Group Personal Accident and Sickness Policy. Intrust Super Fund

Transcription

1 Group Personal Accident and Sickness Policy For Intrust Super Fund Windsor Income Protection Pty Ltd ACN: AFS Licence No:

2 Contents Important Notices... 3 Your Duty of Disclosure... 3 Non Disclosure... 3 A. The Policy Wording... 5 (i) Scope of Cover... 9 (ii) Commencement of Cover... 9 (iii) Cessation of Cover (iv) Takeover Terms (v) Additional Benefits (vi) Definitions (vii) Special Provisions Conditions (viii) Making a Claim (ix) Exclusions B. The Schedule... 5 Page 2

3 Important Notices All cover under this Policy is subject to: 1. The Payment of premium; 2. The terms and conditions contained in this Policy, including The Schedule; 3. The limits of liability referred to in the Policy. Subject to the terms, conditions, exclusions and limitations contained in this Policy, this Policy provides cover for Disablement caused by Accidental Injury and Sickness and Benefits are payable in the circumstances set out in the Policy, subject to the aggregate limit of liability. The particular cover which applies to you and which YOU selected when YOU applied for this insurance is referred to in The Schedule which forms part of this Policy. If for any reason you are not completely satisfied, this Policy may be returned to US within fourteen (14) days of its receipt and, subject to no claim being made, WE will refund in full any premium paid. Data Protection Act 1998 YOU should understand that any information YOU have provided will be processed by US, in compliance with the provisions of the Data Protection Act 1998, for the purpose of providing insurance and handling claims and complaints, if any, which may necessitate providing such information to other parties. Duty of Disclosure Before YOU enter into an insurance policy with US, YOU have a duty, under the Insurance Contracts Act, to disclose to US every matter that YOU know, or could reasonably be expected to know, is relevant to Our decision whether to accept the risk of the insurance and if so, on what terms. The Insurance Contracts Act imposes a different duty the first time YOU enter into the policy to that which applies when YOU renew, vary, extend, reinstate or replace a policy. We set these two duties out below. The duty applies until the Policy is entered into, or where relevant, renewed, extended, varied or reinstated (Relevant Time). If anything changes between the time answers are provided to US or disclosures are made and the Relevant Time, YOU need to tell US. Duty of Disclosure on entry into the Policy with US for the first time We will ask various questions as part of the application process that are relevant to Our decision whether to accept the risk of insurance and, if so, on what terms. When YOU answer those questions, YOU must: give US honest and complete answers; tell US everything YOU know concerning the proposed insurance; and tell US everything that a reasonable person in the circumstances could be expected to know. Page 3

4 Duty of Disclosure on renewal, variation, extension, reinstatement or replacement of the Policy On renewal, variation, extension, reinstatement or replacement of the Policy with US, the duty is to disclose to US before the renewal, variation, extension, reinstatement or replacement, every matter that YOU know, or a reasonable person in the circumstances could be expected to know, is relevant to Our decision whether to accept the risk of the insurance and, if so, on what terms. What YOU Don t Need To Tell US YOU do not need to tell US any matter: That diminishes Our risk; That is of common knowledge; That We know or should know as an insurer; or That We tell YOU We do not need to know. Who Does The Above Apply To? The duty of disclosure applies to YOU each on YOUR own behalf and for anyone else who will be covered by the Policy. The relevant obligation applies up until the time of the relevant entry, renewal, variation, extension, reinstatement or replacement. What Happens If YOU Don t Tell US? The insurer may void the contract within 3 years of entering into it. fraudulent, the insurer may void the contract at any time. If your non-disclosure is An Insurer who is entitled to avoid a contract of insurance may, within 3 years of entering into it, elect not to avoid it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to the Insurer. Page 4

5 A. The Schedule Policy No: Class of Business: Interest: WA104700d Personal Accident and Sickness Weekly Benefits Policy Period: From: 12:01am on 1 st November 2014 To: 12:01am on 1 st November 2017 Commencement Date: 12:01am on 1 st November 2014 The Policy Owner: Fund Name: Address: Insured Members: IS Industry Fund Pty Ltd as Trustee for Intrust Super Fund Intrust Super Fund Level 10, 270 Adelaide Street Brisbane QLD 4000 Australia Employees of ADMITTED EMPLOYERS of THE POLICY OWNER Weekly Injury & Sickness Benefits: (i) Total Disablement: Maximum of 90% of INCOME (ii) Partial Disablement: As per Definition k) (iii) Superannuation Benefit: An amount equal to 10% of the Benefit Paid Maximum Monthly Benefit: Maximum Benefit Period: $50,000 per month, always subject to a maximum of 90% of INCOME Sickness: 104 weeks or to the date the INSURED MEMBER turns 65 years, whichever occurs first. INSURED MEMBER s aged 65 & above 12 weeks or to the date they turn 70 years, whichever occurs first. If on claim when they turn 65 years, the INSURED MEMBER will receive an additional 12 weeks but only to a maximum of 104 weeks total Benefit Page 5

