What are the common visitor insurance exclusions in Canada?

Common visitor insurance exclusions in Canada include pre-existing medical conditions that do not meet stability requirements, routine medical care, high-risk activities, and expenses related to alcohol or drug use. Policies may also exclude non-emergency treatments, travel against medical advice, and claims arising from undisclosed medical conditions. Understanding these exclusions can help visitors choose the right coverage and avoid unexpected claim denials.

Quick glance at common exclusions

What is not covered by visitor insurance to Canada?

While visitor insurance provides essential coverage, a few things can still be excluded. Here are a few things that are not covered by visitor insurance for Canada:

Unstable pre-existing conditions

A medical condition is generally considered unstable if it has changed, required new treatment, involved medication changes, or prompted medical consultations during the policy’s stability period. Claims related to these conditions are, in most cases, excluded from coverage. However, many visitor insurance plans cover pre-existing medical conditions if they have remained stable for a specified period, typically between 90 and 180 days before the policy’s effective date.

Non-emergency procedures

Since health insurance for tourists is for emergency medical care only, it does not cover non-emergency procedures. It excludes coverage for planned surgeries, routine checkups, preventive care, elective surgeries (such as liposuction or cosmetic procedures), holistic treatments, or any care that insurers do not consider medically necessary.

Pregnancy and maternity

Visitor insurance plans do not cover routine pregnancy-related care, including prenatal checkups, childbirth, postnatal care, and fertility treatments. However, some policies may provide limited coverage for unexpected pregnancy-related medical emergencies, subject to policy terms and gestational age restrictions.

Mental health care

Any ongoing mental health treatment, counselling sessions, psychotherapy, and other non-emergency psychiatric services are excluded from the visitor insurance policy. 

Injury or death due to involvement in high-risk activities

Injuries or death resulting from participation in high-risk or hazardous activities are excluded. Examples of high-risk activities include skydiving, bungee jumping, mountaineering, scuba diving beyond recreational limits, motor racing, and other extreme sports. However, TuGo is the only insurance company in Canada that offers a Sports and Activities Coverage add-on that can provide substantial coverage if you participate in some high-risk activities.

Alcohol-related or self-inflicted injuries

Any claims arising from excessive alcohol consumption, drug use, or intentionally self-inflicted injuries are excluded from visitor insurance policies. Self-inflicted injuries also extend to injuries sustained from reckless behaviour or intentional harm. 

Travel against medical advice

Coverage will not be offered if you travel against the advice of a physician or while awaiting medical treatment, test results, or surgery. Visitor insurance providers will also exclude claims related to medical conditions that existed before travel if a health care provider advised against travelling due to those conditions.

Common visitor insurance limitations to understand

Visitor insurance exclusions and limitations are often confused, but they are not the same. An exclusion refers to something the policy does not cover at all, while a limitation means coverage is available but subject to certain restrictions, such as time limits, coverage caps, waiting periods, or eligibility requirements. In the section below, let’s take a closer look at the limitations of a visitor insurance policy:

• Coverage is focused on medical emergencies: Visitor insurance is primarily designed to cover unexpected medical emergencies. Coverage for follow-up care after an emergency may be limited, and benefits for routine medical care or non-emergency treatment are generally restricted
• Follow-up care is limited: Some policies include follow-up care after a covered emergency, but the benefit is usually restricted. For example, Secure Travel has follow-up visits restricted to 3 for both Standard and Enhanced plans
• Side-trip coverage: Most insurers, including Secure Travel, Destination Canada, MSH, and others, offer side-trip coverage under Visitor insurance. But the coverage is often limited, and is only applicable when the trip starts and ends in Canada. Moreover, the number of days covered is also limited. For example, Secure Travel provides a maximum side-trip coverage of 30 days per visit 
• Waiting periods: If you purchase visitor insurance after arriving in Canada, coverage can be limited, and a waiting period may apply. For example, Manulife’s Standard Visitor insurance plan has a waiting period of 72 hours if purchased within the first 30 days after arrival

What is usual, customary & reasonable (UCR) in visitor insurance coverage?

In a visitor health insurance, the ‘usual, customary & reasonable’ is the maximum amount for which your insurer will pay. It is basically determined by what the hospitals or health care centres in your area are charging for that particular service. Insurance companies maintain a database of UC&R for various provinces and review the claims based on it. If the claim is excessively higher than the standard cost of the treatment, they will not provide coverage for it.

Breaking down UCR for visitors:

• Usual: The amount a healthcare provider typically charges patients for a specific medical service or procedure
• Customary: The typical price range charged for the same service by the majority of the healthcare providers in the same geographic area
• Reasonable: A charge that is considered appropriate based on factors such as the complexity of the treatment, the resources required, and local market rates

Example: If the cost of a kidney stone surgery is around $1,000 in Ontario as per the UC&R rate, and your hospital charges $2,000 for the same procedure, you will not receive coverage for the additional $1,000 that is not eligible under the UCR clause. 

What should visitors do if their insurance policy has a significant exclusion?

If a policy has a significant exclusion, visitors should consider purchasing supplemental coverage or a different policy that provides the needed protection. For example, visitors who want to engage in adventure activities during their trip can buy an adventure and sports activities rider from TuGo. It is also advisable to review exclusions thoroughly before purchasing a plan. 

Does visitor insurance cover pregnancy in Canada?

Visitor insurance plans do not cover routine pregnancy care, prenatal checkups, delivery, or newborn expenses. However, some policies may cover unexpected pregnancy-related emergencies, such as complications that require urgent medical treatment, if they occur unexpectedly and within the policy terms.

Are mental health emergencies covered under visitor insurance?

Visitor insurance to Canada will not cover any expenses related to ongoing therapy, counselling, psychiatric follow-ups, or pre-existing mental health conditions. 

Are there any policies that cover all types of medical care without exclusions?

No policy covers all types of medical care without exclusions. All insurance plans come with specific exclusions, but some may offer more comprehensive coverage than others. It is essential to compare policies and choose one that provides the best balance of coverage and cost.

What steps should be taken in case of a medical emergency if the insurance policy has limitations?

In case of a medical emergency, visitors should immediately contact their insurance provider to understand the coverage and limitations. They should also follow the prescribed steps in their policy for emergencies to ensure maximum coverage and avoid claim denials.

Are injuries from adventure sports like skiing or skydiving excluded from visitor insurance in Canada?

Most visitor insurance providers in Canada exclude injuries from adventure sports such as skiing or skydiving. Companies like TuGo offer coverage for injuries arising from high-risk activities, but the premium costs may be significantly higher.

Are cosmetic surgeries or elective procedures covered under visitor insurance policies in Canada?

No, visitor insurance in Canada does not cover elective procedures and cosmetic surgeries. It is primarily designed to protect visitors in Canada from medical emergencies.