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Covered Expenses

See also Eligible Expenses

See also Coverage / Benefit

i.e. Reasonable and Customary Charges that are covered under a health or dental plan as outlined in the Policy document.

How It Works

Covered expenses are the health care services and supplies your plan will actually reimburse, and the amount is the lesser of the expense you actually incurred or the customary charge for that service. For an expense to qualify, the underlying treatment for the disease or injury must be accepted by the Canadian medical profession, proven to be effective, and of a form, intensity, frequency, and duration essential to diagnosing or managing the condition. Reimbursement is based on the reasonable and customary charges for the service rather than the full amount a provider bills, so a plan may pay the full eligible amount up to any stated maximum. A plan can even reimburse covered expenses in full with no deductible applied. Under a private health services plan, the expenses covered must be medical or hospital expenses, or connected expenses incurred within a reasonable time after a medical expense, and for a self-insured plan to qualify as such, all or substantially all of the premiums must relate to medical expenses eligible for the medical expense tax credit.

Example:

A Canadian with a supplementary health plan sees a physiotherapist. The session is a covered expense, but the plan reimburses based on its reasonable and customary charge and any frequency limit. If the clinic charges more than the customary amount, the member pays the difference out of pocket. That unreimbursed portion can sometimes be claimed later as a medical expense on a tax return.

What to Watch For:

Plans do not cover everything. Dental plans, for example, contain limitations and exclusions, so services outside the covered list or beyond frequency limits are not covered expenses. When you are covered by more than one plan, coordination of benefits ensures the total payments from all plans do not exceed the total expenses incurred. On your tax return, you can only claim the part of an expense for which you have not been and will not be reimbursed by a plan.

Related Terms

Coverage / Benefit

Coverage, sometimes referred to as a benefit, is the range of health or dental services, supplies, or treatments that your insurance plan agrees to pay for under its terms and conditions. Each benefit represents a category of care, such as prescription drugs, dental services, vision care, or paramedical treatments.

Coordination of Benefits

Coordination of benefits (COB) is the process used by insurance companies to determine the order in which multiple plans will pay for the same claim when a person is covered under more than one policy. The goal is to ensure that combined reimbursements do not exceed 100 percent of the eligible expense, while allowing the insured to receive the maximum possible coverage across all plans.

Critical Illness Insurance

Critical illness insurance is a type of financial protection that pays a one-time, tax-free lump sum if you are diagnosed with a covered serious illness such as cancer, heart attack, or stroke. Unlike disability insurance, which replaces a portion of your income over time, critical illness insurance gives you a single payout that you can use however you choose - for medical expenses, household bills, recovery time, travel, or lifestyle adjustments.

Conversion Privilege

Conversion privilege is the right to transfer your existing group insurance coverage to an individual policy without providing medical evidence of insurability when your group coverage ends. This option allows you to maintain continuous protection during life transitions such as leaving a job, retiring, or losing eligibility under an employer-sponsored plan. It is a key feature that helps individuals avoid coverage gaps, especially if they have pre-existing medical conditions that could make new insurance difficult to obtain.

Prior Authorization

Prior authorization is the process through which an insurer reviews and approves certain medical treatments, procedures, or prescription drugs before they are performed or dispensed. It ensures that the recommended care is medically necessary, appropriate, and covered under the policy before expenses are incurred. Prior authorization helps manage costs and ensures the use of safe, evidence-based treatments that align with clinical guidelines.

Relevant Plans

Plans that relate to Covered Expenses

Alberta Blue Cross - Blue Assured - Basic

Alberta Blue Cross - Blue Assured - Basic

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced

Alberta Blue Cross - Blue Assured - Enhanced

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced+

Alberta Blue Cross - Blue Assured - Enhanced+

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Premium

Alberta Blue Cross - Blue Assured - Premium

Can apply at anytime, at any age.

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