce weight. When the ferry lands on the island, all owners of the automobile not jettisoned will be required to pay a fair portion of the cost to replace the vehicles jettisoned. The OAP 1 covers these general average assessments. 2. Salvage charges. The policy requires the insured to take all reasonable steps necessary to protect the automobile from further damage following an insured loss. While no repairs may be made without the express consent of the Insurer, an allowance is made for those repairs necessary to reduce further or continuing damage. Any expenses incurred by the insured to protect the vehicle from further damage will be reimbursed by the Insurer. Necessary towing charges would also be reimbursed under this provision. 3. Fire department charges If the vehicle catches fire and the fire department is called to extinguish the fire, the fire department will bill you for their services. The Insurer agrees to pay the fire department charges on behalf of the Insured 4. Customs Duties If the insured is vacationing in California and is involved in an accident, damaging its fender and necessitating its replacement, his collision coverage will respond to have damage repaired. When returning to Canada, the Insured is technically importing a new fender. The Insurer agrees to pay the import duties on any new parts necessary for the repairs. 7.4.2 Foregoing our right to recover The Insurer waives its right of subrogation against a party responsible for damage to the Insured vehicle if the party responsible was given permission by the Insured to use the described automobile. There are two notable exceptions to this rule. 1. The person responsible for the damage is in the business of parking, servicing or selling automobiles. These individuals are bailees to whom insured's have entrusted their vehicle and each have a legal responsibility to return the vehicle to the insured in the same or better condition as it was presented to them. 2. Salvage charges: The policy requires the insured to take all reasonable steps necessary to protect the automobile from further damage following an insured loss. While no repairs may be made without the express consent of the insurer, an allowance is made for those repairs necessary to reduce further or continuing damage. Any expenses incurred by the insured to protect the vehicle from further damage will be reimbursed by the Insurer. Necessary towing charges will also be reimbursed under this provision. 3. Fire department Charges: If the vehicle catches fire and fire extinguishing department is called to extinguish the fire, the fire department will bill you for their services. The insurer agrees to pay the fire department charges on behalf of the insured. 4. Custom Duties: If the insured is vacationing in California and is involved in an accident, damaging his fender necessitating its replacement, his collision coverage will have to respond to have the damage repaired. When returning to Canada, the insured is technically importing a new fender. The insurer agrees to pay the import duties on any new parts necessary for the repairs. 7.4.2 Foregoing over right to recover. The insurer waives its rights of subrogation against a party responsible for damage to the Insured vehicle if the party responsible was given permission by the insured to use the described automobile. There are two notable exceptions to this rule. 1. The person responsible for the damage is in the business of parking, servicing or selling automobiles. These individuals are bailees to whom insureds have entrusted their vehicle and they each have a legal responsibility to return the vehicle to the insured in the same or better condition as it was presented to them. These individuals have their own policies to cover automobiles of their customers. 2. If the person permitted to use the automobile uses it for any of the excluded uses or criminal activities prohibited by the policy. If the insured's friend takes the car and is involved in an accident during its regular use, the insurer will pay for the loss and not subrogate. If the insured's friend should damage the automobile while engaged in a speed test or race of some description, any loss paid out by the insurer will be recovered from the Insured's friend. 7.4.3 Temporary substitute automobiles Covered Also see section 2.2.2 of the policy. Temporary substitute automobiles are automobiles not owned by the insured, or anyone else in the Insured's dwelling, that the insured is using while his or her own automobile is unusable due to its break down, theft, repair, servicing, sale or destruction. Coverage for physical damage to the temporary substitute automobile (TSA) will be provided by the TSA owner's insurance policy if they have purchased the optional loss or damage sections. If the owner of TSA has not purchased this coverage, the insured is legally liable for the damage to the TSA, then the policy will pay for the damage, less the deductible applicable for the coverage. The liability for the damage must be imposed by law or agreed to by the insured under the contract. If the owner of the TSA has coverage under their own policy, but the deductible existing there is higher than the deductible on the Insured's policy, then the policy will pay for difference between the deductibles. Technically, the Insurer is paying the deductible amount on the owner's policy, as that sum represents an amount of loss suffered which is not covered