How To Pay Out Of Pocket On A Life Insurance Policy

Transcription

1 Personal Accident Policy Document Policy Form: PA (Students-xs5)

2 Contents Introduction... 2 Data Protection Policy... 3 Complaints Procedure... 3 What is Covered... 4 What is not Covered... 4 Extensions... 5 Special Conditions... 6 Endorsements... 8 General Policy Conditions... 9 Policy Definitions Introduction Irish Public Bodies Mutual Insurances Ltd. trading as IPB Insurance (hereinafter referred to as the Insurer) and You, the Insured agree that (a) This Policy comprising the Introduction, Policy Schedule, Insuring Agreement, Exclusions, Conditions, Definitions and any operative Endorsements shall be read as one contract and any word or expressions to which a specific meaning has been attached therein shall bear such specific meaning wherever it may appear. (b) Any written proposal and/or Statement of Fact and/or Declaration and/or broking submission made by the Insured or on the Insured s behalf shall be incorporated into and form the basis of the insurance contract Signed for and on behalf of the Insurer Ronan Foley Chief Executive Irish Public Bodies Mutual Insurances Ltd. trading as IPB Insurance is regulated by the Central Bank of Ireland. Reg. No Republic of Ireland. (c) In consideration of the payment of premium, the Insurer will indemnify the Insured in the manner and to the extent described within this Policy whilst carrying on the Business described in the Policy Schedule subject to the Policy Exclusions, Endorsements, Conditions and Definitions as stated or as subsequently endorsed hereon. (d) In accordance with Section 93 of the Insurance Act 1936, it is understood and agreed that all monies which become or may become due and payable by the Insurer under this Policy shall be payable and paid in the Republic of Ireland. (e) The appropriate stamp duty has been or will be paid to the Revenue Commissioners in accordance with the Stamp Duties Consolidation Act 1999, Schedule 1 (as amended). 2

3 Data Protection Policy Personal Data IPB Insurance is registered as a data controller with the Office of the Data Protection Commissioner and is required to comply with the Data Protection Acts 1988 and 2003 and the Data Protection Code of Practice for the Insurance Sector. Further information can be obtained at We will keep the information you provide about you and third parties confidential. We may use it to provide and administer insurance products and financial services provided by us and sometimes with commercial partners. We may share the information both inside and outside the European Economic Area, in confidence, for these purposes with agents or service providers we have appointed, private investigators, regulatory organisations, other insurance and financial services companies (directly or via a central register) and to those whom we outsource certain business operations and as required by law. Complaints Procedure It is important to us that you receive the highest level of service at all times and we hope that you never have to complain. However, if for any reason you need to contact us on a service matter, we do wish to hear from you. It is our policy to deal with all complaints fairly and efficiently. Therefore, if you have a complaint, please contact the Complaints Officer, IPB Insurance, 1 Grand Canal Square, Grand Canal Harbour, Dublin 2. Tel: We will acknowledge all written complaints in writing within 5 business days of receipt and will advise you who is dealing with the complaint until it is resolved or cannot be processed any further. Details of all verbal complaints are recorded in writing. Upon receipt of a verbal complaint, we will offer you an opportunity to have your complaint treated as a written complaint. Our aim is to resolve any complaint as quickly as possible. You will receive a regular written update on the progress of the investigation at intervals of not greater than 20 business days. If your complaint is not resolved within 40 business days, we will inform you of the anticipated time frame in which we hope to resolve the complaint and advise you of your right to refer the matter to the Financial Services Ombudsman, Lincoln House, Lincoln Place, Dublin 2. Lo-Call: Telephone:

4 What is Covered What is not Covered The Insurer will pay to an Insured (or at the request of the Insured, the Insured Person) the appropriate benefit, specified in the Benefits Schedule attaching to this policy, if during the operative time and within the Period of Insurance, the Insured Person sustains accidental bodily injury which within two years is the sole cause of Death, Disablement or incurring of Medical Expenses for which the Benefit is claimed The Insurer shall not be liable to make any payment for accidental bodily injury arising from 1. Suicide or attempt thereat 2. Flying of any kind other than as a passenger Provided that the maximum amount payable by the Insurer under this policy in respect of all benefits specified in the Benefits Schedule shall not exceed the sum specified in the Policy Schedule as the Accident Occurrence Limit, in respect of any one occurrence or all occurrences of a series consequent on one source or original cause irrespective of the number of claims or the number of Insured Persons claiming. 3. Engaging in or practising for rallies trials or speed tests. 4. Driving a motor vehicle with more that the legally permitted level of alcohol in the blood. 5. Driving a motor vehicle whilst under the influence of a drug unless it is taken on proper medical advice and is not for the treatment of drug addiction. 6. War Risks - war invasion acts of foreign enemies hostilities or warlike operations (whether war be declared or not) civil war rebellion revolution insurrection civil commotion assuming the proportions of or amounting to an uprising military or usurped power unless where bodily injury occurs on a journey outside the Insured Person s normal country of residence other than to a country which was a disturbed area at the commencement of the journey subject always to the exclusion of war and terrorism occasioned by the 4

5 nuclear chemical or biological incident also excluding loss damage cost or expense of whatsoever nature directly or indirectly caused by resulting from or in connection with any action taken in controlling preventing suppression in any way such war and terrorism occasioned by any nuclear chemical or biological incident. 7. War or Terrorism occasioned by any Nuclear Chemical or Biological Incident use of any nuclear weapon or device or the deliberate emission discharge dispersal release or escape of any solid liquid or gaseous chemical agent and or biological agent as a direct or indirect result of war risks and terrorism. 8. Nuclear Radioactive Contamination claims in any way caused or contributed to by nuclear reaction, nuclear radiation or radioactive contamination. Extensions Funeral Expenses The Insurer will pay reasonable funeral expenses incurred as a result of death following accidental bodily injury of any one Insured Person up to a maximum of 3,500 provided cover is not provided under any other policy of insurance. Accident Medical Expenses Notwithstanding any payment made under Benefit 7 if during the Operative Time the Insured Person sustains Bodily Injury resulting in a valid claim under Benefits 1-6 Medical Expenses incurred will be reimbursed up to 25% of any amount paid under Benefits 1-6 subject to a maximum of 15,000 any one Insured Person. 9. Radioactive Contamination whether arising directly or indirectly from (i) Ionising radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. (ii) The radioactive toxic explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof. 5

6 Special Conditions Application of the Accident Occurrence Limit In the event of a claim exceeding the Accident Occurrence Limit the Insurer s liability in respect of each Insured Person claimed for shall be proportionally reduced until the total does not exceed that Limit as specified in the Policy Schedule. Application of the Aircraft Accumulation Limit In the event of a claim exceeding the Aircraft Accumulation Limit the Insurer s liability in respect of each Insured Person claimed for shall be proportionally reduced until the total does not exceed that Limit as specified in the Policy Schedule. Benefits 1. Benefit is payable under either Level 1 or Level 2 of the Benefits Schedule as selected at the inception date of the Scheme or the date of joining the scheme (by the Insured Person) once notified to the Insurer. 2. Benefit shall not be payable in respect of any one Insured Person under more than one of Benefits 1 to 4 in connection with the same accident. 4. Loss of Limb or Eye or speech or hearing must be proved to the reasonable satisfaction of the Insurer to be permanent and without expectation of recovery before the Insurer will pay Benefits 2 to Total Disablement must be proved to the reasonable satisfaction of the Insurer to be permanent and without expectation of recovery and any claim for weekly compensation must have been settled in full before the Insurer will pay Benefit If a Death Benefit is not included for an Insured Person, the Insurer will not pay any benefit for Loss of Limb or Eye or speech or hearing until at least thirteen weeks after the date of the accident and the Insurer will only then pay if the Insured Person has not in the meantime died as a result of the accident. 7. If a Death Benefit is included but is less than the Benefit for Loss of Limb or Eye or speech or hearing the Insurer will not pay more than the Death Benefit until at least thirteen weeks after the date of the accident and the Insurer will only then pay the balance if the Insured Person has not died as a result of the accident. 3. On the happening of an accident giving rise to a claim under any of Benefits 1 to 4 this Policy will not cover any further accidents to that Insured Person. 8. If Benefit 3 is payable in respect of the same Insured Person for more than one form of Permanent Disablement as the result of the same accident the total of the percentages payable shall not exceed 100% of Benefit 3. If 6

