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Open Communication
The Corporation recommends that insurers and third party administrators of employee benefit plans inform their customers about pooling arrangements, particularly the annual factor included in the insurance premium or added to the fee (depending on whether it is an insured or non-insured plan).
Where applicable, the Corporation also recommends reporting any difference between the premium that includes the actual annual pooling factor and the offer they make to their clients. This transparency ensures that customers become members on the basis of a clear understanding of the mechanisms in place.
It is up to insurers and administrators to ensure that their financial arrangements are adequate; in case of major claims, the Corporation unfortunately cannot reimburse shortfalls resulting from an underestimation of the cost of the annual protection. Read more
By duly completing and signing the Compliance Certificate, the participant…
A Compliance Certificate that accurately reflects the operations of a participant allows the Corporation not only to fulfill its mandate, but also to justify the amounts received or granted at the time of compensation. Read more
At first glance, tweaking group size* may seem advantageous because the annual pooling factor paid to the Compensation Table is lower than if it reflected the actual size of the group.
However, a participating insurer or benefit plan administrator that continued to interpret the rules to its own advantage in this way would risk a refusal by the Corporation to pay compensation in the event of a very large claim. The participant would then have to cover this claim alone, which could jeopardize continued coverage of the cost of pharmaceutical services and medications for the group.
Moreover, penalties are prescribed by law both for a participant who acts wrongfully (Act respecting prescription drug insurance, Sections 84 and 85), (lien vers URL de la loi sur le site) and for an insurance intermediary who makes statements that are incomplete, false, deceptive, or likely to mislead (measures imposed by the authorities overseeing stakeholders who are subject to the Act respecting the distribution of financial products and services).
* For example by splitting groups or grouping them to pool certain risks in another way or to avoid participating in pooling.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space][/vc_column][/vc_row]
