Tesla Model 3: Security Features

Relevant Background:

About the Security System

If Model 3 does not detect an authenticated phone or key and a locked door or trunk is opened, an alarm sounds. The headlights and turn signals also flash. To deactivate the alarm, press any button on the mobile app or tap your key card against the card reader located just below the Autopilot camera on the driver's side door pillar.

To manually enable or disable the alarm system, touch Controls > Safety > Security Alarm. When enabled, Model 3 activates its alarm one minute after you exit, the doors lock, and a recognized key is no longer detected.

A battery-backed siren (if equipped) sounds in situations where a locked door or trunk is opened and Model 3 does not detect a key nearby. If you also want this siren to sound in situations where the vehicle detects motion inside the cabin, enable Tilt/Intrusion (see Tilt/Intrusion (if equipped)).

Note

If Model 3 is in Sentry Mode (see How to Use Sentry Mode (With a USB Flash Drive)), the Security Alarm setting is not available.

Tilt/Intrusion (if equipped)

Depending on configuration, market region, and date of manufacture, your vehicle may not be equipped with this feature.

The Security Alarm must be on to enable Tilt/Intrusion.

Tilt/Intrusion sounds the alarm in your vehicle if Model 3 detects motion inside the cabin, or is moved or tilted (for example, with a tow truck or jack). To enable, touch Controls > Safety > Tilt/Intrusion.

The intrusion sensor automatically disables in situations where the climate control system is operating when you leave your vehicle. To override, you can manually turn the Tilt/Intrusion Sensor on again after choosing Keep Climate On, Dog, or Camp Mode.

The tilt/intrusion sensor automatically re-enables at the start of every drive cycle.

Note

The Tilt/Intrusion alarm must be turned off to use Cabin Overheat Protection (see Cabin Overheat Protection).

Note

If you plan to leave something that moves inside your locked vehicle, remember to turn off Tilt/Intrusion. If this setting is on, any motion detected inside Model 3 activates the intrusion alarm.

Note

If Model 3 is in Sentry Mode (see How to Use Sentry Mode (With a USB Flash Drive)), the Tilt/Intrusion setting is not available.

PIN to Drive

For an added layer of security, prevent Model 3 from being driven until a 4-digit PIN (Personal Identification Number) is entered. To enable this setting, touch Controls > Safety > PIN to Drive and follow the on-screen prompts to create a driving PIN.

When enabled, in addition to entering the 4-digit driving PIN to drive, you must also use it to enter Valet mode for the first time and create the 4-digit valet PIN to enter and exit Valet mode. In Valet mode, Model 3 can be driven without the need for the valet to enter a driving PIN. The PIN to Drive setting is disabled whenever Valet mode is active.

If you forget your driving PIN, touch the link to enter your Tesla login credentials on the PIN to Drive popup, then follow the instructions on the touchscreen.

Note

In the unlikely event that your touchscreen is unresponsive, you may be unable to enter the PIN. In this case, first try to restart the touchscreen (see Restarting the Touchscreen). If the touchscreen is still unresponsive, you can still bypass PIN to Drive by turning on Keyless Driving in the Tesla mobile app.

Glovebox PIN

Protect the contents in your glovebox with a 4-digit PIN (not related to PIN to Drive). To enable, touch Controls > Safety > Glovebox PIN and follow the directions on the touchscreen. When enabled, you are prompted to enter the PIN to open the glovebox. Select the toggle to disable and then enter the PIN to remove this added security protection.

If you forget your glovebox PIN, reset it by entering your Tesla login credentials, then follow the directions on the touchscreen.

Note

Using a Glovebox PIN allows the glovebox to be opened even when Model 3 is in Valet mode.

Speed Limit Mode

Speed Limit Mode allows you to limit acceleration and maximum driving speed to a chosen value between 50 and 120 mph (80 and 193 km/h). The first time you use this feature, you must create a 4-digit PIN that you must use to enable and disable Speed Limit Mode. When enabled and the driving speed approaches within approximately 3 mph (5 km/h) of the maximum speed, a chime sounds, the touchscreen displays a message, and Model 3 sends a notification to the mobile app. You can also touch Security > Speed Limit Mode to enable from the Tesla mobile app. To enable Speed Limit Mode:

Ensure Model 3 is in Park.
Touch Controls > Safety > Speed Limit Mode on the touchscreen.
Select the maximum driving speed.
Drag the slider to the On position.
Enter the 4-digit PIN that you want to use to enable and disable Speed Limit Mode.
Note
If you forget the PIN, you can disable Speed Limit Mode by entering login credentials for your Tesla account.

Note

While Speed Limit Mode is enabled, the acceleration setting automatically sets to Chill.

Warning

Driving downhill can increase driving speed and cause Model 3 to exceed your chosen maximum speed.

Warning

Speed Limit Mode is not a replacement for good judgment, driver training, and the need to closely monitor speed limits and driving conditions. Accidents occur at any speed and it is your responsibility to drive safely.

Clear Browser Data

You can clear your vehicle's browser data (like you would on a computer or smartphone) by navigating to Controls > Service > Clear Browser Data. This is useful for many situations, such erasing settings or searches from another driver... (Link)

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Relevant Stats relevant to work related accidents: “The ILO estimates that some 2.3 million women and men around the world succumb to work-related accidents or diseases every year; this corresponds to over 6000 deaths every single day. Worldwide, there are around 340 million occupational accidents and 160 million victims of work-related illnesses annually. The ILO updates these estimates at intervals, and the updates indicate an increase of accidents and ill health.....” (World Statistic (ilo.org))

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Relevant Stats relevant to injuries: “

Injuries – both unintentional and violence-related – take the lives of 4.4 million people around the world each year and constitute nearly 8% of all deaths.
For people age 5-29 years, 3 of the top 5 causes of death are injury-related, namely road traffic injuries, homicide and suicide.
Injuries and violence are responsible for an estimated 10% of all years lived with disability.
Injuries and violence place a massive burden on national economies, costing countries billions of US dollars each year in health care, lost productivity and law enforcement...” (Injuries and violence (who.int))***

Relevant Stats relevant to youtube streaming: “Right behind Google, YouTube is an effective search engine in its own right. If someone is specifically searching for a video on a topic they’re interested in, they’ll be more likely to head straight to YouTube and conduct their search from there. As a result, optimizing your videos for search is crucial to your success because it’ll help you rank higher in search results....With its 2.1 billion monthly active users, YouTube is a pretty effective business marketing channel. By running video ads, brands can generate awareness, engagement, and conversions. To show just how powerful its ads can be, here are some YouTube statistics you should be aware of:...YouTube has 2.70 billion monthly active users based all around the world. That number shows no signs of slowing down, with the projected amount of users increasing each year. In terms of daily active users, YouTube sees approximately 122 million users per day. Those are some impressive YouTube statistics!..” (https://thesocialshepherd.com/blog/youtube-statistics)

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Relevant Stats: “ Approximately 1.19 million people die each year as a result of road traffic crashes.

Road traffic injuries are the leading cause of death for children and young adults aged 5–29 years.
92%t of the world's fatalities on the roads occur in low- and middle-income countries, even though these countries have around 60% of the world's vehicles.
More than half of all road traffic deaths are among vulnerable road users, including pedestrians, cyclists and motorcyclists.
Road traffic crashes cost most countries 3% of their gross domestic product...” (Road traffic injuries (who.int))
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Relevant stats relevant to repair shop, storage, parking, vacation and investment properties: “Airbnb has over 7 million active listings in over 220 countries.

394 million ‘nights and experiences’ were booked on Airbnb around the world in 2022.

