Group Critical Illness Protection Technical Guide

Transcription

1 For commercial customers and their advisers only Group Critical Illness Protection Technical Guide Reference BGR/4532/NOV12

2 Contents Page Its aims Employers your commitment Risk factors How does the policy work? 1 What factors should be considered in deciding which benefits to provide? Setting up the scheme 7 3 What premiums will be charged for the cover? 8 4 How does the scheme accounting work? 9 5 Claiming benefit 10 6 What is not covered? 11 7 Can cover be provided for an employee who is not in the UK? 14 8 Taxation of schemes 9 Continuation option Further information Questions and complaints Financial Services Compensation Scheme Law Legislative changes List of critical illness conditions 15 2

3 This technical guide has been produced based on the best practice standard format recommended by the Group Risk Insurance Development Group (GRID) and the Association of British Insurers (ABI). This technical guide is intended for use by commercial customers and their advisers. Its aims To provide insurance to cover a lump sum benefit which is payable if a member, or a child of a member, is diagnosed with one of the specified medical conditions or undergoes one of the listed operations and in both cases survives for at least 14 days. In order for benefit to be payable the condition or operation must meet the definition in the policy conditions. We only cover the critical illnesses we define in the policy and no others. To offer a choice of Standard or Comprehensive schemes. Comprehensive schemes cover an increased number of conditions and operations. To offer the option when the scheme is taken out of providing benefit if a member becomes totally and permanently disabled. This option is available at an extra cost. In order for benefit to be payable the definition of total permanent disability must be met. Employers your commitment To pay us premiums as they become due. To provide all the information we require when you apply for cover, at each annual revision date and premium review date or in support of a claim, and to notify us if these details change. To adhere to the eligibility conditions agreed. To notify us of potential claims within three months of first diagnosis being made or undergoing surgery. To comply with the terms and conditions of the policy. To identify and notify us in writing of any discretionary, late or early entrants. To notify us of any changes in the companies participating in the scheme and the relationship between them. Risk factors Cover will cease if you fail to comply with the policy terms and conditions or if premiums are not paid when they are due. Cover is designed to provide a lump sum benefit on survival of one of the specified medical conditions or operations and has no surrender value. A significant change in the eligibility conditions, your business, the benefit basis and a number of other factors may bring about an adjustment in premiums and terms at any time. The rates used to calculate premiums are normally guaranteed for two years and are then reviewed. However, this guarantee will cease to apply in some specified circumstances and if there is a change of 25 percent or more in the number of members or total benefit insured. Certain causes of claim are excluded (see 6 What is not covered? ). All claims are subject to a pre-existing conditions exclusion. For benefit to be payable: the medical condition diagnosed or operation undergone must be on the list of medical conditions and operations covered by the scheme you have chosen, and in all circumstances the medical condition or operation must in the reasonable opinion of our chief medical officer meet the definition in the policy conditions, and 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 our chief medical officer and is a specialist in an area of medicine appropriate to the cause of claim, and the member or child must survive for 14 days from the date of first diagnosis or, for operations the date of undergoing the procedure. Beyond the 14 day survival period, some of the covered medical conditions and operations incorporate an additional assessment period (ie the period during which we will assess a condition before we make a decision on whether or not to accept a claim). The assessment period will typically start on receipt of the claim form and will be at least three months. (see 1.4 When is the lump sum payment due? ) children must be at least 30 days old before they are covered. We have the right to change the policy conditions at any time for benefits coming into force in the future and for all benefits at any time after the policy has been in force for five years. 3

4 Your questions answered How does the policy work? You decide the type of cover you require by selecting a Standard or Comprehensive scheme. You decide the amount of benefit you require for your employees. You must include all eligible employees in the scheme when they first become eligible. You pay all of the premiums due to keep the cover in force. The cost is usually treated as a trading expense for tax purposes and is a benefit in kind for employees. We provide cover whilst the policy is in force no matter how many claims are made. If you terminate cover we will consider and pay benefits for valid claims where diagnosis or the undergoing of the operation occurred during the period of cover. Members children (including stepchildren and legally adopted children) aged between 30 days and 18 years (or 21 years if in full time education) are automatically covered free of charge for the lower of 20,000 or 25 percent of the members benefit. There is no upper limit to the number of children who can be covered. You notify us of a claim within three months of first diagnosis or undergoing surgery. You and the members concerned must provide us with information to assess a claim. A lump sum benefit is paid for valid claims. We pay the benefits to the member. Under HM Revenue and Customs practices at the time of going to print the lump sum payment will be free of taxes. 1 What factors should be considered in deciding which benefits to provide? We offer a range of options which can help you to design cover to meet your organisation s objectives and budget. The maximum benefit limits are: the lower of five times salary or 500,000 for the member the lower of 25 percent of the member s benefit or 20,000 for children s benefit. 1.1 Who can be covered? (a) Eligibility The eligibility criteria will be agreed prior to cover commencing and will include: the minimum and maximum entry ages for the employees the expiry age for the cover any service qualifications that may apply which categories of staff are eligible to be included (eg all office staff or all employees) when any new entrants will be able to join the scheme (eg immediately they satisfy the eligibility conditions or at the next annual revision date) whether there are any other conditions specified in order to join the scheme (eg pension scheme membership and if the scheme is open to new entrants). Please note that any eligibility criteria connected to age or service need to be considered in light of the Age Regulations. Membership is compulsory for all employees who satisfy the eligibility conditions and meet any applicable actively at work requirements (see 1.1.(b)). Permanent full time and part time employees can be included in the scheme. Fixed term contract workers can be covered throughout the period of their fixed term contract. If pension scheme membership is a condition of joining the group critical illness scheme we need to know the eligibility conditions for joining the pension scheme. If an employee does not join the pension scheme within six months of their first opportunity, evidence of good health will be required before we can provide cover under the group critical illness scheme. Members children (including any stepchildren and children who have been legally adopted) aged between 30 days and 18 years (or 21 years if in full time education) are automatically covered on the commencement of the members cover. (b) Actively at work If an actively at work requirement applies it will be stated on the quotation. Where applicable this is the criterion that any member must meet, in addition to the other eligibility conditions, before they are covered under the scheme. 4

