Effective April 1, 2019, OHIP+ will no longer provide drug coverage for individuals under the age of 25 who have access to private insurance. Therefore, prescription drug claims for children and youth 24 years of age and younger with private plan coverage will have to be submitted directly to their private plan. Click here for details!

Covered Critical Illnesses

Alzheimer's Disease - a progressive degeneration of the brain as diagnosed by a certified neurologist or psychiatrist. The diagnosis must be supported by medical evidence of progressive deterioration of memory and the ability to reason and perceive, to understand, and to express and give effect to ideas. The deterioration must be severe enough to render the insured member incapable of independent living to the extent that he/she requires a minimum of 8 hours of daily supervision. No other dementing organic brain disorders or psychiatric illnesses are included.

Benign Brain Tumour - means a benign neoplasm within the substance of the brain or the meninges. The following conditions are deemed not to be Benign Brain Tumour:

  • Cysts, granulomas, malformations of the intracranial arteries and veins; or
  • Tumours or lesions of the pituitary.

A diagnosis of Benign Brain Tumour must be made by a physician. Interpretation: Benign Brain Tumours are typically more harmful than benign tumours in other parts of the body. This is because any abnormal growth in the brain can place pressure on sensitive tissue causing impaired functions and neurological deficits. Benign tumours within the substance of the brain or the meninges (the membrane enclosing the brain) are covered. Other problems within or near the brain, such as cysts, granulomas, malformations of the intracranial arteries and veins, and tumours or lesions of the pituitary are not covered.

Coma - The diagnosis of a coma must indicate that permanent neurological deficit is present.

Coronary Artery Bypass Graft - The diagnosis of the condition that necessitates a coronary artery bypass graft must be made by a cardiologist and based on angiographic evidence of the underlying disease.

Heart Attack - The diagnosis of heart attack must be based on an event which contains all of the following criteria:

  • associated new electrocardiographic (EKG) changes which support the diagnosis;
  • concurrent diagnostic elevation of cardiac enzymes above normal levels; and
  • confirmatory imaging studies such as thallium scans, MUGA scans, or stress echocardiograms.

Heart Valve Replacement - means replacing any heart valve with either a natural or mechanical valve. The surgery must be recommended and performed by a physician in Canada. The insured member must survive for 30 days following the date of the surgery.

Kidney (Renal) Failure - The diagnosis of end stage renal disease must be based on chronic irreversible failure of the function of both kidneys requiring regular hemodialysis or necessitating kidney transplant.

Life Threatening Cancer - first manifested while the insured member’s insurance under this contract is in effect, which is characterized by the presence of a malignant tumour and by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Life threatening Cancer includes leukemia, Hodgkin’s disease, lymphoma and invasive malignant melanoma as well as cancers for which chemotherapy or radiation treatments have been recommended.

Life Threatening Cancer does not include the following forms of cancer:

  • malignant melanoma to a depth of .75 mm or less;
  • carcinoma in situ;
  • basal cell carcinoma and squamous cell carcinoma of the skin that have not metastasized;
  • early prostate cancer diagnosed as T1a or T1b; and any tumour in the presence of any Human

Immunodeficiency Virus (HIV);

  • pre-malignant lesions, benign tumours or polyps;
  • stage A colon cancer;
  • stage 1 Hodgkin’s disease (unless requiring chemotherapy and/or radiation treatments).

Definitions

  • Basal cell carcinoma - a skin cancer that arises in the basal cells, which are at the bottom of the epidermis (outer layer of skin).
  • Carcinoma in situ - the cancer is superficial and has not penetrated into the organ involved.
  • Malignant melanoma to a depth of .75 mm or less - a cancerous mole which is .75 mm or less when measured under a microscope.
  • Metastasized - spread of the cancer from one part of the body to another.
  • Squamous cell carcinoma - a skin cancer that arises from the upper part of the epidermis (outer layer of skin).

Partial Payment for Non Life Threatening Cancer - Non Life Threatening Cancer must be positively diagnosed by a physician and supported with pathological report. The benefit will provide 25% of the Principal Sum for the following conditions:

  • Malignant melanoma to a depth of 0.75 mm or less, excluding malignant melanoma in situ;
  • Basal or squamous cell carcinoma that has spread beyond the deepest layer of skin and has not metastasized;
  • Ductal carcinoma in situ of the breast;
  • Early prostate cancer diagnosed as T1a or T1b; or
  • Any tumour in the presence of any Human Immunodeficiency (HIV).

Upon payment of the partial payment for Non Life Threatening Cancer, the insurance of the insured member remains in effect with the Principal Sum reduced by the amount of the partial payment. Only one claim per condition is permitted for partial payment for Non Life Threatening Cancer.

Loss of Sight, Speech, or Hearing in Both Ears - The diagnosis of loss of sight, speech or hearing must be made by a licensed specialist in that field of medicine. The diagnosis of loss of sight must indicate that corrected visual acuity must be worse than 20/200 in both eyes or the field of vision must be less than 200 degrees in both eyes.

The diagnosis of loss of speech must be established for a continuous period of 12 months. Psychiatric related causes are not covered. The diagnosis of loss of hearing must include audiometric and sound threshold tests. The auditory threshold cannot be more than 90 decibels.

Major Organ Transplant - The diagnosis is a result of a condition that necessitates a major organ transplant.

Motor Neuron Disease - is defined as a definitive diagnosis of 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 entities. A diagnosis of Motor Neuron Disease must be made by a Physician who is a certified neurologist.

Multiple Sclerosis - The unequivocal written diagnosis by a physician who is certified as a neurologist confirming at least moderate persisting neurological abnormalities, with impairment of function, but not necessarily confining to a wheelchair or bed.

Paralysis - Quadriplegia, Paraplegia, Hemiplegia - The diagnosis of paralysis must include documented evidence of the illness or injury that caused the paralysis.

Parkinson’s Disease - is defined as primary idiopathic Parkinson’s Disease which is characterized by a minimum of two or more of the following clinical manifestations:

  • tremors 
  • muscle rigidity
  • bradykinesis, (abnormal slowness of movement, sluggishness of physical and mental responses)

All other types of Parkinsonism are specifically excluded.

In addition, the insured member must require substantial physical assistance from another adult to perform two or more of the activities of daily living.

Severe Burn - The diagnosis of severe burn must be a result of suffering a full thickness or third degree burn covering 20% or more or the body.

Stroke - The diagnosis of stroke must be made by a licensed neurologist and based on documented neurological deficits and confirmatory neuroimaging studies.

This website describes the conditions of eligibility, coverage and claims procedures under the Teamsters and Toronto Ready Mix Producers Benefit Plan Fund. The Board of Trustees are solely responsible for establishing the eligibility rules of the Trust Fund.

Downloads

Claim Forms:

Brochures:

Others:

*Please note that some changes were made to the booklet after April 2018 and these have been highlighted in red for your information.

Teamsters and Toronto Ready Mix Producers Benefit Plan Fund
c/o Benefit Plan Administrators
90 Burnhamthorpe Road West, Suite 300
Mississauga, Ontario L5B 3C3