anywhere else. The insurer pays all claims less the deductible showing on the Insured's policy, so the amount arrived at is the difference between the deductibles. Tony Tempo's automobile has Collision coverage with a $500 deductible and comprehensive coverage with a $500 deductible. Tony's automobile is at the dealership for a lengthy service, and he borrows Mike's Mercedes automobile to get to and from work for the day. Mike Mercedes' automobile is much more expensive than Tony's and although it also has collision and comprehensive coverages, the deductibles on Mike's policy are $5000 and $1000 respectively. Tony is not used to driving Mike's car. He loses control of the vehicle and drives it in to a tree on the side of the road, causing $10,000 damage. Since Mike has purchased collision coverage, Mike's policy pays for the damage, less his $5000 deductible. Since Mike has suffered a $5000 loss, Tony's Insurer will pay $5000 towards the loss, less the deductible of $500. Tony's policy will pay $4500. 7.4.4 Loss of Use due to theft If the described auto is stolen, and the insured has purchased theft coverage, (either of the specified perils, comprehensive or all perils coverage) the insurer will pay reasonable expenses for the rental of a similar substitute automobile, or if the insured chooses not rent, pay reasonable expenses for taxis and/or public transportation instead. The maximum payable under this benefit is $900. The payment of these expenses will not begin until 72 hours after the insured has reported theft to the police or the insurer. The maximum payable under this additional benefit is $900. The payment of these expenses will not begin until 72 hours after the insured has reported the theft to the police or the Insurer. The coverage will extend until the Insured vehicle is repaired, if recovered, or replaced, or sooner if money is offered to settle the claim. As long as coverage was in place at the time of theft, this coverage will continue until the claim is settled, even if the policy expires in the mean time. 7.5 Your and other Insured Person's responsibility The conditions recorded in the policy under this section are very similar to statutory condition 6: Requirements where loss or damage to automobile. The plain language wording format makes the restatement in this section easier to understand. In summary: 1. The insured must notify the insurer within seven days of the accident; 2. The insured must protect the automobile from further damage, to the best of their ability; 3. The insured must not make any repairs beyond those necessary to protect the vehicle further without the permission of the Insurer, or until the insurer has had time to inspect the vehicle. 4. The insurer must be allowed to copy all the legal documents pertaining to the accident; 5. The insurer must be allowed to inspect the vehicle at any reasonable time; 6. The insured must submit a proof of loss within 90 days; 7. The insured cannot abandon the wreckage of the automobile in to the care of the Insurer unless insurer has made settlement of the claim for the full actual cash value of the vehicle. At that point, the insurer owns the salvage 7.6. Our right to repair replace or rebuild the vehicle This section is a plain language wording of subsection 6 of statutory condition 6: Requirements where loss or damage to Automobile. The decision as to which form of indemnity will be used is solely at the discretion of the Insurer. Should the insurer choose to repair, replace or rebuild the automobile, instead of making a cash settlement for the loss, the insurer will notify the insured within seven days of the accident. Work will be completed within a reasonable time. 7.7 What we will pay. An insurer's maximum liability for the loss or damage to an insured automobile is the actual cash value of the automobile at the of the loss, less the deductible. Students should note that the $1500 limitation under this section for after-market electronic accessories and equipment. While this limitation is most often thought of limiting car audio equipment, automobiles currently have devices ranging from GPS system to play station consoles installed from their original purchase. This stipulation and the $25 limit on recorded material (7.2.1) are generally easier to remember if thought of collectively. Section 8: Statutory Conditions The statutory Conditions for Ontario are quite similar to those in other Canadian Jurisdictions and include: a) Material change in risk b) Incorrect classifications c) Monthly payments d) Authority to drive e) Requirements where loss or damage to persons or property f) Requirements where loss or damage to automobile g) Time Limit h) Inspection of Automobile i) Time and manner of payment of Insurance money j) Who may give notice and proof of claims h) Termination i) Notice j) Statutory Accident Benefits protected The Insurance Act of Ontario requires that these conditions be printed in every automobile insurance policy in Ontario. While violation of any of the statutory conditions generally results in the denial of the coverage, there are some exceptions. In view of the restriction of the right to sue, the government introduced legislative changes, which ensure that certain Accident benefits are available regardless of any violation of the statutory Conditions. Refer to the section on the statutory Accident benefits schedule for details of the exclusions, which relate specifically to it. Statutory Conditions outline the legal duties and responsibilities of each party to the contract and are binding on all parties. Insured must be advised that when they breach conditions applicable to them, a loss of coverage will normally result. The statutory conditions applicable to automobile Insurance policies are essentially the same for all provinces. However, provincial variations may exist. Many of the statutory conditions are explained in plain language in section 1.4 - Your Responsibilities; Section 1.5 - Where to make a claim and who may make it; Section 1.6 - Our rights and responsibilities; and, Section 1.7 - Cancelling your Insurance Despite a failure to comply with these statutory conditions, a person is entitled to such benefits as are set out in the Statutory Accident Benefits schedule. 