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Medical Condition

A medical condition refers to any illness, injury, disease, disorder, or ongoing health issue that affects a person’s physical or mental well-being. In the context of insurance, the term includes both acute and chronic conditions, whether diagnosed, treated, or undiagnosed at the time of application or claim. Examples include high blood pressure, diabetes, asthma, depression, or past surgeries.

Medical conditions are a key factor in underwriting and claims assessment. Insurers use information about your medical history to determine eligibility, premium rates, and coverage terms. Some policies, especially medically underwritten plans, may exclude coverage for pre-existing medical conditions or impose waiting periods before related claims are covered. In contrast, guaranteed issue plans typically cover pre-existing conditions after a defined stability period or at reduced benefit levels.

Example:

If you have been treated for asthma, that is considered a medical condition. When applying for health insurance, the insurer will use that information to evaluate your application and determine whether asthma-related expenses are covered.

What to Watch For:

Always disclose all known medical conditions and treatments when applying for insurance. Failure to do so may result in denied claims or cancellation of coverage. Keep documentation from your healthcare providers, as insurers may request medical reports or test results during underwriting or when reviewing a claim.

Related Terms

Member

A member is an individual who is enrolled and covered under a group insurance plan, typically through their employer, association, or organization. The member is often referred to as the insured employee or plan participant and receives coverage for benefits such as health, dental, life, and disability insurance. The member may also extend coverage to eligible dependents, such as a spouse or children, under the same plan.

Treatment

Treatment refers to any medical, dental, or therapeutic care provided by a licensed healthcare professional to diagnose, manage, or improve a health condition, injury, or disease. In the context of insurance, treatment includes all services, procedures, medications, and interventions that are deemed medically necessary to restore or maintain health. It can range from routine doctor visits and prescription drug use to surgery, rehabilitation, and specialized therapies.

Provider

A provider is a licensed healthcare professional, facility, or service organization that delivers medical, dental, vision, or paramedical care to patients. In the context of insurance, a provider is any individual or entity authorized to perform covered services and submit claims for reimbursement to an insurer. Providers include physicians, dentists, pharmacists, physiotherapists, chiropractors, optometrists, hospitals, and clinics.

Benefit

A benefit is the specific financial protection or coverage provided under an insurance policy. In health and dental insurance, a benefit refers to the payment or reimbursement made by the insurer for eligible medical, dental, or wellness expenses. Each benefit category - such as prescription drugs, dental services, vision care, or physiotherapy - outlines what is covered, how much the insurer will pay, and any applicable limits or conditions.

Health Insurance

Health insurance is a type of coverage that helps pay for medical and healthcare expenses not fully covered by Canada’s public health system. It protects individuals and families from the high cost of prescription drugs, medical services, and treatments that fall outside provincial or territorial government health plans. Health insurance can be obtained through an employer’s group benefits plan or purchased individually from a private insurer.

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