Airbnb has had over 1.5 billion guest arrivals since it started in 2007….typical host in the U.S. earns $14,000 per year from Airbnb…” (https://www.rubyhome.com/blog/airbnb-stats/)

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Relevant Coverage:

A. Travel & Health

“Travel health Insurance - Common Clauses

Health

a) Pre-existing conditions;

b) Sporting activity exclusions;

c) Excess Hospital, medical and extended care for Canadian Travellers;

d) Regular hospital coverage for visitors to Canada;

e) Accident dental treatment;

f) Emergency Transportation

g) Travel of a family member

Death or disability

Funeral Expense;

Repatriation;

Death benefits - accident (ground or Air);

Disability and loss of sight benefits – accident

Travel Health Insurance - Other coverages

Trip cancellation or interruption (usually standalone);

Baggage and other possessions (Standalone)

Return of automobile;

Delay of return travel;

Child care attendant;

Collision waver for rental vehicles;

Pet return (often restricted to dog or cat)

Flight Insurance (usually standalone)

Skill 2: Client Service and Sales skills

Outline:

Manage new and existing clients. Analyze and review risk and provide ongoing service.

Description

Brokers must possess intermediate level understanding of techniques to review and evaluate the risks and need of each travel health Insurance client. Brokers must have Intermediate level ability to negotiate with Insurers and use their rate manuals.

Brokers must have intermediate level knowledge of office procedures in order to process data and information accurately and quickly. They must have intermediate level ability to organize their daily schedules to permit client service work to be undertaken regularly and promptly, including Insurance policy maintenance and claims processing.

Skill 3: Risk Management skill

Outline: Identify and assess exposures of travellers and recommend methods to manage the risks associated with travel.

Description: Brokers must have intermediate level knowledge and understanding of how to identify exposures of Canadians travelling out of province/country and of foreigners travelling to and within Canada.

Brokers must have advanced level ability to identify activity exposures of travellers, including frequency and duration of trips. In particular, planned undertaking of hazardous sports or recreation during trips must be determined.

Brokers must have advanced level knowledge and understanding for the financial exposures of Canadians travelling outside the province/country and of foreigners travelling to and within Canada.

Advanced level knowledge is required to assess those exposures and quantify them. Brokers must then be able to select the Insurer offering the coverage required by clients and help clients complete the application.

Brokers must have Advanced level knowledge and understanding to advise travellers of the appropriate Insurance response to their needs. This also entails clear expectations of terms and limitations, including the procedures to be followed in order to make a claim under a policy. Advanced level skill is required to keep up-to-date on changes to industry travel policy forms and wordings.

Prescribed medication changes, other than to generic brand, must not have occurred within the 12-month period immediately preceding each departure date or the applicant's effective date. Length of time may vary with different carriers.

Definitions:

Definitions may vary amongst Insurers; the following is intended to provide a basic understanding.

Accident:

Unintentional, sudden and unforeseeable event due exclusively to an external cause inflicting, directly and independently of all other causes, bodily harm.

Activate (Activations)

Selection of, and payment of the appropriate premium for, the Multi Trip Annual Plan, Single trip annual plan, and/or any top up Extension coverage by the client.

Carrier

The Insurer underwriting the risk

Change of prescribed Medication

Medication dosage or frequency being reduced, increased, stopped and/or new medications being prescribed and or taken by applicant (Insured)

A change of prescribed medication will be considered for coverage when supported in writing by the applicant (insured's) Physician when

1. The active ingredient or dosage of the medication remains the same or is decreased due to improvement of the medical condition, or

2. Newly developed Drugs introduced to the market are prescribed where a definite improvement in the applicant's condition is anticipated

3. Prescribed Medication changes, other than to a generic brand, must not have occurred within the twelve-month period (12 month) period immediately preceding each departure date or the applicant's effective date. Length of time may vary with different carriers.

Common Carrier

A public land, Air, or water conveyance licensed to carry passengers for hire.

Company

The Insuring company

Critical

In danger of death or life threatening

Deductible

The amount that the applicant must pay before any benefits are payable by the company. A deductible, if chosen, is retroactive to the first day of the applicant's trip and applies to each unrelated medical emergency that leads to an eligible claim.

Departure Date

The earlier of the date the applicant

a) Boards of the ticketed transportation, or

b) Leaves Canada on an insured trip, unless the applicant requested coverage to begin on the date the applicant leaves his/her province/territory of residence.

Departure point

The location where the applicant departs from their province or territory of residence.

Dependant (s)

Any unmarried children residing at home, who are at least 15 days of age, but under 19, and who are living with and dependant upon the applicant for their sole means of support.

Effective date

For the multi-trip annual plan, means the date indicated on the applicant's confirmation letter, when the application and the required premium are received by the company or its representative. If the coverage is purchased after the applicant's departure date, emergency sickness related benefits shall become effective 48 hours after the date and time the required is received by the company.

For the policy, means the date this policy is issued to the applicant and as indicated on the applicant's confirmation letter.

For Top up- Extension, means the date immediately following the termination date of the applicant's existing emergency travel health Insurance coverage.

Elective treatment

Medical Treatment, surgery or any other procedure scheduled by the applicant's physician to occur at a future date.

Emergency

An unexpected or unforeseeable sickness or injury that requires immediate non-discretionary medical attention, treatment or care.

Extended Family:

The applicant's spouse, the applicant's children, their spouse's, the applicant's parent's or guardian(s), the applicant's in -laws, brother, sister's, grandparents and grand children.

Government Health Insurance plan

The ministry in each province overseas a health Insurance plan for its residents. Each province has its own regulatory fee guides and may refer to the plan by different names; e.g., In Ontario, it is called Ontario Health Insurance plan (OHIP)

Hospital

A facility equipped to perform surgery and which regularly treats patients on a medical emergency in patient and out patient basis and is identified and licensed as a hospital in the area where the hospital services are performed. In no event, shall this include a nursing, home, a rest home, convalescent home, rehabilitation center or home for the aged.

Injury

Sudden body harm that is directly caused by an accident during an Insured trip, and that is independent of sickness and all other causes.

Insured

A person or persons named on the application form and confirmation letter for whom insurance coverage is in effect for this policy.

Insured Trip

A trip on which the applicant is travelling outside Canada (or the insured's province/territory of residence, if requested) for which coverage is in effect under a multi-trip annual plan, a single trip daily plan or a top up extension coverage the applicant has activated for that trip. Coverage on a trip begins on the Insured's departure date and ends on earlier of the date the Insured returns to the province, or the number of days of coverage under the plan purchased.

Medical Director

The medical doctor acting on behalf of the company.

Medical Emergency

An unexpected and unforeseeable sickness or injury, which requires immediate non-discretionary medical attention, treatment or care.

Medical Stable and Controlled

Medical treatment must not have been recommended, or required, or obtained, or symptoms must not have appeared or changed and there is no change of prescribed medication (see definition)

Medical Treatment

Medical Advice, Investigation, Consultation, care, service, diagnosis, or prescription rendered by a physician for the Insured's sickness or injury.

Multi-trip Annual Plan

Coverage for an unlimited number of Insured's trip of duration of 30, 60, 90, or 120 days within a continuous 365 - day period commencing from the effective date.

Ontario Health Insurance plan - OHIP

A health Insurance plan for all Ontario residents which the Ontario government oversees and administrates. This plan covers the basic health providers and services as outlined by the applicable health act.

Physician

Medical director or person, other than a relative, who is legally qualified and licensed to practice medicine or perform surgery in the location where services are performed.

Policy period

The Period between the effective and termination date covered by the policy.

Preexisting Medical Condition

Sickness, injury, or medical condition, or any medical condition directly or indirectly related thereto, which existed on or prior to the effective date or any departure date.

