IFF Steering Group. Insurance Data Standards & Educational Tools and Support. Insurance protocols relating to standard list of terms and conditions

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1 IFF Steering Group Workstreams: Insurance Data Standards & Educational Tools and Support Insurance protocols relating to standard list of terms and conditions Purpose: The purpose of this paper is to outline an industry-standard and member list of insurance terms and definitions for consideration and implementation by the Group Risk industry, having regard to existing glossaries and lexicons of insurance terms. The adoption of a standardised dictionary with respect to terms and definitions is considered a key outcome to increasing the efficiency and simplicity of Group Risk insurance, and ultimately improving the member experience and understanding. Out of Scope: The change management process, including but not limited to driving the adoption and implementation of the proposed terms. Medical Dictionaries are also out of scope. VERSION 2.3: 25April 2013 In the process of comparing existing glossaries and lexicons of industry terms and definitions, it is evident that the superannuation industry also uses a long list of abbreviations and acronyms. We have included below a list of regularly used abbreviations and acronyms. Please note that this list is not exhaustive. AAL Automatic Acceptance Limits (or Levels) APRA Australian Prudential Regulation Authority ATO Australian Taxation Office CMO Chief Medical Officer CPI Consumer Price Index DB Defined Benefit DC Defined Contribution DOE Date of event EFT Electronic Funds Transfer ERF Eligible Rollover Fund FOS Financial Ombudsman Service FSG Financial Services Guide GSC Group Salary Continuance (also Income Protection) IME Independent Medical examination PDS Product Disclosure Statement RMP Risk Management Plan RMS Risk Management Strategy RSE Registrable Superannuation Entity SCT Superannuation Complaints Tribunal SEC Securities and Exchange Commission SG Superannuation Guarantee SG Act Superannuation Guarantee (Administration) Act 1992 SGC Superannuation Guarantee Charge SIS Act Superannuation Industry (Supervision) Act 1993 SIS Regulations Superannuation Industry (Supervision) Regulations 1994 SMSF Self Managed Super Fund TFN Tax File Number TPD Total and Permanent Disability (Disablement) Version 2.3 Page 1

2 DEFINITIONS OF COMMONLY USED TERMS TERM Accident only cover Accidental death Accumulation fund Active employment Activities of daily living Administrator Administrator of your estate Agreed value Application form APRA regulated fund Assessor At work Autoconsolidation Automatic Acceptance level (AAL) Beneficiary Benefit expiry age ALTERNATIVE TERM USED Loss of independent existence Executor, legal personal representative Guaranteed value Insurance proposal DEFINITION A regular payment, usually weekly or monthly if you are unable to work because you have had an accident. Usually an agreed set amount. Would not cover you if you had an illness such as cancer. Where the death is caused by a visible and external event such as a car accident that was unintended. You are usually offered some cover for accidental death while you are being underwritten for insurance. A superannuation fund where the value of the final retirement benefit payable to members is the member s account balance at the time of retirement. The test that Group Risk insurers typically use to establish that a members is not restricted due to illness or injury from performing the full normal duties of their occupation. The test is typically used to determine if cover can be provided under automatic acceptance (see AAL) provisions. Some insurers use a range of activities such as bathing, dressing, eating, personal hygiene and getting out of bed as proof of TPD where there is not a regular income. A party contracted by the trustee to provide services such as call centre, record keeping and member account management for the fund. The person who looks after the property you leave when you die and finalises all your legal requirements such as your tax. Is a pre-agreed (at the time of applying for insurance) monthly amount for your Income Protection. Sometimes subject to limits depending on your income when you become disabled. This is the form you use to apply for cover. It can be a paper-based or online form or conducted over the phone with an insurance representative All superannuation funds regulated by APRA under the SIS Act. Does not include SMSFs. The person who will look at your claim and manage your claim Means that you are at work, performing your normal role and are not restricted due to illness or injury and are not receiving any work cover benefits A government initiative to reduce the number of multiple superannuation accounts per employee whereby the ATO will help superannuation funds to auto-consolidate accounts with low balances by providing details of these accounts to a members' active superannuation account. The auto-consolidation process will be based on set rules relating to minimum account balances and period of inactivity. Means the level of cover that you can have before you have to provide any medical information to the insurer. Often linked to the superannuation fund default cover limit. The person who receives the end benefit from the Fund. This may be the member who retires or the person the member s death benefit is paid to. The age at which you no longer have any insurance. This will differ depending on whether it is death cover, TPD cover or Income protection cover. Version 2.3 Page 2

