Living Expenses Cover

Transcription

1 Living Expenses Cover Policy Wording Putting plans in place for the future

2 Welcome to AA Life Helping put plans in place for the unexpected AA Life Services Limited is pleased to provide you with the confidence of knowing that if you re unable to work due to sickness or injury, you could receive the financial support you need. AA Life policies are provided and underwritten by Asteron Life Limited. AA Life s contact details are: Asteron Centre Level 13, 55 Featherston Street Wellington, 6011 PO Box 894, Wellington, 6140 New Zealand Telephone Fax Please call us if you need any information on your policy. 1. Understanding this policy Please carefully read this Policy Wording and the separate Policy Summary that goes with it. this Policy Wording contains important information about the policy. For example, it explains what benefits will be paid, what exclusions apply and how to make a claim. your Policy Summary contains important information specific to you. For example, it sets out who the Person Insured is, the Cover Amount, the Benefit Period and Premium Amounts that apply when the policy starts and any special conditions. In this Policy Wording, you means the Person Insured. The Person Insured is also the Policy Owner of this Living Expenses Cover policy. Some important words in this Policy Wording are Capitalised. These words have a special meaning. The meaning of these words is explained in section 6. Defined terms. Note that this policy has no cash value, so we will not pay any money if you decide to cancel the policy. We realise it s a lot to take in, but take the time to read it now, and you won t have to worry about it later. 2. Benefits of this policy 2.1 Living Expenses Benefit We will pay you a monthly benefit equal to the Cover Amount if you experience a Disability and: at the end of your Waiting Period you are Unable To Work for 10 hours or more per week in your Usual Occupation, or at the end of the Waiting Period you are unable to perform 2 or more Activities of Daily Living (ADLs) without physical assistance from someone else. For us to consider accepting any claim under the Living Expenses Benefit, or make any further monthly payments for that claim, you must: be following the advice of a Registered Doctor on an ongoing basis, including recommended treatment and rehabilitation, and not be working in any other form of work, whether paid or unpaid, outside your Usual Occupation. We will pay the Cover Amount in advance each month, until any of the following occur: you no longer meet the criteria for the Living Expenses Benefit we have paid you a Living Expenses Benefit for your full Benefit Period your 65th birthday. Once your Living Expenses Benefit claim has ended, you will be able to claim again for a different Disability. This will be treated as a new claim, your Benefit Period will start again and another Waiting Period will apply. 2.2 Mental Health Benefit We will pay you a monthly benefit equal to the Cover Amount if you are diagnosed with a Mental Illness, and: at the end of your Waiting Period you are unable to work for 10 or more hours per week in your Usual Occupation. For us to consider accepting any claim under the Mental Health Benefit, or make any further monthly payments for that claim, you must: have a current diagnosis consistent with clinical guidelines for the diagnosis of mental health disorders that are acceptable to us be following the advice of a Registered Doctor on an ongoing basis, including recommended treatment and rehabilitation have been referred to and be consulting with a psychiatrist and/or a psychologist at least every 15 days for the duration of your claim have been prescribed with appropriate medication and be complying with the dosage not be working in any other form of work, whether paid or unpaid, outside your Usual Occupation. We will pay the Cover Amount in advance each month, until any of the following occur: you are eligible to receive a payment under the Living Expenses Benefit you no longer meet the criteria for the Mental Health Benefit you have received the equivalent of 6 monthly payments of the Cover Amount for the Mental Health Benefit your 65th birthday. Once you have received the equivalent of 6 monthly payments of the Cover Amount for the Mental Health Benefit, you will not be able to make any further claims under the Mental Health Benefit.