Reasonable and Customary

Costs that are customarily charged for covered benefits and that are not in excess of the standard fee for the geographical area where the charges are incurred for the comparable medical treatment, services or supplies for a similar sickness or injury

Representative

The financial Institution, agent or other location where payment arrangements have been accepted by the company

Sickness

Illness or disease

Single Trip Daily plan (per Trip)

A fixed number of days of coverage equal to the total length of the Insured's trip, including the Insured's departure date and return date.

Terminal Prognosis

A clinical assessment performed by a licensed physician who determines that an existing medical condition, sickness or injury is expected to result in the Insured's premature death within a specified time, commonly twelve months following any departure date.

Termination Date

For an Insured's trip, means the date any activated coverage ends, being the earlier of the date that the insured returns to their province of residence or the number of days coverage the Insured purchased under the Insured's multi-trip annual plan option, Single trip daily plan, or top up extension coverage for that trip.

For the policy, means 364 days after the effective date for the policy.

Third Party administrator (TPA)

An organization that processes Insurance claims for a separate entity. This can be viewed as outsourcing the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the Insurance.

Travelling Companion

Any person, up to a specified number of persons, including the Insured, who is sharing prepaid accommodation and/or transportation arrangements with the Insured.

Unstable condition

A sickness or injury that would cause an ordinarily prudent person to expect to need medical treatment or investigation following departure.

Vehicle

A private passenger automobile, station wagon, or mini-van defined as a vehicle manufactured and designed a transport a maximum of seven passengers and used exclusively for the transportation of passengers, or a trailer either owned or rented by the Insured. Vehicles also include motor homes and camper units. Motor home means a self-propelled vehicle containing living quarters that are an integral part of the vehicle and are not removable. Camper Unit means a specifically constructed unit for living purposes mounted on or removable from a vehicle.

You or yours

Means Each Insured

Risk Management & Product types

Foreign destinations have always had a wide appeal to the members of the world community and to Canadians in particular. All travel attracts various common and other more uncommon risks. Every destination has a certain associated risks - and some may even be considered too high risk to be eligible for travel Insurance - each method of travel attracts unique risks that need to be Insured against.

In this section, we look at:

a) Types of travel risks;

b) Broad categories of travel Insurance Products; and

c) Types of private plans in detail

In the next section, we look at details of typical coverages in private plans

Travel Risks

Medical risks

Travellers are faced with many risks that may result in financial loss to themselves or members of their families, in the event of sickness, accident or death.

In remote areas of the world, even if western style healthcare were available, the services of a hospital or clinic would cost between $3000 and $5000 US per day.

Enormous increase in foreign healthcare costs and cutbacks in government coverage have resulted in ever-increasing premiums. In an effort to moderate these increases, the carriers have included large deductibles, more exclusion and in some cases very restrictive underwriting practices. Personal claim deductibles now vary in size from $100 to $25000. One company has a $100,000 deductible, which reduces the premium by 80%. In this particular case, it is used as a top up for federal retirement travel benefit. These many changes have resulted in an increased risk to the travelling public. Now in addition, to the concern of lack of coverage, is the risk that the coverage is not broad enough or that benefits may run out due to the exclusions and maximums.

Non- Medical Risks

The traveller could also be faced with costs related to the following:

a) Loss of baggage or other personal possessions;

b) Delays in arriving at, or returning from, a trip;

c) The disability of others such as travel companions, or their trip interruption, resulting from an early or late return from a trip.

d) Automobile Return

e) Rental Vehicle damage

f) Child care

g) Pet return

h) Flight accident

I) Common Carrier travel accident

j) Return of deceased insured

k) Emergency dental

l) Return of Insured to destination

Advising the client of the risk

Cautious travellers, before leaving home, are now faced with a bewildering array of plans and coverages from more than 50 different Insurers. The traveller's individual situation and needs will dictate which plan is required. The Broker's skill and knowledge provides the necessary insight for travellers to make educated decisions to minimize risk.

A large part of your value as a professional advisor will be in how well you keep abreast with the policy changes and innovations that are constantly advanced by the carriers. Professionalism should be composed of equal parts, knowledge, skill and ethical practice.

Product Types - All providers

A wide spectrum of travel Insurance coverage is available under the following:

1. Provincial government health Insurance plans (GHIP), with coverage varying from one province to another.

See Appendix A for provincial and territorial GHIP residency requirements and for details of Ontario's out of country coverage.

See Appendix B for typical benefits provided under the provincial and territorial GHIP's. Individuals who incur health costs while out of the country would be reimbursed at the listed lower amounts.

2. Group Insurance plans (if available), which usually provide out of province/country coverage that pays in excess of what is covered, or which may not be covered at all, by government plans. These private group plan have limitations, exclusions, and maximums that must be examined carefully.

See Appendix C for typical benefits provided under group Insurance plans.

3. Private Travel plans, (Individually purchased travel health Insurance), which often include benefits not available through either government or group plans. Private plans are also referred to as personal plans.

Private travel health Insurance is designed to supplement the coverage that the traveller requires in addition to their GHIP. The government health act prohibits private carriers from competing with the government plan. The private carriers can provide coverage only when the government plan has

a) Been exhausted and ceases to pay; and/or

b) Does not provide coverage

The most typical private travel plans are classified by duration, purpose, and by whether travel is outbound (commonly four types) or inbound for visitors to Canada. Plan coverages also vary according to whether or not travellers are covered by their provincial health care plan.

Product Types - Private plans

Four broad categories of private travel Insurance cover risks associated with outbound travel. A fifth type covers risks associated with Inbound travel to Canada, and can be standalone or incorporated in to the one of the first four types.

Different travel health Insurance providers may classify their products in other ways; e.g., medical only, comprehensive packages covering medical and non-medical risks; single trip versus annual plan coverage, various standalone coverages etc. You will need to become familiar with each provider's products in order to advise your client knowledgeably.

This text primarily deals with travellers who are outbound but coverage for various inbound travellers is described briefly. The travel Health Blueprint at the end of this section is a useful guide for determining which product an insured need.

Out bound Travel Insurance

Short term or one trip coverage

Short term trips are those taken by Canadians who are travelling for a relatively short period for up to 90 days. Short term coverage extends coverage offered under the GHIP plan and offer certain benefits that are not normally included in government plans.

Example of wording for single trip coverage

Short term trips are those taken by Canadians who are travelling for a relatively short period for up to 90 days. Short term coverage extends coverage offered under GHIP plan and offer certain benefits not normally included in government plans

Long-Term One-Trip coverage

Long term trips usually refer to those taken by Canadians who vacation outside Canada for an extended time that does not exceed the coverage time frame specified by the provincial GHIP. In Ontario, OHIP currently has a limit of 212 days, after which the coverage is cancelled. (See Appendix A)

For many long-term travellers, split residency has become part of their lifestyle. It is common, for example, to describe our long-term winter travellers as snow birds, defined as Canadians aged 55+ (now also sometimes known as zoomers) who spend 31+ consecutive nights outside Canada. While the travel patterns of today's retirees are changing, snow birds still account for a sizeable market - it is estimated that their trips account for over $86 million in premiums spent on over 690,000 trips in 2006 and these figures are growing as the baby boomers mature.

Frequent travellers Annual plan

Frequent travel whether for business, pleasure or caregiving to elderly parents, for example, is a way of life for many people. Business travel has become a routine for many. This type of travel incurs special risks that need to be examined and properly insured. As its name implies, this is an annual; coverage for frequent trips. It is identical to short term plans but is paid for on an annual basis. The plan offers a variety of durations, 3-90 days being common but limits the number of days contracted. The traveller is covered for any number of trips in the one-year period.

