Illness and Injury

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​Exclusions



Long Term Disability Insurance

Sun Life Financial will not pay benefits for any period:

  • the employee is not receiving appropriate treatment.

  • the employee does any work for wage or profit except as approved by Sun Life Financial.

  • the employee is not participating in an approved partial disability or rehabilitation program, if required by Sun Life Financial.

  • the employee is on a strike except where specifically agreed to by Sun Life Financial.

  • the employee is absent from Canada longer than 4 months due to any reason, unless Sun Life Financial agrees in writing in advance to pay benefits during the period.

  • the employee is serving a prison sentence or is confined in a similar institution.

Sun Life Financial will not pay benefits if an employee's disability results directly or indirectly from a condition which existed on or before the date the employee's coverage began. However, this limitation will not apply to the employee if:

  • the employee has not had medical care for the condition for a continuous period of 90 days ending on or after the date the employee's coverage began, or
  • the employee has been covered for Long Term Disability with the employer for at least 13 continuous weeks during which the employee has been actively working (up to 3 days of absence does not count) and the employee has not been treated by a doctor, or any medical personnel under the direction of a doctor, for the condition, or
  • the employee became totally disabled more than 1 year after the employee's coverage began. If coverage ends due to a lay-off, Sun Life Financial will consider any period of work before the lay-off towards fulfilling this limitation.

If the employee's coverage ends and the employee is covered again under this contract, Sun Life Financial will use the latest date the employee's coverage began when applying the above limitation, except otherwise indicted above.

Sun Life Financial will not consider the employee totally disabled if the employee's disability results from drug or alcohol abuse. However, this limitation will not apply while the employee is participating in a Sun Life Financial approved treatment program or the employee has an organic disease which would cause total disability even if drug and alcohol abuse ended.

Sun Life Financial will not pay benefits for total disability resulting from:

  • the hostile action of any armed forces, insurrection or participation in a riot or civil commotion.
  • participation in a criminal offense.

Critical Illness Insurance 

  • No benefit is payable for any illness, disorder or surgery not specifically defined under Covered Conditions.
  • No benefits are payable for claims resulting directly or indirectly from any of the following:
    • intentionally self-inflicted injuries or attempted suicide, while sane or insane;
    • the hostile action of any armed forces, insurrection or participation in a riot or civil commotion;
    • participation in a criminal offence;
    • use of illegal or illicit drugs or substances, misuse of drugs or alcohol;
    • the death of the Insured during the required survival period (varies by covered condition).
  • No benefit is payable once you retire or reach age 70, whichever is earlier.
  • Lump sum payments will not be paid for any additional critical illnesses after the date a Critical Illness benefit is paid for a covered condition which you sustain.

Pre-existing Conditions

For any coverage that did not require proof of good health, no benefits are payable for any covered condition that:

  • occurs within 12 months of the effective date of the covered person's coverage, and
  • that resulted from any injury, sickness or medical condition (whether or not diagnosed during the 12 months prior to the effective date of the covered person's coverage) for which:
    • the covered person had symptoms,
    • consulted a physician or other health care practitioner,
    • was provided any health-related care, advice or treatment, or
    • that a reasonably prudent person with such injury, sickness or medical condition would have consulted a physician or any other health care practitioner.

If coverage ends but the person is covered again under this benefit, we will use the latest date the person's coverage began when applying the above limitation. This exclusion does not apply where the Child moratorium period exclusion applies or to any child of the employee or the employee’s spouse who is born or adopted later than 10 months after the date the employee becomes covered for Child Critical Illness.

Child Moratorium Period Exclusions

Any child of you or your spouse will be excluded from Critical Illness coverage if: 

  • that child was born within the 90 day period prior to the date you obtain Child Critical Illness coverage; or,
  • that child is born on or within 10 months after the date you obtain Critical Illness coverage for your existing children,

and, before or within 90 days after that child's birth:

  • that child is diagnosed with any covered condition; or,
  • that child has any signs, symptoms or investigations that lead to a diagnosis of a covered condition within 5 years of the child's birth.
Aortic Surgery
No benefit will be payable under this condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
 
Bacterial Meningitis
No benefit will be payable under this condition for viral meningitis.
 
Benign Brain Tumour Exclusions
  • No benefit will be payable under this condition for pituitary adenomas less than 10 mm.
  • No benefit will be payable for a recurrence or metastasis of an original tumour which was diagnosed prior to the effective date of coverage.