8.1 Material Change in Risk Insured's must notify the insurer promptly in writing of any changes within their knowledge that is material to the contract. The Insurer must be advised of any change which occurs after the policy has been issued which serves to increase the chance for loss. Material Change Required to be reported to the Insurer. The Butler's 19-year-old nephew, Randy, has been living with them for four months. Prior to moving in to their home, Randy had two convictions for impaired driving. When he was 17, he totaled his parent's car while racing against a friend on a gravel road near a town. Bert and betty allow Randy to use their car in the evenings and on weekends. As is indicated by Randy's driving history, there is an obvious increase in exposure to the insurer. The Butler's are obligated to advise the Fortress Insurance company. Other factors which may be material and required to be reported to the Insurer include: a) Change in Insurable Interest When this change occurs without the actual transfer of the automobile, the Insurer's exposure may be increased. For example, when the automobile is given to a member of the Insured's family, the new owner and principal driver may represent a greater exposure to the Insurer. * b) Addition of mortgage or lien If a mortgage, lien or other encumbrance affecting the auto is made after the application has been completed, the insurer must be notified or failing notification coverage for loss or damage to the auto itself may be denied. c) Other Insurance When other insurance for physical damage is purchased during the policy period, the insurer must be advised. Insurers are concerned about the potential for fraudulent losses when insured's purchase Insurance from more than one insurer. 8.2 Incorrect classification If a client has been incorrectly rated, the insurer is required to make the necessary correction. This may require the refund of excess premium and the payment of interest at the bank rate on the overpayment. If a correction requires additional premium to be paid it must be requested within 60 days after the contract is made and no interest is charged. 8.3 Monthly Payments This condition allows the client to pay the premium in equal monthly installments. The interest rate is in accordance with the regulations in the Insurance Act. 8.4 Authority to Drive. The Insured shall not drive or operate the automobile unless the insured is authorized by law to drive or operate it. The same requirement will apply to anyone else that the insured may permit to drive. To be authorized you must have a valid license. Even though you may be qualified to drive, failure to renew your license may invalidate the coverages. The Insured is prohibited to use or permit the vehicle the vehicle to be used in the following: a) Race or speed test b) Any illicit or prohibited trade or profession 8.5 Requirements where loss or damage to persons or property 1. The Insured shall: a) Give to the Insurer written notice, with all available particulars, of any accident involving loss or damage to persons or property and on claim made on account of the incident; Notice is defined later in section 8.7. The written notice specified here must be delivered within seven days of the incident, provided the insured is able to do so. If the insured is unable to provide this notice due to incapacity or injury, the insured must provide this notice as soon as possible thereafter. The requirement for notice is important as the failure to provide such notice could result in a loss of coverage. The courts have ruled that the obligation for notice depends on the circumstances of the loss. For example, in accidents involving serious bodily injury or property damage to others, it is expected that the Insurer will be advised immediately. On the other hand, more time would be permitted to report damage caused to a neighbour's bicycle that was left on the Insured's driveway. b) Verify by statutory declaration, if required by the Insurer, that the claim arose out of the use or operation of the automobile and that the person responsible for the operation of the automobile at the time of the accident is a person insured under this contract; and c) Forward immediately to the Insurer every letter, document, advice or statement of claim received by the Insured from or on behalf of the claimant The Insurer has both a right and duty to defend the Insured in any legal action. When it is clear that the other party involved in the accident is contemplating or has initiated legal action against the Insured, copies of all legal documents received must be forwarded immediately to the Insurer. 