Plan Member
A plan member is an individual who is enrolled in and eligible to receive benefits under a group insurance plan. Typically, the plan member is an employee of a company or a member of an organization that sponsors the group policy. The plan member is covered for the benefits outlined in the plan - such as health, dental, life, and disability insurance - and may also extend coverage to eligible dependents, including a spouse or children.
How It Works
Group insurance means insurance under which the lives or health of a number of plan members are insured under a contract between an insurer and a group policyholder. Under CLHIA's group insurance guideline, group life and group health insurance is purchased by group policyholders on a voluntary basis for their plan members, and it helps provide those plan members and their eligible dependents with protection for planned and unexpected life events. The plan member is distinct from the plan sponsor or policyholder, which is the employer or organization that owns the group contract with the insurer. Coverage can span several types of benefits. For instance, a disability income benefit makes periodic income replacement payments to a plan member insured under a group contract in the event of that member's disability. The plan member's rights and responsibilities, including maintaining accurate personal information and following claim submission procedures, are defined in the group benefits booklet or certificate of insurance.
Example:
Suppose your Canadian employer offers a group health and dental plan. Once you enrol, you become the plan member and can submit claims for eligible expenses such as a dental cleaning or prescription drugs. If they qualify as eligible dependents, you may also add your spouse and children to the plan. If you later leave that job, your plan-member coverage typically ends, although you may be able to convert to an individual policy within the insurer's conversion window.
What to Watch For:
Your coverage is not always complete on its own. In a coordination of benefits provision, the co-payment is the proportion of eligible expenses, net of deductible, not reimbursed by the plan that remains the responsibility of the plan member. It also helps to remember that being a plan member is tied to your relationship with the group policyholder. When you leave your employer, your coverage as a plan member usually ends, but you may be eligible to convert to an individual plan within a set timeframe. Because your rights and obligations live in the group benefits booklet or certificate of insurance, keeping your personal information accurate and following the proper claim submission procedures helps protect your access to benefits.