5 An employee is considered to be actively at work if they are present at their place of work and are mentally and physically capable of performing the normal duties required by the job for which they are employed. Please note that a pre-existing conditions exclusion applies to benefits under this policy (see 6.1 Pre-existing conditions exclusion ). Confirmation that any actively at work requirement has been met must be provided by the employer in writing. 1.2 When will cover cease? Under normal circumstances Cover ceases on the earlier of: a member reaching the scheme expiry age a member leaving service a member no longer satisfying the eligibility criteria the contract of employment ending the death of the member benefit being paid in respect of a member (but see 5.2 Can another claim be made in respect of a person who has received a benefit payment? ). Cover for a child will cease at the same time that cover for the member ceases, or earlier, if a claim is payable in respect of the child or the child reaches the end date for children s cover under the scheme. If benefit is paid for a child, no further benefit will be paid for that child. However, cover will continue for the member and any other children who have not claimed benefit. Cover will also end when the scheme ends. The scheme will end when: you fail to pay any premiums due the number of employees is reduced below the minimum number we agree you fail to comply with any reasonable request for information there is a material change in your business you or any employee covered fail in your duty of utmost good faith towards us you end the scheme. We will pay any valid claims after the scheme ends if they arose during the period of cover Cancelling the cover You can end the scheme at any time provided that: notification is given in writing; and we are given at least 30 days notice. 1.3 What types of cover are available? We offer a choice of a Standard or Comprehensive scheme. Both schemes comply with the industry standard definitions of critical illnesses and conditions set by the Association of British Insurers (ABI) where applicable. The complete list of conditions covered under the Standard scheme and the Comprehensive scheme are set out below in 1.3 (a) and 1.3 (b) respectively. These headings are only a guide to what is covered. The full definitions of the illnesses covered and the circumstances in which a claim can be made are given in List of critical illness conditions at the end of this technical guide. These typically use medical terms to describe the illness but in some cases the cover may be limited. For example: some types of cancer are not covered to make a claim for some illnesses there may be a requirement for symptoms to be permanent. (a) Standard schemes The Standard scheme covers the following conditions and operations (and no others). Alzheimer s disease resulting in cancer excluding less advanced cases cardiac arrest coronary artery by-pass grafts dementia resulting in heart attack of specified severity kidney failure requiring dialysis major organ transplant motor neurone disease resulting in multiple sclerosis with persisting symptoms Parkinson s disease resulting in 5

6 progressive supranuclear palsy resulting in stroke resulting in (b) Comprehensive schemes The Comprehensive scheme covers all the conditions and operations included under the Standard scheme, as well as the following (and no others). aorta graft surgery aplastic anaemia with permanent bone marrow failure bacterial meningitis resulting in benign brain tumour resulting in permanent symptoms or removed via craniotomy benign spinal cord tumour blindness permanent and irreversible cardiomyopathy of specified severity coma resulting in coronary angioplasty to two or more coronary arteries Creutzfeldt-Jakob disease resulting in deafness permanent and irreversible heart valve replacement or repair HIV infection caught from a blood transfusion, a physical assault or at work in an eligible occupation* liver failure of advanced stage loss of hand or foot permanent physical severance loss of independent existence permanent and irreversible loss of speech permanent and irreversible open heart surgery with surgery to divide the breastbone paralysis of limbs total and irreversible respiratory failure of advanced stage terminal illness third degree burns covering 20 percent of the body s surface area or 30 percent loss of surface area to the face traumatic head injury resulting in * The eligible occupations for HIV infection caught at work are: ambulance workers chiropodists dental nurses dental surgeons district nurses fire brigade firefighters general practitioners hospital caterers hospital cleaners hospital doctors, surgeons and consultants hospital laboratory technicians hospital laundry workers hospital nurses hospital porters midwives nurses employed by general practitioners occupational therapists paramedics physiotherapists podiatrists policemen and policewomen prison officers radiologists refuse collectors social workers In addition, subject to agreement by Friends Life, you may be able to include cover for employees who become totally and permanently disabled from performing a suited occupation ever again. This option will result in an extra cost under both the Standard and Comprehensive schemes and is only available for some occupations. rheumatoid arthritis chronic and severe systemic lupus erythematosus with severe complications 6

