Inside You’ll find all You need to know about the
BMO 17 Day Medical Protection features and
benefits offered to BMO MasterCard®*Cardholders.
BMO®
17 Day MedicalProtectionC E R T I F I C A T E O F I N S U R A N C E
CERTIF ICATE OF INSURANCE
IMPORTANT NOTICE – PLEASE READ CAREFULLYThis Certificate of Insurance is designed to coverlosses arising from sudden and unforeseeablecircumstances only. It is important that You read andunderstand this Certificate of Insurance as Yourcoverage is subject to limitations and exclusions.This insurance coverage is available only if You areunder age sixty-five (65). This includes the PrimaryCardholder, his/her Spouse and Dependent Children.Emergency Medical coverage is for the firstseventeen (17) days of Your Trip only. For Trips of alonger duration You may be able to purchase additionalcoverage. Call 1-877-704-0341 or 1-519-741-0782.Right to examine this insurance: If You notify Us thatthis insurance does not meet Your needs withinten (10) days of the date of issue, We will provide a fullrefund if You have not already departed on a Trip andhave not incurred a claim. Refunds are only availablewhen the Operations Centre receives Your request fora refund before Your scheduled Departure Date. Warning: This Certificate of Insurance contains a Pre-existing Conditions Exclusion which applies toMedical Conditions and/or symptoms that existed onor prior to Your Departure Date. There is no coverageunder this Certificate of Insurance for Pre-existingConditions as described in the Limitations andExclusions section of this Certificate of Insurance.You must notify Allianz Global Assistance throughthe Operations Centre when you need medicalTreatment within twenty-four (24) hours whenbeing admitted to a Hospital or as soon as reasonablypossible. Alternatively, someone else may call onyour behalf if Your Medical Condition prevents Youfrom calling. If You do not notify the OperationsCentre as soon as possible, You may receiveinappropriate or unnecessary medical Treatment,which may not be covered by this insurance.Please note that Your prior medical history may bereviewed by Us when a claim is reported.This certificate contains a provision removing orrestricting the right of the insured to designatepersons to whom or for whose benefit insurancemoney is to be payable.PLEASE READ YOUR CERTIFICATE CAREFULLYBEFORE YOU TRAVEL.The Out-of-Province/Out-of-Country EmergencyMedical Benefits described herein are underwritten byAllianz Global Risks US Insurance Company(Canadian Branch) (“Allianz”) under Group Policy No.FC310000-A (the “Policy”) issued to Bank of Montreal(the “Policyholder” or “BMO”). The Insured Person andany claimant under this insurance may request a copyof the Policy subject to certain access restrictions. The
insurance described in this Certificate of Insurance isfor eligible MasterCard Primary Cardholders of whoseAccounts are in Good Standing and where specified,their Spouses, Dependent Children and/or certain otherpersons (referred to herein as “You” or “Your”). ThisInsurance is administered by Allianz Global Assistancethrough the Operations Centre. BMO receivescompensation from the sale of this insurance.
This Certificate of Insurance is effective on the dateBMO receives and approves the Primary Cardholder’srequest that this insurance be included as a feature oftheir MasterCard.
All benefits are subject, in every respect, to the terms ofthe Policy, which alone constitutes the agreement underpayments are made. Only BMO may determine who is aPrimary Cardholder, whether an Account is in GoodStanding and whether the insurance pursuant to thisCertificate of Insurance has come into or is in force.
No person is eligible for coverage under more than onecertificate of insurance providing insurance coveragesimilar to that provided hereunder. In the event thatany person is recorded by Us as an “Insured Person”under more than one such certificate, such person shallbe deemed to be insured only under the certificate,which affords that person the greatest amount ofinsurance coverage. In no event will a corporation,partnership or business entity be eligible for thisinsurance coverage. This Certificate of Insurancesupersedes any certificate previously issued to You.
TABLE OF CONTENTS
1 Definitions.............................................................22 Insurance Effective and Termination Date .......63 Eligibility...............................................................64 Coverage Period and Description of Benefits....7
4.1 Out-of-Province/Out-of-CountryEmergency Medical Benefits .......................7
4.1.1 Coverage Period and Description ofBenefits .........................................................7
4.1.2 Limitations and Exclusions .......................114.1.3 What Should You do in the Event of a
Medical Emergency? ..................................134.2 Out-of-Province/Out-of-Country
Emergency Medical Assistance Services...145 Conditions ...........................................................156 General Provisions .............................................157 Notice of Claims and Filing a Claim .................17
7.1 Notice of Claim ...........................................177.2 Filing a Claim..............................................18
8 Protecting Your Personal Information .............18
In this Certificate of Insurance, certain terms havedefined meanings. Defined terms are capitalizedthroughout this document. Those defined terms areas follows.