Expatriate Insurance

This plan requires that the person must not be Insured or eligible for benefits under a Canadian government health Insurance plan. The person must be either: I) A Canadian citizen residing outside of Canada; ii) A Canadian citizen returning to reside in Canada and awaiting coverage under a government health Insurance plan, or; iii) A non-Canadian citizen residing outside their country of origin while employed by a Canadian company. Coverage is world wide.

The Canadian government recognizes that certain types of extended stays warrant special consideration. Missionaries, diplomats, health care specialists, students and certain other individuals who are out of Canada for extended absences, may receive preferential treatment and can apply for, and have, their GHIP coverage extended and topped up for years. Those with GHIP coverage would also require a traditional travel Insurance plan. Other travellers who are away for extended periods and whose GHIP coverage expires are exposed to all health care costs. Expatriate Insurance therefore becomes effective after GHIP coverage expires, and covers health costs from the first dollar. Generally, contracts can be renewed annually as required.

Inbound Insurance

Inbound Insurance is for travellers arriving in Canada. This includes international workers, professionals who are here on a time limited work basis, visitors, landed immigrants, refugees and students who come to Canada for higher level of education. Inbound Insurance provides benefits for a new sickness or accident incurred while covered. In bound insurance contracts cover health costs from the first dollar. Contracts covering inbound travellers include various restrictions and limitations depending on the carrier. For example, overall policy maximums can vary between $10,000 and $2,000,000. Inbound travel Insurance is available only to individuals who are not covered by GHIP coverage. The following regulations refer to the waiting periods for government coverage for various categories of visitors to Canada, and may vary from province to province.

Landed Immigrant

The effective date of coverage varies between one and three months. In Ontario, coverage becomes effective three months after the date of arrival in the province with Immigrant status, or three months after the immigrant status is acquired if the traveller arrived without Immigrant status.

Refugee

Coverage is effective immediately from the date of arrival in the province for convention refugees. Claimant refugees are covered under the federal government.

International Students

eligibility varied from province to province. In Ontario, International students are not eligible for coverage.

International Workers

Coverage is effective on the day of arrival, provided that the applicant has a minimum of a three-month visa. Family coverage is available if a correct visa is approved by Immigration Canada.

Visitors to Canada

Visitors to Canada are not eligible for any government Insurance plan coverage.

Inbound Insurance policies will not automatically cover preexisting conditions and are subject to an elimination period or a stability period for Visitors to Canada; for other inbound travellers, coverage varies by carrier.

Coverages

Coverage Overview

The number of companies offering travel Insurance has increased tremendously in the last several decades. In the early 1990's only seven carriers offered competitive coverages; this has now increased to over 50 providers. For a listing of current travel Insurance providers, refer to the travel health Insurance Association of Canada (THIA) website, http://thiaonline.com. THIA member companies who are members of the Canadian Life and health Insurance Association (CLHIA) would also be covered under Assuris, the life Insurance Industry's consumer protection plan.

Distribution Channel

The products are distributed through a network of intermediaries or channels.

a) Travel Agents (Responsible for the most sales);

b) Banks and other financial Institutions

c) Life Insurance Agents;

d) General Insurance Brokers;

e) Licensed Financial planners;

f) Travel health Insurance Sites on the Internet;

g) Affinity Associations;

h) Cruise or other tour organizations, and airlines

Other channels offering travel Insurance include credit card companies and group employee benefit plans

Some companies use only their own distribution network while others use a variety of marketing sources.

Typical Outbound Travel Health Insurance Benefits

Types, Amounts, and wordings of travel Insurance benefits may vary from company to company. The following is intended to provide a general explanation.

Note that the following describes typical benefits for most outbound Insurance coverages, with the exception of Expatriate Insurance, which by its nature may contain unique benefits. It, for example, will not include coverage for excess hospital or medical benefits. Similarly, inbound Insurance coverages would not cover the excess or extended benefits described below.

To protect the consumer, contracts must be compared in terms of the following:

a) Benefits;

b) Benefits descriptions;

c) Limitations, exclusions, and maximums;

d) General Provisions;

e) Premium Costs (least Important)

All coverages are prefaced by the caution that the company will pay the reasonable and customary charges for the costs incurred outside the country of residence. It also states that benefits will be paid for charges in excess of amount allowed and/or paid for by any government health Insurance plan (GHIP). The maximum aggregate limit will also be stated. Most insurance providers have stringent rules about written permission from their medical doctor, written direction from the attending physician and copies of receipts for all expenditures.

Excess Hospital

This benefit pays for public ward, semi-private, or private ward hospital accommodation, when directed by the doctor in charge. All other hospital services and supplies for the emergency in excess of what GHIP pays are also included. The limit allowed by OHIP (as of 2008) is $400 per day. All charges in excess of this amount are the responsibility of the patient. Travel health Insurance will pay this excess, within the limitations of the contract.

Excess Medical

This benefit pays charges in excess of what GHIP pays, which are incurred by an insured for services of a legally qualified physician or surgeon who is licensed to practice medicine in the local area where the services are performed.

Extended Health care

Coverage may include the following:

1. Private duty nursing services by a registered nurse up to a stated maximum;

2. Prescribed medication;

3. X-Ray and laboratory Fees;

4. Local Ambulance Services;

5. Appliances and related services such as for wheel chair rental, crutches, and braces;

6. Paramedical Practitioner services, such as chiropractor, osteopath, chiropodist or physiotherapist. In some contracts, a maximum overall dollar value may be stated for each of these practitioners.

Out of pocket expenses

This benefit provides reimbursement of additional out of pocket expenses when an insured is hospitalized (e.g., telephone and television rental charges) up to a daily maximum and an overall dollar maximum. Minimum stay requirements are stated. Additional uses for the allowable "out of pocket expenses" are found in the "transportation of family members" benefit.

Child care attendant

This benefit reimburses costs for a child care attendant (non-relative) to care for the children who were accompanying the Insured in the event the Insured is hospitalized. The benefit will be paid after a minimum hospital stay requirement, and will pay up to a stated maximum.

Emergency Air Ambulance

If the attending physician recommends (in writing) that you must return to your province or country of residence for immediate medical attention following an emergency, the Insurance company will pay the cost of an Air Ambulance, if the patient is unable to return on a regular flight. The Insurance company must approve this in writing and a stated maximum will apply.

Trip Cancellation, Interruption or Delay

Travellers frequently experience unavoidable situations that affect their plans in one of three ways:

1. Personal or family situation such as death or sudden medical emergency that necessitates the cancellation of the trip;

2. An emergency involving family members at home that occurs after the commencement of the trip, requiring the Insured to interrupt the trip to return home early;

3. A situation that delays the scheduled return home, or delays the traveller's departure.

These delays are considered to be outside the Insured's control, and may lead to delays or missed flights and connections.

The coverage is generally broad enough to cover not only the insured traveller, but also members of the immediate or extended family. In addition, this coverage usually extends to a travelling companion or business associate.

Other circumstances include:

a) Being called to Jury duty;

b) Being subpoenaed;

c) Being quarantined (at the Insured's residence);

d) Medical Emergency;

e) Death

Note: Non-medical benefits are not always included in the trip cancellation insurance.

Benefits of trip cancellation Insurance

The following benefits insure the risk outlined in the three situations described above.

1. Prior to the start of the trip: The insured is forced to cancel due to emergency, or to the death of the Insured and/or a family member of the Insured's extended family, travelling companion, or the business associate with whom the insured is travelling. The benefit will pay

a) The non-refundable portion of any prepaid transportation such as air, rail or cruise ship, or

b) The non-refundable portion of any of the unused, prepaid travel arrangements.