6 Injury: 104 weeks or to the date the INSURED MEMBER turns 65 years, whichever occurs first. INSURED MEMBER s aged 65 & above 52 weeks or to the date they turn 70 years, whichever occurs first. If on claim when they turn 65 years, the INSURED MEMBER will receive an additional 52 weeks but only to a maximum of 104 weeks total Benefit The Maximum Benefit Period is restricted to 52 weeks (or to the date the INSURED PERSON reaches the Maximum Age Limit, whichever occurs first) for Disablement caused by a MENTAL CONDITION. Maximum Age Limit: Minimum Waiting Period: Default Waiting Period: 70 years 21 consecutive days 21 consecutive days An INSURED MEMBER can choose to alter their waiting period as follows: 30 consecutive days 45 consecutive days 90 consecutive days Territorial Limits: (a) Non work related: (b) Work related: Premium Rate: Worldwide Australia The total Superannuation Guarantee (SG) contributions of INSURED MEMBERS which are received by THE POLICY OWNER (currently legislated at 9.5%), multiplied by: 21 day waiting period 6.021% 30 day waiting period 5.418% 45 day waiting period 4.816% 90 day waiting period 3.614% The above rates are exclusive of Stamp Duty and GST. Page 6

7 An amount of $12,500 plus GST will be subtracted from the monthly premium total, by the POLICY OWNER prior to remittance. Payment Terms: Rate Guarantee: Guaranteed Renewal Superannuation Guarantee (SG) Conditions: Underwritten By: Premium to be settled to Underwriters in monthly instalments within 60 days of the end of the calendar month in question 36 months from Commencement Date Provided that all terms and conditions of the Policy, including the payment of premiums, have been complied with we guarantee we will offer renewal terms to the Insured at the expiry of the rate guarantee period. The rates and terms may vary from the current policy. Currently legislated at 9.5%. Should the legislated SG amount change during the policy period, the premium rate will be adjusted accordingly to ensure an appropriate premium pool for the exposure. Coverage is on a 24 hour basis Certain Underwriters at Lloyd s Page 7

8 CHOICE OF LAW & JURISDICTION Any dispute between the Insured and Insurers concerning the interpretation of this Policy shall be subject to the law of Australia and to the exclusive jurisdiction of any competent court within Australia. EXPRESS WARRANTIES None other than any which may be included in the contract wording. Please read your contract carefully. Breach of a warranty could result in termination of this contract. CONDITIONS PRECEDENT None other than any which may be included in the contract wording. Please read your contract carefully. Breach of a condition precedent to liability may entitle Insurers to reduce indemnity for or even reject a claim. Breach of a condition precedent to contract entitles an insurer to avoid the contract entirely. Page 8

9 B. The Policy Wording (i) Scope of Cover Insurance has been affected between US and THE POLICY OWNER and this document is evidence of that insurance. YOU should check this document carefully to ensure it meets your requirements. We have agreed to insure YOU subject to the terms, conditions and exceptions contained in or endorsed upon this Document during the Period of Insurance for which the premium has been paid or agreed to be paid. WE agree to pay in accordance with The Schedule of Benefits if during the Period of Insurance an INSURED MEMBER sustains INJURY or SICKNESS as defined herein, subject always to the terms, conditions, provisions, limitations and exclusions hereof. (ii) Commencement of Cover Cover shall commence for all members of THE POLICY OWNER who are ACTIVELY AT WORK on the Policy s commencement date provided premiums shown in The Schedule have been paid by YOU to US. For those members not ACTIVELY AT WORK on the Policy s commencement date, cover shall commence when they recommence employment and are ACTIVELY AT WORK, provided an employer superannuation contribution payment is made by an ADMITTED EMPLOYER after they recommence employment by the quarterly deadlines outlined in the SUPERANNUATION GUARANTEE LEGISLATION. Cover for new members of THE POLICY OWNER will commence from the first date that the first employer superannuation contribution payment made by an ADMITTED EMPLOYER represents, provided that this payment is made by the quarterly deadlines outlined in the SUPERANNUATION GUARANTEE LEGISLATION and the member is ACTIVELY AT WORK and has not nominated in writing to not receive this cover. For those members of THE POLICY OWNER who are eligible for cover but have not accepted cover, cover may re-commence from when their written request to take up this cover is received, provided an employer superannuation contribution payment is made by an ADMITTED EMPLOYER after this request by the quarterly deadlines outlined in the SUPERANNUATION GUARANTEE LEGISLATION. For those members of THE POLICY OWNER where cover has ceased due to the INSURED MEMBER no longer being employed by an ADMITTED EMPLOYER and the INSURED MEMBER later re-commences employment with an ADMITTED EMPLOYER, cover will recommence from the first date that the first employer superannuation payment made by the most recent ADMITTED EMPLOYER represents provided that this payment is made by the quarterly deadlines outlined in the SUPERANNUATION GUARANTEE LEGISLATION and the member is ACTIVELY AT WORK on their first day of employment. Page 9

