HEALTH PLAN INSURANCE SUMMARY FOR EMPLOYEES ON OVERSEAS ASSIGNMENT GRM INTERNATIONAL PTY LIMITED

Transcription

1 GRM INTERNATIONAL PTY LIMITED Policy Period from 30 November 2012 to 30 November 2013 As at 30 November 2012

2 CONTENTS 1. Introduction Contacts Enrolment Who is Covered What is Covered Expatriates / Inpatriates who are 60 years to 75 years... 6 Medical & Additional Expenses... 6 Medical Repatriation & Emergency Evacuation... 6 Group Personal Accident Pre-Existing Medical Conditions How to Claim... 8 Medical Claims... 8 Other Claims ACE Assistance/Customer Care General Information and Claims Enquiries Medical Assistance Other Assistance Claims in Australia Policy Wording Summary i

3 1 Introduction Welcome to GRM s Health Plan ("the Plan"). We want to ensure that you receive maximum benefits from being a member of this Plan. This Booklet explains how the Plan works overseas and in Australia and what benefits you can expect. Please note all benefits are paid subject to the policy conditions of ACE Insurance Limited. This Booklet is intended as a working summary of the Plan. The details shown are necessarily incomplete in detail and do not over-ride or alter the terms of the policy. The full terms and conditions are contained in the policy documents and it is essential that these be read carefully, with particular attention to the exclusions. Also, please note there are some restrictions that apply to benefit limits and conditions in Australia. We recommend you read the following pages carefully in order that you make the best possible use of this Plan. Once you have read this Booklet and if you need to know more, you can call your GRM Representative or Marsh Pty Ltd. Please refer page 2 for contact details. Expression 1

4 2 Contacts GRM International Key Contact For general information about GRM s Plan please contact: Astrid Millar or your GRM Head Office Representative Telephone No.: + 61 (7) Astrid.Millar@grminternational.com Marsh Pty Ltd Marsh Pty Limited is GRM s appointed Insurance Broker please contact: Jeff Bousfield Managing Principal Telephone No.: Facsimile: jeff.p.bousfield@marsh.com Jonathan Bryant Assistant Account Executive Telephone No.: Facsimile: Insurer jonathan.bryant@marsh.com ACE Insurance Limited are the Expatriate Health Insurer, details are below: ACE Insurance Limited ABN AFSL O Connell Street Sydney NSW 2000 AUSTRALIA 2

5 3 Enrolment You and your accompanying Spouse and Dependent Children are automatically enrolled into this plan by GRM. As a member of this plan, you and your family are also covered by the ACE Assistance medical support programme. The contact details for their 24 hour alarm centres are clearly shown on your membership card. Cover is provided 24 hours per day, 365 days per year whilst an Insured Person is expatriated overseas on the business of the Insured. 3

6 4 Who is Covered Cover under this Plan shall apply only whilst you are assigned overseas and shall commence on your transfer date. Cover is included for your accompanying Spouse and Dependent Children, as defined below: SPOUSE/PARTNER means the husband or wife or any de-facto partner with whom the Insured Person has continuously cohabited for at least three months immediately before the date of Injury or Sickness, and is residing with the Insured Person in the Country of Domicile. DEPENDENT CHILD(REN) means an Insured Person s unmarried Dependent Child(ren) as long as they are under nineteen (19) years of age and living with the Insured Person or under twentyfive (25) years of age while they are full-time students at an accredited institution of higher learning in the Country of Domicile and primarily dependent upon the Insured Person for maintenance and support. This includes step or legally adopted children. 4

7 5 What is Covered For full details of coverage please refer to Appendix A 1. Medical Expenses 2. Medical Repatriation and Emergency Evacuation 3. Additional Benefits: Emergency Return Home Repatriation of Mortal Remains Personnel Replacement 4. Political and Natural Disaster Evacuation 5. Group Personal Accident 6. Personal Liability 5

8 6 Expatriates / Inpatriates who are 60 years to 75 years Medical & Additional Expenses Cover for Medical & Additional Expenses for Expatriates/Inpatriates who are 65 years to 75 years is limited to $1,000,000. Medical Repatriation & Emergency Evacuation Cover for Medical Repatriation & Emergency Evacuation is limited to $1,000,000. Group Personal Accident Cover for Personal Accident for events 1-19 is limited to $250,000 6

9 7 Pre-Existing Medical Conditions TAKE-OVER PROVISIONS means that coverage is extended to include all Pre-Existing Conditions including pregnancy, provided an Insured Person has been continuously insured with a Recognised Health Provider in the twelve (12) months immediately preceding their Effective Day of Coverage under this Policy. Recognised Health Provider includes Pacific Underwriting Corporation Pty Limited, AIG, Grand United Corporate Health or other domestic Registered Health Fund or a recognised International Health Benefits Programme in the instance of an Inpatriate member. 7

10 8 How to Claim Medical Claims For Employees, Consultants, Contractors, and Sub-contractors The fully completed form, together with the relevant receipts should be sent to: Corporate Services Network Pty Ltd Level George Street Sydney NSW 2000 Australia or claims@csnet.com.au Claims in respect of hospitalisation can be settled on your behalf by ACE Assistance. Minor claims such as medical consultations, dental and ancillary expenses will be reimbursed direct to you. Settlement is in Australian dollars, but covered expenses can be paid in any tradeable currency. Please note: The claim form must be submitted with a copy of the fully itemised original account. They must show the date of treatment, name of the patient and the charge for each item. Receipts and rebate details from Medicare or equivalent government medical fund must also be included. It is recommended that you keep copies for your own reference. Charges for all drugs and medicines can be refunded only when covered by a written prescription from a doctor. The chemist must be asked to note on the receipt, the prescription number, type of medicine and indicate to whom the prescription applies. Bandages and surgical dressings are also eligible expenses. 8

