PERSONAL ACCIDENT INSURANCE POLICY. Sections 5 to 9 Page 1 of 15 Ref: CAHP2

Transcription

1 PERSONAL ACCIDENT INSURANCE POLICY Sections 5 to 9 Page 1 of 15 Ref: CAHP2

2 SECTION 1 - INSURING AGREEMENT Policy Number Group Policyholder Plutus Health Address 13 Cardiff Road, Newport, South Wales NP20 2EH is hereby insured by Chubb Insurance Company of Europe SE (referred to herein as the Company) in consideration of the payment of the quarterly premiums as agreed and in accordance with the terms conditions and exclusions of the Policy. Effective Date 01 January 2015 Expiry Date 31 December 2015 Both dates inclusive and any subsequent period for which payment for the renewal of this Policy is made and the Company agrees to accept Premium Quarterly premiums as declared by the Group Policyholder Insurance Premium Tax Quarterly as declared by the Group Policyholder This Policy shall not be valid unless it has been signed by an authorised employee of Chubb Insurance Company of Europe SE. Jalil Rehman President and CEO Date: 09 March 2015 Sections 5 to 9 Page 2 of 15 Ref: CAHP2

3 SECTION 2 - BENEFITS If after the Effective Date of this Policy an Insured Person suffers Bodily Injury as a direct result of an Accident benefit will be paid in accordance with the following schedule: Category A Insured Persons All members of Plutus Health contributing to the Foundation or Foundation Plus Plans including members of the Seren and Chamber Plans 1. Accidental Death 5, Permanent Total Disablement 5, Permanent and incurable paralysis of all 5,000 limbs 4. Loss of Sight in both eyes 5, Loss of or loss of use of use of both s 5,000 or feet 6. Loss of Sight in one eye 2, Loss of or loss of use of one or foot 2, Loss of Hearing in a) both ears 2,500 b) one ear Loss of or loss of use of the lens of one eye 1, Loss of or loss of use of four fingers and 2,000 thumb of either 11. Loss of or loss of use of four fingers on one 1, Loss of or loss of use of thumb of either a) both joints 1,000 b) one joint Loss of or loss of use of fingers on either a) three joints 250 b) two joints 175 c) one joint Loss of or loss of use of toes all one foot big both joints big one joint other than big, each complete toe Established non union of fractured leg or 500 knee cap 16. Shortening of leg by at least five (5) 375 centimetres 17. Break of major arm bone(s) (Radius, Ulna 75 &/or Humerus) 18. Break of major leg bone(s) (Femur, Tibia &/or Fibula) If compensation is payable for loss of, or loss of use of a whole member of the body the Company shall not pay for parts of that member other than for Benefits 17 or If compensation is payable in respect of one Insured Person under more than one of Benefits 1 to 16 (inclusive) as a result of any one Accident the total payable shall not exceed 5,000. Sections 5 to 9 Page 3 of 15 Ref: CAHP2

4 SECTION 2 BENEFITS If after the Effective Date of this Policy an Insured Person suffers Bodily Injury as a direct result of an Accident benefit will be paid in accordance with the following schedule: Category B Insured Persons All members of Plutus Health contributing to the Bronze or Bronze Plus Plans including members of the Seren and Chamber Plans 1. Accidental Death 10, Permanent Total Disablement 10, Permanent and incurable paralysis of all 10,000 limbs. Loss of Sight in both eyes 10,000. Loss of or loss of use of use of both s 10,000 or feet. Loss of Sight in one eye 5,000. Loss of or loss of use of one or foot 5,000. Loss of Hearing in c) both ears 5,000 d) one ear 1, Loss of or loss of use of the lens of one eye 2, Loss of or loss of use of four fingers and 4,000 thumb of either 11. Loss of or loss of use of four fingers on one 2, Loss of or loss of use of thumb of either c) both joints 2,000 d) one joint 1, Loss of or loss of use of fingers on either d) three joints 500 e) two joints 350 f) one joint Loss of or loss of use of toes all one foot big both joints big one joint other than big, each complete toe 1, Established non union of fractured leg or 1,000 knee cap 16. Shortening of leg by at least five (5) 750 centimetres 17. Break of major arm bone(s) (Radius, Ulna 150 &/or Humerus) 18. Break of major leg bone(s) (Femur, Tibia &/or Fibula) If compensation is payable for loss of, or loss of use of a whole member of the body the Company shall not pay for parts of that member other than for Benefits 17 or If compensation is payable in respect of one Insured Person under more than one of Benefits 1 to 16 (inclusive) as a result of any one Accident the total payable shall not exceed 10,000. Sections 5 to 9 Page 4 of 15 Ref: CAHP2

