Definitions to Help You Understand Your Benefits
For the purposes of the TMU benefits program, the following terms have the meanings as described below.
For the purposes of the Business Travel Accident Plan and the Voluntary Accident Insurance Plan, an accident is a sudden, unforeseen, and unexpected event that happens by chance and arises from a source that is external to the insured person. It must be the direct cause of the loss or the loss of use and be independent of illness, disease, or other bodily malfunction.
You are considered actively at work on any day on which you are physically and mentally fit to perform all the usual and customary duties of your occupation with TMU. This includes a scheduled working day when you are not present at work but you are capable of working (i.e., you are not in hospital or disabled or ill), or a day when you are not scheduled to work if, on your last scheduled working day you were actively at work.
This is a voluntary, employee paid plan that covers accidental death & dismemberment 24/7. It is available as single or family coverage in units of 1-50. Each unit is $10,000. Maximum coverage is $500,000.
This is one method of paying for benefit coverage. The plan sponsor (TMU) reimburses the insurance company (Sun Life) for all claims paid, plus administration fees & taxes. If the liability or risk can be reasonably measured and cash flow fluctuation is not an issue, than the sponsor is only paying for what has been utilized. The risk to the sponsor is for a catastrophic claim in the tens of thousands of dollars. At TMU, the medical and dental benefits are paid for on an ASO basis.
Your basic annual earnings include your current salary from TMU. It excludes any bonus, commission, overtime, or incentive pay you may receive.
A beneficiary refers to the person who will receive the loss of life benefit from a benefits plan if you die (e.g., the lump sum from a life insurance plan or the loss of life benefit under an accident insurance plan). Under the Voluntary Accident Insurance Plan, if you have not named a beneficiary, the first surviving person(s) in the list below will receive your loss of life benefit, in the following order:
- your spouse;
- in equal shares to your children;
- in equal shares to your parents;
- in equal shares to your siblings;
- to your estate.
You would receive any accident insurance benefits other than the loss of life benefit.
The benefit year is January 1 to December 31, inclusive.
A calendar year is January 1 to December 31, inclusive.
If your spouse has group benefits coverage with another insurance company, or with Toronto Metropolitan University through Sun Life Financial, benefits are coordinated between the two insurance plans. Details on coordination of benefits can be found on the HR website.
The deductible is the amount you pay out of pocket before the plan begins paying for covered expenses. The deductible is $25/year excluding hospital expenses.
Coverage for dental expenses. There is no provincial plan for dental expenses. The plan is an ASO arrangement with Sun Life and TMU pays 100% of the costs.
Dependent children may be insured under the TMU benefits program for medical and dental benefits, voluntary accident insurance and EFAP. The term dependent child means a child who is not married or in any other formal union who:
- is under 21 years of age and depends wholly on you for support; or
- is under 25 years of age, depends wholly on you for support, and is attending an institution of higher learning* as a full-time student; or
- is any age (if covered before age 21, or before age 25 if a student) and who is disabled and incapable of self-support**; and
- is wholly dependent on you for support and is not married or in any formal union recognized by law.
Stepchildren and legally adopted children are eligible if they depend on you for support. Children of a common-law spouse are eligible during the time that coverage for the spouse is in effect and if the children depend on you for support. Foster children are excluded.
* You must provide confirmation of the child's enrollment in full-time studies at an educational institution recognized by the Canada Revenue Agency, to the Human Resources Benefits Unit every September using the HR Self Service eStudent.
** You must obtain and complete a Disabled Dependent Questionnaire from Sun Life for any dependent child(ren) who is/are permanently disabled.
Your dependents include your spouse and dependent children as defined elsewhere in this glossary. They must reside in Canada, or temporarily reside outside of Canada for educational purposes. For the extended health care plan, they must be entitled to benefits under any provincial healthcare plan (e.g. OHIP).
Parents do not meet the definition for dependent.
The amount that the pharmacist charges to dispense a prescription drug.
A doctor is a person who is licensed as a medical doctor or a doctor of osteopathy under the laws of the jurisdiction where treatment is given and who is qualified to provide the medical treatment. Doctor does not include a family member of the insured person, a social worker, a physiotherapist, or a chiropractor.
Under the Voluntary Accident Insurance Plan the term domestic partner means a person who:
- is at least 18 years of age,
- has been your sole spousal equivalent,
- has lived in the same household as you for the past 12 months, and
- intends to continue the relationship described above indefinitely.
Extended Health Care. Designed to complement provincial health plans (e.g. OHIP/UHIP). Coverage for many medical expenses above what is provided by provincial health care. The plan is an ASO arrangement with Sun Life and TMU pays 100% of the costs.
In the Long Term Disability Plan policy, this term refers to a "waiting period" before LTD benefits can begin and usually coincides with the period of time during which Sick Leave benefits are payable, although there are some exceptions. The elimination period begins with the first full day of total disability and ends
- after a period of total disability of 66 working days, or
- on the last day that a benefit under any loss of income or salary continuance plan is payable, if earlier.
If your total disability starts while you are on strike; temporary layoff; an approved leave of absence without pay; or a period of absence recognized as the normal non-work period if you are working a reduced workload or partial year; the elimination period begins on the date you would have normally been scheduled to return to work.
If you are considered to be a reduced workload or partial year employee, and your total disability starts while you are actively at work and continues until the date recognized as the non-work period, the elimination period will be suspended, if not yet completed, and will restart on the date you would have normally been scheduled to return to work.
If your total disability starts while you are on an approved leave of absence with pay, the elimination period begins on the date you become totally disabled.
In the case of pregnancy, the elimination period starts on the earlier of the date pregnancy terminates and the date the employee is totally disabled.
