AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS

Transcription

1 AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS 1

2 Head Office BKIC Tower 2775 Road 2835 Seef District 428 P.O. Box Manama Kingdom of Bahrain TEL: (973) FAX: (973) Diplomatic Area: (973) Arad: (973) East Riffa: (973) Salmabad Motor Claims Center: (973) A MEMBER OF THE GULF INSURANCE GROUP

3 AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS C O N T E N T S SCHEDULE 1 GENERAL CONDITIONS 2 ELIGIBILITY 3 PROOF OF AGE 4 NATURE AND EXTENT OF INSURANCE BENEFITS 5 WAITING PERIOD 6 DEFERRED PERIOD 7 SPECIAL CONDITIONS 8 DEFINITIONS OF CRITICAL ILLNESSES AND DIAGNOSTIC REQUIREMENTS 9 GENERAL EXCLUSIONS 10 PREMIUM 11 PREMIUM PAYMENT 12 SUBSTANTIATION OF CLAIMS / PAYMENT OF INSURED BENEFITS 13 TERRITORIAL LIMITS 14 CURRENCY / TERRITORY & JURISDICTION I5 FINAL DISPOSITIONS 1

4 AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS 1: GENERAL CONDITIONS A. It is hereby declared that the declaration made in the application, forms the basis of this contract. Any conditions printed herein, supplementary contracts, if any, and any endorsements made by the Company to this policy are deemed to be part of this contract. B. It is the Company s prerogative to demand medical examinations to be completed by the Company s appointed doctor as a pre-requisite to accept this assurance. If the proposer submits any fraudulent information about his/her health situation or refrains from disclosing any known information which would affect his/her doctor s decision of his/her case, the company reserves the right to annul the insurance contract Ab initio and initiate legal action as necessary. C. If the Company identifies that while issuing the contract, that false, incomplete or misleading information has been declared to understate the risk which is covered under this contract, the company s liability will be limited to refunding the premiums paid only. 2: ELIGIBILITY The coverage under this Policy will be provided to any individual, who legally qualifies for contracting, has a valid residency and/or work permit in the Country of residence and is not more than sixty four (64) years of age and not younger than eighteen (18) on the date of inception of this insurance. 3: PROOF OF AGE The company reserves the right to seek proof of age at policy inception and/or at the time of claim processing. If the age of the Insured has been understated, any additional amount payable under this policy shall be adjusted as per the premium applicable for the correct age. 4: NATURE & EXTENT OF INSURANCE BENEFITS BKIC agrees to pay to the Insured the agreed sum assured upon being diagnosed to be suffering for the first time in his/her life from one or more of the following illnesses: 1) Major Cancers 2) Coronary Artery (Bypass) Surgery 3) First Heart Attack (Myocardial Infarction) 4) Kidney Failure (End Stage Renal Disease) 5) Stroke 6) Aorta (Surgery of Aorta) 7) Blindness (Loss of Sight) 8) Heart Valve Replacement 9) Major Organ Transplantation 10) Multiple Sclerosis 11) Paralysis 12) Coma as defined in Article 8 of this policy 2

5 Sum Assured : As stated in the schedule Benefit is payable only once, whether one or more diseases /surgery occur simultaneously or otherwise. On payment of the Sum Assured, the Company is fully discharged of all liability under the policy. 5: WAITING PERIOD A Waiting Period of 90 days will apply from the commencement date of the policy, meaning that no benefit will be paid in respect of a disease first diagnosed during the waiting period or for a surgery undergone or requested / prescribed by a Doctor during the waiting period. Any claim resulting, directly or indirectly from a condition (sickness or accident) which originated during the waiting period will be excluded from coverage. 6: DEFERRED PERIOD A claim is payable only when the Insured member survives 30 days after the first conclusive diagnosis. If the Insured member unfortunately passes away during this period, the claim will not be payable. This period of 30 days before a claim is admitted is known as deferred period. 7: SPECIAL CONDITIONS 1) No benefit shall be payable if the covered condition is diagnosed or the surgery is advised as being necessary or is undergone within 90 days after the commencement date of this policy. 2) The principal Sum Assured shall be payable only if the Insured member is alive after the expiry of 30 days from the date of diagnosis of the conditions covered or from the date of surgery of the disease covered. 8: DEFINITIONS OF CRITICAL ILLNESSES AND DIAGNOSTIC REQUIREMENTS 1. Major Cancers A disease manifested by the presence of a malignant tumour characterised by the uncontrolled growth and spread of malignant cells, and the invasion of tissue. Diagnosis has to be confirmed by a specialist and evidenced by definite histology. The term cancer also includes leukaemia and malignant diseases of the lymphatic system such as Hodgkin s disease. Excluded are: Any CIN stage (cervical intraepithelial neoplasia) Any pre-malignant tumour Any non-invasive cancer (cancer in situ) Prostate cancer stage 1 (T1a, 1b, 1c) Basal cell carcinoma and squamous cell carcinoma Malignant melanoma stage 1A (T1a N0 M0) Any malignant tumour in the presence of any Human Immunodeficiency Virus 3