2. The Insured shall not: a) Voluntarily assume any liability or settle any claim except at the Insured's own cost; or Insureds must be advised that any voluntary assumption of liability, or efforts they take to settle any claim except at Insured's own cost; or Insured's must be advised that any voluntary assumption of liability, or efforts they take to settle the claim on their own, may impair the ability of the Insurer to provide a proper defence. The right to investigate, defend and settle claims rests with the Insurer and not the Insured. Accordingly, any obligations or costs incurred without the consent of the insurer are not recoverable under the policy. b) Interfere in any negotiations for settlement or in any legal proceeding. As the Insured's irrevocable attorney, the Insurer has full control over the settlement and defence of all claims against the Insured. By the provisions of this condition, the insured agrees not to interfere in those proceedings. 3. Insureds are required to assist the insurer in their defence. When requested to do so, these costs will be paid by the Insurer. 8.6 Requirements where loss or damage to the automobile 6. 1) Where loss of or damage to the automobile occurs, the insured shall, if the loss or damage is covered by this contract. a) Give notice thereof in writing to the Insurer with the fullest information obtainable at the time. b) At the expense of the Insurer, and as far as reasonably possible, protect the automobile from further loss or damage; and This condition contains the rules applicable to claims involving loss or damage to Insured automobile. Specifically, the Insured must: ** Take all reasonable steps to protect the automobile from further damage. Duty of Insured after loss to protect Automobile from further damage Last Sunday, XYZ lost control of their car on a country gravel and ended up in a ditch. Before the car could be stopped, it ran over a large rock, causing extensive damage to the steering mechanism. Betty called for a tow truck and the car was taken to the company storage compound. The towing and storage costs were paid by the Insurer. There are benefits to insurers in paying all these costs. For example, removing the automobile from the accident site will normally prevent pilferage, vandalism and other losses which might otherwise occur should the automobile be left there. Provide the Insurer with prompt written notice of any claim. c) Deliver to the Insurer within ninety days after the date of the loss or damage a statutory declaration stating, to the best of the Insured's knowledge and belief, the place, time, cause and amount of the loss or damage, the interest of the Insured and all others therein, the encumbrances thereon, all other Insurance, whether valid or not, covering the automobile and that the loss or damage did not occur directly or indirectly through any willful act or neglect of the Insured. A proof of loss must be provided within 90 days of the date of the accident. If this is not done, the Insurer is not legally bound to honor the claim. In practice, most Insurers will provide payment when a proof of loss is received after the allowable period, provided there is a reasonable explanation. 6. (2) Any further loss or damage accruing to the automobile directly or indirectly from a failure to protect it as required under sub condition (1) of this condition is not recoverable under this contract. When the Insured fails to take reasonable steps to protect the automobile from loss, the insurer may deny payment on that portion of the damage which could have been prevented. For example, if the automobile is not removed from the accident site, Theft and vandalism losses will normally occur. These losses could have reasonably been prevented and will not be paid by the Insurer. 6. 3) No repairs, other than those that are immediately necessary for the protection of the automobile from further loss or damage, shall be undertaken and no physical evidence of the loss or damage shall be removed: a) Without the consent of the Insurer; or b) Until the Insurer has a reasonable time to make the examination for which provision is made in statutory condition 9. The insured is authorized to make repairs which are "immediately necessary" for the protection of the automobile. For example, the insured is authorized to replace a tire damaged in the accident in order to move the automobile to a safe location. In all other cases, repair cannot be undertaken without the Insurer's permission. 6. 4) Examination of the Insured Insureds shall submit to examination under oath at such reasonable time and place as is designated by the Insurer and shall produce all documents that relate to the matters in question and permit extracts and copies thereof. This right can be important when the Insurer suspects the Insured may be attempting to make a fraudulent claim or when the Insurer is establishing the basis for the defence for a serious liability claim. 6. 5) Insurer liable for cash value of Automobile Loss or damage shall be ascertained according to actual cash value with proper deduction for depreciation. Factors considered in determining the amount of depreciation to be applied include: a) Exterior paint, trim and condition b) Mechanical condition; c) Mileage d) Interior upholstery claim e) Equipment and Accessories f) Tires; g) Any other information that affects the automobile's value. 