Exclusions

Exclusions are services, conditions, or expenses that your health or dental plan does not cover under any circumstances. Every policy contains an exclusion list to define what falls outside the scope of coverage. Common exclusions include cosmetic surgery, over-the-counter medications, experimental treatments, fertility procedures, and any service not deemed medically necessary.

Understanding exclusions is essential because they determine the boundaries of your protection. Knowing what is not covered helps you plan out-of-pocket expenses and avoid surprises when submitting claims.

Example:

If your plan excludes cosmetic procedures, expenses for elective teeth whitening or Botox injections will not be reimbursed.

What to Watch For:

Review your plan booklet for the full list of exclusions. Even medically necessary services may be excluded if performed outside Canada or by an unlicensed provider.

Related Terms

Effective Date

The effective date is the day your insurance coverage officially begins. From this date forward, you are eligible to receive benefits for covered health, dental, life, or disability expenses under the terms of your policy. The effective date is established once your application has been approved, all requirements are met, and the first premium payment has been received, unless otherwise specified in the policy.

Eligibility Period

The eligibility period is the window of time during which an individual can apply for or enroll in an insurance plan after first becoming eligible. It ensures that applicants join coverage within a reasonable timeframe, helping insurers manage risk and prevent people from waiting until they need care to apply. Eligibility periods are common in both group and individual insurance and are especially important for guaranteed issue or conversion options.

Eligibility Window (Guaranteed Issue)

An eligibility window in a guaranteed issue (GI) plan is the period after losing group benefits during which you can enroll in personal health coverage without completing medical questions. This window is typically 60 to 90 days. Applying within it ensures uninterrupted protection for prescription drugs, dental care, and health services that were previously employer-sponsored.

Eligible Expenses

An eligible expense is any medical or dental service, product, or treatment that qualifies for reimbursement under the terms of your insurance plan. To be eligible, the service must meet several criteria: it must be medically necessary, performed by a licensed or approved provider, and fall within the plan’s specific limits and exclusions.

Elimination Period

The elimination period is the waiting time that must pass after an illness or injury occurs before disability insurance benefits begin to be paid. It functions like a deductible measured in days rather than dollars. During this period, you are responsible for your own income replacement through savings, sick leave, or other sources.

Have questions about your insurance coverage?

Our licensed advisors can help you understand your options and find the right plan for your needs.