The same benefits described above are commonly bundled in employer-sponsored group plans. Key features of the group context:
Participation requirements: most group plans require a minimum percentage of eligible employees to enrol (commonly 75 percent) and apply an actively-at-work requirement at enrollment. An employee on sick leave on the effective date is not yet eligible.
Evidence of insurability (EOI): employees who enrol during the initial enrollment window are admitted without medical underwriting up to the non-evidence maximum (NEM). Employees who join late or who apply for coverage above the NEM must provide evidence of insurability, which means completing a medical questionnaire and possibly undergoing examination or medical tests.
Late applicant: an employee who does not enrol during the initial window and later wants to join must provide EOI. The insurer may decline, exclude specific conditions, or approve with a loading.
Coordination of benefits (COB): when a member is covered under more than one plan (e.g., their own employer plan plus a spouse's plan), COB rules prevent the combined benefit from exceeding the actual expense.
The standard Canadian COB order of priority:
- The plan under which the claimant is an employee (as a member, not a dependent) pays first.
- The plan under which the claimant is a dependent pays second.
- For dependent children with parents who are both members, the birthday rule applies: the plan of the parent whose birthday falls earlier in the calendar year pays first.
Exam application: a scenario often presents a couple where both spouses have group coverage and asks which plan pays first for a dependent child's dental claim. Apply the birthday rule: the parent whose birthday is earlier in the year (January 10 vs. March 15, for example) has the primary plan for the child.