6) Repairing, Rebuilding Except where an appraisal has been made, the insurer, instead of making payment, may repair, rebuild or replace the property damaged or lost if, within seven days after the receipt of the proof of loss, it gives written notice of its intention to do so. The insurer always has the option of making settlement on the basis of repair or replacement as opposed to the payment of money. When it elects to repair or replace, the insured must be advised no later than seven days after the insurer has received the proof of loss. If Insured's have not received the proof of the intentions of the Insurer within that period, they are entitled to be paid on a cash settlement basis. If the Insurer decides to repair the automobile after an accident, the Insurer may, but does not have to use new parts provided by the original equipment manufacturer. It is important to note that the Insurer has the right to use rebuilt or refurbished and non-original (after market) parts, provided these parts are of a like kind and quality of the parts which they are to replace. In case of disagreement as to the nature and extent of the repairs and replacement required, or as to their adequacy, or amounts payable, The Insurance acts provides that these questions shall be determined by appraisal. The majority of physical damage claims are settled without dispute. In the event, the parties cannot agree on the work or repairs to be done, adequacy of repairs or amounts payable, either party may request that an appraisal be provided. The details relating to the appraisal process are provided in the Insurance Act. 6. 7) No abandonment: Salvage There can be no abandonment of the automobile to the Insurer without the Insurer's consent. If the Insurer exercises the option to replace the automobile or pays the actual cash value of the automobile, the salvage if any, shall vest in the Insurer. This simply means that the ownership and responsibility for the automobile after a loss remains with the Insured, even when it is apparent that loss is a total loss. When the automobile is replaced or the full actual cash value is paid by the Insurer, the salvage is the property of the Insurer. This prevents Insureds from profiting from their loss. However, this does not prevent the Insured from negotiating the purchase of the wreck as a part of the final settlement. 8.7 Time Limit This section requires the insured to send the notice stated in the statutory conditions 5 and 6 within seven days of the incident. If the insured is unable because of incapacity notice must be given as soon as possible. This may be applicable if the Insured is seriously injured in the incident. 8.8 Inspection of the Automobile The insured shall permit the Insurer at all reasonable times to inspect the automobile and its equipment. The insurer has the right to inspect the automobile "at all reasonable times" This allows the Insurer to confirm that the automobile for which coverage is being claimed is one which is insured by the policy. Also, such inspection helps to verify the extent of the damage caused to the automobile. 8.9 Time and manner of payment of Insurance money Payment for which the insurer is liable under the contract must be made within 60 days after the receipt of the proof of the loss, provided no appraisal has taken place. If an appraisal has taken place, the insurer is liable to make payment within fifteen days of the appraisal. This allows the Insurer a reasonable amount of time in which to investigate and process the claim. If the insurer refuses to pay the claim, the insurer must promptly inform the insured in writing, stating the reasons for not paying the claim. The insured may not commence an action against the insurer until the requirements of statutory conditions 5 and 6 are complied with. If an action is brought against the Insurer, such action must be commenced within one year after the date of loss for recovery of loss or damage to automobile or its contents, and within two years after the cause of the action arose for loss or damage to persons or other property. 8.10 Who may give notice and proof of claims Notice and proofs may be given and made by the agent of the insured in case of absence or inability of the Insured to give the notice or make the proof, providing absence is satisfactorily accounted for, or if the insured refuses to do so, a claim may be made by a person to whom any part of the insurance money is payable. There may be occasions where insureds are unable to give notice of loss or proof of loss. It would be unfair to deny them the right to collect under the contract in the event they are legitimately unable to do so. In such instances, a person appointed by the Insured can act on their behalf. If insured refuse to file notice and proof of loss, a mortgagee or other party of interest is entitled to make a claim under the policy. All amounts payable under the policy shall be reduced by the applicable deductible amount mentioned in the policy. 