11 Other Claims Any expenses incurred must be paid for first and receipts submitted along with a claim form - please quote your policy number on claim form to assist in expediting claims. Medical expenses incurred outside of Australia will be covered subject to Policy Limits and Conditions. Medical expenses include: dental treatment; medical consultation fees; hospital fees; medicines prescribed by a qualified medical practitioner; services (physiotherapy, chiropractic therapy, eye therapy, home nursing, etc) that are prescribed by a qualified medical practitioner. 9

12 9 ACE Assistance/Customer Care In the event of an Emergency: Call the Customer Care number on your Card, reverse charges and advise: 1. Your name: 2. The Company Name: GRM International Pty Limited 3. Customer Care Membership Number (on card): CC016GRM 4. A return telephone number: 5. Your location: 6. The reason for your call: The telephone number to call is: Australia: (please call Reverse Charge) The website address is: ACE Assistance & Customer Care provide the following services: Emergency Medical Assistance and Advice Evacuation or Repatriation if necessary Liaison and case management with your hospital/medical provider Liaison and case management with ACE Insurance. 10

13 General Information and Claims Enquiries Please contact either your GRM Head Office Representative or Astrid Millar for claims enquiries and general information in regards to the Expatriate coverage on: Telephone: + 61 (7) Astrid.Millar@grminternational.com Note: if you need assistance or think you will need assistance, please inform ACE Assistance promptly. Do not try to solve the problem without involving the experience of ACE Assistance as this may prejudice your right to claim assistance or reimbursement. Medical Assistance 1. Telephone Medical Advice ACE Assistance will arrange to provide medical advice to the Members over the telephone. 2. Medical Service Provider Referral ACE Assistance will provide the Members with information about physicians, hospitals, dentists and dental clinics worldwide 3. Arrangement of Appointments with Doctors ACE Assistance will assist members in arranging appointments with general practitioners or specialised doctors, if medically necessary. 4. Arrangement of Hospital Admission If the medical condition of the Member is of such gravity that hospitalisation is needed, ACE Assistance will assist the Member by arranging for hospital admission. 5. Monitoring of Medical Condition when Hospitalised ACE Assistance doctors will monitor the Member s condition when being hospitalised. 6. Delivery of Essential Medicine ACE Assistance will arrange to deliver to the Member essential medicine or drugs when such medicine or drugs or local equivalent are not available at the Member s location. ACE Assistance will not pay for the costs of such drugs or medicine and any delivery costs thereof. 7. Arrangement of Emergency Medical Evacuation ACE Assistance will arrange for the air and/or surface transportation, medical care during transportation, communications and all usual ancillary services required to move the Member to the nearest hospital where appropriate medical care is available Arrangement of Emergency Repatriation 11

14 ACE Assistance will arrange for the return of the Member to Australia following an emergency medical evacuation for subsequent in-hospital treatment. 9. Arrangement of Repatriation of Mortal Remains ACE Assistance will arrange for the transportation of the Member s mortal remains from the place of death to Australia or such other location as requested by the deceased Member s family and approved by the Subscriber or ACE Assistance will arrange for the local burial at the place of death as approved by the Subscriber. 10. Arrangement of Compassionate Visit ACE Assistance will arrange for the return airfare for a relative or friend wishing to visit the member who was hospitalised outside the home country or usual country of residence. 11. Arrangement of Return of Minor Children ACE Assistance will arrange for one-way airfares for the return of the minor children who are left unattended as a result of the accompanying Member s illness, accident or hospitalisation. The above services (item 6-11) are charged on a case basis. ACE Assistance shall not be responsible for any third party expenses. Other Assistance Customer Care provides the following other services: 1. Worldwide Security Assistance Customer Care provides 24-hour emergency assistance in the event of a security incident such as a riot, political uprising, terrorist attack or natural disaster putting travellers or expatriates at risk. 2. Traveller Information Customer Care can provide up-to-the-minute global security information whilst travelling online or sent by or SMS, and links to travel warnings and advice. This includes online resources to help you prepare before you leave home, reducing the likelihood of illness or injury whilst overseas. 12

15 10 Claims in Australia (Applicable to Australian Citizens only) For medical claims incurred in Australia, whilst on holidays or business trips, the Insurer is restricted in paying certain costs where there is a Medical component. The procedure is as follows: 13

16 Employee Employee Incurs legitimate Medical Incurs expenses legitimate Medical expenses Yes Submit claim to Medicare Were expenses incurred in Were Australia? expenses incurred in Australia? No Submit claim to CSN, your GRM Head Office Contact or Astrid Millar Employee reimbursed Has the claim been Has the claim been paid by Medicare? paid by Medicare? No Yes Employee reimbursed to a prescribed percentage Employee of reimbursed the Scheduled to a Fee prescribed percentage of the Sc The Gap is Employer borne by to the reimburse Employee the - it is illegal for an Employer Employee to reimburse the Employee 14

