Terms and Conditions Friends Life Group Protection Group Critical Illness Protection Scheme for Flexible Benefits. Reference BGR/5557/JUL11-2

Transcription

1 Terms and Conditions Friends Life Group Protection Group Critical Illness Protection Scheme for Flexible Benefits Reference BGR/5557/JUL11-2

2 Contents Page Definitions 3 1 The scheme benefit 6 2 Commencement of cover 3 Claims 7 4 Free cover level 8 5 Exclusions 6 Premiums 9 7 Amendment of cover terms 10 8 Termination 11 9 Other matters Notices Definitions of critical illnesses and operations covered 12 Associated conditions 18 2

3 Definitions The terms set out below are defined terms. Where they are used in bold in these terms and conditions they shall have the meaning set out below unless the context indicates otherwise. Where appropriate, the singular includes the plural, references to males include females and expressions defined in the definitions or elsewhere in the policy shall have the meanings respectively ascribed to them. Reference to any statutory provision shall be deemed to include any consolidation, modification, re-enactment or replacement or regulations thereunder made and in force from time to time. A reference to a person shall include an individual, a corporate body, a firm, association, partnership or trust. Actively at work An employee shall be actively at work if that person is present at their place of work and is mentally and physically capable of performing the normal duties required by the job for which they are employed; Agreed minimum The minimum number of members, as specified in the policy schedule; Associated condition Any medical condition, which is either; in the reasonable opinion of Friends Life s chief medical officer directly or indirectly linked with, or is likely to have led to the occurrence of a critical illness or operation; or listed in clause 12 of this policy; Benefit limit The maximum amount of member benefit payable by Friends Life as specified in the policy schedule; Bupa Health Assurance Limited Bupa Health Assurance Limited is a private company limited by shares, registered in England & Wales, No , registered office: Pixham End, Dorking, Surrey RH4 1QA. Bupa Health Assurance Limited is a part of the Friends Life group; Child Unless otherwise defined in the policy schedule shall mean the natural or legally adopted child or stepchild of a member and who is: (a) aged at least thirty days; and (b) younger than 18 years old; Child benefit The lower of 25% of the member benefit for each child of that member or 20,000 and calculated in accordance with the policy; Commencement date The date on which cover under the policy commences, as set out in the policy schedule; Cover start date In respect of a member: (i) (ii) the date or dates on which cover for a member will begin, or in respect of an increase in member benefit, the date on which that increase takes effect, and, if applicable (iii) the date or dates on which a member is re-admitted to the policy after receiving member benefit. In respect of a child, and if applicable, a partner: (i) (ii) the date or dates on which cover for a child or partner will begin, and, if applicable in respect of an increase in child benefit or member benefit, the date on which that increase takes effect. Critical illnesses and/or operations Where the policy schedule states the scheme type is a Standard Scheme those medical conditions or operations defined as a critical illness or operation in the Standard Scheme Conditions as set out in clause 11.1 of this policy; Where the policy schedule states the scheme type is a Comprehensive Scheme those medical conditions and operations defined as a critical illness or operation in the Comprehensive Scheme Conditions as set out in clause 11.2 of this policy; Total and permanent disability benefit as defined in clause 11.3 of this policy will be included as a critical illness and operation if total and permanent disability benefit is shown on the policy schedule on the basis specified there; 3

4 Employee An employee of an employer; Employer The principal employer or (to the extent applicable) any participating employer; Expiry age The age specified in the policy schedule at which a member will cease to be covered under the policy; Free cover level The level up to which member benefit will normally be provided to all members without medical underwriting, as specified from time to time in the policy schedule; Please Note: The way in which the free cover level operates is set out in clause 4. This clause specifies, amongst other things, when the free cover level may not apply and when it may apply only subject to pre-existing conditions; Friends Life cover Friends Life cover is provided by Bupa Health Assurance Limited, which is now part of the Friends Life group. Bupa Health Assurance Limited is a private company limited by shares, registered in England & Wales No Registered Office: Pixham End, Dorking, Surrey RH4 1QA; Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the U.K. at the time of the claim; Member An employee of the principal employer or any participating employer who: (a) fulfils the eligibility criteria for the scheme set out in the policy schedule; and (b) is ordinarily working in the United Kingdom; and (c) was actively at work, at the time and in accordance with the requirements set out in the policy schedule; and (d) is specified as a member by the policyholder; or (e) any other person who is an employee not fulfilling the above criteria or the spouse or partner of an employee who; (i) fulfils the eligibility criteria for such person set out in the policy schedule; and (ii) is specified as a member by the policyholder; or (iii) whose cover is otherwise agreed in writing by Friends Life, subject to any additional or amended terms as Friends Life may apply; Member benefit The agreed lump sum payable by Friends Life in the event that a member is diagnosed with or undergoes a critical illness or operation set out in the policy schedule subject to the benefit limit and calculated in accordance with the policy; Minimum premium level The minimum premium level specified in the policy schedule; Normal salary For an employee shall mean that employee s total basic annual salary (excluding benefits and bonuses) on the date immediately prior to the date a valid claim can first be made for a critical illness or operation in respect of the member or any child of the member or such other basis as may be set out in the policy schedule; and For a member who is not an employee shall mean the total basic annual salary (excluding benefits and bonuses) of the employee in respect to whom that member s cover under the policy relates on the date immediately prior to the date a valid claim can first be made by the member for a critical illness or operation; Partner Shall have the meaning given in the policy schedule; Participating employer Any employer (other than the principal employer) which is directly or indirectly controlled by or associated with the principal employer where; 4