1 DEF INIT IONS
Account means the Primary Cardholder’sMasterCard account, which is in Good Standing.
Certificate of Insurance means a summary of thebenefits provided under the Policy issued to BMOcovering accident and sickness.
Coverage Period means the time insurance is ineffect, as indicated in the various sections of thisCertificate of Insurance.
Covered Servicemeans a service or supply, specifiedherein, for which We provide benefits under thisCertificate of Insurance.
Departure Datemeans the date on which You departon Your Trip.
Dependent Child(ren)means an unmarried natural,adopted or stepchild of a Primary Cardholderdependent on the Primary Cardholder formaintenance and support who is:
• twenty (20) years of age and under; or• twenty-five (25) years of age and under and afull-time student attending a recognizedcollege or university; or
• twenty-one (21) years of age or older andpermanently mentally or physically challengedand incapable of self-support and became sowhile eligible as a dependent child.
Emergency Dental Care means the services orsupplies provided by a licensed dentist, Hospital orother licensed provider that are immediately andMedically Necessary.
Good Standingmeans being in full compliance withall of the provisions of the cardholder agreement inforce between the Primary Cardholder and BMO, asamended from time to time.
Government Health Insurance Plan (GHIP)meansthe health insurance plan offered by the governmentof Your province or territory of residence.
Hospital means an institution which is licensed toprovide, on an Inpatient basis, medical care andTreatment of sick and injured persons through
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medical, diagnostic and major surgical facilities,under the supervision of a staff of Physicians andwith twenty-four (24) hour a day service; however,Hospital does not include any institution or part of aninstitution which is licensed or used principally as aclinic, a continued care or extended care facility, aconvalescent home, a rest home, a nursing home or ahome for the aged, or a health spa or a treatmentcentre for drug addiction or alcoholism.
Immediate Family Member means the InsuredPerson’s Spouse, child including adopted children andstepchildren, parent, sibling, legal guardian, parent-in-law, grandparents, grandchildren, daughter-in-law,son-in-law, brother-in-law and sister-in-law.
Injurymeans any bodily harm caused by an accidentwhich results in a covered loss and which requires theimmediate medical care or Treatment of a Physician.
Inpatient means a person who is treated as aregistered bed patient in a Hospital or other facilityand for whom a room and board charge is made.
Insured Personmeans those persons covered for thebenefits described in this Certificate of Insurance asspecifically defined in each of the benefit sections.
MasterCardmeans a MasterCard card issued by BMOand for which BMO has received and approved thePrimary Cardholder’s request to include this insuranceas a feature of the card.
Medical Condition means any Sickness, Injury orsymptom.
Medical Emergencymeans any unforeseen Sicknessor Injury, which occurs during a Trip. A medicalemergency ends when the Sickness or Injury hasbeen treated such that Your condition has stabilized.Treatment provided when medical evidenceindicates You could delay Treatment or return toCanada for such Treatment is not considered amedical emergency and is not covered.
Medically Necessary or Medical Necessity meansthe services or supplies provided by a Hospital,Physician, licensed dentist or other licensed providerthat are required to identify or treat Your Sickness orInjury and that We determine are:
• Consistent with the symptom or diagnosis andTreatment of Your condition, Sickness, ailmentor Injury;
• Appropriate with regard to standards of goodmedical practice;
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• Not solely for the convenience of You, aPhysician or other licensed provider; and
• The most appropriate supply or level of servicethat can be safely provided to You.
When applied to the care of an Inpatient, it furthermeans that Your medical symptoms or conditionrequire that the services cannot be safely provided toYou as an Outpatient.
Operations Centre means the operations centremaintained by Allianz Global Assistance. FromCanada and the U.S. call 1-877-704-0341. Fromelsewhere call collect 1-519-741-0782.
Outpatientmeans someone who receives a CoveredService while not an Inpatient.
Physician means a person, other than an InsuredPerson or member of the Insured Person’s family (byblood or marriage), who is a medical practitioner andwhose legal and professional standing within his orher jurisdiction is equivalent to that of a doctor ofmedicine (M.D.) licensed in Canada.
Primary Cardholdermeans the cardholder who hassigned an application for a MasterCard, as primarycardholder, for whom the MasterCard Account isestablished, and for whom BMO has received andapproved a request to include this insurance as afeature of the MasterCard.
