POLICY DOCUMENT for the NFU Mutual Level Temporary Assurance with Critical Illness Cover PROTECTION

Transcription

1 POLICY DOCUMENT for the NFU Mutual Level Temporary Assurance with Critical Illness Cover PROTECTION

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3 POLICY TERMS AND CONDITIONS CONTENTS Definitions Proof of the life assured s date of birth and what happens if you gave us the wrong date When does the policy pay out? 3. The critical illnesses covered 4. Paying your premiums during the period of cover What happens if you are late paying a premium? 6. What happens if you stop paying premiums or do not pay within a period of grace 7. How you can apply to restart a cancelled policy 8. What happens if the life assured commits suicide? 9. How to make a claim How to notify us if you transfer ownership of the policy to someone else 11. When the policy will not provide cover 12. The law governing the policy and changes to it Charitable assignment condition Level Temporary Assurance With Critical Illness Cover 03

4 DEFINITIONS The definitions below give the meanings of words we use throughout policy terms and conditions 1 to 12 and in the schedule, where they will appear in bold text. They do not apply to policy condition 13, which has specific defined terms contained within it. Throughout the policy words that we use in the singular will also include words in the plural, and words of the masculine gender will also include those of the feminine, unless the context requires otherwise. A reference to an Act of Parliament, or other regulation, includes any amendments or replacements after the date this policy is issued. application date means the date you applied to buy the policy. It is stated in your schedule. assignment means the legal transfer of ownership of the policy by the policyholder (the assignor) to another person or company (the assignee) as evidenced by a notice of assignment. cancer in-situ means the presence of malignant/ cancerous cells at a stage of development such that they have not spread into surrounding healthy cells or tissue. In medical terminology, this means that the cancer cells are confined to the epithelium (the tissue that lines the internal and external surfaces of the body). For malignant melanomas of the skin, this means that cancer cells are confined to the epidermis and may be categorised as Clark s level 1. clinical means relating to the observed symptoms and course of a disease. Diagnosis based on a study of the signs and symptoms of a disease. due date means the day in each month or year, as stated in your schedule when premiums are due. The schedule may include a special provision to allow monthly premiums instead of the yearly amount shown. eligible occupation means: the emergency services police, fire, ambulance the medical profession including: administrators, cleaners, dentists, doctors, nurses and porters the armed forces. end date means the date the policy ends. endorsement means a signed document we may issue to confirm an alteration or amendment to the policy. It forms part of the policy. histological/histologically means the appearance of the cancer under the microscope which leads to its diagnosis and, additionally, gives information on its differentiations or grading (how aggressive it may be). invasion means the occurrence of malignant/ cancerous cells that have spread into surrounding healthy cells and tissue (that is, more extensive than cancer in-situ). irreversible means cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of the claim. life assured means any person named in the schedule whose life is covered by the policy. period of cover means the period starting on the start date and ending on the end date, as shown in the schedule. permanent/permanently means expected to last throughout life with no prospect of improvement, irrespective of when the cover ends or the insured person expects to retires. permanent neurological deficit with persisting clinical symptoms means dysfunction in the nervous system that is present on clinical examination and expected to last throughout the insured person s life. To include numbness, hyperaesthesia (increased sensitivity), paralysis, localised weakness, dysarthria (difficulty with speech), aphasia (inability to speak), dysphagia (difficulty in swallowing), visual impairment, difficulty in walking, lack of coordination, tremor, seizures, dementia, delirium and coma. The following are not covered: An abnormality seen on brain scan or other scans without definite related clinical symptoms. Neurological signs occurring without symptomatic abnormality, e.g. brisk reflexes without other symptoms. Symptoms of psychological or psychiatric origin. policy means the policy document and the schedule with it. policyholder means the person named in the schedule, who is the legal owner of the policy. pre-malignant means cells which may develop into a malignant tumour but have not yet done so. premium means a series of payments you make either monthly or yearly on the due dates, in return for the cover set out in the schedule. registered office means the registered office of The National Farmers Union Mutual Insurance Society Limited, which is at Tiddington Road, Stratford upon Avon, Warwickshire, CV37 7BJ. schedule means a schedule issued as part of this policy, including any amendments made to it by endorsement and/or by the issue of replacement schedules. sum assured means the sum assured amount shown on the schedule. start date means the date when the policy starts, as shown on the schedule. UK means Great Britain and Northern Ireland, the Isle of Man and the Channel Islands. we, us or our means The National Farmers Union Mutual Insurance Society Limited ( NFU Mutual ). you or your means the policyholder, as named in the schedule, or the policyholder s legal personal representative, or any person we are satisfied is authorised to act on the policyholder s behalf. 04