This would include:

a) Hotel;

b) Meals;

c) Airplane fare; and

d) Other scheduled expenses arranged prior to departure.

Some travel health plans stipulate "after you leave home" and therefore do not cover cancellation prior to departure.

2. Interrupted Trip Benefits

Apply to a trip already in progress. If an occurrence prohibits the Insured from completing the trip as scheduled, the benefit will return:

a) Any non-refundable portion of any unused prepaid accommodation; and/or

b) The extra cost to change the return ticket to a one-way economy fare by regular scheduled transportation back to the departure point or to the group's next destination

3. Delayed Departure Benefits will cover the scheduled benefits as in (2) above if the departure is delayed due to an emergency.

Delayed Departure causes include:

** Severe weather conditions;

** Mechanical Breakdowns;

** An accident involving land transportation to your departure point

Trip cancellation Insurance is most often sold as an integral benefit to completely round out a travel health Insurance benefit for both domestic and foreign travel.

Other Benefits:

Other less typical benefits include the following:

Pet Return

Provides funds up to a stated maximum for return of an accompanying pet, usually limited to a cat or dog

Rental Car Collision

Provides funds up to stated maximum for damage to a vehicle rented from a commercial rental agency

Automobile return

Provides funds to a stated maximum to return a personal vehicle (land or water) to the home destination, due to a covered sickness or injury.

Flight Accident

Insured may choose amongst several levels of coverage; e.g., $200,000 to $500,000 for death and loss of limb(s), sight, etc., due to an aircraft accident whether in flight including but not limited to on the airport premises before boarding or immediately after alighting from an aircraft.

Limitations and Exclusions

The study of travel Insurance would not be complete without examining the exclusions and limitations section

Exclusions and limitations prevent undue selection against the carrier and the premium paying consumer, and limit the exposure to normal travel risks. Benefits may vary slightly, but the real challenge lies in comparing the different companies’ policy wordings.

Typical Exclusions in Outbound Travel Insurance

Note: As mentioned in explaining typical benefits, the following describes typical exclusions for most outbound Insurance coverages, with the exception of Expatriate Insurance, which by its nature may contain unique exclusions. Similarly inbound Insurance coverages would contain various different exclusions

1. Any sickness or injury that occurs while the policy is not in effect, or during a trip or part of the trip that is not an insured trip, or for trip arrangements for which no premium was paid before departure.

2. Sickness or injury: which does not relate directly to an emergency, including general assessments or check ups, experimental drugs, preventative medicines or vaccines, elective treatment, elective or cosmetic surgery in any form, or treatment that can be delayed until return to the Insured's country of residence.

3. Expenses due to early or delayed return home, when caused by a situation that, before leaving, was aware would make it unlikely to complete the trip as booked.

4. Expenses due to trip delay or interruption: When the purpose of the trip is to visit a person who is ill, and the medical condition of the ill person worsens or death occurs, causing a delay or interruption to the Insured.

5. Hospital or medical treatment: Where the policy is sought specifically for the purpose of obtaining such treatment, whether or not recommended by a physician. This would include the birth of a child whole travelling, prenatal care or complications of a pregnancy or child birth within eight weeks of expected delivery date.

6. Pregnancy, Child Birth, Miscarriage, or any complications due to pregnancy occurring within eight weeks of the expected delivery date is a common limitation to coverage during pregnancy. This would include the birth of a child while travelling, prenatal care, or complications of the pregnancy or child birth. Some policies totally exclude any costs related to pregnancy.

7. Suicide or self-inflicted Injury: Or attempt thereat whether sane or insane, insanity, mental or emotional disorders (anxiety, depression) unless hospitalized, abuse of medication, drugs or intoxicants, or treatment of same, or accidents related thereto. This exclusion would encompass expenses incurred because the Insured failed to follow prescribed therapies or treatment.

8. Civil disorders, war or acts of war (whether war be declared or not). Action of foreign enemies or wilful exposure to peril, except in an attempt to save a human life.

9. Air Travel: Other than as a passenger in a commercial aircraft licensed to carry passengers for hire

10. Continuing medical treatment: If the insured is medically fit to return to their country of residence following treatment of a critical sickness or injury.

11. Sporting Activity Exclusions: Any costs incurred due to an injury as a result of participation as a paid professional in a sanctioned competitive sport, or as a result of hand-gliding rock climbing, mountaineering, parachuting, para-sailing, skydiving, bungee jumping, snorkelling, scuba diving, cave exploration, or motorized speed or racing contests will not be covered. The sport activities exclusions may differ with different insurers.

12. Certain destinations may be excluded due to political unrest, or other circumstances.

13. Pre-existing conditions: This is undoubtedly the most often referenced limitation and exclusion clause. Because of its importance, it is discussed in detail in the section that follows.

Pre-existing conditions

Of all the limitations and exclusions that exist, none are more referenced and restrictive than "pre-ex" There are many variations, but all focus on the question, "What happened to you medically in the preceding days, months and sometimes years, prior to leaving on this trip?'

Typical Pre-ex question

What medical history, occurrence, or symptoms have you experienced prior to the date of application?

Remember that last year's medical occurrence may become this year's pre-existing condition. Worse still is the situation involving another's company's benefits.

Consider the following: Company A issues a policy providing coverage for 60 days, and the insured incurs a medical condition during those sixty days. Company B has issued a top up policy with a 60-day elimination. Company B declares the occurrences pre-ex, even though it is the same trip and the insured has not yet made it home. A second consideration complicates the issue. A clear - cut situation would reflect symptoms for which the ill or injured person would consult a medical authority and receive a diagnosis. However, would this situation be considered a pre-ex if the symptoms were not acted on immediately? The consensus is "YES" if a "person" experiencing such symptoms, whether or not the condition was deteriorating. An additional consideration concerns medicines or treatment prescribed to the applicant whether or not the applicant had acted on it. To further complicate the issue, a change in the prescription dosage, or type (increase or decrease) would also activate the pre-existing condition. The pre-existing period may extend from three, six, or nine months, or up to one full year prior to the date of issue. The company may include the 48 hours after purchasing the policy in the pre-existing period. In most policies, any medical condition that occurs prior to departure will trigger the pre-existing clause and it is up to applicant to provide any information regarding medical changes right up to their date of departure; otherwise, the policy may not be valid. The only remedy may be full disclosure to underwriting, asking either for elimination of the pre-ex-clause or a weighted offer. The response could also be denial of issue, limitation of benefits, or caps on expenditures.

Examples of pre-existing condition wording

1. Any medical pre-existing condition which existed, or caused symptoms, or was treated or investigated, whether or not it was deteriorating, or for which medication was changed in type or dosage, on or prior to departure date.

2. Any pre-existing condition that is unstable in the three months before the traveller leaves home, or before the date policy coverage starts.

In some instances, the carrier provides for another method to eliminate the exclusion. This may take the form of

a) Underwriting

b) A top up requiring additional premiums; or

c) A departure date within a prescribed time limit of policy purchase.

Brokers, to receive full and open disclosure from their clients and to conduct their own due diligence, must realize that diagnosis is not necessary to define pre-existing conditions. It asks only if the symptoms existed. The fact that abnormal symptoms existed prior to the purchase of the policy, or that any symptoms or signs of illness or disease were known to the insured prior to the effective date of policy is sufficient. Once this occurs, it is up to the Insurer to determine the extent of the risks and the amount of premium required.

Insuring agreement

Each contract contains a statement known as the Insuring agreement. This is a broad statement of the benefits and the purpose of the policy. This statement is then augmented by the benefits and restricted by exclusions and limitations.

