YOUR PREMIUM PAID CRITICAL ILLNESS EXTENSION CRITICAL ILLNESS COVERAGE FORM

Transcription

1 YOUR PREMIUM PAID CRITICAL ILLNESS EXTENSION CRITICAL ILLNESS COVERAGE FORM SECTION 1. DEFINITIONS AGE means attained age (last birthday). BENEFICIARY means the FIRM. COVERED PERSON means a person who: a) is a sole proprietor, partner or shareholder of a FIRM; and b) has a minimum 25% ownership in the FIRM if a partner or shareholder; and c) is less than sixty-five (65) years of age. CRITICAL ILLNESS means an illness, disorder or SURGERY which is specifically covered under the Coverage Form as defined under Section 3 and which is not specifically excluded. DATE OF DIAGNOSIS means the date on which a Canadian SPECIALIST first DIAGNOSED the COVERED PERSON with one of the covered critical illnesses. The DATE OF DIAGNOSIS must be after the COVERED PERSON S RETROACTIVE DATE or latest date of REINSTATEMENT of the Coverage Form. DIAGNOSIS/DIAGNOSED means the written confirmation of the existence of an insured critical illness condition that is covered under this Coverage Form by a doctor recognized as a SPECIALIST in the field of medicine relating to the applicable insured condition by the doctor s medical licensing body. The DIAGNOSIS must be supported by objective medical evidence. The DIAGNOSIS under the Coverage Form means the complete fulfillment of the definition of the condition as described in Section 3 of this Coverage Form. FIRM means a commercial business insured by us and that is listed on the Policy Declarations. IRREVERSIBLE means the condition cannot be improved by medical or surgical treatment at the time of DIAGNOSIS. The medical or surgical treatment need not be undertaken if it would involve undue risk to your health. LIFE SUPPORT means the COVERED PERSON is under the regular care of a licensed physician and is being kept alive through nutritional, respiratory and/or cardiovascular support even though irreversible cessation of all functions of the brain has occurred. LIMITS OF INSURANCE means the SUM INSURED in this Coverage Form. REINSTATEMENT is the date the insurance under this Coverage Form is put back into force if the policy to which this Coverage Form is attached terminates as a result of unpaid premiums. RETROACTIVE DATE for a COVERED PERSON is the latest of: a) the original purchase date of this Coverage Form; or b) the date of last REINSTATEMENT of this Coverage Form; or c) the date the individual became a COVERED PERSON of this Coverage Form. SPECIALIST means a licensed medical doctor who has been trained in the specific area of medicine relevant to the covered critical illness condition for which benefit is being claimed, and who has been certified by a specialty examining board. The SPECIALIST must be practicing in Canada. SPECIALIST includes, but is not limited to, cardiologist, neurologist, nephrologist, oncologist, ophthalmologist, burn specialist and internist. The SPECIALIST must not be the policy owner, the COVERED PERSON, a relative or business associate of the policy owner or the COVERED PERSON. SURGERY means that you actually undergo SURGERY performed on the written advice of a doctor. The SURGERY must be performed by a doctor, in Canada. SURGERY will include the medical procedure for transplanting bone marrow. SURVIVAL PERIOD means the minimum number of consecutive days, immediately following the DATE OF DIAGNOSIS of the critical illness condition which YOU must survive before a critical illness benefit may become payable. The SURVIVAL PERIOD is thirty (30) days unless a longer period is specified in Section 3 of this Coverage Form. The SURVIVAL PERIOD does not include the number of days on LIFE SUPPORT. The COVERED PERSON must be alive at the end of the SURVIVAL PERIOD and must not have experienced IRRESVERSIBLE cessation of all functions of the brain. SUM INSURED means the premium for the policy term at the DATE OF DIAGNOSIS for all coverage provided by the policy for that term. The SUM INSURED will be paid once only in any one policy period. The SUM INSURED will never exceed $50,000. WE, US, OUR, THE INSURER or THE COMPANY means Aviva Insurance Company of Canada. YOU or YOUR means the COVERED PERSON insured under this Coverage Form.