17 APPENDIX A Policy Wording Summary Policy Schedule Policy Number 01PX Insured(s) GRM International Pty Limited, GRM Futures Group Pty Ltd and/or all subsidiary companies and related body corporate (as defined in the Corporations Law) including those acquired or incorporated for their respective rights, interests and liabilities Period of Insurance From: 30 November 2012 (at 4.00 pm) To: 30 November 2013 (at 4.00 pm) Insured Person(s) Any person nominated by the Insured for Insurance under this Policy and whose name appears on the Schedule of Insured Persons of this Policy and includes the Spouse and/or Dependent Children residing with the Insured Person in the Country of Domicile where insurance for the Spouse and/or Dependent Children has been purchased. Scope of Cover 24 hours per day 365 days per year cover while the Insured Person is expatriated overseas on the business of the Insured. 15

18 Schedule of Benefits Sum Insured as per Table of Conditions Each Insured Person Coverage A Expatriate Medical & Repatriation Expenses Section 1: Medical & Additional Expenses Categories Sum Insured Annual Aggregate Deductible Worldwide 1,000, USA/Canada/Japan 2,000, Section 2: Medical Repatriation & Emergency Evacuation Categories Sum Insured Worldwide 1,000,000 USA/Canada/Japan 2,000,000 Section 3: Additional Benefits Categories Sum Insured Emergency Return Home 10,000 Repatriation of Mortal Remains 20,000 Personnel Replacement 20,000 Section 4: Political & Natural Disaster Evacuation (Worldwide) Categories Sum Insured Limit per Insured Person 10,000 Aggregate Limit of Liability Solomon Islands 200,000 Aggregate Limit of Liability except Solomon Islands 100,000 16

19 Coverage B Group Personal Accident Categories Part A Table of Events Lump Sum Benefit Employee Events ,000 Spouse Events ,000 Dependent Children Events ,000 Part B Weekly Benefits Injury Excess Period (Days) % of Salary Part B Employee 1,000 (104 weeks) 7 85 Coverage C Personal Liability Categories Sum Insured Excess Insured Persons 5,000,000 1,000 Coverage D Aggregate Limit of Liability Any One Period of Insurance 10,000,000 Non-Schedule Aircraft 1,000,000 17

20 Endorsements War Exclusion Removal It is declared and agreed that should war (whether declared or not) invasion or civil war break out in any country, ACE Insurance will remove General Exclusion 3 (p 43) for the first seven days (7) days if an Insured Person is within or travelling to such war zone. Should the Insured Person require the removal of General Exclusion 3, for the duration of the noted journey/expatriation an additional premium will be charged on each declaration. Definition of War/Civil War Civil War means any of the following, whether declared or not, armed opposition, insurrection, revolution, armed rebellion, sedition between two or more parties belonging to the same country where the opposing parties are of different ethnic, religious or idealistic groups. War means war, whether declared or not, or any warlike activities, including use of military force by any sovereign nation to achieve economic, geographic, nationalistic, political, racial, religious or other ends. 18

21 General Definitions Applicable to all Categories CIVIL WAR means any of the following, whether declared or not,: armed opposition, insurrection, revolution, armed rebellion, sedition between two or more parties belonging to the same country where the opposing parties are of different ethnic, religious or idealistic groups DEPENDENT CHILD(REN) means an Insured Person s unmarried Dependent Child(ren) as long as they are under nineteen (19) years of age and living with the Insured Person or under twenty-five (25) years of age while they are full-time students at an accredited institution of higher learning in the Country of Domicile and primarily dependent upon the Insured Person for maintenance and support. This includes step or legally adopted children. DOCTOR means a person legally qualified and registered to practice medicine and surgery who is not an Insured Person or a relative of an Insured Person. EFFECTIVE DATE OF COVERAGE means the date advised to us that Your cover commenced under the policy. EMPLOYEE means any person in Your service including directors (executive and nonexecutive) and at Your option, includes consultants and/or self-employed persons undertaking work on Your behalf. HOME LEAVE means leave where the Insured Person(s) returns to their Country of Residence. INSURED PERSON(S) means any person nominated by You for insurance under this Policy and whose name appears on the Schedule of Insured Persons of this Policy and includes the Spouse/Partner and/or Dependent Child(ren) residing with the Insured Person in the Country of Domicile where insurance for the Spouse/Partner and/or Dependent Child(ren) has been purchased. PERIOD OF INSURANCE means the period of time shown on the current Schedule. POLICY means the Policy Wording and the Schedule. POLICY PERIOD means the period shown in the Schedule as the Period of Insurance. SCHEDULE means the Schedule attached to the Policy Wording or any subsequently substituted Schedule. SPOUSE/PARTNER means the husband or wife or any de-facto partner with whom the Insured Person has continuously cohabited for at least three months immediately before the date of Injury or Sickness, and is residing with the Insured Person in the Country of Domicile. WAR means war, whether declared or not, or any warlike activities, including use of military force by any sovereign nation to achieve economic, geographic, nationalistic, political, racial, religious or other ends. WE/OUR/US The Insurer means ACE Insurance Limited ABN YOU/YOUR means the Insured named in the Schedule. 19