3 Benefit period Binding death nomination Choice architecture Choice Fund Choice product Commission Cover CPI linked Critical illness insurance (Trauma insurance) Crosssubsidisation Date of disablement Date of event Death cover Default cover Default cover Increasing Claim Payment Trauma Insurance Term Life Cover The maximum period of time your income protection benefit will be paid to you if you are disabled e.g. 2 years or to age 65. An instruction to your superannuation fund stating which of your beneficiaries should be paid your benefit upon your death. You can only nominate dependants or a legal personal representative. The nomination is valid for 3 years. A model for the regulation and governance of the superannuation system where regulation and trustee responsibility is based on the degree to which members make choices and take responsibility for their super. This is a superannuation fund where you have actively chosen a particular product. It does not have to offer a default level of death and TPD cover. A superannuation product other than a MySuper product. This means members must make an active choice to be invested in that product. Typically a % fee payable as an incentive or reward to the seller of a product, usually based on the value of the goods or services sold, and can reoccur in future years with no additional servicing provided to the customer or exertion from the seller of the product. The amount of death, TPD or Income Protection insurance held. When you are on an Income Protection claim the amount paid to you is increased each year in line with CPI to make sure the money you are receiving keeps pace with inflation. Important if you are on a long term claim Is a payment of a lump sum if you are diagnosed with a defined event such as cancer, heart attack or stroke. You can receive this benefit even if you go back to work so it is not included within Superannuation Polices. The practice of subsidising costs and/or benefits from one group of members and applying to another group within the same entity/fund. Where members subsidise costs and/or benefits attributable to other members within the same Fund. The date of injury or illness in which a GP certifies the member as no longer being able to perform the duties of their occupation This term refers to the event date of the injury or illness for the purposes of assessing eligibility for payment of an insurance benefit. Insurance payable if you die and in some cases if you have a terminal illness and have less than 12 months to live. If you live to a certain agreed age (usually between 70 and 90) you do not receive any benefit, similar to insuring your car. The amount of Death, TPD or Income Protection cover you automatically receive when joining a Superannuation Fund. It is linked to AAL and in most cases you can increase or decrease the amount of cover. The insurance benefit design of the Fund that dictates the type and level of insurance cover that is provided to eligible members in a Fund and will apply unless the member opts out of cover or is able to obtain a different or higher level of cover. The amount of Death, TPD or Income Protection cover that members automatically receive when joining a Superannuation Fund without having to apply. It is linked to the AAL and in most cases the member can increase or decrease the amount of cover if they wish. Version 2.3 Page 3

4 Default fund Deferred cover Defined benefit Dependants Duty of disclosure Eligible Member Eligible rollover funds (ERFs) Excluded Member Excluded Occupation Exclusion Executor Financial advisor Fixed cover Full Cover Full time Also Administrator of your estate, legal personal representative Financial Planner The superannuation fund to which an employer s Superannuation Guarantee contributions will be paid if the employee does not direct the employer to make the contributions to a fund of their choice. An insurer may offer cover at deferred time (such as at the end of a pregnancy) subject to no problems arising for the pregnancy. A superannuation benefit the value of which is determined by reference to a formula. The formula may reflect a prescribed rate of return that is not lined to traditional investment markets. Your dependants are, your spouse (legal or de-factor, including samesex), your children, anyone who is wholly or partly dependent on you and anyone who is in an interdependent relationship with you at the time of your death. Means that when you are applying for any type of insurance you need to tell the insurer everything you know about your health, occupation, family history, sports and income. If you don t the insurer may find out when you claim and you may not receive a benefit. You are an eligible member to join a Super Funds insurance offering if you meet certain criteria set out in their Product Disclosure Document. (PDS). If you are an eligible member you would receive the Funds default level of cover. Superannuation funds or approved deposit funds that are eligible to receive benefits that are automatically rolled over from other funds as a result of various triggers, including but not limited to minimum account balances coupled with inactive account status. ERFs typically accept superannuation money from other funds where the member has become lost. The insurer may not offer insurance to members that do not meet their eligibility for automatic cover, i.e. are not at work, prior TPD claim, have not joined the Fund within the prescribed period or not received employer SG contributions within the prescribed time period. Refers to an occupation that the insurer will not offer insurance for. If you participate in a hazardous sport such as hang gliding or you have had medical problems such as a bad back the insurer may still offer you insurance cover but exclude any claims relating to that activity or medical condition. You will know at the time of applying for your insurance if this is the case and you can have exclusions reviewed at a later date if your circumstances change. The person who looks after the property you leave when you die and finalises all your legal requirements such as your tax. Someone who is licenced by ASIC to be able to provide personal advice about insurance and your particular financial needs. Where the sum insured, or benefit amount, is fixed (can increase by CPI) and the premium paid changes with age. Cover that is provided by the insurer under Automatic Acceptance provisions and is not subject to sub-standard acceptance terms Typically is defined as the ability of a member to work at least 30 hours per week on an unrestricted basis. Version 2.3 Page 4

