Limitations Payment is not made for:
- services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program unless explicitly listed as covered under this benefit.
- any portion of the charges for services or supplies over the customary and reasonable charges, in the locality where they are provided.
- services or supplies that are not approved by Health Canada or other government regulatory body for the general public.
- services or supplies that are not generally recognized by the Canadian medical profession as effective, appropriate and required in the treatment of an illness in accordance with Canadian medical standards.
- services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada).
A benefit is not paid for:
- charges incurred for an illness due to or resulting from any cause for which indemnity or compensation is provided under any Workers’ Compensation Act, Criminal Injuries Compensation Act or similar legislation.
- charges for services and supplies, rendered or prescribed by a person who is normally resident in the patient’s home or who is related to the patient by blood or marriage.
- charges for services or supplies for cosmetic purposes only, or for conditions not detrimental to health, except those required as a result of an accident.
- any service or supply for which there would be no charge in the absence of this coverage.
- charges for services rendered in connection with medical examinations for insurance, school, camp, association, employment, passport or similar purposes.
- charges for experimental services or supplies, for which substantial evidence provided through objective clinical testing of the service’s or supply’s safety and effectiveness for the purpose and under the conditions of the recommended use does not exist to Sun Life’s satisfaction.
- the portion of any charge which is the legal liability of another party.
- charges for services provided by a doctor licensed and practising in Canada where the person is eligible to be insured under a provincial health insurance plan, except for such services which are specifically included under this provision.
- expenses for benefits which are legally prohibited by the government from coverage.
- the portion of charges which are payable under a provincial health insurance plan or a provincially sponsored program.
- the portion of charges for services or supplies, other than those listed in Type 2 items 3 and 4, provided in a hospital outside of Canada that would normally be payable under a provincial health or hospital plan if the service or supply had been rendered in a hospital in Canada.
- charges for items purchased primarily for athletic use.
- dental expenses, other than those indicated as eligible expenses.
- expenses for ambulance services for a medical evacuation which are eligible under the Emergency Travel Assistance Benefit Provision.
- expenses for repairs or replacement of purchased durable equipment.
- coinsurance charges or similar charges for hospital care which are in excess of charges payable by a provincial or territorial government health or hospital insurance plan and which are not charges made for utilization of semi-private or private accommodation.