10 (iii) Cessation of Cover Cover for an INSURED MEMBER under this policy ceases; a) when the INSURED MEMBER elects in writing to no longer have this cover; or b) when the INSURED MEMBER reaches the Maximum Age Limit as stated in The Schedule, or c) when the INSURED MEMBER is no longer employed by an ADMITTED EMPLOYER refer (v) Additional Benefit No. 3; or d) when the INSURED MEMBER ceases to be a member of THE POLICY OWNER; or e) when all cover for every INSURED MEMBER under this Policy ceases, subject to Financial Services Council Guidance Note No. 11 Group Insurance Takeover Terms (iv) Takeover Terms WE accept the Financial Services Council Guidance Note No. 11 Group Insurance Takeover Terms in relation to both the takeover of cover and the cessation of this policy, subject to OUR definition of ACTIVELY AT WORK, to determine liability between insurers on claims. Page 10

11 (v) Additional Benefits 1. Rehabilitation Assistance In the event of the payment of a claim under this Policy WE, at OUR absolute discretion, may elect to assist the INSURED MEMBER in arranging for training or advice from a licensed vocational school, provided such training or advice is undertaken with the agreement of the INSURED MEMBER S attending physician. Assistance may also include family counselling to help the INSURED MEMBER and his or her family cope with the INSURED MEMBER S disability and to enable the INSURED MEMBER to live an independent life. Any payment under this clause will be paid directly to the provider of the service(s) by US and not paid to the claimant. The maximum amount payable by US in respect of rehabilitation assistance is AUD25, Return to Work Assistance In the event of the payment of a claim under this Policy WE, at OUR absolute discretion, may elect to assist the INSURED MEMBER in arranging for professional assistance to improve their physical and/or emotional condition. Assistance includes special equipment for and/or modifications to the INSURED MEMBER S normal home or workplace. Any payment under this clause will be paid directly to the provider of the service(s) by US and not paid to the claimant. The maximum amount payable by US in respect of return to work assistance is AUD25, Extended Cover Coverage under this Policy continues for a period of no more than thirty (30) days from the date the INSURED MEMBER ceases his or her current employment with an ADMITTED EMPLOYER provided that the INSURED MEMBER has accepted a position with another ADMITTED EMPLOYER prior to ceasing his or her employment. If the INSURED MEMBER does not have a position to go to with another ADMITTED EMPLOYER, then cover will cease under this Policy on the date he or she leaves their employment. 4. Superannuation i. In the event of an INJURY or SICKNESS claim under this Policy, WE will also pay to YOU a Superannuation Benefit for the INSURED MEMBER equal to the amount specified in The Schedule. ii. If the INSURED MEMBER is receiving a PARTIAL DISABLEMENT Benefit, the Superannuation Benefit is reduced proportionately. iii. The benefit above is payable quarterly in arrears on a pro rata basis and to the FUND. Page 11

12 (vi) Definitions a) ACTIVELY AT WORK means when an INSURED MEMBER i. is considered to be genuinely performing all the duties of their usual occupation and capable of working their usual hours without restriction, for their usual ADMITTED EMPLOYER(S). ii. An INSURED MEMBER who is on paid annual leave, paid sick leave, paid long service leave, paid parental leave and all employer-approved unpaid leave shall also be considered to be ACTIVELY AT WORK provided; That leave is not in connection to the INJURY or SICKNESS that leads to the Disablement; and They were ACTIVELY AT WORK for the full week prior to that leave. b) ADMITTED EMPLOYER means an employer who makes employer superannuation contributions to THE POLICY OWNER on behalf of an INSURED MEMBER. c) ANY ONE EVENT means all insured losses which arise directly from the same cause and which occur during the same period of time and in the same area. Such cause is understood to be the peril which directly occasions the losses or where there are several perils which, in an unbroken chain of causation, have occasioned the losses, the peril which triggered the chain of causation. For example, as long as they are covered by this Policy, losses occasioned by the perils set out below at letters (a) to (g) shall constitute single events: (a) storm due to an atmospheric disturbance usually so designated by a meteorological institute; (b) hail and/or thunderstorms and/or tornadoes due to an atmospheric disturbance; (c) earthquake, tsunami, volcanic eruption; (d) flood by one and the same instance of high water which may have more than one peak and which may occur in one or more bodies of water; (e) conflagration; (f) strike, riot, civil commotion or violent demonstration occurring within the boundaries of one city, town or village; (g) any communicable disease arising from a single source or pathogen The following hours clause is then applied. An event shall thus encompass a continuous period of time starting with the occurrence of THE POLICY OWNER s first individual loss and lasting; 72 hours for perils mentioned under (a), (b), (e) and (f); 168 hours for perils mentioned under (c) and (d) as well as those perils not referred to above but covered by this Policy; 504 hours for perils mentioned under (g) In the case of differing perils which are not connected to each other by an unbroken chain of causation, the applicable number of hours corresponds to those of the peril which has caused the largest amount of damages. Page 12