3 2.3 Recurrent Disability Benefit If you experience a Disability and we accept your claim for a benefit under this policy, we will not apply another Waiting Period if you experience the same or a related Disability again. For your Disability to be considered recurring, your previous claim must have ended within 12 months of the recurrence and before we: paid your full Benefit Period if your claim was for a Living Expenses Benefit, or paid you the equivalent of 6 monthly payments of the Cover Amount if your claim was for the Mental Health Benefit. Your Benefit Period will not start again for a recurrent Disability. It will continue from when your previous claim ended. The maximum that we will pay for your Disability (including any recurrences of it) is limited to: your full Benefit Period being paid under a Living Expenses Benefit 6 monthly payments of your Cover Amount under the Mental Health Benefit. 2.4 Disability Reset Benefit If you go back to work full time for 12 consecutive months after your Living Expenses Benefit claim ends we will reset your Benefit Period. This means that if you need to claim another time for that same or a related Disability, you will be able to claim for your full Benefit Period again. We will treat any claims where your Benefit Period has been reset as a new claim and the Waiting Period and all other terms of the Living Expenses Benefit will apply. Please note: The Disability Reset Benefit does not apply to the Mental Health Benefit. 2.5 Waiver of Premium Benefit You will not be required to pay premiums to us for your Living Expenses Cover for the period of time you are receiving any benefit payments under this policy from us. You will need to pay premiums during your Waiting Period, but we will refund these premiums to you with the first payment of your monthly Cover Amount if we accept your claim. You will need to start paying premiums again as soon as your claim ends. 2.6 Cover Suspension Benefit You can tell us to put your Living Expenses Cover policy and premiums on hold. We will suspend cover and premiums for a minimum of 3 months and a maximum of 12 months from the time you tell us in writing. The Cover Suspension Benefit is only available if your policy has been continuously in force for, and premiums have been paid for, at least the previous 12 consecutive months, and either: you become unemployed you are on employer-approved leave without pay. If cover is suspended, it is not automatically restarted. To restart the cover you must, within 12 months of the date the cover was suspended, ask us to restart the cover and pay the next premium. Otherwise, we will cancel your Living Expenses Cover. If your cover is restarted, we will not pay any claim for any Disability that arises directly or indirectly from a medical condition that, while your cover was suspended: you experienced signs or symptoms of you sought advice for, or you were diagnosed with. 3. Policy exclusions 3.1 What policy exclusions apply? We will not pay any claim if your Disability occurs as a direct or indirect result of any of the following: you participating in a criminal or illegal act an intentional self-inflicted act a Mental Illness, unless covered under the Mental Health Benefit pregnancy, miscarriage or childbirth, unless you are Unable to Work for more than 3 months after the pregnancy ends. If this is the case, we will consider your Disability to start 3 months after the pregnancy ended Human immunodeficiency virus (HIV) or Acquired immunodeficiency syndrome (AIDS) war or any war-like activity, whether war is declared or not you using drugs or being under the influence of alcohol (unless those drugs were prescribed by a Registered Doctor and taken as directed) you engaging in a work or a lifestyle activity that involves explosives, weapons, heights above 20 metres, depths below 30 metres or speeds above 130km per hour other than as a fare-paying passenger on a commercial airline you being in a country or region where the New Zealand Government has advised against all travel or advised that all non-essential travel should be deferred. These countries or regions are currently classified as Extreme or High risk and can be found at If the New Zealand Government no longer publishes these ratings, we will use the last rating list published by the New Zealand Government. Otherwise we will choose an alternative list that we will inform you of on or before the next anniversary of the start date of your policy. We will also not pay a claim if you are: eligible to receive a benefit from Accident Compensation Corporation (ACC) for your Disability working in any paid employment other than your Usual Occupation. 3.2 Pre-Existing Conditions Exclusion If your Policy Summary shows that you have a Pre-Existing Conditions Exclusion this section applies to you. If you have this exclusion, it will be in the Special Notes section of your Policy Summary. We will not pay any claim arising directly or indirectly from: any medical condition that you have been diagnosed with but you have not recovered from, by the date your Cover Starts or Restarts; or any sickness or injury or medical condition for which, in the 5 years before the date your Cover Starts or Restarts: you had symptoms that would cause a reasonable person to seek advice or treatment from a Registered Doctor or any other medical practitioner; or medical advice or treatment was recommended by, or received from, a Registered Doctor or any other medical practitioner. If you claim for the effects of stroke, brain haemorrhage, heart attack or coronary heart disease, we will not pay a benefit if in the 5 years before the date your Cover Starts or Restarts, you: had a Body Mass Index (BMI) of 40 or greater; had a total blood cholesterol above 7.0 mmol/l; have resting systolic blood pressure above 160 mmhg and diastolic blood pressure above 100 mmhg; or were a diabetic and: suffered from proteinuria, kidney disease, retinopathy or neuropathy; or were admitted to hospital for treatment of diabetes or any condition resulting from diabetes.