5 (a) that employer has made an arrangement with the policyholder to be included in the scheme as a participating employer; and (b) Friends Life has agreed that employer may be covered under the policy as a participating employer (with written confirmation from Friends Life); Permanent Expected to last throughout the member s life, irrespective of when the cover ends or the member retires; Permanent neurological deficit with persisting clinical symptoms Symptoms of dysfunction in the nervous system that are present on clinical examination and expected to last throughout the member s life. Symptoms that are covered include numbness, hyperaesthesia (increased sensitivity), paralysis, localised weakness, dysarthria (difficulty with speech), aphasia (inability to speak), dysphagia (difficulty in swallowing), visual impairment, difficulty in walking, lack of coordination, tremor, seizures, lethargy, dementia, delirium and coma. The following are not covered: An abnormality seen on brain or other scans without definite related clinical symptoms Neurological signs occurring without symptomatic abnormality, e.g. brisk reflexes without other symptoms Symptoms of psychological or psychiatric origin; Policy This policy, which shall include the policy schedule, the terms and conditions together with any endorsements; Policyholder The holder of the policy for the time being; Policy schedule The details of cover in respect of the policy set out in the schedule to the policy as amended from time to time; Policy year In the case of the first such period, the period from (and including) the commencement date to (and including) the day before the first scheme anniversary date and thereafter each annual period from (and including) the scheme anniversary date to (and including) the day immediately preceding the next scheme anniversary date or the date of termination of the policy, if sooner; Pre-existing condition For any member shall mean any critical illness or operation covered by the policy which that member has suffered or undergone at any time prior to the member s cover start date; For any child shall mean any illness, condition, injury or operation which that child has suffered or undergone at any time prior to the cover on that child commencing; Premium The premium payable in respect of the policy calculated in accordance with the terms of the policy as charged from time to time; Premium guarantee period In the case of the first such period, the period from (and including) the commencement date and ending immediately before the first premium review date and thereafter a period from each premium review date to the day immediately before the succeeding premium review date; Premium review date The second scheme anniversary date and every second anniversary thereafter or such other dates agreed in writing by Friends Life and set out in the policy schedule; Principal employer The principal employer named in the policy schedule or any other company, firm, organisation, person or body of persons which succeeds the principal employer under the policy, and Friends Life acknowledges as having done so; Qualification date The date on which a person becomes a member; 5

6 Scheme anniversary date The annual review date set out in the policy schedule; Scheme benefit The maximum amount of member benefit capable of being paid under the policy for all members at the relevant time assuming a valid claim had been made under the policy for the full amount of member benefits; Single premium amount The premium notified by Friends Life to the principal employer for each member for a policy year. Unless the previous policy year ends on a premium review date Friends Life may only change the single premium rate used to calculate the premium for each member to reflect the change in that member s age, Friends Life shall only amend the single premium rate applicable for each age at a premium review date; Single premium rate The rate of premium used by Friends Life to calculate the single premium amount; Survival period 14 days commencing on the date of first diagnosis or undergoing surgery in respect of a critical illness or operation; Please note: For some critical illnesses and operations claims will not be payable for a period greater than the survival period. This will apply where specified in the definition for the critical illness and operation; Terms and conditions These terms and conditions reference BGR/5557/JUL11-2; Unit rate The rate of premium specified in the policy schedule as the unit rate as changed from time to time being the amount payable for every 1,000 of the amount of the scheme benefit during the policy year; Working day A day other than a Saturday or Sunday or a public holiday in England and Wales or in Scotland or Northern Ireland. 1 The scheme benefit 1.1 Friends Life will provide cover for each member equal to the member benefit and/or child benefit calculated in accordance with the policy. 1.2 Friends Life shall pay to the member in the event of; (a) that member being diagnosed with or undergoing one of the critical illnesses or operations during the policy year and surviving for the survival period the member benefit in respect of that member; or (b) a child of that member being diagnosed with or undergoing one of the critical illnesses or operations during the policy year and surviving for the survival period the child benefit in respect of that child. Child benefit shall only be paid to any member who is an employee. Payment is subject to; (i) the terms and conditions; and (ii) the policyholder having claimed such member benefit or child benefit and having complied with all its obligations under these terms and conditions (including, without limitation, all requests from Friends Life for information pursuant to clauses 3 and 6). Subject to clause 2.3 and 2.4 for a member, the member benefit or child benefit will only be payable once for each member or child. Scheme membership will cease once member benefit has been paid for a member. Please note: As part of the terms and conditions it is a requirement that before any claim will be paid the terms of the definition of the critical illness or operation must be met. These are the definitions set out in clause 11 and not any other definitions which may be used generally (including in some cases additional waiting periods). 2 Commencement of cover 2.1 Subject to these terms and conditions and the policy schedule, cover under the policy will begin on the commencement date and continue until determined in accordance with the policy. 2.2 Subject to these terms and conditions and the policy schedule cover for any member will begin on the cover start date and continue until determined in accordance with the policy. 6