6 AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS 2. Coronary Artery (Bypass) Surgery The actual undergoing of open chest surgery for the correction of two or more coronary arteries, which are narrowed or blocked, by coronary artery bypass graft (CABG). The surgery must have been proven to be necessary by means of coronary angiography and realisation of the surgery has to be confirmed by a specialist. Excluded are: Angioplasty Any other intra-arterial procedures Key-hole surgery 3. First Heart Attack (Myocardial Infarction) The death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. Diagnosis has to be confirmed by a specialist and evidenced by all the following criteria: a) A history of typical chest pain b) New characteristic electrocardiogram changes c) Elevation of infarction specific enzymes. Troponins or other biochemical markers Excluded are: Non-ST-segment elevation myocardial infarction (NSTEMI) with only elevation of Troponin I or T Other acute Coronary Syndromes (e.g. stable/unstable Angina pectoris) Silent myocardial infarction 4. Kidney Failure (End Stage Renal Disease) End stage renal disease presented as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist. 5. Stroke Any cerebrovascular incident producing permanent neurological sequelae and including infarction of brain tissue, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist and evidenced by typical clinical symptoms as well as typical findings in CCT Scan or MRI of the brain. Evidence of neurological deficit for at least 3 months has to be produced. Excluded are : Transcient ischemic attacks (TIA) Traumatic injury of the brain Neurological symptoms due to migraine Lacunar strokes without neurological deficit 4 6

7 6. Aorta (Surgery of Aorta) The actual undergoing of surgery for a chronic disease of the aorta needing excision and surgical replacement of the diseased aorta with a graft. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches. Realisation of the aortic surgery has to be confirmed by a specialist. 7. Blindness (Loss of Sight) Total, permanent and irreversible loss of all sight in both eyes as a result of sickness or accident. Diagnosis has to be confirmed by a specialist (best by an ophthalmologist) and evidenced by specific results. 8. Heart Valve Replacement Surgical replacement of one or more heart valves with prosthetic valves. This includes the replacement or aortic, mitral, pulmonary or tricuspid valves with prosthetic valves due to stenosis or incompetence or a combination of these factors. Realisation of the heart valve replacement has to be confirmed by a specialist. Excluded are : Heart valve repair Valvulotomy Valvuloplasty 9. Major Organ Transplantation The actual undergoing of transplantation as the recipient of a heart, lung, liver, pancreas, small bowel, kidney or bone marrow. Realisation of the transplantation has to be confirmed by a specialist. 10. Multiple Sclerosis Unequivocal diagnosis of Multiple Sclerosis by a specialist (preferably by a neurologist). The disease has to be evidenced by typical clinical symptoms of demyelination and impairment of motor and sensory function as well as by typical MRI findings. For proving the diagnosis, the Insured must either exhibit neurological abnormalities that have existed for a continuous period of at least 6 months or must have had at least two clinically documented episodes at least one month apart or must have had at least one clinically documented episode together with characteristic findings in the cerebrospinal fluid as well as specific cerebral MRI lesions. 5