7 For the purposes of this benefit the relevant specialists must reasonably expect that the disability will last throughout life with no prospect of improvement, irrespective of when the cover ends or the member expects to retire. Evidence must be supplied that the condition has been investigated and managed by an appropriate consultant. Subject to prior agreement by Friends Life, it may be possible to provide cover on the basis that benefit is payable if a member is totally and permanently disabled from performing his or her own occupation ever again. This option will result in an increased premium. We will confirm what definition will apply before any cover starts. The following conditions are not available for any children covered under the scheme: HIV infection caught from a blood transfusion, a physical assault or at work in an eligible occupation loss of independent existence total permanent disability. 1.4 When is the lump sum payment due? Lump sum benefit payments for valid claims are made if a member survives at least 14 days from the date of: diagnosis of one of the covered conditions or surgery if he or she undergoes one of the listed operations. Payment of any benefit under the policy is subject to, in the reasonable opinion of our chief medical officer, the claim meeting the appropriate definition under the policy conditions. Beyond the 14 day survival period, some of the definitions for covered conditions and operations (eg multiple sclerosis) incorporate an additional assessment period (ie the period during which we will assess a condition before we make a decision on whether or not to accept a claim). The assessment period will typically start on receipt of the claim form and will be at least three months. Full definitions for covered conditions and operations are set out at the end of this technical guide (see List of critical illness conditions ). 1.5 Are there any special coverages possible under the scheme? Where a member is off work due to sickness or injury, the cover can continue for up to three years. For absence due to any other reason the cover can be maintained for up to one year. If required we can normally maintain cover until the scheme expiry age for absence due to sickness or injury and for up to three years for other absences. Cover will be at the level in force on the day before absence begins. This clause is subject to the member continuing to be employed by you and premiums being paid during the period of absence. 2 Setting up the scheme 2.1 Requirements to set up the scheme If a scheme starts within three months of the quotation and providing any specific requirements within the quotation have been met, then to provide cover we require: a completed application form details of any employee to be covered details of employees with benefits in excess of the free cover level details of employees who do not satisfy any applicable actively at work requirement a deposit premium scheme history, including number of members and total benefit if previously insured (including details of any underwriting decisions for members underwritten under the previous scheme and the underwriting basis for that scheme) full and up to date claims history for the last five years or such shorter time as the scheme has been in force if previously insured. If all of the above are not received within 30 days of the commencement date then cover will cease immediately. A premium will be charged for time on risk. Benefit payments will be made once we have established that the defined illness or operation has occurred and that the member has survived the survival period. 7

8 2.2 Evidence of health to be provided before members are covered Since a group scheme is designed to cover all the employees who satisfy the eligibility conditions, we normally only require medical information or pastime information for those employees whose benefit exceeds the free cover level. The free cover level is usually based on the number of members and benefits provided under the scheme. There must be at least 10 members in the scheme for a free cover level to be available. Benefits within the free cover level are subject to a pre-existing conditions exclusion (see 6.1 Pre-existing conditions exclusion ). If a member s cover exceeds the free cover level they will be asked to complete an employee health declaration. We may apply to their own doctor for a report and in some circumstances request a medical examination or other medical tests. The underwriting process may result in additional premiums or exclusions being applied to cover in excess of the free cover level for some members. In some cases we may be unable to provide cover in excess of the free cover level. For members who have been underwritten and accepted at ordinary rates of premium and on standard terms we may be able to accept future increases in benefit without further medical underwriting. In such cases a forward underwriting bar will be allocated and the employee will not be underwritten again for five years unless their benefit increases by more than the amount of the bar. Please note that the free cover level will not apply to discretionary entrants, late entrants or early entrants. Discretionary entrants include employees joining the scheme who do not satisfy the normal eligibility conditions. Late entrants are those employees joining the scheme after the date of their first opportunity to do so. Early entrants are employees joining the scheme before they meet the normal eligibility conditions. All cover for discretionary entrants, late entrants and early entrants will be subject to prior agreement by us. Evidence of good health will be needed before we can provide cover. Initially these employees will be asked to complete an employee health declaration but further medical evidence may be required depending on the information supplied. All children s benefit is subject to the pre-existing conditions exclusion and will not require evidence of health for underwriting purposes (see 6.1 Pre-existing conditions exclusion ). 2.3 What happens if a claim arises before a decision has been made? Where a member s benefit is subject to underwriting because it exceeds the free cover level we provide a period of temporary cover of up to 90 days from the date they are first covered. Temporary cover applies to the amount of benefit being underwritten and is subject to the member being actively at work. During the period of temporary cover we will insure the employee for their full benefit (as long as the cover has not previously been declined by us or another insurer), but any benefit in excess of the free cover level or previously insured benefit will be subject to the pre-existing conditions exclusion. Claims will be subject to any other underwriting restriction we may specify. Temporary cover will end on the earlier of: the expiry of the 90 days the date that we issue the terms, if any, on which cover can be provided. Temporary cover does not apply to discretionary, late or early entrants. 3 What premiums will be charged for the cover? The premium calculated depends on factors which include the nature and amount of the benefits to be provided and details of the employees to be insured. The information used to calculate the premiums includes: level of benefits eligibility and entry conditions ages and genders of the employees occupation of the employees location of the workforce claims history if the scheme has been insured previously. 8