Reasonable and Customary Chargesmeans chargeswhich do not exceed the general level of chargesmade by other providers of similar standing in thelocality or geographical area where the charges areincurred, when furnishing comparable Treatment,services or supplies for a similar Medical Emergency.
Recurrence means the appearance of symptomscaused by or related to a Medical Condition, whichwas previously diagnosed by a Physician or for whichTreatment was previously received.
Sickness means any sudden illness or diseaserequiring the immediate medical care or Treatmentof a Physician.
Spouse means the person who is legally married tothe Primary Cardholder; or if there is no such person,the person who has been living with the PrimaryCardholder in a conjugal relationship and whoresides in the same household as the PrimaryCardholder and is publicly represented as the spouseof the Primary Cardholder. For the purposes of this
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insurance the Primary Cardholder may have onlyone (1) spouse.
Terrorismmeans the unsanctioned and illegal use offorce that causes destruction of property, Injury ordeath by an individual or group for the expresspurpose of achieving a political, ethnic or religiousgoal or result.
Travel Advisory means a formal written noticeissued by the Canadian government to advisetravelers against non-essential travel to a foreigncountry or a given region in that country. This doesnot include travel information reports.
Treatment means medical advice, care and/orservice provided by a Physician. This includes, but isnot limited to, diagnostic measures and prescribeddrugs (including pills and inhaled or injectedmedications). It does not include checkups or caseswhere You have no specific symptoms.
Tripmeans a single period of travel of definite lengthoutside the Insured Person’s province/territory of residence.
We, Our, Us means Allianz Global Risks USInsurance Company (Canadian Branch).
You or Yourmeans the Insured Person.
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2 INSURANCE EFFECT IVE ANDTERMINATION DATE
Except as otherwise stated herein, this insuranceshall come into effect on the date BMO receives andapproves the Primary Cardholder’s request toinclude the BMO 17 Day Medical Protection as afeature of their MasterCard.
Except as otherwise stated herein, this insuranceshall terminate for all insureds on the earliest of:1. The date the Insured Person is no longer eligible
to participate;2. The date the eligible Account is defined as
ineligible by BMO; 3. 00:01h of the date the Primary Cardholder cancels
this coverage or otherwise chooses to close theMasterCard Account; or
4. The date the Policy is terminated.
3 EL IGIBIL ITY
You are eligible for this insurance while You meet allof the following conditions:1. You are the Primary Cardholder of an Account in
Good Standing;2. You are under age sixty-five (65) at time of
purchase or on Your annual renewal date, (forDependent Children see the definition for agelimits);
3. You are a resident of Canada;4. You are covered by a GHIP.
If You are age 65 or older and wish to obtainalternative optional coverage, please contact theOperations Centre. From Canada and the U.S. call1-877-704-0341. From elsewhere call collect1-519-741-0782.
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4 COVERAGE PERIOD ANDDESCRIPT ION OF BENEFITS
4.1 OUT-OF-PROVINCE/ OUT-OF-COUNTRY EMERGENCY MEDICAL BENEFITS
4.1 .1 COVERAGE PERIOD ANDDESCRIPTION OF BENEFITS
Coverage EligibilityYou do not need to charge Your Trip to YourMasterCard to be eligible for this coverage, providingYour MasterCard Account is in Good Standing.
Insured Person means the Primary Cardholder,Spouse and/or Dependent Child(ren).
Coverage PeriodYour seventeen (17) day Coverage Period beginswhen You depart from Your province or territory ofresidence on Your Departure Date providing YourMasterCard Account is in Good Standing.
Your Coverage Period will terminate on the earliest ofthe following:1. The date You return to Your Canadian province or
territory of residence;2. The date Your MasterCard Account is cancelled;3. The date Your MasterCard Account is no longer in
Good Standing;4. Your next annual renewal date in the year You
attain age sixty-five (65), (for DependentChildren see the definition for age limits); or
5. At 00:01 a.m. on the 18th day (including YourDeparture Date) after You leave on Your Trip.
Optional Extension of Coverage Your Coverage Period can be extended provided noevent has occurred that would give rise to a claimunder this insurance and provided You request anextension by phone prior to Your scheduled returndate. Your total Trip length including extensionscannot exceed the number of days for which You arecovered under Your Government Health InsurancePlan (183 days or more depending on Your province orterritory of residence).