5 1. PROOF OF THE LIFE ASSURED S DATE OF BIRTH AND WHAT HAPPENS IF YOU GAVE US THE INCORRECT DATE 1.1 Before we pay a claim under the policy we must receive satisfactory proof of the life assured s age. 1.2 If we have been advised of an incorrect date of birth, we will recalculate the level of benefit using the correct date of birth and the actual premiums paid. 2. WHEN DOES THE POLICY PAY OUT? 2.1 We will pay the sum assured to the person who is legally entitled to it if, during the period of cover, and providing the policy is still in force, the life assured: (a) dies, or (b) is earlier diagnosed with a critical illness covered under condition 3. The life assured must survive for at least 30 days after the date of diagnosis (or second HIV test under condition 3.11) before we can accept a claim. 2.2 The schedule shows any restrictions we have put on your cover. 3. THE CRITICAL ILLNESSES COVERED 3.1 Alzheimer s disease before age 65 a definite diagnosis of Alzheimer s disease before age 65 by a Consultant Neurologist, Psychiatrist or Geriatrician. There must be permanent clinical loss of the ability to do all of the following: remember reason; and perceive, understand, express and give effect to ideas. Other types of dementia. 3.2 Aorta graft surgery the undergoing of surgery for disease or trauma to the aorta with excision and surgical replacement of a portion of the diseased aorta with a graft. The term aorta includes the thoracic and abdominal aorta but not its branches. Any other surgical procedure, for example, the insertion of stents or endovascular repair. 3.3 Benign brain tumour a non-malignant tumour or cyst originating from the brain, cranial nerves or meninges within the skull, resulting in permanent neurological deficit with persisting clinical symptoms. tumours originating from bone tissue tumours in the pituitary gland angiomas and cholesteatoma 3.4 Blindness permanent and irreversible loss of sight to the extent that even when tested with the use of visual aids, vision is measured at 3/60 or worse in the better eye using a Snellen eye chart. 3.5 Cancer any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, sarcoma and lymphoma except cutaneous lymphoma (lymphoma confined to the skin). All cancers which are histologically classified as any of the following: - pre-malignant - non-invasive - cancer in-situ - having borderline malignancy; or - having low malignant potential. All tumours of the prostate unless histologically classified as having a Gleason score of 7 or above or having progressed to at least TNM classification T2bN0M0. Chronic lymphocytic leukaemia unless histologically classified as having progressed to at least Binet Stage A. Any skin cancer (including cutaneous lymphoma) other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin). 3.6 Coma a state of unconsciousness with no reaction to external stimuli or internal needs which: requires the use of life support systems for a continuous period of at least 96 hours; and with associated permanent neurological deficit with persisting clinical symptoms. medically induced coma Coma secondary to alcohol or drug abuse. 3.7 Coronary artery by-pass grafts the undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a Consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts. 3.8 Deafness permanent and irreversible loss of hearing to the extent that the loss is greater than 95 decibels across all frequencies in the better ear using a pure tone audiogram. 3.9 Heart attack death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction: Typical clinical symptoms (for example, characteristic chest pain). New characteristic electrocardiographic changes. Level Temporary Assurance With Critical Illness Cover 05

