Friends Life Individual Protection Critical Illness Cover and Critical Illness with Life Cover Membership handbook Who cares if you know what you are covered for? We care.
Membership handbook Contents Welcome 3 General definitions 5 Critical illness definitions - critical illness cover 9 Your membership 19 Additional options 23 What you are covered for 31 What you are not covered for 39 Changes to your membership 41 Premium options 47 How to make a claim 51 Your right to cancellation 55 General information 57 Getting in touch 59
Welcome Welcome Thank you for choosing Friends Life Individual Protection Thank you for choosing critical illness cover or critical illness with life cover from Friends Life Individual Protection. Friends Life Individual Protection products are provided by Friends Life Limited, part of the Friends Life group. With this membership we aim to provide you and your dependants with protection should serious illness or incapacity affect the member s ability to work and cause you financial hardship and help secure your dependants financial future if a member is to die. The membership has been designed to offer you the flexibility to provide you with the right level of financial health protection to match your circumstances. Friends Life flexible financial protection is the umbrella plan which provides cover through a series of separate memberships for different types and levels of cover. Your registration certificate will show which type of membership you have. Each membership will have a separate handbook. This handbook explains what is covered by Friends Life Individual Protection Critical Illness and Friends Life Individual Protection Critical Illness with Life Cover and what to do if you need to make a claim. Using the membership handbook Where the words we, us or our are used, this refers to Friends Life Individual Protection. The words you or your refer to the person, or people, who are entitled to receive the benefits of the membership. Where we refer to the member(s), this refers to the person, or people, covered under the same membership. The terms you and member may refer to the same people or different people. Words printed in bold type in this handbook are defined terms. Defined terms have a specific meaning explained in the definition section below or later on in the terms of this handbook. Where we refer to you or to the member and this refers to two people, we mean both people jointly unless we say otherwise. For example, where we say we will pay the benefit to you, we mean both schemeholders jointly (we will not pay the benefit twice). 3
General definitions
General definitions General definitions Please refer to the definition explanations below for further information on their meanings. Average Weekly Earnings The measure used by the Office of National Statistics which has replaced the average earnings index. This measure is an indicator of short-term earnings growth and provides a monthly estimate of the level of average weekly earnings per employee. Alternatively, if this measure is not published during any period of your membership the average weekly earnings measure will be any substituted index or index of figures published by that Office. Benefit The critical event benefit shown on your registration certificate excluding the terminal illness benefit. However, where benefit is used in this handbook as being of general application to all benefits covered by this handbook, it shall be read so as to read the benefit or the terminal illness benefit as appropriate. Friends Life Individual Protection approved hospital A centre of treatment which is registered, or recognised under the local country s laws, as existing primarily for: carrying out major surgical operations, or providing treatment which only consultants can provide; and which has been approved by Friends Life Individual Protection. Child / children Any natural child or adopted child of you or your spouse, partner or civil partner or any child for which either you or your spouse, partner or civil partner are the legal guardian. Childcover benefit The childcover benefit as defined in the What you are covered for section in this handbook. Commencement date The date your membership starts, as shown on your registration certificate. Consultant A surgeon, anaesthetist or physician who: is legally qualified to practice medicine or surgery following attendance at a recognised medical school, and is recognised by the relevant authorities in the country in which the treatment takes place as having specialised qualification in the field of, or expertise in, the treatment of the disease or illness being treated. By recognised medical school we mean a medical school which is listed in the World Directory of Medical Schools, as published from time to time by the World Health Organisation. 6
General definitions Critical illness(es) Any of the illnesses and operations as defined in the Critical illness definitions section in this handbook relate to any illness or operation separately, not all of them together. Endorsement(s) Change(s) that you require and we agree to be made to your membership after it commences which are recorded in the endorsement section of your registration certificate. Fracture The fractures defined in Black s Medical Dictionary (39th edition), comminuted, complicated, compound, depressed, greenstick, pathological and simple. The fracture definition does not include any other type of fracture. Handbook This handbook setting out the general terms and conditions of your membership. Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the NHS in the UK at the time of the claim. Member The person (or people) named as a member in your registration certificate. This is the person (or people) for whom cover is provided. Membership The agreement between you and us to provide the benefit on the terms set out in the handbook and the documents referred to in the section Your membership. Mental impairment Mental disorder causing incapacity which has failed to respond to a minimum of two years optimal treatment by a consultant psychiatrist and requires the need for continuous psychotropic medication, supervision and care from a consultant and results in severe dysfunctioning and the prognosis is considered poor or worse. NHS National Health Service. Occupation A trade, profession or type of work undertaken for profit or pay. It is not a specific job with any particular employer and is independent of location and availability. Permanent Expected to last throughout the life of the person covered, irrespective of when the membership ends or the member expects to retire. 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 member s life. 7
General definitions 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. Registration certificate The most recent registration certificate, we issue to you. Renewal date If your registration certificate states that your Type of Cover is Renewable Term (five years), the renewal date will be the fifth anniversary of the commencement date and the end date of every following five year period. If your registration certificate says the Type of Cover you have is Renewable Term (ten years), the renewal date will be the tenth anniversary of the commencement date and the end date of every following ten year period. Retail Price Index The general index of retail prices published by the Office for National Statistics. Alternatively, if that index is not published during any period of your membership, the retail price index will be any substituted index or index of figures published by that Office. Special condition Any condition we set to limit your entitlement under your membership, as shown in the Special Conditions section of your registration certificate. Suited occupation Any work you could do for profit or pay taking into account your employment history, knowledge, transferable skills, training, education and experience, and is irrespective of location and availability. Terminal illness benefit The equivalent benefit in value to the benefit but only relating to a member being diagnosed with a terminal Illness under a Critical Illness with Life Cover membership. UK England, Northern Ireland, Scotland and Wales We / us / our Refers to Friends Life Individual Protection. You / your Refers to the person (or people) named as the schemeholder on your registration certificate or any person (or people) to whom your membership is validly assigned. This is the person (or people) who hold the membership. 8