To arrange for an extension call the Operations Centre at1-877-704-0341 while in North America, or if elsewhere,
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call collect 1-519-741-0782. Premium payment must becharged to Your BMO MasterCard Account.
When making a claim hereunder, evidence of YourDeparture Date from, scheduled and actual returndates to, Your province or territory of residence willbe required.
Automatic Extension of CoverageWhen You are in Hospital due to a MedicalEmergency on Your scheduled return date, Yourcoverage will remain in force for as long as You are inHospital plus a further period of three (3) daysfollowing Your discharge from Hospital.
The Coverage Period is also automatically extendedfor three (3) days when:• The delay of a plane, bus, ship or train in which
You are a passenger causes You to miss Yourscheduled return date; or
• The personal means of transportation in whichYou are travelling is involved in an accident ormechanical breakdown that prevents You fromreturning on or before Your scheduled returndate; or
• You must delay Your scheduled return due to theMedical Emergency of another Insured Person.
This insurance covers the Reasonable and CustomaryCharges up to a maximum of $2,000,000 (unlessspecified otherwise below for a specific benefit)incurred by an Insured Person for the medicalTreatment and Covered Services listed below arisingfrom a Medical Emergency which occurs during theCoverage Period.
Following are eligible expenses covered by thisinsurance, subject to all limitations and exclusionsdescribed in this Certificate of Insurance. AnyTreatment or service not listed below is notcovered. Neither We, nor the Operations Centre, norBMO are responsible for the availability, quality orresults of any medical Treatment or transportation, orthe failure of an Insured Person to obtain medicalTreatment.
Coverage BenefitsThis Out-of-Province/Out-of-Country EmergencyMedical insurance covers Reasonable and CustomaryCharges for the following Covered Services arisingfrom a Medical Emergency of an Insured Personoccurring during the Coverage Period.
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Emergency Hospital, Ambulance & Medical Expenses1. Hospital room and board charges, up to semi-
private or the equivalent. If Medically Necessary,expenses for Treatment in an intensive orcoronary care unit are covered;
2. Treatment by a Physician;3. X-rays and other diagnostic tests;4. Use of an operating room, anesthesia and surgical
dressings;5. The cost of licensed ambulance service;6. Emergency room charges;7. Prescription drugs and medication, limited to a
thirty (30) day supply;8. The cost for rental or purchase of minor medical
appliances such as wheelchairs and crutches.
Private Duty Nursing ExpensesBenefits are payable to a maximum of $5,000 perInsured Person for the professional services of aregistered nurse (not related to You by blood ormarriage) while hospitalized, provided theseservices are Medically Necessary and prescribed bythe attending Physician.
Emergency Air Transportation or EvacuationThe following are covered expenses provided theyare approved and arranged in advance by theOperations Centre:1. Air ambulance to the nearest appropriate medical
facility or to a Canadian Hospital;2. Transport on a licensed airline for emergency
return to the Insured Person’s province orterritory of residence for immediate medicalattention; and
3. A medical attendant to accompany You on theflight back to Canada.
All air transportation expenses must be approvedand arranged in advance by the Operations Centre.
Other Professional ServicesWhere the professional services of a physiotherapist,chiropractor, osteopath, chiropodist or podiatrist areMedically Necessary, coverage will be provided to amaximum of $150 per Insured Person per discipline.
Emergency Dental Care ExpensesThis insurance covers the cost to repair or replacenatural teeth or permanently attached artificial teethrequired as the result of an Injury to the mouth, to amaximum of $2,000 per Insured Person. Chewingaccidents are not covered. To be eligible for coverage,dental Treatment must take place during Your Trip.
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Treatment for the emergency relief of dental pain iscovered to a maximum of $150 per Insured Person.
Transportation to the BedsideThis insurance covers one round-trip economy airfareby the most direct and cost-effective route fromCanada, plus lodging and meals up to a maximum of$250, for any one Immediate Family Member to:a. Be with an Insured Person who is travelling alone
and has been admitted to a Hospital as anInpatient. The Insured Person must be expectedto be an Inpatient for at least seven (7) daysoutside their home province or territory and haveverification from the attending Physician that thesituation is serious enough to require the visit; or
b. Identify a deceased Insured Person prior torelease of the body, where necessary.
Return of DeceasedIn the event of the death of an Insured Person while ona Trip, this insurance covers up to $3,000 for thepreparation (including cremation) and transportationof the deceased’s remains to his/her province orterritory of residence. The cost of a burial coffin or urnis not covered.