22 Coverage A Expatriate Medical & Repatriation Expenses Definitions Applicable To Coverage A The following definitions apply: ANCILLARY SERVICES means the reasonable and necessarily incurred charges for Ancillary Services such as physiotherapy, chiropractic, acupuncture, podiatry, dietetics and the like. ANNUAL AGGREGATE EXCESS (OR ANNUAL AGGREGATE DEDUCTIBLE) means the amount We will not pay in any one policy period per single, couple or family. COUNTRY OF DOMICILE means the country named in the Policy Schedule as the country where the Insured Person(s) is/are residing on foreign assignment. DAY CARE means medical treatment provided in a Hospital or in a specially equipped clinic or treatment centre which: (a) (b) (c) does not require the Insured Person to be confined in a Hospital, is provided by a Specialist or under the direct supervision of a Specialist, and includes surgery performed by Doctors or Specialists in private practice. DENTIST means a person legally qualified and registered to practice dentistry who is not an Insured person or a relative of an Insured Person. GENERAL DENTAL SERVICES means charges made by a duly qualified oral surgeon or dentist for examinations, scaling and cleaning, dental filling and restorations, diagnostic services, X-Rays, injections and extractions of teeth. HOSPITAL means a place registered as a hospital for the care and treatment of sick or injured persons and which has the following characteristics: (a) (b) (c) (d) has organised diagnostic and surgical facilities, either on premises or in facilities available to the Hospital on a pre-arranged basis; provides 24-hours-a-day nursing services by registered nurses; is under the supervision of a Doctor; and is not primarily a clinic, a place for custodial care, a place for the treatment of alcoholics or drug addicts, a nursing, rest or convalescence home or home for the aged or similar establishment. 20

23 HOSPITAL SERVICES means charges for semi-private Hospital room and board, including Doctor s charges for any anaesthesia and its administration, use of operating theatre, medicines, dressings, splints, plaster casts, rental of wheelchair or other prosthetic devices or Hospital equipment during the confinement period, other miscellaneous Hospital equipment during the confinement period and other miscellaneous Hospital charges for other services necessarily and regularly given by a Hospital for treatment of that Injury or Sickness. INJURY means a physical injury caused by a violent, external and visible means which occurs fortuitously and which results solely and directly and independently of any pre-existing condition within the Policy Period. MATERNITY CARE/TREATMENT means pre-natal, childbirth and post-natal charges (up to six (6) months after the birth of the child) for the care of the mother provided that the Insured Person s pregnancy commenced during the Period of Insurance and after their Effective Date of Coverage. MEDICAL PRIMARY CARE AND SPECIALIST OUTPATIENT CARE means all treatment of an Injury or Sickness that is provided by a Doctor or Specialist, which is not more specifically defined. NEW BORN CHILD EXPENSES means charges for the routine care of a new born child from birth up to six (6) months of age. OPTICAL means charges for spectacles and/or contact lenses as prescribed by the treating Doctor or Specialist. PRE-EXISTING MEDICAL CONDITIONS means: (a) (b) (c) any condition for which a Doctor was consulted or for which treatment or medication was prescribed, or a condition, the manifestation of symptoms of which a reasonable person in the circumstances would be expected to be aware of within three (3) calendar months prior to the Effective Date of Coverage of the Insured Person, or any condition known to the Insured Person prior to the Effective Date of Coverage under this Policy and where the Insured person: (i) (ii) (iii) (iv) is on a waiting list for treatment; travels for the purpose of obtaining treatment; has received a terminal prognosis; has been recommended to continue or to commence any medical treatment or medication after Effective Date of Coverage. PRESCRIBED MEDICINES means medicine, including bandages and surgical dressings, which has been prescribed by a Doctor or Specialist. 21

24 PSYCHOLOGY AND PSYCHIATRY means charges made by a duly qualified Psychologist or Psychiatrist for the provision of mental health services provided that the Insured Person is referred for such treatment by the treating Doctor or Specialist. REHABILITATION AND OCCUPATIONAL THERAPY means the reasonable and necessarily incurred charges for Rehabilitation treatment and/or Occupational therapy as prescribed by the treating Doctor or Specialist as a result of an Injury or Sickness as defined. SICKNESS means sickness or disease of the Insured Person first manifesting itself while the Insured Person is insured under this Policy, but does not include any Pre-Existing Medical Conditions. SPECIAL DENTAL SERVICES means charges made by a duly qualified oral surgeon or dentist for root treatment, endodontic treatment, oral surgery, anaesthetic services, periodontic surgery, interceptive orthodontic services, installation of and repairs to crowns and bridges, new dentures, dental repairs and remodelling and other Specialist and orthodontic services. SPECIALIST means a Doctor recognised and referred to by another Doctor for his or her experience, qualification and training in a particular branch of medicine or surgery or in the treatment of a specific Injury or Sickness and includes but is not limited to optometrists. TAKE-OVER PROVISIONS means that coverage is extended to include all Pre-Existing Conditions including pregnancy, provided an Insured Person has been continuously insured with a Recognised Health Provider in the twelve (12) months immediately preceding their Effective Day of Coverage under this Policy. Recognised Health Provider includes Pacific Underwriting Corporation Pty Limited, AIG, Grand United Corporate Health or other domestic Registered Health Fund or a recognised International Health Benefits Programme in the instance of an Inpatriate member. Cover is also extended to include all Pre-existing Medical Condition(s), provided that in the twelve (12) months immediately preceding the Effective Date of Coverage of the replacement policy the person to be insured was continuously insured under Policy No. 04PP with ACE Insurance Limited. VERY SERIOUSLY ILL means a medical condition certified by the attending Doctor or Specialist to be such as to warrant a notification to relatives that their attendance is desirable in view of the imminent danger to the patient. 22

