ACE GROUP PERSONAL ACCIDENT & SICKNESS INSURANCE

Transcription

1 ACCIDENT & HEALTH ACE GROUP PERSONAL ACCIDENT & SICKNESS INSURANCE SUMMARY OF KEY CHANGES Please note: This document provides a brief summary of the key changes made to the ACE Group Personal & Sickness Insurance Policy Wording and Product Disclosure Statement (PDS). This is not an exhaustive list of the changes made and does not form part of the PDS. For a full description of the terms, conditions and exclusions of the cover please refer to the PDS and any other supporting documents that we issue you. Description of Key Changes Change Policy Wording Reference Description New definition for "Benefit Period Means: the maximum period of time for which a benefit is payable under Events 25, 26, 27 and/or 28 as shown in the Schedule. New definition for "Claimant Means: the Policyholder, a Covered Person or any other person entitled to claim under the Policy. New definition for "Non-Scheduled Flights" Means: travel in an aircraft whose flights are not conducted in accordance with fixed flying schedules, over specific air routes, to and from fixed terminals. Amended definition of "Permanent Means: having lasted twelve (12) consecutive months from the date of the Bodily Injury and at the expiry of that period, being beyond hope of improvement. Amended definition of "Permanent Total Disablement Means: the disability having lasted twelve (12) consecutive months from the date of the Bodily Injury and at the expiry of that period, being beyond hope of improvement. New definition for "Pre-Existing Medical Condition Previously pre-existing bodily injuries were excluded under the former General Definition of Bodily Injury - "it does not mean (b) any pre-existing physical or congenital conditions (except illness or disease directly resulting from medical or surgical treatment rendered necessary by any Bodily Injury) together with the pre-existing medical condition exclusion. Previously pre-existing sicknesses were excluded under the former General Definition of Sickness first manifesting itself not less than thirty days after they became a Covered Person together with the preexisting medical condition exclusion. The introduction of the Pre-Existing Medical Condition definition, below, facilitates the exclusion of Pre-Existing Medical Conditions whilst allowing for continuity of cover in specific circumstances.

2 The new definition of Pre-Existing Medical Condition means: a) any physical defect, condition, illness or disease for which treatment, education or advice (including advice for treatment) has been received or prescribed by a Doctor or Dentist in the three (3) years immediately prior to becoming a Covered Person under the Policy; or b) a condition, the manifestation of symptoms of which a reasonable person in the circumstances would be expected to be aware of three (3) months prior to becoming a Covered Person under the Policy. Notwithstanding the above, any physical defect, condition, illness or disease will not be deemed to be a Pre-Existing Medical Condition where the Covered Person has been employed by the Policyholder and covered under a group personal accident and sickness insurance policy underwritten by Us and held by the Policyholder for the period or periods of insurance immediately prior to the Period of Insurance. The Pre-existing Medical Condition exclusion will apply under the Policy in respect of a Covered Person if that Covered Person has not had continuous cover under a group personal accident and sickness insurance underwritten by Us and held by the Policyholder immediately prior to the Policy. Amended definition of "Professional Sport" Professional Sport is defined by reference to the proportion of a Covered Person's income derived from their participation in the sport. Means: any sport for which a Cover Person receives a fee, allowance, sponsorship or monetary reward as a result of their participation, which in totality accounts for more than 15% of their annual income from all sources. New definition for "Renewal Period" Means: the period of insurance applicable to the Renewal Policy New definition for "Renewal Policy" Means: the group personal accident and sickness insurance policy underwritten by Us which takes effect immediately at the end of the Period of Insurance New definition for "Seek Employment Means: the Covered Person being registered with the government agency or department in their Country of Residence which is responsible for providing unemployment services, (such as Centrelink in Australia) and/or a recruitment company and then providing Us with proof of a minimum of two (2) new job applications per week Amended definition of "Sickness" Means: any illness or disease of the Covered Person occurring during the Period of Insurance and whilst the person is a Covered Person. It does not mean any Pre- Existing Medical Condition. The following words have been removed: first manifesting itself not less than thirty (30) days after they become a Covered Person