Critical illness definitions
Critical illness definitions Critical illness definitions Alzheimer s disease 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 The following are not covered: other types of dementia 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 Confirmation by a consultant haemotologist of a definite diagnosis of complete bone marrow failure which results in anaemia, neutropenia and thrombocytopenia and requires as a minimum, one of the following treatments: blood transfusion bone-marrow transplantation immunosuppressive agents marrow stimulating agents All other forms of anaemia are specifically excluded. Bacterial meningitis Bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in permanent neurological deficit with persisting clinical symptoms. The diagnosis must be confirmed by a consultant neurologist. The following is not covered: all other forms of meningitis, not mentioned above, including viral meningitis Benign brain tumour A non-malignant tumour or cyst in the brain, cranial nerves or meninges within the skull, resulting in permanent neurological deficit with persisting clinical symptoms or undergoing invasive surgery to remove part or all of the tumour. The following are not covered: tumours in the pituitary gland angiomas 10
Critical illness definitions Benign spinal cord tumour A non-malignant tumour in the spinal canal, involving the meninges or the spinal cord. This tumour must be interfering with the function of the spinal cord which results in permanent neurological deficit with persisting clinical symptoms. The diagnosis must be made by a relevant consultant and must be supported by CT, MRI or histopathological evidence. For the above definition, the following are not covered: cysts, granulomas, malformations in the arteries or veins of the spinal cord, haematomas, abscesses, disc protrusions and osteophytes. Blindness 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. Cancer 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 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. 11
Critical illness definitions 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) Cardiomyopathy The unequivocal diagnosis by a consultant cardiologist of cardiomyopathy resulting in one or more of the following: impaired ventricular function and marked limitation of physical activity where the member is unable to progress beyond stage two of a treadmill exercise test using the standard Bruce protocol; or is classified as Stage III under the New York Heart Association (NYHA) Functional Classification. For the purpose of this definition NYHA Stage III is classified as a marked limitation in activity due to symptoms even during less than ordinary activity. The patient is only comfortable at rest. The following is not covered: all other forms, other than those specified above, of heart disease, heart enlargement and myocarditis are specifically excluded Chronic rheumatoid arthritis A definite diagnosis by a consultant rheumatologist of chronic rheumatoid arthritis as evidenced by widespread joint destruction with major clinical deformity. In addition the member must permanently satisfy three of the four following criteria: Bending - The inability to bend or kneel to pick up something from the floor and stand up again and the inability to get into and out of a standard saloon car. Dexterity - The inability to use hands and fingers to pick up and manipulate small objects such as cutlery, including being unable to write using a pen or pencil. Lifting - The inability to lift, carry or otherwise move everyday objects by hand. Everyday objects include a kettle of water, a bag of shopping and an overnight bag or briefcase. Mobility - The inability to walk a distance of 200 metres on flat ground, with or without the aid of a walking stick and without having to rest or experiencing severe discomfort. Coma 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 12
Critical illness definitions The following is not covered: coma secondary to alcohol or drug abuse Coronary artery by-pass grafts The undergoing of surgery requiring thoracotomy (keyhole surgery or median sternotomy) on the advice of a consultant cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts. Creutzfeld-Jacob disease Confirmation by a consultant neurologist of a definite diagnosis of Creutzfeld-Jacob disease resulting in permanent neurological deficit with persisting clinical symptoms. Deafness Permanent and irreversible loss of hearing to the extent that loss is greater than 95 decibels across all frequencies in the better ear using a pure tone audiogram. Dementia 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 is not covered: Alzheimer s disease Heart attack 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. The following are not covered: angina other acute coronary syndromes Heart valve replacement or repair The undergoing of surgery requiring thoracotomy (keyhole surgery or median sternotomy) on the advice of a consultant cardiologist to replace or repair one or more heart valves. HIV infection Infection by Human Immunodeficiency Virus resulting from: a blood transfusion given as part of medical treatment; a physical assault; or 13
Critical illness definitions 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 Kidney failure Chronic and end stage failure of both kidneys to function, as a result of which regular dialysis is necessary. Liver failure Chronic liver disease, being end stage liver failure due to cirrhosis and resulting in all of the following: permanent jaundice ascites encephalopathy Loss of hands or feet Permanent physical severance of any combination of one or more hands or feet at or above the wrist or ankle joints. Loss of independence The total and permanent loss of the ability to perform routinely at least three of the 14
Critical illness definitions specified six activities of daily living without the continual assistance of someone else, even with the use of special devices or equipment. The following are activities of daily living; Washing - this means being able to wash and bathe unaided, including getting into and out of the bath or shower. Dressing - this means being able to put on, take off, secure and unfasten all necessary items of clothing. Feeding - this means being able to eat pre-prepared foods unaided. Continence - this means being able to control bowel or bladder functions, whether with or without the use of protective undergarments and surgical appliances. Moving - this means being able to move from one room to another on level surfaces. Transferring - this means being able to get on and off the toilet, in and out of bed and move from a bed to an upright chair or wheelchair and back again. Loss of speech Total permanent and irreversible loss of the ability to speak as a result of physical injury or disease. 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 A definite diagnosis of motor neurone disease by a consultant neurologist. There must be permanent clinical impairment of motor function. Multiple sclerosis 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. Open heart surgery The undergoing of open heart surgery requiring thoracotomy on the advice of a consultant cardiologist. The following is not covered: any percutaneous, transluminal or investigative procedure Paralysis of limbs Total and irreversible loss of muscle function to the whole of any one limb. 15