An example of an Insuring agreement

In consideration for the application of Insurance and the payment of the appropriate premium for the plan and coverage option you select, and subject to What is covered and what is not covered, the company will pay reasonable and customary charges up to the amounts specified below, which are in excess of any deductible amounts, for expenses incurred as a result of a medical emergency while on an insured trip. Under this policy, only medical emergencies which are unexpected or unforeseeable and not related to pre-existing conditions are covered, unless you have been underwritten and received approval to have pre-existing medical conditions covered. Under this policy, only medical conditions that are unexpected and unforeseeable, and not related to Pre-existing medical conditions are covered, unless you have been underwritten and received approval to have pre-existing medical conditions covered.

The Insuring clause becomes effective after the application has been completed, signed and forwarded with the appropriate premium.

Extension of Coverage

Extension of Coverage falls in to two categories:

1. Voluntary decision to remain at the trip destination past the original intended date of return (or termination date)

2. An involuntary extension past the date of return, for reasons beyond the control of Insured person.

Voluntary extension

Some plans provide no extension of benefits past the date of termination (or return date). If the Insured is out of Canada. Others may provide extension (or top up) while the Insured is at their destination, provided there has been no change in their medical condition that may result in a claim. Conditions may include a requirement that a request be made before a minimum period prior to the planned date of return, a minimum extension period (e.g. four to seven days), and a minimum premium.

Some contracts require that extension requests not exceed a maximum number of days; e.g., 212 days in Ontario. A requirement may be that no extension will be granted if the request is made beyond 12 months after the Insured originally left home.

Involuntary Extension

This generally results from a medical condition that causes a delayed return. Other conditions may also apply.

This extension may be offered to

1. The insured only

2. A member of Insured's family

3. A travelling companion

Trip interruption coverage usually outlines the involuntary extensions and details the circumstances under which extensions will be granted and length of time allowed.

Example:

An automatic extension of up to 72 hours may be granted without extra premium, if the Insured trip is delayed due to circumstances beyond their control, such as

a) An emergency involving the Insured

b) A delay to the Insured's common carrier

c) Extreme weather causing hazardous travelling conditions

d) Other situations that may be submitted for consideration

Coordination of benefits with other Insurance plans

The benefits in a private plan will pay in excess of the GHIP of the Insured's home province. Benefits are also coordinated with other existing plans held by the Insured; e.g. Benefits will not be paid under current policy if the other coverage would have paid, had the current policy not been in effect. The travel health policy becomes, in effect, 2nd payor.

Coordination of benefits is intended to ensure that benefits payable under all policies do not exceed 100% of all eligible expenses incurred.

Other Coverages would include, but not limited to:

a) home owner's Insurance

b) Tenant's Insurance

c) Multi-risk Insurance

d) Extended Health care (Group or personal plans)

e) Auto Insurance Benefits;

f) Credit Card Policy

If an insured receives payment from a second insurer that should have been from a first Insurer, the second Insurer is entitled, under the subrogation clause, to recover their costs from the first Insurer.

Example of subrogation clause

If the Insured acquires the right of action against any individual, firm, or corporation, for a covered loss, for which payment has been made under this policy, this right of claim must be transferred to the Insurer upon their request, so that they can recover expenses paid.

Applications and Underwriting

Applications forms vary widely from company to company, but all attempt to elicit the same information. Some are simple -- most are not! - but they do have some similarities. They provide for a full and open disclosure of the past (pre-existing) and present health of the applicant, to allow complete and accurate underwriting of the risk.

Application Forms - Outbound Insurance

As noted earlier with respect to benefits and exclusions, expatriate and inbound Insurance applications would differ significantly. The following describes a typical application for outbound travellers, excluding expatriate Insurance.

All applications need to show the time exposure involved in the trip. It may list an effective date and/or date of departure, and termination date (completion date).

The only exception would be for top up or add- on benefits added to existing coverage. The effective date then would be the date of termination of the existing coverage. If the policy is an instant issue, the effective date will be the date written.

The effective date provides not only the time and date from which all coverage commences, but also a start point from which all pre-existing health conditions are measured.

All applications are designed in sections to supply the following information:

1. Name (In Quebec, maiden name must be provided);

2. Age;

3. Residence Address;

4. Date and point of departure;

5. Destination and date of return (or Termination of coverage);

6. Single, Couple or family coverage, and names of those to be covered;

7. Existing Supplemental Insurance

Section 1: Policy Coverage

This section determines who is to be covered under the policy. There may be a primary Insured and a dependant's section that would list the spouse and any dependant children travelling with the Insured.

Section 2: Date of Birth

The date of birth is required for most applications, and last age is commonly used to calculate the premium. The premium may be based on exact age, or more likely on five -year age bands (e.g., 40-44, 45-49, 50-54, etc)

Section 3: Home Address

Applicants are required to provide their home address in their province of residence

Section 4: Dat and point of departure

This section may look simple but can have complications. Consider the following:

1. Are the effective date and departure date two separate dates or the same date? Is the date the coverage is required the same as the date the applicant will leave the country of residence, or will they already be at their destination (i.e., is the plan topping up or adding on to an existing plan)?

2. Point of departure may be meaningless if the Insured is already at his/her destination when this coverage ceases.

3. If the Insured has to return home in response to a home emergency, and then leave the country to continue their scheduled trip, coverage would cease upon re-entry and would become effective again only when they depart.

Section 5: Destinations and Date of return (Termination of coverage)

Destinations may be one location (Vacation location) or a series of locations (cruise or tour). Generally speaking, the first location to be reached will be listed as the destination. The date of return may also differ from the termination date of the plan. Some coverage applies only to a set period, e.g., 30-90 days. The applicant, however, may be away longer and may insure the balance with a top up plan or decide to leave the remainder uninsured. Either way, it is important to the underwriter to know the exact terms of coverage and the dates to which they apply.

Section 6: Covered Individuals

Many families travel together, but occasionally people travelling together may not be family, but may be friends or travelling companions. Families receive reduction in premiums but non-related travelling companions do not!

Section 7: Existing Supplemental Insurance

Frequently, associations or affinity groups will provide travel health Insurance for a limited duration. It is important that the traveller disclose this pre-existing coverage. Some companies will not provide top up Insurance and some require this add-on Insurance to be written prior to leaving the home province. A few companies will issue after the termination date when the applicant is at their destination, but all companies will want to know the original company's coverage and duration.

Broker Identification

1. Name and Telephone Number;

2. Broker Code

Additional Information

This section seeks to disclose other pertinent details such as:

a) Smoker and Non-smoker status

b) Date of last medical and health status;

c) Provincial health card number;

d) Deductibles (If any);

e) Additional non-medical benefits (Riders and options)

Pre-existing Conditions

Most companies today provide a comprehensive medical questionnaire that may be required when pre-existing conditions have been disclosed. The applications may be rejected entirely or the applicant may be offered one of the following:

a) Coverage subject to paying additional premiums

b) Coverage allowing for one or two conditions;

c) Co-Insurance or a limitation on coverage;

d) Elimination of coverage of all pre-existing conditions, in which case coverage applies only for medical conditions or accidents that are new or not previously experienced and that originate after the trip commences.

To underwrite any pre-existing condition, the client and the broker must have sufficient time before the client's departure date to obtain the necessary information, including medical reports, if required. Clients who request coverage only days before departure will not have the advantage of having the pre-existing condition (S) underwritten. As a broker, you should encourage and educate your clients to apply for coverage well in advance of their departure dates to allow for a proper underwriting analysis.