5 Gainfully employed Grandfathering Group risk insurance Guaranteed future insurability Guaranteed value Health evidence Illness Inactive account Income protection Income protection insurance Increasing claim payment Indemnity Injury Insurance proposal Insured member Interdependent (Life and age event cover Agreed Value Personal Statement of Health see Accident and Sickness, Total and Temporary Disablement or Salary Continuance see CPI Linked Application Form Means that you are employed or self-employed and receiving a salary, reward or profit in a business, occupation or profession. There may be a stipulated number of hours such as 15 hours per week. The preservation and continuation of certain insurance arrangements for a defined group when a new offering is introduced across a Fund. Grandfathering is a tool typically utilised under successor fund transfers and mergers. Wholesale insurance arrangements acquired by a superannuation fund trustee that collectively covers all the persons who may, from time to time, be members of the fund and which covers fund members in the event of death, TPD and loss of income due to disability. The Policy Owner is the Trustee. Is the option to increase your benefit or sum insured without having to provide health evidence or go through the underwriting process (see underwriting). Usually offered on specific events such as marriage, birth of a child or taking out a mortgage. Is a pre-agreed (at the time of applying for insurance) monthly amount on your Income Protection. Sometimes subject to limits depending on your income when you become disabled. Information received from you or your Doctor about your health that will allow the insurance company to either underwrite your request for cover or pay a claim. includes sickness, disease and disorder Generally, a member account in a superannuation fund where the fund has not received a contribution or rollover in respect of the member within a prescribed period as set out by the Fund s rules. A regular payment, usually monthly, if you are unable to work because you are ill or have had an accident. It is usually based on a percentage of your salary and may include contributions to your Super account. An insurance product designed to provide periodic benefits to a claimant to continue (wholly or partly) the income that the member was receiving before commencing a period of disability caused by injury or illness. When you are on an Income Protection claim the amount paid to you is increased each year in line with CPI to make sure the money you are receiving keeps pace with inflation. Important if you are on a long term claim Means you will have to prove your income at claim time (similar to proving the market value of your car for car insurance). An event that is caused by a visible and external event such as a car accident, which was unintended. This is the form you use to apply for cover. It can be a paper-based or online form or conducted over the phone with an insurance representative The person covered by the policy, the member of the Super Fund Two people of any gender who have a close personal relationship and Version 2.3 Page 5

6 relationship Interdependent relationship. Interim cover Legacy product Legal personal representative Level premium Life and age event options or cover Limited cover Loaded premium Loss of independent existence Lump sum Maximum benefit level Medical practitioner Member protection MySuper MySuper product Administrator of your estate, Executor Guaranteed Future Insurability Loaded contribution Activities of daily living financially and domestically support each other. Some one of either sex that you live with, and, have a close personal relationship with, and, financially and domestically support each other. The cover you have while your application for insurance is being underwritten. Interim cover may be less than the cover you are applying for and is usually only payable due to an accident or an illness that would have not led the insurance company to decline the application or to put a loading or exclusion on that injury or illness. Generally, an older generation superannuation product held by fund members that is no longer available for issue to new members. Also refers to technology platforms. The person who looks after the property you leave when you die and finalises all your legal requirements such as your tax. When you apply for the insurance the premium is calculated at your age at the start of the policy and does not go up as you get older. This means that the insurance premium may be higher at younger ages but cheaper at older ages than other types of insurance. With some policies, the member s level of cover will reduce. Is the option to increase your benefit or sum insured without having to provide health evidence or go through the underwriting process. Usually offered on specific events such as marriage, birth of a child or taking out a mortgage. The amount of cover provided due to the member not meeting Automatic Acceptance (see AAL) eligibility. Typically provides cover for events occurring after insurance is approved only. A surcharge applied to a member s premium to reflect an increased risk due to occupation, pastimes or medical evidence. Some insurers use a range of activities such as bathing, dressing, eating, personal hygiene and getting out of bed as proof of TPD where there is not a regular income. An amount of insurance benefit paid to a fund member as a stand alone amount that typically extinguishes any future liability, i.e. death benefit. Benefits can be paid as one or more lump sums. The maximum amount you are able to apply for under the policy A registered and qualified medial practitioner usually in Australia and who is not related to you. Regulatory arrangements under which, generally, superannuation fund members with an account balance of less than $1,000 cannot have that balance debited for fund administration costs greater than the earnings on the account. A superannuation product or investment choice that can be offered as a default by employers. It will provide default Death and TPD insurance for all members unless you opt out. You can increase your insurance if required, subject to the rules of the Fund. A superannuation product or investment choice in the choice architecture model where, among other things, members rely on the trustee to make decisions for them with respect to investment and insurance. Version 2.3 Page 6