7 Benefit is payable for loss of use of a whole member of the body the Benefits for parts of that member cannot also be claimed. 9. The Benefit amount shown under Item 3 of the Benefits Schedule shall be a percentage of the amount for that benefit shown in the Benefits Schedule, applicable to the forms of disablement specified under items 3(a) to 3(m). For forms of permanent disablement not specified the degree of disability will be assessed by comparison with the percentages shown in the scale without taking into account the Insured Person s occupation. The appropriate percentage shall be applied to the amount for Benefit 3 shown in the Benefits Schedule or to the Limit per Insured Person under Benefit 3 whichever is the lesser. 10. No Benefit will be payable due solely to the Insured Person being disabled from taking part in sport or pastimes. 11. Benefits 5 and 6 are payable per week for a maximum of 104 weeks in all not necessarily consecutive. Disappearance In the event of disappearance of the Insured Person, if after a suitable period of time, it is reasonable to believe that death has occurred as a result of accidental Bodily Injury the Death Benefit shall become payable subject to a signed undertaking that if the belief is subsequently found to be wrong such Death Benefit shall be refunded to the Insurer. Exposure If an Insured Person suffers Death or Disablement as a result of exposure to the elements the Insurer will consider that as having been caused by accidental Bodily Injury. Minors If the Insured Person is under the age of 18 and is not one of the Insured s employees 1. Benefit 1 will be limited to 10, Benefit 4 shall read Permanent Total Disablement from gainful employment of any and every kind. 3. No amount will be payable under Benefits 5 or Benefit shall not be payable in respect of any Insured Person who had ceased to be an Employee prior to an accident giving rise to a claim (this condition applies where the policy is effected for the benefit of employees). 7

8 Endorsements Endorsement No 1 In respect of any claim for Medical Expenses these shall be limited to such expenses incurred within 12 months of the date of injury. Endorsement No 6 The Insurer will not pay for any benefit where bodily injury is the result of the insured person engaging in mountaineering or rock climbing unless supervised by guides and experts in this particular field. Endorsement No 2 The benefit provided under Benefit 7 (Medical Expenses) of the Benefits Schedule is subject to an excess of 500 each and every claim. Endorsement No 3 The Insurer will not pay for any benefit where bodily injury is as a result of the Insured person taking part in military, airforce or naval operations (other than reserve of volunteer training). Endorsement No 4 The Insurer will not pay for any benefit for death or disablement directly or indirectly caused by or contributed by self injury, provoked assault, duelling or fighting (except bona fide self defence or sporting activities) or from insured persons own criminal act or whilst engaged in civil commotion or riots of any kind. Endorsement No 5 The Insurer will not pay for any benefit where bodily injury is the result of the insured person driving in any kind of motor or motor cycle race or riding in any kind of horse race 8

9 General Policy Conditions hereunder cannot be assigned without written consent of the Insurer. 1. Arbitration All differences arising out of this policy shall be referred to the decision of an Arbitrator to be appointed in writing by the parties in difference or if they cannot agree upon a single arbitrator to the decision of two arbitrators one to be appointed in writing by each of the parties within one calendar month after having been required in writing so to do by either of the parties or in case the arbitrators do not agree of an umpire appointed in writing by the arbitrators before entering upon the reference. The umpire shall sit with the arbitrators and preside at their meetings and the making of an award shall be a condition precedent to any right of action against the Insurer. If the Insurer shall disclaim liability to the Insured for any claim hereunder and such claim shall not within 12 calendar months from the date of such disclaimer have been referred to arbitration under the provisions herein contained then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder. 3. Assignment The Insurer will not be bound to accept or be affected by any trust charge lien assignment or other dealing with or relating to this Policy. 4. Cancellation This Policy may be cancelled at any time by seven days' notice by registered letter from the Insurer to the Insured s last known address and in such event the Insurer will return a pro rata portion of the premium for the unexpired part of the Period of Insurance. 5. Cancellation of War Risks This Policy may cancel any insurance provided by this Policy against War Risks by sending seven days notice to Insured s last known address. The Insurance in respect of any journey involving travel outside the Insured Person s country of residence, which commences before the expiry of such notice shall not be affected. 2. Alteration If at any time or from time to time any change shall occur materially varying any of the facts existing at inception date of the Policy, the Insured shall within seven days give notice in writing to the Insurer and no amendment shall be effective unless expressly agreed to by the Insurer. No amendment to this Policy will be effective unless it is made by written endorsement duly executed on behalf of the Insurer. This policy and any rights 6. Claims Procedures Claims Notification as soon as possible after the Insured / Insured Person is aware that an accident has happened which may give rise to a claim the Insured must notify the Insurer in writing. Evidence Required - the Insured / Insured Person must produce to the Insurer at their own expense, such original 9

