Total Care Plan. Policy Document

Transcription

1 Total Care Plan Policy Document This document is an agreement between you and The Colonial Mutual Life Assurance Society Limited ABN AFSL (CMLA). This document is issued by The Colonial Mutual Life Assurance Society Limited, Level 12, 52 Martin Place, Sydney NSW 2000.

2 Important information The Colonial Mutual Life Assurance Society Limited ABN AFSL (CMLA) (the Insurer) is a wholly-owned subsidiary of the Commonwealth Bank of Australia ABN Commonwealth Bank of Australia and its subsidiaries do not guarantee the obligations or performance of the Insurer or the products it offers. CommInsure is a registered business name of CMLA. For the purposes of this document, the terms we, our and us will refer to CMLA, the Life Company issuing the life insurance Policy.

3 Contents Some information about this Policy 2 Overview 2 Worldwide cover 2 Premiums 2 Upgrade provision 2 Policy conditions 3 1. Interpreting this Policy Document 3 2. Important definitions 5 3. Benefits Life Care (death cover) Life Care Advance Payment Benefit Life Care Loyalty Bonus Benefit Life Care Severe Hardship Booster Benefit Terminal Illness Benefit Guaranteed Insurability Option (Personal Events) Guaranteed Insurability Option (Business Events) and Business Safe Cover Option 3.8 Accidental Death Cover Trauma Cover Trauma Cover Loyalty Bonus Benefit Trauma Cover Severe Hardship Booster Benefit Trauma Cover Buy Back Benefit Evidence of Severity Option Child Cover Option Total and Permanent Disability Cover (TPD Cover) 3.16 TPD Cover Loyalty Bonus Benefit TPD Cover Severe Hardship Booster Benefit Option to take out death cover Death Benefit Plan Protection Option (waiver of premium while disabled) 3.21 Life Care Buy Back Benefit Financial Planning Benefit Accommodation Benefit Indexation and premiums Automatic Indexation Policy premiums Charges Payment of premiums Reinstatement Claims Trauma Cover Policy definitions

4 Some information about this Policy Overview Total Care Plan is a comprehensive insurance policy with three important elements: Life Care, which pays a lump sum in the event of death or Terminal Illness Trauma Cover, which pays a lump sum on the occurrence of a specified medical condition, and Total and Permanent Disability Cover (TPD Cover), which pays a lump sum on Total and Permanent Disablement. If Life Care applies under this Policy, the amount of any Trauma Cover or TPD Cover cannot exceed the amount of the Life Care. Worldwide cover Unless this Policy provides otherwise, it covers you 24 hours a day anywhere in the world. Premiums The cost of the Total Care Plan Policy issued to you is based on the Insured Person s age, health, gender, whether or not they smoke, any sporting or recreational activities in which they participate and the type and level of insurance selected. The Insured Person s occupation may also affect the cost of cover. Generally, the cost of cover increases as the Insured Person gets older unless the Level Premium Rate Option applies and the Policy Anniversary Date preceding the Insured Person s 65th birthday has not occurred. Tables of premium rates are available on request. Premiums are payable annually in advance and can also be paid in monthly, quarterly or half-yearly instalments by a method approved by us. The Policy may be cancelled if premiums are not paid within 30 days of the Premium Due Date. Future premium rates are not guaranteed to be the same as current rates. We reserve the right to change these for all policies in a group. Premiums for all benefits outlined in this Policy will be placed in the Life Company s No.5 Statutory Fund and insurance claims will be paid from that fund. The Total Care Plan does not acquire a surrender or cash-in value at any point. Upgrade provision Future versions of this product may be introduced. If this happens, all policies in a group will be upgraded to include the improved terms and conditions within a reasonable time frame (generally on the next Policy Anniversary Date), but only if no policy in that group will be disadvantaged. Improved terms and conditions may not apply in respect of any pre-existing conditions at the time the improvement took place. 2