3 New definition for "Specially Designated List" Means: names of a person, entities, groups, or corporate specified on a list who are subject to trade or economic sanctions or other such similar laws or regulations of the United States of America, Australia, United Nations, European Union or United Kingdom. This definition facilitates the new "Sanctions Clause, contained within the General Provisions Applicable to the Policy. Amended definition of "Temporary Partial Disablement" General Definitions: Temporary Partial Disablement Means: where in the opinion of a Doctor, the Covered Person is temporarily unable to engage in a substantial part of their usual occupation or business duties resulting in their earnings post Bodily Injury or Sickness of at least 25% less than their Salary. If the Covered Person ceases to be employed by the Policyholder after the Event(s) occurs, then Temporary Partial Disablement means disablement which prevents the Covered Person from engaging in any occupation for which they may be suited by way of their education, training or experience which reduces their capacity to undertake an occupation by at least 25%. In both instances the Covered Person must be under the regular care of and acting in accordance with the instructions or advice of a Doctor. Amended definition of "Temporary Total Disablement" General Definitions: Temporary Total Disablement Means: where in the opinion of a Doctor, the Covered Person is temporarily unable to engage in any aspect of their usual occupation or any of their business duties. If the Covered Person ceases to be employed by the Policyholder after the Event(s) occurs, then Temporary Total Disablement means disablement which prevents the Covered Person from engaging in any occupation for which they may be suited by way of their education, training or experience. In both instances the Covered Person must be under the regular care of, and acting in accordance with the instructions or advice of a Doctor. Amendment to the Insuring Clause Extent of Cover Bodily Injury The requirement that the Event occurs within twelve months of the date of the Bodily Injury is maintained. The definition is amended such that, with respect to Events 25 and/or 26 (weekly benefits), the Event must also occur during the Period of Insurance or any Renewal Period. Therefore, if the Event (i.e. the Covered Person temporarily ceasing work due to a Bodily Injury) first occurs outside a current policy period, then there is no cover. Amendment to the Insuring Clause Extent of Cover Sickness The requirement that the Event occurs within twelve months of the date of the Sickness is clarified such that the Event must occur within twelve months of the date the Covered Person first sought treatment for and/or advice in relation to the Sickness from a Doctor or Dentist. The definition is amended such that, with respect to Events 27 and/or 28 (weekly benefits), the Event must also occur during the Period of Insurance or any Renewal Period, Therefore, if the Event (i.e. the Covered Person temporarily ceasing work due to a Sickness) first occurs outside a current policy period, then there is no cover.

4 Amendment to Events 2, 3 and 19 Permanent Total Disablement Paraplegia or Quadriplegia Permanent partial disablement not otherwise provided for under Events 2 to 18 inclusive Amendment to Event 9 (b) Loss of hearing in one ear Any amount payable under Events 2,3 or 19 will be reduced by any benefits payable under Events 25 or 26 (weekly benefits) for any period greater than fifty-two weeks. from 20% to 30%. Amendment to Event 10 Permanent Loss of use of four Fingers and Thumb of either Hand from 75% to 80%. Amendment to Event 11 Permanent Loss of the lens in: (a) two eyes (b) one eye Amendment to Event 13 Permanent Loss of use of four Fingers and of either Hand Amendment to Event 19 Permanent partial disablement not otherwise provided for under Events 2 to 18 inclusive Loss of lens in two eyes is a new benefit at 100% of the sum insured. from 40% to 50%. The benefit is no longer payable at ACE s absolute discretion. Rather we will seek the medical opinion of three Doctors as to the percentage reduction in whole bodily function, one of whom will be the Covered Person s treating Doctor and the remaining two appointed by ACE. The maximum payable under this benefit remains at 75% of the sum insured. As per above, any amount payable under Event 19 will be reduced by any benefits payable under Events 25 or 26 (weekly benefits) for any period greater than fifty-two weeks. Amendment to Event 21 Amputation of Limb Part B Bodily Injury Resulting In Surgery Benefits from 50% to 100%. Amendment to Events 26 and 28 Temporary Partial Disablement Amendment to Event 30 Brain surgery Part B Weekly Benefits Bodily Injury and Part C Weekly Benefits Sickness Part C Sickness Resulting In Surgery Benefits We now stipulate: If a Covered Person is able to return to work in a reduced capacity (whether or not with the Policyholder) yet elects not to do so, then the benefit payable shall be 25% of the Covered Person s Salary. from 50% to 100%. New Additional Benefits Additional Cover Under The Policy The following benefits have been added. They may be payable in addition to some Events claimed. The sums insured are shown in the Schedule. Return to Work Assistance In the case of weekly benefits being payable, we at our absolute discretion may elect to assist the Covered Person in arranging for professional assistance to improve their physical and/or emotional condition in order to return to their usual occupation. Assistance includes but is not limited to special equipment for and/or modifications to the Covered Person s usual workplace.

