Effective April 1, 2018, Plan Members and Dependents who use insulin to manage their diabetes are eligible for FreeStyle Libre Flash glucose monitor and sensors. For more information Click here

Critical Illness Coverage

If you suffer any of the critical illnesses covered by the policy, you will receive the Benefit Amount shown below in a lump sum payment. Under some circumstances, if you return to active work and later suffer another critical illness, you may qualify for a second benefit payment equal to your first payment. 

If you qualify for a Critical Illness benefit payment, you can use it any way you wish - for example, to help cover extra costs associated with your illness, or to help make up for lost income. 

All benefit payments are subject to the terms and conditions of the policy, which are summarized in this website. 

Eligibility

All active members of Insulators Local 95 Benefit Fund who are under the age of 70 and who meet the eligibility requirements of the Trust Fund.

Benefit Amount

$20,000

The amount payable for a critical illness will be reduced by 50% if you are age 65 or older on the date the benefit becomes payable.

A Second Event Benefit may be payable equal to the Benefit Amount, subject to certain conditions as described under Second Event Benefit.

Insured Conditions

If you are diagnosed with a critical illness by a physician, you may be eligible for the $20,000 benefit.

The diagnosis must be for one of the following conditions:

  1. Alzheimer's Disease
  2. Benign Brain Tumour
  3. Coma
  4. Coronary Artery Bypass Graft
  5. Heart Attack
  6. Heart Valve Replacement
  7. Kidney (Renal) Failure
  8. Life-Threatening Cancer
  9. Loss of Sight, Speech or Hearing
  10. Major Organ Transplant
  11. Motor Neuron Disease
  12. Multiple Sclerosis
  13. Paralysis - Quadriplegia, Paraplegia, Hemiplegia
  14. Parkinson's Disease
  15. Severe Burn
  16. Stroke

Benefit Payment Conditions

Payment of benefits upon the first diagnosis of the critical illnesses listed above is subject to the following:

  • survival for at least 30 days after diagnosis of a covered Critical Illness;
  • the diagnosis is made within Canada;
  • the diagnosis is made while your coverage is in effect under the policy;
  • payment is not precluded by any general or specific exclusion or limitation set forth in the policy or any failure to meet any condition precedent set out below; and
  • once 100% of the maximum Benefit Amount has been paid, coverage terminates and no further benefits are payable, except as described under Second Event Benefit.

Critical Illness Definitions

Alzheimer's Disease - a progressive degeneration of the brain as diagnosed by a certified neurologist or psychiatrist.   The diagnosis must be supported by medical evidence of progressive deterioration of memory and the ability to reason and perceive, to understand, and to express and give effect to ideas.  The deterioration must be severe enough to render you incapable of independent living to the extent that you require a minimum of 8 hours of daily supervision.  No other dementing organic brain disorders or psychiatric illnesses are included.

Benign Brain Tumour - a benign neoplasm within the substance of the brain or the meninges (the membrane enclosing the brain).  The following conditions are deemed not to be Benign Brain Tumour:

  • Cysts, granulomas, malformations of the intracranial arteries and veins; or
  • Tumours or lesions of the pituitary.

A diagnosis of Benign Brain Tumour must be made by a physician. Interpretation: Benign Brain Tumours are typically more harmful than benign tumours in other parts of the body.  This is because any abnormal growth in the brain can place pressure on sensitive tissue causing impaired functions and neurological deficits. Benign tumours within the substance of the brain or the meninges are covered.  Other problems within or near the brain, such as cysts, granulomas, malformations of the intracranial arteries and veins, and tumours or lesions of the pituitary are not covered.

Coma - The diagnosis of a coma must indicate that permanent neurological deficit is present.

Coronary Artery Bypass Graft - The diagnosis of the condition that necessitates a coronary artery bypass graft must be made by a cardiologist and based on angiographic evidence of the underlying disease.

Heart Attack - The diagnosis of heart attack must be based on an event which contains all of the following criteria: 1) associated new electrocardiographic (EKG) changes which support the diagnosis; 2) concurrent diagnostic elevation of cardiac enzymes above normal levels; and 3) confirmatory imaging studies such as thallium scans, MUGA scans, or stress echocardiograms.