7 2.3 An employee who has received member benefit may be re-admitted to membership at a later date, and treated as a new member from the date of such re-admission providing: (i) the individual meets the eligibility criteria for the policy; and (ii) the individual has returned to work following the payment of member benefit and has been actively at work for a continuous period of ten days; and (iii) member benefit was not paid in respect of the following critical illnesses or operations: Alzheimer s disease, coma, Creutzfeldt-Jakob disease, dementia, HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation, liver failure, loss of independent existence, motor neurone disease, progressive supranuclear palsy, systemic lupus erythematosus, total and permanent disability or traumatic head injury. The cover start date for any such member will be the date of re-entry to the policy and, for the avoidance of doubt, pre-existing conditions shall be determined on this basis. 2.4 A member who is not an employee may be re-admitted to membership on the basis set out in the policy schedule. 2.5 Where any member is re-admitted to membership the provisions of this clause 2.5 shall apply in addition to the other terms and conditions. The additional provision is that no child shall be covered under the policy from the date of re-admission where child benefit has been paid prior to that date for that child. 3 Claims Member benefit payment 3.1 The policyholder shall inform Friends Life of a member or his or her child being diagnosed with or undergoing one of the critical illnesses or operations as soon as practicable, and in any event within three months of first diagnosis or the undergoing of the operation. If written notice is not provided to Friends Life within three months of first diagnosis or the undergoing of the operation Friends Life shall not pay member benefit or child benefit where any evidence required is no longer available due to the lapse of time, in particular (but without being limited to) cases where an independent medical assessment does not provide substantive evidence to support the claim. 3.2 In order for a claim to be valid the following conditions must be satisfied: (a) the critical illness or operation for which member benefit or child benefit is being claimed must be on the list of critical illnesses and operations covered by the policy; and (b) the critical illness or operation must, in the reasonable opinion of Friends Life s chief medical officer, meet the definition for that critical illness or operation as set out in clause 11 of this policy; and (c) any diagnoses or medical opinions must be given by a medical specialist who is a consultant at a hospital in the UK, is acceptable to Friends Life s chief medical officer and is a specialist in an area of medicine appropriate to the cause of claim; and (d) the member or child must survive for the survival period. 3.3 The policyholder shall provide in respect of a member or child who is the subject of a claim such information as Friends Life may reasonably request, including, without limitation: (a) evidence of the member s membership and the earnings of the member where that member is an employee or of the employee to whom the members cover relates if not, (b) an original copy of the member s birth certificate (or child s birth certificate in the case of a claim for child benefit) (c) a claim form signed by the member and received by Friends Life as soon as possible and in any case within three months of first diagnosis or undergoing surgery (d) confirmation of survival of the survival period (e) medical evidence to confirm that the diagnosis or operation meets the definition of the critical illness or operation (f) in the case of a claim for total and permanent disability, a job description and a completed occupational questionnaire. 3.4 If the policyholder fails to comply with any of the provisions of this clause 3 in relation to any member or child then Friends Life shall be entitled to withhold payment until the relevant requirement has been fulfilled. 7

