Proposed Policy wording Absa Accidental Death and Permanent Disability Plan March 2011

Transcription

1 Proposed Policy wording Absa Accidental Death and Permanent Disability Plan March 2011 Contents Terms of contract This explains the basis of the contract Description of cover This explains the cover and when and how we will compensate you Definitions This explains commonly used words and phrases Table of Benefits This shows the benefits and s of cover Extensions This explains the additional covers of the policy General Conditions These are conditions which apply throughout the policy Claims information This explains the claiming procedures and conditions Exclusions This explains what is not covered under the policy Important disclosures and contact details This details important information which we must disclose to you Terms of contract This policy is underwritten by Absa Life Limited, Reg No 1992/001738/06. We agree to provide insurance under this policy during any period of insurance for which you have paid premium. We will accept any proposal or declaration that you have made as true and use that information as the basis of the contract. You must read the policy wording and schedule together as one contract. If we make any changes to your policy wording or schedule, it will form part of the policy. When and how we will compensate you This policy will cover you and/or your spouse and children who you have nominated for cover and who are listed on the policy schedule. If any insured person is injured in an accident during the period of insurance, leading to accidental death or permanent disability within 24 months of the accident, we will pay you the benefit shown in the Table of Benefits. Payment of benefits is based on the plan you chose when you took out the policy and when an accident happens. Definitions 1. Accident means an unexpected and specific future event, caused only by violent, accidental, external, physical and visible means, which occurs at a time and place that can be identified, which results in injury. 2. Beneficiary or Beneficiaries means the person or people nominated by you to receive Benefits 3. Benefit means the s shown in the Table of Benefits. 4. Children means your natural or legally adopted unmarried children or step children between the ages of 6 months and: 18 years, or 25 years if the child is a full time student attending an accredited school, college or university and still depends on you for support. 5. Inception date means the date when your first premium is collected, which is when the cover starts. 6. Injury means bodily injury or physical trauma to an insured person. 7. Insured person means you, your spouse and children who have been nominated for cover, and reside in the Republic of South Africa. 8. Legally Appointed Representative means the person who will manage your legal affairs if you are incapable of doing so or dead. 9. Loss of Limb or Limbs means physical removal or the total and permanent loss of use of an arm or leg. 10. Loss of Hearing means the complete and permanent loss of hearing of all sounds. 11. Loss of Sight means the complete and permanent loss of sight. 12. Loss of Speech means injury to the vocal chords resulting in inability to make understandable words or language, continuing uninterrupted for 24 months. 13. Medical Practitioner means a person currently legally licensed and registered to practice medicine in the Republic of South Africa, not including the insured person or members of his or her immediate family. 14. Medical Treatment means a medical practitioner s medical advice, treatment, consultations, and prescribed or repeat medication. 15. Period of Insurance means from the inception date of the policy and while you continue to pay premiums, until your policy is cancelled or terminated. 16. Policy means this document, the schedule, the application form and any information provided during the application process and includes any later changes made to the policy. 17. Professional sport means sport from which the insured person earns 50% or more of their income. 18. Spouse means your lawful or common law spouse or life partner who permanently lives with you. Example: If you and your life partner live together in the same house, that person will be considered to be your spouse.

2 19. You/Your means the policyholder, who has taken out this cover and is paying the monthly premium. 20. We/ Us /Our means Absa Life Limited. TABLE OF BENEFITS Accidental Death: As a result of an accident Disappearance of an insured person for a period longer than 24 consecutive calendar months As a result of exposure to the elements of nature Loss of 2 or more limbs Loss of one limb Loss of sight in both eyes Loss of sight in one eye Loss of speech Loss of hearing Loss of hearing in ear Maximum payable for any one claim Accumulation limit BENEFIT INSURED PERSON BENEFIT SPOUSE BENEFIT CHILDREN Benefits for children are limited to: Birth to 5 years R10, years and older R30,000 Extensions that apply to your policy Disappearance If any insured person disappears and: it is likely that he/she could have died as a result of an accident, and is legally declared dead. we will pay the benefit for Accidental Death. If it later becomes known that the insured person did not die as a result of an accident, you or your legally appointed representative must pay the benefit back to us. Exposure to the elements of nature If any insured person is involved in an accident, and because of that accident is left without protection from harsh weather conditions, which then results in his/her death, we will pay the benefit for Accidental Death. Example: If you were hiking alone, you could fall and break your leg and be unable to call for help. If you then died because you were exposed to extreme cold overnight, the claim would be covered. General Conditions 1. This policy is governed by the laws of the Republic of South Africa. 2. The courts of the Republic of South Africa have the right to hear any matters about this policy. 3. If there are differences between this policy and any other information that you have received about your policy, this policy will be considered correct. 4. We will not be responsible for any tax liability that you may incur when we pay you any benefit. 5. This policy replaces or substitutes any Absa Accidental Death and Permanent Disability policies that have previously been issued to you. 6. We may change any part of this policy by giving you 30 days written notice. 7. We will automatically renew your policy on a monthly basis, as long as you pay your premium on time. The policy will be renewed as is, unless we tell you that we have made changes. 8. You can cancel this policy within 30 days of receiving our policy summary, and we will refund you any premium you have paid. You must send us your cancellation in writing. We will not refund you any premium if you have claimed or received any benefits under the policy. We will deduct the cost of providing you with cover up until the time we receive your cancellation from any premium refund. Age entry and limits Insured Person Entry age Cover end age You years 80 years Your Spouse years 80 years Your children 6 months 18 years or years or 25 years if a

