Employee benefits glossary
Plain-language definitions for common group benefits, health and dental, life and disability, claims, eligibility, and plan administration terms.
Use this glossary to reduce confusion, support employee communication, and prepare better questions before a plan review, renewal, enrolment change, or claims conversation.
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General Benefits Terms
General Benefits Terms
The amount a plan may pay once a claim meets the plan’s eligibility, documentation, and reimbursement rules.
Useful when explaining why a submitted expense and the paid amount may differ.
General Benefits Terms
The insurer’s process for deciding whether a product, service, drug, treatment, or supply fits the plan’s coverage criteria.
Helps employers explain why coverage can change or require additional review.
General Benefits Terms
The date a person’s benefits begin, based on eligibility, enrolment timing, waiting period, and active-work status.
Important during onboarding, new hires, life events, and plan changes.
General Benefits Terms
The amount a covered person pays before the plan starts reimbursing eligible expenses.
Some plans have no deductible; others apply one each year or by benefit type.
General Benefits Terms
A cost the plan may cover because it fits the plan rules, is medically or dentally appropriate, and is not already paid elsewhere.
One of the most important terms for claim expectations.
General Benefits Terms
A drug that has the required regulatory approval and has also been accepted under the plan’s drug review rules.
Regulatory approval alone does not always mean the plan will cover it.
General Benefits Terms
The window after a person becomes eligible when they should enrol to avoid late-applicant rules.
Missed enrolment windows can create evidence, delay, or limit issues.
General Benefits Terms
Someone who applies for coverage after the plan’s required enrolment period has passed.
Late applicants may face evidence of insurability or temporary limits.
General Benefits Terms
The employee or other covered person enrolled in the group benefits plan.
Often the primary person through whom dependent coverage is arranged.
General Benefits Terms
A spouse or eligible child who qualifies for coverage under the member’s plan.
Eligibility depends on age, student status, dependency, disability, and plan wording.
General Benefits Terms
A legal spouse or common-law partner who meets the relationship requirements in the plan.
Plans usually cover one spouse at a time.
General Benefits Terms
A major family change, such as marriage, separation, divorce, birth, adoption, or a dependent eligibility change.
Life events often trigger enrolment or coverage update opportunities.
General Benefits Terms
Public health, drug, dental, or medical coverage provided by federal, provincial, or territorial governments.
Group benefits are usually designed to supplement, not replace, public coverage.
General Benefits Terms
The process insurers use to decide which plan pays first when a person has coverage under multiple plans.
Helps avoid overpayment while allowing families to use both plans properly.
General Benefits Terms
The option, in some situations, to move from group coverage to individual coverage after group benefits end.
Time limits and eligibility rules usually apply.
General Benefits Terms
The point when benefits end because of retirement, job change, loss of eligibility, age limits, or plan termination.
Employers should communicate this clearly during offboarding.
General Benefits Terms
A feature that may continue certain dependent benefits for a period after the covered member dies.
Plan-specific, but helpful for family protection conversations.
General Benefits Terms
Health or personal information an insurer may require before approving certain types or amounts of coverage.
Often relevant for late applicants, optional coverage, or amounts above a limit.
General Benefits Terms
The maximum amount of insurance available without requiring evidence of insurability.
Useful for explaining guaranteed issue limits.
General Benefits Terms
The length of time an employee must work before becoming eligible for benefits.
Usually set by the employer’s plan design.
Health and Dental Terms
Health and Dental Terms
Coverage that helps pay for eligible health-related costs not fully covered by a government health plan.
Often includes drugs, paramedical services, supplies, and travel emergency coverage.
Health and Dental Terms
A charge that falls within the usual range for a similar service, product, or supply in a comparable area.
Plans may reimburse based on customary amounts rather than the full billed charge.
Health and Dental Terms
A medication specially prepared by a pharmacy when a standard manufactured drug does not meet the patient’s needs.
Coverage depends on the plan’s drug rules and review process.
Health and Dental Terms
The professional fee a pharmacy charges to prepare and provide a prescription.
Can affect the total cost of a drug claim.
Health and Dental Terms
A non-prescription drug that may be considered essential to sustaining life and may be eligible if the plan allows it.
This is plan-specific and usually subject to review.