9 A minimum premium will be set for each scheme and this is currently 500 annually, 300 quarterly, and 100 monthly. Premiums payable more frequently than annually must be paid by direct debit. All premium payments are to be paid in sterling, or other such currency as may be agreed in writing by us. 3.1 How will premiums be calculated? (a) Schemes covering between five and 19 people: Single premium costed schemes Premiums will be calculated for each employee based on the premium rates current at the beginning of the premium guarantee period. The premium guarantee period is the two year period either from the commencement of a scheme or from the last review of premium rates. For this type of scheme the premium for each employee is recalculated each scheme year based on the applicable premium rate and the employee s age at the start of that year. Premium rates increase with age. If the number of employees increases to 20 or more the scheme will be administered and the premium calculated as a unit rate scheme, as set out below, from the annual revision date following the increase. (b) Schemes covering 20 or more people: Unit rate schemes For these schemes a premium rate is calculated and expressed as a rate per 1000 of benefit. The rate is calculated using the individual data provided. If the number of employees decreases below 20 the scheme will be administered and the premium calculated as a single premium costed scheme, as set out above, from the annual revision date following the decrease. 3.2 Will there be any unexpected extra premiums? The unit rate and the rates used in calculating the single premium costed schemes are usually set for two years. New rates may be applied at the end of the two year period. The rates and conditions may be varied at any time in the following circumstances: if the number of members or the total benefits insured increases or decreases by more than 25 percent from the number at the start of the premium guarantee period if you fail to provide any information reasonably required within 60 days if there is a material change in your business if there is any change in legislation or taxation which affects the cost of cover. Additional premiums may be applied to employees whose benefits exceed the free cover level, discretionary entrants, late entrants or early entrants, if they are suffering from certain medical conditions or partake in hazardous pastimes. You will be notified of any increase in the premiums and the date from when they will be payable. 3.3 What commission is included within the premium? The standard rate of commission for these schemes is 12 percent. The rate of commission will be shown on the quotation. 3.4 Is there a discount for good claims experience? Claims experience is one of the factors used to assess the final premium or unit rate for a scheme and therefore good claims history will usually be reflected in the premium charged. 4 How does the scheme accounting work? The policy normally operates on a one year accounting period. Premiums are payable on account on either an annual, quarterly or monthly basis as selected. At each annual revision date and premium review date we must be provided promptly with all the necessary information to prepare the account. Until we have the most accurate data we will charge approximate premiums. if the number of employees covered is reduced below the agreed minimum 9

10 4.1 What information is required for accounting purposes? (a) Single premium costed schemes: A list of all employees in the scheme will be required at the start and end of each policy year. The list must show the name, occupation, location of work, gender, date of birth, salary and, if applicable, the date of joining and the date of leaving for each employee. It is also necessary to advise us immediately of: employees whose cover exceeds the free cover level during the scheme year, discretionary entrants, late entrants and early entrants. (b) Unit rate schemes: Details of the total number of employees and the total salary or benefit covered at the start and end of any policy year will be required. It is also necessary to advise us of: employees whose cover exceeds the free cover level during the scheme year, discretionary entrants, late entrants and early entrants. Additional information will be required when the rates used to calculate the premiums are reviewed. 4.2 How are accounts adjusted for members who join, leave or have benefit rises during the year? (a) Single premium costed schemes: A premium adjustment will be calculated reflecting the amount and duration of the cover actually provided. Any premium adjustment for employees who join, leave or have benefit increases becomes payable at the end of the scheme year. (b) Unit rate schemes: A premium adjustment will be calculated based on the average total benefit for all employees covered during the previous policy year. Effectively this means salary and staff changes are treated as if they occurred at mid-year. 4.3 If the policy is discontinued mid-year will premiums paid in advance be lost? No. A final account will be produced based on the cover provided up to the date when you cancelled the policy. Either a refund will be paid or any outstanding premiums will be requested. 5 Claiming benefit This section deals with common questions which arise following a member or child being diagnosed with one of the covered conditions or undergoing one of the listed operations. 5.1 How are claims made? The evidence required to assess a claim will include, but not be limited to: evidence of the employee being covered and their earnings an original copy of the member s birth certificate (or the child s birth certificate in the case of a claim for children s benefit) a member s claim form signed by the member and received by us as soon as possible and in any case within three months of first diagnosis or undergoing surgery a completed employer s claim form confirmation of survival of the 14 days following diagnosis or undergoing surgery medical evidence to confirm that the diagnosis or operation meets the definition in the policy conditions any diagnosis or medical opinions must be given by a medical specialist who is a consultant at a hospital in the UK, is acceptable to our chief medical officer and is a specialist in an area of medicine appropriate to the cause of claim. The evidence required to assess a total permanent disability claim will additionally include but not be limited to: a job description an occupational questionnaire completed by you. You and the member must provide us within 28 days, of us requesting it, all the information we require to assess a claim. 10