3 years if a full time student (see definition) full time student (see definition) If you have not given us the correct ages: We will only pay the benefit for the correct age, or, If we would not have given cover at all, we will refund you the premiums and no claims will be paid. Cancellation and termination of your policy You can cancel this policy by giving us one calendar month s notice in writing. We can cancel this policy by giving you thirty days notice in writing, sent to your last known address. Your policy will end: On your 80 th birthday, or If you do not pay your premium, or If you die Premium Payments You must pay your premiums monthly in advance by debit order. If you do not pay your premium on time, you have a 15 day grace period to pay. If you do not pay your outstanding premium during the grace period, cover shall cease until the premium is paid in full. We will attempt to debit your account with two premiums on your next chosen debit order date. If you do not pay two consecutive premiums, we will cancel your policy with effect from the first returned debit order date. If you claim during the 15 day grace period, we can deduct the premium due by you from your claim. Due to legislation, we are required to process all debit orders on a random basis without preference to any institution. We therefore use a system which will allow us to resubmit your debit order after the agreed payment date if it is returned due to insufficient funds. This will ensure that your valuable cover remains active by keeping your premiums up to date. If your chosen debit order date falls on a weekend or public holiday, we will debit you on the last working day before this date. Screening of Application, Instructions and Transactions We are part of a global financial institution and at all times obey international and local legal requirements governing: Money Laundering Terrorist financing Financial Sanctions Prohibited business activities We may screen, verify and monitor any of your information at any time. This could cause: Delays in us carrying out certain transactions Us not being able to carry out certain transactions at all Us ending our business relationship with you Should this happen, we will inform you of any action we intend to take, to the extent that we are able to. We, and any person connected to us, will not be liable for any loss that you may suffer as a result of this action. Claims information Claims Procedure If you or your legally appointed representative need to claim under this policy, please contact us. You or your legally appointed representative must notify us of a claim within 30 days of an accident Payment of benefits 1. This policy cannot be transferred. Only you have rights under this policy against us. Example: If you were applying for a loan, you couldn t use this policy as a security. 2. We will only pay benefits to you, your nominated beneficiary/ies or your estate. 3. We will not pay any benefits if an insured person does not meet all requirements contained in this policy 4. We will not pay interest on any benefit payment. 5. If you have more than one policy with us that includes accidental death benefits, we will add the benefits together and will not pay more than R in total. 6. If you have more than one policy with us that includes permanent disability benefits, we will add the benefits together and will not pay more than R1,000, If you are claiming for multiple injuries, we will add the benefits together, but will not pay more than the maximum payable. 8. Any changes in cover to your policy will only apply to claims that happen after the effective date of these changes. 9. We will not pay benefits until the total claim has been agreed. We may choose to make interim payments. 10. We will only make payments into a valid South African bank account in South African Rands. Claims conditions General You must prove claims with medical evidence that we ask for. Example: In order to properly assess a claim for one of the permanent disability benefits, we will need specialist medical reports. We can ask that any insured person have a medical examination at our cost. We can choose to have your claim reviewed by a medical practitioner or nurse.