Health and Dental Terms
Amounts added to the manufacturer’s drug price before the medication reaches the patient.
Useful when explaining drug-cost transparency.
Health and Dental Terms
A pharmacy that participates in an insurer’s preferred provider or pharmacy network.
May be relevant for cost control or specialty drug programs.
Health and Dental Terms
A licensed health professional who provides an eligible service within their professional scope.
Examples may include physiotherapists, chiropractors, counsellors, or similar providers.
Health and Dental Terms
A person, clinic, organization, or supplier approved to provide eligible services, supplies, or equipment.
The provider must meet licensing and plan eligibility requirements.
Health and Dental Terms
A provincial or territorial dental pricing guide used to help determine eligible dental claim amounts.
Dental reimbursement may be tied to the applicable guide.
Health and Dental Terms
A plan-specific dental schedule showing covered services, limits, frequencies, and eligible fees.
The plan schedule may differ from what a dental office charges.
Health and Dental Terms
Dental treatment needed because of a sudden external injury to natural teeth or dental prosthetics.
Often handled under health coverage rather than regular dental, depending on the plan.
Health and Dental Terms
Preventive and routine restorative services, often including exams, cleanings, fillings, and related care.
Usually the foundation of a dental plan.
Health and Dental Terms
More significant dental work, such as crowns, bridges, dentures, inlays, or onlays, depending on the plan.
Often reimbursed at a lower percentage or subject to larger maximums.
Health and Dental Terms
Support services that help coordinate medical care, transportation, or related help during a travel emergency.
Not the same as unlimited travel insurance; plan limits and trip-duration rules can apply.
Health and Dental Terms
A review that may be required before certain high-cost services, supplies, drugs, or equipment are covered.
Helps reduce claim surprises before care or equipment is purchased.
Health and Dental Terms
Health services provided by eligible practitioners outside a hospital or physician setting.
Common examples include massage therapy, physiotherapy, counselling, and chiropractic care.
Health and Dental Terms
Reusable medical equipment that supports care, mobility, monitoring, or daily function.
Plans often require medical documentation and may prefer rental before purchase.
Life, AD&D, and Disability Terms
Life, AD&D, and Disability Terms
Employer-sponsored life insurance that pays a benefit if an insured employee dies while covered.
The amount is usually defined in the schedule of benefits.
Life, AD&D, and Disability Terms
Life insurance that may pay a smaller benefit if an insured spouse or child dies while covered.
Offered by some plans, but not all.
Life, AD&D, and Disability Terms
Accidental Death and Dismemberment coverage, which pays a benefit for certain serious accidental losses.
Separate from regular life insurance and subject to specific loss definitions.
Life, AD&D, and Disability Terms
The base amount used to calculate AD&D payments.
Different losses may pay all or part of this amount.
Life, AD&D, and Disability Terms
A feature that may allow part of a life insurance benefit to be paid early if the insured person has a qualifying terminal condition.
Usually reduces the amount later payable to the beneficiary.
Life, AD&D, and Disability Terms
A provision that may pause premium payments when a covered person meets the plan’s disability criteria.
Rules differ by benefit and insurer.
Life, AD&D, and Disability Terms
The earnings used to calculate certain insurance or disability benefits.
May include or exclude bonuses, overtime, commissions, or other income depending on plan wording.
Life, AD&D, and Disability Terms
Earnings after required taxes and compulsory government deductions.
Sometimes relevant when integrating disability benefits.
Life, AD&D, and Disability Terms
The length of time a disability benefit may be payable after the waiting or elimination period is satisfied.
May end at a stated age, retirement, recovery, or another plan limit.
Life, AD&D, and Disability Terms
The continuous period of disability that must pass before disability benefits may begin.
Comparable to a waiting period for disability benefit payments.
Life, AD&D, and Disability Terms
A condition that prevents a person from performing the duties required under the plan’s disability definition.
The definition can change over the course of an LTD claim.
Life, AD&D, and Disability Terms
A situation where a person can work in a limited way but still has reduced capacity and earnings because of the same illness or injury.
Important for gradual return-to-work planning.
Life, AD&D, and Disability Terms
A disability that returns from the same or related cause after a previous disability claim.
May affect whether a new elimination period applies.
