Expect to understand your Women s Recover Plus Insurance
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- Helena Reynolds
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1 Expect to understand your Women s Recover Plus Insurance POLICY WORDING Women s Recover Plus Insurance Contents 1. The Policy 2. Who is offering this insurance? 3. Who is covered under this Policy? 4. Cover Start Date 5. What is the Anniversary Date of this Policy? 6. Expiry Date 7. Free look period 8. Insurance promise 9. Situations in which Cigna will not pay 10. Can the Life Insured enrol in more than one Policy? 11. Limitation of cover 12. The premium 13. End of Policy due to non-payment of premiums 14. Policy changes 15. End of insurance 16. Policy cancellation 17. Does the Policy have any surrender or cash value? 18. Currency, law 19. What evidence is required to make a claim? 20. How to register a complaint 21. Cigna s Financial Strength 22. Contact us 15/02/1550/01 CIG634 DATE 01/15 GADGET 8038
2 1. The Policy This Policy Wording and the Policy Summary (this Policy) describe the insurance contract between the Policy Owner (Life Insured) and Cigna Life Insurance New Zealand Limited (Cigna). In return for premium payments, Cigna insures the Life Insured named on the Policy Summary under the terms and conditions set out in this Policy Wording. 2. Who is offering this insurance? This insurance product is offered by TSB Bank Limited (TSB Bank) and underwritten by Cigna. TSB Bank receives a commission for arranging Women s Recover Plus Insurance. TSB Bank does not guarantee the obligations of Cigna. If Cigna refuses a claim TSB Bank will not be liable. 3. Who is covered under this Policy? In order to be covered under this Policy a person must be: between the ages of 18 and 60 at the Cover Start Date; and named on the Policy Summary as the Life Insured. 4. Cover Start Date The Cover Start Date is the date that Cigna receives the fully completed application or acceptance over the telephone and: a fully completed direct debit authority; or credit card details; or the first half-yearly or yearly premium payment if payments are to be made by cash or cheque. 3 1
3 5. What is the Anniversary Date of this Policy? The Anniversary Date is 12 months after the Cover Start Date, as set out in the Policy Summary, and the same date every following year. a covered Cancer other than Cancer Specific to Women; or a covered Coronary Artery Disease requiring Bypass Surgery; or a covered Heart Attack; or a covered Stroke, as defined under Definitions below, provided that: 6. Expiry Date The Expiry Date is the date this Policy expires, as set out in the Policy Summary. 7. Free look period There is a 30 day free look period in which this Policy may be cancelled by advising Cigna. Cigna will provide a full refund of any premiums paid within the free look period and will provide written confirmation that this Policy has been cancelled. 8. Insurance promise Subject to the terms and conditions of this Policy, Cigna promises to pay the Life Insured the following benefits: 8.1 Cancer Specific to Women Benefit Payment of a one-off benefit following first diagnosis of a covered Cancer Specific to Women, as defined under Definitions below, provided that: the Life Insured survives 14 days after diagnosis of the covered Cancer Specific to Women; and this Policy is in force at the time of the diagnosis. On payment of a Cancer Specific to Women Benefit, the Cancer Specific to Women cover will cease. 8.2 Major Illness Benefit Payment of a one-off benefit following first diagnosis of: the Life Insured survives 14 days after diagnosis of the Major Illness; and this Policy is in force at the time of the diagnosis. On payment of a Major Illness Benefit, the Major Illness cover will cease. 8.3 Cash Assist Benefit A Cash Assist Benefit will be paid to the Life Insured for a claim made within six months of the date that Cigna paid the Cancer Specific to Women Benefit under this Policy where, solely as a direct result of a covered Cancer Specific to Women the Life Insured: worked for 15 hours or more per week in paid work continuously for at least six months prior to the date of diagnosis and is unable to continue in paid work for at least 15 hours or more per week; or did not work, or worked less than 15 hours per week in paid work at the date of diagnosis and cannot carry out her normal domestic duties because she is confined to bed for at least 18 hours each day, on the advice of a registered medical practitioner approved by Cigna, and she requires assistance from another person to undertake her domestic duties. The Cash Assist Benefit is payable for each complete month that the Life Insured is unable to work or is confined to bed (as detailed above) for up to a maximum of six consecutive months. However, if the Life Insured dies while receiving a Cash Assist Benefit, the Benefit will end. 2 3
