How To Understand The African Hospital Accident Plan Policy

Transcription

1 Absa Insurance Company Limited, Reg No 1992/001737/06 Absa Hospital Accident Plan Policy Contents Terms of contract Description of cover Definitions Table of Benefits General Conditions Claims information Exclusions Important disclosures and contact details This explains the basis of the contract This explains the cover and when and how we will compensate you This explains commonly used words and phrases This shows the benefits and amounts of cover These are conditions which apply throughout the policy This explains the claiming procedures and conditions This explains what is not covered under the policy This details important information which we must disclose to you Terms of Contract This policy is underwritten by Absa Insurance Company Limited, Reg No 1992/001737/06.We agree to provide insurance under this policy during any period of insurance for which you have paid premium. We will accept any proposal or declaration that you have made as true and use that information as the basis of the contract. You must read the policy wording and schedule together as one contract. If we make any changes to your policy wording or schedule, it will form part of the policy. When and how we will compensate you This policy will cover you and/or your spouse and children who you have nominated for cover and who are listed on the policy schedule. If an insured person is hospitalised as an in-patient for longer than a day due to accident or illness during the period of insurance, we will pay you the benefit shown in the Table of Benefits. Payment of benefits is based on the plan you chose when you took out the policy and when an insured person is hospitalised. Definitions Example: If you have chosen a benefit amount of R400 and you are hospitalised for 10 days, your benefit is calculated as: R400 x 10 days = R4, Accident means an unexpected and specific future event, caused only by violent, accidental, external, physical and visible means, which occurs at a time and place that can be identified, which results in injury. Example: an accident is something that is unexpected and can happen at any time - a motor vehicle accident while travelling to work in a taxi or being assaulted while on the way to the shop, which results in injuries. 2 Benefit means the amounts shown in the Table of Benefits. 3 Children means your natural or legally adopted unmarried children or step children between the ages of 6 months and: 18 years, or 25 years if the child is a full-time student attending an accredited school, college or university and still depends on you for support. 4 Day means 24 uninterrupted hours 5 Hospital means a medical facility that holds a licence as a hospital or nursing home, where illness and injury are treated. Example: If you are treated at a rest home or rehabilitation facility, your hospitalisation will not be covered under this policy. ABSA 4141 EX Authorised Financial Services Provider ABSA (04/12/2009)

2 6 Inception date means the date when your first premium is collected, which is when the cover starts. 7 Injury means bodily injury or physical trauma to an insured person. 8 Insured person means you, your spouse and children who have been nominated for cover, and reside in the Republic of South Africa. 9 Legally Appointed Representative means the person who will manage your legal affairs if you are incapable of doing so or are dead. 10 Medical Practitioner means a person currently legally licensed and registered to practice medicine, not including the insured person or members of his or her immediate family. 11 Medical Treatment means a medical practitioner s medical advice, treatment, consultations, and prescribed or repeat medication. 12 Period of Insurance means from the inception date of the policy and while you continue to pay premiums, until your policy is cancelled or terminated. 13 Policy means this document and the schedule and includes any later changes made to the policy. 14 Professional sport means sport from which the insured person earns 50% or more of their income. 15 Spouse means your lawful or common law spouse or partner who permanently lives with you. 16 You/Your means the policyholder, who has taken out this cover and is paying the monthly premium. 17 We/Us/Our means Absa Insurance Company Limited. Table of Benefits Example: If you and your life partner live together in the same house, that person will be considered to be your spouse. Benefit Plan A Plan B Plan C Plan D Plan E Plan F You You and your spouse You and your children R1 500 R1 200 R1 000 R750 R500 R250 Your whole family General Conditions 1 This policy is governed by the laws of the Republic of South Africa. 2 The courts of the Republic of South Africa shall have the exclusive right to hear any matters about this policy. 3 If there are differences between this policy and any other information that you have received about your policy, this policy will be considered correct. 4 We will not be responsible for any tax liability, if any, that you have to pay when we pay any benefit. 5 This policy replaces any Absa Hospital Accident Plan policies that may have previously been issued to you. 6 We may change any part of this policy by giving you 30 days written notice. 7 We will automatically renew your policy on a monthly basis, as long as you pay your premium on time. The policy will be renewed as is, unless we tell you that we have made changes. 8 You can only include a maximum of five children on your policy. Age limits Insured person Entry age Cover end age You years 80 Your Spouse Your children years 6 months 18 years or 25 years if a full time student (see definition) If you have not given us the correct ages: We will only pay the benefit for the correct age, or, If we would not have given cover at all, we will refund you the premiums and no claims will be paid. Cancellation and termination of your policy If this policy is cancelled or terminated, you will not be entitled to any refund of premium. Your policy will end: o If we give you thirty days notice in writing, sent to your last known address, or, o If you give us thirty days notice in writing, or, o If you do not pay your premium, or, o If you reach the age of 80, or, o If you die years or 25 years if a full time student (see definition)