Benign Brain Tumour Moratorium Period Exclusions

If, within 90 days following the later of:

  • the date the employer receives enrolment information for any amount of coverage; or

the covered person has any of the following:

  • signs, symptoms or investigations that lead to a diagnosis of benign brain tumour (covered or excluded under this coverage), regardless of when the diagnosis is made; or
  • a diagnosis of benign brain tumour (covered or excluded under this coverage),

no benefit will be payable for benign brain tumour for such amount of coverage. In addition, if the person subsequently becomes covered for additional amounts of coverage, no benefit will be payable for benign brain tumour for those additional amounts. All other coverage remains in force.

This information described above must be reported to Sun Life within 6 months of the date of diagnosis. If this information is not provided, Sun Life has the right to deny any claim for benign brain tumour or any critical illness caused by any benign brain tumour or its treatment.

If a person's Critical Illness coverage ends but the person is covered again under this benefit, Sun Life will use the latest date the person's coverage began when applying the Moratorium Period Exclusion.

 

Cancer (Life-threatening) Exclusions

No benefit will be payable for a recurrence or metastasis of an original cancer which was diagnosed prior to the effective date of coverage.

No benefit will be payable under this condition for the following:

  • lesions described as benign, pre-malignant, uncertain, borderline, non-invasive, carcinoma in-situ (Tis), or tumours classified as Ta;
  • malignant melanoma skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;
  • any non-melanoma skin cancer, without lymph node or distant metastasis;
  • prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;
  • papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis;
  • chronic lymphocytic leukemia classified less than Rai stage 1; or
  • malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than AJCC Stage 2.

Cancer Moratorium Period Exclusions

If, within 90 days following the later of:

  • the date the employer receives enrolment information for any amount of coverage; or
  • the effective date of such amount of coverage,

the covered person has any of the following:

  • signs, symptoms or investigations that lead to a diagnosis of cancer (covered or excluded under this coverage), regardless of when the diagnosis is made; or
  • a diagnosis of cancer (covered or excluded under this coverage),

no benefit will be payable for cancer for such amount of coverage. In addition, if the person subsequently becomes covered for additional amounts of coverage, no benefit will be payable for cancer for those additional amounts. All other coverage remains in force.

The information described above must be reported to Sun Life within 6 months of the date of diagnosis. If this information is not provided, Sun Life has the right to deny any claim for cancer or any critical illness caused by any cancer or its treatment.

If a person's Critical Illness coverage ends but the person is covered again under this benefit, Sun Life will use the latest date the person's coverage began when applying the Moratorium Period Exclusion.

For the purposes of this benefit, the terms Tis, Ta, T1a, T1b, T1 and AJCC Stage 2 are to be applied as defined in the American Joint Committee on Cancer (AJCC) cancer staging manual, 7th Edition, 2010.

For the purposes of this benefit, the term Rai staging is to be applied as set out in KR Rai, A Sawitsky, EP Cronkite, AD Chanana, RN Levy and BS Pasternack: Clinical staging of chronic lymphocytic leukemia. Blood 46:219, 1975.

 
Coma Exclusions
No benefit will be payable under this condition for:
  • a medically induced coma; or,
  • a coma which results directly from alcohol or drug use; or,
  • a diagnosis of brain death.

 

Coronary Artery Bypass Surgery
No benefit will be payable under this condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
 
Dementia, including Alzheimer's Disease

No benefit will be payable under this condition for affective or schizophrenic disorders or delirium.

For purposes of this benefit, reference to the Mini Mental State Exam is to Folstein MF, Folstein SE, McHugh PR, J Psychiatr Res. 1975;12(3):189.

 
Heart Attack Exclusions
No benefit will be payable under this condition for:
  • elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves; or,
  • ECG changes suggesting a prior myocardial infarction, which do not meet the heart attack definition as described in the Critical Illness section under Illness/Injury.
Heart Valve Replacement or Repair
No benefit will be payable under this condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
 
Loss of Speech Exclusions
No benefit will be payable under this condition for any psychiatric related causes.
 
Occupational HIV Infection Exclusions
No benefit will be payable under this condition if:
  • the covered person has elected not to take any available licensed vaccine offering protection against HIV; or,
  • a licensed cure for HIV infection has become available prior to the accidental injury; or,
  • HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.
Parkinson’s Diseases Exclusions
Parkinson's Disease Moratorium Period Exclusion
If, within 1 year following the later of:
  • the date Sun Life receives enrolment information for any amount of coverage; or
  • the date the employer receives enrolment information for any amount of coverage; or
  • the effective date of such amount of coverage,

the covered person has any of the following:

  • signs, symptoms or investigations that lead to a diagnosis of Parkinson’s disease, a specified atypical parkinsonian disorder or any other type of parkinsonism (covered or excluded under this coverage), regardless of when the diagnosis is made; or
  • a diagnosis of Parkinson’s disease, a specified atypical parkinsonian disorder or any other type of parkinsonism (covered or excluded under this coverage),

no benefit will be payable for Parkinson’s disease or specified atypical parkinsonian disorders for such amount of coverage. In addition, if the person subsequently becomes covered for additional amounts of coverage, no benefit will be payable for Parkinson’s disease or specified atypical parkinsonian disorders for those additional amounts. All other coverage remains in force.

