Health & Dental Insurance

Individual health and dental insurance is a type of insurance that covers your health-care expenses that are not fully covered (or covered at all) by your provincial or territorial health-care plan. This can include medical, dental, vision, prescription drugs, hospitalization, paramedical services, and more. This type of insurance can be purchased by individuals who are not covered by employer-sponsored health or dental insurance plans, such as self-employed individuals, part-time employees, or retirees.

You may think that you don’t need individual health and dental insurance because you have a provincial or territorial health-care plan. However, these plans only cover the basic and essential health-care services, such as doctor visits, diagnostic tests, and emergency care. They do not cover many other health-care expenses that you may incur, such as:

Dental care: Most provincial or territorial plans do not cover routine dental check-ups, cleanings, fillings, crowns, bridges, implants, orthodontics, or dentures.
Vision care: Most provincial or territorial plans do not cover eye exams, glasses, contact lenses, laser eye surgery, or treatments for eye diseases.
Prescription drugs: Most provincial or territorial plans do not cover the full cost of prescription drugs, especially if they are not listed on their formulary or if they are dispensed outside of a hospital. You may also have to pay deductibles, co-payments, or dispensing fees.
Hospitalization: Most provincial or territorial plans do not cover the full cost of staying in a hospital ward or a semi-private or private room. You may also have to pay for extra services such as television, telephone, or internet access.
Paramedical services: Most provincial or territorial plans do not cover the full cost of services provided by paramedical practitioners such as physiotherapists, chiropractors, massage therapists, acupuncturists, naturopaths, podiatrists, or psychologists.

These health-care expenses can add up quickly and put a strain on your finances. If you don’t have individual health and dental insurance, you may have to pay for them out of your own pocket or use your savings or credit cards. This can affect your ability to meet your other financial obligations or goals.

Therefore, having individual health and dental insurance can help you protect your health and your wallet. It can reimburse you for eligible health-care expenses that are not fully covered by your provincial or territorial plan. It can also give you access to a wider range of health-care services and providers that may not be available through the public system.

Features of individual health and dental insurance

Individual health and dental insurance policies can vary depending on the insurance company and the specific policy. However, common features of these policies include:

Deductibles: This is the amount of money that the policyholder is required to pay before the insurance company starts to pay for covered expenses.
Coinsurance: This is the percentage of covered expenses that the policyholder is responsible for paying after the deductible has been met.
Co-pays: This is a fixed amount that the policyholder is responsible for paying for certain covered expenses, such as doctor visits or prescription drugs.
Maximum out-of-pocket limit: This is the maximum amount of money that the policyholder is responsible for paying for covered expenses in a given year. Once this limit is reached, the insurance company will pay for all covered expenses for the remainder of the year.

What are the types of individual health and dental insurance?

There are different types of individual health and dental insurance available in Canada. Some of the common ones are:

Basic plans: These plans provide coverage for the most common and essential health-care expenses, such as prescription drugs, dental care, vision care, and hospitalization. They usually have lower benefit amounts and higher deductibles and co-payments than other plans. They are suitable for people who want to have some coverage for unexpected health-care costs but don’t need a lot of coverage or services.
Enhanced plans: These plans provide more comprehensive coverage for a wider range of health-care expenses, such as prescription drugs, dental care, vision care, hospitalization, paramedical services, and more. They usually have higher benefit amounts and lower deductibles and co-payments than basic plans. They are suitable for people who want to have more coverage and services for their health-care needs and preferences.
Customized plans: These plans allow you to choose the coverage and services that suit your needs and budget. You can mix and match different options and features, such as benefit amounts, waiting periods, deductibles, co-payments, riders, and more. They are suitable for people who want to have more flexibility and control over their coverage and costs.

How Does Individual Health and Dental Insurance Work?

Individual health and dental insurance works by providing coverage for medical and dental expenses incurred by the policyholder. The policyholder pays a premium to the insurance company, and in exchange, the insurance company agrees to pay for covered expenses.

In order to receive coverage, the policyholder must meet the terms of the policy, including paying the deductible, coinsurance, and copays as required. The insurance company will pay for covered expenses up to the maximum out-of-pocket limit. There are 2 ways the expenses are paid:

Direct billing: The medical service provider directly submits the claim on behalf of the policyholder to the insurance provider. If the claim is approved, depending on the policy and the amount approved, the policyholder does not pay for the medical services availed up-front or only pays the portion that was not approved.
Reimbursement model: The policy holder pays for the medical services first and then submits the expense to the insurance provider who then pays out the policyholder as per the policy coverage. If you have a health-care expense that is covered by your individual health and dental insurance policy, you should follow these steps to make a claim:
- Pay for the service: You should pay for the service yourself at the time of receiving it. You should also get a receipt that shows the details of the service, such as the date, the provider’s name and address, the amount charged, and the patient’s name.
- Submit the claim: You should fill out a claim form that is provided by your provider or available on their website. You should attach the original receipt and any other documents or information that are required by your policy. You should then send the claim form and the receipt to your provider by mail, fax, email, or online portal within a specified time limit.
- Wait for reimbursement: Your provider will review your claim and verify your eligibility for benefits. They will then reimburse you for the eligible amount according to your policy. They may also request additional information or evidence if needed. They will notify you of their decision to approve or deny your claim, or pay a partial or reduced benefit.

Who Should Consider Getting Individual Health and Dental Insurance?

Individual health and dental insurance can be a valuable type of insurance coverage for individuals who are not covered by employer-sponsored health or dental insurance plans. This can include self-employed individuals, part-time employees, or retirees.

Individuals who may want to consider getting individual health and dental insurance include those who:

Are not covered by employer-sponsored health or dental insurance plans
Have a high level of medical or dental expenses
Have a family history of medical or dental conditions that could lead to high expenses
Are concerned about the financial impact of unexpected medical or dental expenses

It is important to note that individual health and dental insurance policies can vary depending on the insurance company and the specific policy. It is important to research your options and evaluate your insurance needs when considering individual health and dental insurance coverage.