5 Unexpired Membership Benefit A benefit to reimburse a pro-rata amount of a pre-paid sport or gym membership, association or registration fee for the current season or membership period. Modification Expenses A benefit available to modify the Covered Person s home and/or vehicle, or costs associated with relocating the Covered Person to a more suitable home as medically necessary Executor Emergency Cash Advance Advanced payment of a portion of the benefit in the event of the Covered Person s accidental death, whilst the administration of the estate is being arranged. Amendment to Condition 4 Amendment to Condition 9 Amendment to Condition 10 General Conditions Applicable to the Policy Condition 4 General Conditions Applicable to the Policy Condition 9 General Conditions Applicable to the Policy Condition 10 Amended to specify that the Policyholder must provide documentation in the case of a workers compensation top-up claim and other amounts that will be offset against weekly benefit amounts claimed. The amount of any benefit payable for Temporary Total Disablement and Temporary Partial Disablement will be reduced by the amount of any: a) periodic compensation benefits payable under any workers compensation or accident compensation scheme. Where We are making payments for a top-up amount above the workers compensation weekly amount up to the benefit amount payable under the Policy as stated in the Policy Schedule, the Policyholder must provide copies of all documentation in respect of the related workers compensation claim; and b) common law entitlement or other income protection insurance; and c) sick pay received, or at the discretion of the Policyholder sick leave entitlement, monies paid or payable for the notice period in the event of a redundancy, or any disability entitlement. Amended to allow for offset of the benefit payable under Events 2, 3 and 19 where weekly benefits have been paid for longer than a 52 week period. If as a result of Bodily Injury, the Covered Person is entitled to a benefit under Events 25 and/or 26 and subsequently becomes entitled to a benefit under Events 2, 3 or 19, all benefits payable under Events 25 and 26 shall cease from the date of such entitlement. In addition, any weekly benefit amounts paid under Events 25 or 26 for any period greater than fifty two (52) weeks shall be offset against the benefit amount payable under Events 2, 3 or 19. An example of the offset calculation is in the PDS. Amended to stipulate the maximum benefit payable in the case of a non-salary earning employee: With respect to, where the Lump Sum Benefit is Salary linked and the Employee is not in receipt of a Salary, the benefit amount shall be limited to fifty percent (50%) of the Lump Sum Benefit shown in the Schedule against their respective category of Covered Person to a maximum of $250,000.

6 New Condition 11 General Conditions Applicable to the Policy Condition 11 Included to stipulate that benefits shall only be payable under one ACE policy. Should a benefit be payable under this section of the policy that is also payable under any other insurance policy with ACE, then only one (1) policy can be claimed against (i.e. the policy with the greatest benefit). Deletion of General Exclusion Previously Exclusion 5 The following exclusion has been deleted: results from the use, existence or escape of nuclear weapons material or ionising radiation from or contamination by radioactivity from any nuclear fuel or nuclear waste or from the combustion of nuclear fuel. Deletion of General Exclusion Previously Exclusion 9 The age exclusion has been deleted. It was previously 65 years. Note: this exclusion has been replaced by an Age Limitations provision, as per General Provisions Applicable to the Policy (see below) New General Exclusion Exclusion 3 The policy now specifically excludes: any loss, damage, liability, Event, Bodily Injury or Sickness which is directly or indirectly results from a Covered Person suffering from any stress or psychiatric condition, including but not limited to depression, anxiety, neurosis, psychosis, mental or emotional stress, physical fatigue, mental disease or associated disorders. Amendment to War/Civil War exclusion Exclusion 4 The General Exclusion for War or Civil War now only applies in respect of the following specified countries: Australia or a Covered Person s Country of Residence, or any of the following countries: Afghanistan, Chad, Chechnya, Côte d Ivoire (Ivory Coast), Democratic Republic of Congo, Iraq, Israel, Somalia or Sudan. New General Exclusion Exclusion 5 The policy now specifically excludes any loss, damage, liability, Event, Bodily Injury or Sickness which is covered by: Medicare; any workers compensation legislation; any transport accident legislation; any common law entitlement; any government sponsored fund, plan or medical benefit scheme; any other insurance policy required to effected under law. Amendment to Pre-Existing Medical Conditions exclusion Exclusion 7 The General Exclusion for losses arising from Pre-Existing Medical Conditions now specifies that this does not apply where an illness or disease results directly from medical or surgical treatment rendered necessary by any Bodily Injury. Refer also to the new definition of Pre-Existing Medical Condition. Amendment to HIV/AIDS exclusion Exclusion 9 The policy still has a General Exclusion for HIV/AIDS and variances but now provides cover if contracted through Bodily Injury.

