Claims and services

Before making a claim, you can view your eligibility or submit a “mock” claim to confirm your coverage, how much will be paid and any limits or conditions under your plan. There are two ways to do this:

• Sign in to Online Insurance. On the Policy Summary page, select Submit Claims, then Manage Health Benefits.
• Sign in to the My Benefits app and and select ‘My Coverage’.

If you or your dependents are covered under more than one benefit plan (for example, your spouse’s plan), you can claim up to 100% of an eligible expense by coordinating your benefits under both plans.

How to coordinate your benefits:

• Submit your claim under your plan first, and send any remaining balance to your spouse’s plan.
• Your spouse’s claims should go to his or her plan first, with any remaining balance sent to your plan.
• Dependent children are covered first by the plan of the parent whose birthday falls earlier in the year. So, if your birthday falls in January and your spouse’s birthday is in March, you should submit your child’s claims to your plan first.
• You will receive an Explanation of Benefits (EOB) statement from the first insurance company you file with showing how much of the claim has been covered. Submit the EOB statement, along with copies of your expense receipts, to the second insurance company in order to claim any remaining eligible balance.

Not sure if a service is covered? We recommend that you get pre-authorization from us first before you receive any service valued over $300. This can help avoid surprises and out-of-pocket expenses in case a certain service isn’t covered.

Some health and dental providers can submit claims to us on your behalf, and let you know if you owe any amounts due to deductibles and reimbursement levels. Check with your provider to see if this option is available.

Once we receive your completed claim form, we will acknowledge our receipt of it within one business day. We will schedule a telephone call with the assigned disability claims specialist, and make a decision to approve—or ask for more information—within 10 business days. You will be provided with a status of your claim every 30 days until a decision is made.

We recommend submitting your completed claims forms (client + authorization, employer and physician statements) 8 weeks prior to the end of the elimination period to ensure a timely decision.

• Complete the sections on the form that apply to you, and have your doctor complete the ‘attending physician’s’ section of the form
• Be sure your doctor includes a specific diagnosis and indicates how your condition affects your ability to do your job
• Your doctor will also need to list all treatments you are receiving, including surgery, medications, physiotherapy, etc.
• Submit the form to your benefit administrator or human resources department so they can complete their section to confirm your absence

Make sure your claim form is accurate and completed in full, signed, and submitted with the paid receipt enclosed. We cannot accept photocopies and faxed receipts.

Always keep your personal information up-to-date (bank account, address, etc.) You can make updates easily by signing in to Online Insurance

Ensure your Explanation of Benefits claim statements are correct and double-check receipts to be sure you received what is being charged to your plan. Providing false claim documents or exaggerating services constitutes fraud. If you realize you have made a mistake after submitting a claim, let us know right away so we can help correct the situation.

Dealing with a disability can be stressful. We’re here to help support you and make things as easy as possible. Review the following for an overview of what to expect when making a disability claim.

• Make sure all required claim forms are completed and submitted as early as possible—ideally at least 8 weeks prior to the end of the elimination period.
• While on claim, focus on your recovery and follow any treatment program that your physician recommends.
• 
  Keep in touch with your disability claims specialist and your employer.
• See the Disability Claim FAQs below for additional guidance on what to expect throughout the claims process.

Dealing with a disability can be stressful. We’re here to help support you and make things as easy as possible. Review the following for an overview of what to expect when making a disability claim.

• Make sure all required claim forms are completed and submitted as early as possible—ideally at least 8 weeks prior to the end of the elimination period.
• While on claim, focus on your recovery and follow any treatment program that your physician recommends.
  Keep in touch with your disability claims specialist and your employer.
• While on claim, focus on your recovery and follow any treatment program that your physician recommends.
• See the Disability Claim FAQs below for additional guidance on what to expect throughout the claims process.

Instead of returning receipts to you, we will send you an Explanation of Benefits (EOB) statement, which includes information you may need for tax purposes (like the information on a receipt) as well as any deductibles, maximums, or co-payments applied to your claim payment.

It’s a good idea to make a copy of all receipts and forms for your records before submitting them to us for payment.

We are committed to preventing insurance fraud. Audits on group benefits claims are conducted regularly to help guard against both intentional and unintentional misuse. Fraud increases plan costs for your employer, which puts your own coverage at risk. You may end up needing to pay increased premiums or lose certain benefits to cover these higher costs. Should you receive a claim audit questionnaire, please complete it promptly—it helps us protect all of our plan members and their benefit plans from abuse. Learn more about insurance fraud

If you are going to be absent from work for an extended period of time and you anticipate that you will not be returning to work prior to the end of your elimination period (i.e. waiting period before benefits are paid), you should begin the claim process.

• Client’s Statement of Disability: You will need to complete this form. Provide as much detail as possible about the circumstances that led to your absence from work. Be sure to sign the section that authorizes us to communicate directly with the doctors and specialists who are treating you.
• Employer’s Statement of Disability: Your employer must complete this form and submit it directly to RBC Insurance.

