GENERAL PROVISIONS SAMPLE

Transcription

1 GENERAL PROVISIONS 1. ENTIRE CONTRACT The insurance plan, including the Policy Schedule, the attached tables and the application, constitutes the entire contract between the parties. 2. DEFINITIONS "Company" refers to Desjardins The policyowner is the person who applied for the contract or his assigns. If this contract is subject to Quebec law, the policyowner may exercise the rights conferred on the policyowner without the consent of the beneficiary, even a beneficiary designated as irrevocable. The beneficiary is the person to whom money is payable. Unless otherwise specified in the application, the money is paid to any beneficiary (in equal shares if more than one) who survives the applicable person whose life is insured or, if no beneficiary survives the person whose life is insured, the money is payable to the policyowner, if living, or the policyowner's estate. The policyowner may change the designation of a beneficiary named as an irrevocable beneficiary with the written consent of such person. Policy years will be computed from the initial date, and each anniversary of the initial date is a policy anniversary. Policy years are used, if applicable, to determine the termination of an insurance benefit as well as items such as the premium, amount of insurance, cash value and dividends. The initial date does not establish the date when insurance begins. SUICIDE If any person whose life is insured under this contract commits suicide, whether sane or not, and the death occurs within one year of the date insurance first began under any plan or benefit of this contract, no benefits will be paid. MODIFICATION Any change will be effective only if the policyowner requests it, and the Company gives its written approval signed by one of its officers. CLAIMS Each claim must be in writing, and supported by proof of all necessary facts. The Company may require production of the plan and all information or documents that it considers necessary to prove the claim. CURRENCY All payments are to be made in Canada in Canadian money. ASSIGNMENTS AND OTHER DOCUMENTS The Company is not bound by any documents that affect rights under this contract unless the document itself, or written notice of it, is sent to us at our Head Office. The Company is not responsible for ensuring that any such document is valid or has the desired effect. Page 1 of 12

2 PROMO ACCILIFE PLUS PURPOSE OF THE COVERAGE The coverage includes the following benefits: 1. DEATH BENEFIT 2. ACCIDENTAL DEATH OR DISMEMBERMENT BENEFIT 3. ACCIDENTAL FRACTURE BENEFIT 4. EMERGENCY HEALTH CARE IN CASE OF ACCIDENT WHILE TRAVELLING BENEFIT 1. DEATH BENEFIT a) BENEFIT PAYABLE The Company will pay to the policyowner or the beneficiary if designated the amount of insurance if the person insured under this coverage dies while this coverage is in force. The amount of insurance is $5,000. b) EXCLUSIONS In those cases, no payment will be made under this benefit by the Company: When, at the date of death, the person insured under this coverage has not reached the age of 15 days or; When the person insured s cause of death is due to a health problem diagnosed by a physician or for which the insured has received one or more treatments prior to the effective date of the contract. Page 2 of 12

3 2. ACCIDENTAL DEATH OR DISMEMBERMENT BENEFIT a) BENEFIT PAYABLE If any person who is insured under this provision suffers any of the losses shown in the Table of Losses below subsequent to an accident, the Company will pay, subject to prescribed limitations and upon receipt of satisfactory proofs, the applicable amount of insurance shown below. The loss must be sustained within 365 days following the date of the accident, whatever the loss is. Any amount payable under this benefit as the result of accidental death is payable to the policyowner or the beneficiary if designated. All other amounts are payable to the policyowner. b) TABLE OF LOSSES LOSS OF AMOUNT OF INSURANCE Life $25,000 Either both hands or both feet $25,000 Sight of both eyes $25,000 One hand and one foot $25,000 One foot and the sight of one eye $25,000 One hand and the sight of one eye $25,000 One hand or one foot $12,500 Sight of one eye $12,500 The amount paid by the Company will be twice the amount stated above, if the insured person sustains an accident in one of the following: when travelling as a paying passenger on a regular line of public transport; while on an elevator or escalator intended for use of the public; when a public building is on fire or when one of its exterior walls collapses (excluding a building which is solely or partly residential) provided that the person insured is inside the building when the fire starts or when the wall collapses; because of lightning, a hurricane or a cyclone reported by the weather bureau of the region where the accident took place. c) LIMITATIONS Only one of the losses mentioned above is payable as a result of any one accident. When the insured person sustains more than one of the losses mentioned above subsequent to the same accident, the total of the amounts paid cannot exceed $25,000. d) DEFINITIONS "Accident" means any bodily injury sustained while this benefit is effective and produced directly and independently of any other cause, by the sudden, violent, and unforeseen action of an external cause. "Loss of" one hand, one foot or the sight of one eye means respectively the complete and irreparable loss of use of one hand, one foot or one eye. Page 3 of 12