Critical illness definitions Parkinson s disease 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 Confirmation by a consultant neurologist of a definite diagnosis of progressive supranuclear palsy. There must be permanent clinical impairment of all of the following; motor function eye movement disorder; and postural instability Respiratory failure Confirmation by a consultant physician of severe lung disease which is evidenced by all of the following: the need for continuous daily oxygen therapy on a permanent basis; evidence that oxygen therapy has been required for a minimum period of six months; FEV1 being less than 40 percent of normal; and vital capacity less than 50 percent of normal Severe Crohn s disease A definite diagnosis by a consultant gastroenterologist of Crohn s disease with fistula formation and intestinal strictures. There must have been two or more bowel segment resections on separate occasions. There must also be evidence of continued inflammation with ongoing symptoms, despite optimal therapy with diet restriction, medication use and surgical interventions. Stroke Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in permanent neurological deficit with persisting clinical symptoms. The following are not covered: transient ischaemic attack Systemic lupus erythematosus (SLE) A definite diagnosis of systemic lupus erythematosus (SLE) by a consultant rheumatologist resulting in: permanent impaired renal function evidenced by a glomerular filtration rate below 30 ml/min/1.73m2 and urinalysis showing proteinuria or haematuria; or permanent neurological deficit evidenced by one of the following persisting clinical symptoms - paralysis, localised weakness, dysarthria (difficulty with speech), dysphagia (difficulty in swallowing), difficulty in walking or lack of coordination. For the purposes of this definition 16
Critical illness definitions seizures, headaches, fatigue, lethargy or any symptoms of psychological or psychiatric origin will not be accepted as evidence of permanent neurological deficit. Terminal illness A definite diagnosis by the attending consultant of an illness that satisfies both of the following: the illness either has no known cure or has progressed to the point where it cannot be cured; and in the opinion of the attending consultant, the illness is expected to lead to death within 12 months Third degree burns 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. Traumatic head injury Death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms. ketosis. The first diagnosis for the member must come after the age of 40. Permanent insulin injections must be the only possible treatment to prevent life threatening diabetic ketoacidosis and these must have continued for a period of at least 12 months. The following are not covered: gestational diabetes unless the member has been on continuous insulin injections to prevent diabetic ketoacidosis for 12 months after delivery of a baby. Type 2 diabetes mellitus treated with oral medications or treated with insulin to improve diabetic control. We will not pay the benefit for Type 1 insulin dependent diabetes mellitus, as defined above, if the diagnosis is made within the 12 months before the date on which your membership will end and may not be renewed. Ulcerative Colitis A definite diagnosis of ulcerative colitis which is treated with total colectomy (removal of entire large bowel). A definite diagnosis of ulcerative colitis must be confirmed by a consultant gastroenterologist. Type 1 insulin dependent diabetes mellitus A definite diagnosis of Type 1 insulin dependent diabetes mellitus by a consultant. There must be abrupt onset, accompanied by ketonuria or other biochemical evidence of 17
Your membership - critical illness cover or critical illness with life cover
Your membership Your membership - critical illness cover or critical illness with life cover Your membership is made up of the following documents: your application for cover This includes your initial application and any further applications you make where your membership is varied. It also includes any declarations you made at our request when you applied for cover. your registration certificate and any endorsements These set out the current details of your membership. The Special conditions section of your registration certificate shows any special conditions we apply to your membership. Your registration certificate may also refer to other memberships you have under the Friends Life flexible financial protection plan. We explain how your registration certificate may change in the General information section. this handbook This contains all the general terms and conditions of your membership. It is referred to as the Friends Life Individual Protection Critical Illness and Friends Life Individual Protection Critical Illness with Life Cover membership handbook, reference number PBHA/4564/AUG12. When your membership starts and ends Your membership starts on the commencement date and is subject to you paying your first premium. The date your membership ends depends on the type of cover you have. If your registration certificate shows that the type of cover you have is Renewable term (either five years or ten years), your membership will end on the earliest of the following: any renewal date on which you do not renew your membership or we end your membership where the renewal term is five years the renewal date is before the member s 65th birthday (or the eldest member if more than one) where the renewal term is ten years, the renewal date is before the member s 70th birthday (or the eldest member if more than one) where you have a critical illness cover membership, the death of a member 20
Your membership the date we pay you the benefit 30 days after the premium due date, we will allow your membership to continue if you pay any outstanding amounts within the 30 day period after it became due If you do not have Renewable term cover your membership will end on the earliest of the following: the expiry date shown on your registration certificate where you have a critical illness cover membership, the death of a member the date we pay you the benefit 30 days after the premium due date where you do not pay any amounts. We will allow your membership to continue if you pay any outstanding amounts within the 30 day period after it became due Your membership will end at any time when we reasonably consider that you have or a member has, misled us (intentionally or carelessly), by either giving us false information or by keeping relevant information from us. Your membership will end regardless of whether it was you or a member or both who misled us. You can end your membership by writing to us providing 30 days notice to tell us at the address stated in the General information section. 21
Additional options
Additional options Additional options Your registration certificate will show whether we have provided any of the following additional options to you. If there is more than one member, your registration certificate will show to which member the option applies or whether it applies to both. The following are the full list of additional options. These are only applicable if you have selected and we have agreed to provide the option: indexation options fracture cover option premium waiver option total permanent disability option reinstatement option Indexation options For each of these options, on each anniversary of the commencement date, we will increase the benefit under your membership. The amount the benefit increases by will depend on the indexation option applicable. If we have agreed to provide this option, your registration certificate will show which indexation option you have of the following: RPI (Retail Price Index) AWE (Average weekly earnings) five percent three percent The increases for each indexation option are as follows: RPI (Retail Price Index) option On the anniversary of the commencement date, we will increase the benefit in proportion to the increase in the retail price index during the first 12 months of the 15 month period immediately before the anniversary of the commencement date. The maximum increase on any anniversary will be 10 percent of the benefit. AWE (Average weekly earnings) option On the anniversary of the commencement date we will increase the benefit in proportion to the increase in the average weekly earnings measure over the first 12 months of the 17 month period immediately before that anniversary of the commencement date. Five percent option On the anniversary of the commencement date, we will increase the benefit by five percent a year. Three percent option On the anniversary of the commencement date, we will increase the benefit by three percent a year. 24