13 In the case of more than one event, if it is impossible to allocate any losses, THE POLICY OWNER shall allocate them to the event whose cause is most likely to have occasioned them. In case of uncertainty over scientific issues, the parties agree to seek expert advice from a neutral and recognised organization. d) COMMENCEMENT DATE means the date of commencement of cover under this Policy as set out in The Schedule. e) CONTINUOUS COVER means an unbroken period of time that an INSURED MEMBER has been covered under an Income Protection policy provided by US. If an INSURED MEMBER ceases cover, their continuous cover period ends on that date. If an INSURED MEMBER recommences cover under an Income Protection policy provided by US, their new continuous cover period commences on the date their cover recommences. f) INCOME Employee: means the average weekly income before personal deductions and income tax, and including all overtime and all allowances actually paid to the INSURED MEMBER which was earned from personal exertion from his or her usual employment, from which they are a member of THE INSURED, for the number of weeks so engaged during the twelve (12) month period immediately preceding INJURY or SICKNESS resulting in payment of the Benefits covered by this Policy. Self Employed: For the purpose of this policy, income shall mean the lesser of this year s SG payments made multiplied by 11 or the gross income earned less all business expenses incurred in earning that income. (INSURED MEMBER s will be required to supply their last year s tax assessment.) g) INJURY means a physical injury caused by a violent, external and visible means which occurs fortuitously whilst this insurance is in force and which results in payment of any of the Benefits specified in the Policy, within 12 calendar months from the date of its occurrence, but does not include any condition which is also a SICKNESS. h) INSURED MEMBER means a member of the POLICY OWNER who has not opted-out, is ACTIVELY AT WORK, employed by an ADMITTED EMPLOYER and for whom the premiums shown in The Schedule have been paid by YOU to US. i) MEDICAL PRACTITIONER means a medical practitioner legally qualified and registered to practice in Australia who is a person other than the INSURED MEMBER, their relatives; business partners, shareholders or employees. Where the INSURED MEMBER is outside Australia the Medical Practitioner must have qualifications which are recognised by the Australian Medical Association as equivalent with those required of a medical practitioner registered to practice in Australia. In this situation the onus of proof sits with the INSURED MEMBER. Page 13

14 j) MEMBERSHIP STATUS means: BRONZE MEMBER an INSURED MEMBER who has had less than two years of CONTINUOUS COVER under an Income Protection policy provided to YOU by US and has not had a claim accepted by US or any previous Insurer. SILVER MEMBER an INSURED MEMBER who has had two years but less than four years of CONTINUOUS COVER under an Income Protection policy provided to YOU by US and has not had a claim accepted by US or any previous Insurer. GOLD MEMBER an INSURED MEMBER who has had four years but less than six years of CONTINUOUS COVER under an Income Protection policy provided to YOU by US and has not had a claim accepted by US or any previous Insurer. PLATINUM MEMBER an INSURED MEMBER who has had six years or greater of CONTINUOUS COVER under an Income Protection policy provided to YOU by US and has not had a claim accepted by US or any previous Insurer. k) MENTAL CONDITION means an INSURED PERSON suffering from: stress related conditions; and/or any psychological conditions; and/or physical fatigue conditions caused by stress related or psychological conditions The above includes but is not limited to; depression; neurosis; psychosis; mental or emotional stress or anxiety conditions; or mental disease and associated disorders. l) PARTIAL DISABLEMENT means that as a result of an INJURY or SICKNESS an INSURED MEMBER is prevented from engaging in a substantial part of his or her usual occupation with their ADMITTED EMPLOYER in Australia. The INSURED MEMBER must be ACTIVELY AT WORK at the time the said INJURY or SICKNESS occurs and must be under the regular care of and acting in accordance with the instructions or professional advice of a MEDICAL PRACTITIONER other than the INSURED MEMBER. If during such DISABLEMENT the INSURED MEMBER is able to return to work in a reduced capacity then the compensation payable shall be calculated as the difference between their earnings from reduced work capacity and their pre-disability INCOME, multiplied by the Benefit for TOTAL DISABLEMENT. If the INSURED MEMBER is able to return to work in a reduced capacity, and that work is available but the INSURED MEMBER declines to do so, has resigned or has accepted a redundancy payment and would otherwise have been fit for light duties, then the compensation payable will be reduced to 25% of the compensation for TOTAL DISABLEMENT per week. m) POLICY OWNER means the entity that pays the premium to US. n) POLICY PERIOD means the period specified in The Schedule, or any prior or subsequent periods in respect of which YOU pay and WE accept the premium required for the continuation of this Policy. o) PRE-EXISTING SICKNESS means any sickness that an INSURED MEMBER is having or has had treatment for or advice for treatment for and has not ceased all treatment or advice with the agreement of a MEDICAL PRACTITIONER prior to the date of commencement, recommencement or increase of his or her cover under the Policy. Page 14