Life, AD&D, and Disability Terms
A work-related or training-based plan intended to support a disabled employee’s return to employment.
Can involve modified duties, training, or vocational support.
Life, AD&D, and Disability Terms
An illness or injury that existed, was treated, or was medically reviewed before coverage or an increased amount of insurance began.
Can limit some claims depending on timing and plan wording.
Life, AD&D, and Disability Terms
Pre-disability earnings adjusted over time using a stated inflation measure.
Relevant to some long-term disability calculations.
Life, AD&D, and Disability Terms
The process of reducing LTD benefits when other disability, retirement, workers’ compensation, or similar income is available.
Prevents total disability income from exceeding the plan’s intended level.
Life, AD&D, and Disability Terms
A person or estate designated to receive eligible life or AD&D proceeds, where the plan allows a designation.
Employers should encourage employees to keep beneficiary records current.
Claims, Eligibility, and Administration Terms
Claims, Eligibility, and Administration Terms
A request for the insurer to review and reimburse or pay an eligible benefit.
Claims usually require receipts, forms, medical information, or proof of loss.
Claims, Eligibility, and Administration Terms
The latest date a claim or proof of claim must be submitted for review.
Missed deadlines can result in unpaid claims.
Claims, Eligibility, and Administration Terms
A claim-payment arrangement where the insurer pays the pharmacy or provider directly for eligible expenses.
The member usually pays only the uncovered portion at the point of service.
Claims, Eligibility, and Administration Terms
A request to have claim payment made directly to a provider rather than reimbursed to the member.
Availability depends on the plan and insurer rules.
Claims, Eligibility, and Administration Terms
The insurer’s right to recover amounts that should not have been paid.
Can arise after eligibility changes, duplicate coverage, or claim errors.
Claims, Eligibility, and Administration Terms
The person or team responsible for administering the employer’s group benefits plan.
Often handles enrolment, changes, terminations, and employee questions.
Claims, Eligibility, and Administration Terms
The period after a premium or contribution due date when payment can still be made before the plan is terminated.
Usually important for employer plan administration.
Claims, Eligibility, and Administration Terms
The minimum percentage or number of eligible employees who must be enrolled for a benefit to remain in force.
Affects plan stability and insurer pricing.
Claims, Eligibility, and Administration Terms
The requirement that an employee be working regular duties, or otherwise considered capable of work, when coverage begins or changes.
Coverage can be delayed if the employee is not actively at work.
Claims, Eligibility, and Administration Terms
A temporary period away from work where coverage may continue if the plan rules and contribution requirements are met.
Employers should handle similar situations consistently.
Claims, Eligibility, and Administration Terms
A protected employment leave where benefits may continue if contribution arrangements are maintained.
Plan wording and employment standards rules should be reviewed.
Claims, Eligibility, and Administration Terms
The process for restoring coverage after an employee returns or becomes eligible again.
Timing matters; delays may create new waiting periods.
Claims, Eligibility, and Administration Terms
The most a plan will pay for a benefit during a stated period, or over a lifetime, depending on the benefit.
A key comparison point when reviewing plan quality.
Claims, Eligibility, and Administration Terms
The percentage of an eligible expense the plan pays after any deductible, limits, and plan rules are applied.
A plan can cover 80 percent of eligible costs without covering 80 percent of every billed amount.
Claims, Eligibility, and Administration Terms
A service, expense, situation, or condition the plan does not cover.
Exclusions should be explained clearly to reduce frustration.
Claims, Eligibility, and Administration Terms
A condition, cap, frequency rule, or timing rule that restricts how a benefit is paid.
Limits are often as important as the headline coverage.
Need context?
This glossary is designed to help employers, employees, HR teams, and plan administrators understand common terms related to group benefits, eligibility, coverage, claims, and plan administration in Canada.
Yes. Immix can help employers understand how plan design, claims experience, eligibility rules, funding structures, renewal terms, and insurer wording apply to their specific group benefits program.
No. This glossary is educational. Employers and employees should always review the specific wording in their benefits booklet, contract, insurer materials, and plan administration documents.
Benefits guidance
If a benefits term is raising questions about your current plan, renewal, claims experience, eligibility rules, or employee communication, Immix can help you understand what it means in practice.