2 SECTION 2. INSURING PROVISIONS 2.1 Insuring Clause If, while this Coverage Form is in force and the COVERED PERSON is insured under this Coverage Form, the COVERED PERSON is DIAGNOSED by a SPECIALIST with a critical illness and survives for thirty (30) days following the DATE OF DIAGNOSIS or such period as described in Section 3 of this Coverage Form, we will pay the SUM INSURED to the BENEFICIARY, subject to the limitations and exclusions and the other terms and conditions of this Coverage Form. The DIAGNOSIS must be established after the RETROACTIVE DATE of the COVERED PERSON S coverage. SECTION 3. COVERED CRITICAL ILLNESS CONDITIONS 3.1 Benign Brain Tumour is defined as a definite DIAGNOSIS of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgical or radiation treatment or cause irreversible objective neurological deficit(s). The DIAGNOSIS of Benign Brain Tumor must be made by a SPECIALIST. Exclusion: No benefit will be payable under this condition for pituitary adenomas less than 10 mm. 3.2 Blindness is defined as a definite DIAGNOSIS of the total and irreversible loss of vision in both eyes, evidenced by: a) the corrected visual acuity being 20/200 or less in both eyes; or, b) the field of vision being less than 20 degrees in both eyes. The DIAGNOSIS of Blindness must be made by a SPECIALIST. 3.3 Cancer (life-threatening) is defined as a definite DIAGNOSIS of a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The DIAGNOSIS of Cancer must be made by a SPECIALIST. Exclusion: No benefit will be payable under this condition for the following non-life-threatening cancers: a) carcinoma in situ; or b) Stage 1A malignant melanoma (melanoma less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion); or c) any non-melanoma skin cancer that has not metastasized; or d) Stage A (T1a or T1b) prostate cancer. 3.4 Coma is defined as a definite DIAGNOSIS of a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least ninety-six (96) hours, and for which period the Glasgow coma score must be 4 or less. The DIAGNOSIS of Coma must be made by a SPECIALIST. a) a medically induced coma; or, b) a coma which results directly from alcohol or drug use; or, c) a DIAGNOSIS of brain death. 3.5 Coronary Artery Bypass Surgery is defined as the undergoing of heart SURGERY to correct narrowing or blockage of one or more coronary arteries with bypass graft(s), excluding any non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of obstruction. The SURGERY must be determined to be medically necessary by a SPECIALIST. 3.6 Deafness is defined as a definite DIAGNOSIS of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The DIAGNOSIS of Deafness must be made by a SPECIALIST. 3.7 Heart Attack is defined as a definite DIAGNOSIS of the death of heart muscle due to obstruction of blood flow, that results in: Rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following: a) heart attack symptoms; b) new electrocardiogram (ECG) changes consistent with heart attack; c) development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty. The DIAGNOSIS of Heart Attack must be made by a SPECIALIST. a) elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or b) ECG changes suggesting a prior myocardial infarction, which do not meet the heart attack definition as described above. 3.8 Loss of Speech is defined as a definite DIAGNOSIS of the total and irreversible loss of the ability to speak as the result of physical injury or disease, for a period of at least one hundred and eighty (180) days. The DIAGNOSIS of Loss of Speech must be made by a SPECIALIST. Exclusion: No benefit will be payable under this condition for all psychiatric related causes.