8.11 Termination The OAP 1 Termination Statutory condition differs from most of the other property/casualty policies due to legislated three strikes for non-payment of premiums. The insureds may cancel the policy at any time, subject to a short rate return of any prepaid premium. Should the Insurer cancel, for any reason other than the non-payment of the premiums, cancellation is subject to a 15 day notification period beginning the day following the mailing of the notification, which must be sent by registered mail. This period can be shortened to a 5-day notification period if the notice is personally hand delivered. If there is a refund due to the Insured, the refund is issued on a prorata basis, and should accompany the cancellation notice. The first two cancellations for non-payment of premiums in a policy term are subject to a 30-day notification period beginning the day following the mailing of the notification, which must be sent by registered mail, or, a 10 day notification period if the notice is personally hand delivered. To prevent the cancellation taking effect, the insured must pay the premium owing at the time of the cancellation, as printed on the notification, by noon of the business day proceeding the cancellation date specified. The third cancellation for non-payment in a policy term follows the same format as any other cancellation. 15 or 5 days notice is provided, depending on the notification method used by the Insurer, and there is no requirement for the insurer to reinstate the policy, even if the premiums owed to them are paid prior to the cancellation effective date. Cancellations are effective at 12:01 am on the date specified, which means the insured actually has only one minute of coverage on the cancellation date. 8.12 Notice Any written notice to the Insurer may be delivered, or sent by registered mail to, the chief agency or the head office of the Insurer in the province. Written notice may be given to the insured named in this contract by letter personally delivered to the insured or by registered mail addressed to the insured at the insured's latest post office address as notified to the insurer. In this condition, the expression registered means "registered in or outside Canada. This Condition serves to outline the rules respecting communications between the Insured and Insurer. Insureds who fail to advise the Insurer of a change in residences during the policy period may have their coverages terminated without being aware of the termination. This is because the insurer is required only to address such notice to "latest post office as notified to the Insurer" 8.13 Statutory Accident benefits protected. The statutory condition allows for payments as set out in the statutory accident benefits schedule outlined in section 4 of the Ontario Automobile policy (OAP1) even if there has been a failure to comply with the statutory conditions. Endorsements are used to make changes (i.e., adding or deleting coverage) to insurance policies. The endorsements used to modify the OAP 1 are known as Ontario policy change forms and are referred to as OPCF's. Many endorsements have been standardized over time and, like the policy wording, have been written in plain language. The content of an endorsement may not be aletered in any way. A bried description of some of the standard endorsements have been set out below. It is recommended, however, that you refer to the actual endorsement for more details. Those endorsements currently included within the OAP 1 wording are highlighted. Students should take particular note of these. OPCF 2 - Providing coverage when named persons drive other automobiles This endorsement extends the "other Automobiles" coverage provided under section 2.2.3 of the OAP 1 to persons named in the endorsement. It is used to prevent a shortfall in coverage, as the policy limits these coverages specifically to the named insured and his or her spouses. OPCF 3 - Drive government Automobiles Provides coverage for a person driving a vehicle owed by the government of Canada or any province or territory of Canada. Government Vehicles are exempt from the mandatory insurance requirements. OPCF 4a - Permission to carry explosives Provides coverage to carry specified explosives. The policy specifically excludes coverage when the vehicle is used for such purposes, which would result in coverage being denied. OPCF 4B: Permission to carry radioactive material Similar to OPCF 4A, this endoresements grants permission to carry specified radioactive material OPCF 5: Permission to rent or lease automobiles and extending coverage to specified lessee Provides coverage to lessee as if the lessee was the named Insured and to every other person who uses or operates the automobile with the lessees’ consents. This is a very important change to policy wording as only the registered owner should be the named insured in every other case. It is a lengthy endorsement which essentially changes all phrases within the policy from "you" to "the lee see" OPCF 5C - Permission to rent or lease This endorsement gives the lessor permission to lease the automobile to the applicant. The insurer agrees to indemnify the lessee and every person who with the lessee’s consent drives the automobile. The automobile cannot be leased or rented for more than 30 days to any one person (short term leases only) OPCF 5D - Conversion Coverage (Rented or leased Automobiles)_ This endorsement is used for vehicles that are rented or leased. Under Section 7 "Loss or damage coverages", you should be aware of the following: The insurance company will not pay for a claim resulting from a dishonest claim of ownership, illegal disposal, or theft of the automobile by anyone who has legal possession of it under a written agreement except a lease. OPCF 6 A - Permission to carry paying passengers This endorsements allows the automobile to be used to carry paying passengers. OPCF 6B - School Bus Permits carrying