5 SECTION 2 BENEFITS If after the Effective Date of this Policy an Insured Person suffers Bodily Injury as a direct result of an Accident benefit will be paid in accordance with the following schedule: Category C Insured Persons All members of Plutus Health contributing to the Silver or Silver Plus Plans including members of the Seren and Chamber Plans 1. Accidental Death 15, Permanent Total Disablement 15, Permanent and incurable paralysis of all 15,000 limbs 4. Loss of Sight in both eyes 15, Loss of or loss of use of use of both s 15,000 or feet 6. Loss of Sight in one eye 7, Loss of or loss of use of one or foot 7, Loss of Hearing in e) both ears 7,500 f) one ear 2, Loss of or loss of use of the lens of one eye 3, Loss of or loss of use of four fingers and 6,000 thumb of either 11. Loss of or loss of use of four fingers on one 3, Loss of or loss of use of thumb of either e) both joints 3,000 f) one joint 1, Loss of or loss of use of fingers on either g) three joints 750 h) two joints 525 i) one joint Loss of or loss of use of toes all one foot big both joints big one joint other than big, each complete toe 2, Established non union of fractured leg or 1,500 knee cap 16. Shortening of leg by at least five (5) 1,125 centimetres 17. Break of major arm bone(s) (Radius, Ulna 225 &/or Humerus) 18. Break of major leg bone(s) (Femur, Tibia &/or Fibula) If compensation is payable for loss of, or loss of use of a whole member of the body the Company shall not pay for parts of that member other than for Benefits 17 or If compensation is payable in respect of one Insured Person under more than one of Benefits 1 to 16 (inclusive) as a result of any one Accident the total payable shall not exceed 15,000. Sections 5 to 9 Page 5 of 15 Ref: CAHP2

6 SECTION 2 BENEFITS If after the Effective Date of this Policy an Insured Person suffers Bodily Injury as a direct result of an Accident benefit will be paid in accordance with the following schedule: Category D Insured Persons All members of Plutus Health contributing to the Gold or Gold Plus Plans including members of the Seren and Chamber Plans 1. Accidental Death 20, Permanent Total Disablement 20, Permanent and incurable paralysis of all 20,000 limbs 4. Loss of Sight in both eyes 20, Loss of or loss of use of use of both s 20,000 or feet 6. Loss of Sight in one eye 10, Loss of or loss of use of one or foot 10, Loss of Hearing in g) both ears 10,000 h) one ear 3, Loss of or loss of use of the lens of one eye 5, Loss of or loss of use of four fingers and 8,000 thumb of either 11. Loss of or loss of use of four fingers on one 4, Loss of or loss of use of thumb of either g) both joints 4,000 h) one joint 2, Loss of or loss of use of fingers on either j) three joints 1,000 k) two joints 750 l) one joint Loss of or loss of use of toes all one foot big both joints big one joint other than big, each complete toe 3,000 1, Established non union of fractured leg or 2,000 knee cap 16. Shortening of leg by at least five (5) 1,500 centimetres 17. Break of major arm bone(s) (Radius, Ulna 300 &/or Humerus) 18. Break of major leg bone(s) (Femur, Tibia &/or Fibula) If compensation is payable for loss of, or loss of use of a whole member of the body the Company shall not pay for parts of that member other than for Benefits 17 or If compensation is payable in respect of one Insured Person under more than one of Benefits 1 to 16 (inclusive) as a result of any one Accident the total payable shall not exceed 20,000. / Sections 5 to 9 Page 6 of 15 Ref: CAHP2