8 AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS 11. Paralysis Total and irreversible loss of use of two or more limbs through paralysis due to accident or sickness of the spinal cord. These conditions have to be medically documented by a specialist for at least 3 months. Excluded is : Paralysis due to Guillain-Barré-Syndrome 12. Coma A state of unconsciousness with no reaction or response to external stimuli or internal needs, persisting continuously with the use of life support systems, for a period of at least ninety-six (96) hours. Permanent neurological deficit, as certified by a consultant neurologist, must be present. Coma resulting directly from alcohol or drug abuse is excluded. 9: GENERAL EXCLUSIONS No benefits will be payable under the scheme if a claim or event suffered by the Insured is directly or indirectly caused or exacerbated as a result of any of the following: 1) Failure to seek or follow medical advice. 2) Living abroad (living outside the territory for more than 13 consecutive weeks in any 12 months). 3) War or hostilities (whether war be declared or not). 4) Civil war, rebellion, revolution, civil unrest or riot. 5) Participation in any armed force or peace keeping activities. 6) An act of any person acting on their own or on behalf of or in connection with any group or organization to influence by force any group, corporation or government by terrorism, kidnapping or attempted kidnapping, attack, assault, or any other violent means. 7) An intentional or self-inflicted act or Suicide or attempted suicide. 8) Congenital defects defined as any abnormality, defect or deformity existing at the time of birth and their consequences. 9) All pre-existing conditions defined as any illness, disease, bodily injury or related conditions which the Insured member had prior to obtaining the policy whether known or unknown to the member. 10) All type of racing and all aviation risks. 11) Should any of the covered conditions ever be deemed to be generally curable on the basis of genetic manipulation, substitution, deletion, vaccination or any other treatment medical or otherwise, such condition will no longer be valid. 12) Drug-taking other than under the direction of a qualified medical practitioner, abuse of alcohol or the taking of poison. 13) Any disease in presence of HIV/AIDS. 14) Any disease that first occurs prior to the inception date of the policy. 15) Nuclear fusion, nuclear fission, nuclear waste or any radioactive or ionizing radiation. 16) Deliberate participation of the member in an illegal or criminal act. 6

9 17) Injuries or diseases arising from professional sports, racing of any kind, scuba-diving, aerial flights (including bungee-jumping, hang-gliding, ballooning, parachuting and sky-diving) other than as a crew member or as a fare-paying passenger on a licensed commercial passenger aircraft operating in a regular scheduled route or any hazardous activities or sports unless agreed by special endorsement. 10: PREMIUM BKIC charges the premiums to the account of the Insured member at the beginning of each year or in advance for the whole period of cover as stated in the schedule attached. 11: PREMIUM PAYMENT All premiums are payable annually in advance or in advance for the whole period of cover at the rates referred to in Article 10 above. The annual premiums shall be paid not later than thirty (30) days after the inception and/or renewal date. If a premium is not paid at the end of this period, BKIC shall notify the Policyholder by registered mail that if the premiums are not paid within a grace period of fourteen (14) days calculated from the date of dispatch of the notification, coverage will cease as of the 15th day and can only be restored at the insurer s discretion upon payment of all outstanding premiums. 12: SUBSTANTIATION OF CLAIMS / PAYMENT OF INSURED BENEFITS To substantiate a claim for Critical Illness benefits covered by the terms of this Policy the following documents have to be submitted by the Insured : Immediate written notification of any claim occurrence shall be made to the Insurer; All supporting documents such as completed claim form together with a detailed medical report from the attending physicians on the onset, course and consequences of the Critical Illness. The Insured member should provide complete medical evidence sufficient to support the claim at his/her expense. The Insurer will pay the insured benefits as soon as it has satisfied itself of the validity for claim from the documents required and or completion of the Deferred period. 13: TERRITORIAL LIMITS Kingdom of Bahrain only, but worldwide for the purpose of travel for business or pleasure. 7

10 AMAL - CRITICAL ILLNESS INSURANCE TERMS AND CONDITIONS 14: CURRENCY / TERRITORY & JURISDICTION The currency of this Policy is the Bahrain Dinar. The premiums are payable and the benefit payments will be made in the Kingdom of Bahrain. This insurance is subject only to the jurisdiction of the Kingdom of Bahrain. Should any differences arise between the contracting parties of this Policy, the Courts in the Kingdom of Bahrain shall be considered competent. 15: FINAL DISPOSITIONS This Policy may be terminated by either party, subject to one month s notice, to the other party by registered post to the last known address. There shall be NO REFUND of premium in the event of cancellation by either party for yearly premium payments. For premiums paid in advance for the whole period of cover (i.e. more than one year), proportionate refund of premiums will be allowed for the remaining period of the policy after retaining an amount of BD 24/- towards the administration charges. No refund will be payable in case a claim has been registered under the policy. Termination of the Policy shall cease all mutual obligations. 8

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