Health and Dental Coverage After Separation in Ontario

If you are covered under your spouse's workplace health and dental plan, separation can feel like a threat to prescriptions, glasses, dental work and counselling that you rely on. The worry is reasonable, and it is worth acting on early.

This article explains who decides whether coverage continues, how children's coverage is treated in support cases, and how to deal with the issue in a separation agreement in Ontario. It cannot tell you what your particular plan says, because that is set by your plan.

Does a separated spouse stay on the plan?

There is no general statute that answers this. Whether a separated or divorced spouse stays on a workplace group plan depends on the plan contract and the insurer. Some plans define a spouse in a way that ends coverage at divorce, others earlier, and some allow a transition period. You cannot safely assume either way.

The plan booklet and the plan administrator, often a human resources department or benefits provider, are the best places to find the answer. Ask in writing so you have a record.

• How the plan defines a spouse, and whether that includes a separated spouse.
• What event ends a spouse's coverage: separation, divorce, or a notice from the plan member.
• Whether the plan member can remove a spouse without the spouse's agreement.
• Whether you can convert to an individual policy, and how soon you must apply.

What happens to the children's coverage

Children are treated differently from spouses. In making a child support order, where medical or dental coverage for the child is available to either parent through an employer or otherwise at a reasonable rate, the court may order that the coverage be acquired or continued. This is found in the Ontario Child Support Guidelines, and in the Federal Child Support Guidelines for divorce cases.

Even with coverage, some costs fall outside it. Child support special expenses include health-related expenses that exceed insurance reimbursement by at least $100 a year, such as orthodontic treatment, counselling, physiotherapy, prescription drugs, hearing aids and glasses. How those costs are shared is something to settle in the agreement or order.

Keeping coverage in your agreement

A separation agreement can be made by two people who cohabited and are living separate and apart. It is unenforceable unless it is in writing, signed by the parties and witnessed. A verbal promise to keep you on the plan will not hold up.

A court may also set aside a domestic contract, including a separation agreement, if a party failed to disclose significant assets, debts or other liabilities. Ask for plan details and be open about your own, so the agreement is built on accurate information.

• Which parent keeps the children on their plan, and for how long.
• Who pays any premiums and who pays the deductible or co-payments.
• How uninsured health and dental costs are shared, including those above the $100 a year threshold.
• Whether the plan member must tell the other parent if coverage changes or ends.
• What happens when the plan member changes jobs or the plan is replaced.

Be realistic about the spouse's own coverage. Because it depends on the plan contract, an agreement that says the plan member will keep you on the plan may not be something the insurer will honour. Raise this with a lawyer before you sign.

Planning for a gap in your own coverage

If you may lose coverage, work out your options before the date it ends. Check whether you have a plan of your own through work, school or a professional association, and ask insurers about individual policies. Book any needed dental or vision care while you are still covered, if the plan allows.

If you have ongoing prescriptions or treatment, speak to your pharmacist or provider about options. If the cost of replacement coverage is a real issue in your finances, it can be raised when support is discussed.

What to do next

• Get a copy of the plan booklet and the names of the plan administrator and insurer.
• Ask in writing how and when a spouse's coverage ends.
• Confirm that the children are covered, and by whom.
• Gather recent benefit statements to show the health and dental costs your family has.
• Contact a Family Law Information Centre for general information about separation.
• Have a lawyer review any coverage terms before you sign an agreement.

Ontario's Family Law Information Centres are free services across Ontario that give information about separation, divorce and related family law issues, with information and referral coordinators and duty counsel provided by Legal Aid Ontario.

Frequently asked questions