Explanation of Terms

The process of reviewing a claim to determine eligibility under the group contract.

Employer self-insures selected benefits, and contracts a Third Party Administrator to adjudicate and pay claims. The employer then reimburses the Third Party Administrator for claims paid plus an administration fee and taxes.

Term used in connection with disability benefits. It ensures that a plan member’s total income from all sources does not exceed a specified percentage of pre-disability income.

The inclination of a plan member to only choose benefits based on a known or expected medical condition.

Term applicable to the definition of disability for disability benefits. Under this definition, a plan member is considered totally disabled if unable to perform the duties of ‘any occupation’ for which the plan member is able or may reasonably become able, by means of education, training or experience.

Benefits are made payable to the provider, as authorized by the plan member.

A program provided by the province of Ontario to financially assist residents with long-term physical disabilities to obtain assistive devices appropriate for the individual’s needs. Learn more about the Assistive Devices Program.