8 3.5 Friends Life shall not be liable for any error or omission arising directly or indirectly from any error in or omission from any data, information or evidence provided to it by the policyholder or member. 3.6 Friends Life shall be entitled to recover from the policyholder any overpayment of benefit which was the direct or indirect result of any incorrect data, information or evidence provided to it. 4 Free cover level 4.1 The benefit limit shall not be restricted by the free cover level for a particular member from the date where Friends Life has agreed in writing with the policyholder that it will provide cover in excess of the free cover level for that member. In such a case the benefit limit shall include the additional amount agreed in writing by Friends Life. 4.2 Where an application for cover which exceeds the free cover level has been submitted to Friends Life for a member, the benefit limit shall be limited by the amount applied for and 250,000, save as set out in clause 4.3 below, in place of the free cover level in respect of any claim in relation to that member between the date on which the application was notified to Friends Life and the earlier of: (a) the day being 90 days after the qualification date of that member or such other date as Friends Life may agree in writing for that member; and (b) the date from which Friends Life has agreed or declined to provide terms for a benefit limit in excess of the free cover level in respect of the relevant member; subject to the terms of the policy, including without being limited to, clause Where clause 4.2 applies, the benefit limit shall be the free cover level (or any previously agreed increase in excess of the free cover level) in respect of any member for whom an application for cover which exceeds the free cover level has been made and who has been accepted for cover under the policy on non-standard terms. 4.4 Any application made by the employer for a benefit limit in respect of a member which exceeds the free cover level shall be considered by Friends Life at its sole discretion and may result in exclusions, loadings, postponements, declinatures or additional terms and the policyholder shall provide to Friends Life in respect of each member such evidence of his health and other matters relevant to the assessment of risk as Friends Life may reasonably require. 4.5 The benefit limit shall not include the free cover level for any member where at any time following their qualification date; (a) the member was not within the eligibility criteria set out in the policy schedule which relates to them; or (b) the maximum amount of benefit payable in respect of that member agreed in writing by Friends Life was less than the free cover level; or (c) any application for additional cover for the member was considered by Friends Life and the application was declined; or the member was not actively at work, at the time and in accordance with the requirements set out in the policy schedule. 5 Exclusions 5.1 Friends Life will not be liable for any claim for member benefit or child benefit which directly or indirectly, in whole or in part arises out of or relates to a pre-existing condition. A pre-existing condition for a member is any critical illness or operation covered by the policy which the member has suffered or undergone at any time prior to the member s cover start date and for a child is any illness, condition, injury or operation which that child has suffered or undergone at any time prior to the cover start date for that child. 5.2 In addition to the provision in clause 5.1 Friends Life will not be liable for any claim for member benefit in respect of the following critical illnesses or operations where there is a direct or indirect link to a prior critical illness or operation. Blindness, coma, deafness, loss of independent existence, loss of speech, paralysis of limbs, terminal illness or total and permanent disability. 5.3 No claim for member benefit or child benefit will be paid in respect of cancer (as defined in clause 11) where that definition was met for a malignant tumour the member or child suffered at any time before the member or child were covered under the policy, whether the cancer is associated or connected to the previous cancer or not. For the avoidance of doubt where a member is re-admitted to membership under clause 2.3 the period of cover shall be deemed to begin on the date of re-admittance. 5.4 For the purposes of this clause, the onset or occurrence of aorta graft surgery, coronary angioplasty, coronary artery by-pass graft, heart attack, heart transplant, heart valve replacement or repair, stroke or valvuloplasty will all be considered to be directly linked. 8

9 5.5 Friends Life will not be liable for any claim for member benefit for any member, or child benefit for any child, for any critical illness or operation in respect of which any associated condition existed (whether diagnosed or not) at any time prior to the cover start date. This exclusion will not apply if: (a) at least two consecutive years have passed since the member s cover start date without the member or child (as appropriate) suffering a critical illness or operation; and (b) the claim is for a critical illness or operation other than loss of independent existence, paralysis of limbs, terminal illness and total and permanent disability. 5.6 Friends Life will not be liable for any claim for member benefit or child benefit which directly or indirectly, in whole or in part arises out of, relates to or occurs during any of the following: (a) inappropriate use of alcohol or drugs, including but not limited to the following: consuming too much alcohol taking an overdose of drugs, whether lawfully prescribed or otherwise taking Controlled Drugs (as defined by the Misuse of Drugs Act 1971) otherwise than in accordance with a lawful prescription; (b) unreasonable failure to seek or follow medical advice; (c) intentional self inflicted injury. 5.7 No claim will be paid in respect of a child of a member for the following critical illnesses and operations: (a) HIV infection - caught in the U.K. from a blood transfusion, a physical assault or at work in an eligible occupation (b) loss of independent existence (c) total and permanent disability. 5.8 No claim will be paid in respect of a member who is not an employee for the following critical illnesses and operations: (a) HIV/AIDS caught at work in an eligible occupation (b) total and permanent disability (c) children s benefit. 6 Premiums Premiums payable 6.1 The policyholder shall pay the premium to Friends Life for each policy year and the minimum premium payable for a policy year shall be the minimum premium level. Single premium amount schemes 6.2 If the costing basis shown in the policy schedule is the single premium basis, the premium the policyholder shall pay shall be calculated as a separate premium for each individual who is or becomes a member during the policy year and the premium payable for each member for the policy year shall be the single premium amount. 6.3 The policyholder shall pay in respect of the premium to be paid where clause 6.2 applies an amount on account for each individual who is a member at the commencement of the policy year. The amount shall be the sum equivalent to the premium that would be payable for the policy year if the individual remained a member for the whole of the policy year and the member benefit in respect of the member remained the same as at the commencement of the policy year. Unit rate schemes 6.4 If the costing basis shown in the policy schedule is the unit rate basis, the premium the policyholder shall pay shall be a single premium for all the individuals who are members during the policy year as a group. The premium shall be calculated applying the following formula: (a + b) x c where: 2000 a = the scheme benefit at the commencement of the policy year b = the scheme benefit at the end of the policy year c = the appropriate unit rate. 6.5 The policyholder shall pay in respect of the premium to be paid where clause 6.4 applies an amount on account. The amount on account shall be the amount of the premium that would be payable for the policy year if the scheme benefit in respect of the members remained the same as at the commencement of the policy year. 9