7 SECTION 2 BENEFITS If after the Effective Date of this Policy an Insured Person suffers Bodily Injury as a direct result of an Accident benefit will be paid in accordance with the following schedule: Category E Insured Persons Chamber Plans All members of Plutus Health contributing to the Executive Plan including members of the Seren and 1. Accidental Death 25, Permanent Total Disablement 25, Permanent and incurable paralysis of all 25,000 limbs 4. Loss of Sight in both eyes 25, Loss of or loss of use of use of both s 25,000 or feet 6. Loss of Sight in one eye 12, Loss of or loss of use of one or foot 12, Loss of Hearing in i) both ears 12,500 j) one ear 3, Loss of or loss of use of the lens of one eye 6, Loss of or loss of use of four fingers and 10,000 thumb of either 11. Loss of or loss of use of four fingers on one 5, Loss of or loss of use of thumb of either i) both joints 5,000 j) one joint 2, Loss of or loss of use of fingers on either m) three joints 1,250 n) two joints 875 o) one joint Loss of or loss of use of toes all one foot big both joints big one joint other than big, each complete toe 3,750 1, Established non union of fractured leg or 2,500 knee cap 16. Shortening of leg by at least five (5) 1,875 centimetres 17. Break of major arm bone(s) (Radius, Ulna 375 &/or Humerus) 18. Break of major leg bone(s) (Femur, Tibia &/or Fibula) If compensation is payable for loss of, or loss of use of a whole member of the body the Company shall not pay for parts of that member other than for Benefits 17 or If compensation is payable in respect of one Insured Person under more than one of Benefits 1 to 16 (inclusive) as a result of any one Accident the total payable shall not exceed 25,000. Sections 5 to 9 Page 7 of 15 Ref: CAHP2

8 SECTION 3 DEFINITIONS Insured Person Any person who has been accepted by the Group Policyholder for a Plutus Health scheme including his/her Partner if the Partner Scheme option has been opted for. Effective Date The date the Group Policyholder registers the Insured Person s application form. Accident A sudden unforeseen and fortuitous identifiable event and the word accidental shall be construed accordingly. Bodily Injury Injury to an Insured Person which solely and independently of any other cause results within 24 months of the date of the Accident in the Insured Person s death, permanent disability as noted under benefits 2 to 16 and fracture or break of a specified bone or bones. Bodily Injury excludes any condition resulting from any gradually operating cause or degenerative process. Partner Spouse, co-habiting partner, civil partner as registered under a civil partnership and/or any other person recognised as the lawful partner of the Insured Person under common law whose enrolment details are held by the Group Policyholder Disappearance If an Insured Person disappears and it is reasonable to believe that he/she has sustained Bodily Injury resulting in death during the Effective Time the death benefit shall become payable. In the event of this belief being incorrect the death benefit shall be repaid to the Company. Effective Time 24 hours a day. Exposure Death or injury to an Insured Person as a direct result of unavoidable exposure to the elements shall be deemed to have been caused by Bodily Injury. Permanent Total Disablement If an Insured Person is gainfully employed Permanent Total Disablement shall mean disablement caused other than by loss of limb or Loss of Sight which, having lasted for at least 12 months, will in all probability entirely prevent the Insured Person from engaging in or giving attention to his/her usual occupation for the remainder of his/her life Where the Insured Person is not gainfully employed Permanent Total Disablement shall mean disablement caused other than by loss of limb or Loss of Sight which, having lasted for at least 12 months, will in all probability entirely prevent the Insured Person from engaging in or giving attention to a gainful occupation of any and every kind for the remainder of his/her life. Sections 5 to 9 Page 8 of 15 Ref: CAHP2