5 Policy conditions 1. Interpreting this Policy Document This Policy is a contract This Policy is a contract that consists of: the application form on which you applied for this Policy any other documents which you have signed for the purpose of this Policy the Policy conditions in this document the latest Policy Schedule we have issued for this Policy, and any document we have issued which records an authorised variation to this Policy. Alterations and variations No change to this Policy will be valid unless we confirm the change in writing. Assignment You may assign (transfer) the ownership of this Policy by completing the attached Memorandum of Transfer and having the assignment registered by us. Confirmation of Electronic Application and Personal Statement If you applied for this Policy electronically via our online application facility, this Policy terminates at midnight on the Termination Date unless: we receive, on or before the Termination Date, a Confirmation of Electronic Application and Personal Statement ( the Confirmation ) in respect of your application for this Policy, and the Confirmation received by us is in the oral or written form, and provided by you and such other person or persons, required by us where the Termination Date is the 30th day after the Date Insured From. Cancellation of an existing Policy If the Special Provisions section of your Policy Schedule indicates that this Policy is to replace existing cover that insures the Insured Person, your cover under this Policy is conditional on that existing cover being cancelled before the occurrence of an insured event under the existing cover. Until this cancellation occurs, you will not be covered under this Policy despite any provision in it to the contrary. If your cover under this Policy exceeds the existing cover to be replaced, this condition will not apply to the cover under this Policy to the extent that it exceeds the existing cover. Changes in the law We may immediately vary any of the terms and conditions of this Policy, including premiums, if there is a material change to the law and as a result: it becomes impossible or impractical to carry out our obligations under the Policy the basis of taxation of CMLA or this Policy is changed government levies relating to CMLA or this Policy are imposed or changed, or the provisions of the Policy would otherwise become inconsistent with the law. This condition does not apply to the extent that it would prevent the Policy from being treated as life insurance business under the Life Insurance Act 1995 (or any legislation that replaces it). Cooling-off period From the date we issue this Policy you have 28 days to check that it meets your needs. This is known as the cooling-off period. Within this time you may cancel the Policy and receive a full refund of any premiums (and charges) paid. If you wish to cancel, we ask that you put your request in writing and send it to us with this Policy Document and your Policy Schedule. Currency All payments made in connection with this Policy, whether to us or by us, must be made in Australian currency. Guaranteed renewable Provided premiums are paid within 30 days of the Premium Due Date and we receive the Confirmation if required under this Policy, this Policy will remain in force until all cover under it ceases and we cannot cancel this Policy, increase the premium rates for this Policy or place any further restrictions on the cover presently provided by this Policy as a result of: the number of claims made under this Policy or any change in the Insured Person s state of health, occupation or pastimes. Legal interpretation This Policy is subject to and governed by the laws of the State of New South Wales. Notices Any notice you give to us under this Policy must be given to us in writing. Any notice which we give to you must also be given in writing, and will be effective if it is delivered personally, or delivered to or posted to the address last known to us. Policy Schedule The Policy Schedule contains the individual details of your Policy and must be read in conjunction with these Policy conditions. References In this Policy Document a reference to you or your is a reference to the person whose name appears in the Policy Schedule as the Policy Owner. Where the context permits, it also includes the person whose name appears in the Policy Schedule as the Life Insured or Child Life Insured. However, in the context of any payment we make to you, or any changes you request regarding the Policy, you and your only refers to the Policy Owner. 3

6 Policy conditions Superannuation policies If you hold this Policy subject to the trusts of a superannuation fund, you agree to operate the superannuation fund at all times in accordance with the trusts of the fund and in a manner which ensures that it complies with the Superannuation Industry (Supervision) Act You also agree to notify us if at any time the Policy ceases to be subject to the trusts of the superannuation fund, or the fund ceases to be administered in accordance with its trusts, or it ceases to comply with the Superannuation Industry (Supervision) Act Should any of these events happen we may terminate the Policy and issue a replacement Policy, or make any changes to the terms and conditions of the Policy as we consider appropriate. There may be situations where, even though a claim is admitted by the Insurer and payment is made to the trustee of a complying superannuation fund, legislation or the rules of the fund may prevent the release of the benefit. 4