No benefit will be payable under Parkinson’s disease and specified atypical parkinsonian disorders for any other type of parkinsonism.

The information described above must be reported to Sun Life within 6 months of the date of diagnosis. If this information is not provided, Sun Life has the right to deny any claim for Parkinson’s disease or specified atypical parkinsonian disorders or any critical illness caused by Parkinson’s disease or specified atypical parkinsonian disorders or its treatment.

If a person's Critical Illness coverage ends but the person is covered again under this benefit, Sun Life will use the latest date the person's coverage began when applying the Moratorium Period Exclusion.

 
Stroke (cerebrovascular accident) Exclusions

No benefit will be payable under this condition for:

  • transient ischaemic attacks; or,
  • intracerebral vascular events due to trauma; or,
  • lacunar infarcts which do not meet the definition of stroke as described in the Critical Illness section of Illness/Injury.

Dependent Insurance

No restrictions apply to payment of Dependent Insurance benefits.

Accidental Death and Dismemberment Insurance

Benefits are not payable if the loss or loss of use results from (or is associated with):
  • self-inflicted injuries, by firearm or otherwise (including a drug overdose),
  • carbon monoxide inhalation,
  • attempted suicide or suicide while sane or insane,
  • the hostile action of any armed forces, insurrection or participation in a riot or civil commotion,
  • full-time service in the armed forces of any country,
  • participation in a criminal offense.

Business Travel Accidental Death and Dismemberment Insurance 

No benefit is payable for:
  • expenses paid for or furnished under the terms of any other Health Care Plan arranged through the employer,
  • services provided by an agency or department of any government normally provided free-of-charge,
  • non-emergency medical treatment, routine health check-ups, eye and ear examinations, eye glasses and hearing aids, or treatment that can be reasonably delayed until return to Canada,
  • dental care,
  • dental services or supplies and appliances, except as previously mentioned,
  • hospital charges for non-medical services, such as radio or telephone,
  • services not listed as covered expenses,
  • services rendered before coverage became effective or after termination of employment or termination of insurance,
  • cosmetic surgery or treatment, except as required for correction of damage caused by accidental injury sustained while this coverage is in force,
  • services or supplies that are available through any plan established pursuant to the laws or regulations of any government, including any motor vehicle no fault coverage required by statute,
  • any service to the extent that any government prohibits payment of benefits,
  • services, drugs or supplies which are deemed experimental in nature,
  • delivery and transportation charges,
  • services and supplies which are required for recreation or sport, but which are not medically necessary for regular activities,
  • services received for confinement, which is primarily for chronic or custodial care,
  • services received in a government hospital unless you are required to pay for such services,
  • services to which you are entitled without charge, or for which there would be no charge if there were no insurance,
  • services received from a dental or medical department maintained by NAV CANADA, a mutual benefit association, labour union, trustee or similar type of group,
  • expenses in respect of services provided by a member of your family or by a person customarily living with you,
  • chronic alcoholism or drug addiction,
  • mental or nervous disorders or psychiatric treatment, unless necessitating hospital or institutional confinement, in which case coverage shall not extend beyond three months,
  • AIDS or AIDS-related disease or disorders,
  • any condition for which you received medical advice for treatment during the 90 days immediately prior to becoming insured, until after the expiration of 12 months from the date you are eligible for insurance.
  • normal commuting to and from work,
  • intentionally self‑inflicted injuries, suicide or any attempt thereat, while sane or insane,
  • full-time, active duty in the armed forces,
  • injury sustained while you are performing any common, manual, or mechanical labour that may be construed as part of your regular duties for NAV CANADA,
  • any accident that occurs during the period you are required to live in another community, away from the work premises in the city of permanent assignment, for reasons of training or work assignments lasting longer than 60 days,
  • acrobatic flying as defined by the Department of Transport,
  • operations requiring a special permit or waiver from the Department of Transport even though granted, other than a permit waiver issued because of the territory to be flown over or landed upon, except operations requiring a ferry permit or test flight permit from the Department of Transport where such aircraft does not have a valid certificate of airworthiness and operations requiring aerial work under Transport Canada CAR 702 Operating Certificate; or
  • crop dusting or spraying, seeding, fire fighting, sky-writing, pipeline inspection, power-line inspection, aerial photography, exploration, racing, endurance test or exhibition stunt flying.
Published on February 01, 2016