How to Read a Canadian Benefits Statement

Medically necessary hospital and physician services are billed directly to your provincial plan under the Canada Health Act, and no statement is issued to you.^[1] A benefits statement — sometimes labelled an explanation of benefits or claim summary — comes from a private insurer such as Sun Life, Manulife, Canada Life, Green Shield, Desjardins or a provincial Blue Cross, and covers things the public plan excludes: prescription drugs, dental, vision, paramedical services, medical equipment and travel claims.^[2]

A benefits statement is not a bill. If money is owed, it will appear separately on the provider's invoice.

• Claim number and date of service — quote both in any phone call.
• Provider and service — who was paid, and for what category.
• Submitted / charged amount — what the provider actually billed you.
• Eligible amount — the portion the plan recognizes. Often lower than the charge because of a fee guide cap or a per-visit limit.
• Reimbursement level / coinsurance — commonly 80% or 100% of the eligible amount, not of what you paid.
• Deductible applied — less common in Canada, but present on some plans.
• Amount paid — to you, or directly to the provider if the claim was assigned.
• Annual maximum and remaining balance — per category, e.g. $500/year for physiotherapy, or a combined paramedical pool.
• Reason / explanation codes — the insurer's shorthand for any reduction.

Note where the 80% is applied: to the $90 eligible amount, not the $120 charge. That is the most misread number on any Canadian benefits statement.

• "Exceeds reasonable and customary" — the charge is above the plan's fee guide; the excess is yours.
• "Annual maximum reached" — the category pool is exhausted until the plan year resets.
• "Frequency limit exceeded" — e.g. one eye exam every two years.
• "Requires prior approval" — pre-authorization was needed, common for major dental and equipment.
• "Not an eligible expense" — excluded by the contract; ask for the clause.
• "Referral required" — a physician referral must be on file.
• "Submitted after the deadline" — usually 90 days to 12 months after service.
• "Coordination of benefits — submit to primary carrier" — the other plan pays first.

If you and a spouse both have coverage, submit to your own plan first, then send the statement showing the unpaid portion to the second plan. For dependent children, the standard rule is that the parent whose birthday falls earliest in the calendar year is the primary payer. Between them, two plans frequently reimburse close to 100% — but only if you submit the first statement to the second insurer.

• Claim unreimbursed amounts through a Health Care Spending Account, if your employer offers one.
• Keep official receipts for the Medical Expense Tax Credit — only the portion you weren't reimbursed for is claimable.^[3]
• Check whether a provincial program covers it (drug plans, assistive devices, senior benefits).
• Ask the provider whether they bill the insurer directly next time, so you're not out of pocket.

Start with the insurer's member line and ask for the specific contract wording behind the reduction. If that fails, escalate through the insurer's formal internal appeal, and then to the OmbudService for Life & Health Insurance, a free and independent service for unresolved complaints against Canadian life and health insurers.^[4] Provincially regulated plan issues can also go to your provincial insurance regulator.