HealthSure Personal Accident Cover and Accidental Death Cover. Terms and Conditions

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1 HealthSure Personal Accident Cover and Accidental Death Cover Terms and Conditions 1

2 Conditions a) If compensation is payable in respect of one Insured Person under more than one form of Permanent Disability as a result of one accident the total payable shall not exceed 100% of the Sum Insured. b) If compensation is payable for loss of or loss of use of a whole member of the body then compensation for parts of that member cannot also be claimed. c) Eligible children, if included, shall receive a benefit of 10% of the Sum Insured stipulated under the scale of benefits. Special Extension Retraining Expenses If a claim is paid under any of Items 2 to 8 the Benefit Payable will be increased by 10% as a contribution towards retraining costs. We will not pay Benefits for both Death and Disability arising from the same accident. Where an accident results initially in Disability and subsequently Death we will pay the Death Benefit. Part A Personal Accident In the event of an Insured Person sustaining Bodily Injury during the Operative Time in any Policy Period we will pay to the Insured Person compensation in accordance with the percentages stated in the Personal Accident Specification. Provided always that in respect of any one Insured Person, compensation shall not be payable under more than one of the Benefits 1 to 4 in respect of any one Event, and in respect of Benefits 1 to 15, no more than 100% of Benefit will be payable. Extensions to Part A Disappearance If any Insured Person disappears and after a suitable period of time it is reasonable to believe that such Insured Person has died as a result of Bodily Injury, the Death Benefit shall become payable subject to the Insured Person s representative signing an undertaking that if the belief is subsequently found to be incorrect such Death Benefit shall be refunded to us. Exposure Death and/or Injury to an Insured Person as a direct result of exposure to the elements shall be deemed to have been caused by Bodily Injury. Exclusions to Part A We shall not be liable in respect of Bodily Injury directly consequent upon: a) the Insured Person committing or attempting to commit suicide, or intentionally inflicting self-injury; b) the Insured Person engaging in flying or other aerial activity except as a passenger; 2

3 c) the Insured Person participating in any sport as a professional; d) the Insured Person engaging in active service in any of the Armed Forces of any nation; e) War within the Country of Nationality and Country of Domicile of the Insured Person(s); f) radioactive contamination; g) the Insured Person engaging in or taking part in rock climbing or mountaineering normally involving ropes or guides, hang gliding, parachuting or driving or riding in any kind of race; h) the Insured Person being in a state of insanity (temporary or otherwise) or any psychiatric, mental, nervous or stress related disorder or anxiety state; i) deliberate exposure to exceptional danger (except in an attempt to save a human life), the Insured Person s own criminal act or the Insured Person engaging or taking part in civil commotion or riots of any kind; j) pregnancy or childbirth; k) injuries resulting from Osteoporosis disease. Definitions Accident/Accidental Shall mean a sudden, unexpected, unusual specific Event which occurs at an identifiable time and place but also includes exposure resulting from a mishap to a conveyance in which the Insured Person is traveling. Bodily Injury Injury which is caused by an Accident and which solely and independently of any other cause results within twelve months from the date of such injury in the Insured Person's death, dismemberment or disablement. Bodily Injury does not include sickness, disease, any naturally occurring condition, any gradually operating cause or post traumatic stress disorder, other than as a direct result of accidental Bodily Injury caused by an Event. Dependant Children Shall mean children under 18 years of age, normally resident with an Insured Person and not in full time employment. Event Shall mean any one occurrence or all occurrences of a series consequent upon or attributable to one source or original cause. Loss of Eye(s) Loss of Eye(s) shall include total and irrecoverable loss of sight, which shall be deemed to have occurred: a) in both eyes when the condition is shown to our satisfaction to be permanent and without expectation of recovery and the Insured Person s name has been added to the Register of Blind Persons on the authority of a fully qualified ophthalmic specialist; b) in one eye when the degree of sight remaining after correction is 3/60 or less on the Snellen scale and we are satisfied that the condition is permanent and without expectation of recovery. Loss of Limb(s) Loss of Limb(s) shall mean: a) in the case of a lower limb by permanent physical severance at or above the ankle or permanent total loss of use of an entire leg or foot; 3