4 e) EXCLUSIONS No payment will be made under this benefit by the Company if the insured person sustains the loss resulting directly or indirectly from: deliberate actions by the insured person, whether sane or insane; the insured person's participation in any criminal act or an attempt; war, whether war be declared or not, armed conflict, or any related act; the insured person's participation in a public commotion, riot, revolution or insurrection; exercising or attempting to exercise the duties of an aircraft crewmember, or taking part in any aviation training or instruction course; driving a motor vehicle while the insured person is under the influence of alcohol, narcotics or illicit drugs; The Company has the right to have any person who suffers a loss examined by a medical practitioner and, in the event of death, to obtain a report on any autopsy to the extent permitted by law. f) CLAIM Any claim must be filed in writing and sent to the Company during the thirty-day (30) period following the date of the sustained loss or as soon as it is reasonably possible to do so. However, the claim must be filed during the year following the date of the loss. g) EVIDENCE OF LOSS The rightful claimant must provide the Company with evidence of the loss sustained during the ninety-day (90) period which follows the date of the loss or as soon as it is reasonably possible to do so. The Company shall pay no benefit as long as satisfactory evidence of loss has not been provided. Page 4 of 12

5 3. ACCIDENTAL FRACTURE BENEFIT a) BENEFIT PAYABLE If any person insured under this provision sustains a fracture or a complete severance subsequent to an accident, the Company will pay, subject to prescribed limitations and upon receipt of satisfactory proofs, the amount of insurance in accordance with the table below. For the benefit to be payable, the fracture must be diagnosed during the 30-day period following the accident. Any amount payable under this benefit as the result of accidental fracture is payable to the policyowner. b) TABLE OF CLAIMS FRACTURE SUM INSURED Of the skull (dome of the skull) $2,500 Of the spine (excluding the coccyx) $2,500 Of the pelvis $2,500 Of the femur $2,500 Of a rib $ 750 Of the sternum $ 750 Of the scapula $ 750 Of the humerus $ 750 Of the patella $ 750 Of the tibia $ 750 Of the fibula $ 750 Of a bone not listed above $ 250 The amount paid by the Company will be twice the amount stated above, if the insured person sustains an accident in one of the following: when travelling as a paying passenger on a regular line of public transport; while on an elevator or escalator intended for use of the public; when a public building is on fire or when one of its exterior walls collapses (excluding a building which is solely or partly residential) provided that the person insured is inside the building when the fire starts or when the wall collapses; because of lightning, a hurricane or a cyclone reported by the weather bureau of the region where the accident took place. c) LIMITATIONS A benefit is payable for each fracture or complete severance, provided each fracture or complete severance results from a different accident. When the insured person sustains more than one fracture or complete severance subsequent to the same accident, the Company will pay a benefit only for the fracture or complete severance which gives entitlement to the highest amount. Page 5 of 12