passengers for compensation for school purposes that would otherwise be excluded under section 1.8.1 of the policy. OPCF 6C - Public passengers Vehicles Permits carrying passengers for compensation or hire and sets out limits of liability that are available. OPCF 6D - Driving Training School Permits carrying passengers for compensation or hire only. OPCF 7 - Separate Limits Separates and specifies the limits under the liability coverage afforded in section 3. OPCF 8 - Property Damage Reimbursement This endorsement makes the insured responsible for part or all of any loss or damage to other people's property covered under section 3 of the policy "Liability Coverage" OPCF 9 - Marine Use Excluded Excludes loss or damage occurring while the automobile is on or in water or during the landing or launching process. OPCF 13C - Restricting Glass coverage Restricts the coverage for glass damage to losses caused by perils listed in the endorsement. OPCF 16 - Suspension of Coverage This endorsement suspends certain coverages for a specific period of time (this endorsement is often requested if the vehicle will not be driven during winter months). You will often be asked about the OPCF 16. It is important that you understand this endorsement. OPCF 17 - Reinstatement of coverage As the name implies, this endorsement reverses that action of OPCF 16 and restores coverage. OPCF 19 - Limiting the Amount paid for loss or damage This specifies that the insurer shall not be liable under section 7 of OAP 1 for any more than the actual cash value of the insured vehicle or the amount specified under this endorsement, whichever is less. This endorsement could be used on high value vehicles, vans, motor homes, ATV's snow mobiles, etc OPCF 19A - Agreed value of Automobiles This endorsement is in reference to section 7 of OAP #1 and allows a described automobile to be insured on a value basis. This could be used to insure classic, custom or antique vehicles, etc (You should know the difference between OPCF 19 and OPCF 19A) OPCF 20 - Coverage for transportation replacement This endorsement expands upon section 7.4.4 of the policy and provides replacement transportation for any insured loss under section 7: Loss or damage coverages that exceeds the deductible amount for any one claim. OPCF 21A - Monthly Reporting Basis Fleet (Applicable to Ontario Licensed Automobile) Provides coverage for vehicles that are leased for a period of more than 30 days. Vehicles must be listed and statements of receipts or mileage (or other agreed means of rating) must be submitted to insurer on a monthly basis. OPCF 21B - Blanket fleet coverage for Ontario licensed Automobiles This endorsement is used to insure automobile fleets and provides other methods to identify what automobiles are covered. OPCF 22 - Damage to property of passengers Provides coverage to property of passengers as if it belongs to the insured. OPCF 23A - Lienholder protection This endorsement provides protection for the lienholder's interest in the insured vehicle. Should there be a claim to loss or damage to the described automobile in which the lienholder has an interest, and the claim is settled in the form of a payment instead of a repair or replacement being made, the payment will be made jointly to the Insured and the lienholder. The lienholder is also protected through notification of any deletion of physical damage coverages or of any cancellation of the policy by the insurer. OPCF 23 B - Mortgage (broad Form) This endorsement provides a greater measure of protection for the lienholder or the mortgagee than the OPCF 23A. OPCF 24 - Fire Apparatus Eliminates the Insurer's liability for loss or damage to firefighting, salvage or rescue equipment removed from the Insured vehicle at the location of a fire. OPCF 25A - Alteration Covers a wide variety of possible changes to the policy that is indicated in the appropriate spaces. OPCF 27 - Liability for damage to Non-owned Automobile(S) and providing other coverages when Insured person's drive other Automobiles. This endorsement extends coverage to a non-owned automobile including its equipment resulting from the care, custody or the control of the non -owned auto by the Insured persons and persons named in the endorsement. (eg. A rental vehicle) It is important that you understand fully the coverage provided in this endorsement. OPCF 27 B - Business operations - Liability for damage to Non-owned Automobile(S) in the insured's care, Custody or control This endorsement is designed for commercial clients who have automobiles belonging to others in their care, custody or control OPCF 28 - Reducing Coverage for Named Person This endorsement reduces coverages, limits of liability and loss of damage for specified named persons OPCF 28A - Excluded Driver This allows for specific individuals to be excluded from the coverage under the automobile policy, other than for certain Accident benefits coverage. The excluded driver must sign this endorsement. OPCF 29: Additional coverage for named person Extends coverage to allow specifically named person tooperate the insured vehicle. OPCF 30: Removing coverage for Attached Machinery With this endorsement an insurer will not be liable under section 3 Liability Coverage and section 4 Accident Benefits of the policy for loss or damage arising out of the ownership, use or operation of specified machinery, apparatus or its equipment, mounted or attached to the automobile. The insured