11 Claim forms can be obtained by writing to Friends Life Group Protection Claims Management Team, 2nd Floor, Anchorage 1, Anchorage Quay, Salford Quays M50 3YL Call us on Calls may be recorded and may be monitored. 5.2 Can another claim be made in respect of a person who has received a benefit payment? Benefit can be paid only once in respect of a member during scheme membership. If benefit is paid in respect of a member their cover will end. There is an option for the employee to re-enter the scheme one day after their cover has ended. They will be treated as a new member and the pre-existing conditions exclusion will be re-applied from the date they re-enter the scheme. Please note that this option is not available to those who have claimed for Alzheimer s disease, coma, Creutzfeldt-Jakob disease, dementia, HIV infection, liver failure, loss of independent existence, motor neurone disease, progressive supranuclear palsy, systemic lupus erythematosus, total permanent disability benefit or traumatic head injury. 5.3 Who pays for medical evidence? We will pay for any medical evidence we require. We will pay for any independent medical examination but will not pay for any expenses a claimant has incurred in attending. 6 What is not covered? A pre-existing conditions exclusion and a general exclusion apply under the critical illness scheme. A pre-existing conditions exclusion applies to benefits up to the free cover level under both Standard and Comprehensive schemes. Cover is only provided (subject to the pre-existing conditions exclusion where appropriate), for those conditions and operations selected by you when the scheme starts. No other conditions and operations are covered under this policy. All children s benefit is subject to the pre-existing conditions exclusion. 6.1 Pre-existing conditions exclusion The pre-existing condition exclusion means that if an employee is suffering from or has suffered from any critical illness or undergone any operation covered by the scheme at any time prior to entering the scheme then they will not be able to claim for that or any further incidence of that critical illness or operation or for any other critical illness or operation which is directly or indirectly linked to the prior critical illness or operation. For employees children the pre-existing condition exclusion means that an employees child is not covered for any critical illness or operation linked directly or indirectly to any condition or illness suffered prior to cover commencing. In addition: No benefit will be paid in respect of any critical illness or operation where that employee or the employee s child has suffered from an associated condition (including but not limited to those listed below) prior to the commencement of cover, regardless of whether any treatment has been administered and/or diagnosis made in respect thereof. For all critical illnesses or operations with the exception of loss of independent existence, paralysis of limbs, terminal illness, and total permanent disability, the associated conditions will be disregarded if the employee does not suffer a critical illness or operation covered by the policy within two years from the date of entry to the scheme. Associated conditions for loss of independent existence, paralysis of limbs, terminal illness, and total permanent disability remain applicable indefinitely. Important: For the purpose of this exclusion, the onset or occurrence of aorta graft surgery, cardiac arrest, cardiomyopathy, 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. No benefit will be paid in respect of blindness, coma, deafness, loss of independent existence, loss of speech, paralysis of limbs, terminal illness or total permanent disability linked directly or indirectly to a prior critical illness or operation. 11

12 If an employee or employee s child suffers from any malignant tumour(s) defined as cancer whilst covered by the policy or has suffered from cancer at any time in the past then no benefit shall be paid in respect of any subsequent cancer whether or not such cancer is connected or associated with the prior diagnosis of cancer. The pre-existing conditions exclusion applies from the date of commencement of cover. Those members who re-enter a scheme (including following a claim (subject to the actively at work requirements having been met)) will be treated as new members and the pre-existing conditions exclusion will be re-applied from the date of re-entry to the scheme. The Associated Conditions are: Condition: Aorta graft surgery Associated conditions: Any disease or disorder of the heart or any obstructive/occlusive arterial disease. Condition: Aplastic anaemia with permanent bone marrow failure Associated conditions: Polyposis Coli, papilloma of the bladder or any cancer in situ. Condition: Bacterial meningitis resulting in Associated conditions: Chronic ear disease, hydrocephalus. Condition: Benign brain tumour resulting in or removed via craniotomy Associated conditions: Neurofibromatosis (von Recklinghausen s disease) or haemangioma (von Hippel-Lindau s syndrome). Condition: Benign spinal cord tumour Associated conditions: Neurofibromatosis, meningomyelocele, and syringomyelia. Condition: Blindness permanent and irreversible Associated conditions: Stroke or transient ischaemic attack. No benefit will be payable under the blindness critical condition in respect of an insured member who, at any time prior to the date of entry into the scheme has been registered blind. Condition: Cancer excluding less advanced cases Associated conditions: Polyposis Coli, papilloma of the bladder or any cancer in situ. Condition: Cardiac arrest Associated conditions: Coronary artery disease, heart failure and cardiomyopathy, left ventricular hypertrophy, myocarditis, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, brugada syndrome, idiopathic VF (also called primary electrical disease), congenital or acquired long QT syndrome, familial SCD of uncertain cause, Wolff-Parkinson-White syndrome. Condition: Cardiomyopathy of specified severity Associated conditions: Any disease or disorder of the heart, diabetes mellitus or any obstructive/occlusive arterial disease. Condition: Coronary angioplasty to two or more coronary arteries Associated conditions: Any disease or disorder of the heart, diabetes mellitus or any obstructive/ occlusive arterial disease. Condition: Coronary artery by-pass grafts Associated conditions: Any disease or disorder of the heart, diabetes mellitus or any obstructive/ occlusive arterial disease. Condition: Creutzfeldt-Jakob disease resulting in Associated conditions: Organic brain disease, disease of the central nervous system, Parkinson s disease, depression, epilepsy, dementia, amnesic memory disorder, aphasia, psychosis. Condition: Deafness permanent and irreversible Associated conditions: Acoustic nerve tumour, neurofibromatosis. Condition: Dementia resulting in Associated conditions: Stroke, cerebrovascular disease, organic brain disease, brain tumours, disease of the central nervous system, hydrocephalus, Alzheimer s disease, Creutzfeldt-Jakob disease, Parkinson s disease, depression, epilepsy, pure amnesia, aphasia, psychosis. Condition: Heart attack of specified severity Associated conditions: Any disease or disorder of the heart, diabetes mellitus or any obstructive/ occlusive arterial disease. Condition: Heart valve replacement or repair Associated conditions: Any disease or disorder of the heart or any obstructive/occlusive arterial disease. Condition: Kidney failure requiring dialysis Associated conditions: Familial polycystic kidney disease, diabetes mellitus or any chronic renal disease or disorder. 12