7 2. Important definitions Accidental Death Cover Accidental Death Cover is the benefit payable on the death of the Life Insured as a result of an Accident. The amount of the benefit is that shown in the Policy Schedule together with any increases as a result of Automatic Indexation. Annual Premium This is the Annual Premium specified in the Policy Schedule and includes the premiums for the benefits attached to this Policy and the Policy Fee. Automatic Indexation Unless otherwise specified, on each Policy Anniversary Date we will index your benefits in line with the movement in the Consumer Price Index. Automatic Indexation is explained in detail on page 24. Child Cover Child Cover is the benefit payable under the Child Cover Option if the Child Life Insured dies or suffers from a Child Trauma Cover condition covered by this Policy. The amount of the benefit is that shown in the Policy Schedule together with any increases as a result of Automatic Indexation. Child Cover Expiry Date The Policy Anniversary Date preceding the Child Life Insured s 18th birthday. Child Life Insured The Child Life Insured is the person on whose life a benefit is payable under the Child Cover Option. The Child Life Insured s name appears on your Policy Schedule. Cover Expiry Date The date (if any) shown as such in the Policy Schedule, being the date when all cover for an Insured Person ends under this Policy. Date Insured From This is the date, shown on your Policy Schedule, from which your Policy becomes effective. Day One Condition A condition which is Cardiomyopathy, Primary Pulmonary Hypertension, Major Head Trauma, Motor Neurone Disease, Multiple Sclerosis, Muscular Dystrophy, Paraplegia, Quadriplegia, Hemiplegia, Diplegia, Tetraplegia, Dementia and Alzheimer s Disease, Parkinson s Disease, Blindness, Loss of Speech, Loss of Hearing, Chronic Lung Disease or Severe Rheumatoid Arthritis (as these conditions are defined in condition 6). Immediate Family Member An Immediate Family Member includes a spouse, de facto spouse, parent, parent-in-law, sibling and a child. Injury An accidental bodily injury occurring while this Policy is in force. Insured Person A Life Insured or, if applicable, a Child Life Insured. Life Care Life Care is the benefit payable on the death of the Life Insured. The amount of the benefit is that shown in the Policy Schedule together with any increases as a result of Automatic Indexation. Life Insured The Life Insured is the person on whose life Life Care, Total and Permanent Disability (TPD) Cover, Trauma Cover or Accidental Death Cover benefits are payable. The Life Insured s name appears on your Policy Schedule. A Life Insured does not include a Child Life Insured. Medical Practitioner A registered medical practitioner other than you, the Life Insured or an Immediate Family Member or business partner of you or the Life Insured. For the purpose of this definition, a registered medical practitioner is a legally qualified medical practitioner whose credentials have been formally accepted by the Medical Authority of the Australian state or territory in which he or she practises as a medical practitioner and who is registered by that Medical Authority to carry out the duties of a medical practitioner according to the rules set by the Medical Authority. A Medical Authority is the registered authority, board, association or body which has the power to authorise or license a person to practise as a medical practitioner in the relevant Australian state or territory. Nominated Beneficiary A natural person, corporation or trust nominated by you to receive any money payable under the Life Care benefit or Accidental Death Cover. Nominated Beneficiaries are explained on page 8 of this Policy. Occupation Occupation means the full-time gainful occupation of the Life Insured immediately prior to Total and Permanent Disablement or Total and Temporary Disability, as applicable. Policy Anniversary Date The date on which your Policy s annual review will take place and from which your premiums are calculated. The Policy Anniversary Date will fall on each anniversary of the Date Insured From shown in the Policy Schedule. Premium Due Date Premiums are payable annually in advance and are due on the Date Insured From and on each Policy Anniversary Date. Each of these dates is a Premium Due Date. Premiums can also be payable in monthly, quarterly or halfyearly instalments by a method approved by us. If we agree to accept the premium in instalments, the date that an instalment is due to be paid is a Premium Due Date. Qualifying Period The Qualifying Period is for the Trauma Cover benefit and the Child Cover benefit and any increases in those benefits other than by Automatic Indexation. 5