6 d) DEFINITIONS For the purposes of this benefit, the expression: a. "accident" means any bodily injury sustained while this benefit is in-force and produced directly and independently of any other cause, by the sudden, violent and unforeseen action of an external cause; b. "fracture" means the violent rupture of a bone; c. "complete severance" means the sectioning of a bone into at least two parts resulting in the complete and irreparable loss. e) EXCLUSIONS No payment will be made under this benefit by the Company if the accidental fracture results directly or indirectly from: deliberate actions by the insured person, whether sane or insane; the insured person's participation in any criminal act or an attempt; war, whether war be declared or not, armed conflict, or any related act; the insured person's participation in a public commotion, riot, revolution or insurrection; exercising or attempting to exercise the duties of an aircraft crewmember, or taking part in any aviation training or instruction course; bodily or mental infirmity, illness or disease of any kind; driving a motor vehicle while the insured person is under the influence of alcohol, narcotics or illicit drugs; insured person's participation in a sporting activity for which the insured person receives remuneration. Furthermore, no payment will be made by the Company if the insured person sustains an accident and dies subsequent to this accident during the 30-day period following it; the death benefit payable under the contract is then reduced by any benefit already paid under this benefit. When a claim is filed, the Company has the right to have the insured person examined, at its own expense, by a medical practitioner of its choice. f) CLAIM Any claim must be filed in writing and sent to the Company during the thirty-day (30) period following the date of the sustained loss or as soon as it is reasonably possible to do so. However, the claim must be filed during the year following the date of the loss. g) EVIDENCE OF THE LOSS The rightful claimants must provide the Company with satisfactory evidence of the fracture or complete severance within the 90-day period following the date of the accident, or as soon as it is reasonably possible to do so. The Company will pay no benefit as long as the satisfactory evidence of the fracture or complete severance has not been provided. Page 6 of 12

7 4. EMERCENCY HEALTH CARE IN CASE OF ACCIDENT WHILE TRAVELLING a) BENEFIT PAYABLE This benefit provides for reimbursement to the policyowner of the eligible expenses incurred by an insured person in the first 9 days of any trip outside his province of residence if: these expenses are not reimbursed by a government agency or by any other private insurance plan; and the insured person is covered under the government health and hospital insurance plan in his province of residence. The Company provides for the reimbursement of the eligible expenses incurred by the insured person as of: the moment he crosses the border of his province of residence; or the moment of take-off, if he is travelling by airplane. No reimbursement of eligible expenses will be made once: the insured person returns to his province of residence and crosses the border; or the airplane on which the insured person is travelling lands in his province of residence. To be eligible, the expenses incurred must be reasonable and necessary for the treatment of the insured person. They must also be incurred in an emergency situation further to an accident. The maximum amount reimbursed by the Company under this benefit is limited to $10,000 per accident, per insured person. b) DEFINITIONS Accident: a sudden and unforeseen event arising from an external cause that results in bodily injury or death. The injury or death must be certified by a physician and be directly and solely the result of the accident. Canadian resident: a person who: lives in a Canadian province or territory; has lived in Canada for at least 183 days in the 12 months prior to the date of a claim; and is covered under the health insurance plan and hospital insurance plan from his province of residence. Commercial vehicle: any type of an air, sea or land vehicle used for business purposes, including revenueproducing activities or activities for which expenses may be deducted from business income or as a self-employed worker. Family members: spouse, sons, daughters, father, mother, brothers, sisters, father-in-law, mother-in-law, grandparents, grandchildren, half-brothers, half-sisters, brothers-in-law, sisters-in-law, sons-in-law, daughters-inlaw, uncles, aunts, nephews and nieces. Illness: deterioration in health or bodily disorder certified by a physician. Organ donations and related complications are also considered to be illnesses. Insured person: a Canadian resident insured under this contract for whom the Company can reimburse the eligible expenses incurred. The name of the insured person is indicated in the Policy Schedule. Page 7 of 12