Additional options How does indexation affect your premiums? You will have to pay an increased premium for any increase in the benefit. your premium will increase at a higher rate than your benefit as we will allow for member s age and remaining term at the time of the increase in the benefit. For guaranteed and reviewable premiums the increase will be based on our premium rates at the commencement date. For renewable premiums, the increase will be based on our premium rates applicable at the later of the commencement date or at the last renewal. When we write to tell you about the increase in the benefit, we will tell you about the increase in your premium. Cancelling an increase You can cancel the increase in the benefit and your premium by writing to us within 30 days of the date of our letter telling you about the increase. If you cancel any increases we will cancel your indexation option and no further increases will be made (this will not affect previous increases). Fracture cover option If we have agreed to provide the fracture cover option, your registration certificate will show this option. If there is more than one member we may have agreed to cover one or both members and this will also show on your registration certificate. If the member suffers one of the fractures shown in the table below, we will pay fracture cover benefit to you. The amount of the fracture cover benefit we will pay is shown in the table below: Fracture closed fracture of the skull open fracture of the skull fracture of the vertebra fracture of the shoulder blade fracture of the jaw fracture of the sternum fracture of the pelvis fracture of the wrist fracture of the hand fracture of the upper leg fracture of the knee fracture of the lower leg fracture of the arm fracture of the cheekbone fracture of the foot fracture of the ankle fracture of the ribs fracture of the collar bone To make a claim for fracture cover benefit you must: Fracture cover benefit contact us to ask for a claim form; and then fill in the claim form and return it to us You must make your claim as soon as reasonably practicable. 1,200 2,100 900 900 900 900 1,200 900 900 2,100 2,100 1,200 1,200 900 900 1,200 600 600 25
Additional options We will only pay the benefit to you for the following fractures as defined in Black s Medical Dictionary (39th edition); comminuted, complicated, compound, depressed, greenstick, pathological and simple. We will not pay the benefit for any other type of fracture. Where more than one of the above fractures occurs at any time, we will only pay fracture cover benefit for one of the fractures. you can decide which fracture you claim for. We will not pay fracture cover benefit to you if the fracture arises out of the same event as that for which we have paid the benefit to you. We will only pay fracture cover benefit to you for one fracture suffered during any 12 month period. The first 12 month period will start on the commencement date and then each subsequent 12 month period will begin on each anniversary of the commencement date. We will not pay fracture cover benefit for a fracture suffered by a child. Total permanent disability option This is only applicable if you have selected and we have agreed to provide the total permanent disability option, this will show on your registration certificate. If there is more than one member we may have agreed to cover one or both members and this will also show on your registration certificate. This option ends when your membership ends. With this option we will pay the benefit if the member that the option applies to becomes totally and permanently disabled as defined in this handbook. Any disability must continue for a minimum of six months before we will consider whether it is a total and permanent disability for the purpose of your membership. What is total permanent disability? Your registration certificate will show whether the definition of total permanent disability for a particular member is own, suited or activities of daily work. The definitions are as follows: Own definition Loss of the physical or mental ability through an illness or injury to the extent that the member is unable to do the essential duties of their own occupation ever again. The essential duties are those that are normally required for, and form a significant and integral part of, the performance of the member s own occupation that cannot reasonably be omitted or modified. The relevant consultant 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. Suited definition Loss of the physical or mental ability through an illness or injury to the extent that the member is unable to do the essential duties 26
Additional options of a suited occupation ever again. The essential duties are those that are normally required for, and form a significant and integral part of, the performance of a suited occupation that cannot reasonably be omitted or modified. The relevant consultant 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. Activities of daily work definition Loss of the physical ability through an illness or injury to do at least three of the six work tasks listed below ever again. The relevant consultant 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. The member must need the help or supervision of another person and be unable to perform the task on their own, even with the use of special equipment routinely available to help and having taken any appropriate prescribed medication. Activities of daily work The work tasks are: Walking The ability to walk more than 200 metres on a level surface. Climbing The ability to climb up a flight of 12 stairs and down again, using the handrail if needed. Lifting The ability to pick up an object weighing 2kg at table height and hold for 60 seconds before replacing the object on the table. Bending The ability to bend or kneel to touch the floor and straighten up again. Getting in and out of a car The ability to get into a standard saloon car, and out again. Writing The manual dexterity to write legibly using a pen or pencil, or type using a desktop personal computer keyboard. Premium waiver option This is only applicable if you have selected and we have agreed to provide the premium waiver option, this will show on your registration certificate. If there is more than one member we may have agreed to cover one or both members and this will also show on your registration certificate. This option ends when your membership ends. If the member that the option relates to is in an occupation and was on the commencement date, we will waive your premiums for the period the member is unable to do their normal occupation, as a 27
Additional options result of illness and injury, provided that the member is not doing any other occupation. If the member that the option relates to is not in an occupation or was not on the commencement date, we will waive your premiums for the period that the member is, as a result of illness or injury, unable to do at least three of the daily activities listed below: Daily activities Shopping Being able to get to and from the nearest shops and carry a small bag of shopping. Cooking Being able to prepare and cook a basic meal. Housework Being able to carry out light housework such as dusting, washing dishes and making beds. Handling money Being able to handle basic household finances and recognise the value of money. Taking medicine Being able to take routine medication prescribed by a recognised medical practitioner. Child minding Being able to care for, feed, wash and dress a child under the age of five. We will waive your premiums until: the member can do their occupation; or the member starts any paid work; or the member becomes capable of doing four or more of the daily activities shown above (if the member was not in an occupation); or your membership ends If, as a result of illness or injury, the member becomes unable to do their occupation or unable to do at least three of the daily activities listed above, you must make a claim to us to waive your premiums before you are entitled to any waiver. To do this you must: contact us to ask for a claim form; and then fill in the claim form and return it to us You must give us any information or proof we reasonably require to consider your claim both at the time of your claim and at any time when we are waiving your premiums. If we accept your claim, we will not waive your premiums until the end of the three month period following either the date the member became unable to do their occupation or the date they became unable to do at least three of the daily activities as appropriate. You must make your claim within six months of the illness or injury arising or as soon as reasonably practicable. If you do not, we may not waive your premiums for the period of delay in making your claim. 28