8 Policy conditions Sickness An illness or disease that becomes apparent while this Policy is in force. Terminally Ill The Life Insured is suffering from a disease or condition which in the opinion of an appropriate specialist Medical Practitioner and, where we consider appropriate, supported by our chief medical officer, will lead to his or her death within twelve months. Total and Temporary Disability Disability resulting from Sickness or Injury that has caused the Life Insured to be continually and significantly unable to perform his or her Occupation for a period of three consecutive months. The Life Insured is not Totally and Temporarily Disabled if he or she is or has been, during that period, engaged in any occupation for wage or profit. The Life Insured must have been throughout the three month period, and must continue to be, under the regular care and attendance of, or following treatment prescribed by, a Medical Practitioner. Total and Permanent Disability Cover (TPD Cover) TPD Cover is the benefit payable on the Total and Permanent Disablement of the Life Insured. The amount of the benefit is that shown in the Policy Schedule together with any increases as a result of Automatic Indexation. Total and Permanent Disablement Total and Permanent Disablement Own Occupation If the words Own Occupation appear on your Policy Schedule then Total and Permanent Disablement means that: the Life Insured has been absent from active employment as a result of Sickness or Injury for a period of three consecutive months and at the end of the three months, the Life Insured continues to be incapacitated to such an extent that he or she will be unlikely to engage in his or her own Occupation ever again, and is under regular treatment, and following the advice, of a Medical Practitioner the Life Insured has been absent from active employment as a result of a Day One Condition and the Life Insured continues to be incapacitated to such an extent that he or she will be unlikely to engage in his or her own Occupation ever again and is under the regular treatment, and following the advice, of a Medical Practitioner the Life Insured has suffered Loss of Limbs or Sight (as defined in condition 6), or the Life Insured has suffered Loss of Independent Existence (as defined in condition 6). If, however, the Life Insured has been engaged in full-time domestic duties or child rearing at the time of the Sickness or Injury that causes Total and Permanent Disablement, then Total and Permanent Disablement means the Life Insured: has been, through Sickness or Injury, unable to perform domestic duties or child rearing and has been confined to the home for a period of three consecutive months and is under the regular treatment, and following the advice, of a Medical Practitioner, and continues to be so incapacitated to the extent that he or she is unable to engage in (whether or not for reward) any occupation for which he or she is reasonably suited by education, training or experience and is likely to be so disabled for life has been unable to perform domestic duties or child rearing and confined to the home as a result of a Day One Condition and is under the regular treatment, and following the advice, of a Medical Practitioner, and continues to be so incapacitated to the extent that he or she is unable to engage in (whether or not for reward) any occupation for which he or she is reasonably suited by education, training or experience and is likely to be so disabled for life or has suffered Loss of Limbs or Sight (as defined in condition 6), or has suffered Loss of Independent Existence (as defined in condition 6). Total and Permanent Disablement Any Occupation Where the words Any Occupation appear on your Policy Schedule, then Total and Permanent Disablement means the Life Insured: has been absent from active employment as a result of Sickness or Injury for a period of three consecutive months and has throughout that time been unable to engage in any occupation: for which he or she is reasonably suited by education, training or experience, and which would pay remuneration at a rate greater than 25% of the Life Insured s earnings during his or her last consecutive 12 months of work, and is under the regular treatment, and following the advice, of a Medical Practitioner and is likely to be so disabled for life has been absent from active employment as a result of a Day One Condition and is unable to engage in (whether or not for reward) any occupation for which he or she is reasonably suited by education, training or experience and is under the regular treatment, and following the advice, of a Medical Practitioner and is likely to be so disabled for life has suffered Loss of Limbs or Sight (as defined in condition 6), or has suffered Loss of Independent Existence (as defined in condition 6). If the Life Insured has been engaged in full-time domestic duties or child rearing at the time of the Sickness or Injury that causes Total and Permanent Disablement then Total and Permanent Disablement means the Life Insured: has been through Sickness or Injury unable to perform domestic duties or child rearing and confined to the home for a period of three consecutive months and is under the regular treatment, and following the advice, of a Medical Practitioner, and continues to be so incapacitated to the extent that he or she is unable to engage in (whether or not 6

9 for reward) any occupation for which he or she is reasonably suited by education, training or experience and is likely to be so disabled for life has been unable to perform domestic duties or child rearing and has been confined to the home as a result of a Day One Condition and is under the regular treatment, and following the advice, of a Medical Practitioner, and continues to be so incapacitated to the extent that he or she is unable to engage in (whether or not for reward) any occupation for which he or she is reasonably suited by education, training or experience and is likely to be so disabled for life has suffered Loss of Limbs or Sight (as defined in condition 6), or has suffered Loss of Independent Existence (as defined in condition 6). Trauma Cover Trauma Cover is the benefit payable if the Life Insured suffers from a Trauma Cover condition covered by this Policy. The amount of the benefit is that shown in the Policy Schedule together with any increases as a result of Automatic Indexation. 7

