Sanlam Office Staff Trauma Insurance. February 2015

Transcription

1 Sanlam Office Staff Trauma Insurance February 2015

2 content introduction 1 submission of claims 10 definitions 2 payment of claims 10 traumatic illnesses 2 exclusions 11 contracting of a traumatic illness 7 waiting period 12 proof of good health 8 premium 12 benefit payable 9 continuation of cover 12

3 introduction This insurance is additional to the group life insurance. Trauma insurance will pay a benefit when a member is diagnosed with an illness listed under Traumatic illness. Membership All permanent employees appointed before 1 July 2005 had an once-off option to become members of this insurance from 1 July Employees who were permanently appointed between 1 July 2005 and 30 April 2011 had a once-off option at appointment to become members of this insurance. As from 1 May 2011 membership of the trauma insurance is compulsory for all new permanent appointees. Employees who migrated to this insurance had a once-off option at migration date. 1

4 definitions Benefit Cessation Date in regard to a member means: as soon as the benefit has been paid; termination of employment; retirement; death; or at age 65; whatever event happens first. Waiting period means a period of seven days immediately following the date of contracting the Traumatic illness. Pensionable remuneration means Former PEAR in respect of all employees appointed before 1 March 2002 and PEAR to employees appointed on or after 1 March

5 traumatic illnesses Blindness Illness Definition means the total, permanent and irrecoverable loss of vision of two eyes, or irreversible visual acuity loss in two eyes with Snellen equivalent of 6/30 after correction, or worse. means a 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. Cancer Chronic Renal Failure Coronary Artery Bypass surgery The following conditions are excluded from this definition: any cancers in situ and any pre-malignant condition, or any 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, or any skin cancers, other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin), or Clark level 2 or more depth invasion. means chronic irreversible end-stage renal failure, as a result of which regular peritoneal dialysis or haemodialysis is required on a long-term basis. means the undergoing of surgery to correct the narrowing of, or blockage to, any one coronary artery by means of a bypass graft. Coronary artery bypass graft, if it is only an insertion of a stent, is excluded from this definition. 3

6 Illness Definition means a condition of unconsciousness where the Insured Deep coma presents with a Glascow Coma Scale of 8 or less, and is dependent on life-sustaining aids, such as a ventilator and intravenous infusion for an uninterrupted period of at least 96 hours. A coma which is artificially induced for purposes of ventilation, such as applied for a flail chest, is excluded for benefits. Major Burns means third-degree burns (not first-degree nor second-degree burns), i.e. full skin thickness, which cover at least 20% (as determined by international standards) of the surface area of the body. means a heart attack of specified severity. A heart attack is the death of heart muscle, due to the inadequate supply of blood, as evidenced by all of the following three criteria: Myocardial Infarction compatible clinical symptoms, and; characteristic electrocardiographical (ECG) changes, which can be either of the following: new pathological Q waves, or ST segment and T wave changes indicative of myocardial injury, but only when accompanied by diagnostic raised cardiac markers, and; raised cardiac markers, which include the following: Troponin T greater than 0.5ng/ml or Troponin I greater than 0.25ng/ml, or CK-MB mass above the normal reference values, or Total CPK elevation of more than the normal values, with at least 6% being CK-MB. 4

7 Illness Definition The evidence must show a definite acute myocardial infarction. Other acute coronary syndromes, including but not limited to angina, are not covered by this definition. ECG, ST segment and T wave changes indicative of myocardial ischaemia that may progress to myocardial infarction in patients Myocardial Infarction with ST segment elevation, are new or presumed new ST segment elevation at the J point in two or more contiguous leads with the cut-off points greater than or equal to 0.2mV in leads V1,V2 or V3, and greater than or equal to 0.1mV in other leads. Contiguity in the frontal plane is defined by the lead sequence AVL, I and II, AVF and III. without ST segment elevation, are ST segment depression of at least 0.1mV, or T wave abnormalities only. New pathological Q waves refer to any new Q wave in leads V1 through V3, or a new Q wave greater than or equal to 40 ms (0.04 s) in leads I, II, AVL, AVF, V4, V5 or V6, or the appearance of a new complete bundle branch block. Both the first two new Q-wave must be present in any two contiguous leads, and must be greater than or equal to 1mm in depth. Organ transplant Paraplegia means the undergoing of an organ transplant as recipient of a kidney, heart, lung, liver, pancreas or bone marrow. means the total, permanent and irrecoverable loss of function of both lower extremities, with or without loss of bowel or bladder function 5

8 Illness Definition means the death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in neurological deficit lasting longer than 24 hours, confirmed by neuro-imaging investigation and appropriate clinical findings by a neurologist. For the above definition, the following are not covered: Stroke a transient ischaemic attack (TIA),or a vascular disease affecting the eye or optic nerve, or migraine and vestibular disorders, or a traumatic injury to brain tissue or blood vessels. A full neurological examination by a neurologist three months or later after the event, must confirm that the INSURED has a whole person impairment (WPI) of class 1 (1%-10%) or more. WPI figures are calculated according to the principles and ratings of the latest edition of the American Medical Association s Guides to the Evaluation of Permanent Impairment. 6

9 contracting of a traumatic illness Sanlam determines the time of contracting a traumatic illness taking into account the medical proof submitted. in the case of cancer the date of contracting the traumatic illness is taken as the date of the first diagnosis thereof; and in the case of coronary artery bypass surgery and organ transplant the date of contracting the traumatic illness is taken as the date on which the need for the surgery or transplant was first diagnosed by a registered medical practitioner. The preceding subclause must not be construed as meaning that the trauma benefit is payable for coronary artery bypass surgery or organ transplant before the actual undergoing of the surgery or transplant. 7

10 proof of good health For members who became members before 1 May 2011 the same percentage cover and medical exclusions that were granted at appointment in respect of death benefits in terms of the Group Life Insurance (GLI), will also apply in respect of the Trauma Insurance. Examples A member whose cover in terms of the GLI is limited to, for instance, 50 %, will also enjoy only 50 % of the normal cover in terms of the Trauma Insurance at the full premium. A member with 100 % exclusion for death cover in terms of the GLI will not qualify for trauma cover. A member excluded for heart diseases in terms of the GLI, will not enjoy cover in respect of heart attacks in terms of the Trauma Insurance, but will qualify for cover in respect of other traumatic illnesses. Different exclusions/limitations as determine according to the medical assessment on inception date of membership will be applicable to members who became members as from 1 May

11 benefit payable If a member contracts a traumatic illness before the benefit cessation date and does not die before the end of the waiting period, Sanlam pays the member an amount equal to once the member s annual pensionable remuneration as applicable immediately before contracting the traumatic illness, but not exceeding R1,15 million. Please note Traumatic illness benefits are limited so that the aggregate amount, which is paid to one person in terms of similar benefits from all sources, does not exceed R4 million. Once a trauma benefit has been paid to a member, no further trauma benefit is payable to such a member. A trauma claim is payable only once in respect of a member. 9

12 payment of claims The trauma benefit is paid only if and after Sanlam is satisfied on grounds of proof submitted on behalf of the member and at his/her expense that the benefit has become payable. submission of claims No obligation to make any payment for a traumatic illness exists, unless the claim is received by Sanlam s Human Resources department within six months of the time of contracting the particular traumatic illness. A trauma claim is payable only if the member has survived the traumatic illness for at least 7 days. For example: No trauma benefit will be paid if a member dies within 7 days of a heart attack. A claim for trauma insurance must be submitted to HR Support Services within 6 months from contracting the traumatic illness. A trauma claim is payable only once in respect of a life insured. 10

13 exclusions No benefit is paid if the traumatic illness (a) is a direct or indirect consequence of active participation in war, invasion, acts of foreign enemies, hostilities, warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power; (b) is a direct or indirect consequence of: (i) the use of nuclear, biological or chemical weapons, or any radioactive contamination; or (ii) attacks on or sabotage of facilities (including, but not limited to, nuclear power plants, reprocessing plants, final repository sites and research reactors) and storage depots, which lead to the release of radioactivity or nuclear, biological or chemical warfare agents, Irrespective whether any of the aforesaid has been performed with the specific use of information technology. 11

14 waiting period If, on the latest date on which the insurance of the trauma benefit, or of any increase in the insurance by virtue of an amendment to the stipulations regarding the benefit, commences with regard to a member (but for this clause), the member is incapable of performing his/her normal duties with the employer as a result of an illness or a bodily injury, then he/she becomes entitled to the benefit or the increase (as the case may be) only when he/she is capable of resuming his/her normal duties and has done so for twenty continuous working days. The trauma benefit or any increase in the benefit by virtue of an amendment to the Policy, is not paid for a traumatic illness contracted by a member within two years of the latest date on which the insurance of this benefit or the increase, as the case may be, commences with regard to him/her, if that traumatic illness directly or indirectly arises from or is traceable to a diseased condition of which the member was aware or experienced symptoms or for which medical treatment was received during the two years immediately before the said date. premium The premium for the Trauma Insurance is R0.257 per R1 000 sum assured. Example Pensionable Remuneration (*Former PEAR/PEAR) Sum assured in respect of Trauma Insurance (1 x Pensionable Remuneration): R Monthly premium = R0.257 x R R1 000 = R51.40 * Former PEAR is the applicable pensionable remuneration for calculating the benefits and premiums for all employees permanently employed before 1 March 2002 and PEAR is applicable remuneration for calculating the benefits and premium for all employees employed on or after 1 March continuation of cover No option is available to convert this cover to a policy when it ceases. Trauma cover is continued during disability if the disablement is the result of a cause other than a TRAUMATIC ILLNESS. The premiums after the date of disablement are deducted from the member s disability income. 12

15 Disclaimer This summary does not form part of the official Rules and Policies. In the event of any contradiction between the contents of this summary and the official Rules and/or Policies, the provisions of the Rules and Policies shall prevail. These Rules and Policies are available on request at Chrisna Swart, Sanlam Head Office, Tel: Chrisna Swart - SSUF: Principal Officer T E [email protected] 2 Strand Road, Bellville 7530 PO Box 1, Sanlamhof 7532, South Africa T +27 (0) F +27 (0) Sanlam Life Insurance Limited Reg no 1998/021121/06. Licensed Financial Services and Registered Credit Provider (NCRCP43).