4 8.4 Definitions Cancer means the presence of one or more malignant tumours. The malignant tumour is to be characterised by the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue for which major interventionist treatment or surgery (excluding endoscopic procedures alone) is considered medically necessary. The following types of Cancer are specifically excluded: carcinoma in situ (including cervical dysplasia CIN1, CIN2, and CIN3), or tumours which are histologically described as pre-malignant. Carcinoma in situ of the breast is included where it leads to the removal of the breast by a mastectomy. The procedure must be performed as a direct result of the carcinoma in situ and specifically to arrest the spread of malignancy, and be considered the necessary and appropriate treatment; all skin cancers, including hyperkeratoses, squamous or basal cell carcinomas, unless there is evidence of metastases; malignant melanomas of less than 1.5mm maximum thickness as determined by histological examination using the Breslow method; papillary micro-carcinoma of the thyroid or bladder; chronic lymphocytic leukaemia less than Rai Stage 3; Kaposi s sarcoma and other tumours associated with AIDS or the HIV virus, unless they are the result of medically or occupationally acquired HIV. Cancer Specific to Women means Cancer where the primary site is: Breast Cancer arising in epithelial or supporting breast tissue and spreading locally to surrounding tissue; Cervix Cancer arising in the cervical epithelium but extending into and beyond the underlying stroma; Fallopian Tube Cancer arising in the fallopian tube; Ovary Cancer arising in the ovary; Uterus Cancer arising in the lining or wall of the uterus; Vulva or Vagina Cancer arising in the epithelium of the vulva or vagina. Coronary Artery Disease requiring Bypass Surgery means the open heart surgical grafting of a bypass to a coronary artery to overcome narrowing or obstruction. Heart Attack means the death of a portion of heart muscle arising from inadequate blood supply to the relevant area. The diagnosis must be supported by the following criteria being present, and consistent with a Heart Attack: clinical features; and confirmatory new electrocardiogram (ECG) changes; and diagnostic elevation of cardiac enzyme CK-MB or an elevation of Troponin of 5 times the upper limit of normal. HIV - Medically Acquired means the accidental infection with the Human Immunodeficiency Virus (HIV) which Cigna believes, on the balance of probabilities, arose from one of the following medically necessary events which must have occurred to the Life Insured, in New Zealand or Australia, by a recognised and registered health professional: a blood transfusion; transfusion with blood products; organ transplant to the Life Insured; assisted reproductive techniques; or a medical procedure or operation performed by a doctor. HIV infection transmitted by any other means including any sexual activity or recreational intravenous drug use is excluded. 4 5
5 Notification and proof of the incident will be required via a statement from a District Health Board or equivalent statutory body confirming that the infection was medically acquired. HIV - Occupationally Acquired means infection with the Human Immunodeficiency Virus (HIV) where the HIV was acquired as a result of: an accident arising out of the Life Insured s normal occupation; or a malicious act of another person or persons arising out of the Life Insured s normal occupation; and sero-conversion to HIV occurs within 6 months of the accident or malicious act. HIV infection transmitted by sexual activity or recreational intravenous drug use is excluded. Any incident giving rise to a potential claim must be: reported to the relevant authority or employer within 7 days of the incident; reported to Cigna with proof of the incident within 7 days of the incident; and supported by a negative HIV Antibody test taken within 7 days of the incident. Stroke means cerebrovascular incident being diagnosed as an infarction of brain tissue, by thrombosis, haemorrhage or embolisation from an extracranial source producing permanent neurological sequelae and causing at least a 25% impairment of whole person function which is permanent. Evidence of a permanent neurological deficit must be produced and confirmed by a consultant neurologist. Transient ischaemic attacks (TIA), or vascular accidents affecting solely the eyes, or neurologic deficits due to migraines, physical head injury, or any blood vessel outside the cranium except embolism resulting in stroke are excluded. 9. Situations in which Cigna will not pay Cigna will not pay any benefit under this Policy, or will only pay the benefit in force before any upgrade in cover if: the Life Insured s condition is directly or indirectly caused or contributed to by: - any condition or symptom of a condition which existed or for which she had, or should reasonably have, received medical treatment or advice from a registered medical practitioner before the Cover Start Date, or the date of any subsequent upgrade in cover; or - any condition or symptom of a condition that first occurs within three months of the Cover Start Date or the date of any subsequent upgrade in cover; or - the Life Insured dies within 14 days of diagnosis of a covered condition. 10. Can the Life Insured enrol in more than one Policy? The Life Insured cannot be covered under more than one Women s Recover Plus Policy. If this occurs, Cigna will consider the Life Insured to be insured under the first Policy issued and premiums will be refunded for the other Policy. 11. Limitation of cover If the Life Insured has a Cancer Specific to Women or Major Illness claim accepted by Cigna under this Policy and also has cover under any other Policy held with Cigna with similar Cancer Specific to Women or Major Illness benefits, then the maximum sum payable for such claim will be the lesser of: the maximum sum insured in respect of all such policies equal to the combined sums insured specified in each applicable Policy Summary; and $1,000,