3 Premium Payments 1 You must pay your premiums monthly in advance by debit order. 2 If you do not pay your premium on time, you have a 15 day grace period to pay. 3 If you do not pay your outstanding premium during the grace period, we will cancel your policy from the date the premium was due. 4 If you claim during the 15 day grace period, we can deduct the premium due by you from your claim amount. 5 Due to legislation, we are required to process all debit orders on a random basis without preference to any institution. We therefore use a system which will allow us to resubmit your debit order after the agreed payment date if it is returned due to insufficient funds. This will ensure that your valuable cover remains active by keeping your premiums up to date. 6 If your chosen debit order date falls on a weekend or public holiday, we will debit you on the last working day before this date. Screening of Application, Instructions and Transactions We are part of a global financial institution and at all times obey international and local legal requirements governing: Money Laundering Terrorist financing Financial Sanctions Prohibited business activities We may screen, verify and monitor any of your information at any time. This could cause: Delays in us carrying out certain transactions Us not being able to carry out certain transactions at all Us ending our business relationship with you Should this happen, we will inform you of any action we intend to take, to the extent that we are able to. We, and any person connected to us, will not be liable for any loss that you may suffer as a result of this action. Claims information Claims Procedure If you or your legally appointed representative need to claim under this policy, please contact us. You or your legally appointed representative must notify us of a claim within 30 days of your last day in hospital. Payment of benefits 1 This policy cannot be transferred. Only you have rights under this policy against us. Example: If you were applying for a loan, you couldn t use this policy as a guarantee. 2 We will only pay benefits to you, your nominated beneficiary(ies) or your estate. 3 We will not pay any benefits if an insured person does not meet all policy requirements. 4 We will not pay interest on any benefit payment. 5 If you have more than one policy with us that includes hospital cash benefits, we will add the benefits together and will not pay more than R Any changes in cover to your policy will only apply to claims that happen after the effective date of these changes. Example: If you upgrade your policy, we will only apply the new benefits to claims that happen after you have upgraded your policy. Claims that have already happened before you upgrade your policy will be paid at the old benefit levels. 7 We will not pay benefits until the total claim amount has been agreed. We may choose to make interim payments. 8 We will only make payments into a valid South African bank account in South African Rands. Claims conditions General 1 You must prove claims with medical evidence that we ask for. Example: In order to properly assess your claim, we will need medical reports and hospital records. 2 We can ask that any insured person have a medical examination at our cost. 3 We can choose to have your claim reviewed by a medical practitioner or nurse. 4 An insured person must seek and follow qualified medical advice without delay. If he or she does not, we will not pay the part of any claim which, in the opinion of our medical practitioner, is because of his or her failure to do so. 5 If a claim is because of a criminal incident, you must give us a certified police report. 6 We will only pay for the number of days spent in hospital that our medical practitioner considers medically necessary.

4 True and honest information You must at all times give us true and honest information. We can reject your claim and cancel your policy if you did not give us true, correct and complete information about yourself when you applied for insurance or when any of your information changed. We can reject your claim and cancel your policy if you do not give us true, correct and complete information when claiming. If we pay you any benefits and find out later that the information you gave us was not true, correct and complete, you must pay us back the benefit amount as soon as we ask for it. Time limits if we do not accept your claim If we do not accept your claim, you may appeal against our decision. You must appeal in writing within 90 days of us not accepting the claim. If your appeal is not successful, you may take the matter further with the Short-term Insurance Ombudsman. If you want to take legal action against us, you must do so within 180 days of the date your appeal was not successful. If you do not do so in time, your right to start legal action against us expires. Exclusions These exclusions apply at all times to the whole policy and to all insured persons who are covered under this policy. We will not pay any claims that result from any insured person: 1 Committing any criminal or illegal act. 2 Deliberately injuring himself or herself, committing suicide or attempting suicide. 3 Wilfully or deliberately exposing himself or herself to danger (except in an attempt to save human life). 4 Suffering from insanity or any psychiatric, psychological or emotional condition. 5 Being under the influence of alcohol or drugs unless these drugs are prescribed and taken on a medical practitioner s instructions. 6 Taking part in underground mining or shaft sinking. 7 Taking part in professional sport. 8 Taking part in contact sport. Example: A contact sport is a sport that involves physical contact between players as part of the game, e.g, boxing or rugby. 9 Taking part in sport on ice or snow, mountaineering using ropes. 10 Taking part in speed or endurance racing, driving contests, drag racing or rallying. 11 Flying, if not a fare paying passenger. 12 Living permanently outside of the Republic of South Africa. We will not pay for claims that result from: 13 Chronic or inherited medical conditions. Example: a chronic condition is one that is long-lasting or lifelong, such as diabetes or high blood pressure. 14 Voluntary or cosmetic procedures. 15 Any medical or physical condition for which any Insured Person has received medical treatment or advice in the 12 months before the inception date of the policy. 16 AIDS or HIV infection. 17 War, invasion, act of foreign enemy, hostilities, whether war be declared or not, civil war, rebellion, revolution, insurrection and/or military or usurped power. 18 Any terrorist act or bomb threat. 19 An insured person receiving treatment in a rest or convalescent home, rehabilitation centre, hospice or similar facility.

5 Important Disclosures and Contact Information This policy is underwritten by: Absa Insurance Company Limited, Reg. No. 1992/001737/06 Absa Financial Services Building 21 Kruis Street PO Box Absa Insurance Company Limited, Reg. No. 1992/001737/06 will appoint a third party to sell this product on our behalf. The third party will receive a pre-negotiated fixed cost per sale and no commission is payable. Policy Administration Please contact Collective Dynamics on Claims Please contact Absa Insurance Company on Complaints Resolution If you have a complaint about this policy, please contact: The Chairman of the Complaints Resolution Committee PO Box Fax: Absa Insurance Company Compliance Officer Absa Financial Services Building PO Box Kruis Street Tel: Ombudsman for Short-term Insurance Tel: nd Floor JCC House Fax: Owl Street Share call: info@osti.co.za 2001 P O Box Braamfontein 2017