Additional options During any period where we waive your premiums, you must notify us as soon as practicable of the member: starting an occupation no longer being incapable of doing three or more of the daily activities being capable of doing their occupation If you fail to do so, we may end your membership. Reinstatement option This is only applicable if you have selected and we have agreed to provide you with the reinstatement option. If we have provided the reinstatement option and we pay the benefit to you in the event of a member suffering or undergoing a critical illness, you can take out a new membership subject to all of the following: you tell us in writing that you want to take out the new membership if the benefit was paid due to a member having cancer, the new membership can only be taken out within five years of the date we paid the benefit and you must provide us with all of the following: the written confirmation of the doctors who treated the member that the member made a full recovery at least one year prior to you applying to us for the new membership; and evidence that the member has not undergone any tests that show the presence of cancer since the full recovery from cancer was made; and evidence that the member has attended all consultations and check ups and undergone all tests recommended by the medical specialist for cancer if the benefit was paid due to a critical illness other than cancer, the new membership can only be taken out between 12 and 24 months after the date we paid the benefit the only critical illnesses to be covered under the new membership are the following (the illnesses and definitions of these will be those we apply at the time the new agreement is taken out): aorta graft surgery aplastic anaemia bacterial meningitis cancer cardiomyopathy heart attack HIV/AIDS kidney failure liver failure major organ transplant motor neurone disease multiple sclerosis Parkinson s disease progressive supranuclear palsy stroke systemic lupus erythematosus third degree burns 29
Additional options claims for the same event for which we paid benefit to you will be excluded from the new membership we will only consider claims under the new membership for events or illnesses occurring or being diagnosed after the commencement of your new membership the new membership will cover the same member (or both if more than one) as under this membership the new membership will not continue beyond the date your membership would have ended the membership must have been capable of continuing for at least five years after the date we receive the request for your new membership the amount of benefit provided will be the lower of 100,000 or the benefit we paid under your membership the member to be covered by the new membership (or eldest member if more than one) is under 50 years of age life cover will only be provided under the new membership where your original membership is for critical illness with life cover no additional options can be included in the new membership no claim for terminal illness benefit will be included in the new membership the terms and conditions of the new membership will be those we apply at the time the new membership is taken out we accepted the initial application for cover without increasing the premiums above our standard rates at that time or applying any special conditions to the membership The premiums you will have to pay for the new membership will be based on our premium rates and the member s age on the commencement date of the new membership. The reinstatement option is not available for and will not include childcover benefit. The reinstatement option can only be effected once. 30
What you are covered for
What you are covered for What you are covered for Benefit We will pay the benefit to you: if, during the period of your membership any of the following happens: a member suffers or undergoes a critical illness; or a member becomes totally and permanently disabled (if we have provided the total permanent disability option); or where you have a critical illness with life cover membership, either of the following happens; a member dies or; a member is diagnosed with a terminal illness. The relevant benefit payable for a terminal illness for a Critical Illness with Life Cover membership will be the terminal illness benefit. Payment of the benefit is subject to: you complying with the requirements and obligations set out in the How to make a claim section. your claim not being excluded by any of the circumstances listed in the What are you not covered for section. We will only pay the benefit or the terminal illness benefit once and not both under this membership, on the first of the above events to happen. For any claim under the total and permanent disability option, we will only pay the benefit after the disability has continued for six months, subject to the additional terms of the total permanent disability option set out in the Additional options section. Carcinoma in situ of the cervix uteri requiring hysterectomy We will pay the lower of 12.5 percent of the benefit and 12,500 if a member is diagnosed with carcinoma in situ of the cervix uteri (cervix) requiring treatment with hysterectomy. The hysterectomy must have been performed on the advice of a consultant to treat carcinoma in situ. The following tumors are excluded: all grades of dysplasia; cervical squamous epithelial lesion (SIL) and cervical intra-epithelial neoplasia (CIN), unless carcinoma in situ is present. The carcinoma in situ of the cervix uteri requiring hysterectomy benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Carcinoma in situ of the urinary bladder We will pay the lower of 12.5 percent of the benefit and 12,500 if a member is diagnosed with carcinoma in situ of the urinary bladder. 32
What you are covered for The diagnosis must be histologically confirmed on a pathology report. This benefit is payable only once. Non-invasive papillary carcinoma, stage Ta bladder carcinoma and all other forms of non-invasive carcinoma are specifically excluded. The carcinoma in situ of the urinary bladder benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Cerebral aneurysm - with surgical repair We will pay the lower of 12.5 percent of the benefit and 12,500 if a member undergoes either of the following surgical procedures in order to treat a cerebral aneurysm: surgical correction via craniotomy (surgical opening of the skull), or endovascular treatment using coils or other materials (embolisation) The cerebral aneurysm benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Cerebral arteriovenous malformation - with surgical repair We will pay the lower of 12.5 percent of the benefit and 12,500 if a member undergoes either of the following surgical procedures in order to treat a cerebral arteriovenous malformation: surgical correction via craniotomy (surgical opening of the skull), or endovascular treatment using coils or other materials (embolisation) The cerebral arteriovenous malformation benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Coronary angioplasty We will pay the lower of 25 percent of the benefit and 25,000 if a member undergoes any of the following: balloon angioplasty atherectomy rotablation laser treatment and / or insertion of stents The above operations must have been carried out on the advice of a consultant cardiologist to treat severe coronary artery disease in two or more main coronary arteries. The above operation must be to treat at least 70 percent diameter narrowing. If an operative procedure is only performed on one main coronary artery there must be at least 70 percent diameter narrowing in another main coronary artery. For the purposes of this definition main coronary arteries are described as one or more of the following: right coronary artery 33