may purchase a Commercial General Liability policy to cover this exposure OPCF 31: Non- owned equipment Extends coverage to equipment not owned by the Insured, but normally attached to the automobile. OPCF 32 - Use of recreational vehicles by Unlicensed operators This defines recreational vehicles as including snowmobile, trail bike, mini automobile, motor scooter, mini cycle, snow plane, motorized toboggan, moped, and motor assisted vehicle, all terrain vehicle, dune buggy or similar vehicles. It waives compliance with statutory condition 4.1 of the policy, which prohibits the insured or anyone with the permission of the Insured, from operating the Insured vehicle unless authorized by law to do so. As a result, this would allow someone under the age of 16 to be insured while operating such a vehicle off a public highway. OPCF 35 - Coverage for Emergency Road service Provides reimbursement for up to $50 for emergency services each time the insured vehicle is disabled. OPCF 38 - Agreed limit for automobile Electronic Accessories and Equipment This endorsement limits the amount the company will pay for the loss or damage to automobile electronic accessories and equipment other than factory installed equipment to agreed amounts. This is an important new endorsement which came in to effect January 1, 2001. OPCF 40 - Fire Deductible This endorsement makes loss caused by fire or theft of your entire automobile, if not already subject to it, subject to a deductible. This endorsement is normally added to recreational vehicles. OPCF 43 - Removing Depreciation Deduction In the event of a loss or damage to the insured automobile by a peril insured against, the insurer agrees not to deduct for depreciation. The amount payable is limited to actual purchase price of the vehicle and its equipment, the manufacturer's suggested list price at the time of the purchase, or the cost to replace automobile with a new automobile of the same make and model, similarly equipped whichever is less. The insured must be the original purchaser of the automobile. OPCF 43 A - Removing depreciation deduction for specified lee see It removes the Insurer's right to deduct depreciation when settling a claim for loss or damage similar to OPCF 43. OPCF 44R - Family protection Endorsement This endorsement will indemnify an eligible claimant for the amount that he or she is entitled to recover from an adequately insured or uninsured motorist as compensatory damages in respect of bodily injury to or death of an insured person arising directly or indirectly from the use or operation of an automobile. This endorsement exists on almost every policy sold in Ontario. The minimum limit of the liability coverage in the province is $200,000. Almost everybody with an insurance policy will have a coverage for an amount greater than the minimum, either $500,000 or $1,000,000. The endorsement is designed to provide the same level of protection to the insured and his or her family as the insured has provided to the public at large with the liability limit shown on the insured's policy. If the Insured is struck by an under insured motorist, carrying only $200,000 liability coverage, and the insured's policy provides coverage up to $1,000,000 for legal liability, the family protection endorsement could be called upon to pay up to $800,000 - the difference between the insured's limit of liability and the limit of liability on the under insured motorists policy. If the insured suffers a threshold injury as a result of the above-mentioned collision and sues the under insured motorist for $600,000, the under insured motorist will pay only $200,000. Without the family protection endorsement, that would be all the insured could recover. With the family Protection endorsement on the policy, the insured would collect the remainder of the settlement, $400,000 from the endorsement, as if it were the under insured motorist's liability policy. The endorsement can be called upon to pay up to the difference between an underinsured motorists’ policy and the Insured policy liability limits for any incident of a similar nature. This endorsement will also top up the amount recoverable under these circumstances when only $200,000 is recoverable under the uninsured motorist’s section of the policy, or if the absolute liability provision is brought in to play due to the illegal and prohibited actions of the at-fault motorist. OPCF 46 - Predetermined Income from self employment Agreement It is designed to allow the Insured and Insurer to come to a prearranged agreement on what the Insured's annual income will be for the purposes of determining accident benefits. OPCF 47 - Agreement not to rely on SABS priority of payment rules If a client purchases Optional Accident Benefits, the insurer is required to issue an OPCF 47 at no charge. This endorsement allows the insured to claim Accident benefits including optional benefits provided by the policy regardless of the priority of payment rules in section 268 of the Insurance Act. OPCF 48 - Added Coverage to offset Tort Deductibles The Insurer agrees to indemnify the insured for $10,000 for an insured person and $5000 for a claimant under the family law act for non-pecuniary claim (Pain and suffering) ..” (RIBO)
***
Relevant Insurance Coverage:
A. Auto Insurance - Comprehensive (All perils)
B. Liability Insurance
C. Travel and Health Coverage
D. Life Insurance
**
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