4 4. How this policy works 4.1 How is your Cover Amount calculated? Your Cover Amount is the amount shown on your Policy Summary when the policy starts. On each anniversary of the date your Cover Starts, we will offer to increase your Cover Amount in line with inflation. This means that as the average cost of living increases, so will your Cover Amount. We will offer to increase your Cover Amount by: the same percentage as the increase in the Consumer Price Index (CPI) published by Statistics New Zealand for the year ending on the previous 31 March, to a maximum of 10%, or a minimum of 2% if the CPI is less than 2%. If the increase in CPI for that year is not available on the anniversary date, we will use the increase in CPI for the previous year. If the CPI is no longer published we will choose an alternative index. We will offer this increase regardless of any changes to your health or occupation, and your premium will be increased to reflect the increase in Cover Amount. We will write to you at least 28 days before the anniversary date of your policy to tell you about changes to your Cover Amount and Premium Amount. We will not offer to increase your Cover Amount if: you have previously declined 3 successive offers to increase your Cover Amount, or your Cover Amount has reached the maximum of $3, How is your premium calculated? Your premium is not fixed. On each anniversary of the date your Cover Starts, your premium will be recalculated based on our premium rates at that time and your: current Cover Amount Benefit Period current age gender smoking status occupation as recorded at application premium loadings applied to your cover at application. We will also apply any discounts you are entitled to, including the Health and Lifestyle discount and AA Member discount. If these are applied they will appear on your most recent Living Expenses Cover statement sent to you by us. The Premium Amount must be paid in New Zealand dollars by a payment method approved by us. We will give you at least 28 days written notice of any change to your Premium Amount, posted to your last known address. The notice is considered to have been received by you on the third day after posting. Premiums are payable until the policy ends. 4.3 When does your cover start and end? Your cover under this policy begins on the date your Cover Starts as shown on your Policy Summary or the date we choose if we restart your policy. Your Cover Ends on the earliest of: the date your Cover Ends as shown on your Policy Summary the date you turn 65 years old your death the date you cancel this policy 30 days after you miss a premium payment. No benefits will be paid for any Disability that occurs before the date your Cover Starts or after the date your Cover Ends. If your policy ends because of an unpaid premium, you can apply to us to restart your policy. You must apply within 12 months of your policy ending. We will advise you of the conditions for restarting your policy and will tell you in writing if and when it is restarted. 5. Claiming under this policy 5.1 How do you claim? To make a claim, contact AA Life on: Telephone ; or claims@aalife.co.nz; or Mail AA Life Claims, PO Box 894, Wellington Contact us and tell us about your claim. Do this straight away; don t wait until the end of your Waiting Period. If you don t tell us as soon as the claimable event has happened, we may not be able to assess your claim. Complete the claim form we send you. You will need to complete some sections, and your treating doctor will need to complete some sections. Send us your completed claim form along with: copies of medical reports and results of investigations performed (whether the investigations were specifically requested by us or not) any financial information we have requested from you. Once we have received the above information and it is satisfactory to us, we will assess your claim against the criteria set out under this Living Expenses Cover policy. If we find a claim is payable, you will be eligible for your first payment of your claim from the end of your Waiting Period. During your claim, you will need to provide ongoing medical and financial information satisfactory to us. You are responsible for the cost of providing all of this information to us. You can be covered by more than one Living Expenses Cover policy issued by Asteron Life. The total maximum combined cover possible for you under any Living Expenses Cover policies issued by Asteron Life is $3,500 per month. 5.2 Can you claim from overseas? You can claim from anywhere in the world, so if you are working overseas, you can still make a claim under any of the Living Expenses Cover benefits. We will make a maximum of 3 payments of your monthly Cover Amount before you will need to return to New Zealand at your own expense for further assessment before we will make any further claim payments. 5.3 Who will the benefits be paid to? All benefits under this Living Expenses Cover policy are payable directly to you as the Policy Owner in New Zealand dollars.