What you are covered for left main stem left anterior descending circumflex The following is not covered: procedures to any branches of any of the main coronary arteries The coronary angioplasty benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Crohn s disease treated with surgical intestinal resection We will pay the lower of 12.5 percent of the benefit and 12,500 if a member is diagnosed with Crohn s disease and has undergone surgical intestinal resection. A definite diagnosis of Crohn s disease must be confirmed by a consultant gastroenterologist. Crohn s disease treated with surgical intestinal resection benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. We will not pay this benefit to you if we have already paid the benefit to you for Severe Crohn s disease as defined in the Critical illness definitions section of this handbook. Ductal carcinoma in situ of the breast - with specified treatment We will pay the lower of 12.5 percent of the benefit and 12,500 if a member is diagnosed with ductal carcinoma in situ (DCIS), histologically confirmed, and as a result requires total mastectomy, segmentectomy or lumpectomy. DCIS of the breast treated by other methods and lobular carcinoma in situ are specifically excluded. DCIS of the breast benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Low-grade prostate cancer We will pay the lower of 25 percent of the benefit and 25,000 if a member is diagnosed with a tumour of the prostate histologically classified as having a Gleason score between 2 and 6 inclusive provided: the tumour has progressed to at least clinical TNM classification T1N0M0; and treatment included the complete removal of the prostate or external beam or interstitial implant radiotherapy. For clarity, cases treated with cryotherapy, other less radical treatment (eg transurethral resection of the prostate), experimental treatments or hormone therapy are not included. 34
What you are covered for The low-grade prostate cancer benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Non-malignant pituitary adenoma - with specified treatment We will pay the lower of 12.5 percent of the benefit and 12,500 if a member is diagnosed with a non-malignant pituitary tumour requiring radiotherapy or surgical removal. Non-malignant tumours of the pituitary gland treated by other methods are specifically excluded. This benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Removal of one or more lobe(s) of the lung for disease and trauma We will pay the lower of 12.5 percent of the benefit and 12,500 if a member undergoes the removal of one or more lobes of the lung due to underlying disease or trauma. The surgery must be carried out on the advice of a consultant physician. The removal of one or more lobe(s) of the lung for disease and trauma benefit is payable in addition to the benefit you have under your membership. We will only pay this benefit once for each member regardless of the number of memberships held. Acceleration payment benefit for specified surgical treatments We will make an advance payment if a member is on the NHS waiting list for one of the following types of surgical treatments, as defined in Critical illness definitions section of this handbook: aorta graft surgery coronary artery by-pass grafts heart valve replacement or repair open heart surgery We will pay the lower of 25 percent of the benefit and 25,000. To be eligible for this acceleration payment benefit, the member must be on the relevant NHS waiting list for the hospital where it is proposed the surgical treatment is to take place. When an advance payment is made under this acceleration payment benefit for specified surgical treatments, your benefit will be reduced by the amount of the accelerated payment we make to you. This accelerated payment is also applicable for eligible children. We will always pay the benefit in respect of carcinoma in situ of the cervix requiring hysterectomy; Crohn s disease treated with surgical intestinal resection; ductal carcinoma in situ of the breast - with specified treatment; 35
What you are covered for low-grade prostate cancer; coronary angioplasty; cerebral aneurysm - with surgical repair; cerebral arteriovenous malformation - with surgical repair; non-malignant pituitary adenoma - with specified treatment, removal of one or more lobe(s) of the lung for disease and trauma or surgical treatments as a lump sum, with the lump sum calculated by reference to the benefit. Childcover benefit We will pay childcover benefit to you, if during the period of the agreement, a child suffers or undergoes a critical illness, suffers hydrocephalus as defined below, requires intensive care as defined below or suffers or undergoes one of the conditions as defined in What you are covered for section of this handbook, subject to you complying with the requirements and obligations set out in the How to make a claim section, unless your claim is excluded by any of the circumstances listed in the What you are not covered for section. Children s intensive care benefit requiring mechanical ventilation for 7 days We will pay childcover benefit to you, if during the period of the agreement, a child due to any sickness or injury is requiring continuous mechanical ventilation by means of tracheal intubation for 7 consecutive days (24 hours per day). Please refer to What you are not covered for section for exclusions and limitations of the cover. Child s Hydrocephalus - treated with the insertion of a shunt We will pay childcover benefit to you if the child suffers hydrocephalus if the hydrocephalus is treated with an insertion of shunt. Childcover benefit is the lower of 25 percent of the benefit and 25,000 unless the child suffers one of the following: carcinoma in situ of the cervix requiring hysterectomy; carcinoma in situ of the urinary bladder; cerebral aneurysm - with surgical repair; cerebral arteriovenous malformation - with surgical repair; Crohn s disease treated with surgical intestinal resection; ductal carcinoma in situ of the breast with specified treatment; non-malignant pituitary adenoma - with specified treatment; removal of one or more lobe(s) of the lung for disease and trauma; or then the childcover benefit will be the lower of 12.5 percent of the benefit and 12,500. The childcover benefit will only be paid once for any child regardless of number of memberships held. We will only pay childcover benefit where you are the member or spouse, partner or civil partner of the member. 36
What you are covered for We will always pay the childcover benefit as a lump sum, with the lump sum calculated by reference to the benefit. Family income benefit We will pay the benefit to you as an annual income where the benefit is a family income benefit, subject to you complying with the requirements and obligations set out in the How to make a claim section, unless your claim is excluded by any of the circumstances listed in the What you are not covered for section. We will pay the benefit annually on each anniversary of the payment until the last anniversary before the expiry date set out in your registration certificate. If your registration certificate shows that you have family income benefit, the benefit figure that will be used for the lump sum calculation for these benefits will be the annual benefit as per the following calculations: The annual benefit as shown on your registration certificate x the remaining number of years of your membership x 12.5 percent, up to a maximum of 12,500, for the following benefits: carcinoma in situ of the cervix requiring hysterectomy; Crohn s disease treated with surgical intestinal resection; ductal carcinoma in situ of the breastwith specified treatment; non-malignant pituitary adenoma - with specified treatment; removal of one or more lobe(s) of the lung for disease and trauma; or Each of these benefits is defined in the What you are covered for section of this handbook. The annual benefit as shown on your registration certificate x the remaining number of years of your membership x 25 percent, up to a maximum of 25,000, for the following benefits: childcover benefit low-grade prostate cancer coronary angioplasty acceleration payment benefit for specified surgical treatments Each of these benefits is defined in the What you are covered for section of this handbook. carcinoma in situ of the urinary bladder; cerebral aneurysm - with surgical repair; cerebral arteriovenous malformation - with surgical repair; 37