8 Necessary for the treatment: means care, services, items, appliances, supplies or medication recommended by a physician or specialist that the Company determines to be: appropriate in view of the symptoms, diagnosis and treatment of the insured person's illness or injury; provided in accordance with federal standards of medical practice; prescribed in accordance with the most appropriate dose or quantity. However, the fact that the insured person's attending physician recommends care, services, items, appliances, supplies or medication does not mean that the Company automatically considers them necessary for the treatment of the insured person and covered under this contract. Nurse: any person, other than the insured person or a person who works with the insured person, who is licensed to practice his profession in the region where he is providing care. The nurse must also not be a family member of the insured person or live with him. Physician: any person, other than the insured person or a person who works with the insured person, who is licensed to practice medicine in the region where he is providing care by a competent authority. The physician must also not be a family member of the insured person or live with him. Province of residence: Canadian province or territory where the insured person resides. Reasonable charges: fees paid for treatment, care, services, items, appliances and supplies that do not exceed those normally charged in the area where they are provided. Reimbursement: the amount that the Company reimburses for the eligible expenses incurred by an insured person in accordance with the provisions of the contract. Specialist: any person, other than the insured person or a person who works with the insured person, who is licensed to practice medicine in the region where he is providing care by a competent authority. The specialist must be practicing in the field related to the diagnosed illness or health condition. The specialist must also not live with the insured person or a member of his family. Treatment: treatment must relate to a given injury or illness or its related symptoms. It includes: hospitalizations; medical exams; surgeries; taking medication; and consultation or any other care or services recommended by a physician, or a specialist. Vehicle: a car, motorcycle, motor home or van with a maximum load capacity of 1,000 kilograms. c) EXPENSES ELIGIBILITY a. The following conditions must be met for the expenses incurred for treatment, care, services, items, appliances, supplies and medication to be eligible under this benefit, unless otherwise indicated. The expenses must be incurred while the contract is in force. The expenses incurred for care, services, items, appliances, supplies and medication must be reasonable. The expenses incurred for care, services, items, appliances, supplies and medication must be necessary for the treatment of the insured person. Page 8 of 12

9 b. Detail regarding eligible expenses The Company considers that the eligible expenses are deemed to have been incurred on the date the service, treatment or care was provided or the date the appliances, items, supplies or medication were obtained. The necessary proof must be submitted to the Company for the eligible expenses incurred by the insured person to be eligible for reimbursement. d) ELIGIBLE EXPENSES 1) Hospital care Hospitalization in a semi-private room (two beds) or, if required by the insured person's state of health, private accommodation (one bed). 2) Medical care and services The care and services of a physician, a surgeon and an anesthetist. 3) Medical care and services provided on the recommendation of a physician Lab tests and X-rays. Private duty nursing provided while confined to a hospital. Drugs that can only be obtained on a prescription of a physician. The purchase or rental of crutches, canes, splints, or the rental of a wheelchair, respirator or other medical or orthopedic appliances. The total rental cost of any of these items must not exceed the purchase price of the item. 4) Transportation expenses e) CLAIMS Expenses to transport the insured person to the nearest facility where appropriate medical treatment is provided. Claims must be sent to the Company within 6 months following the date of the accident that may give rise to a reimbursement. Claims submitted by an insured person while he is not a Canadian resident will be refused by the Company. The Company may request any information, evidence or document that it deems necessary to analyze a claim. f) RIGHT OF SUBROGATION Once it reimburses or agrees to reimburse the expenses incurred, the Company substitutes itself for the insured person in terms of all the rights to recover its loss from any person and may institute legal proceedings on behalf of the insured person to enforce these rights. Page 9 of 12

10 g) LIMITATIONS 1) During the contract period, the total number of days during which an insured person can be insured under this benefit is limited to 90 days. This 90-day limit applies regardless of the number of trips taken by the insured person during the contract period and it includes the day the insured person leaves his province of residence and the day he returns for each trip taken. 2) The prescription drugs taken when the insured person is not hospitalized are limited to a 30-day supply. h) EXCLUSIONS No reimbursement will be made in the following cases. 1) If the expenses incurred result from an illness. 2) If the expenses incurred are related to an accident that occurs while the insured person was using narcotics or abusing drugs or alcohol. Abusing drugs means exceeding the dosage recommended by a health specialist. 3) If expenses incurred by the insured person outside his province of residence are related to care not covered under the hospital insurance plan in his province of residence. 4) If the expenses are incurred in a region or a country that the Canadian government has advised Canadians against visiting prior to the start of the trip. This exclusion does not apply, however, if it can be demonstrated that the situation in the country visited did not contribute to the expenses incurred. 5) If the expenses incurred are related to an accident that results from participating in the following activities: gliding; hang gliding; parachuting; mountain climbing; climbing; bungee jumping; or rodeo. 6) If the expenses are incurred further to: the insured person's participation in a motor vehicle competition; training of the insured person in order to participate in a motor vehicle competition. The definition of "motor vehicle" is not limited to the definition of "vehicle" shown in this section. It also includes all means of transportation that use one or more engines. 7) If the expenses result from the insured person's participation in sports or underwater activities as a professional. "Professional" means a person who engages in a gainful activity from which he derives his main source of income. 8) If the expenses result from the insured person participating in scuba diving as an amateur. This exclusion does not apply, however, if he holds a basic scuba diving licence from a certified dive school. Page 10 of 12