6 The characteristic rise of cardiac enzymes or Troponins recorded at the following levels or higher: - Troponin T > 200 ng/l (0.2 ng/ml or 0.2 ug/l) - Troponin I > 500 ng/l (0.5 ng/ml or 0.5 ug/l) The evidence must show a definite acute myocardial infarction. other acute coronary syndromes angina without myocardial infarction Heart valve replacement or repair the undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a Consultant Cardiologist to replace or repair one or more heart valves HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation. Infection by Human Immunodeficiency Virus resulting from: A blood transfusion given as part of medical treatment; A physical assault; or An incident occurring during the course of performing normal duties of employment (from an eligible occupation) after the start of the policy, and satisfying all of the following: The incident must have been reported to appropriate authorities and have been investigated in accordance with the established procedures. Where HIV infection is caught through a physical assault or as a result of an incident occurring during the course of performing normal duties of employment, the incident must be supported by a negative HIV antibody test taken within 5 days of the incident. There must be a further HIV test within 12 months confirming the presence of HIV or antibodies to the virus. The incident causing infection must have occurred in the UK. For this definition, the following is not covered: HIV infection resulting from any other means, including sexual activity or drug abuse Kidney failure chronic and end stage failure of both kidneys to function, as a result of which regular dialysis is permanently required Loss of hands or feet permanent physical severance of any combination of 2 or more hands or feet at or above the wrist or ankle joints Loss of speech total permanent and irreversible loss of the ability to speak as a result of physical injury or disease Major organ transplant the undergoing as a recipient of a transplant from another person of bone marrow or of a complete heart, kidney, liver, lung, or pancreas, or inclusion on an official UK waiting list for such a procedure. For this definition, the following is not covered: Transplant of any other organs, parts of organs, tissues or cells Motor neurone disease a definite diagnosis of one of the following motor neurone diseases by a Consultant Neurologist. There must also be permanent clinical impairment of motor function: Amyotrophic lateral sclerosis (ALS) Primary lateral sclerosis (PLS) Progressive bulbar palsy (PBP) Progressive muscular atrophy (PMA) Multiple sclerosis a definite diagnosis of Multiple Sclerosis by a Consultant Neurologist. There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months Paralysis of limbs total and irreversible loss of muscle function to the whole of any 2 limbs Parkinson s disease a definite diagnosis of Parkinson s disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function with associated tremor and muscle rigidity. For this definition, the following is not covered: Parkinsonian syndromes/parkinsonism Stroke death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in permanent neurological deficit with persisting clinical symptoms. transient ischaemic attack; traumatic injury to brain tissue or blood vessels; death of tissue of the optic nerve or retina/eye stroke Terminal illness where death is expected within 12 months a definite diagnosis by the attending Consultant of an illness that satisfies both of the following: the illness either has no known cure or has progressed to the point where it cannot be cured, and in the opinion of the attending Consultant, the illness is expected to lead to death within 12 months Third degree burns burns that involve damage or destruction of the skin to its full depth through to the underlying tissue and covering at least 20% of the body s surface area Total permanent disability loss of the physical ability through an illness or injury to do at least 3 of the 6 tasks listed below ever again. The relevant specialists must reasonably expect that the disability will last throughout life with no 06

7 prospect of improvement, irrespective of when the cover ends or the life assured expects to retire. The life assured must need the help or supervision of another person and be unable to perform the task on their own, even with the use of special equipment routinely available to help and having taken any appropriate prescribed medication. The tasks are: Washing the ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily by other means. Getting dressed and undressed the ability to put on, take off, secure and unfasten all garments and, if needed, any braces, artificial limbs or other surgical appliances. Feeding yourself the ability to feed yourself when food has been prepared and made available. Maintaining personal hygiene the ability to maintain a satisfactory level of personal hygiene by using the toilet or otherwise managing bowel and bladder function. Getting between rooms the ability to get from room to room on a level floor. Getting in and out of bed the ability to get out of bed into an upright chair or wheelchair and back again. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered Traumatic brain injury death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms The policy only covers the critical illnesses described in conditions 3.1 to PAYING YOUR PREMIUMS DURING THE PERIOD OF COVER 4.1 The schedule shows how much your yearly premium is, and the date you must pay it each year. 4.2 If you have arranged with us to pay the yearly amount by monthly premiums, the schedule will confirm this in the special provisions section. The first monthly premium will be due on the date the first yearly premium would have been due. 4.3 We will request the premiums from your bank account when they are due, until the end date or until we pay a claim under condition If you make a claim for one of the critical illnesses, you must keep paying premiums until we tell you of our decision about your claim. If we do not accept your claim, you must continue to pay premiums. 5. WHAT HAPPENS IF YOU ARE LATE PAYING A PREMIUM? 5.1 If we do not receive a yearly or monthly premium on the due date, we will give you a period of grace of one calendar month to pay it. We will not allow a period of grace for the first premium. 5.2 If you make a claim during a period of grace, we will deduct any overdue premiums from any amount we are due to pay out for the claim. 6. WHAT HAPPENS IF YOU STOP PAYING PREMIUMS OR DO NOT PAY WITHIN A PERIOD OF GRACE? 6.1 We will cancel your policy if you do not pay any yearly or monthly premium by the end of a period of grace, as described in condition You will no longer be able to make a claim under the policy, and you will not get any money back from it. 7. HOW YOU CAN APPLY TO RESTART A CANCELLED POLICY 7.1 If we cancel your policy because you did not pay any premium within a period of grace, you can apply to restart it within 6 months of when your first unpaid premium was due. You must apply in writing to our registered office, unless we have notified an alternative method of communication to you. 7.2 To do this: (a) you must provide us with any evidence we ask for about the health of the life assured at the time (b) you must pay all unpaid premiums that are due (c) you must pay a late payment fee of 1.5% of the total premiums due. 7.3 We have the right to refuse your application to restart the policy if we reasonably believe: (a) the likelihood of a claim has increased since, the last premium was paid, or (b) that there is the risk of a claim occurring within a shorter period than was the case at the date on which, the last premium was paid. 8. WHAT HAPPENS IF THE LIFE ASSURED COMMITS SUICIDE? 8.1 We will not be liable to pay a claim under condition 2.1 if the life assured commits suicide within 12 months of: (a) the start date, or (b) the date of restarting the policy under condition 7. Level Temporary Assurance With Critical Illness Cover 07