7 Non- binding death nomination Occupation category Opt out Partial disability PDS (Product Disclosure Document) Personal Health Statement Policy or Group Life Policy Portability Post-motra TPD Pre-Disability Income Pre-existing condition Health Evidence Policy Document Where you nominate who you would prefer to receive your benefit when you die. Your super fund will use the nomination as a guide but the Fund can decide to pay the benefit to someone else, or to more than the person you have nominated, if they believe they are dependant on you. Grouping together occupations with similar duties and risk levels such as "blue collar" or "white collar" Where you decide to cancel your insurance cover. This may be because you do not want to be charged the insurance premiums or you have enough insurance elsewhere. Means that you have been disabled but are able to go back to work part time and are earning less than what you were earning before you were disabled. Some insures will pay you a reduced benefit taking into account the hours you are now working. The document that holds key information about your superannuation arrangement and insurance cover you have or can apply for, and should be read before joining a super fund or acquiring a financial product. The PDS will not cover everything that is in the Policy Document, however is a good guide. You can usually ask to see the Policy Document if you are unsure of anything in the PDS. Information received from you or your Doctor about your health that will allow the insurance company to either underwrite your application for cover or pay a claim. The Group Life policy issued by the insurer to the Super Fund to cover the Super Fund members. A fund trustee s obligation under the SIS Act to pay (within a 30 day period) the value of a member s benefits to another superannuation fund on request of the member. A situation where there is a direct link between the cause of a TPD claim and the Death of the claimant, and this occurs prior to the finalisation of the assessment of the original TPDclaim. Usually your average income in the 12 months before you where disabled. An injury that first occurred or an illness which first became apparent to you before the date you applied for or were given the insurance cover. Includes any directly or indirectly related condition. Premium Rate How much your insurance cover costs. This may be deducted directly from your superannuation account so it has no impact on your takehome pay, or it may be paid by your employer as an extra staff benefit. Premium Premium loading Preservation age Loading In relation to Group Risk (wholesale) insurance, a financial transaction where premium is paid to the underwriter to secure insurance coverage. Generally, the premium is paid by the fund trustee to obtain insurance cover in relation to the members of the fund. If you are at higher risk of claiming due to such things as being overweight, a smoker or having a high-risk job the insurer may still offer you cover but add an extra premium or loading. If your health improves you can have the premium loading reviewed usually at your own cost. The minimum age prescribed in the SIS Regulations at which the superannuation benefits of a fund member become available to be paid from the superannuation fund to the member, e.g. retirement. Rate Premium How much you will pay for your insurance cover. This may be deducted from the money your employer pays or direct from you superannuation Version 2.3 Page 7