Additional Hotel and Meal ExpensesIf Your return to Canada is delayed due to a MedicalEmergency, this insurance covers the cost for hoteland meal expenses incurred after Your plannedreturn date up to $200 a day to a maximum of ten (10)days per Account. To receive reimbursement,original receipts must be submitted.
Return of VehicleIf neither You nor anyone travelling with You is ableto operate Your owned or rented vehicle due toSickness, Injury or death while travelling outsideYour province or territory of residence, You will bereimbursed up to a maximum of $1,000 for the costsassociated with the return of the vehicle. Eligible forreimbursement is the cost of the return performed bya professional agency; or the following necessary andreasonable expenses incurred by an individualreturning the vehicle by a direct route and in areasonable time frame on behalf of the InsuredPerson: fuel, meals, overnight accommodation andone-way economy airfare. Benefits will only bepayable when the return of the vehicle is pre-approved and/or arranged by the Operations Centreand the vehicle is returned to Your normal place ofresidence or the nearest appropriate rental agencywithin thirty (30) days of Your return to Canada.
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To receive reimbursement, original itemizedreceipts must be submitted. Any other expenses arenot covered. Expenses incurred by anyone travellingwith the person returning the vehicle are not covered.
4.1.2 EXCLUSIONS ANDLIMITATIONS
The insurance does not cover, provide services or payclaims resulting from:
1. Pre-existing Conditions: This insurance will notpay for expenses incurred during the CoveragePeriod related to:• the continuing Treatment, Recurrence, ormedically recognized complication relatingdirectly or indirectly to a Medical Condition, forwhich You consulted, investigated, werediagnosed or for which Treatment was taken byYou during the six (6) month period immediatelybefore Your Coverage Period began;
• the Treatment of, or relating to, a MedicalCondition for which a person exhibited anysymptom during the six (6) month periodimmediately before Your Coverage Periodbegan for which a reasonable person wouldhave made inquiries regarding their MedicalCondition, regardless of whether or not suchinquiries were made.
Please note: This exclusion does not apply to aMedical Condition controlled by the consistentuse of medication(s) taken as prescribed by aPhysician provided that during the six (6) monthperiod before Your Coverage Period began therehas been no change in any medication(s) and noother Treatment has been taken orrecommended. A new medication or an alterationin usage or dosage of a medication constitutes achange in medication.
2. The continued Treatment, Recurrence orcomplication of a Medical Condition followingemergency Treatment of that Medical Conditionduring Your Trip, if the medical advisors of theOperations Centre determine that the InsuredPerson is able to return to Canada and the InsuredPerson chooses not to return.
3. A Medical Condition for which You delayed orrefused further Treatment or investigation, whichwas recommended by Your Physician before YourDeparture Date.
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4. Surgery, including but not limited to angioplastyand/or cardiac surgery, and any associateddiagnostic charges, which are not approved bythe Operations Centre prior to being performedexcept in extreme circumstances where surgeryis performed on an emergency basis immediatelyfollowing admission to a Hospital.
5. The following procedures, including anyassociated charges, which are not authorized inadvance by the Operations Centre: MRI (MagneticResonance Imaging); CAT (Computer AxialTomography) scans; sonograms; ultrasounds; andbiopsies.
6. Emergency air transportation, which is notapproved in advance by the Operations Centre.
7. Treatment not performed by or under thesupervision of a Physician or dentist.
8. Pregnancy, routine pre-natal care, miscarriage,childbirth or complications of any of theseconditions occurring within nine (9) weeks of theexpected date of birth.
9. Riot or civil disorder; committing or attempting tocommit a criminal offence.
10. Intentional self-injury, suicide or attemptedsuicide while sane or insane.
11. Abuse of any medication or non-compliance withprescribed medical Treatment or therapy.
12. Mental, nervous or emotional disorders that donot require immediate hospitalization.
13. Any Injury or accident occurring while theInsured Person is under the influence of illicitdrugs or alcohol (where the concentration ofalcohol in the Insured Person’s blood exceedseighty (80) milligrams of alcohol in one hundred(100) millilitres of blood or when the InsuredPerson illustrates a visible impairment due toalcohol or illicit drugs) and any chronic illness orhospitalization related to, or exacerbated by, thehabitual use of alcohol or illicit drugs.
14. The Insured Person voluntarily and knowinglyexposing himself/herself to risk from: an act ofwar whether declared or undeclared; rebellion;revolution; hijacking or Terrorism; and anyservice in the armed forces.
15. Drugs and medication, which are commonlyavailable without a prescription or which are notlegally registered and approved in Canada.