3 3.9 Major Organ Transplant is defined as a definite DIAGNOSIS of the IRREVERSIBLE failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under major organ transplant, the COVERED PERSON must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The DIAGNOSIS of Major Organ failure must be made by a SPECIALIST Paralysis is defined as a definite DIAGNOSIS of the total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least ninety (90) days following the precipitating event. The DIAGNOSIS of Paralysis must be made by a SPECIALIST Renal (kidney) Failure is defined as a definite DIAGNOSIS of chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis or renal transplantation is initiated. The DIAGNOSIS of Renal (kidney) Failure must be made by a SPECIALIST Severe Burns is defined as a definite DIAGNOSIS of third-degree burns over at least 20% of the body surface. The DIAGNOSIS of Severe Burns must be made by a SPECIALIST Stroke is defined as a definite DIAGNOSIS of an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with: a) acute onset of new neurological symptoms, and b) new objective neurological deficits on clinical examination, persisting for more than thirty (30) days following the DATE OF DIAGNOSIS. These new symptoms and deficits must be corroborated by diagnostic imaging testing. The DIAGNOSIS of Stroke must be made by a SPECIALIST. a) Transient Ischaemic Attacks (TIA); or b) Intracerebral vascular events due to trauma; or c) Lacunar infarcts which do not meet the definition of stroke as described above. SECTION 4. EXCLUSIONS AND LIMITATIONS 4.1 Exclusions No critical illness benefit will be due or payable if a critical illness results directly or indirectly from any of the following: a) suicide, or any attempt at suicide, while sane or insane; b) intentionally self-inflicted injury; c) use of illegal or illicit drugs or substances, or misuse of medication obtained with or without prescription; d) declared or undeclared war; e) flying, except as a fare paying passenger on any aircraft; f) while the COVERED PERSON is committing or attempting to commit an assault, battery, or criminal office, whether or not the COVERED PERSON has been charged with a criminal offence; g) operating a motorized vehicle where the COVERED PERSON: (1) was found to have a blood alcohol level in excess of 80 milligrams of alcohol per 100 millimetres of blood; or (2) has been convicted of an alcohol-related offence such as driving while impaired; or (3) has refused to take a breathalyzer test. h) If the COVERED PERSON was negligent or non-compliant in seeking and/or following reasonable medical treatment, consultation, care or services including diagnostic measure as prescribed by their attending physician; i) Participation in the following: (1) Underwater diving; or (2) Hang-gliding, parachuting, skydiving; or (3) Power boat racing, and any form of motorized vehicle racing including time trials; or (4) Rock climbing, mountaineering, caving or rodeo riding. 4.2 When the Benefit is Payable The critical illness benefit under this Coverage Form is not payable unless the COVERED PERSON survives for thirty (30) days following the DATE OF DIAGNOSIS or such longer period as described in Section 3 of this Coverage Form. 4.3 First Occurrence Clause Critical illness benefits are not payable if the critical illness condition as defined in Section 3 is a second or subsequent occurrence of a critical illness previously DIAGNOSED. Critical illness benefits are not payable if the COVERED PERSON is DIAGNOSED with or treated for a defined critical illness condition prior to the retroactive date or date of most recent REINSTATEMENT of the Coverage Form. SECTION 5. CLAIMS 5.1 Claim Forms THE COMPANY will furnish forms for proof of claim within fifteen (15) days after receiving notice of claim, but where the claimant or BENEFICIARY has not received the forms within that time they may submit proof of claim in the form of a written statement of the cause or nature of the loss giving rise to the claim.

4 5.2 Notice and Proof of Claim Before any settlement under this Coverage Form is made, the claimant or BENEFICIARY must give written notice of claim to THE COMPANY, a) by delivery thereof, or by sending it by registered mail to the head office; or b) by delivery thereof to an authorized agent of the company in the province, where the business is located as per the address on the schedule no later than thirty (30) days from the date a claim arises under this Coverage Form on account of a critical illness. Such notice and proof must be given to make a valid claim within ninety (90) days from the date a claim arises under this Coverage Form on account of a critical illness, furnish proof satisfactory to THE COMPANY of the DIAGNOSIS of the critical illness. 5.3 Failure to Give Notice or Proof Failure to give notice of claim or furnish proof of claim within the time prescribed by the above condition does not invalidate the claim if the notice or proof is given, or furnished as soon as reasonably possible, and in no event later than three hundred and sixty five (365) days from the date a claim arises under this Coverage Form if it is shown that it was not reasonably possible to do so within the time so prescribed. 