6 12. The premium The initial premium is set out in the Policy Summary. Half-yearly or yearly premiums may be paid by cash, cheque, direct debit from a bank account or by deduction from a credit card. Monthly premiums may be paid by deduction from a credit card or direct debit from a bank account. The Life Insured may change the method and frequency of premium payments by advising Cigna. Premiums will increase on the Anniversary Date following the Life Insured s attainment of the following ages: 25 years 30 years 35 years 40 years 45 years 50 years 55 years 60 years Before each Anniversary Date, Cigna will send the Life Insured a written notice advising her of the amount of premium required to be paid for the coming year. Apart from these increases, if the premium is going to change the Life Insured will be given 14 days written notice. All notices will be mailed to the most recent address that Cigna has on record for the Life Insured. It is the Life Insured s responsibility to maintain current address details with Cigna. 13. End of Policy due to non-payment of premiums This Policy will end if premiums remain unpaid for three months after the date that the premium was due. Cover under this Policy will end from the date the last premium was paid up to. 14. Policy changes Cigna can change the insured events and exclusions of this Policy if it is reasonably necessary to protect Cigna s legitimate business interests. For example (but not limited to): if changes in the law or its interpretation occur after the Cover Start Date and Cigna reasonably believes that those changes will affect their tax liability, or how the Policy works, or the amount of benefit payable if claims experience across all Women s Recover Plus insurance policies becomes significantly adverse. In such case Cigna can change the provisions of the Policy or benefits in whatever way they reasonably decide is necessary to protect their legitimate business interests. The Life Insured will be given at least thirty days written notice in advance of any such change. 15. End of insurance This Policy ends when one of the following occurs: Cigna pays a Cancer Specific to Women Benefit and Major Illness Benefit claim; or premiums have not been paid as set out above; or the TSB Bank account to which premiums were charged is closed and the Life Insured has not made other suitable payment arrangements with Cigna; or the Expiry Date is reached; or the Life Insured dies. 16. Policy cancellation The Life Insured may cancel this Policy at any time by advising Cigna. 8 9
7 Cigna may cancel all policies by giving 90 days notice in writing to the Life Insured. The notice will be mailed to the most recent address Cigna has on record for the Life Insured. 17. Does the Policy have any surrender or cash value? This Policy does not accrue any surrender or cash value. 18. Currency, law All payments made in respect of this Policy will be in New Zealand currency. Any dispute or action in connection with this Policy shall be determined in accordance with New Zealand law. 19. What evidence is required to make a claim? To make a claim under this Policy the Life Insured must complete a claim form provided by Cigna and return it together with evidence, satisfactory to Cigna, to support the claim. For a Cancer Specific to Women Benefit or Major Illness Benefit claim, the Life Insured will be required to provide documentation including, but not limited to: a written diagnosis and prognosis by two unaffiliated registered medical practitioners satisfactory to Cigna; and supporting evidence, including radiology, histology or laboratory reports. For a Cash Assist Benefit claim, the Life Insured will be required to provide documentation confirming that she is either: unable to return to work; or All evidence in support of a claim required by Cigna is to be provided at the Life Insured s expense. All medical information must be provided by an appropriate medical practitioner registered in New Zealand or Australia (or any other country approved by Cigna). Cigna s medical advisers must support the occurrence of a covered condition and may require the Life Insured to undergo an examination or other reasonable tests to confirm the occurrence of a covered condition. 20. How to register a complaint If you have a complaint we are happy to discuss it. Please contact us on the TSB Bank Cigna Insurance Helpline on (or if you are calling from outside New Zealand), or us on complaintsandquality.nz@cigna.com. Our Customer Service team will do their best to resolve your issue straight away. However, if they can t sort out the issue, our dedicated Customer Resolution Consultants will personally take on your case. Also, Cigna is a member of the Insurance and Savings Ombudsman (ISO) scheme, a free, independent service which can help settle any dispute you are unable to resolve with us. Any dispute or action relating to your policy will be determined in accordance with New Zealand law. ISO contact details Post PO Box , Wellington 6143 Phone info@iombudsman.org.nz Website confined to bed for at least 18 hours per day
8 21. Cigna s Financial Strength A copy of Cigna s latest financial statements is available on request. We are required under the Insurance (Prudential Supervision) Act 2010 to establish a statutory fund. The statutory fund relevant to your policy is Cigna s Statutory Fund Number One. Cigna Life Insurance New Zealand Limited has an A- (Excellent) financial strength rating which was given by A.M. Best Company Inc. The rating scale is: Secure Vulnerable A++, A+ Superior B, B- Fair 22. Contact us Cigna Life Insurance New Zealand Limited Phone Fax contactus.nz@cigna.com For general information about your Policy, including premiums, address changes etc. claims.nz@cigna.com To request a claim form or ask any questions related to a claim Postal address Cigna Life Insurance P O Box Wellington 6142 A, A- Excellent C++, C+ Marginal B++, B+ Good C, C- Weak D E F S Poor Under regulatory Supervision In Liquidation Suspended For more rating information visit 12
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