An emergency is an acute unexpected condition, illness, disease, or injury that requires immediate assistance.
An employee is a person employed by TMU. An employee must reside in Canada, or may temporarily reside outside Canada if on a leave of absence approved by TMU. Anyone who is not entitled to benefits under either a provincial health care plan (e.g., OHIP or UHIP, see definition below) or a federal government plan that provides similar benefits is not considered to be an employee for purposes of health coverage.
The EFAP provides professional, confidential support services and programs for employees and members of their immediate families. The EFAP is offered through Shepell-fgi.
The fee guide of the Ontario Dental Association (ODA) lists procedure codes that identify individual treatments performed by dentists in Ontario. The guide also provides a recommended fee for each treatment. Sun Life, the carrier for the TMU Dental Plan, refers to the current ODA General Pracitioner fee guide to determine the maximum the Plan will pay for each dental service. In the case of laboratory fees, the Plan will reimburse 66⅔% of the procedure fee listed in the current fee guide.
A health spending account is coverage to pay for eligible expenses incurred by the employee or dependent. The expenses must qualify as medical expenses in accordance with the Income Tax Act of Canada.
A hospital is a facility licensed to provide care and treatment for sick or injured patients, primarily while they are acutely ill. It must have facilities for diagnostic treatment and major surgery. Nursing care must be available 24 hours a day. It does not include a nursing home, rest home, home for the aged or chronically ill or a facility for treating alcohol, drug abuse, or beds set aside for any of these purposes in a hospital.
A hospital licensed to provide rehabilitation and not custodial care.
An illness is a bodily injury, disease, mental infirmity, or sickness.
Under the Business Travel Accident Insurance Plan and the Voluntary Accident Insurance Plan, a loss is as follows:
- Arms and legs - severance through or above elbow or knee joints.
- Feet - severance through or above ankle joints.
- Hand - severance through or above the knuckle joints of at least four fingers on the same hand or at least three fingers and the thumb on the same hand.
- Thumb and index finger of the same hand - severance through or above knuckle joint of each digit.
- Toes - severance through or above metatarsophalangeal joints.
- Sight - entire and irrecoverable loss of sight. Remaining vision in that eye must be no better than 20/200 using a corrective aid or device, as determined by a doctor.
- Speech and hearing - permanent, irrecoverable, and total loss, without the aid of mechanical devices, as determined by a doctor.
- Quadriplegia, paraplegia, hemiplegia complete and irreversible loss of all motion and all practical use of an arm or leg that is continuous for 12 months, as determined by an doctor.
If a limb, hand, foot, thumb, or index finger is later reattached, the original loss is still considered an eligible loss under the policy.
Under the Business Travel Accident Plan and the Voluntary Accident Insurance Plan, loss of use means the total and irrecoverable loss of use of a body part. For benefits to be payable, the loss of use must continue for 12 consecutive months after which the benefit for loss of use is payable, and nerve damage must be determined to be permanent afterward.
A minor is someone who is less than 18 years old.
This government-operated program provides health insurance for Ontarians. It pays for ward accommodation in hospitals and for most routine medical services.
Enrollment is handled directly by Service Ontario. Each member of your family (even children under 21 years of age) who is covered by OHIP should have his or her own individual OHIP health card.
Information about OHIP coverage and the covered services and supplies is available from the Ontario Ministry of Health and Long-Term Care (external link) .
Coverage is provided while employees are out of the province and require medical care. An emergency means an acute illness or accidental injury that requires immediate, medically necessary treatment prescribed by a doctor. Having a heart attack while vacationing in Florida would be covered; needing regular dialysis treatment would not. For more information, visit the Travel emergency medical coverage webpage.
A drug that has a drug identification number (DIN) and is prescribed in writing by a doctor.
A revocable beneficiary is a beneficiary designation which you have the right to change at any time without the beneficiary’s consent.
Your spouse may be insured under the TMU benefits program for medical and dental benefits, voluntary accident insurance and EFAP.
Your spouse is either
- the person to whom you are married by virtue of a legal marriage or under any other formal union recognized by law, or
- a person whom you've been living with, in a common-law relationship, who is publicly represented as your spouse and has been continually so represented for at least the previous year.
At any time, only one person may be covered as your spouse. If you are separated (marriage or common law) or divorced, your former spouse is no longer eligible as an eligible dependent.
Under the Voluntary Accident Insurance Plan, the term "spouse" also includes "domestic partner” (see other definition).
For some benefits, the government determines that the TMU-paid premiums count as income for tax purposes. Such a benefit is called a taxable benefit because you must pay tax based on this assessed value. For example, tuition waiver and premiums for group life insurance are taxable benefits.
Under the Long-Term Disability Plan, you are considered to be totally disabled for the first 36 months of benefits for TFA, or for the first 24 months of benefits for non TFA, if you are unable to perform the duties of your own occupation. After this 36-month or 24-month period, you are totally disabled if you cannot engage in any occupation for which you are reasonably suited by education, training, or experience.
Coverage in the event of accidental death or dismemberment while travelling on TMU business. The benefit is four times your basic salary to a maximum of $500,000. TMU pays 100% of the premium.
This plan provides coverage for international residents or Canadian residents (and their dependents) who have been out of Canada for more than six months and are hired to work in Ontario and who are not eligible for OHIP.
TMU, along with 11 other Ontario Universities has joined to together for the purpose of pooling or sharing the risk for the life insurance plans. More members spread the risk.
TMU reserves the right, at any time, to amend, change or discontinue any benefit coverage. If there is a question about coverage referred to in any portion of this benefits communication, the master contract from the insurer is the governing document.