frequently asked questions (faqs)welcome to canopy this leaflet has been prepared to introduce you...

FREQUENTLY ASKED QUESTIONS (FAQS)

W E L C O M E T O C A N O P Y

this leaflet has been prepared to introduce you to Canopy Insurance Limited and to provide answers to frequently asked questions. The Canopy Team looks forward to serving you; we are here for you 24/7/365.

A B O U TC A N O P Y

1. Who is Canopy?

Canopy Insurance Limited is a newly formed Group Life and Health Insurance Company powered by two renowned Jamaican companies, GraceKennedy and Musson. Its mission is to remove the hassle of Health Insurance administration and consistently deliver delightful service to its customers.

2. What are some of the differences?

• Mobile and desktop-friendly Online Member Portal• Track claims status and history• View benefit balances• View detailed health and life coverages• Add or change dependents• Upload paper claims• Submit preauthorization requests• Request replacement health cards• Look up participating providers• Canopy Live Chat, which allows you to

communicate with a Customer service associate in real time.

• Automated email / SMS confirmation messages to mitigate fraud & abuse

• 24-hour toll-free number for customer contact any time of day or night

• Ability to swipe for out of hospital maternity benefits

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FA Q S

Canopy Health Insurance

3. Does Canopy offer Individual Health?

Currently Canopy does not.

4. How can I contact Canopy Insurance?

Canopy Insurance Limited is located at Building 1, 58 Half-Way tree Road, Kingston 10Telephone numbers are 876 654 7205 or 876 654 838124-hour toll free number is 888 4CANOPY (888 422 6679)Website is www.canopy-insurance.comEmail address is [email protected]

2Canopy Health Insurance

H E A L T H C A R D S

5. Will Canopy provide benefit and swipe health cards?

Yes, we will

6. What happens if my card is lost or stolen?

You are asked to report it immediately to Canopy. You may ask HR to request the replacement cards for you, or you may request it yourself via Canopy’s Online Member portal.

7. Is there a replacement fee for cards?

Canopy urges you to store your cards safely. Should a replacement become necessary, Canopy will replace your first set of cards free of cost. For subsequent requests the cost will be $300 for the benefit card and $300 for the swipe card.

8. If I am covered by two plans insured by Canopy, can I use both cards?

Yes, you can. The card on which you are the employee is to be used first.

9. If I am covered by two plans, one insured by another Health Insurance carrier, can I use both cards?

Yes, you can. You must present the one on which you are the employee first.

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FA Q S


D E P E N D E N T S

10. Who are defined as dependents?

Your spouse, children, stepchildren, legally adopted children and foster children

11. If I wish to change my spouse, what is the procedure?

A change of spouse can be facilitated. You will be required to complete the Change Request form providing the necessary information as well as the Health History questionnaire. There is a waiting period of 6 months before a new spouse can be added.

12. Is there a limit to the number of dependent children that I can cover?

No, once they qualify as dependents; please note that birth certificates are always required; in the case of adopted children the formal documents are required, and in the case of guardianship, the legal documents are required.

13. Is there an age limit for dependents?

Spouse should be under age 75 at date of entry to the plan, while dependent children are covered up to attainment of 27th birthday. Coverage ceases earlier if the dependent child marries or is employed.


S O M E H E A L T H I N S U R A N C E T E R M S E X P L A I N E D

14. What is co-insurance?

15. What is a deductible?

A small, fixed amount or percentage, outlined in the Schedule of Benefits, that a member pays each time a covered service is provided.

A deductible is the amount you will have to pay out of pocket for covered health care services before benefits will be paid from Major Medical.

This deductible amount is to be paid only once per contract year and not each time there is a claim. It may be accumulated over a period of 3 months. It is non-refundable; coinsurance will not count towards your deductible.

Co-insurance paid by insured member

Remaining cost paid by Canopy health

MEDICAL BILL

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FA Q S


16. What is Major Medical?

Major medical is a buffer that offers additional coverage for the costs associated with a serious illness or catastrophic care, after the basic benefits on your plan have been fully used. Major Medical helps with the high costs of surgical and hospitalization expenses, prescription drugs and diagnostic services, complications of maternity, chemotherapy, radiation, renal dialysis and other services.

Major Medical has a set amount (deductible) which a member is responsible for paying. Once that is met, Major Medical covers 80% of the eligible expense, with the member paying the coinsurance of 20%. Major medical is subject to a Lifetime maximum.

17. What is the meaning of UCR?

UCR means Usual Customary and Reasonable. Medical professionals set their fees, which varies within the same specialties for the same services. UCR applies to different benefits outlined in your Schedule of benefits, in particular surgery. UCR is the reasonable and customary fee being charged by providers in a geographic area for the same or similar medical service. The allowable benefit paid is based on the determined UCR.


18. Are Dental and Optical covered under major medical?

Dental and Optical are Riders and are subject to the Dental and Optical maximums stated in the Schedule of Benefits. However, diseases of the eye which require treatment and surgical intervention by an ophthalmologist are covered under major medical. Root Canal treatment and Permanent crowns are also included under Major medical.