15 However such condition will be covered provided: a. an INSURED MEMBER has, with the agreement of a MEDICAL PRACTITIONER, ceased all treatment or advice for at least six (6) months during the POLICY PERIOD; OR b. An INSURED MEMBER has had two years of CONTINUOUS COVER under this policy prior to the time of their Disablement and had been ACTIVELY AT WORK prior to the Disablement which leads to the claim. p) PREMIUM DUE DATE means 15 th day of each month, payable monthly in arrears. q) PROFESSIONAL SPORTING ACTIVITIES means participating in any sporting activity, including training for that activity, where the INSURED MEMBER earns more than 50% (including any sponsorship they receive) of their annual gross income from that activity r) SICKNESS means a state of being ill which is first contracted or which the INSURED MEMBER first becomes aware of while this insurance is in force and which continues for a period of not less than the WAITING PERIOD and excludes any PRE-EXISTING SICKNESS and any INJURY. s) STATUTORY BENEFIT means a weekly benefit payment to an INSURED MEMBER from a relevant Workers compensation insurer or authority or as a result of a transport accident. t) SUPERANNUATION GUARANTEE LEGISLATION means the Superannuation Guarantee (Administration) Act 1992 and associated Regulations. u) TOTAL DISABLEMENT means that as a result of INJURY or SICKNESS the INSURED MEMBER is prevented from engaging in his or her usual occupation with their ADMITTED EMPLOYER in Australia for which they are a member of THE POLICY OWNER. The INSURED MEMBER must be ACTIVELY AT WORK at the time the said INJURY or SICKNESS occurs, and must be under the regular care of and acting in accordance with the instructions or professional advice of a MEDICAL PRACTITIONER other than the INSURED MEMBER. v) WAITING PERIOD means the continuous period stated in The Schedule before a Benefit is payable, commencing with the first day of Disablement, as certified by a MEDICAL PRACTITIONER, other than the INSURED MEMBER. If the INSURED MEMBER returns to work during the waiting period, the waiting period starts again unless they return to work once and for a period of no more than 5 consecutive days, as certified by a MEDICAL PRACTITIONER. w) YOU/YOUR means the POLICY OWNER, as shown in The Schedule. x) WE/OUR/US means the Insurers listed as the Underwriters in The Schedule. Page 15

16 (vii) Special Provisions 1. Aggregate Limit of Liability. Our total liability for all claims arising under this Policy from ANY ONE EVENT during any Policy Period shall not exceed AUD25,000,000 In the event that claims made under this Policy exceed the Aggregate Limit of Liability, then the amount by which the claims exceed it will be proportionally reduced. 2. Compensation shall not be payable: a) For the Waiting Period b) In excess of the Maximum Benefit Period, as specified in The Schedule, in respect of any one INJURY or SICKNESS c) Beyond 28 days from the date of the INSURED MEMBER S death d) If the INSURED MEMBER fails to provide the requested medical information. e) If an INSURED MEMBER agrees to commute their claim. f) If an INSURED MEMBER has previously accepted a TPD settlement for the same or related condition. g) Under more than one of the Benefits in respect of the same period of time h) Once the INSURED MEMBER is deemed fit to return to work by a MEDICAL PRACTITIONER 3. Compensation for a period of less than one week will be paid at the rate of one-seventh (1/7th) of the Weekly Benefit for each day during which INJURY or a SICKNESS continues. 4. Benefits shall be payable fortnightly in arrears or such other period as may be agreed between YOU and US from time to time and case to case, commencing at the end of the first fortnight after the WAITING PERIOD. 5. If an INSURED MEMBER suffers a recurrence of Disablement from the same or related cause or causes, the subsequent period of disablement will be deemed a continuation of the prior period and a new Waiting Period will not apply unless between such periods The INSURED MEMBER has worked on a full-time basis for a least six (6) consecutive months, in which case the subsequent period of disablement shall be deemed to have resulted from a new INJURY or SICKNESS and a new WAITING PERIOD shall apply. 6. If an INSURED MEMBER is entitled to make a claim to be paid under this Policy through being unable to follow their usual occupation with their ADMITTED EMPLOYER and continues to earn an income from another source or employer then that income from that other employer will not affect the payment of a benefit under this Policy unless the total of the payment under this Policy and the income derived from the other employment exceeds the total INCOME as at the date of occurrence of the SICKNESS or INJURY. Should the total figure exceed the INCOME then the excess portion of that INCOME will be deducted from payments under this Policy. Page 16 This provision does not apply in the case where an INSURED PERSON suffers a work related INJURY/SICKNESS as a result of their employment by another Employer who is not an ADMITTED EMPLOYER of THE POLICY OWNER. In such cases no benefit is payable under this policy.