There are three ways forms can be submitted:

By email : intake@rbc.com

By fax : 1-800-714-8861

By mail : RBC Life Insurance Company, Life & Health Claims Department

P.O. Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Once we have received all of your completed forms we will assign a disability claims specialist to your claim and begin our assessment. We will contact you for a telephone interview to answer any questions we have about your claim and to better understand your functional capabilities and limitations related to your condition. You will also be able to ask us questions about your claim.

We may also need to contact your doctor and/or your employer to ask additional questions or collect any missing information.

Our normal processing time to make a claim decision, from the time all forms are received to the completion of our initial review, is 10 business days.

If your claim is pended, this means we may need more information from you, your doctor or your employer. We will let you and your employer know (verbally and in writing) what we need to complete our assessment. We will facilitate any requests but it’s also a good idea if you follow up with your doctor for any information we might need.

Be sure to complete and submit your portion of the claim form right away. We also suggest that you follow up with your doctor to make sure the Attending Physician Statement and any additional information is submitted to us in a timely manner.

After your claim has been approved, we will call to notify you and your employer. We will also send you an approval letter confirming the decision and outlining the next steps and expectations for the ongoing management of your claim.

You will be assigned a disability claims specialist who will call you on a regular basis to understand your medical status and ensure your recovery is progressing as expected. We may also ask that your doctor provide medical updates and we will work together to ensure you are receiving appropriate treatment. In some cases, we may ask you to have an independent medical examination to further clarify your medical situation. If this is required, we will arrange and pay for the examination.

We will call to notify you and your employer. We will also send you a detailed letter clearly explaining why benefits cannot be paid and outlining the necessary steps to appeal our decision. If you disagree with our decision and wish to appeal, you will have 90 days from the date of the decision letter to submit your written request. Any appeal should include new information to support your request to reassess your claim.

Examples of reasons why a claim may not be approved:

• The definition of disability was not met
• The claim is due to a pre-existing condition, that is, the disability occurred within a defined period of time of the coverage start date
• Care is not being provided by a physician
• The minimum hour requirement was not met to qualify for coverage

Please review your group policy for full details of all terms of coverage, or speak with your disability claims specialist for more information.

Your benefits are paid on a monthly basis and will start when the elimination period ends. If there are delays during the claim decision process and the benefits start date has passed, we will make a payment for benefits retroactively. You can choose to receive your benefits by cheque or direct deposit (recommended).

Your benefit is based on a percentage of your monthly earnings at the time you stopped working. It may be reduced by other sources of income as defined by your group policy. For example, if you are receiving any disability benefits under the Workers’ Compensation Act or Canada/Quebec Pension Plan (CPP/QPP), these amounts may be subtracted from your disability payment.

You will only receive a tax slip if your benefits are taxable. If you are not sure if the disability benefits you receive are considered taxable income, we will advise you on your letter of approval. If they are taxable, we will issue a T4A slip and mail it to you by the end of February for benefits paid to you during the previous tax year.

No. Your group policy includes waiver of premium coverage, which means you do not have to pay premiums while receiving disability benefits.

You will continue to receive payments as long as you:

• Meet the definition of disability outlined in your group policy
• Satisfy other contractual requirements outlined in your group policy, such as complying with appropriate treatment or participating in a vocational rehabilitation program

Please see your Employee Benefits Booklet or group policy for more information.

While you can collect income from other sources—such as Workplace Safety and Insurance Board (WSIB) benefits or Canada Pension Plan (CPP)/Quebec Pension Plan (QPP) disability benefits—your group disability benefits will be reduced by these amounts as outlined in your policy. Let us know as soon as you have been approved for any other benefits so that we can recalculate your benefits and avoid any overpayment.

Your privacy is very important to us. Any information we collect pertaining to your medical status—including diagnosis, medication and treatment plans—will not be shared with your employer unless we have signed consent from you to do so. Only the status of your claim, or when you are expected to return to work will be discussed with your employer.

• Focus on your recovery and follow all treatment programs that your doctor recommends.
• Keep in touch with your disability claims specialist and let them know of any changes in your medical condition, how you are recovering, and if you are receiving income from other sources.
• Stay in touch with your employer.

We will also talk to you about returning to work when the time is right, and may expect you to participate in a rehabilitation or return-to-work program.

If your medical condition improves and you are ready to return to work, please contact us.

• We will work with you, your employer and your doctor to develop a return-to work plan that accommodates any restrictions and limitations you may have.
• If more expertise is required, a vocational rehabilitation specialist may help with your return-to work plan.
• If you have been away from work for an extended period, we may recommend a graduated, modified or part-time return.

Ultimately, you returning to work in a safe and sustainable manner is what matters most.