19. How will the change from my current Insurance carrier to Canopy affect my Major Medical Lifetime Maximum?

Your coverage with Canopy will be a new policy; the history from your previous insurance carrier will not be shared with Canopy, so all your benefits will start over, both annual and lifetime limits. The full Lifetime maximum will be available under Canopy.

20. Please explain how credit facilities for maternity will work.

One of Canopy’s differences is that a member can use the Canopy swipe card to access out of hospital maternity benefits. Fifty percent (50%) of the maternity maximum will be available for out of hospital expenses and the other 50% for in hospital expenses.

The amount for out of hospital expenses will be used for Ante-natal visits/Diagnostic services. There will be a limit per ante-natal visit and a limit on the number of covered visits; the remainder will be allocated to Diagnostic services.

In cases where a member does not use any of the maximum benefit allotted for antenatal visits or diagnostic services, or uses only a portion, this difference will be added to the In-hospital amount of the maternity benefit.

The benefit for in hospital (Delivery/Hospitalization), will be on a reimbursement basis. However, by prior arrangement between you, your doctor and Canopy, it may be possible to facilitate credit.

S O M E B E N E F I T S E X P L A I N E D

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FA Q S


21. How do I know my benefit balance?

This information is accessible from Canopy’s customer service associates, via our 24-hour toll-free number and can also be obtained from your employee portal.

O V E R S E A S T R E A T M E N T

22. What happens if my condition cannot be treated locally?

Although your Health plan is a local one, designed to cover services rendered in Jamaica, Canopy has made allowances for conditions that cannot be treated locally. A letter of referral is required from your attending consultant, and this will be reviewed by Canopy’s Medical Consultant. Once approved, a pre-authorization letter is provided. Please note that your electronic card can be swiped in Jamaica only, so services accessed overseas will have to be paid up front and claims submitted for reimbursement. Charges will be converted to Jamaican currency, using official rates of exchange that apply to each service date, and settlement will be made in Jamaican dollars, based on these converted charges. Benefits are paid from Major Medical and the maximum reimbursement will be subject to the Major Medical Lifetime balance.

23. Suppose I did not seek approval before going overseas for treatment, will the claim be paid?

Yes. Reimbursement will be based on local charges for similar services, and not based on the currency of the claim.

24. How do I access Overseas Emergency Medical Services? (if applicable)

If you have a medical emergency while travelling overseas, your Provider should call Canopy’s toll-free number. After receiving the call, and obtaining answers to a few questions, Canopy will determine whether your condition satisfies the definition of Emergency.


Do remember that OEMS is available only in the event of a medical emergency, defined as:

Serious dysfunction or impairment to a bodily organ or part or to vital bodily functions, caused by injury or the sudden unexpected onset of sickness.

Such sickness must be of a severe nature that immediate medical care has to be given. Examples include uncontrolled bleeding, poisoning, heart attack, stroke, convulsions and loss of consciousness.

A medical emergency must not be related to a pre-existing condition.

The OEMS benefit is valid for a 30-day trip.

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FA Q S


P A R T I C I P A T I N G P R O V I D E R S

25. How will I know if my Health care provider accepts Canopy Health card?

The list of Canopy participating providers will be accessible from your Canopy Online Member Portal after enrollment.

26. If I am at a Provider and when my card is swiped there is an issue, what should I do?

Ask the Provider to contact Canopy or you may contact Canopy using our toll-free number


A B O U T C L A I M S

27. What are the requirements for a surgical procedure?

Pre-authorization is required; your doctor will submit a request to Canopy outlining the diagnosis, type of procedure and cost. Canopy will respond to the doctor within 48 hours.

28. How long does a referring letter from a specialist remain valid?

A referral is valid for 180 days from the date of the letter.

29. How are paper claims submitted?

Submission of paper claims is an alternate method to swiping your card. Please ensure that the Canopy claim form is properly completed. Claim forms will be available at your HR department or downloadable from your Online Member Portal. You have the following options for submission of your paper claims:

1. Scan and upload the paper form and receipts via Canopy Online Member Portal;

2. Submit the hard copies directly to Canopy’s office at 58 Half Way Tree Road

3. Leave the claim form and receipts with HR or your Broker

30. How long will I have to wait for my claim to be settled?

Properly completed claims will be paid within five (5) to ten (10) business days.

31. If I have elected reimbursement directly to my account, how will I be informed when the payment has been made?

Canopy will send you an Explanation of Benefits (EOB) via email. You may also log in to the Online Member Portal using your credentials and the information will be available under “Track Claims”.

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FA Q S


32. How long does it take for you to have a record of claim details reflected on the portal?

Within 24 hours of settling the claim.


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FA Q S


Customer Service:888-4- CANOPY (888-422-6679)

Office Address:58 Half Way Tree RoadKingston 10

Website:www.canopy-insurance.com

frequently asked questions (faqs)welcome to canopy this leaflet has been prepared to introduce you...

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