17 7. In the case where an INSURED MEMBER, after the expiry of the WAITING PERIOD, receives sick leave payments or receives or should receive other not-at-work related payments from any source, WE will pay the difference between the sick leave payment received or the other not-at-work related payment which the INSURED MEMBER receives or should receive and the amount shown in The Schedule. 8. WE will pay the difference between the STATUTORY BENEFITS and amount per week specified in the Schedule for as long as the INSURED MEMBER is entitled to receive the STATUTORY BENEFITS or the end of the Maximum Benefit Period, whichever occurs first. When the relevant Workers Compensation Insurer or Authority decides to cease weekly STATUTORY BENEFITS payable to the INSURED MEMBER due to the INSURED MEMBER being medically able to return to work, WE will also cease payments and no further claim will be accepted or benefit payable with respect to the INJURY/SICKNESS from which the INSURED MEMBER received the STATUTORY BENEFITS. When the STATUTORY BENEFITS payable to the INSURED MEMBER cease but the INSURED MEMBER is medically unable to return to work, WE will continue to pay a benefit, up to the Maximum Benefit Period, with respect to the INJURY/SICKNESS from which the INSURED MEMBER received the STATUTORY BENEFITS, equal to 65% of INCOME, provided the INSURED MEMBER is assessed by an Independent Medical Officer (arranged by US) who then confirms the INSURED MEMBER is medically unable to return to work. The above is subject to Special Provision If the INSURED MEMBER reaches an agreement with the relevant Workers Compensation Insurer or Authority to cease weekly STATUTORY BENEFITS and receives a Lump Sum in lieu of those benefits, WE will pay to the INSURED MEMBER a Lump Sum in lieu of future weekly benefits payable by US under Special Provision 8 above, calculated as follows: The lesser of, the Maximum Benefit Period, less any period of payments already made by US under clause Special Provision 8, or the number of weeks used in the calculation of the Lump Sum by the Workers Compensation Insurer or Authority. Once determined, the benefit payable by US will be that number of weeks multiplied by the last per week payment made by US under clause Special Provision 8. Page 17

18 10. If an INSURED MEMBER suffers a work-related Injury or Sickness and is not covered by the State s Workers Compensation Scheme, for whatever reason, or chooses not to lodge a claim with the State s Workers Compensation Scheme, WE will only pay the difference between what the INSURED MEMBER would have received if they were covered by the State s Workers Compensation Scheme and amount per week specified in the Schedule for as long as the INSURED MEMBER would have been entitled to receive the Statutory Benefits or the end of the maximum benefit period as specified in the Schedule, whichever occurs first. 11. INSURED MEMBERS who: a. were covered by an Income Protection policy of THE POLICY OWNER s, up to the commencement date of this policy, and who transfer to this policy on the commencement date will have their continuous coverage under that previous policy recognised when considering the application of (x) Exclusions - No.4 applying to them when making a claim, provided their cover under this policy remains continuous. b. are employees of United Voice s Queensland Branch, who were covered by a previous Income Protection policy and who transferred to this Policy will have their continuous coverage under that previous policy recognised when considering the application of Exclusion 4 when making a claim, provided: i. Their cover under this Policy remains continuous ii. The benefit payable and waiting period applied to a claim relating to a SICKNESS or an INJURY that first occurred prior to their cover commencing under this Policy will match their previous policy, provided it does not exceed this Policy s maximum benefits. 12. If an INSURED MEMBER suffers an INJURY or SICKNESS whilst on employer-approved unpaid leave WE will consider a claim on the same basis as if the INSURED MEMBER was not on leave, except that: a. Benefits shall only become payable from the date the employer-approved unpaid leave was due to cease. b. Once the date of Disablement is established, if the period of unpaid leave remaining is greater than the elected WAITING PERIOD, no new WAITING PERIOD will be required to be served. c. The INCOME of an INSURED MEMBER who has been on employer-approved unpaid leave will be averaged over the 12 month period directly prior to the employerapproved unpaid leave commencing. 13. In the event of a period of Disablement exceeding an INSURED MEMBER s WAITING PERIOD: A Platinum Member s Benefit Period commences 21 days prior to the last day of their WAITING PERIOD A Gold Member s Benefit Period commences 14 days prior to the last day of their WAITING PERIOD A Silver Member s Benefit Period commences 7 days prior to the last day of their WAITING PERIOD A Bronze Member s Benefit Period commences the first day after the last day of their WAITING PERIOD Page 18

19 All of the above is always subject to the Maximum Benefit Period stated in The Schedule 14. If an INSURED MEMBER elects to reduce their WAITING PERIOD, Exclusion 4 of this Policy will be applied to the days between the previous higher WAITING PERIOD and the new WAITING PERIOD. Exclusion 4 will be removed once the INSURED MEMBER has had one year of continuous cover from the date they elected to reduce their WAITING PERIOD. 15. WE are not liable to pay a benefit relating to any further Disability caused by the same INJURY or SICKNESS once the Maximum Benefit Period expires. Subject to the terms of this policy and payment of Premium, WE will be liable to pay a benefit for any further Disability which is caused by an unrelated INJURY or SICKNESS. 16. a) When an INSURED MEMBER has a claim under this Policy, their membership status may be affected. The following rules will apply to this section of the Policy: Membership Status Bronze Silver Gold Platinum If a claim is paid (must be accepted and a benefit paid) before the INSURED MEMBER reaches the first/next Loyalty Bonus level and the claim is for a benefit period of 60 days or less You retain Bronze and your continuous cover with no claims period continues without a break. You retain Silver and your continuous cover with no claims period continues without a break. You retain Gold and your continuous cover with no claims period continues without a break. You retain Platinum and your continuous cover with no claims period continues without a break. If a claim is paid (must be accepted and a benefit paid) before the INSURED MEMBER reaches the first/next Loyalty Bonus level and the claim is for a benefit period greater than 60 days You retain Bronze and your continuous cover with no claims period restarts. You return to Bronze and your continuous cover with no claims period restarts at 0 years. You return to Silver and your continuous cover with no claims period restarts at 2 years. You return to Gold and your continuous cover with no claims period restarts at 4 years. b) In reference to MEMBERSHIP STATUS, any period of employer-approved unpaid leave does not count towards the INSURED MEMBER s period of CONTINUOUS COVER. However the period of CONTINUOUS COVER will not be deemed to have been broken. Page 19

