Your DGC Benefits Plan provides you and your family with valuable, affordable mental and physical health coverage and financial protection if you experience an illness, injury or disability. In this section, we explain how the plan works and what’s covered under each level.
Critical illness insurance helps guard against the financial burden of a serious, life-altering illness. If you’re diagnosed with a covered critical illness, you can apply to receive a full lump-sum benefit, which you are then free to use as you see fit.
The benefit can help you cover expenses such as: loss of income, medical costs and care, home modifications, career changes, mortgage or line of credit payments, time off work taken by your spouse during treatment, or transportation costs associated with treatments.
Critical illness coverage for you and your family will be based on your coverage level as outlined below. Only Level II and Level III coverage are eligible for Critical Illness insurance. Basic Coverage, Level I and Life Members are not covered.
LEVEL II | LEVEL III |
|---|---|
Member $25,000
Coverage ends at age 70
Spouse $5,000
Dependent Child $2,500 | Member $50,000
Coverage ends at age 70
Spouse $10,000 Dependent Child $5,000 |
The following critical illnesses are covered — subject to a number of limits, exclusions and definitions outlined in the contract. Please contact AGA Benefit Solutions for more specific policy details.
Each illness must meet certain criteria before a claim can be paid.
For example, if you experience hearing loss, no benefit would be paid unless you have total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz.
The rules for determining whether a particular illness is covered are strictly applied by the insurer, Desjardins Insurance, and in all cases, Desjardins will make the final decision on whether or not a claim is paid. If you do experience a critical illness and have questions about your condition or would like a second opinion, remember that the DGC Benefits Plan also provides Teladoc Medical Experts service for this advice.
Alzheimer’s disease
Aortic surgery
Aplastic anemia
Bacterial meningitis
Benign brain tumour
Blindness
Cancer (life-threatening)
Coma
Coronary artery bypass surgery
Deafness
Dilated cardiomyopathy
Fulminant viral hepatitis
Heart attack
Heart valve replacement
Kidney failure
Liver failure of advanced stage
Loss of independent existence
Loss of limbs
Loss of speech
Major organ failure (on waiting list)
Major organ transplant
Motor neuron disease
Multiple sclerosis
Muscular dystrophy
Occupational HIV infection
Paralysis
Parkinson’s disease
Primary pulmonary
hypertension
Progressive systemic sclerosis
Severe burns
Stroke
Level III also includes 7 more covered illnesses for dependant children
Cerebral palsy, Congenital heart disease requiring surgery, Cystic fibrosis,
Down’s syndrome, Serious cerebral lesion, Serious mental deficiency, and Spina bifida cystica
In addition, the plan provides:
Payment of 10% of the amount of insurance (up to $25,000) for
Coronary angioplasty
Prostate cancer
Skin cancer or Breast cancer
Cancer recurrence
Multiple occurrence coverage
Conversion privilege
Alzheimer’s disease — a progressive degenerative disease of the brain, resulting in a significant reduction in mental and social functioning, as demonstrated by:
Aortic surgery — surgery for disease of the aorta requiring excision and surgical replacement of the diseased aorta with a graft. Aorta refers to the thoracic and abdominal aorta but not its branches.
Aplastic anemia — a chronic persistent bone marrow failure, confirmed by biopsy, which results in anemia, neutropenia and thrombocytopenia requiring blood product transfusion. Treatment includes at least one of the following: marrow stimulating agents, immunosuppressive agents, or bone marrow transplantation.
Bacterial meningitis — a definite diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of diagnosis.
No benefit will be payable under this condition for viral meningitis.
Benign brain tumour — a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgical or radiation treatment or cause irreversible objective neurological deficit(s). The medical information required must be reported to the Insurer within 6 months of the date of the diagnosis.
Blindness — a definite diagnosis of the total and irreversible loss of vision in both eyes, evidenced by the corrected visual acuity being 20/200 or less in both eyes, or by the field of vision being less than 20 degrees in both eyes.
Cancer (life-threatening) — a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The medical information required must be reported to the Insurer within 6 months of the date of the diagnosis.
Coma — a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least 4 days.
No benefit will be payable under this condition for the following: a medically induced coma, a coma which results directly from alcohol or drug use, or a diagnosis of brain death.
Coronary artery bypass surgery — heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s).
No benefit will be payable under this condition for non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of an obstruction.
Deafness — the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz.