25 Section 1 Medical Expenses Extent Of Cover This Policy pays the actual, necessary and reasonable expenses incurred by the Insured Person during the Policy Period for Medical Primary Care and Specialist Outpatient Care as defined and as limited in the Schedule of Benefits. Schedule Of Benefits Medical Primary Care And Specialist Outpatient Care Hospital Services (as defined) In Hospital Medical Charges either Inpatient / Same Day Surgery Out of Hospital Services Doctor s charges, Specialist charges and approved same day clinic charges Worldwide Maximum Per Insured Person Any One Policy Period USA/Canada/Japan 100% to $1,000, % to $2,000, % to $1,000, % to $2,000,000 Prescribed Medicines In Hospital 100% to $1,000, % to $2,000,000 Maternity Care Expenses You are only covered for maternity expenses if Your pregnancy commenced during the Period of Insurance and after Your Effective Date of Coverage Maternity Care/Treatment Routine Maternity Care/Treatment (pre natal, delivery and post natal charges (up to six (6) months after birth of child) for the care of the mother. Additional Delivery Expenses Emergency and/or Complicated Delivery Charges Routine Maternity Care for the child from birth to six (6) months of age (at which time child becomes an Insured Person under the policy) Worldwide USA/Canada/Japan $20,000 $20,000 $100,000 in addition to Maternity Care/Treatment above $100,000 in addition to Maternity Care/Treatment above $20,000 $20,000 Dental Services Worldwide USA/Canada/Japan General Dental Services (as defined) 85% to maximum $1,200 85% to maximum $2,400 Special Dental Services (as defined) 85% to maximum $1,200 85% to maximum $2,400 23

26 Ancillary Services Worldwide USA/Canada/Japan Acupuncture/Naturopathy/Hypnotherapist 100% to maximum $ % to maximum $1,000 Chiropractic/Osteopathy $100 per visit to maximum $1,000 $100 per visit to maximum $2,000 Dietician 100% to maximum $ % to maximum $1,000 Optical 100% to maximum $ % to maximum $1,000 Physiotherapy $100 per visit to maximum $1,500 $100 per visit to maximum $3,000 Podiatry 100% to maximum $ % to maximum $1,000 Prescribed Medicines 100% to maximum $2, % to maximum $4,000 Prosthesis and Hearing Aids (one appliance every two (2) years) 100% to maximum $1, % to maximum $2,000 Speech Therapy 100% to maximum $ % to maximum $1,000 Other Services Rehabilitation and Occupational Therapy Psychology and Psychiatry Worldwide 100% to a maximum of $10, % to a maximum of $2,500 USA/Canada/Japan 100% to a maximum of $20, % to a maximum of $5,000 Home Nursing Home Nursing following an Injury or Sickness as defined by a qualified nurse who is not a relative of the Insured Person Worldwide $750 per week to maximum 4 weeks USA/Canada/Japan $1,500 per week to maximum 4 weeks Annual Aggregate Deductible $500 per Insured person any one Policy Period 24

27 Section 2 Medical Repatriation And Emergency Evacuation Medical Repatriation Benefit We will pay the actual, necessary and reasonable expenses incurred by the Insured person during a Policy Period for Medical Primary Care and Specialist Outpatient Care where such treatment is obtainable, provided that the Insured Person contacts ACE Assistance and obtains a written certification by the attending Doctor stating that the Insured is suffering Injury or Sickness and it is necessary that the Insured Person obtains specialised treatment, surgery or post-operative attention which is unobtainable in the Country of Domicile. The maximum amount payable in respect of an Insured Person during any one Policy Period shall be the amount stated in The Schedule per Insured Person per Policy Period. The following items of benefit are payable:- (a) Repatriation Expenses of Insured Person Charges for airfare (economy airfare where possible) in transporting the Insured Person by scheduled airline on a scheduled flight to the airport nearest to the recommended Hospital where the Insured Person is to be confined for specialised treatment, surgery or post operative attention. Such charges will include ground transport from the airport to the nearest recommended hospital. Including return airfare charges (economy airfare where possible) if the Insured Person returns to his or her Country of Domicile following Repatriation, within twelve (12) calendar months of sustaining Injury or Sickness. Where an Insured Person under sixteen (16) years of age is repatriated, additional charge for airfare (economy fare where possible) on a scheduled flight of one adult to accompany such Insured Person is payable. Where an Insured Person is repatriated but is not recommended to travel alone, provided the need for an escort for such Insured Person is certified by the Insured Person s attending Doctor and ACE Assistance as medically necessary, the additional charge for airfare (economy fare where possible) on a scheduled flight of one adult to accompany such Insured Person is payable. (b) (c) Pre-Hospitalisation and Post-Hospitalisation Accommodation Charges For the Insured Person up to a maximum $250 per day and for a period of no more than twenty (20) days, where certified by the Insured Person s attending Doctor, ACE Assistance and the Hospital as medically necessary, for the purpose of waiting for medical test or examination results. The maximum amount payable shall be $5,000. Accompanying Person s Accommodation Charges for hotel or other accommodation incurred by the accompanying person for the period of Hospital confinement of the Insured Person including any period of prehospitalisation and post-hospitalisation accommodation of the Insured Person subject to such charges not exceeding $250 per day and for a period of no more than twenty (20) days. The maximum amount payable shall be $5,