16. Prescription refills.17. Replacement of lost or damaged eyeglasses,
contact lenses or hearing aids.
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18. Participation in professional sports; any speedcontest; full contact bodily sports; SCUBA diving,unless the Insured Person holds a basic SCUBAdesignation from a certified school or otherlicensing body; hang-gliding; skydiving;parachuting; bungee jumping; parasailing;spelunking; mountaineering; rock climbing; heli-skiing; skiing outside of marked trails; or airtravel other than as a ticketed passenger.
19. Any Treatment or surgery, where the InsuredPerson can return to his/her province or territoryof residence for such Treatment withoutadversely affecting his/her Medical Condition.
20. Any Treatment or surgery during the Trip, whenthe Trip is undertaken for the purpose of securingor with the intent of receiving medical or Hospitalservices, whether or not such Trip is on the adviceof a Physician.
21. Any Trip commenced or continued against theadvice of the Insured Person’s Physician.
22. Regular care of a chronic Medical Condition;elective Treatment; cosmetic Treatment, or anyTreatment or surgery that is not required for reliefof acute pain or suffering.
23. Your Travel to a country for which the Canadiangovernment has issued a Travel Advisory inwriting prior to Your Departure Date.
4.1.3 WHAT SHOULD YOU DO INTHE EVENT OF A MEDICALEMERGENCY?
You must contact the Operations Centre in the eventof a Medical Emergency.
From Canada and the United States call: 1-877-704-0341
From elsewhere call collect: 1-519-741-0782Fax: 1-519-742-8553
Or visitwww.allianzassistanceclaims.ca
to obtain a claim form.
Assistance coordinators are available twenty-four (24)hours a day, every day of the year. The OperationsCentre will assist in finding and arranging medicalcare; provide claims management and paymentassistance under this insurance; pay Hospitals andother medical providers directly whenever possible;and coordinate claims with Your Government HealthInsurance Plan whenever possible.
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If the covered medical expense is relatively small, theHospital or Physician may ask You to pay. You will bereimbursed for covered expenses upon submission of aclaim.
In order to benefit from payment assistance and otherassistance services, You must notify the OperationsCentre when You need medical Treatment withintwenty-four (24) hours or as soon as reasonablypossible after being admitted to a Hospital. If You donot notify the Operations Centre at an early stage inYour claim, You may receive inappropriate orunnecessary medical treatment, which may not becovered by this insurance.
Note: Failure to contact the Operations Centrecould result in Your expenses not being covered,denial or a delay in the settlement of Your claim.
4.2 ASSISTANCE SERVICES
In addition to the medical insurance benefits, thefollowing Assistance Services are provided:
Medical Assistance and ConsultationYou will be directed to the nearest appropriatemedical facility wherever possible.
Payment AssistanceSubject to the limitations of this insurance, theOperations Centre will offer to all Hospitals, whichprovide an Insured Person with Medically NecessaryTreatment, a guarantee of coverage for CoveredServices. If the guarantee is not accepted, theOperations Centre will assist in arranging andcoordinating payment wherever possible.
Note: If You do not contact the Operations Centre assoon as possible, and receive medical attention,You may be responsible for paying the bills andsubmitting a claim after You return to Yourprovince or territory of residence.
Emergency Message CentreIn case of a Medical Emergency, the OperationsCentre can help to relay important messages to orfrom Your family, business or Physician.
Please call the Operations Centre at 1-877-704-0341or 1-519-741-0782 if You have any questionsregarding what is not covered.
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5 CONDIT IONS
1. In consultation with the Insured Person’sattending Physician, We reserve the right totransfer the Insured Person to another Hospital orto return the Insured Person to his/her province orterritory of residence. Refusal to comply by theInsured Person will release Us of any liability forexpenses incurred after the proposed transfer date.
2. False Claim: If a Primary Cardholder or InsuredPerson makes any claim knowing it to be false orfraudulent in any respect, this Certificate ofInsurance shall cease and there shall be nopayment of any claim made under this Certificateof Insurance or the Policy.
3. Subrogation: In the event of a payment under thisCertificate of Insurance, We have the right toproceed in the name of any Insured Personagainst third parties who may be responsible forgiving rise to a claim under this insurance. Wehave full rights of subrogation. The InsuredPerson will execute and deliver such documents,and fully cooperate with Us, so as to allow Us tofully assert Our right to subrogation. The InsuredPerson will not do anything after the loss toprejudice such rights.
4. You must repay to Us amounts paid or authorizedfor payment on Your behalf if We later determinethe amount is not payable under this insurance.
