Exclusions & limitations

The following provisions apply for the plans you are eligible to participate in if you are a full-time employee, part-time faculty or a continuing education instructor. However, if you are a part-time employee covered under the RAMQ Drug Plan Equivalent, you are covered for the drugs listed on the RAMQ formulary; for more details, go to the government plan site.

The Concordia Health Plan does not cover:

• Any charges in excess of the usual and prevailing charges for the area in which the service was rendered.
• Any one prescription for drugs or medicines in excess of a 60-day supply or a 100-day supply in the case of maintenance drugs
• Any services, treatment or supplies that an insured person receives without charge, or that are reimbursed under a provincial or federal law. If that person is not covered under these laws, Desjardins Financial Security will not reimburse the expenses that would normally be covered under the hospital or health insurance legislation in force in the person’s province of residence.
• Charges by a licensed physician for time spent travelling, broken appointments, transportation costs, room rental expenses, or for advice given by telephone or any other means of telecommunication.
• Charges for drugs prescribed for the treatment of infertility that exceed a lifetime maximum of $5,000.
• For an insured person, whether or not domiciled in Quebec, products or drugs used as smoking cessation aids that are covered under the Quebec drug insurance plan, in accordance with the provisions provided for under the Quebec Drug Insurance Plan.
• Cosmetic surgery or treatment, unless required for the correction of damage caused by accidental injury and begun within 90 days following the accident sustained while you or your insured dependent is covered under the plan.
• Custodial care.
• Dental services or supplies and appliances, except as described under Dental treatment directly resulting from an accidental injury to natural teeth.
• Diapers for incontinence.
• Diaphragms, condoms, contraceptive jellies or appliances normally used for contraception whether or not prescribed for a medical reason.
• Drugs available without a prescription, whether or not they are prescribed for a medical reason, except drugs that must be covered by law in Québec.
• Drugs, sera, injectables and supplies that are not approved by Health Canada or that are experimental or limited in use, whether or not so approved.
• Equipment such as “Obus Forme” type.
• Exercise and fitness programs; floating, mud and therapeutic baths; postural evaluations; and ear candling.
• Expenses incurred as a result of self-inflicted injuries, while sane or insane.
• Expenses incurred for bodily injury resulting directly or indirectly from insurrection, war, and participation in a riot or service in the armed forces of any country.
• Experimental medical procedures or treatment methods not approved by the Canadian Medical Association or by the appropriate medical specialty society.
• Monitoring devices such as stethoscopes, sphygmomanoters and similar equipment, and domestic appliances such as air purifiers, air conditioners, whirlpools, and similar equipment.
• Non-emergency care while outside your province of residence: The plan does not cover any expenses incurred by you or your insured dependents on a non-emergency or referral basis, while outside your province of residence.
• Periodic health checkups or examinations required for the use of a third party.
• Prescriptions dispensed by a doctor, dentist, clinic or in any non-accredited hospital pharmacy.
• Products, hormones and injections used in the treatment of obesity. Xenical is a covered drug if the insured person’s body mass is equal to or greater than 30, or equal to or greater than 27 if this person presents other risk factors.
• Products used in the treatment of sexual dysfunctions.
• Vision care examinations, unless you are part of an eligible employee group.
• Sclerosing injections used in the treatment of varicosities, telangiectasia and minor dilation when this treatment is primarily for cosmetic purposes.
• Services or an acupuncturist for habit-breaking treatment (e.g., nail biting, smoking) or treatment of obesity.
• Services or supplies for which the individual receiving them is not required to make payment, or where payment is received as a result of legal action or settlement.
• Services or supplies obtained in connection with an injury sustained while committing or attempting to commit a criminal offence.
• Services or supplies to the extent that such services or benefits for such services are available under any plan or program established pursuant to the laws or regulations of any government, including Workers’ Compensation, any motor vehicle no-fault coverage required by statute, and any services to the extent that any government prohibits the payment of insurance benefits therefor.
• Services rendered and received before coverage for you or your eligible dependent became effective.
• Services, treatment or supplies provided to the insured person by the employer.
• Supplies and services of a preventive nature (other than vaccines).
• The following products, whether prescribed or not: shampoos and other scalp care products, including hair growth products; beauty care products; cosmetics; so-called “natural” products and homeopathic preparations; sunscreens; soaps; over-the-counter laxatives; over-the-counter antacids; skin softeners; disinfectants and ordinary dressings; mineral water; any infant milk formulas; protein and food supplements; any other proprietary medicines which bear a general product number, as defined by the Foods and Drugs Act.
• Travel for health reasons.
• For an insured person age 65 and over domiciled outside of Quebec, expenses used to cover the Ontario Drug Benefit Plan or other Provincial Drug Benefit Plan deductible and co-insurance amount for individuals insured under this public plan.
• For expenses used to cover the Quebec drug insurance plan deductible and co-insurance amount for individuals insured under this public plan.
• Vitamins (other than those that can only be injected and which are not for weight loss) and dietary supplements.
• Wheelchairs adapted or designed for sports activities.

Special exclusions and limitations for emergency care and travel assistance outside your province of residence

No benefit is payable for:

• expenses incurred under any of the conditions listed as an exclusion in the list above;
• expenses not included in the list of eligible expenses;
• expenses for services, treatment, or supplies received free-of-charge or normally reimbursed under provincial or federal law;
• expenses incurred after returning or refusing to return upon request, to the province of residence;
• expenses incurred on a non-emergency or referral basis;

If you or your insured eligible dependent fails to immediately contact Sigma Assistel when emergency medical services are required, reimbursement of eligible expenses may be reduced or denied.

Neither Concordia, Sigma Assistel nor Desjardins Financial Security is responsible for the availability or quality of medical treatment or services received by you or an insured eligible dependent.