Heart Valve Replacement - replacing any heart valve with either a natural or mechanical valve.  The surgery must be recommended and performed by a physician in Canada.  To qualify, you must survive for 30 days following the date of the surgery.

Kidney (Renal) Failure - The diagnosis of end stage renal disease must be based on chronic irreversible failure of the function of both kidneys requiring regular hemodialysis or necessitating kidney transplant.

Life-Threatening Cancer -  characterized by the presence of a malignant tumour and by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The condition must be first manifested while your insurance under this policy is in effect. Life-threatening Cancer includes leukemia, Hodgkin’s disease, lymphoma and invasive malignant melanoma as well as Cancers for which chemotherapy or radiation treatments have been recommended.

Life-Threatening Cancer does not include the following forms of Cancer:

  1. malignant melanoma to a depth of 0.75 mm or less;
  2. carcinoma in situ;
  3. basal cell carcinoma and squamous cell carcinoma of the skin that have not metastasized;
  4. early prostate Cancer diagnosed as T1a or T1b; and any tumour in the presence of any Human Immunodeficiency Virus (HIV);
  5. pre-malignant lesions, benign tumours or polyps; 
  6. stage A colon Cancer;
  7. stage 1 Hodgkin’s disease (unless requiring chemotherapy and/or radiation treatments).

Cancer-related Definitions

Basal cell carcinoma - a skin Cancer that arises in the basal cells, which are at the bottom of the epidermis (outer layer of skin).

Carcinoma in situ - the Cancer is superficial and has not penetrated into the organ involved.

Malignant melanoma to a depth of 0.75 mm or less - a Cancerous mole which is 0.75 mm or less when measured under a microscope.

Metastasized - spread of the Cancer from one part of the body to another.

Squamous cell carcinoma - a skin Cancer that arises from the upper part of the epidermis (outer layer of skin)

Partial Payment for Non-Life-Threatening Cancer - 25% of the Benefit Amount for the following conditions:

  1. Malignant melanoma to a depth of 0.75 mm or less, excluding malignant melanoma in situ;
  2. Basal or squamous cell carcinoma that has spread beyond the deepest layer of skin and has not metastasized;
  3. Ductal carcinoma in situ of the breast;
  4. Early prostate Cancer diagnosed as T1a or T1b; or
  5. Any tumour in the presence of any Human Immunodeficiency (HIV).

Must be positively diagnosed by a physician and supported with a pathological report. Upon payment of the partial payment for Non-Life-Threatening Cancer, your insurance remains in effect with the Benefit Amount reduced by the amount of the partial payment.  Only one claim per condition is permitted for Non-Life-Threatening Cancer.

Loss of Sight, Speech, or Hearing - The diagnosis of loss of sight, speech or hearing must be made by a licensed specialist in that field of medicine.  The diagnosis of loss of sight must indicate that corrected visual acuity must be worse than 20/200 inboth eyes or the field of vision must be less than 20 degrees in both eyes.  The diagnosis of loss of speech must be established for a continuous period of 12 months.  Psychiatric related causes are not covered.  The diagnosis of loss of hearing must include audiometric and sound threshold tests, and the auditory threshold must be more than 90 decibels.

Major Organ Transplant - The diagnosis is a result of a condition that necessitates a major organ transplant.

Motor Neuron Disease - a definitive diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy, or pseudo bulbar palsy; and limited to these entities. The diagnosis must be made by a physician who is a certified neurologist.

Multiple Sclerosis - The unequivocal written diagnosis by a physician who is certified as a neurologist confirming at least moderate persisting neurological abnormalities, with impairment of function, but not necessarily causing confinement to a wheelchair or bed.

Paralysis - The diagnosis of paralysis must include documented evidence of the illness or injury that caused the paralysis.

Parkinson’s Disease - primary idiopathic Parkinson’s disease which is characterized by a minimum of 2 or more of the following clinical manifestations:

  • tremors;
  • muscle rigidity; or
  • bradykinesis (abnormal slowness of movement, sluggishness of physical and mental responses).

All other types of Parkinsonism are specifically excluded. In addition, you must require substantial physical assistance from another adult to perform 2 or more of the activities of daily living.