5. Cooperation:You agree to cooperate fully with Usand as a condition precedent to the payment ofbenefits, the Operations Centre reserves the rightto obtain all pertinent records or informationfrom any Physician, dentist, practitioner,Hospital, clinic, insurer, individual or institutionto assess the validity of a claim submitted by or onbehalf of any Insured Person. Failure to providethe requested documentation to substantiate Yourclaim under this Certificate of Insurance willinvalidate Your claim.
6. Physical Examination: The Operations Centrehas the right to investigate the circumstances ofloss and to require a medical examination; and inthe event of death to require an autopsy at the costof the Insurer, if not prohibited by law.
6 GENERAL PROVIS IONS
1. This Out-of-Province/Out-of-Country EmergencyMedical Insurance provided herein is
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supplemental in that it pays for covered expenses inexcess of Your Government Health Insurance Planand any other insurance plan. Benefits payableunder any other insurance plan under which Youmay have coverage will be coordinated inaccordance with the current guidelines issued bythe Canadian Life & Health Insurance Association.Payment under the insurance and any other planshall not exceed 100% of the eligible chargesincurred. This insurance also allows Us/theOperations Centre to receive in Your name, andendorse and negotiate on Your behalf, these eligiblepayments. When Government Health InsurancePlan and other insurance payments have beenmade, this releases Government Health InsurancePlan and the other insurers from any furtherliability in respect of that eligible claim.
2. All amounts stated in the Certificate of Insuranceare in Canadian currency unless otherwiseindicated. If You have paid a covered expense,You will be reimbursed in Canadian currency atthe prevailing rate of exchange on the date theservice was provided.
3. Payment of Benefits: Benefits payable under thisCertificate of Insurance will be paid withinsixty (60) days of receipt of satisfactory proof ofloss. Payment made in good faith will dischargeUs to the extent of this claim.
4. Legal Action: Every action or proceeding againstan insurer for the recovery of insurance moneypayable under the contract is absolutely barredunless commenced within the time set out in theInsurance Act (for actions or proceedingsgoverned by the laws of Alberta and BritishColumbia), The Insurance Act (for actions orproceedings governed by the laws of Manitoba),the Limitations Act, 2002 (for actions orproceedings governed by the laws of Ontario), orother applicable legislation. For those actions orproceedings governed by the laws of Quebec, theprescriptive period is set out in the Quebec CivilCode. In addition You, Your heirs and assignsconsent to the venue of any action or arbitrationbeing only in the province or territory where theCertificate of Insurance was issued and at a venueWe and/or Allianz Global Assistance choose.
5. Waiver: Notwithstanding anything to thecontrary, no provision of this insurance shall bedeemed to have been waived, either in whole or
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in part, unless the waiver is clearly stated inwriting and signed by Us.
6. Governing Law: The benefits, terms andconditions of this Certificate of Insurance shall begoverned by the insurance laws of the province orterritory in Canada where the Insured Personnormally resides.
7. Conflict with Laws: Any provision of thisCertificate of Insurance which is in conflict withany federal, provincial or territorial law of theInsured Person’s place of residence, is herebyamended to conform to the minimum requirementsof that law.
7 NOTICE OF CLAIM AND F IL ING A CLAIM
7 .1 NOTICE OF CLAIM
You, or someone acting on Your behalf, must givewritten notice of a claim to the Operations Centre notlater than thirty (30) days from the date the claimarises. The Operations Centre must be provided byYou or someone acting on Your behalf withsatisfactory proof of loss no later than ninety (90)days from the date the claim arises.
Satisfactory proof of loss means proof satisfactory toUs of:
• the Departure Date;• the occurrence of the Injury or thecommencement of the Sickness;
• the cause or nature of the Injury or Sickness;• the loss, expense or service for which benefitsare being claimed (original itemized receipts);
• the Primary Cardholder’s age;• the claimant’s age; and• the right of the claimant to receive payment.
Failure to give notice of claim or furnish proof of losswithin the time prescribed does not invalidate theclaim if it is shown that it was not reasonably possibleto give notice or furnish proof within the time soprescribed and if the notice or proof is given orfurnished as soon as reasonably possible, and in noevent later than one (1) year from the date of the eventfor which benefits are being claimed. Failure toprovide the requested documentation to substantiateYour claim under this Certificate of Insurance willinvalidate Your claim.
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7.2 F IL ING A CLAIM
Please contact Us at 1-877-704-0341 or 1-519-741-0782or visit www.allianzassistanceclaims.ca to obtain aclaim form.