5 6. Defined terms 6.1 Activities of Daily Living There are 5 Activities of Daily Living (ADLs), these are: 1. bathing and showering 2. dressing and undressing 3. eating and drinking 4. maintaining continence with a reasonable level of personal hygiene 5. getting in and out of bed, a chair or a wheelchair or moving from place to place by walking, wheelchair or walking aid. 6.2 Benefit Period The Benefit Period is the maximum length of time we will pay you a Living Expenses Benefit when you are disabled. Your chosen Benefit Period is shown on your Policy Summary. 6.3 Cover Amount The Cover Amount is the monthly benefit we will pay if you are eligible to receive a benefit under the Living Expenses Cover. You can find your current Cover Amount on your most recent Living Expenses Cover statement sent to you by AA Life. 6.4 Disability A Disability means that as a direct result of a sickness or injury (that is not excluded from this cover) you are unable to function as you did before you suffered the sickness or injury. The sickness or injury must be diagnosed by a Registered Doctor. 6.5 Mental Illness A Mental Illness means a Disability that occurs directly or indirectly from a mental health disorder including, but not limited to, any of the following: anxiety disorders, chronic fatigue syndrome, fatigue or exhaustion, depression, fibromyalgia, psychiatric complications of physical disorders, behavioural disorders, or any other mental or functional nervous disorder. 6.6 Registered Doctor A Registered Doctor is a doctor who is legally qualified and properly registered in New Zealand. The doctor cannot be: you a business partner of you related to you. Asteron Life reserves the right to accept the advice of a medical practitioner if practising outside New Zealand. The medical practitioner must have qualifications equivalent to New Zealand standards. 6.7 Unable to Work If you are Unable to Work, it means you cannot perform your Usual Occupation. This must be based on medical advice, including the opinion of your Registered Doctor, or another Registered Doctor approved by us. Asteron Life s Chief Medical Officer (CMO) must also agree with the Registered Doctor s advice that you are unable to perform your Usual Occupation. 6.8 Usual Occupation Your Usual Occupation is the occupation that you were working 20 hours or more per week in and getting paid for, immediately before suffering a Disability. If, in the 6 months immediately before becoming Disabled, you became unemployed from an occupation, we will consider that to be your Usual Occupation if: you were working 20 hours or more per week in your previous occupation, and you were getting paid for your previous occupation. If you have been unemployed for more than 6 months, or are working less than 20 hours per week immediately before suffering a Disability, we will consider you to have no Usual Occupation. 6.9 Waiting Period The Waiting Period is a set period of time that starts as soon as you experience a Disability and are Unable to Work. If your claim is accepted, your first month s benefit is payable from the end of the Waiting Period. It is important you do not wait until the end of the Waiting Period to tell us about your Disability. Tell us as soon as it happens, as we will begin to assess your claim during this time. Your Waiting Period is shown on your Policy Summary. 7. Other important information about this policy 7.1 The information you provide must be correct We have issued this policy in good faith believing that you have: completely and truthfully answered all our questions told us any information that would influence our decision to offer insurance or the terms of that offer, increase benefits or restart the policy. If we find that we were given any incorrect information at any time or information has been withheld, we can reduce the benefits. We may also exercise any legal rights we have to cancel or avoid the policy from the date your Cover Starts and retain any premiums paid. If we find that your date of birth is wrong on the Policy Summary, we can adjust the benefits provided under the policy to reflect your correct age and actual premiums paid. Alternatively, if your age has been overstated, we may, at our discretion, refund any overpayments of premium. If we find that your smoking status is wrong on the Policy Summary, we can adjust the benefits provided under the policy to reflect your correct smoking status and actual premiums paid. 7.2 Other matters When your policy starts, Asteron Life will pay a commission to AA Life. This policy will be interpreted according to New Zealand law. Asteron Life as underwriter of your policy is required under the Insurance (Prudential Supervision) Act 2010 to establish a statutory fund. The statutory fund relevant to your policy is Asteron Life Statutory Fund 1.

6 We re here to help you Call us anytime Visit us online aalife.co.nz Or come in and see us at your nearest AA Centre Asteron Centre, Level 13, 55 Featherston Street, Wellington, PO Box 894, Wellington, 6140 New Zealand Telephone Fax Copyright 2013 Asteron Life Limited. All rights reserved. No part of this policy may be reproduced or copied in any form or by any means without our written agreement.