4 b) in the case of an upper limb loss by permanent physical severance of the entire four fingers through or above the meta carpo phalangeal joints or permanent total loss of use of an entire arm or hand. Permanent Total Disablement a) Where the Insured Person is gainfully employed, Permanent Total Disablement means disablement caused other than by Loss of Limb(s), Loss of Eye(s) or Total Loss of Hearing which will entirely prevent the Insured Person from engaging in his/her usual occupation for the remainder of his/her life. b) Where the Insured Person is not gainfully employed, Permanent Total Disablement means disablement, caused other than by Loss of Limb(s), Loss of Eye(s) or Total Loss of Hearing which will entirely prevent the Insured Person from engaging in any and every occupation for the remainder of his/her life. Sum Insured The maximum amount payable under the terms and conditions or your policy. Total Loss of Hearing Total, permanent and irrecoverable loss of hearing. War War, whether declared or not, between any of the following countries, namely, China, France, United Kingdom, Commonwealth of Independent States (CIS) including the Baltic States and the United States of America, or war in Europe, whether declared or not (but including any enforcement action by or on behalf of the United Nations) in which any of these countries or any armed forces thereof are engaged. General Insurance Conditions 1. Special Claims Conditions It is a condition precedent to our liability that in the event of any circumstances which a) Could give rise to a claim under this policy the Insured Person shall: i. give notice to us by the most expeditious means; ii. confirm the facts in writing as soon as possible, with as much information as available; iii. make no admission of liability without our prior written consent; iv. provide us or our appointed representatives with: a) all necessary assistance in a timely manner b) all information reasonably required c) all documentation and records necessary to establish and assess indemnity hereunder d) copies or extracts as may be reasonably required v. provide us or our appointed representatives with: prove the loss to our reasonable satisfaction; vi. forward immediately to us or our representatives any letter, writ or other document received in connection with any claim made under this policy; vii. assist and concur with all reasonable arrangements for our medical and other advisers to examine any Insured Person in respect of which a claim has arisen. b) As often as may be reasonably required provide a statutory declaration sworn before a solicitor, justice of the peace or notary public, on all matters connected with a claim, at such reasonable time and place as may be designated by the Company No act of ours or 4

5 our representatives in connection with any investigation hereunder, shall be deemed a waiver of any defence which the we might otherwise have. All acts shall be deemed to have been made without prejudice to our liability. We reserve the right to: a) take such steps as they deem necessary to prevent, mitigate or minimise a loss; b) take over and conduct the defence or settlement of claims made against an Insured Person that are covered by this policy; c) pursue all rights or remedies available to the Insured whether or not payment has been made hereunder; d) require independent medical examination of any Insured Person(s) who gives rise to a claim hereunder. Upper Age Limit Provided an Insured Person has taken out a Policy before their 65th birthday, this Policy will continue for an unlimited period so long as the Insured Person continues to pay the premiums. Benefit Limits Where an accident results initially in disability and subsequently death we will pay the Death Benefit. On payment of a Benefit in respect of any of the items, 1, Death, 2, Permanent Total Disablement, 3, Permanent and curable paralysis of all limbs and 4, Permanent and incurable insanity, all cover will cease in respect of the Insured Persons who is the subject of the claim. How to claim If you have a claim please call us on for a claim form. All claims must be made through you or your legal representatives. If necessary, the insured person must also agree to a medical examination, at our expense, whenever we ask for one. We will pay any benefit due under this policy to you (if you are living) or to your estate (if you have died). We will not add interest to any amount we pay. The full effects of an accident are not always immediately known and, although permanent disability may happen at the time of the accident, we have to wait a reasonable length of time to make sure that we know the full effects. Premiums You must continue to pay your premiums to be entitled to claim. Failure to do so will mean we will suspend your policy. You cannot make changes to your premium level. Insurance Premium Tax (IPT) is included in your premium. If the Government changes IPT, we may have to amend your premium from the date that the IPT change is implemented. We will notify you of this change separately. 5