20 17. If any provision of this Policy is held invalid or unenforceable by any court of competent jurisdiction, the other provisions of this Policy will remain in full force and effect. Any provision of this Policy held invalid or unenforceable only in part or degree will remain in full force and effect to the extent not held invalid or unenforceable. Page 20

21 (viii) Conditions 1. Non Payment of Premium If at the time of making a claim under this Policy it is found that the instalment Premium has remained unpaid for a period of thirty (30) days or more past the last premium Due Date, then WE can delay payment of the claim until this premium has been received by US. If premiums remain in arrears for a further period of thirty (30) days or more then WE may cancel this Policy by giving YOU 30 day s written notice. If this Policy is cancelled due to Non Payment of Premium, the amount owing will be deducted from any outstanding claim payments. This condition applies as each and every premium installment becomes due and cannot be disregarded because WE may have previously accepted an installment after thirty (30) days. If at any time the premium is more than 30 days in arrears we will notify THE POLICY OWNER in writing and allow THE POLICY OWNER 14 days to rectify the premium arrears prior to taking any further action. 2. Premium Increase After the guaranteed period stated in The Schedule WE may vary premium payments under this Policy. Such premium variation shall be notified to YOU in writing and will take effect from the next Premium Due Date. 3. Time of the Payment of Claim Compensation other than periodic payment will be paid immediately upon receipt of due written proof of the Claim. Periodic payment will be paid in the manner specified in (vii) Special Provisions - No Clerical Error Any clerical error by any of the parties to this insurance shall not invalidate this insurance, nor shall this insurance continue if it was not validly in force. 5. Fraud Any fraud, misstatement or concealment by YOU or an INSURED MEMBER in relation to any matter affecting this insurance or in connection with the making of any claim under it will give Us the rights provided for in the Insurance Contracts Act including where appropriate the right to reduce or refuse payment of any claim or to cancel or avoid the Policy. 6. Code of Practice This Policy is not subject to the Insurance Council of Australia s General Insurance Code of Practice. Page 21

22 7. Disputes & Complaints (a) Any enquiry or complaint relating to this Insurance should be referred to US in the first instance. If this does not resolve the matter or you are not satisfied with the way a complaint has been dealt with, you should write to Lloyd s Underwriters General Representative in Australia at the address below. Lloyd s Underwriters General Representative in Australia Suite 2, Level 21 Angel Place 123 Pitt Street Sydney NSW 2000 Telephone Number: (02) Facsimile Number: (02) (b) WE will establish a Disputed Claims Group which will consist of four people, two people nominated by YOU and two people nominated by US. The group s role is to meet in Sydney, or another agreed location within Australia, to review claims that have been rejected, where an INSURED MEMBER has lodged a complaint with YOU or US about the decision. A majority decision of this group will be binding on US but will not affect the INSURED MEMBER s rights to seek further redress of the disputed claim. (see b) below) (c) If YOUR dispute remains unresolved YOU will be referred to the Lloyd s General Representative in Australia at Lloyd s Australia Ltd and then if necessary the Financial Ombudsman Service or the Superannuation Complaints Tribunal. For other disputes you will be referred to other proceedings for resolution. Details are available from Lloyd s Underwriters General Representative in Australia at the address above. 8. Subrogation/Offset (a) If WE make weekly payments under this Policy to an INSURED MEMBER, then to the extent that the INSURED MEMBER receives payments (other than Benefits under this Policy): i. from an ADMITTED EMPLOYER, or a former ADMITTED EMPLOYER, a new employer, a business partnership, or other similar source; ii. from a Superannuation or pension plan; iii. from any other disability, injury or sickness policy; (except for lump sum benefits received for total and permanent disablement under such an insurance policy); iv. From any Mortgage, Credit Card, Bill payer or similar insurance policy v. from any workers compensation insurer, compulsory third party motor vehicle insurer or public liability insurer; vi. from any government authority or government instrumentally in the form of a pension or allowance; vii. by way of commission payments or remuneration relating to the period(s) from which the INSURED MEMBER is paid under this Policy Page 22