This insurance will not pay for any interest.
As a condition to the payment of benefits under thisinsurance, We will need certain information fromYou if You need to file a claim. This documentationwill include, at a minimum, and is not limited to, thefollowing:
1. General Documentation• Receipts and itemized bills for all expenses.
2. Out-of-Province/Out-of-Country EmergencyMedical Benefits• Any explanation of diagnosis(es) along withYour original itemized bills and receipts.
• The claimant’s enrollment in his/herprovincial or territorial Government HealthInsurance Plan, and valid health card number.
• The provision of an authorization to securemedical records.
• The provision of any forms or authorizationsrequired to pursue reimbursement from YourGovernment Health Insurance Plan, any otherinsurance and/or any third parties.
• Your Departure Date and Your scheduled andactual dates of return.
8 PROTECTING YOUR PERSONALINFORMATION
Travel Insurance Personal Information NoticeAllianz Global Risks US Insurance Company,Canadian Branch (the “insurer”) and the insurer’sinsurance administrator, Allianz Global Assistance,and the insurer’s agents, representatives andreinsurers (for the purpose of this PersonalInformation Notice collectively “we” “us” and “our”)require personal information including:
• details about you including your name, date ofbirth, address, telephone numbers, e-mailaddress, employer, and other identification
• medical records and information about you• records that reflect your business dealings withand through us.
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This personal information is collected for thefollowing insurance purposes when offering andproviding insurance and related services:
• To identify and communicate with you• To consider any application for insurance • If approved, to issue a Policy or Certificate ofinsurance
• To administer insurance and related benefits• To evaluate insurance risk, manage andcoordinate claims, re-price medical expensesand negotiate payment of claims expenses;
• To investigate claims and to determineeligibility for insurance benefits
• To provide assistance services • For fraud prevention and debt collectionpurposes
• As required or permitted by law.
We only collect personal information necessary to theinsurance purposes from individuals who apply forinsurance, Certificate holders, insureds, claimants.In some cases we also collect personal informationfrom members of a Certificate holder’s, insured’s orclaimant’s family or their friends when they areunable, for medical or other reasons, to communicatedirectly with us. We also collect and discloseinformation for the insurance purposes from, to andwith, third parties such as, but not necessarily limitedto, health care practitioners and facilities in Canadaand abroad, government and private health insurersand family members and friends of the insured,Certificate holder or claimant. We may also use anddisclose information from our existing files for theinsurance purposes.
Our employees who require this information for thepurposes of their duties will have access to this file.
Upon your request and authorization, we may alsodisclose this information to other persons.
From time to time, and if permitted by applicable law,we may also collect, use or disclose personalinformation in order to offer additional or upgradedproducts and services (the “optional purposes”).
When an individual applies for, purchases, or iscovered by one of our insurance policies or submits aclaim for insurance benefits, he or she is presumed toconsent to the personal information practicesdescribed in this notice. If an individual does notwish to have their personal information used for theoptional purposes they need only notify Allianz
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Global Assistance. A person may decline to have theirinformation collected, used or disclosed for theinsurance purposes but in that instance we will likelybe unable to provide insurance and related services.
Personal information is maintained in the Certificateholder’s, insured’s or claimant’s file that we establishand maintain in the offices of Allianz GlobalAssistance. In some instances we may additionallymaintain or communicate or transfer information tohealth care and other service providers locatedoutside of Canada. As a result, personal informationmay be accessible to regulatory authorities inaccordance with the law of these other jurisdictions.
For information about how to obtain access towritten information about our policies andprocedures with respect to service providers outsideof Canada, please contact the Privacy Officer [email protected].
We will retain the personal information we collect fora specified period of time and in a storage methodappropriate with legal and our internal corporaterequirements. Personal information will be securelydestroyed following the expiration of the appropriateretention period.
Individuals have a right to request to access or correctpersonal information we have on file by contactingthe Privacy Officer at [email protected] by writing to:
Privacy OfficerAllianz Global Assistance4273 King Street EastKitchener, ON N2P 2E9
For a complete copy of our Travel Insurance PrivacyPolicy, please visit www.allianz-assistance.ca
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Notes
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5144456 (06/16)
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BEFORE YOU TRAVEL
It is important that You understand what isand isn’t covered under your coverage
Read Your Certificate of Insurance carefullyfor complete coverage details
We’re available 24/7 to answer yourquestions. Call 1-877-704-0341 or collect 1-519-741-0782.