6 How does cover end? All cover under this policy will end automatically in the following circumstances: a) You cancel your policy by giving us one month s notice. We will not refund any premiums you have already paid. b) You or any third party who is paying your premiums on your behalf miss paying three consecutive monthly premiums. We may reinstate that cover once all outstanding premiums have been paid. c) You die. d) We exercise our right to cancel your policy if we make a commercial decision to stop providing this policy or an equivalent policy. We will give you at least three months written notice of our decision. Customer care We aim to provide you with the very highest levels of customer service and care at all times. To maintain this service standard, we have a procedure you can use to raise any concern, complaint or recommendation you have. In the first instance you should contact Customer Services on or write to Simplyhealth Customer Services, at our registered office address of Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. If you are unhappy with the response, your complaint will be referred to the Simplyhealth Group Quality Assurance team for a final decision. If you remain dissatisfied with our final response, you have the right to refer your complaint to: Financial Ombudsman Service South Quay Plaza 183 Marsh Wall London E14 9SR Telephone: Full details of our complaints procedures are available on request. Changing your mind you have 14 days from receiving your welcome letter to change your mind and receive a full refund of any premiums you have paid, provided you have not made any claims. If you change your mind, please call or write to Simplyhealth Customer Services at our registered office address, and we will cancel your policy for you. Changes to your details you must inform us as soon as reasonably possible of any changes to the information you have given to us, including any change of address, marital status or any other material change. Failure to do so may result in changes being made to your policy without notification, for example your premium being increased. You are protected by the Financial Services Compensation Scheme (FSCS) in the unlikely event that we go out of business or into liquidation the FSCS protects you. Should this happen, any valid outstanding claims you have at that point would be paid by the scheme. For more details on the scheme please visit or contact the FSCS direct on

7 How we use information that we hold about you We will store and process your personal data ( your information ) in accordance with the Data Protection Act We and other companies within the Simplyhealth group will use your information for providing our services, for assessment and analysis, for assessing premiums and risks, for handling claims, for improving our services, and for protecting our interests. We and other companies within the Simplyhealth group will use your information to keep you informed by post, telephone, or other means about products and services that may be of interest to you. If you do not wish your information to be used for these purposes, please write to: The Data Controller Simplyhealth Hambleden House Waterloo Court Andover Hampshire SP10 1LQ. We will keep your information confidential. However, we may give your information and information about how you use our products to the following: a) Fraud prevention agencies and other organisations who may record, use and give out information to other insurers b) People who provide a service to us or act as our agents on the understanding that they will keep the information confidential and in accordance with the Data Protection Act 1998 c) Anyone to whom we may transfer our rights and duties under this agreement d) We may also give out your information if we have a duty to do so (such as to regulatory bodies), or if the law allows us to do so or if the person requesting your information has, in our opinion, a legitimate interest in the disclosure Sensitive data to assess the terms of the insurance contract or administer claims, we may collect data that the Data Protection Act 1998 defines as sensitive. By agreeing to these terms and conditions, you consent to us processing this data and assessing the terms of the insurance contract or administering claims. You have the right to see your information which is held by us. There may be a charge if you want to do this. For more details, write to the Data Controller at the address shown above. You are declaring that you have a right to give us information about your partner and anyone else referred to by you. Your calls may be recorded and monitored for training and quality assurance purposes. General terms and conditions We have the absolute right to change any of the terms and conditions relating to the policy if we give you one month s notice for changes to: a) the cover the policy provides b) terms and conditions c) premiums 7

8 Waiver the failure or delay by either you or us to insist upon the strict performance of any term or condition of the policy or to exercise any related right or remedy does not waive any breach or subsequent breach of that term or condition. Enforcement no term of this policy or any part of it is enforceable under the Contracts (Rights of Third Parties) Act 1999 ( the Act ) by a person who is not party to it. For the purposes of the Act your partner or children (or both) are not party to the policy. Choice of law and jurisdiction the parties to insurance contracts in the United Kingdom may choose which law will apply. Unless we agree otherwise in writing, English law will apply to your policy. The Courts of England have sole jurisdiction over any claims arising in connection with the policy. Simplyhealth is a trading name of Simplyhealth Access, registered and incorporated in England and Wales, No Registered office: Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. Authorised and regulated by the Financial Services Authority. Your calls may be recorded and monitored for training and quality assurance purposes. 8

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