What you are not covered for
What you are not covered for What you are not covered for We will not pay the benefit, childcover benefit, fracture cover benefit, premium waiver benefit or any of the benefits set out in section What you are covered for in any of the following circumstances: where your claim is excluded by any special condition where your claim, other than a claim for the death or terminal illness benefit of a member, in whole or part, results directly or indirectly from a self inflicted injury where your claim is for critical illness, unless the member survives for 14 days after undergoing that critical illness or being diagnosed with that critical illness (unless the benefit is claimed under a critical illness with life cover membership) where we reasonably consider that you have, or the member has misled us (intentionally or carelessly) by either giving us false information or by keeping relevant information from us relating to your membership or your claim Additional terms apply to fracture cover benefit and the premium waiver benefit and are found in the Additional options section. We will not pay childcover benefit in the additional following circumstances: if symptoms first arose before: the commencement date the child reaching the age of 30 days your legal adoption or legal guardianship of the child if the condition is brought about by intentional harm inflicted on the eligible child by you if the child is over 18 years of age when it suffers or undergoes a critical illness if the child suffers a total and permanent disability if the child dies before 14 days following diagnosis of the illness we will not pay any claim in relation to a member: if it relates to any operation, or intended operation, unless it was, or is, medically necessary and was performed by a consultant in a hospital in which such operations are routinely carried out 40
Changes to your membership
Changes to your membership Changes to your membership There are various changes that can be made to your membership by you and by us. Changes we can make If you have Renewable term cover, you need to renew your membership on each renewal date. Renewal is subject to our entitlement to change the terms and conditions of your membership and / or your cover (including your premiums). At least 60 days before each renewal date, we will write to tell you either about any changes we will make to the terms and conditions of your membership or your cover on renewal or if we intend to end your membership. If we do not end your membership and you continue to pay your premiums, your membership will automatically be renewed and any changes to your membership will come into effect upon renewal. Changes you can make At any time you may write and ask us to change the terms of your membership, we will consider your request at our discretion. If you ask us to increase the benefit you have, we can ask you to give us extra medical, financial or other information to allow us to consider your application. If we accept your application, we will provide the increase either: under a new membership governed by the terms and conditions we apply at the time; or as an increase to the benefit under your membership Any increase in the benefit will increase your premiums. You may want to increase the benefit you have when the member, or either member if more than one: gets married or becomes a civil partner gets divorced or separated obtains a dissolution of a civil partnership has a child or adopts a child or becomes the legal guardian of a child takes out a larger mortgage due to moving house or undertaking home improvements is promoted by their current employer or starts a new job with a different employer and their salary increases 42
Changes to your membership In these circumstances, we will provide the increase to you without asking the member to provide extra medical evidence subject to all of the following: you write to us asking for the increase within six months of the event, supplying written evidence to us to show that the particular circumstance has happened eg a marriage certificate or mortgage loan offer the maximum increase in the benefit for each of the above is the lower of 25 percent of the benefit on the commencement date and 50,000 or if the member has family income benefit cover the lower of 25 percent of the annual benefit and 8,000 per annum the total of all increases in the benefit under this option is not more than the lower of 100 percent of the benefit on the commencement date and 125,000 for family income benefit, the total increases will not exceed 125,000 as calculated by the annual benefit multiplied by the remaining term under this membership if you want to increase the benefit due to a mortgage loan increase must be due to the member either moving home or undertaking home improvements if you want to increase the benefit because a member s salary has increased, the percentage increase is not more than the percentage increase in their salary we still offer this type of membership at the time you ask for the increase in benefit the member (or eldest member, if more than one) is under 55 years of age at the time we receive your request for an increase when we accepted your initial application for cover we did not apply premiums above one and a half times our standard rates at that time or apply any special conditions to your membership. the increase in the benefit is provided under a new membership governed by the terms and conditions (excluding any option to increase the benefit) that we apply when you ask for the increase or, at our option, as an increase in the benefit under your membership the amount by which your premiums will rise for any increase, is more than the minimum premium for this type of membership at the time you ask for the increase you may only increase the benefit once for each of the reasons set out above any increase due to a change made is based on the original benefit on the commencement of the original membership no changes to the membership will be made or will be effective in the event that a critical illness has already arisen. 43
Changes to your membership Any increase in benefit will increase your premiums. Your premiums will increase by the cost of providing the extra benefit, based on the member s age and our premium rates at the time of the increase in benefit. Changes applicable for key person/ shareholder protection only Where you have taken out the membership as a business on a person working in your business (a key person ) or as protection for your interest in a business ( shareholder/ partnership cover ) or if you are a sole trader, you may wish to increase the benefit you have to reflect changes in your business or the levels of cover you need. We will allow you to increase the cover you have without providing extra medical information where one of the events set out below occurs and the reason you took out the cover was one which applies for that event. We will only allow this subject to the applicable conditions which are set out in this section. In all cases the following conditions must be met: you write to us asking for the increase within three months of the event, supplying written evidence to us to show that the particular circumstance has happened the member is under 55 years of age at the time we receive your request for an increase when we accepted the initial application for cover we did not apply premiums above one and a half times our standard rates at that time or add any special conditions to your membership the increase in the benefit is provided under a new membership governed by the terms and conditions (excluding any option to increase the benefit) that we apply when you ask for the increase or, at our option, as an increase in the benefit under your membership the amount by which your premiums will rise for any increase is more than the minimum premium for this type of membership at the time you ask for the increase we still offer this type of membership at the time you ask for the increase in benefit the membership was taken out for one of the reasons specified as applying for the event in which you are seeking to exercise the option only one increase will be allowed for the membership The events on which this option may be exercised together with the reasons for taking out the membership which must apply are as follows: 44