11 9) If the insured person is travelling in a commercial vehicle of which he was the driver, pilot, crew member or non-paying passenger. This exclusion does not apply if the insured person was using the vehicle in question solely as a means of private transportation on vacation and if it was one of the following vehicles: a car; a van with a maximum load capacity of 1,000 kg; a road vehicle in which he is not travelling as a driver. 10) If the insured person is travelling aboard an aircraft free of charge. In this case, the term "aircraft" means any craft capable of flight. 11) If the expenses incurred are a direct or indirect result of: the insured person's participation in any criminal act or an attempt; war, whether war be declared or not, armed conflict, or any related act; the insured person's participation in a public commotion, riot, revolution or insurrection; an accident that occurs while the insured person is performing duties as a member of the armed forces of any country. 12) If the expenses incurred are reimbursed under any public plan. 13) If the expenses incurred are reimbursed by a government body or agency, such as the health insurance plan or the hospital insurance plan in the insured person's province of residence. 14) If the expenses are reimbursed under a provincial or federal law. 15) If the expenses incurred are prohibited under a provincial or federal law. 16) If the expenses are incurred outside the insured person's province of residence and they exceed the charges that the Company deems to be reasonable. In this case, the Company limits the reimbursement to the reasonable charges only. i) BENEFIT COORDINATION The total amount of the reimbursements provided for by all the public or private insurance plans under which a person is insured may never exceed the amount of expenses actually incurred. If a person insured under this contract is also insured under another plan that does not have a coordination of benefits clause, the reimbursement provided for under this other plan must be applied first. The Company's responsibility under this policy is then limited to the balance of eligible expenses actually incurred. If the other plan contains a coordination of benefits clause, the initial reimbursement is the responsibility of the plan under which the insured person is not considered a dependent. The unpaid eligible expenses are then the responsibility of the plan under which the insured person is considered a dependent. However, if the primary insured holds at least one other plan under which he is not considered a dependent, the reimbursement provided for under this other plan must be applied first, whether for himself or his dependents. The responsibility of the Company is then limited to the balance of eligible expenses actually incurred. In the case of children, the initial reimbursement comes under the plan of the insured spouse whose birthday occurs first in the calendar year. Any unpaid eligible expenses are then payable under the plan of the other spouse. The Company may, subject to the consent of the insured person if required by law, obtain from any person or communicate to the insured person any information that could: be required to apply this clause; or facilitate the reimbursement of benefits under this contract. Page 11 of 12

12 TERMINATION This coverage terminates on the earliest of the following dates: a) the expiry date set out in the Policy Schedule; b) the date corresponding to the first policy anniversary of the coverage. PERSONAL INFORMATION MANAGEMENT Desjardins Financial Security Life Assurance Company (DFS) handles the personal information it has on you in a confidential manner. DFS keeps this information on file so that you can benefit from the financial services (insurance, annuities, credit, etc.) it offers. This information is consulted solely by DFS employees who need to do so in the course of their work. You have the right to consult your file. You may also have information corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a written request to the following address: Privacy Officer, Desjardins Financial Security Life Assurance Company, 200, rue des Commandeurs, Levis, Quebec, G6V 6R2. DFS uses service providers located outside of Canada to perform certain specific activities in its normal course of business. As such, personal information may be transferred to another country and be subject to the laws of that country. For information about DFS's policies and practices regarding the transfer of personal information outside of Canada, visit the DFS Website at or write to the DFS Privacy Officer at the address indicated above. The Privacy Officer can also answer any questions about the transfer of personal information to service providers located outside of Canada. DFS can send promotional information or offer new products to individuals whose names appear on its client list. DFS may also give its client list to another component of the Desjardins Group for the same purposes. If you do not want to receive such offers, you may have your name removed from the list by sending a written request to the Privacy Officer at DFS. Page 12 of 12