13 Condition: Liver failure of advanced stage Associated conditions: Chronic liver disease, including but not limited to hepatitis B & C, primary sclerosing cholangitis, and portal hypertension. Condition: Loss of hand or foot permanent physical severance Associated conditions: Diabetes mellitus, peripheral vascular disease, bone and soft tissue cancer. Condition: Loss of independent existence permanent and irreversible Associated conditions: Multiple sclerosis, muscular dystrophy, motor neurone disease or any disease or disorder of the brain, spinal cord or column. Condition: Loss of speech permanent and irreversible Associated conditions: Stroke, transient ischaemic attack, motor neurone disease, brain or throat tumour, laryngeal polyps. Condition: Major organ transplant Associated conditions: Cardiomyopathy, coronary artery disease, cardiac failure, chronic liver disease, chronic pancreatitis, pulmonary hypertension, chronic lung disease or chronic kidney disease. Condition: Motor neurone disease Associated conditions: Progressive muscular atrophy, primary lateral sclerosis, progressive bulbar palsy. Condition: Multiple sclerosis Associated conditions: Any form of neuropathy, encephalopathy or myelopathy (disorders of functions of the nerves) including but not restricted to the following: abnormal sensation (numbness) of the extremities, trunk or face/weakness or clumsiness of a limb/ double vision/partial blindness/occular palsy/vertigo (dizziness)/difficulty of bladder control/optic neuritis/spinal cord lesion/abnormal MRI scan. Condition: Open heart surgery with surgery to divide the breastbone Associated conditions: Any disease or disorder of the heart, diabetes mellitus or any obstructive/ occlusive arterial disease. Condition: Paralysis of limbs total and irreversible Associated conditions: Multiple sclerosis, muscular dystrophy, motor neurone disease or any disease or disorder of the brain, spinal cord or column. Condition: Parkinson s disease resulting in Associated conditions: Treatment with dopamine antagonist, tremor, extra pyramidal disease. Condition: Progressive Supranuclear Palsy resulting in Associated conditions: Organic brain disease, disease of the central nervous system, Parkinson s disease, treatment with dopamine antagonist, tremor, extra pyramidal disease, depression, epilepsy, dementia, amnesic memory disorder, aphasia, psychosis. Condition: Respiratory failure of advanced stage Associated conditions: Any disease or disorder of the respiratory system including the lungs, bronchi and trachea. Condition: Rheumatoid arthritis chronic and severe Associated conditions: Inflammatory polyarthropathy. Condition: Stroke resulting in Associated conditions: Atrial fibrillation, transient ischaemic attack, diabetes mellitus, hypertension, intracranial aneurysm or occlusive arterial disease. Condition: Systemic lupus erythematosus with severe complications Associated conditions: Hughes syndrome, rheumatoid arthritis, and Sjogren s syndrome. Condition: Terminal illness Associated conditions: Any medical condition that is listed as a critical illness condition. Condition: Total permanent disability Associated conditions: Multiple sclerosis, muscular dystrophy, motor neurone disease, or any disease or disorder of the brain, spinal cord or column. Arthritis. Chronic or recurrent mental illness. Chronic or recurrent back, neck, joint or muscle pain. Chronic or recurrent fatigue. 6.2 General exclusions We will not pay a critical illness claim if it is caused directly or indirectly from the following: Self inflicted injury intentional self inflicted injury. In addition, exclusions for claims arising from certain specified medical conditions or for specified circumstances may be imposed on benefits that are subject to underwriting. 13