10 Premium adjustment 6.6 Friends Life shall at the end of the policy year, calculate the total amount due under clause 6.2 or 6.4 in respect of premiums for the whole of the policy year, taking into account, as appropriate, individuals who have become or ceased to be members and any changes to the scheme benefit during the policy year. If the total amount due is more than the total amount received on account the policyholder shall pay to Friends Life the amount of the difference and vice versa. Premium due dates 6.7 The payments on account in respect of each policy year shall, unless stated otherwise in the policy schedule, be payable in advance on the later of: (a) the working day which falls 30 days after the relevant premium (or estimate thereof) is notified by Friends Life to the policyholder; and (b) the commencement of the policy year. 6.8 If it is not possible for Friends Life to calculate the premium or payments on account (under clause 6.3 or 6.5) in respect of any policy year prior to the commencement of the policy year or within 30 days of the end of the policy year in the case of the premium, then Friends Life shall estimate the premium or payment on account on the basis of such information as it has in its possession and notify the policyholder accordingly. The policyholder shall pay such estimated amount as if it were the premium or payment on account as the case may be. When it is possible to calculate the premium or payment on account, Friends Life shall inform the policyholder of the actual premium or payment on account accordingly. Subject to clause 6.9 Friends Life shall refund any overpayment and any underpayment by the policyholder shall become due for payment within 30 days of notification by Friends Life to the policyholder of the relevant amount. 6.9 Friends Life may agree with the policyholder that any underpayment or overpayment pursuant to clause 6.6 or 6.8 shall be repaid or recouped by adjustment of the premium or estimated premium for the succeeding policy year Annual payments to Friends Life shall be made by cheque or by direct debit. Quarterly or monthly payments shall be made only by direct debit. Non-payment 6.11 If the policyholder fails to make any payment when due under the policy then, cover under the policy shall terminate with immediate effect, and all outstanding payments under the policy shall become due and payable. If the policyholder makes the outstanding payment which has given rise to a termination of cover under this clause within 30 days of the due date Friends Life may at its entire discretion reinstate cover If at any time the monthly or quarterly premium payable by the policyholder is reduced to less than the monthly or quarterly minimum premium level, Friends Life shall be entitled to require full payment for the policy year in advance. 7 Amendment of cover terms 7.1 The policyholder will immediately inform Friends Life, providing full details of: (a) any change in the identity of the principal employer; or (b) any addition to, or subtraction from, the participating employers; or (c) any material change in the nature of the business or undertaking of the principal employer or any participating employer. Changes to terms by Friends Life 7.2 Friends Life shall have the right to vary, modify or amend forthwith any term of the policy at any time during any premium guarantee period (including, without limitation the premium rate and free cover level) by notice to the policyholder if: (a) the number of members is reduced below the agreed minimum; or (b) the number of members at any time increases or decreases during a premium guarantee period by more than 25 per cent; or (c) the aggregate amount of the scheme benefit under the policy increases or decreases during a premium guarantee period by more than 25 per cent; or 10

11 (d) the policyholder has failed to comply to Friends Life s reasonable satisfaction with any request for additional information under the policy within 60 days of such request; or (e) there is any material change in the nature of the business or constitution of the principal employer or of any participating employer; or (f) there is any material change in law or practice of any governmental or statutory body (including without limitation rates of taxation and social security benefits or practice or any levy or charge under the Financial Services Compensation Scheme) which materially affects the cost to Friends Life of providing cover; or (g) there is any addition to or subtraction from the participating employers; or (h) there is any change in the identity of the principal employer. 7.3 The policyholder shall promptly notify Friends Life of any circumstance coming to their attention within any of the sub-clauses 7.2 (a) to (e) (inclusive) and 7.2 (g) to (h) and provide Friends Life with full details of the same. Changes on premium review 7.4 Prior to any premium review date the policyholder must provide such information as is reasonably requested by Friends Life to allow Friends Life to determine the terms on which cover may be provided. 7.5 In addition to the provisions set out in clause 7.2 and 7.8 Friends Life shall be entitled to vary, amend or modify any term of the policy (including, without limitation the premium rate, the free cover level and premium payment provisions) with effect from every premium review date. 7.6 Variations, amendments or modifications under clause 7.5 other than changes to the premiums payable or premium rates under the policy shall only affect cover under the policy in respect of persons who become members and increases in the level of member benefits after the changes take effect. 7.7 Friends Life will give notice to the policyholder of any variation, amendment or modification pursuant to clause 7.5 but, subject to clause 7.8, shall not be obliged to provide such notice prior to the relevant premium review date. Policyholder s right to terminate 7.8 Following notification by Friends Life of any variation, amendment or modification of a term of the policy the policyholder shall be entitled to terminate cover with immediate effect by notice given to Friends Life within 30 days of service of such notice from Friends Life subject to the terms and conditions of the policy which existed immediately prior to the giving of the notice by Friends Life or, in the case of a notice under clause 7.7 the premium review date on which the change would otherwise have taken effect. In the absence of service of a notice by the policyholder within 30 days, the policyholder will be deemed to have accepted the changes notified by Friends Life. Changes by Friends Life after the fifth anniversary 7.9 In addition to the provisions set out in clauses 7.2 and 7.5 Friends Life may at any time after the fifth anniversary of the commencement date vary, amend or modify any term of the policy (with the exception of the premium rate which shall only be modified in accordance with clause 7.5) Variations, amendments or modifications under clause 7.9 shall apply to all members with the exception of those in respect of whom a claim for member benefit has been made at the date the change applies Friends Life will give notice to the policyholder of any variation, amendment or modification pursuant to clause 7.9 at least 14 days before the date on which the changes are due to take effect. 8 Termination 8.1 Cover will terminate under the provisions of clause Termination by Friends Life 8.2 Cover under the policy may be terminated by Friends Life: (a) in any of the circumstances referred to in clauses 7.2(a), 7.2(d), and 7.2(e); (b) with immediate effect in respect of any or all members, by notice from Friends Life, if the policyholder has failed in its duty of utmost good faith by supplying misleading, incorrect or incomplete information to Friends Life or in respect of any member if that member has failed in said duty. 11