Dilated cardiomyopathy — a condition of impaired ventricular function resulting in significant physical impairment. Impairment means that the patient is comfortable at rest and is symptomatic during less than ordinary daily activities despite the use of medication and dietary adjustment, with evidence of abnormal ventricular function on physical examination and laboratory studies.
Fulminant viral hepatitis — means a definite diagnosis of a submassive to massive necrosis of the liver caused by any virus leading precipitously to liver failure.
No benefit will be payable under this condition for chronic hepatitis or liver failure caused by alcohol, toxins and/or drugs.
Heart attack — the death of heart muscle due to obstruction of blood flow that results in the rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:
Heart valve replacement — surgery to replace any heart valve with either a natural or mechanical valve.
No benefit will be payable under this condition for heart valve repair.
Kidney failure — chronic irreversible failure of both kidneys to function, as a result of which regular hemodialysis, peritoneal dialysis or renal transplantation is initiated.
Liver failure of advanced stage — liver failure due to cirrhosis and resulting in permanent jaundice, ascites, and encephalopathy.
No benefit will be payable under this condition for liver disease secondary to alcohol or drug use.
Loss of independant existence — a total inability to perform, by oneself, at least two of the following six activities of daily living or cognitive impairment, as defined below, for a continuous period of at least 90 days with no reasonable chance of recovery.
Activities of Daily Living
Cognitive impairment means mental deterioration and loss of intellectual ability, evidenced by deterioration in memory, orientation and reasoning, which are measurable and result from demonstrable organic cause as diagnosed by a specialist. The degree of cognitive impairment must be sufficiently severe as to require a minimum of 8 hours of daily supervision. Determination of a cognitive impairment will be made on the basis of clinical data and valid standardized measures of such impairments.
Loss of limbs — complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation.
Loss of speech — total and irreversible loss of the ability to speak as the result of physical injury or disease, for a period of at least 180 days. No benefit will be payable under this condition for all psychiatric-related causes.
Major organ failure (on waiting list) — irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, where transplantation is medically necessary.
To qualify, the insured person must become enrolled as the recipient in a recognized transplant centre in Canada or in the United States, that performs the required form of transplant surgery. For the purposes of the survival period, the date of diagnosis is the date of the insured person’s enrolment in the transplant centre.
Major organ transplant — irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify, the insured person must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow.
Motor neuron disease — means one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy, or pseudo bulbar palsy, and limited to these conditions.
Multiple sclerosis — means at least one of the following:
Muscular dystrophy — hereditary muscle disorders in which slow, progressive deterioration occurs, leading to increasing weakness and disability. Diagnosis must be supported by DNA analysis, electromyography and muscle biopsy.
Occupational HIV infection — infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the insured person’s normal occupation, which exposed the person to HIV- contaminated body fluids.
The accidental injury leading to the infection must have occurred after the later of the date coverage began, or the effective date of the last reinstatement of insurance.
Payment under this condition requires satisfaction of all of the following:
No benefit will be payable under this condition if you have 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 the HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.
Paralysis — a total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event.
Parkinson’s disease — idiopathic and degenerative Parkinson’s disease diagnosed by a duly qualified neurologist. The diagnosis must be based on two or more of the following: rigidity, tremors, or bradykinesia.
Primary pulmonary hypertension — primary pulmonary hypertension with a substantial right ventricular enlargement confirmed by investigations (including cardiac catheterization), resulting in permanent irreversible physical impairment to the degree of at least Class IV of the New York Heart Association (NYHA) Classification of Cardiac Impairment. Class IV means the inability to engage in any physical activity without discomfort. Symptoms may be present even at rest.
No benefit will be payable under this condition for all other types of pulmonary arterial hypertension.
Progressive systemic sclerosis — progressive systemic scleroderma with systemic involvement of the heart, lungs or kidneys. The diagnosis must be unequivocally supported by biopsy and serological evidence.
No benefit will be payable under this condition for localized scleroderma (linear scleroderma or morphea), eosinophilic fasciitis, or CREST syndrome.
Severe burns — third-degree burns over at least 20% of the body surface.
Stroke — an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with:
These new symptoms and deficits must be corroborated by diagnostic imaging testing.
No benefit will be payable under this condition for transient ischæmic attacks, intracerebral vascular events due to trauma, or lacunar infarctions which do not meet the definition of Stroke as described above.
If you have Level III coverage, your dependant children are covered for the full list of critical illnesses outlined above, plus the following seven additional illnesses.