10 certificates, information and evidence as the Insurer may from time to time reasonably require. If the Insurer considers it necessary each Insured Person must also agree to have a medical examination (which the Insurer will pay for) as often as the Insurer may require in connection with any claim following any accident. 7. Interest Interest will not be added to any amount paid. 8. Jurisdiction and Governing Law Any interpretation of this Policy or issue relating to its construction, validity or operation is governed by the laws of the Republic of Ireland. The parties agree to submit to the exclusive jurisdiction of the Courts of the Republic of Ireland. proportion being determined by reference to the cover provided under each of the relevant policies. 11. Other interests The Insured s receipt shall discharge the Insurer s liability to pay any amount in respect of a claim. The Insured Person or the Insured Person s personal representatives shall have no right to claim from or sue the Insurer. If the Insured comprises more than one party having an interest in the Insured Person the settlement made by the Insurer shall represent the total amount payable in respect of that Insured Person or property for all interests covered by this Policy. 12. Reasonable Care The Insured and each Insured Person shall take all reasonable precautions to avoid accidental bodily injury. 9. Observance of Terms The due observance and fulfilment of the terms, conditions and endorsements of this Policy insofar as they relate to anything to be done or complied with by the Insured shall be conditions precedent to any liability of the Insurer to make any payment under this Policy. 10. Other Insurances If at the time of any accident giving rise to a claim there is any other medical expenses insurance policy in force in the Insured s name or the Insured s Persons name, which also covers the Insured or the Insured Person concerned for the same expense then the Insurer will only pay a proportion of the claim such 10

11 Policy Definitions Insured to the Insured Person at the date accidental Bodily Injury is sustained. In this Policy, the following words shall have the definitions that follow: Accident Occurrence shall mean each and every loss or series of all individual losses arising out of one and the same catastrophic incident. The duration and radius of any one accident occurrence shall be limited to (1) 72 consecutive hours and (2) 160 Km radius (but 160km radius is not applicable in respect of natural catastrophes) and no individual loss, which occurs outside the distance or period, shall be included in that Accident Occurrence. Accident Occurrence Limit shall mean the maximum amount the Insurer will pay in the aggregate under this Policy and any other policy of Personal Accident Insurance issued by the Insurer in the Insured s name in respect of all losses arising out of one and the same accident. Benefit shall mean the sum of money that the Insurer has agreed to pay the Insured or as applicable, the Insured Person as described in the Benefits Schedule. Biological Agent shall mean any pathogenic micro-organism and or biologically produced toxin(s) including genetically modified organism and chemically synthesised toxins, which results in Bodily Injury or Death Disablement or incurring of Medical Expenses. Bodily Injury shall mean bodily injury caused solely by accidental violent external and visible means including unavoidable exposure to the elements but not including sickness or disease or any naturally occurring condition or degenerative process or the result of any gradually operating cause. Chemical Agent shall mean any compound which when suitably disseminated produces Bodily Injury or Death Disablement or incurring of Medical Expenses. Aircraft Accumulation Limit shall mean the maximum amount the Insurer will pay under this Policy or any other Policy issued by the Insurer in the Insured s name in respect of all Insured Persons travelling in the same aircraft. Commuting shall mean all travel within Ireland, from the departure of the Insured Person from residence or place of business (whichever occurs last) until arrival back at such residence or place of business (whichever occurs first) at the end of the journey. Annual Salary shall mean the total annual remuneration excluding payments for overtime commission or bonus payable by the Disturbed Area shall mean any area where war hostilities or widespread and serious disturbances in the way of rioting civil strife terrorism or any other such form of 11