14 7 Can cover be provided for an employee who is not in the UK? Individual consideration will be given to covering employees who either work overseas or spend much of their time travelling overseas. In order to be considered the employees must satisfy the eligibility conditions of the scheme and normally be paid through the UK payroll. In order to grant cover we will need to know where the employee will work and the duration of the contract (see Risk factors ). 8 Taxation of schemes Normally schemes are financed by the employer with no contribution from employees. In this situation the cost to the employer is allowed as a trading expense and lump sum benefits are paid tax free (under current HM Revenue and Customs practice) to the member. The premiums are a benefit in kind for the members and are taxed under the PAYE system. HM Revenue and Customs does not normally grant tax relief on premiums paid for any members with a proprietorial interest in the company. However, they may sometimes grant tax relief provided that a substantial number of other employees are entitled to similar benefits. Clarification of the tax position in such cases should be sought from your local Inspector of Taxes. 9 Continuation option A continuation option allowing cover to continue for employees leaving service is not available. Further information Friends Life Group Critical Illness Protection is provided under a group critical illness insurance scheme by Friends Life Limited, part of the Friends Life group. Questions and complaints We want you to be entirely satisfied with your group critical illness scheme. If you have a query or complaint, then in the first instance please contact the financial adviser who arranged the scheme. If there was no adviser, please contact us directly. If this does not resolve the matter then please contact: Head of Group Protection, Friends Life Group Protection, 2nd Floor, Anchorage 1, Anchorage Quay, Salford Quays M50 3YL Call us on Calls may be recorded and may be monitored. If you meet the eligibility criteria set by the Financial Ombudsman Service you may refer the matter to the Financial Ombudsman Service, as detailed below. If you are complaining about the decision we have made on a claim we will consider any new medical evidence submitted by you or the employee. The medical evidence should support the contention that the employee or child of an employee has been diagnosed with one of the specified medical conditions or undergone one of the listed operations. Information should be sent to Friends Life Group Protection Claims Management Team, 2nd Floor, Anchorage 1, Anchorage Quay, Salford Quays M50 3YL. Any appeal by you or the employee must be made in writing within three months of receipt of notification from us of a claim being rejected. If a disagreement continues with regard to the claim decision following such written appeal the member may refer the question of whether he or she or their child has been diagnosed with one of the specified medical conditions or undergone one of the listed operations for the purposes of the policy to: The Financial Ombudsman Service South Quay Plaza, Marsh Wall, London E14 9SR Telephone or Financial Services Compensation Scheme In the unlikely event that we cannot meet our financial obligations, you may be entitled to compensation from the Financial Services Compensation Scheme (FSCS). This will depend on the type of business and the circumstances of your claim. The FSCS may arrange to transfer the policy to another insurer, provide a new policy or where appropriate, provide compensation. Further information about compensation scheme arrangements is available from FSCS on or at its website 14

15 Law The policy is issued subject to the law of England. Our standard policy provides that employees do not have any rights under the Contracts (Right of Third Parties) Act This means that there is no requirement to involve employees in day to day decisions on the administration and insurance of the scheme. However, under the standard policy the claims appeal procedure provides that following a decision by us concerning a claim, the employee may engage directly with us in order to ensure that the terms of the policy are met with regard to the claim. This promises vital protection and accounts for the majority of disputes in this type of insurance. Legislative changes HM Revenue and Customs rules regarding taxation of benefits and premiums may change in the future. This document is a guide to the features of the group critical illness product and should be read in conjunction with the quotation which accompanies it. Full details of the insurance are contained in the policy document in conjunction with the quotation. A copy of this document is available on request. List of critical illness conditions Benefit payment is subject to the diagnosis meeting the definition of the relevant condition or operation as given in the policy conditions. In the definitions of critical illness conditions and operations the following terms will have the meanings set out below: Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of the claim. Permanent Expected to last throughout the insured person s life, irrespective of when the cover ends or the insured person 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 insured person 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, eg brisk reflexes without other symptoms Symptoms of psychological or psychiatric origin. Standard schemes: Alzheimer s disease resulting in 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 except cutaneous lymphoma (lymphoma confined to the skin). 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 six or having progressed to at least clinical TNM classification T2N0M0. 15

16 chronic lymphocytic leukaemia unless histologically classified as having progressed to at least Binet Stage A. any skin cancer (including cutaneous lymphoma) other than: malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin) or the occurrence of a malignant basal cell carcinoma or malignant squamous cell carcinoma positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. To satisfy the definition of skin cancer in this bullet point, the skin cancer must have invaded and spread to lymph nodes or metastasised to distant organs. Cardiac Arrest Sudden loss of heart function with interruption of blood circulation around the body resulting in unconsciousness and resulting in either of the following devices being surgically implanted: Implantable Cardioverter-Defibrillator (ICD); or Cardiac Resynchronization Therapy with Defibrillator (CRT-D) 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. Dementia resulting in 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 a bone marrow, or transplant of a complete heart, kidney, liver, lung or pancreas, or transplant of a lobe of liver, or transplant of a lobe of lung, or inclusion on an official UK waiting list for such a procedure. For the above definition transplantation of any other organ is not covered: Motor neurone disease resulting in 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 three months. Parkinson s disease resulting in 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. Progressive supranuclear palsy resulting in A definite diagnosis of progressive supranuclear palsy by a Consultant Neurologist. There must be permanent clinical impairment of eye movements and motor function. 16