Cerebral palsy — a chronic disorder that appears in the first few years of life, caused by damage to the motor areas of the brain, characterized by varying degrees of limb weakness, involuntary movements and speech problems.
Congenital heart disease requiring surgery — any serious cardiac malformation present at birth for which corrective surgery has been performed.
Cystic fibrosis — a genetic disease affecting the sweat and mucous glands, particularly in the lungs and digestive system, and characterized by excess production of thick mucous leading to chronic progressive respiratory disease and nutritional problems.
Down’s syndrome — a congenital condition caused by an extra copy of chromosome 21, primarily characterized by varying degrees of mental retardation, though other defects, particularly congenital heart disease, may be present.
Serious cerebral lesion — any lesion that is characterized by an invasive development problem or serious intellectual deficiency, that prevents an individual from performing the basic activities of daily living and requires professional specialized services for his treatment, rehabilitation, re-education or schooling on a daily basis.
Serious mental deficiency — a deficiency which, when evaluated through standard testing, demonstrates that an individual has an IQ under 70.
Spina bifida cystica — a congenital defect, diagnosed by a licensed specialist physician, caused by failure of the spine to close properly, allowing the spinal cord and its protective covering (meninges) to protrude through the skin, characterized by varying degrees of the following: hydrocephalus, paralysis, bowel and bladder problems.
No benefit will be payable under this condition for Spina Bifida Occulta.
If you are diagnosed with of one of the following four illnesses, you may qualify for a benefit equal to 10% of the amount of insurance specified in the benefit schedule, up to $25,000.
No benefit will be paid if you die within 30 days of being diagnosed with a critical condition.
A benefit will be paid to you provided satisfactory medical proof is received within 365 days of your 30-day waiting period ending. The benefit amount will be paid once for covered conditions resulting from the same or related illness or disease. See also multiple occurrence coverage.
A pre-existing condition is a condition or symptom(s) that you (or your eligible dependants) experienced within 24 months before your insurance coverage began or was reinstated, for which:
If you become ill due to a pre-existing medical condition within 24 months of the start of your coverage, no benefits will be payable. Also, keep in mind that if you drop to Level I coverage or Basic Coverage after qualifying for coverage of a pre-existing condition and then later resume coverage under Level II or III, you will once again have to wait two years to re-qualify for coverage of a pre-existing condition.
If you experience a cancer recurrence, the full benefit amount may be paid again. While covered, if you receive a life-threatening Cancer diagnosis after receiving a previous cancer diagnosis, you may be eligible to receive an additional benefit if:
With multiple occurrence coverage, if you suffer a critical illness and are then diagnosed with another critical illness, you may be eligible to receive another benefit.
Contact AGA Benefit Solutions for details and exclusions.
SAMPLE BENEFIT PAYMENTS FOR A $50,000 POLICY
Critical illness Phillip has a serious heart attack | Payment $50,000 |
|---|---|
He is later diagnosed with skin cancer | One lifetime payment of $5,000 |
Shortly thereafter, he finds out he has Parkinson’s disease | $50,000 |
Phillip then has a stroke | $0 Not eligible because a stroke (and other illnesses) is considered related to his heart attack. |
No benefit is payable for:
Exclusion period for certain illnesses
No benefit will be payable for certain illnesses if the diagnosis occurs within the first 90 days of the start of the insurance coverage or the last reinstatement of the insurance. Please contact AGA Benefit Solutions for further details.
Note: More details on exclusions and limitations are available from AGA Benefit Solutions.
Your coverage ends when you turn 70 or are no longer a member in Active Good Standing with the Guild — whichever comes first.
Your spouse’s coverage where applicable ends when your coverage ends or your spouse turns 70 — whichever comes first.
Coverage for a dependant child where applicable ends when your coverage ends or the child no longer qualifies as a dependant — whichever comes first.
If you have not reached age 70 and lose your critical illness coverage under this benefit because you are no longer a member in good standing with the DGC, or if you have dropped to Level I coverage or Basic Coverage – you may apply to convert your coverage to an individual critical illness policy within 31 days of cessation or termination, and without evidence of insurability. This privilege does not apply where loss of coverage is due to termination of this policy or benefit.
If a critical illness is diagnosed outside Canada following an accident or illness, the insurer will only assess the claim once you (or your eligible dependant) have returned to Canada and obtained a medical assessment of the previously made diagnosis.