12 lawlessness involving violence are in progress or have been reported in the national press to be imminent. Employee shall mean any person under a contract of service or apprenticeship with the Insured. Insured Person shall mean any person or category of persons as described in the Policy Schedule. Ireland shall mean the Republic of Ireland and Northern Ireland. Loss of Limb shall mean a) in the case of a leg loss by permanent physical severance at or above the ankle or permanent and total loss of use of a complete foot or leg. b) in one eye if the degree of sight remaining after correction is 3/60 or less on the Snellan Scale (meaning seeing at 3 feet what the Insured Person should see at 60 feet). Medical Expenses shall mean the cost of medical surgical or other remedial attention treatment or appliances given or prescribed by a Medical Practitioner and all Hospital Nursing Home and ambulance charges. Medical Practitioner shall mean any legal qualified medical practitioner other than a) an Insured Person b) a member of the immediate family of an Insured Person c) an employee of the Insured. Multi Engined Aircraft shall mean a) Any multi engined aircraft. b) in the case of an arm loss by permanent physical severance of the four fingers at or above the meta carpo phalangeal joints (where the fingers join the palm of the hand) or permanent and total loss of use of a complete arm or hand. Loss of an Eye shall mean permanent total loss of sight, which will be considered as having occurred a) in both eyes if the Insured Person is declared blind on the authority of a fully qualified ophthalmic specialist. b) Any helicopter operating a scheduled service from an international airport. Operative Time as described in the policy schedule shall have the following meanings unless otherwise described in the policy schedule- 24 Hours shall mean 24 hours a day, 365 days a year. Assault shall mean whilst the Insured Person is engaged upon duties incidental to the Insured s official business and as a result of Assault 12

13 other than by the explosion of any bomb or explosive device, including assault which is a direct consequence of the Insured Person s employment with the Insured. Emergency Call Out shall mean whilst the Insured Person is engaged on official emergency call-out duties or mock call out for the purpose of training exercises. including travelling directly to or directly back from such events as part of an organised party. Life Guard Duty shall mean whilst engaged as a Lifeguard including attendance at any training course organised by or under the direction of the Insured including commuting and assault. Fire Brigade shall mean whilst the Insured Person is engaged on the official business of the Insured a) At any fire drill or training course b) At any Fire Brigade Duty (including physical testing) or present under the control of a responsible officer at or engaged in a competition or exhibition of Fire Brigades. c) Proceeding to or returning directly from such fire or drill or training course or competition or exhibition including commuting. d) Fire Prevention type inspections and Community Fire Safety activities. e) Whilst the Insured is engaged in the above duties (a) to (d) as a result of assault. Junior Traffic Wardens shall mean whilst engaged in Junior Traffic Warden Duties and while training for this duty under the direction of the Garda Siochana, including participation in annual outings and regional national competitions Occupational Accidents shall mean whilst the Insured Person is engaged on the official business of the Insured. Occupational Accidents/ Commuting shall mean whilst the Insured Person is engaged on the official business of the Insured including commuting. Official Functions shall mean whilst the Insured Person is attending or travelling directly to or from any Council, Committee meeting, function or engagement which forms part of the Insured Persons official duties. Scheme A shall mean while the Insured Person is attending official Local Authority functions including all travel connected with such Functions from the time of leaving home or place of business whichever is the later until return to home or place of business whichever is the earlier but such travel not necessarily being taken by the most direct route. Scheme B shall mean on a 24 hour, 365 day basis. 13

14 14 Search Rescue and Recovery shall mean whilst the Insured Person is engaged on the official business of the Insured including commuting, training, diving and involvement with Helicopters and whilst involved in fundraising activities.