4 An insured person must seek and follow qualified medical advice without delay. If he or she does not, we will not pay the part of any claim which, in the opinion of our medical practitioner, is because of his or her failure to do so. If a claim is because of a criminal incident, you must give us a certified police report. Claims conditions for permanent disability benefits If you have any existing medical or abnormal physical condition, and are involved in an accident, we will only pay for the degree of disability that resulted from the accident. We will calculate this by taking into account your existing physical condition before the accident and the degree of permanent disability after the accident. If you die from natural causes before the final disability assessment can be done, we will pay what we reasonably could have paid. True and honest information You must at all times give us true and honest information. We can reject your claim and cancel your policy if you did not give us true, correct and complete information about yourself when you applied for insurance or when any of your information changed. We can reject your claim and cancel your policy if you do not give us true, correct and complete information when claiming. If we pay you any benefits and find out later that the information you gave us was not true, correct and complete, you must pay us back the benefit as soon as we ask for it. Time limits if we do not accept your claim If we do not accept your claim, we will inform you in writing. You may write to us about our decision within 90 days of our notice to you. We will then consider the matter and inform you in writing within 30 days whether we have changed our decision or if we still stand by it. If you are not satisfied with our decision, you may take the matter further with the Ombudsman for Long-term Insurance. No benefits will be payable if legal proceedings are not commenced within 365 days of any disclaimer of liability by us. Exclusions No benefit will be payable if an insured event is as a result of, by or from: 1. war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, rebellion, revolution, insurrection or military or usurped power, labour disturbances, riot, strike or lock-out; or 2. the intentional use of military force to intercept, prevent, or mitigate any known or suspected Terrorist Act; or 3. Being in service or on duty with or undergoing training with any military or police force, or militia or paramilitary organisation; or 4. Injury arising from any criminal or illegal act committed by an insured person; or 5. For the insured person travelling by air, except as a passenger on a legally licensed commercial aircraft; or 6. Self-inflicted injury, suicide, or attempted suicide, insanity or any acute and/or chronic psychiatric, psychological or emotional condition; or 7. Investigations, operations or treatment of a purely cosmetic nature, for obesity, to cure or improve impotency or undertaken to facilitate pregnancy; or 8. Injury caused by, traceable to, prolonged by or otherwise affected by any physical defect, infirmity or condition existing prior to the effective date of this policy; or 9. congenital abnormalities from which the insured person suffered at any time before the inception date of this policy and any conditions arising or resulting therefrom; or 10. diabetes or epilepsy; or 11. Mental disorders including, but not limited to anxiety disorders, eating disorders, psychotic disorders, affective disorders, personality disorders, substance use disorders, somatoform disorders, dissociate disorders, psychosexual disorders, adjustment disorders, organic mental disorders, mental retardation and autism; or 12. (a) being under the influence of alcohol, drugs or narcotics unless such drugs or narcotics were administered by a medical practitioner (other than the insured person) or unless prescribed by and taken in accordance with the directions of a medical practitioner (other than the insured person), (b) driving a motor vehicle and having more than the legal limit of alcohol in his blood. The onus will rest upon the insured person or the beneficiaries to prove that a) or b) was not the cause of the accident; or 13. the insured person participating in any sport as a professional player; or 14. the insured person engaging in motor cycling (where the engine capacity exceeds 200cc or the cycle is under control of an unlicensed rider), steeple chasing, polo or horseback riding, hunting, bungee jumping, abseiling, white water rafting, hiking (unless accompanied by a recognised guide or on a clearly marked trail), mountaineering, scuba diving (unless licensed and/or accompanied by a qualified instructor),potholing, fighting (except in bona-fide self defence), racing (other than on foot or under sail in in-land waters), speed or endurance racing or practise thereof (other than athletics), or any hazardous pursuits or activities or pastimes, or training for or engaging in contact sports; or 15. the insured person s wilful or deliberate exposure to danger (except in an attempt to save human life); or 16. engaging in underground occupational activities or occupational activities requiring the use of explosives; or 17. injury arising from any Terrorist Act or bomb or threat thereof; or 18. the use, release or escape of nuclear materials that directly or indirectly results in ionising, radiation or contamination by radioactivity from any nuclear fuel or from nuclear weapons materials. For the purpose of this exclusion only combustion will include any self-sustaining process of nuclear fission; or 19. the dispersal or application of pathogenic or poisonous biological or chemical materials. 20. All exclusions shall apply to: (a) Any subsequent increase in benefits from the date of such increase. (b) Any insured person being added to this policy from the date of his acceptance onto the policy. Important Disclosures and Contact Information This policy is underwritten by: Absa Life Limited, Reg. No. 1992/001738/06 Absa Financial Services Building 21 Kruis Street PO Box Absa Life Limited, Reg. No. 1992/001738/06 will appoint a third party to sell this product on our behalf. The third party will receive commission.

5 Administration Queries Please contact Computer Facilities on Claims Please contact Absa Life Complaints Resolution If you have a complaint about this policy, please contact: The Chairman of the Complaints Resolution Committee PO Box Fax: Absa Life Limited Compliance Officer Absa Financial Services Building PO Box Kruis Street Tel: Ombudsman for Long term Insurance Tel: Private Bag X 45 Fax: Claremont Share call: info@ombud.co.za