12 Termination by policyholder 8.3 Cover under the policy may be terminated by the policyholder: (a) under clause 7.8; (b) at any time by notice to Friends Life with immediate effect if Friends Life is in material breach of its obligations under the policy and such breach has not been remedied within 60 days of service by the policyholder of notice of such breach; (c) at any time provided that no less than 30 days prior written notice of such termination has been served by the policyholder on Friends Life. Continuation of claims 8.4 All valid claims, accepted by Friends Life as such, notified to Friends Life in respect of a member or child being diagnosed or undergoing a critical illness or operation prior to the date on which notice of termination is duly served in accordance with this clause 8 shall continue to be eligible for payment. Termination of membership 8.5 A member will cease to be covered under the policy on the earliest to occur of the following events: (a) on reaching the expiry age (unless otherwise agreed in writing by Friends Life); or (b) on the death of the member; or (c) a valid claim being paid under the policy in respect of the member unless re-admitted in accordance with clauses 2.4 and 2.5; (d) on the employee to whom the cover relates electing not to continue cover under the terms offered to them by the policyholder; (e) on the termination of the policy; (f) on their cover ending in accordance with clause Cover will cease under the policy for any member who is an employee and for any member whose cover is linked in any way to that employee on the earliest to occur of the following events: (a) on the employee retiring from service of the principal employer or any participating employer prior to the expiry age; (b) on the employee leaving the service of the principal employer or any participating employer; (c) on the expiry of the employee s contract of employment; (d) on the employee ceasing for any reason to be covered by the policy. 8.7 A child of a member will cease to be covered under the policy on the earliest to occur of the following events: (a) on the child s 18th birthday; or (b) on cover for the member ceasing; or (c) a valid claim being paid under the policy in respect of the child. 9 Other matters 9.1 All payments to be made by Friends Life under this agreement shall be payable in sterling at the address of Friends Life stated in Clause The receipt of any benefits payable under this policy by the policyholder or any person authorised by them for payment shall be a good discharge to Friends Life which shall not be concerned to see further to the discharge of such benefits. 9.3 The policy shall have no surrender value at any time. 9.4 The policy and/or any benefit payable under it shall be incapable of assignment by the policyholder without the prior written consent of Friends Life. 9.5 No benefit shall be payable under this policy by virtue of any statutory provision, governmental or regulatory restriction or rule of law which applies to it. 9.6 No variation or amendment of the terms of this policy shall be effective unless it is in accordance with the terms set out in this policy or as otherwise agreed in writing by or on behalf of the policyholder and Friends Life. 9.7 No failure or delay by Friends Life in exercising any right, power or privilege under this policy shall act as a waiver thereof or shall preclude the exercise by Friends Life of any other right or power available to it. 9.8 The policy and the agreement underlying it shall be governed by English law and the policyholder and Friends Life both submit to the exclusive jurisdiction of the English courts in all matters pertaining to it. 9.9 This contract is only capable of enforcement by the parties to it. No rights of enforcement or any other rights are given to any third parties, including those described in these conditions. 12

