8 Basic Health Care Provision (For All Members with Comprehensive Coverage)

8.1  General

8.1.1 The provision is available only to members who reside outside Canada and are not covered under a provincial/territorial health insurance plan. Its purpose is to provide reimbursement for services, excluding hospital services, which are the equivalent, as far as possible, to those services available to individuals residing in Canada and covered under a provincial/territorial health insurance plan. The co-payment does not apply under this provision.

8.1.2 The maximum eligible expense for these services is equal to a multiple of the amount otherwise payable based on the current fee schedule in force under the Health Insurance Act 1972 of Ontario on the day when the expense is incurred. The multiple is specified in the Summary of Maximum Eligible Expenses.

8.2  Eligible Expenses

8.2.1 The eligible expenses include:

1. services of a physician including:
   1. physician's services in the participant's home, the physician's office, clinic or in a hospital,
   2. diagnosis and treatment of illness and injury,
   3. one annual health examination,
   4. treatment of fractures and dislocations,
   5. surgery, including surgery performed by a Doctor of Podiatric Medicine (DPM) when performed in the United States of America,
   6. administration of anaesthetics,
   7. x-rays for diagnostic and treatment purposes,
   8. obstetrical care, including prenatal and postnatal care,
   9. laboratory services and clinical pathology when ordered by and performed under the direction of a physician;
2. services of an optometrist;
3. services of a physiotherapist;
4. ambulance services;
5. services of a chiropractor, osteopath or podiatrist.

Exclusions

8.2.2 No benefit is payable for:

1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.
2. physician services rendered as a salaried employee of a hospital. An employee posted outside Canada may be reimbursed for these expenses under the Hospital (Outside Canada) Provision.