9 Loss of Sight The total and irrecoverable loss of sight when an Insured Person s name has been added to the Register of Blind Persons or when the degree of sight remaining after correction is 3/60 or less on the Snellen Scale. Loss of Hearing Total, permanent and irrecoverable loss of hearing. War War shall mean armed conflict between nations including forces acting for any international authority, whether War be declared or not, invasion, civil war, any attempt to usurp power, or any activity arising out of an attempt to participate in military force between nations. Country of Permanent Residence The country in which an Insured Person resides indefinitely or an Insured Person has the intent to reside indefinitely. Sections 5 to 9 Page 9 of 15 Ref: CAHP2

10 SECTION 4 EXCLUSIONS The Company shall not pay for: 1. Bodily Injury resulting directly or indirectly from or contributed to by: a) an Insured Person engaging in active service in the armed forces of any nation; b) an Insured Person committing or attempting to commit suicide or intentionally inflicting self injury; c) an Insured Person engaging in flying or other aerial activity other than as a passenger; d) injuries resulting from Osteoporosis disease. e) deliberate exposure to exceptional danger (except in an attempt to save a human life), the Insured Person s own criminal act or an Insured Person engaging or taking part in civil commotion or riots of any kind; f) an Insured Person being in a state of insanity (temporary or otherwise) or any psychiatric, mental, nervous or stress related disorder or anxiety state; g) an 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) War within the Insured Person s Country of Permanent Residence i) an Insured Person participating in any sport as a professional; j) radioactive contamination; k) pregnancy or childbirth. 2. The Company shall not be liable to provide cover or benefit or pay any sums if that would directly or indirectly put the Company or any of its group companies in breach of any applicable economic or trade sanctions. Sections 5 to 9 Page 10 of 15 Ref: CAHP2

11 SECTION 5 TERMINATION 1. Automatic Termination An Insured Person s cover under this Policy shall terminate on the date he/she ceases to be a current member or eligible dependent of a current member of a Plutus Health scheme. 2. Time The insurance shall terminate on any day described above at hours Greenwich Mean Time or British Summer Time. Sections 5 to 9 Page 11 of 15 Ref: CAHP2

12 SECTION 6 CLAIMS 1. Claims Procedure Written notice should be submitted by the Insured Person or his or her personal representative to the Group Policyholder within 3 months of any Accident. The Company will provide the Group Policyholder with an adequate supply of claim forms for filing proof of claim. The Insured Person will be responsible for completing the required section of the claim form before submitting to the Company as soon as possible thereafter. Any document or evidence reasonably required by the Company to verify the claim shall be provided by the Insured Person or his or her personal representative at his or her personal expense. Any medical examination required by the Company to prove the claim will be at the Company s expense. 2 Payment of Benefit Any payment due under this Policy will be paid to the Insured Person, if living, otherwise to his/her personal representative within 21 days of the claim being substantiated to the satisfaction of the Company. Any receipt which an Insured Person, anyone acting on the Insured Person s behalf or his/her representative may provide to the Company for benefits payable under this Policy shall be a final and complete discharge of the Company s liability in respect of such benefit. 3 Arbitration If any dispute or difference arises between the Company and the Insured Person or the Company and the Group Policyholder concerning any matter arising out of this Policy such matter shall be referred to two arbitrators (who shall be disinterested parties) one appointed by the Company and one by the Group Policyholder or Insured Person as appropriate. The award of such arbitrators or their umpire shall be binding on all parties. 3. Interest No amount under this Policy shall carry interest. 4. Terms and Conditions The Group Policyholder shall exercise and ensure that any Insured Person shall exercise all due diligence and care to avoid or diminish any loss or circumstance likely to give rise to a claim under this Policy. It shall be a condition precedent to any liability of the Company to make any payment under this Policy for the Group Policyholder or Insured Person to duly observe the Specifications Endorsements and terms of this Policy and the truth of the statements and answers and information supplied on or in connection with any proposal. 5. Fraudulent Claims Coverage shall be void if the Group Policyholder (and Insured Person) deliberately or recklessly provides false information to the Company whether at inception, when advising of a change or when making a claim. If the Group Policyholder (and Insured Person) is careless in providing information to the Company then the Company may amend the Coverage by making an appropriate adjustment to the premium, amend the terms of the policy or cancel the policy in accordance with the policy conditions. Sections 5 to 9 Page 12 of 15 Ref: CAHP2