13 10 Notices 10.1 Any notice or other communication to be given or served under or in connection with this policy shall be in writing and shall be sufficiently served or given if delivered or sent: In the case of Friends Life to: Friends Life Group Protection 1st Floor, Crosswall, London EC3N 2JY Fax us on Marked for the attention of the Head of Group Protection In the case of the policyholder, to the last address of the principal employer correctly notified to Friends Life in accordance with this clause Any such notice or other communication shall be delivered by hand or sent by courier, fax or pre-paid first class post. If sent by courier or fax such notice or communication shall, in the case of service in the United Kingdom, conclusively be deemed to have been given or served 24 hours after the time of despatch (in the case of fax the time of despatch being the time on which the fax has been sent in readable form in its entirety), or 48 hours after despatch in the case of international service. If sent by pre-paid post such notice or communication shall, in the case of inland mail in the United Kingdom, conclusively be deemed to have been received 48 hours from the time of posting, or three days after despatch in the case of international mail. 11 Definitions of critical illnesses and operations covered 11.1 Standard scheme Alzheimer s disease resulting in permanent symptoms A definite diagnosis of Alzheimer s disease by a Consultant Neurologist, Psychiatrist or Geriatrician. There must be permanent clinical loss of the ability to do all of the following: remember; reason; and perceive, understand, express and give effect to ideas. For the above definition, the following are not covered: Other types of dementia. Cancer excluding less advanced cases Any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, lymphoma and sarcoma. For the above definition, the following are not covered: All cancers which are histologically classified as any of the following: pre-malignant; non-invasive; cancer in situ; having either borderline malignancy; or having low malignant potential. All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0. Chronic lymphocytic leukaemia unless histologically classified as having progressed to at least Binet Stage A. Any skin cancer other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin). Coronary artery by-pass grafts The undergoing of surgery on the advice of a Consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts. 13

14 Dementia resulting in permanent symptoms A definite diagnosis of dementia by a Consultant Neurologist, Psychiatrist or Geriatrician. There must be permanent clinical loss of the ability to do all of the following: remember; reason; and perceive, understand, express and give effect to ideas. For the above definition, the following are not covered: dementia secondary to alcohol or drug abuse. Heart attack of specified severity Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction: New characteristic electrocardiographic changes. The characteristic rise of cardiac enzymes or Troponins recorded at the following levels or higher; Troponin T > 1.0 ng/ml AccuTnI > 0.5 ng/ml or equivalent threshold with other Troponin I methods. The evidence must show a definite acute myocardial infarction. For the above definition, the following are not covered: Other acute coronary syndromes including but not limited to angina. Kidney failure requiring dialysis Chronic and end stage failure of both kidneys to function, as a result of which regular dialysis is necessary. Major organ transplant The undergoing as a recipient of a transplant of bone marrow or of a complete heart, kidney, liver, lung, or pancreas, or inclusion on an official UK waiting list for such a procedure. For the above definition, the following is not covered: Transplant of any other organs, parts of organs, tissues or cells. Motor neurone disease resulting in permanent symptoms A definite diagnosis of motor neurone disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function. Multiple sclerosis with persisting symptoms A definite diagnosis of multiple sclerosis by a Consultant Neurologist. There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least six months. Parkinson s disease resulting in permanent symptoms A definite diagnosis of Parkinson s disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function with associated tremor, rigidity of movement and postural instability. For the above definition, the following is not covered: Parkinson s disease secondary to drug abuse. Progressive supranuclear palsy resulting in permanent symptoms A definite diagnosis of progressive supranuclear palsy by a Consultant Neurologist. There must be permanent clinical impairment of eye movements and motor function. Stroke resulting in permanent symptoms Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in permanent neurological deficit with persisting clinical symptoms. For the above definition, the following are not covered: Transient ischaemic attack Traumatic injury to brain tissue or blood vessels Comprehensive scheme The Comprehensive scheme covers all the conditions and operations included under the Standard scheme in section 11.1, as well as the following (and no others). Aorta graft surgery for disease The undergoing of surgery for disease to the aorta with excision and surgical replacement of a portion of the diseased aorta with a graft. The term aorta includes the thoracic and abdominal aorta but not its branches. For the above definition, the following are not covered: Any other surgical procedure, for example the insertion of stents or endovascular repair. Surgery following traumatic injury to the aorta. Aplastic anaemia with permanent bone marrow failure A definite diagnosis of aplastic anaemia by a Consultant Haematologist. There must be permanent bone marrow failure with anaemia, neutropenia and thrombocytopenia. Bacterial Meningitis resulting in permanent symptoms A definite diagnosis of bacterial meningitis resulting in permanent neurological deficit with persisting clinical symptoms. For the above definition, the following are not covered: All other forms of meningitis other than those caused by bacterial infection. 14