7 New General Provision "Age Limitations" New General Provision Aggregate Limit of Liability - War / Civil War Amended General Provision "Currency" New General Provision "Sanctions Clause" Amended General Provision "Subrogation" As above, the age exclusion (previously 65 years) has been replaced by this Age Limitations provision, which limits the amounts recoverable by Covered Persons over the age of 75, as follows: Covered Persons aged 75yrs - 79yrs: Events 1-19 maximum sum insured is $250,000 (or Schedule amount, if less) Covered Persons aged 80yrs - 89yrs: Events 1-19 maximum sum insured is $100,000 (or Schedule amount, if less) Covered Persons aged 90yrs or over: Event 2 (PTD) is excluded Events 1 & 3-19 maximum sum insured is $25,000 Furthermore, there is no cover for Events, 25,26,27 and 28 (weekly benefits) benefits for Covered Persons aged 75 years or over at the time of loss. War / Civil is now covered for certain countries (refer to General Exclusion 4). This aggregate limit of liability applies per period of insurance, as shown on the Schedule. The reference to currency being in AUD is removed. The applicable currency is to be specified on the Schedule. The international operations of the ACE Group necessitates the inclusion of this clause: This insurance does not cover or pay claims arising directly or indirectly from, caused by, a consequence of, arising in connection with or contributed to by any loss or expenses with respect to a specially designated person, entity, group or company on the Specially Designated List or to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including but not limited to, the payment of claims. All other terms and conditions of the Policy remain unchanged. The following wording is added to the existing subrogation clause: We will not be liable for a loss where the Claimant is a party to an agreement that excludes or limits Our rights to recover damages from a third party in respect of that loss, whenever that agreement was made, i.e. before or after the loss occurred. The effect of this provision is that the Claimant may prejudice the Claimant s rights with regard to a claim if the Claimant makes or has made any agreement with a third party that will prevent Us from recovering the loss from that party or another party. ACE Group is an American company which necessitates the inclusion of this clause.

8 About ACE ACE Group is one of the world s largest multiline property and casualty insurers. With operations in 54 countries, ACE provides commercial and personal property and casualty insurance, personal accident and supplemental health insurance, reinsurance and life insurance to a diverse group of clients. ACE Limited, the parent company of ACE Group, is listed on the New York Stock Exchange (NYSE: ACE) and is a component of the S&P 500 index. ACE, via acquisitions by its predecessor companies, has been present in Australia for over 50 years. ACE s operation in Australia (ACE Insurance Limited) provides specialised and customised coverage s, including Marine, Property, Liability, Energy, Professional Indemnity, Directors & Officers, Financial Lines, Utilities, as well as Accident & Health insurance, to a broad client base. ACE is a major insurer of many of the country s largest companies. With five branches and 400 staff in Australia, it has a wealth of local expertise backed by its global reach and breadth of resources. More information can be found at CONTACT US Australia Head Office and New South Wales Branch The ACE Building 28 O Connell Street Sydney NSW 2000 Tel: (02) Fax: (02) Queensland Branch Level 27, 10 Eagle Street Brisbane, QLD 4000 Tel: (07) Fax: (07) South Australia Branch Level 7, 147 Pirie Street Adelaide SA 5000 Tel: (08) Fax: (08) Victoria Branch Level 16, 600 Bourke Street Melbourne VIC 3000 Tel: (03) Fax: (03) Western Australia Branch Level 26, 44 St. George s Terrace Perth WA 6000 Tel: (08) Fax: (08) The Group Personal Accident & Sickness Insurance is issued by ACE Insurance Limited (ABN ; AFSL ). Any information provided is factual only. Potential purchasers should read the policy wording and Product Disclosure Statement available online at to decide if the product is right for them ACE Group. ACE, ACE logo, and ACE insured are trademarks of ACE Limited. ACE