10 Policy conditions 3. Benefits 3.1 Life Care (death cover) The Life Care benefit applies when the words Life Care appear under the Plan Benefits section in the Policy Schedule. The Life Care benefit cannot apply to a person if the Child Cover Option applies to that person. Subject to the conditions of this Policy, we will pay the Life Care benefit if, while the Life Care benefit applies, the Life Insured dies. The Life Care benefit ceases to apply: on the death of the Life Insured from the Policy Anniversary Date preceding the Life Insured s 99th birthday from the Cover Expiry Date, if any when this Policy terminates whichever happens first. Exclusions The Life Care benefit will not be payable when the Life Insured (whether sane or insane) commits suicide within one year from: the Date Insured From the date the Life Care benefit came into force the date on which the Policy was last reinstated, or the date of an increase to your cover (the exclusion will then apply only to the amount of the increase). However, where we have agreed to replace existing death cover you may have which is subject to a suicide exclusion, and your level of cover has not increased under this Policy, the period within which suicide must occur for this exclusion to apply will be one year less the expired period of the suicide exclusion which applies to your existing death cover. Where the relevant period under the suicide exclusion, which applies to your existing death cover, is at least one year and has expired then we waive this exclusion except to the extent it applies to a reinstatement of, or increase in, cover. Where the Life Care benefit under this Policy exceeds the death cover being replaced, this exclusion will apply in its entirety to the amount of the excess. Where the death cover being replaced is not subject to a suicide exclusion, this exclusion will apply in its entirety. Nominated Beneficiaries You may nominate up to five beneficiaries to receive all or part of your Life Care benefit, Life Care Advance Payment Benefit, Financial Planning Benefit (but only where payable on payment of the Life Care benefit), Life Care Loyalty Bonus Benefit, Life Care Severe Hardship Booster Benefit and any Accidental Death Cover under this Policy subject to the following rules: a Nominated Beneficiary can be a natural person, corporation or trust a Nominated Beneficiary will receive the designated portion of any money payable under the relevant benefit. If a Nominated Beneficiary dies before a claim is made under this Policy and no change in nomination has been made, then any money payable will be paid to the Nominated Beneficiary s legal personal representative conditional nominations cannot be made if ownership of the Policy is assigned to another person or entity, then any previous nomination is automatically superseded (i.e. the nomination is removed) a Nominated Beneficiary has no rights under the Policy, other than to receive the relevant benefit proceeds after a claim has been admitted by us. He or she cannot authorise or initiate any Policy transaction, and you may change a Nominated Beneficiary or revoke a previous nomination at any time prior to a claim event. A person you nominate will be regarded as having the benefit of this Policy in accordance with the provisions of Section 48A of the Insurance Contracts Act Life Care Advance Payment Benefit The Life Care Advance Payment Benefit applies where the words Life Care appear under the Plan Benefits section in the Policy Schedule. The Life Care Advance Payment Benefit does not apply to the extent the Policy is owned by a trustee of a superannuation fund or such a trustee is a Nominated Beneficiary. On production of the Life Insured s death certificate, we will provide a cash advance of the Life Care benefit (excluding the Life Care Loyalty Bonus Benefit and the Life Care Severe Hardship Booster Benefit) of up to $30,000 in total. The Life Care Advance Payment Benefit is only available to a Policy Owner or Nominated Beneficiary who survives at the time of claim and who would be entitled to all or part of any Life Care benefit that may become payable under this Policy. The Life Care Advance Payment Benefit will be paid to claimants in the proportion to which they would be entitled to any normal Life Care benefit that may become payable. We will not pay on account of this benefit more than $30,000 for each Life Insured. The Life Care benefit is reduced by the Life Care Advance Payment Benefit payment. Payment of the Life Care Advance Payment Benefit is not an admission of our liability to pay the Life Care benefit and is made without prejudice to our right to deny liability for that benefit. The Life Care Advance Payment Benefit will not be payable when the Life Insured (whether sane or insane) commits suicide within one year from:the Date Insured From the date the Life Care benefit came into force the date on which the Policy was last reinstated, or the date of an increase to your cover (the exclusion will then apply only to the amount of the increase). 8