23 Then WE are entitled to recalculate and reduce the Benefit, to the INSURED MEMBER, under this Policy, by any amount received from any of the above. (b) (c) (d) Any difference between the Benefit paid and the recalculated Benefit shall be repaid by the INSURED MEMBER. If the INSURED MEMBER does not fully repay US we can reduce future Benefits by the amount of the unpaid difference and/or be entitled to a repayment of the recalculated Benefits. If an INSURED MEMBER receives payments from any of the categories in (a) above, after the Benefit has been paid by US, then WE are entitled to a repayment of the recalculated Benefit in full. The INSURED MEMBER is obliged to disclose to US immediately details of any payments received, in accordance with (a) above, either before, during or after receiving their Benefit under this Policy. 9. Choice of Law and Jurisdiction In the event of a dispute arising under this Policy, WE, at the request of THE POLICY OWNER will submit to the jurisdiction of any competent Court in the Commonwealth of Australia. Such dispute shall be determined in accordance with the law and practice applicable in such court. 10. Service of Suit WE hereon agree that: - (i) Any summons notice or process to be served upon the Underwriters may be served upon: Lloyd s General Representative in Australia Lloyd s Australia Ltd Suite 2, Level 21 Angel Place 123 Pitt Street Sydney NSW 2000 who has authority to accept service and to enter an appearance on OUR behalf, and who is directed at the request of THE POLICY OWNER to give a written undertaking to THE POLICY OWNER that they will enter an appearance on OUR behalf. (ii) If a suit is instituted against any one of the Underwriters, all Underwriters hereon will abide by the final decision of such Court or any competent Appellate Court. 11. Surrender Value No surrender value is acquired under this Policy. 12. Cancellation This Policy may be terminated at any time by the POLICY OWNER. Page 23

24 13. Change in Law We reserve the right to vary premiums and / or the terms under this Policy upon written notification to YOU in the event of any change in the law and as a result: a) it becomes impractical or impossible to carry out our obligations; or b) our Policy is inconsistent with the law; or c) Government charges relating to the Policy are imposed or changed. 14. Sanctions WE shall not provide any benefit under this contract of insurance to the extent of providing cover, payment of any claim or the provision of any benefit where doing so would breach any sanction, prohibition or restriction imposed by law or regulation. Page 24

25 (ix) Making a Claim 1. Claims Procedure: a) Written notice must be given to: Windsor Income Protection Pty Ltd 1A Homebush Bay Drive, Rhodes NSW 2138 or such other address as WE may advise YOU in writing. b) All certificates and evidence required by US shall be furnished as required at the INSURED MEMBER S expense as often as is reasonably required. c) In order to assess a claim an INSURED MEMBER shall submit to a medical examination: i. If in Australia - at OUR expense as often as is required. ii. If outside Australia the INSURED MEMBER s may be required to return to Australia at their expense. Once having returned to Australia, the medical examination will be at OUR expense as often as is required. iii. If an INSURED MEMBER fails to attend a medical examination; the cost of the examination as charged by the examiner will be deducted from any benefit payment; the Benefit payments will cease until such time as the INSURED MEMBER submit to the examination and they are certified as meeting the definition of Disablement. 2. Proof of Claim Written Proof of Claim must be furnished to US, via Windsor Income Protection Pty Ltd, within ninety (90) days after the date of the INJURY or SICKNESS. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to do so, provided that the proof is furnished as soon as is reasonably possible and in no event except in the absence of legal capacity, later than 12 calendar months from the time it would normally be required. 3. Report of Claim WE will, upon receipt of a notice of claim, furnish such forms as are usually required by US for filing Proof of Claim. Page 25

26 (x) Exclusions This Policy shall not apply to any INJURY/SICKNESS directly caused by or resulting from: 1. Any consequence of war, invasion or civil war 2. Intentional self-inflicted INJURY or SICKNESS, including any attempt at suicide 3. Pregnancy, childbirth or miscarriage other than; a) A complication arising from pregnancy which requires hospitalisation for greater than 24 hours within the first thirty-three (33) weeks of pregnancy. All benefit payments will cease at the date of birth and/or termination of the pregnancy. No benefit shall be payable for any complications arising after the thirty third week of pregnancy. Or b) A new INJURY or SICKNESS which occurs during childbirth or miscarriage. The waiting period will commence from the conclusion of the Government s and/or Employer s paid maternity leave benefit period, whichever is the greater. No benefits shall be payable during any period of parental leave. 4. Any PRE-EXISTING SICKNESS refer Definition (o) 5. Any act which results in an INSURED MEMBER being charged by the police. Should the INSURED MEMBER subsequently be found not guilty of the act in question, this exclusion will not apply. 6. An INSURED MEMBER being a pilot or crew member of any aircraft; or engaging in any aerial activity except as a passenger in a properly licensed aircraft. 7. Any PROFESSIONAL SPORTING ACTIVITIES 8. Any INJURY that occurs prior to the Period of Insurance. Page 26

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