17 Stroke resulting in 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. Comprehensive schemes: The Comprehensive scheme covers all the conditions and operations included under the Standard scheme, as well as the following (and no others). Aorta graft surgery The undergoing of surgery to the aorta with excision and surgical replacement of a portion of the affected aorta with a graft. The term aorta includes the thoracic and abdominal aorta but not its branches. The following is not covered: Any other surgical procedure, for example, the insertion of stents or endovascular repair. 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 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. 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. 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 6/60 or worse in the better eye using a Snellen eye chart, or visual field is reduced to 20 degrees or less of an arc, as certified by an ophthalmologist. 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 A state of unconsciousness with no reaction to external stimuli or internal needs which: requires the use of life support systems; and 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 percent narrowing or blockage of two or more coronary arteries as a single procedure. Angiomas. 17

18 Creutzfeldt-Jakob disease resulting in 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 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; a physical assault; or an incident occurring during the course of performing normal duties of employment from the eligible occupations listed below: ambulance workers chiropodists dental nurses dental surgeons district nurses fire brigade firefighters general practitioners hospital caterers hospital cleaners hospital doctors, surgeons and consultants hospital laboratory technicians hospital laundry workers hospital nurses hospital porters midwives nurses employed by general practitioners occupational therapists paramedics physiotherapists podiatrists policemen and policewomen prison officers radiologists refuse collectors social workers after the start of 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 following is not covered: HIV infection resulting from any other means, including sexual activity or drug misuse. 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. 18

19 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 insured 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 there must be arthritis of at least three joint groups with soft tissue swelling or fluid observed by a physician the arthritis must involve at least one of the following sites: wrists or ankles hands and fingers feet and toes there must be symmetrical arthritis there must be subcutaneous nodules there must be radiographic changes typical of rheumatoid arthritis. Systemic lupus erythematosus with severe complications A definite diagnosis of systemic lupus erythematosus by a Consultant Rheumatologist resulting in either of the following: permanent neurological deficit with persisting clinical symptoms; or the permanent impairment of kidney function tests as follows: Glomerular Filtration Rate (GFR) below 30 ml/min. Terminal illness Advanced or rapidly progressing incurable illness where, in the opinions of an attending Consultant and our Chief Medical Officer, the life expectancy is no greater than twelve months. We shall not consider a claim for this event submitted after the death of the member. Third degree burns covering 20 percent of the body s surface area or 30 percent loss of surface area to the face Burns that involve damage or destruction of the skin to its full depth through to the underlying tissue and covering at least 20 percent of the body s surface area or 30 percent loss of surface area of the face which for the purposes of this definition includes the forehead and ears. 19

20 Traumatic head injury resulting in Death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms. Total permanent disability unable to do a suited occupation ever again Loss of the physical or mental ability through an illness or injury to the extent that the member is unable to do the material and substantial duties of a suited occupation ever again. The material and substantial duties are those that are normally required for, and/or form a significant and integral part of, the performance of a suited occupation that cannot reasonably be omitted or modified. A suited occupation means any work the member could do for profit or pay taking into account their employment history, knowledge, transferable skills, training, education and experience, and is irrespective of location and availability. The relevant specialists must reasonably expect that the disability will last throughout life with no prospect of improvement, irrespective of when the cover ends or the member expects to retire. Total permanent disability unable to do your own occupation ever again Loss of the physical or mental ability through an illness or injury to the extent that the member is unable to do the material and substantial duties of their own occupation ever again. The material and substantial duties are those that are normally required for, and/or form a significant and integral part of, the performance of the member s own occupation that cannot reasonably be omitted or modified. Own occupation means a member s trade, profession or type of work they do for profit or pay. It is not a specific job with any particular employer and is irrespective of location and availability. The relevant specialists must reasonably expect that the disability will last throughout life with no prospect of improvement, irrespective of when the cover ends or the member expects to retire. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered. Friends Life Group Protection reserves the right not to include Total Permanent Disability cover, or offer the cover on a different basis for certain occupations. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered. Friends Life Group Protection reserves the right not to include Total Permanent Disability cover, or offer the cover on a different basis for certain occupations. 20

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22 Friends Life provides a range of pensions, investments and insurance products and services. We have a heritage dating back over 200 years and now look after over 5 million customers worldwide. We focus on ways of helping people achieve greater long-term financial security for themselves and their families. We re always looking for new solutions that are more effective, more relevant and more valuable for our customers. We offer a comprehensive range of group protection products including: - Group critical illness protection - Group income protection - Group life protection For more information, please call Calls may be recorded and may be monitored. Friends Life Limited An incorporated company limited by shares and registered in England and Wales, number Registered office: Pixham End, Dorking, Surrey RH4 1QA. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Calls may be recorded. Friends Life is a registered trade mark of the Friends Life group. BGR/4532/NOV12