11 3.3 Life Care Loyalty Bonus Benefit The Life Care Loyalty Bonus Benefit applies where the words Life Care appear under the Plan Benefits section in the Policy Schedule. If the Life Insured becomes Terminally Ill or dies after the fifth anniversary of the Date Insured From (the fifth anniversary) and as a result a Terminal Illness Benefit or Life Care benefit is payable under this Policy, the applicable Terminal Illness Benefit or Life Care benefit (excluding any increase under the Life Care Severe Hardship Booster Benefit) we pay will be increased by 5%. If this Policy: is reinstated in accordance with condition 4, or is replaced by another policy (where we agree it is a replacement Policy) we will, for the purposes of applying this condition, treat the reinstated Policy or the replacement Policy or, if this Policy is the replacement policy, treat this Policy as a continuation of the original Policy, on the following basis: the Life Care benefit and Life Care Loyalty Bonus Benefit will only recommence from the date of reinstatement or replacement for the avoidance of doubt, the period during which the Policy was not in force or the period in which the previous policy was in force will be taken into account in determining if and when the fifth anniversary has occurred. 3.4 Life Care Severe Hardship Booster Benefit The Life Care Severe Hardship Booster Benefit applies where the words Life Care appear under the Plan Benefits section in the Policy Schedule. If the Life Insured becomes Terminally Ill or dies due to Meningococcal Disease, Legionnaires Disease or Motor Neurone Disease and as a result a Terminal Illness Benefit payment or Life Care benefit is payable under this Policy, the applicable Terminal Illness Benefit payment or Life Care benefit (excluding any increase under the Life Care Loyalty Bonus Benefit) we pay will be increased by the lesser of 100% of that benefit and $250,000. We will only ever pay the Life Care Severe Hardship Booster Benefit in respect of either Terminal Illness or death but not both. 3.5 Terminal Illness Benefit The Terminal Illness Benefit applies where the words Life Care appear under the Plan Benefits section in the Policy Schedule. In the event of the Life Insured becoming Terminally Ill we will provide a cash advance against the Life Care benefit of 100% of the Life Care benefit (excluding the Life Care Loyalty Bonus Benefit and the Life Care Severe Hardship Booster Benefit). It will not, however, be available after the Life Care benefit ceases. The sum insured payable under Life Care, Trauma Cover or TPD Cover will be reduced by the Terminal Illness Benefit payment (including any Life Care Loyalty Bonus Benefit or Life Care Severe Hardship Booster Benefit paid in respect of that Terminal Illness Benefit payment). 3.6 Guaranteed Insurability Option (Personal Events) Guaranteed Insurability Option (Personal Events) applies where the words Guaranteed Insurability Option (Personal Events) appear under the Additional Options section in the Policy Schedule. This option is not available for a Policy with Guaranteed Insurability Option (Business Events) or Business Safe Cover Option. Up to the earlier of the Cover Expiry Date, if any, and the Policy Anniversary Date preceding the Life Insured s 46th birthday, you can increase your Life Care benefit and any Trauma Cover benefit without further evidence of insurability following the occurrence of certain events to the Life Insured, that is: marriage or the second anniversary of a de facto relationship the birth or adoption of a child the commencement of secondary school by a child the mortgaging of a home or increasing of a home mortgage divorce a change in employment which, within 30 days of the change, results in an increase in annual income of more than $10,000. A change in employment can occur while the Life Insured remains employed by the same employer but will not in any circumstances be taken to have occurred while the Life Insured remains self-employed or if the change involves a change to self-employment. Self-employed and self employment for this purpose includes employment by the Life Insured s own company, employment by an Immediate Family Member, employment by a company owned by one or more Immediate Family Members, employment by a trust the beneficiaries of which are Immediate Family Members and employment by a Life Insured under this Policy. A de facto relationship means the Life Insured, although not legally married to a person, lives with the person on a genuine domestic basis in a relationship as a couple. In the event the Life Insured: marries or reaches the second anniversary of a de facto relationship adopts or becomes a natural parent of a child has a child commence secondary school, or divorces the Life Care benefit and any Trauma Cover benefit can be increased without further evidence of insurability by up to 25% of the relevant benefit, subject to a maximum increase for the relevant benefit of $200,000 per event. In the event the Life Insured mortgages a home or increases a home mortgage, the maximum increase is limited to the lower of: 9