13 SECTION 7 GENERAL CONDITIONS 1. Consideration The Policy is issued in consideration of the agreement by the Group Policyholder, the Insured Person or the Insured Person s employer to pay the premium. 2. Geographical Limits The insurance provided by this Policy operates 24 hours a day anywhere in the world. 3. Interpretation This Policy, including the applicable brochure and application form, shall be read together as one contract. Any word or expression to which a specific meaning has been attached shall, unless the context otherwise requires, bear that specific meaning wherever it may appear. 4. Entire Contract: Changes This Policy including the applicable brochure and application form shall constitute the entire contract between the Company and the Insured Person. No change in this Policy shall be valid unless approved by the Group Policyholder and the Company and evidenced by endorsement hereon or attached hereto. 5. Jurisdiction The Company shall in all competent judicial proceedings at the instance of the Group policyholder or the Insured Person in respect of matters arising out of this insurance acknowledge the jurisdiction of the courts in England and Wales, Scotland, Northern Ireland, the Channel Islands, the Isle of Man or the Republic of Ireland. 6. Governing Law The Policy shall be governed by and in accordance with English law. 7. Data Protection The Company collects and processes personal information about individuals who may receive cover under the Policy from the Group Policyholder and/or Insured Person, such as their name, address, and any other personal details which are provided in order to provide the insurance and claims services. The Company will treat this information in accordance with applicable data protection law. For policy administration purposes, the Company will use and store any such personal information on an electronic database, which may also be available to selected authorised representatives of member insurers of the Chubb Group of Insurance Companies operating outside Europe. The Company has taken reasonable measures to protect such personal information once it is transferred outside Europe in accordance with their normal data security policies. The company may also disclose such personal information to outside parties, such as premium collection agencies, reinsurers, outside counsel and claims administrators, to provide the insurance and claims services, or as allowed by law. Please ensure that the Insured Persons are aware of the same. Sections 5 to 9 Page 13 of 15 Ref: CAHP2

14 8. Complaints Procedure The Company aim to provide a first class service. If you have cause for complaint, in the first instance contact the Intermediary or contact the Company at: The Manager, Accident and Health Department, Chubb Insurance Company of Europe SE, 106 Fenchurch Street, London, EC3M 5NB Telephone If you remain dissatisfied, you may ask the Financial Ombudsman s Service to review your case at the address shown below. The Financial Ombudsman Service, Exchange Tower, London, E14 9SR Telephone complaint.info@financial-ombudsman.org.uk 9. Financial Services Compensation Scheme The Company is covered by the Financial Services Compensation Scheme. The Group Policyholder or Insured Person may be entitled to compensation should the Company be unable to meet its financial obligations. You can obtain further information from the Company at the above address, or from the Financial Services Compensation Scheme at the following address: Financial Services Compensation Scheme, 10th Floor Beaufort House 15 St Botolph Street London EC3A 7QU Tel: Sections 5 to 9 Page 14 of 15 Ref: CAHP2

15 SECTION 8 - PREMIUM 1. Premium Due Dates a) From the Insured Person or the Insured Person s employer Premium for the cover at the rate agreed between the Group Policyholder and the Company is automatically included within the weekly or monthly premium payable by the Insured Person for a Plutus Health scheme. This premium shall be collected by the Group Policyholder in accordance with the procedures as agreed with the Company. b) From the Group Policyholder The total of all such premiums collected including Insurance Premium Tax at the prevailing rate based on the number of Insured Persons at the end of each month shall be sent to the Company in the agreed manner within 28 days at the end of each quarterly period. Chubb Insurance Company of Europe SE Registered office: 106 Fenchurch Street, London EC3M 5NB, England Telephone: +44 (0) Facsimile: +44 (0) A European company incorporated in England & Wales registered under company number SE13. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. Sections 5 to 9 Page 15 of 15 Ref: CAHP2