28 (d) En-route Accommodation Charges not recoverable from the airline for hotel accommodation up to $250 per night, where an Insured Person is required by airline schedules to stay over-night en-route to the Hospital. The maximum amount payable shall be $5,000. Emergency Evacuation Expenses Benefit We will pay the charges incurred for emergency evacuation incurred by the Insured Person during the Policy Period for the charter of an aircraft or air ambulance or other available means of transport to evacuate the Insured Person to receive urgent surgery or urgent specialised treatment, provided that the Insured Person or his/her representative obtains prior agreement from ACE Assistance or from Us confirming such charter is necessary and the Insured Person obtains written verification by the attending Doctor or Specialist stating:- (a) (b) that such Injury or Sickness of the Insured Person was of a critical nature, and it was necessary that the Insured Person obtain urgent surgery or urgent specialised treatment which is not available in the Country of Domicile. The maximum amount payable in respect of an Insured Person during any one Policy Period shall be the amount stated in The Schedule and limited to only two emergency evacuation per Insured Person per Policy Period. Expenses include return economy airfare charges if the Insured Person returns directly to his or her Country of Domicile following evacuation. 26

29 Section 3 - Additional Benefits EMERGENCY RETURN HOME means in the event of the unexpected death of the Insured Person s Spouse/Partner, Dependent Child(ren), parent, parent-in-law, child, brother, sister, brother-in-law, sister-in-law, daughter-in-law, son-in-law, grandparent or grandchild, or in the event of them becoming Very Seriously Ill, necessitating the Insured Person returning to his or her earlier country of residence, then subject to prior approval being obtained from Us and/or ACE Assistance, We will pay reasonable travel and accommodation expenses thereby incurred provided such person is at the relevant time not more than eighty (80) years of age. The maximum amount payable shall be $ 10,000. REPATRIATION OF MORTAL REMAINS means in the event of the death of an Insured Person, We will pay the reasonable expenses incurred for the cost of returning his or her mortal remains to his or her country of residence or the reasonable funeral and related costs if the body is buried or cremated at the place of death. The maximum amount payable shall be $20,000. PERSONNEL REPLACEMENT means in the event that an Insured Person, excluding Spouse/Partner or Dependent Child(ren), becomes Very Seriously Ill, We will pay reasonable travel and additional temporary accommodation expenses incurred by the Insured for:- (a) (b) the sending of a qualified replacement employee to the Country of Domicile of the Insured Person to complete the unfinished business commitments of the Insured Person, or the return of the Insured Person to the Country of Domicile after his or her recovery to complete those original business commitments. The maximum amount payable shall be $20,

30 Section 4 Political & Natural Disaster Evacuation Political Evacuation If during the Period of Insurance and whilst on secondment, an Insured Person is recommended to leave the country in which they are seconded by officials in that country OR the Insured Person is expelled or declared persona non grata from that country OR there is wholesale seizure, confiscation or expropriation of the Insured Person s property, plant or equipment in that country, We will pay the cost of the Insured Person s return to their home country or the nearest place of safety up to the cost of an economy class airfare for the same trip AND the Insured Person s reasonable accommodation costs up to a maximum of $250 per day for fourteen (14) days if the Insured Person is unable to return to their home country, up to the amount shown on the Schedule against Section 4. Conditions Specific to Political Evacuation Section 4 If an Insured Person is required to leave the country they are in, ACE Assistance must be contacted beforehand to confirm cover. Where possible ACE Assistance will make the travel arrangements and in all cases, We will decide where to send the Insured Person. Exclusions Specific to Political Evacuation Section 4 We will not pay any claim directly or indirectly from: 1. an Insured Person violating the laws or regulations of the country they are in. 2. an Insured Person s failure to produce or maintain necessary immigration, work, residence or similar visas, permits or other documentation. 3. debt, insolvency, commercial failure, repossession of property by a titleholder or any other financial cause. 4. failure to honour any contractual obligation or bond or to obey any conditions in a license. 5. an Insured Person being a national of the country which they are to be evacuated from. 6. natural disasters Natural Disaster Evacuation If a major natural disaster has occurred in the country the Insured Person is in necessitating his or her immediate evacuation in order to avoid risk of Personal Injury or Sickness to him or herself We will commence arrangements for the Evacuation of the Insured Person. The decision to evacuate will be made after consultation with interested governments and the insured person. Evacuation will be initiated after reasonable local measures to protect the health and safety of the Insured Person have been exhausted or when We decide that an Insured Person, who is not in need of medical attention, is at high risk due to adverse local conditions. 28

31 If We consider the situation will continue for less than thirty (30) days duration, evacuation will be made; to the nearest location outside the impacted area or; if out of the country to the nearest country which the Insured Person will be accepted If We consider the situation will continue for more than thirty (30) days duration, evacuation will be made to the Insured Person s home country. WE WILL PROVIDE AND PAY FOR arrangements necessary for the evacuation commencing immediately after the decision to evacuate return trip to the Insured Person s workplace after evacuation up to the cost of an economy class airfare for the same trip. We will grant a period of ten (10) days for Insured Persons to avail themselves of the evacuation arrangements as soon as they can be offered. If evacuation is not possible We will use resources at Our disposal to maintain contact with the Insured Persons until evacuation becomes possible or the situation has ended. Exclusions Specific to Natural Disaster Evacuation - Section 4 We will not pay for claims arising directly or indirectly out of: Evacuation assistance or travel arrangements made independently by the Insured or Insured Person Accommodation and living expenses incurred following evacuation The natural disaster that resulted in the Insured Persons evacuation being in existence prior to the Insured person entering the country or its occurrence being foreseeable to a reasonable person before the Insured Person entered the country. If an Insured Person needs to leave the country he or she is in, ACE Assistance must be contacted beforehand to confirm cover. Where possible ACE Assistance will make the travel arrangements and in all cases We will decide where to send the Insured Person. The maximum amount We will pay is $10,000 per person, $100,000 aggregate limit of liability per policy period except with respect to Insured Persons based in the Solomon Islands where the maximum amount We will pay is $10,000 per person, $200,000 aggregate limit of liability per policy period. 29