5.4 Attending Physician Reports and Rights of Examination WE may, at OUR expense, request an attending physician s report and/or medical examination regarding the claim for benefits. No benefit will be paid until such medical evidence is obtained. 5.5 When Money is Payable All money payable under this Coverage Form will be paid by THE COMPANY within sixty (60) days after satisfactory proof of claim has been received. 5.6 Reserving Rights THE COMPANY reserves the right to: a) examine the full details regarding the claim; b) require YOU to undergo a medical examination; c) to disallow the claim based on information developed from the attending physician s report, medical examination, or other sources of pertinent data. 5.7 Limitations of Actions Any action or proceeding against THE COMPANY for the recovery of a claim under this Coverage Form will not be commenced more than one year after the date the insurance money became payable or would have been payable if it had been a valid claim. 5.8 Liability THE COMPANY will take no responsibility or liability for errors, omissions, or misadventure from a diagnostic procedure performed on a COVERED PERSON. WE take no responsibility to ensure that technicians, health care providers, or physicians performing diagnostic procedures are competent; have no outstanding criminal or civil proceedings against them, or whether they are in good standing with applicable licensing body. 5.9 Fraudulent Claims Any claims for benefits under the Coverage Form which is based on false or incorrect information on an application, claim form or other documents required to verify benefits will result in the benefits being denied or the liability assumed by the COVERED PERSON if the benefit has already been provided or performed. SECTION 6. TERMINATION 6.1 Termination of Coverage The COVERED PERSON S insurance coverage will terminate on the earliest of: a) the date YOU are no longer a COVERED PERSON; b) the date this Coverage Form terminates; c) the date the COVERED PERSON ceases to be covered by a provincial health insurance plan; d) the date the COVERED PERSON S FIRM no longer meets the definition of FIRM; e) the date of the COVERED PERSON S sixty-fifth (65th) birthday; 6.2 Termination by Us a) Subject to paragraph b. below, we may terminate this policy by giving to the first Named Insured (1) 5 days written notice of termination personally delivered, or (2) 15 days notice of termination by registered mail if termination is for non-payment of premium, or (3) 30 days notice of termination by registered mail if termination is for any other reason. Registered mail termination takes effect 15 or 30 days after receipt of the letter by the post office to which it is addressed, depending upon the reason for termination. b) To the extent that the Civil Code of the Province of Quebec is applicable to this policy General Conditions and Provisions as set out in the Civil Code of the Province of Quebec apply. Accordingly, we may terminate this policy by giving to the first Named Insured (1) 15 days notice of termination by registered mail if termination is for non-payment of premium, or (2) 30 days notice of termination by registered mail if termination is for any other reason.. Registered mail termination takes effect 15 or 30 days after receipt of the notice at the last known address of the first Named Insured, depending upon the reason for termination. c) The policy period will end on the date termination takes effect. d) If this policy is terminated, we will send the first Named Insured any premium refund due. If we terminate, the refund will be pro rata. If the first Named Insured terminates, the refund may be less than pro rata. The termination will be effective even if we have not made or offered a refund.

5 SECTION 7. GENERAL PROVISIONS 7.1 Administration We will deal solely with the FIRM who will be deemed the representative of each COVERED PERSON. Any action taken by the FIRM will be binding on the participating individuals. 7.2 Contract The Coverage Form and any amendment attached to it when issued or agreed upon in writing after this Coverage Form is issued constitute the entire contract and no agent has authority to change this Coverage Form or waive any of its provisions. 7.3 Currency All payments made to or by us under the policy will be in Canadian dollars. 7.4 Policy Changes Changes may be made in the Coverage Form only by amendment signed by US acting through our President, Vice President or Secretary. 7.5 Gender The male pronoun as used herein will be deemed to include the female. 7.6 Governing law This policy shall be governed by and interpreted in accordance with the laws of the Province or Territory of the COVERED PERSONS residence. 7.7 Misstatement of age If a COVERED PERSONS age has been misstated, the benefits available under the Coverage Form will be those which the premiums paid would have purchased for the correct age. 7.8 Misrepresentation and incontestability The Coverage Form will be void and our liability will be limited to the return of any premiums paid if incomplete, inaccurate, untrue or wrong information was submitted to US at any time and a claim arises under the Coverage Form during the first two (2) years from the RETROACTIVE DATE or two (2) years from most recent date of reinstatement.