Ambulance fees, medication, crutches … these are just some of the costs that can quickly add up if you get sick or are in an accident. In some situations, you might even have to stop working for several weeks or even months.
However, by paying regular premiums, you can protect yourself through one or more types of insurance. In this case, your insurer agrees to compensate or refund you for certain expenses if you get sick or are in accident. These types of insurance include health insurance, illness and accident insurance, drug insurance, disability insurance and salary insurance.
In Québec, there are two main types of protection against illness and accidents: public plans and private plans.
The public plan for illness, accidents and disability
The public plan includes different basic insurance programs. These programs are run by the provincial or federal government.
Here are some examples of programs offered at the provincial level:
- Public health insurance plan run by the Régie de l’assurance maladie du Québec (RAMQ). This plan includes services provided by doctors who take part in the plan. It also covers some of the costs related to these services.
- Workers compensation program of the Commission des normes, de l’équité, de la santé et de la sécurité du travail du Québec (CNESST). This program provides compensation for loss of salary in the event of a work accident or occupational disease. It also covers medical assistance and rehabilitation in some cases.
- Quebec Pension Plan (QPP). This plan can provide you with basic income if you become disabled.
- Société de l’assurance automobile du Québec (SAAQ). It can provide compensation for loss and inconvenience related to an injury if you’re in an accident.
At the federal level, the public plan includes these programs:
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Did you know? Anyone permanently living in Québec must be covered by a public or private prescription drug insurance plan. The RAMQ runs the public drug insurance plan. You’re generally eligible for the public plan if you don’t have access to a private plan. If you do have access to a private plan, you’re required to join that plan and get coverage for your spouse and children too. |
Private insurance
Private insurance usually pays for some of the expenses or losses not covered or only partially covered by public plans.
In the health sector, for example, private insurance can pay for treatments provided by certain specialists not covered by the RAMQ, such as physiotherapists, chiropractors and acupuncturists. Private insurance sometimes pays for ambulance costs as well. It all depends on what’s included in your contract.
Private insurance can include disability insurance, which is also known as salary insurance. This type of insurance protects against loss of income caused by an illness or accident preventing you from doing your regular job.
Private insurance is available for individuals or offered as part of a group insurance plan at work. You can check whether you qualify for this type of group insurance.
Who is insured?
You can purchase insurance coverage as protection if you become ill or are injured in an accident. In this case, you’re both the “policyholder” and the “insured.”
In addition to insurance that covers your own illness and accidents, you can also purchase insurance for illnesses and accidents involving other people, such as your children or spouse. In this case, you, your children and your spouse are the insureds.
Insurance amounts paid
An indemnity is the payment you’re entitled to receive under your insurance contract.
Usually, indemnities paid by your insurer do not cover all financial losses and costs related to an illness or accident.
In most cases:
- You’re responsible for paying a minimum amount before your insurer will pay compensation. This amount is called a deductible.
- You’re entitled to a percentage of the financial losses and other expenses resulting from the illness or accident on the amount exceeding your deductible. For example, your disability insurance might pay 60% of your salary.
Your insurance contract might also provide maximum amounts beyond which your insurer will not cover you. These are referred to as coverage “limits.”
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Did you know? An insurer can refuse to compensate an insured if it can prove this person intentionally injured themselves or made themselves sick. |
Paying for your insurance
The amount of money you pay to your insurer to benefit from illness and accident insurance is called a premium.
The premium amount is based in part on these factors:
- Scope of your coverage: situations where you’ll receive compensation.
- Amount of the indemnity: amount your insurer is required to pay in case of an illness or accident.
- Deductibles provided in the insurance contract: minimum amount you must pay before your insurer will compensate you.
In addition, the amount of the premiums you pay and the indemnities you may be entitled to can vary significantly depending on the insurer.
You must pay the premiums when indicated in the insurance contract. If you don’t pay your premiums, the insurer can cancel your contract by giving you a written notice at least 15 days in advance.
Beginning of protection
Protection under your illness and accident insurance usually begins when you receive your insurance policy, which is a copy of your contract.
End of protection
Protection under your illness and accident insurance ends on the date indicated in the insurance contract or on another date you agree to later with your insurer.
It also ends if you don’t pay your premiums despite a 15-day notice from your insurer.
What you must tell your insurer
You must provide information to your insurer in order to receive insurance coverage. Here are some examples of what you usually have to declare:
The insured’s state of health
Before providing insurance coverage, your insurer can ask you to complete an initial declaration of risk. In the declaration, you must indicate the state of health of the people who will be insured, in other words, your own state of health or the health of the people you’re insuring.
You must answer the insurer’s questions to the best of your knowledge. Therefore, you cannot lie or leave out important details, such as the fact that you smoke or if you’ve had a heart attack.
If you don’t declare your actual state of health or the state of health of the other people insured, or if you forget to mention important information, your insurer can ask the court to cancel your illness and accident insurance contract.
Once insurance coverage begins, you’re no longer required to inform your insurer about changes in your state of health or the state of health of the people insured.
Declaring risks associated with the insured’s job
In addition to declaring the state of health of the insured, you must declare all risks related to their job. These involve activities at work that can affect their health. This is also referred to as “occupational risk.” For example, repetitive movements on a production line is an occupational risk.
Once insurance coverage begins, the insurer is required to reduce the premium if the occupational risk decreases over a period of six months or more. However, if the occupational risk increases over a period of six months or more, your insurer can proportionately reduce the indemnity it must pay to you in the event of an illness or accident.
Declaring the age of the insured
If asked by your insurer, you must indicate the age of the insured (your age or the age of the person you’re insuring).
If the age you provide isn’t the person’s actual age, the insurer is allowed to adjust
- the amount of the insurance indemnity, or
- the amount of the premium.
In this situation, the indemnity can be decreased or the premium can be increased based on the actual age of the insured.
In the event of an illness or accident
You must notify your insurer in order to receive an indemnity under your contract if you become ill or are injured in an accident. Note that you won’t necessarily receive the indemnity immediately because your insurer has a certain amount of time in which to pay you.
Notifying your insurer
In case of an illness or accident, you or the insured must do the following:
- Send a notice to the insurer advising it of the illness or accident within 30 days of learning about it.
- Send all information about what happened (often in the form of the insured’s medical report or medical record) within 90 days of learning about the illness or accident.
Your insurance contract might provide longer periods for sending a notice or providing information, which is to your advantage.
Receiving the insurance indemnity
The insurer has 60 days to pay the indemnity after receiving the notice and all necessary information.
However, if the insurance covers salary loss, the insurer must pay the indemnity within 30 days after receiving the notice and information. Important: A salary insurance policy can provide a waiting period during which time no salary replacement payments are made. In this case, the 30-day period for paying the indemnity is calculated from the expiry of the waiting period.
Glossary of useful terms
- Insurance policy: A written document showing that an insurance contract exists and setting out its main points.
- Premiums: Amounts of money you pay to the insurer in return for insurance coverage.
- Rider: A document you sign to modify or add an item to your insurance contract.
- Loss: A situation that arises when an event covered by your insurance contract takes place (in this case, an accident or illness).
- Insurance indemnity: The amount of money you’ll receive if the insured becomes sick or is in an accident.
- Deductible: The amount of money you must pay before your insurer compensates you.