32 Section 5 Medical Expenses in Australia Home Leave Home Leave - Australian Citizens The policy also provides for coverage as detailed in the Schedule of Benefits for coverage whilst on home leave except for treatment or services covered by Medicare (refer Exclusion 3, Exclusions Applicable Coverage A). Home Leave Entitlements - Non Australians The policy also provides for coverage as detailed in the Schedule of Benefits for coverage whilst on home leave, PROVIDED THAT we are not prohibited from providing medical coverage in that country by that country s laws and regulations. 30

33 Exclusions Applicable to Coverage A We will not pay for claims arising directly or indirectly out of: 1. Cosmetic, elective or plastic surgery, (except and to the extent that it is necessary for the cure or alleviation of Injury to the Insured Person) or out of any routine physical examinations not provided for in the Schedule of Benefits. 2. Pre-Existing Medical Conditions are covered for the benefits in Sections 1 and 5 of this Policy once an Insured Person has been insured under this Policy for longer than twelve (12) calendar months from the Effective Date of Coverage for the Insured Person. We will only pay for Pre-Existing Medical Conditions expenses that are incurred for treatment received from the first day after the twelve (12) calendar months of the Insured Person s Effective Date of Coverage. 3. Treatment or services which are covered by Medicare or by compensation under any workers compensation act or transport accident laws or by any government sponsored fund, plan, or medical benefit scheme, or any other insurance policy required to be effected. 4. Charges for non-medical services including but not limited to telephone, television, newspapers and the like. 5. Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Syndrome (HIV) infection however caused unless as a result of an accident or a medical procedure. The maximum amount that we will pay for any one condition is $200,000 (increased to $400,000 for USA, Canada, and Japan). 6. Sexually transmitted disease, infertility, sterilisation, suicide or any attempt threat while sane or insane, intentionally self-inflicted injuries, abortion (unless certified as medically necessary by the attending Doctor or Specialist), congenital deformities or abnormalities. 31

34 Coverage B Group Personal Accident Policy Definitions Applicable To Coverage B The following definitions apply: - ACCIDENTAL DEATH means death occurring as a result of an Injury. EVENT(S) means the event(s) described in the Table of Events set out in Personal Accident and Injury Cover. EXCESS PERIOD means the period of time following an Event giving rise to a claim for which benefits are not payable. FINGERS, THUMBS or TOES means the digits of a Hand or Foot FOOT means the entire foot below the ankle. HAND means the entire hand below the wrist INJURY means a bodily injury resulting from an accident and which is not an illness and which: (a) is caused by violent, external and visible means; and (b) occurs during the Period of Insurance; and (c) results solely and independently of any other causes, including any pre-existing physical or congenital conditions (except illness or disease directly resulting from medical or surgical treatment rendered necessary by any Injury). LIMB means the entire Limb between the shoulder and the wrist or between the hip and the ankle. LOSS means in connection with: (a) a Limb, Permanent physical severance or Permanent total loss of the use of the Limb; (b) an eye, total and Permanent loss of all sight in the eye; (c) hearing, total and Permanent loss of hearing; (d) speech, total and Permanent loss of the ability to speak; and (e) which in each case is caused by Injury. PARAPLEGIA means the Loss of use of both legs and the Permanent Loss of use of part of or whole of the lower half of the body. PERMANENT means having lasted twelve (12) consecutive months and at the expiry of that period, being beyond hope of improvement. QUADRIPLEGIA means the Loss of use of both arms and both legs. 32

35 SALARY means: 1. in the case of an Employee, their weekly pre-tax income, excluding commission, bonuses, overtime payments and any allowances, averaged during the period of twelve (12) months immediately preceding the commencement of the disability or over such shorter period as they have been employed; or 2. in the case of a self-employed person, their weekly pre-tax income derived from personal exertion, after deduction of all expenses incurred in connection with the derivation of that income, averaged over the period of twelve (12) months immediately preceding the commencement of the disability or over such shorter period as they have been selfemployed. TEMPORARY PARTIAL DISABLEMENT means the temporary inability of the Insured Person to engage in a substantial part of their usual occupation or business duties, while they are under the regular care of and acting in accordance with the instructions or advice of a Doctor. TEMPORARY TOTAL DISABLEMENT means the temporary inability of the Insured Person to engage in their usual occupation or business duties, while they are under the regular care of and acting in accordance with the instructions or advice of a Doctor. TOTAL DISABLEMENT means the inability of the Insured Person to engage in or attend to any occupation or business. 33