Severe Burn - The diagnosis of severe burn must be a result of suffering a full thickness or third degree burn covering 20% or more of the body.

Stroke - The diagnosis must be made by a licensed neurologist and based on documented neurological deficits and confirmatory neuroimaging studies.

Second Event Benefit

If you are diagnosed with Cancer for which the Benefit Amount has been paid and you are then actively at work for at least 90 days and are subsequently diagnosed with a Heart Attack, Stroke, Coronary Artery Bypass Graft, Alzheimer’s Disease, Coma, Lost of Sight, Speech or Hearing, Motor Neuron Disease, Multiple Sclerosis, Parkinson’s Disease, Quadriplegia, Paraplegia, Hemiplegia or Severe Burn, then a Second Event Benefit equal to the Benefit Amount will be payable.  The Second Event Benefit is subject to your surviving for 30 days after the diagnosis of the second event.

If you are diagnosed with Heart Attack, Stroke or Coronary Artery Bypass Graft for which the Benefit Amount has been paid and you are then actively at work for at least 90 days and are subsequently diagnosed with Cancer, Alzheimer’s Disease, Coma, Lost of Sight, Speech or Hearing, Motor Neuron Disease, Multiple Sclerosis, Parkinson’s Disease, Quadriplegia, Paraplegia, Hemiplegia or Severe Burn, then a Second Event Benefit equal to the Benefit Amount will be payable.  The Second Event Benefit is subject to your surviving for 30 days after the diagnosis of the second event.

The Second Event Benefit is payable only once. Payment of the Second Event Benefit will represent full and final discharge of all claims under the Second Event Benefit.

Diagnostic Requirements

All Critical Illnesses - The insurer reserves the right to have any critical illness diagnosis reviewed by a physician of its choosing.  

In the event of any dispute or disagreement regarding the appropriateness or correctness of the diagnosis, the insurer shall have the right to request an examination of either you or the evidence used in the arriving at your diagnosis by an independent acknowledged expert selected by the insurer in the applicable field of medicine. The opinion of such expert as to such diagnosis shall be binding on both you and the insurer.

Continuance of coverage If you:

  1. are laid-off on a temporary basis, 
  2. are temporarily absent from work due to disability, 
  3. are on leave of absence, or on maternity leave, or 
  4. have your benefits extended subject to a negotiated settlement following termination of employment by Insulators Local 95 Benefit Fund.

Your coverage may be extended for a period of up to 24 months, subject to payment of premium.

Notice of Claim

Written notice of claim must be filled within 20 days after the diagnosis, or as soon thereafter as is reasonably possible.

Claim Forms

Claim forms can be obtained from the administrator at:

Benefit Plan Administrators Limited
90 Burnhamthorpe Road West Suite 300
Mississauga, Ontario
L5B 3C3

Proof of Loss

Written proof of loss must be furnished within 90 days after the date of the diagnosis.  Failure to furnish proof within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required.

Notice of Claim

Upon receipt of due written proof of loss, benefit payments will be made to you (or on behalf of you, if applicable).  If you should die before all payments due have been made, the amount still payable will be paid to your beneficiary.

If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee’s property.  If the payee has no legal guardian for his or her property, a payment not exceeding $1,000 may be made to any relative by blood or connection by marriage of the payee who, in the insurer’s opinion, has assumed custody and support of the minor or responsibility for the incompetent person’s affairs.

Exclusions and Limitations

The policy does not provide benefits caused in whole or in part by, or resulting in whole or in part from, the following:  

  1. suicide or any attempt at suicide, or intentionally self-inflicted injury or any attempt at intentionally self-inflicted injury; 
  2. declared or undeclared war, or any act of declared or undeclared war;
  3. commission of or attempt to commit a felony; 
  4. voluntary participation in any riot or civil insurrection;
  5. illness specifically excluded from the definitions of critical illness.

This website is a summary of benefits only.  In the event of a dispute, all terms and conditions of the Master Policy shall prevail.

The Master Policy is on file with Insulators Local 95 Benefit Fund.

 

 

Insulators Local 95 Benefit Trust Fund c/o Benefit Plan Administrators 
90 Burnhamthorpe Road West, Suite 300 Mississauga, Ontario L5B 3C3