RBC Insurance will send you an application package for Canada Pension Plan (CPP)/Quebec Pension Plan (QPP) disability benefits. Once you receive the application, call your disability claims specialist with any questions you have regarding completing the application and we will try to help with your questions. The complete application should be sent to Service Canada.

We will also include authorization forms that should be completed and returned to RBC Insurance that permit Service Canada to communicate with us concerning your application, and also, permit Service Canada to send us the first payment so that an overpayment does not occur on your RBC Insurance claim. The letter will identify where each form should be sent.

It would be beneficial for you to apply for Canada Pension Plan (CPP)/Quebec Pension Plan (QPP) disability benefits as the period during which you receive benefits from CPP/QPP is included in CPP’s/QPP’s contributory period when retirement benefits are calculated. A period of disability not recognized by CPP could adversely affect your contributory period and the retirement benefit you may receive from CPP/QPP could be reduced.

As per the terms of your contract, if you do not apply for CPP/QPP disability benefits, and pursue the relevant appeals if you are denied, RBC Insurance may deduct from your disability benefit an estimate of the amount that you would be entitled to receive as CPP/QPP disability income payments if you had successfully applied.

Depending on the type of claim, you may be able to file online, from your smartphone, or have your service provider file electronically on your behalf.

Yes, if you or your dependents are covered under more than one benefit plan (for example, your spouse’s employee plan), you may be eligible to claim up to 100% of an eligible expense by coordinating your benefits under both plans. To coordinate your benefits:

• Submit your claim under your plan first, and send any remaining balance to your spouse’s or partner’s plan.
• Your spouse/partner’s claims should go to his or her plan first, with any remaining balance sent to your plan.
• Dependent children’s claims should first be submitted to the plan of the parent whose birthday falls earlier in the year (e.g. if your birthday falls in January and your spouse’s birthday is in March, you should submit your child’s claims to your plan first and then submit any remaining balance to your spouse’s plan).
• You will receive an Explanation of Benefits (EOB) statement from the first insurance company you file with showing how much of the claim has been covered. Submit the EOB statement, along with copies of your expense receipts, to the second insurance company in order to claim any remaining eligible balance.

Unless your benefit plan documents state otherwise, all claims must be received by RBC Insurance no later than 12 months from the date the eligible expense was incurred.

Sign in to Online Insurance. By selecting More and navigating to the View Health/Dental Claims option on the Home Page, you will able to check on the status of existing and past claims. This is also available through the RBC Insurance My Benefits app on your smartphone.

If you are enrolled in Online Insurance, and submitted a health and dental claim electronically, you will receive a notification sent to your communications email once the claim has been adjudicated.

The RBC Insurance Online Health & Dental Claims Centre monitors claims for early identification of fraudulent activity. If you are alerted of an audit, additional information will be required to support your claim. Use the upload feature to submit the required requested information

Claims under your Group Critical Illness coverage are administered and paid by Allstate Benefits. For support, please contact them by phone at 1-844-436-1105 or by e-mail at RBCI_CI_Claims@allstatevoluntary.ca.

Please refer to your Benefits Booklet to confirm which critical illnesses are covered under your company’s plan.

Yes. RBC Insurance offers 50% of your benefit amount at no additional charge for all covered dependent children.

You have the option to transfer take your critical illness coverage with you them wherever they go – even if they leave the Group plan, the Master policy terminates, or their employment is terminated. For further details, please contact Allstate Benefits by phone at 1-844-436-1105 or by e-mail at admin@allstatevoluntary.ca.

You may receive benefits for each critical illness covered under your plan as long as each instance is separated by at least 90 days.

If you die soon after diagnosis, the beneficiary you designated during enrolment can submit a claim form and supporting documentation for consideration. As long as your employer or administrator has your Designation of Beneficiary information on file, your beneficiary is eligible to receive any benefits you are due. There is no survival period, meaning there is no set amount of time you must remain alive aafter your diagnosis to be eligible to receive benefits.

Claims under your Newcomer Health Plan Coverage are managed by Cowan.
Service providers on the Cowan Preferred Provider Network can bill directly to Cowan, however, a paper claim can be submitted if a member has paid for eligible services.
Email: clients@cowangroup.ca
Call: 1-888-509-7797

Please refer to the NHP Benefits Booklet to confirm what is covered under your company’s plan.

Yes, the Newcomer Health Plan provides coverage for necessary hospital and medical services for eligible employees under 75 years of age and their dependents, who are not eligible for coverage under a government health insurance plan (GHIP).

Eligible dependents are those persons who reside in Canada and who are:

• your legally married spouse or, common-law spouse who has continuously cohabited with you for not less than one full year;
• your unmarried, unemployed children under the age of 21 years – their coverage will continue up to age 26 if enrolled and in full-time attendance at an accredited educational institution and;
• your unmarried, unemployed dependent children to any age who are incapable of self-sustaining support or employment by reason of mental or physical disability and have been continuously so disabled since the age of 21.