36 Personal Accident Cover Extent Of Cover Personal Accident If during the Period of Insurance an Insured Person suffers from an Event described in COVERAGE B Group Personal Accident, Section 1 Parts A or B of the following Table of Events as result of an Injury, We will pay the corresponding benefit for that Event set out in the Table of Events, provided an amount is shown on the Schedule for that Event against Section B, Section 1 Parts A or B. Table of Events Coverage B, Part A Lump Sum Benefits Cover for an Event under this part applies only if an amount for that Event is shown on the Schedule against COVERAGE B Group Personal Accident, Part A Lump Sum Benefits. The Events Injury resulting directly in the following Event(s), which occur within twelve (12) months of the date of the Injury: 1. Accidental Death 100% 2. Permanent Total Disablement 100% 3. Paraplegia or Quadriplegia 100% 4. Loss of sight of both eyes 100% 5. Loss of sight of one (1) eye 100% 6. Loss of use of two (2) Limbs 100% 7. Loss of use of one (1) Limb 100% 8. Permanent and incurable insanity 100% 9. Loss of hearing in:- (a) both ears 100% (b) one (1) ear 20% 10. Permanent Loss of use of four (4) Fingers and Thumb of either Hand The Benefit Being a percentage of the amount shown in the Schedule against Part A - Lump Sum Benefits for each Insured Person. 75% 11. Permanent Loss of the lens of one (1) eye 60% 12. Third degree burns and/or resultant disfigurement which covers more than 40% of the entire external body 50% 13. Permanent Loss of use of four (4) Fingers of either Hand 40% 14. Permanent Loss of use of one (1) Thumb of either Hand:- (a) both joints 30% (b) one (1) joint 15% 34

37 The Events Injury resulting directly in the following Event(s), which occur within twelve (12) months of the date of the Injury: 15. Permanent Loss of use of Fingers of either Hand:- (a) three (3) joints 15% (b) two (2) joints 10% (c) one (1) joint 5% 16. Permanent Loss of use of Toes of either Foot:- (a) all - one (1) Foot 15% (b) great both joints 5% (c) great one (1) joint 3% (d) other than great - each Toe 1% 17. Fractured leg or patella with established non-union 10% 18. Shortening of leg by at least 5 cm 7.5% 19. Permanent Partial Disablement not otherwise provided for under Events 5 to 18 inclusive. The Benefit Being a percentage of the amount shown in the Schedule against Part A - Lump Sum Benefits for each Insured Person. Such percentage of amount as We in Our absolute discretion shall determine and being in Our opinion not inconsistent with the benefits provided under Events 5 to 18 inclusive. Event 19 is limited to a maximum of 75% of the amount shown in the Schedule against Part A Lump Sum Benefits. Coverage B. Part B Weekly Benefits - Injury Cover for an Event under this Part applies only if an amount is shown on the Schedule against COVERAGE B Group Personal Accident, Part B Weekly Benefits - Injury. Injury resulting directly in the following Events which occur within twelve (12) months of the date of the Injury: THE BENEFITS 20. Temporary Total Disablement During such disablement, the Weekly Benefit shown on the Schedule against Part B Weekly Benefits Injury, but not Exceeding the Salary of the Insured Person. 35

38 Injury resulting directly in the following Events which occur within twelve (12) months of the date of the Injury: THE BENEFITS 21. Temporary Partial Disablement During such disablement, the Weekly Benefit shown on the Schedule against Part B Weekly Benefits Injury less any amount of current earnings as a result of working in a reduced capacity with the Insured provided the combined amount does not exceed the Salary of the Insured Person. Should the Insured Person be able to return to work in a reduced capacity, yet elect not to do then the benefit payable shall be 25% of the amount payable for Event

39 Additional Cover applicable to Coverage B Exposure If during the Period of Insurance an Insured Person is exposed to the elements as a result of an accident and within twelve (12) months of the accident they suffer from any of the Events as a direct result of that exposure, they will be deemed for the purpose of this Policy to have suffered an Injury on the date of the accident. Disappearance If during the Period of Insurance an Insured Person disappears following the disappearance, sinking or wrecking of a conveyance in which they were travelling and their body has not been found within twelve (12) months after the date of that disappearance, they will be deemed to have died as a result of an Injury at the time of the disappearance, sinking or wrecking of the conveyance. If the benefit for Event 1 in the Table of Events (Accidental Death) is payable because of a Disappearance, We will only pay if the legal representatives of the Insured Person s estate give Us a signed undertaking that these amounts will be repaid to Us, if it is later found that the Insured Person did not die or did not die as a result of an Injury. Escalation of Claim Benefit After payment of a benefit under Events 20 and/or 21 continuously for twelve (12) months and again after each subsequent period of twelve (12) months during which a benefit is paid, the benefit will be increased by 5% per annum. Rehabilitation Expenses On the occurrence of Events 20 and/or 21 or Event 22, We will reimburse expenses incurred for tuition or advice for the Insured Person from a licensed vocational school, provided such tuition or advice is undertaken with Our prior written agreement and the agreement of the Insured Person's Doctor. Compensation under this provision will be limited to the actual costs incurred not exceeding $500 per month and will be payable for a maximum of six (6) months. Guaranteed Payment If an Insured Person sustains an Injury for which benefits are payable under Events 20, We will immediately pay ten (10) weeks benefits provided that proper medical evidence is produced from a Doctor certifying that the total period of Temporary Total Disablement will be a minimum of twenty-six (26) weeks. Conditions Applicable To Coverage B Group Personal Accident 1. If an Insured Person suffers an Injury resulting in any one of Events 2-8, We will not be liable under this Policy for any subsequent Injury to that Insured Person. 2. Benefits shall not be payable for more than one of Events 1 to 19 in respect of the same Injury. 3. Benefits shall not be payable:- a) for Events 20 and/or 21 in excess of a total period of one hundred and fifty six (104) weeks in respect of any one Injury, unless otherwise stated on the Schedule; 37