Premium Calculation

Each plan has standard coverage that requires a basic premium calculation. This is followed by options that will increase or decrease the premium. Some examples are:

a. Excess flight coverage above the minimum offered in the plan;

b) Single, couple or family coverage, which require different premiums;

c. Coverage including both departure and return day;

d. Good health reductions, if available;

e. Non-Smoker reductions;

f. Deductibles, if any;

g. Coverage for pre-existing conditions that require an additional premium charge. The contract may offer this surcharge, OR if only one or tow of the pre-existing conditions apply, may offer full coverage subject to additional premiums;

h. In Quebec only, certain additional coverages that are required (with an extra premium charge)

Companies may offer deductibles as a method of reducing the premium. The percentage of premium reduction corresponds to the size of the deductible. This may be in the form of a straight dollar value reduction, or of a separate policy offer.

Co-Insurance and deductibles are used not only as a method of reducing premiums, but may also be used as a provision by claims administrators when some failure to comply with plan requirement occurs. An example would be an applicant's failure to notify the claims administrator immediately (or within 24 or 48 hours) of the commencement of the medical emergency, in which case the Insurer could void the contract or revert to larger deductibles.

Each consideration should be calculated before completing the application. For example, should a husband or wife who are travelling together or returning separately have two policies or one? It may not matter, or it may to their advantage to have two separate contracts. Over a certain age (55-60), it may be mandatory to issue separate policies.

Underwriting Pre-existing conditions

Due to the tremendous impact of pre-existing conditions on claim costs, the applicant may be required to complete a medical questionnaire after a preliminary disclosure of an existing medical condition (or symptom and/or separate treatment). This form will seek to determine the existence and extent of a pre-existing condition (S).

Medical questions have long been the primary method life and health Insurance companies use to determine the degree of risk. Many of the travel health Insurance underwriters are now using this method as well. For these travel Insurers, the initial defence has been the disclosure of pre-existing conditions.

A current alternative is to channel the risk in to plans with restricted benefits. When an applicant indicates a medical condition, the application itself can divert the applicant to the restricted plan. The application form is divided in to sections which develop the following information in addition to the general information described earlier, such as name, address, date of birth, provincial health card number, etc.

The application form is divided in to sections which develop the following information in addition to the general information described earlier, such as name, address, date of birth, provincial health card number, etc.

Physicians’ Information

1. Name, Address and telephone number;

2. Date of last visit;

3. reason and results

Medical Condition

This is a general statement of health Impairments, followed by a detailed listing of diseases and illnesses. The applicant will be required to list medication dosage and medical status when the last symptom, treatment to medication change had taken place.

Additional Information frequently requested would include

1. Details of any surgery;

2. Future treatment or medical recommendation, not yet fulfilled;

3. Smoker status

Declaration or Release Statement

This statement, which must be signed and dated, may be found on the underwriting questionnaire or application. Its purpose is to provide full disclosure to enable accurate underwriting.

a) It verifies that the statements made by the applicant (S) are, to the best of their knowledge, true and fully disclosed.

b) It verifies the questionnaire forms part of their application.

c) It verifies that the health status changes between the date signed and the date of departure, the Insured will notify the company. This may be negated, i.e., this rule does not apply, if the time to departure is short (two weeks or less).

d) It authorizes the release of all medical information held by doctors and other medical providers.

e) It acknowledges that if at the time of claim, it is discovered that any question was not answered truthfully, accurately, and completely, it will result in the rejection of the claim (non-payment of the claim). In this event, the policy becomes null and void, and all premiums will be refunded. In effect, this acknowledgement gives notice of penalty provided for fraudulent intent, without stating it.

No broker is to be party to underwriting at the time of claim due to lack of true information at the time of issue. All brokers and licensed intermediaries are responsible for assisting in ensuring that all required information is provided to the Insurance company.

Claims Administration

The very nature of travel health Insurance guarantees that a certain percentage of policies issued will result in claims. These claims can develop within weeks or even days of the effective date. It is important that the broker's understand and assist, however possible, in the claims process.

The broker's most important task, however is to explain the coverage to the applicant at the time of purchase.

Procedure at time of claim

The following is a basic outline of claims procedures.

Most Insurance carriers provide (and insist that it be used immediately) a communication system for their travelling insureds who find themselves in a traumatic health or other emergency situation. The first and foremost function of the entire system is the restoration of the health of the Insured or, failing that, the arresting and stabilizing of the situation that caused the emergency. A secondary purpose is the orderly and timely payment of the resulting charges.

The Hotline

Toll free 1-800 service numbers

Emergency response: (Managed Health care services)

The first step is the use of a hotline or the emergency response telephone number usually located somewhere on your policy documentation or wallet card to notify the Insurance carrier. For Insureds covered by two, three or more Insurers, the Canadian Life and health Association (CLHIA) has put together a protocol for multicarrier claims management and payments.

The basic premise is that the first Insurer called provides case management and claims payments. After the GHIP payments, the insurers are assessed for payments for all claims according to the terms of their contracts. The protocol provides for an orderly coordination of claims payments.

The 24-hour WORLDWIDE EMERGENCY assistance hotline will:

a) Assist Insured in obtaining emergency medical care;

b) Direct Insured to the nearest appropriate physician or medical facility, and if possible, to a contracted facility (which will often offer discounts), to meet the Insured's needs;

c) Contact friends or relatives on Insured's behalf;

d) Contact the health care provider to outline the terms of Insured's Insurance policy and payment arrangements;

e) Case manage and monitor progress daily;

f) Arrange appropriate transportation home and accompanying medical staff if required

The actual claims process is quite complex, Once the claim has been accepted, the claim(s) will proceed as shown on the claims management flow chart at the end of this section. However, before it is accepted or declined, it must follow a critical path for evaluation and adjudication.

The notification of the claim can come from one or several sources:

a) Broker/Agent;

b) Insured/Family;

c) Medical Provider

It will be processed and completed by the hotline or mail system, but if required, the Insured will be directed to a managed care unit that is part of the health Maintenance organization (HMO). Many of the providers and services have been prearranged and/or contracted. Note that this terminology applies primarily to claims occurring in the United States. "The language of Managed care" in Appendix D provides more detail on this aspect of the US system. Outside the US, the Insured would be directed to an appropriate healthcare facility. At this point, the claims administrator takes full control of the medical solution, surgery, or other required treatment in coordination of the medical facility and the personnel. They may also contact the policy holder's personal doctor and family for additional consultation. The billings will be directed to an assessor who adjudicates the statements, and makes critical decision on whether to pay or decline based on a strict interpretation of the policy, with particular attention to exclusions and pre-existing conditions. The assessor may request additional information before making the decision. Most declines are open to appeal on additional information not previously reported.

Cost reductions and Containments

Costs will be contained by avoiding a lengthy hospital stay and reducing time in the hospital prior to the repatriation charge. The costs of the claim are controlled and prearranged through the following techniques or services.

Managed Care Unit

* Physicians on call;

* Pre-admission management

* Surgical options;

* Air Evacuations

Cost Containment Unit

* Utilization and coding review

* Reasonable and Customary charges

* Expanding preferred provider Organizations network (PPO)

Pre pricing

* Clinics, hospitals, physicians are managed through PPO's;

* Hospitals issue Usual and Customary rates (UCR)

* UCR rates can be repriced and significantly discounted

* Physician's bill may be discounted up to 40%

* Hospital Bills may be discounted by up to 10% after the fact

Claims Assessment

A claims assessor reviews the claim and pays, declines, or defers it for further review, subject to additional information

A claim is paid: if all relevant information has been received and policy mandates payment on the submitted claim.

A claim is declined if the medical or other situation does not meet the policy requirements.