8 8.2 Condition 8.1 will not apply if, before the date of death, we have been notified of a transfer of ownership under condition 10, and the transfer was not made as a gift. 9. HOW TO MAKE A CLAIM 9.1 Only one claim can be paid under the policy. If we accept a critical illness claim, under condition 2.1 (b) we will not accept a later claim for the death benefit under condition 2.1 (a). 9.2 Making a claim for critical illness To make a claim under condition 2.1 (b) you must notify us within 6 months after the life assured has been diagnosed with one of the critical illnesses defined in condition 3 (or the second HIV test under condition 3.11) You must write to our registered office, unless we have notified an alternative method of communication to you We will ask you to complete a claim form. We may also ask you to provide us with evidence to support the diagnosis. This may involve the life assured having a medical examination, which we will pay for All diagnoses and medical opinions must be given by a medical specialist who: (a) holds an appointment as a Consultant at a hospital in the UK; (b) is accepted by our Chief Medical Officer; and (c) is a specialist in an area of medicine appropriate to the cause of your claim We may ask you to provide evidence to prove you are legally entitled to make the claim The life assured must survive for a period of 30 days after diagnosis (or the second HIV test under condition 3.11) before we can accept a critical illness claim Once we accept your claim is valid, we will pay the sum assured to the person who is legally entitled to it. The policy will end when we pay the claim and we will have no further liability under it If we do not accept your critical illness claim as a valid one, this will not prevent us from accepting a later claim under conditions 2.1 (a) and 2.1 (b). 9.3 Making a claim on death of the life assured To make a claim under condition 2.1 (a) you must write to our registered office, unless we have notified an alternative method of communication to you We will only pay the claim when we have received satisfactory proof of the death, and appropriate documentation confirming that the person claiming is legally entitled to it We will pay the death benefit to the person who is legally entitled to it. The policy will end when we pay the claim and we will have no further liability under it. 10. HOW TO NOTIFY US IF YOU TRANSFER OWNERSHIP OF THE POLICY TO SOMEONE ELSE 10.1 You must send the notice of assignment to our registered office. 11. WHEN THE POLICY WILL NOT PROVIDE COVER 11.1 We will not pay a claim under condition 2.1 (a) or (b) and we have the right to cancel the policy, if: (a) at the time you apply for the policy (or for restarting the policy), or when making the claim, you do not answer all our questions truthfully, accurately and completely to the best of your knowledge or you do not provide all the information we ask for. (b) you did not tell us about any of the changes listed below, that happened between the time you made your application for the policy (or for restarting the policy) and the start date (or restart date) and the change would have affected our decision whether or not to accept your application (or restart), or the disclosure would have been material to the claim. Changes to the life assured s: - health - family medical history - occupational duties - overseas travel - country of residence - hazardous leisure activities 11.2 We will not pay a claim you make under condition 2.1 (b) if the critical illness you are claiming for under condition 3, is caused directly or indirectly by any of the following: (a) Alcohol or drug abuse Inappropriate use of alcohol or drugs, including but not limited to the following: - consuming too much alcohol - taking an overdose of drugs, whether lawfully prescribed or otherwise - taking Controlled Drugs (as defined by the Misuse of Drugs Act 1971) otherwise than in accordance with a lawful prescription. (b) Cancer during the first 90 days of the policy Cancer as defined in condition 3.5, which is diagnosed at any time as having been present within 90 days from the start date. (c) Criminal acts Taking part in a criminal act. (d) Flying Taking part in any flying activity, other than as a passenger in a commercially licensed aircraft. (e) Hazardous sports and pastimes 08