8 Reasonably apparent Recurring claim Regular occupation Replacement rate RSE licence RSE licensee Salary continuance Scale Self insurance Self managed superannuation fund (SMSF) Sole purpose test Spouse Standard cover Standard Rates Stepped premium Accident and Sickness, Total and Temporary Disablement or Income Protection account. Means that a reasonable person in the circumstances could have been expected to be aware of the symptoms. Means that you have made a claim, recovered and then become disabled again from the same or a related cause. When this happens within a certain time period (usually 12 months) then the insurer will usually waive any waiting period. The occupation you normally hold for most of your working hours The proportion of a member s current employment income that the current value of the member s insurance benefits represents. Typically applies to income protection insurance. A registrable superannuation entity licence granted by APRA under the SIS Act. A trustee that is a body corporate or that is a group of individuals who hold an RSE licence. A regular payment, usually monthly if you are unable to work because you are ill or have had an accident. Usually based on a percentage of your salary and may include a contribution to your super account. Using the bulk purchasing power of a group of members in a fund to purchase insurance on a group risk/wholesale basis and achieve discounting benefits, as opposed to purchasing insurance as an individual. Also refers to the effect of generally lowering the cost of each iteration of an activity when the activity is conducted on an increasing scale. Where a superannuation fund insources the liability in relation to the value of members death or disability benefits (or both) (that is, from the fund s assets), rather than covering these benefits through external insurance arrangements. A superannuation fund that has fewer than five members, all of whom are trustees or are directors of a corporate trustee, and is regulated by the ATO and the SIS Act. No member can be an employee of another member unless they are related. The obligation under the SIS Act that a superannuation fund must be maintained by the trustee only for specific retirement purposes and a limited number of other purposes (such as the release of the benefit in the case of death or disablement). Normally means the person (irrespective of gender) you are living with is in a domestic arrangement while providing each other with financial and domestic support and personal care. Generally refers to the default level of cover The premium paid by a member when the rate is not loaded by the insurer. The premium for your cover will be recalculated (and usually increase) each year based on your age. Version 2.3 Page 8

9 Successor fund transfer Superannuation Guarantee Tailored cover The transfer of a members benefits from one fund to another without their consent where the trustees of both the transferring and the receiving funds agree that equivalent rights are provided to the transferring members in the receiving fund after the transfer. The legal requirement under the SG Act for an employer to make contributions at least quarterly equal to a percentage (currently 9 per cent per annum) of an employee s ordinary time earnings into a superannuation fund or RSA on behalf of the employee. When you have made a choice to increase or decrease your cover. Term life cover Death cover Insurance payable to your beneficiaries upon your death. In some cases the benefit will be paid to you if you have a terminal illness and have less than 12 months to live. If you live to a certain agreed age (usually between 70 and 90) you do not receive any benefit, similar to when you insure your car. Terminal illness Terminal An illness that is likely to lead to death within 12 months even with Total and permanent disablement Total and temporary disablement TPD Trauma insurance Trust Trust deed Trustee Underwriting Illness TPD Accident and Sickness, Salary Continuance or Income Protection Total and Permanent Disablement Critical Illness Insurance medical treatment. When you have an illness or had an accident resulting in you never being able to work again. In most cases you need to wait between 3 and 6 months before you can receive the benefit. A regular payment, usually fortnightly or monthly if you are unable to work because you are ill or have had an accident. Usually an agreed set amount. Means you have an illness or had an accident and you will never work again. In most cases you need to wait 6 months before you can receive the benefit. Any Occupation means that you are unable to work in any occupation at all (most policies take your training and experience into account) while own occupation means that you cannot work in your own occupation. Is a payment of a lump sum if you are diagnosed with a defined event such as cancer, heart attack or stroke. You can receive this benefit even if you are working or go back to work so it is not included within Superannuation Polices. A legal structure in which a person (the trustee) holds property on behalf of others (the beneficiaries) who are intended to benefit from the property or income of that property. A trust is the accepted legal structure for providing superannuation in Australia. The legal document establishing and governing a superannuation fund. The trust deed is the source of the trustee s powers and sets out the benefits to be paid to members from the fund. A person or company holding property on behalf of and acting for the benefit of another party. A trustee has fiduciary duties to beneficiaries. The trustee of a superannuation fund is the entity with sole legal responsibility under the SIS Act for the management of the fund for the benefit of fund members. The process where the insurance company looks at your medical background, your occupation, your activities and your income to decide if they will accept your application for cover. The underwriting process may range from being immediate or a few weeks if Doctors reports are Version 2.3 Page 9

10 Unit-based cover Waiting period required. Following underwriting the insurer will either accept you at standard rates, offer you cover with a loading, exclusion or decline your application. Cover that is based on a number of units where one unit equals a set amount of cover. The level of cover generally decreases with age, but the premium will remain the same (as opposed to Fixed cover). The number of days (normally chosen by you) you have to wait before you begin to receive your income protection benefit. Most claims are paid monthly in arrears so if you chose a 30day waiting period your first payment may not be received for 60 days. The waiting period reflects the excess under an income protection policy. Source includes APRA Version 2.3 Page 10

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