A claim is subject to further review if factors do not permit a pay or decline decision. These factors may include;

a) Insufficient Information

* Possible appearance of fraud, misrepresentation or other legal complication;

* Possible errors and excesses in submitted invoices.

Claims adjudication

Terms and conditions are established to determine the nature of claims payout. Discretion in the adjudication process increases the risk of claims payout. Subrogation may substantially reduce claims pay out.

Claims Adjusting

* Review for non-payment, in whole or in part;

* Review medical reports for pre-existing conditions;

* Review for fraud and Misrepresentation, etc.

* Administer in accordance with established discounting relationships (PPO's)

* Administer for retrospective discounts (quick pays, etc)

Subrogation

Initial primary responsibility falls with the provincial GHIP for payment of a claim. As noted earlier, subrogation can occur when more than on Insurer's coverages makes them liable for the claim. The primary Insurer is allowed to collect (subrogate) from the second carrier (s) with Insurance policies in effect at the time.

Audits

Audits of hospital invoices for substantial amounts ($50,000) almost always result in a reduced billing.

Claims procedures and payments have the potential of either major assistance or major frustration to the Insured. Denial of payment can result in financial hardship or, in some cases, bankruptcy. The best protection is to provide full disclosure at time of writing the application.

Claims Management Flowchart

Insured experiences travel health emergency - Call the hotline - Managed care Unit - Assessor reviews and decides - Decline the claim - pay full or partial - Defer: Request more information from provider, broker/agent, and/or insured

Broker Responsibility

To be responsible broker involves much more than product knowledge. To be regarded as competent professionals requires a constant updating of knowledge and practice of the art of full disclosure to both our clients and our underwriters. As in many other professions, the responsibilities of the broker have greatly increased. New regulations, continuing education requirements, and a determination by the Insurers to know all the facts prior to the issue, have all combined to strengthen the facilitator - advisor role of the broker. This, together with the Insurer's unwillingness to pay claims when faced with non-disclosure of pre-existing conditions or other prejudicial information, requires more from the broker than simply completing the application. The first of the professional skills that are required is the "know of your client" rule. Brokers must remember that they don't make medical prognoses and that symptoms that appear of no consequence in the "pre-app chat" can highly significant at claims time.

Sales & Service

Providing effective sales and service involves the following:

** Selecting the carrier (See Travel Health Insurance Checklist, page 14-53);

** Completing the application (See Broker Checklist, Page 14-54);

** Calculating the premium;

** Analyzing the client's needs (See client profile, page 14-55);

** Determining the client's medical condition.

Selecting the proper Carrier

Selection of the proper carrier requires due diligence and involves the following two steps

Research the market

Each Insurance carrier has an Insuring philosophy and type of coverage that they market. A careful reading of the sales material may not fully prepare you to deal with the public. When in doubt, request further descriptions of coverage and insuring clauses from the companies. Sample wordings are available on the Internet from many companies.

Understand the Key areas

Sales Brochures from different providers will all offer attractive approaches to the products. The benefits will appear to have similar protection. It is only when you compare the exclusions, limitations and definitions that the true coverage become apparent. Benefits that appear broad may have restricted maximums. Always compare the pre-existing conditions. Determine which of the carriers offers the maximum coverage at the most reasonable price. Price and commissions payable are not necessarily the deciding factors in determining which company(ies) you wish to offer to the consumer. Due to the enormity of the claim exposure, the broadest, most comprehensive benefit description will often be the deciding factor in the sale.

Completing the application

The previous section dealt extensively with the application form. It is of the utmost importance that this form (some complex and some simple) be filled out in its entirety with full and adequate disclosure. Adding to the complexity of the application form is the variety of plans and options that are available to your client.

The better you understand your client’s history and travel plans, including his or her destination, the better you are able to inform the underwriter. This will also facilitate a quick policy issue.

Calculating the premium

Calculating the premium may or may not be as easy as it first appears.

The following questions must be taken in to consideration:

a) Is this a short-term, Long-term, Expatriate, Frequent Traveller, or Inbound policy?

b) Are premiums charged by the attained age or by age bands? Is it age restricted?

c) What is the duration of the travel time?

d) What additional options have been chosen?

e) Are there any pre-existing conditions or is health history clear?

f) Are there any special rates for cruises and tours?

g) Are there deductibles and/or co-insurance>?

h) Are there special rates for individually underwritten plans?

i) Is tax payable on any of the optional non-medical benefits>?

All companies maintain toll-free telephone numbers that are available to applicants and agents to request additional information or confirm rates.

Analyzing the Client's needs

Each type of traveller, and indeed each individual traveller, has unique needs that require examination prior to commitment by completing the application.

For ease of examination, we will present them in the following categories:

a) Type of Traveller;

b) Trip Duration

c) Destination

d) Analyzing Existing Coverage;

e) Uncovering prior medical history

Type of Traveller

As previously mentioned, travel health Insurance falls in to fairly well-defined categories of travel outside Canada.

a) short term (One-trip)

b) Long Term (One trip)

c) Expatriate Coverage

d) Offered both inside and outside Canada;

e) Frequent Travellers

Trip Duration

Trip duration is important because statistics show that the longer the Insured is away from home, the greater the risk of substantial claim.

Rates therefore favour short-term durations and costs increase substantially as the period away lengthens.

Destination

Destination has always had an effect on the premium rates and the validity of the contract. Costs to destinations where western style medical care is available and where the area enjoys political stability will less than to a country with less than desirable medical care, political unrest and any medical outbreak. No coverage is available if foreign affairs has issued a warning to avoid any specific country.

Analyzing Existing coverage

Travellers need to integrate or at least be aware of coverage that protects them

** Most group Insurance plans already offer "out of Canada" health coverage as well as travel emergency options. Benefits in their out of Canada Insurance are similar to what the plan covers within Canada.

** Credit cards often offer coverage that is automatic with a card purchase or is available with a check off selection

** Certain travel clubs, affinity groups and business organizations have travel benefits which may simply require an application.

** Lastly, all GHIP's offer some limited out of Canada benefits. See appendix A for details of out of Canada coverage provided by Ontario and Appendix B for typical GHIP benefits provided by all provincial governments and territories.

Appendix A: Provincial/Territorial Residency requirements and OHIP Out of country Coverage.

If you have a valid provincial health card you are entitled to certain benefits when outside Canada. But because coverage for out-of-country health care services is limited, you should purchase supplementary Insurance. When planning a trip outside Canada, get all the facts about your health coverage first - and get extra health Insurance before you leave. Remember, one day in American hospital can cost as much as $5000 per day up to $10,000 for specialized care.

Provincial Residency requirements

Most provinces and territories require residents to reside within their province for a specified number of days (in most cases - 183 days - approximately six months) in order to maintain their provincial health Insurance Coverage. If this requirement is met, the resident or the Insurer on behalf of the resident would be eligible to claim against applicable GHIP plan for a percentage of medical costs in curred either out of province, or out of Canada.

Note: Residency requirement periods may differ from the period an insured is allowed to be outside of Canada and still qualify for out of country coverage.

a) Province

Newfoundland and labrador

Annual requirement: 4 months

Flexibility in Application: None

b) Nova scotia

Annual requirement: 183 days: Short absences permitted beyond 183 days.

C) Prince Edward Island:

183 days: Short absences within the country permitted beyond 183 days

d) New Brunswick:

183 days: Short absences permitted beyond 183 days

e) Quebec: 182 days

Trips up to 21 days do not count against the 182 days

f) Ontario

153 days

A 30-day grace period will be permitted

g) Manitoba: 183 days

Year long absences are permitted every 3 years

h) Saskatchewan: