Group Critical Illness

Transcription

1 Group Critical Illness Standard Terms and Conditions Introduction This document sets out the standard terms and conditions governing the Generali Worldwide Insurance Company (referred to as we or us from now on) Group Critical Illness product. The Standard Terms and Conditions, together with the corresponding quotation form part of the contract, and prospective clients are advised to read these carefully. Any special terms detailed in the quotation shall replace the corresponding standard wording contained in this document. In the event of any conflicts in any of the wordings between these documents, the wording of the Policy Document (once issued) will prevail. General We will not assume risk for any Policy until all outstanding information requested in the corresponding quotation has been received, and we are satisfied that such information is acceptable. 1) Our quotations are valid for 1 calendar month from date of issue shown. 2) No return of premium will be made in year one if the contract is cancelled. 3) All our quotations include active employees, but exclude individuals in receipt of an income from any sickness or incapacity insurances. Cover may be approved for any such individuals once we have been provided with written confirmation of the nature of the illness or injury and the corresponding first date of absence from normal duties. 4) A full listing of the eligible membership must be provided within 1 calendar month of the Policy incepting. 5) Provided that satisfactory confirmation of the Policy s eligibility and take-up rate has been received by us, individuals will not be required to be medically underwritten if their full benefit entitlement does not exceed the insured free cover limit. 6) Individuals not joining the Policy at the first opportunity or who do not satisfy the eligibility conditions in any other way will be excluded from any free cover limit. 7) If the Policy is governed by a unit rate, the rate is guaranteed for two years provided that (i) the number of lives, or (ii) the total sum assured do not change by more than 20% to those in-force at the commencement date. In such circumstances, we reserve the right to change the premium rate at the date on which such changes first occurred. At the expiry of the guarantee period, the Policy shall be reviewed. 8) An individual s benefit entitlement will be assumed to be based on their annual basic salary. Other salary definitions to be insured must be explicitly advised to us at quotation stage. 9) No early or late retirees will be covered by any Policy. 10) The Policy will be terminated, immediately and without notice, unless the invoiced premium has been paid within 30 days of the invoice date. 11) We do not offer Continuation Options. Commencement of Assurance at Policy inception For any individual who is eligible to be covered by the Policy, assurance for their full benefit entitlement commences on the corresponding commencement date with the following exceptions: (i) Individuals who have had periods of absence from work due to illness or injury in the 12 month period immediate to inception date. For all such individuals, we will require written confirmation of the nature of the illness or injury and dates of corresponding absence before consenting to commencement of the member s insurance. Cover for such individuals would only commence once we have issued written confirmation. Please refer to the wording in the quotation which explicitly details the period of time of such absence for which we shall require to be notified. (ii) Benefit in excess of the insured free cover limit will be subject to our appropriate medical underwriting procedures. a) Any individual being underwritten will be covered for their full benefit entitlement (excluding pre-existing medical conditions) for a period of 90 days to allow for the underwriting procedure to complete. If, after this period has elapsed, the underwriting decision remains outstanding, individuals will be restricted to the insured free cover limit, or for accidental death only in the absence of a free cover limit, and will continue to be so until the decision has been made. b) If the underwriting decision remains outstanding after 90 days, we may agree to an extension of full cover (excluding pre-existing medical conditions) at our discretion. Page 1 of 5 GW Grp CI T&Cs 07 10

2 (i) Any individual who is not actively at work on the commencement date as a result of illness or injury will not be covered until they have returned to work in their usual capacity for two consecutive months. Actively at work means that the individual: a) is working their contracted number of hours and undertaking their usual duties and b) is not working contrary to medical advice received. We will not agree to backdate cover for the Policy as a whole, or for any individuals subsequently joining after Policy commencement. Termination of Assurance The assurance of a Member covered under the Policy will cease immediately on the earliest of the following occurrences: (i) The date that cover ceases under the Policy; (ii) Payment of a critical illness claim to the Member; (iii) Attainment of Normal Retirement age; (iv) Attaining age 60; (v) The date the Member ceases to be eligible in any way under the Policy; (vi) The date the Member ceases to be an employee of the Insured; (vii) Discontinuance of payment of premiums; (viii) Any Member whose period of cover exceeds the provisions laid down under the Policy s temporary absence clause. Temporary Absence The periods of permitted absence from work covered by the Policy are as follows: (i) 12 months for any period of illness or injury; (ii) During any period of maternity leave; (iii) 6 months for any other reason. Should payment of premium be discontinued in respect of any Member covered in temporary absence, such cover will cease for that Member. No-worse terms For insured policies that switch to us, all medical underwriting terms applied by the previous insurer will be matched by us on a no-worse terms basis at the date of switch of cover subject to: (i) Such terms will only apply to the Member s sum assured that had been previously underwritten. Any subsequent increase in sum assured that a Member is entitled to would be underwritten on our terms; (ii) If our free cover limit is higher than the previous insurer s, our free cover limit will not apply to any Members whose previous cover had been subject to adverse underwriting decisions, or who had previously had any benefit entitlement restricted due to non completion of medical underwriting; further increases in benefit entitlement for these Members will be fully underwritten on our terms. (iii) The previous underwriting decision was made less than 36 months before the date of the Policy switching to us. (iv) For Members whose underwriting decisions were made prior to this 36-month period, we reserve the right not to offer noworse terms; (v) Such terms will only apply to previous medical ratings of up to +300% extra morbidity. (vi) No Member had been restricted to a previous free cover limit as a result of poor health. For individuals restricted in this manner, we would underwrite the Member for their full benefit entitlement before terms would be considered; (vii) Similarly, any Member previously declined cover by the previous insurer would be underwritten for their full benefit entitlement before acceptance terms would be considered. In instances of (v) or (vi), any free cover limit that the Policy may have will not apply to such Members. Clients shall agree to provide any information requested by us to support previous underwriting terms. Failure to provide such details will result in the offer of no-worse terms being withdrawn by us. Benefit When Payable: The insured benefit shall be payable to the policyholder once we are satisfied that the Member claiming has suffered an insured Critical Illness (as described in the Section Definitions), and that Member has survived the 30-day period after first diagnosis is made (the Waiting Period). A claim under this Policy will only be considered if submitted within two years of the first diagnosis. The Waiting Period will be deemed to have commenced for the following insured conditions: Coronary Artery Bypass Surgery: The date of the surgery; Major Organ Transplant: The earlier of the date of surgery or the date the Member was first accepted onto an official waiting list for the organ to be transplanted; Multiple Sclerosis: The date at which continuous impairment has persisted for 6 months; Terminal Illness: The date of the opinion made by an attending Consultant and our Chief Medical Officer. Page 2 of 5 GW Grp CI T&Cs 07 10

3 Benefit Limitation: The maximum benefit payable shall be the lesser of (i) 4x Scheme Salary (ii) 1,000,000 or currency equivalent. Children s Benefits: For no additional premium, a lump sum equal to 25% of the Member s own insured benefit (subject to a maximum of 15,000 or currency equivalent) will become payable for any Member s child aged between 30 days and 18 years who suffers an insured Critical Illness upon survival of the Waiting Period. Please refer to the Section Exclusions, Policy Exclusions (vi). Spouse s Benefits: For an additional premium, a Member s spouse who has not attained age 60 may be covered under the Policy for up to 20,000 or currency equivalent. Such benefit would be paid once we are satisfied that the Member s spouse suffered an insured Critical Illness and had survived the Waiting Period. Definitions We offers two coverages Basis A (Core Illnesses) and Basis B (Additional Insured Conditions) which are explained below. It should be noted that all diagnoses and medical opinions must be given by a medical specialist who: (i) Holds an appointment as a Consultant at a hospital; and (ii) Has specialised in a field appropriate to the cause of the claim; and (iii) Is acceptable to our Chief Medical Officer. Basis A (Core Illnesses) Cancer: A malignant tumour characterised by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The term cancer includes leukaemia and Hodgkin s disease but the following are excluded: (i) All tumours which are histologically described as premalignant, as non-invasive or as cancer in situ; (ii) All forms of lymphoma in the presence of any Human Immunodeficiency Virus; (iii) Kaposi s sarcoma in the presence of any Human Immunodeficiency Virus; (iv) Any skin cancer other than malignant melanoma. Coronary Artery Bypass Surgery: The undergoing of open heart surgery on the advice of a Consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with bypass grafts but excluding balloon angioplasty, laser relief or any other procedures. Heart Attack: The death of a portion of heart muscle as a result of inadequate blood supply as evidenced by an episode of typical chest pain, new electrocardiograph changes and by the elevation of cardiac enzymes. The evidence must be consistent with the diagnosis of heart attack. Kidney Failure: End stage renal failure presenting as chronic and irreversible failure of both kidneys to function, as a result of which either regular renal dialysis or renal transplant is instituted. Major Organ Transplant: The actual undergoing as a recipient of a heart, liver, lung, pancreas or bone marrow. The addition to an official waiting list for a transplant of heart, liver, lung, kidney, pancreas or bone marrow subject to evidence from a consultant surgeon that the transplant is the most appropriate way of treating a condition which threatens the life of the Member. Multiple Sclerosis: A definite diagnosis of Multiple Sclerosis by a Consultant Neurologist which satisfies all of the following criteria: (i) There must be current impairment of motor or sensory function, which must have persisted for a continuous period of at least six months; (ii) The diagnosis must be confirmed by diagnostic techniques current at the time of the claim; The Member may not necessarily be confined to a wheelchair. Stroke: A cerebrovascular incident resulting in permanent neurological damage. Transient cerebral ischaemic attacks are specifically excluded. Page 3 of 5 GW Grp CI T&Cs 07 10

4 Basis B (Additional Insured Conditions) As Basis A plus: Aorta Graft Surgery: Undergoing surgery for disease of the aorta needing excision and surgical replacement of a portion of the diseased aorta with a graft. For this definition, aorta means the thoracic and abdominal aorta but not its branches. Alzheimer s Disease (before age 60): A clinically established diagnosis of Alzheimer s disease (pre-senile dementia) made prior to age 60, resulting in the ability to perform four of the six listed activities under Activities of Daily Living. Benign Brain Tumour: A non-malignant tumour in the brain resulting in permanent deficit to the neurological system. Tumours or lesions in the pituitary gland are not covered. The Policy also covers any benign brain tumours which have required surgical removal, excluding cysts, malformations in or of the arteries or veins of the brain, haematomas and tumours in the pituitary gland. Blindness: Total, permanent and irreversible loss of sight in both eyes. Coma: A state of unconsciousness with no reaction to external stimuli or internal needs, persisting continuously with the use of life support systems for a period of at least 96 hours and resulting in permanent neurological deficit. Loss of Limbs: The permanent physical severance of two or more limbs from above the wrist or ankle joint. Loss of Speech: Total, permanent and irreversible loss of the ability to speak as a result of physical injury or disease. Motor Neurone Disease: Confirmation by a Consultant Neurologist of a definite diagnosis of Motor Neurone Disease. Paralysis/Paraplegia: Total irreversible loss of muscle function or sensation to the whole of any two limbs as a result of injury or disease. The disability must be permanent, established for a continuous period of 12 calendar months and be supported by appropriate neurological evidence. Parkinson s Disease (before age 60): Confirmation by a Consultant Neurologist of a definite diagnosis of idiopathic Parkinson s Disease before age 60. Parkinson s Disease secondary to alcohol or drug misuse is not covered. Terminal Illness: Advanced or rapidly progressing incurable disease where, in the opinion of an attending Consultant and our Chief Medical Officer, the life expectancy is no greater than 12 months. Acquired Immune Deficiency Syndrome (AIDS) is specifically excluded and not included in this definition. Third Degree Burns: Third degree burns covering at least 20% of the body surface area. Coma secondary to alcohol or drug misuse is specifically excluded. Creutzfeldt-Jacob Disease: Becoming permanently disabled through acquiring Creutzfeldt- Jacob disease to the extent of being unable to perform four of the six listed activities under Activities of Daily Living. Deafness: The total permanent and irreversible loss of hearing in both ears. Heart Valve Replacement or Repair: Undergoing open heart surgery from medical necessity to replace or repair one or more heart valves. Activities of Daily Living The permanent, total and irreversible inability of the Member, as a result of illness or injury, to perform four of the six activities listed below without special equipment and someone s assistance throughout: (i) Washing in the bath or shower and maintaining adequate personal cleanliness; (ii) Full dressing or undressing, include putting on and taking off medically necessary surgical appliances; (iii) Getting to and from the toilet, getting on and off the toilet and maintaining adequate levels of personal hygiene; (iv) Voluntarily controlling bowel and bladder function; (v) Moving into and out of a chair or bed; (vi) Drinking or eating prepared food. Page 4 of 5 GW Grp CI T&Cs 07 10

5 Exclusions Policy Exclusions No benefit shall be paid in respect of claims that are directly or indirectly attributable to, or consequential upon: (i) No Benefit will be payable in respect of an insured condition, or a repeat of the same insured condition, if it was first diagnosed, treated or known by the Member to be in existence (or, in respect of a child, known to be in existence by the Member or the Member s spouse) prior to the commencement of cover for that Member. Please note that Aorta Graft Surgery, Coronary Artery Bypass Surgery, Heart Attack, Heart Transplant, Heart Valve Replacement or Repair and Stroke are regarded as one insured condition. For example, if a person has previously undergone Coronary Artery Bypass Surgery, payment of Benefit would be excluded for that condition and for Aorta Graft Surgery, Heart Attack, Heart Transplant, Heart Valve Replacement or Repair and Stroke. Catastrophe Limit The Company will not pay more than the quoted catastrophe limit in the aggregate for the total of benefits which may be due under this Contract as a consequence of any single incident or series of incidents arising out of one event or occurrence and resulting in claims in which 2 (two) or more Members die within a period of 12 (twelve) months of the event. Where the event in question is a natural disaster such as earthquake, storm or flood, all claims resulting there from within a period of 72 (seventy-two) hours of the occurrence of the event shall be considered as arising from a single event. If a Member has previously suffered any of the defined conditions, no Benefit will be payable for Paralysis. This restriction will only be imposed when a Member joins the scheme; it will not apply when Benefits are increased as a result of salary reviews. (ii) (iii) (iv) Related Conditions No Benefit will be payable for an insured condition in respect of which any related condition existed at any time prior to the Commencement Date unless at least two consecutive years have elapsed since the person concerned last had symptoms of or received treatment or advice in respect of, the related condition. In respect of any Members children being covered, the presence of congenital or hereditary conditions; Nuclear transmutation, or radiation, resulting from the artificial acceleration of atomic particles. Chemical or biological substances which are not used for peaceful means. Member-specific Exclusions In certain instances, Members may have specific conditions applied to them resulting in exclusions of cover. Claims arising either directly or indirectly from causes excluded in this manner will not be accepted under any circumstances. These will be explicitly detailed if they apply to any Members. Page 5 of 5 GW Grp CI T&Cs 07 10