15 Benign brain tumour resulting in permanent symptoms or removed via craniotomy A non-malignant tumour or cyst in the brain, cranial nerves or meninges within the skull, resulting in either of the following: permanent neurological deficit with persisting clinical symptoms or removal of the tumour by craniotomy (surgical opening of the skull). For the above definition, the following are not covered: Tumours in the pituitary gland. Angiomas. Benign spinal cord tumour A non-malignant tumour in the spinal canal or spinal cord, resulting in either of the following: permanent neurological deficit with persisting clinical symptoms or invasive surgery to remove the tumour. For the above definition, the following is not covered: Radiotherapy for any tumour. Blindness permanent and irreversible Permanent and irreversible loss of sight to the extent that even when tested with the use of visual aids, vision is measured at 3/60 or worse in the better eye using a Snellen eye chart. Cardiomyopathy of specified severity A definite diagnosis of cardiomyopathy by a Consultant Cardiologist. There must be clinical impairment of heart function resulting in the permanent loss of ability to perform physical activities to at least Class 3 of the New York Heart Association classification s of functional capacity*. For the above definition, the following are not covered: Cardiomyopathy secondary to alcohol or drug abuse. All other forms of heart disease, heart enlargement and myocarditis. * NYHA Class 3. Heart disease resulting in marked limitation of physical activities where less than ordinary activity causes fatigue, palpitation, breathlessness or chest pain. Coma resulting in permanent symptoms A state of unconsciousness with no reaction to external stimuli or internal needs which: results in permanent neurological deficit with persisting clinical symptoms. For the above definition, the following is not covered: Coma secondary to alcohol or drug abuse. Coronary angioplasty to two or more coronary arteries The undergoing of balloon angioplasty, atherectomy, laser treatment or stent insertion on the advice of a Consultant Cardiologist to correct at least 70% narrowing or blockage of two or more coronary arteries as a single procedure. Creutzfeldt-jakob disease resulting in permanent symptoms A definite diagnosis of Creutzfeldt-jakob disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function and loss of the ability to do all of the following: remember; reason; and perceive, understand, express and give effect to ideas. For the above definition, the following are not covered: Other types of dementia. Deafness permanent and irreversible Permanent and irreversible loss of hearing to the extent that the loss is greater than 95 decibels across all frequencies in the better ear using a pure tone audiogram. For the purposes of the above definition we shall use 1 decibel as the appropriate starting point from which the loss will be measured. Heart valve replacement or repair The undergoing of surgery including balloon valvuloplasty on the advice of a Consultant Cardiologist to replace or repair one or more heart valves. HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation Infection by Human Immunodeficiency Virus resulting from: a blood transfusion given as part of medical treatment; or a physical assault; or an incident occurring during the course of performing normal duties of employment from the eligible occupations listed below 1 ; requires the use of life support systems for a continuous period of at least 96 hours; and 15

16 after the start of the member s cover under the policy and satisfying all of the following: The incident must have been reported to appropriate authorities and have been investigated in accordance with the established procedures. Where HIV infection is caught through a physical assault or as a result of an incident occurring during the course of performing normal duties of employment, the incident must be supported by a negative HIV antibody test taken within five days of the incident. There must be a further HIV test within 12 months confirming the presence of HIV or antibodies to the virus. The incident causing infection must have occurred in the UK. For the above definition, the following is not covered: HIV infection resulting from any other means, including sexual activity or drug abuse. 1 Note: The eligible occupations for HIV infection caught at work are: the emergency services police, fire and ambulance the medical profession including administrators, cleaners, dentists, doctors, nurses and porters the armed forces. Liver Failure of advanced stage Liver failure due to cirrhosis and resulting in all of the following: permanent jaundice ascites encephalopathy. For the above definition, the following is not covered: Liver disease secondary to alcohol or drug abuse. Loss of hand or foot permanent physical severance Permanent physical severance of one or more hand or foot at or above the wrist or ankle joints. Loss of independent existence permanent and irreversible The permanent loss of the ability to perform routinely at least three of the following six activities of daily living, without the assistance of another person, even with the use of special devices or equipment. The activities of daily living are: 1. Washing - The ability to wash in the bath or shower (including getting into and out of the bath or shower) such that an adequate level of personal hygiene can be maintained. 2. Dressing - The ability to put on, take off, secure and unfasten all necessary garments and any braces, artificial limbs or other surgical appliances. 3. Transferring - The ability to move from a bed to an upright chair or wheelchair and vice versa, or to get on and off a toilet or commode. 4. Mobility - The ability to move indoors from one room to another on a level surface in the member s normal place of residence. 5. Continence - The ability to manage bowel and bladder functions such that an adequate level of personal hygiene can be maintained. 6. Feeding - The ability to feed oneself once food and drink has been prepared and made available. Loss of speech permanent and irreversible Total permanent and irreversible loss of the ability to speak as a result of physical injury or disease. Open heart surgery with surgery to divide the breastbone The undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a Consultant Cardiologist, to correct any structural abnormality of the heart. Paralysis of limbs total and irreversible Total and irreversible loss of muscle function to the whole of any limb. Respiratory Failure of advanced stage Advanced stage emphysema or other chronic lung disease, resulting in all of the following: The need for regular oxygen treatment on a permanent basis. The permanent impairment of lung function tests as follows; Forced Vital Capacity (FVC) and Forced Expiratory Volume at 1 second (FEV1) being less than 50 percent of normal. Rheumatoid arthritis chronic and severe A definite diagnosis of rheumatoid arthritis by a Consultant Rheumatologist resulting in all of the following: there must be morning stiffness in the affected joints of at least one-hour duration 16