9 Taking part in (or practising for) boxing, bungee-jumping, caving, climbing, horse racing, jet skiing, martial arts, mountaineering, off-piste skiing, pot-holing, power boat racing, underwater diving, yacht racing or any race, trial or timed motor sport. (f) Self-inflicted injury Intentional self-inflicted injury. (g) Unreasonable failure to follow medical advice Unreasonable failure to seek or follow medical advice. (h) War and civil commotion War, invasion, hostilities (whether war is declared or not), civil war, rebellion, revolution or taking part in a riot or civil commotion. (i) Something we have stated in the schedule that we will not provide cover for. 12. THE LAW GOVERNING THE POLICY AND CHANGES TO IT 12.1 The law of England will apply to this policy unless the policyholder has agreed otherwise with us before the policy is issued If, during the lifetime of the policy, there is a change in the law or in regulation (or how they are interpreted) that directly or indirectly affects the policy, we may alter the policy conditions but any alteration will reasonably reflect such changes. This includes any change affecting the tax treatment of the policy If we amend or alter the policy conditions for this purpose, we will issue an endorsement. Any endorsement we issue will form part of the policy We may need to make deductions from the policy, or alter the benefits payable under it, to meet our regulatory or legal obligations under: (a) the Financial Services Compensation Scheme (b) the Financial Services and Markets Act 2000 (c) any other legal or regulatory requirement affecting the policy directly or indirectly. but any deduction will reasonably reflect such obligations. 13. CHARITABLE ASSIGNMENT CONDITION This condition forms part of the terms on which YOUR policy is issued. Words printed in capitals in this condition are explained in paragraph 4 below. 1 Unless paragraph 3 applies, YOU agree with US and the CHARITY that YOU will transfer to the CHARITY the right to any WINDFALL which YOU would otherwise be entitled to receive in respect of the policy and any renewal or reissue of it. 2 To ensure that the agreement YOU have entered into in paragraph 1 can be effectively carried out: (a) YOU authorise US to transfer any WINDFALL direct to the CHARITY; (b) YOU agree to sign any documents and to do anything else which may be needed to transfer any WINDFALL, and YOUR right to receive the WINDFALL, to the CHARITY; (c) YOU appoint US and any of OUR officers and (as a separate appointment) the CHARITY and any of its officers to be YOUR agent to take any of the steps mentioned in (b) above on YOUR behalf; (d) YOU authorise US to provide the CHARITY with any information it reasonably requires about YOU and any policy YOU hold with US, and YOU consent to US and the CHARITY holding and processing such information for this purpose; (e) YOU cannot revoke the authority contained in (a) or (d) above, or the appointment contained in (c) above. 3 Paragraph 1 shall not apply in respect of any WINDFALL which arises from a BUSINESS TRANSFER to any company or other body corporate which is at the time of such transfer OUR subsidiary, in circumstances where such transfer is not in any way related to a DEMUTUALISATION or to any sale or other disposal (or proposed sale or other disposal) of such subsidiary. 4 In this condition: (a) the CHARITY is the NFU Mutual Charitable Trust Limited or, if it ceases to exist, any other charity which becomes entitled to the benefit of the agreement YOU have entered into in paragraph 1; (b) BUSINESS TRANSFER means a transfer of part or all of OUR business to any other person, firm or company; (c) DEMUTUALISATION means a change (or proposed change) in OUR constitution or corporate status (whether or not involving or associated with a BUSINESS TRANSFER) which has the effect that WE cease to be a MUTUAL ORGANISATION; (d) MUTUAL ORGANISATION means a company or other body whose constitution limits membership and voting rights wholly or mainly to persons purchasing goods or services from it or otherwise trading with it; (e) WE, US and OUR refer to The National Farmers Union Mutual Insurance Society Limited and any company or other organisation which becomes entitled to all or part of its BUSINESS; (f) a WINDFALL means any benefit to which YOU become entitled as one of OUR members on or in connection with any future BUSINESS TRANSFER or DEMUTUALISATION; (g) YOU and YOUR refer to OUR member under the policy. Level Temporary Assurance With Critical Illness Cover 09

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12 nfumutual.co.uk NFU Mutual is The National Farmers Union Mutual Insurance Society Limited (No ). Registered in England. Registered Office: Tiddington Road, Stratford upon Avon, Warwickshire CV37 7BJ. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. A member of the Association of British Insurers. For security and training purposes, telephone calls may be recorded and monitored. POL/LTC/011215