Changes to your membership the member is employed by you and their salary has increased the reason for taking out cover for this event must have been to protect you against losses you would suffer to your business or the costs your business would incur if the member could not continue in their employment ( key person cover ) a business loan you have is increased the reason for taking out cover for this event must have been to provide security for the loan and have been a requirement of the lender in making the loan, but excludes applications from sole traders on their own lives ( loan cover ) the value of your interest in a business you own has increased the reason for taking out cover for this event must have been to provide funds to purchase your interest in the business which has increased in value ( shareholder/ partnership cover ) where you are a sole trader and either your net relevant earnings have increased or a business loan you have is increased the reason for taking out cover for this event must have been to provide funds for your dependants to replace the earnings from your trade or to provide security for the business loan and have been a requirement of the lender in making the loan ( sole trader cover ) The following conditions must be met for increases in relation to the different types of cover: Key person cover the maximum increase in the benefit is the lower of 50 percent of the benefit on the commencement date and 250,000 the increase does not exceed five times the increase in salary to which the request relates any request for an increase greater than 150,000 is subject to the member making a true declaration that they are in good health and our agreement that the financial evidence supports the request for the increase you cannot extend the term of your membership Loan cover or shareholder/partnership cover the maximum increase in the benefit is the lower of 50 percent of the benefit on the commencement date and 250,000 you cannot extend the term of your membership 45
Changes to your membership Sole trader cover the maximum increase in the benefit is the lower of 50 percent of the benefit on the commencement date and 150,000 if you want to increase the benefit because your net relevant earnings have increased the increase does not exceed five times the increase net relevant earnings any request for an increase greater than 150,000 is subject to the member making a health declaration and our agreement that the financial evidence supports the request for the increase you cannot extend the term of your membership Any increase in benefit will increase your premiums. your premiums will increase based on the cost of providing the extra benefit, based on the member s age and our premium rates at the time of the increase in benefit. 46
Premium options
Premium options Premium options Paying your premiums You must pay your premiums in advance throughout your membership (except whilst you are receiving the premium waiver benefit). The amount you must pay, and how often, are shown on your registration certificate and any endorsements to it. If you cannot pay your premiums, contact us immediately. Changing premiums This section explains how your premiums may change (except for yearly increases if we have provided an indexation option see the Additional options section) Whenever we change your premium we will write to tell you about this at least 60 days before the date the changes takes effect. We may increase your premium if any change in law or taxation increases the cost to us of providing cover under your membership by writing to tell you. In these circumstances, the increase in your premiums will be limited to the amount necessary to cover the increase in cost to us of providing cover. Your membership is subject to the payment of a monthly plan fee, which we collect as part of your premium. If you have more than one Friends Life flexible financial protection membership we will only charge you a plan fee with your premiums on one membership. If any other Friends Life flexible financial protection membership you have ends (for any reason) we have the right to increase the premium on your membership. We will only increase the premium by the amount of any plan fee forming part of the premium of the membership which has ended. Your registration certificate will show whether your premium option is guaranteed, reviewable or renewable. The effect of these different options is explained below. Guaranteed premiums if your premium option is guaranteed, your premium will remain the same for the term of the membership unless: we increase your guaranteed premium as set out above premium increases if the benefit is increased, for example, if an indexation option is selected 48
Premium options Reviewable premiums if your premium option is reviewable, we may increase or decrease your premiums on the fifth anniversary of the commencement date and at the end of every following five year period when we decide what premiums we charge under this option, we make assumptions about the future level of inflation, claim costs, expenses, investment returns, taxes and levies. When we review your premiums under this option, we consider if the combined effect of these factors is better or worse than we had assumed and if, as a result, the cost of the benefit needs to account for this. We may, as a result, increase or reduce your premiums by the amount we reasonably believe is necessary we may also increase your premiums under this premium option due to changes in the law or taxation or to collect plan fees as set out above, and where you increase the benefit under your membership which results in an increase in your premium. we will write to tell you about any change to your premiums at least 60 days beforehand if your premium needs to increase, you can tell us to keep the premium the same and reduce the amount of benefit instead. Alternatively, you can cancel the membership and stop paying premiums altogether Renewable premiums if your premium option is renewable your premiums may increase or decrease at each renewal without the need for further medical evidence based on the age of the member and our premium rates at that time. Your premiums will almost certainly increase on each renewal date because of an increase in age of the member renewable premiums are only available with renewable term we will write to tell you about any change to your premiums at least 60 days beforehand if your premium needs to increase, you can tell us to keep the premium the same and reduce the amount of benefit instead. Alternatively, you can cancel the membership and stop paying premiums altogether we can also increase your renewable premium on the renewal date as set out above 49
How to make a claim
How to make a claim How to make a claim If you wish to make a claim in relation to your membership, please contact: Friends Life Individual Protection Claims department The Core 40 St Thomas Street Bristol BS1 6JX Or telephone us on 0845 600 3122* You must make your claim as soon as you reasonably can. When initially notifying us of a claim, you must provide the following information: details of the person(s) dealing with the claim, their name(s), address, and telephone number. In some instances this may be a third party eg solicitor, next of kin or executor the nature of the illness, disability, operation or cause of death details of the member s total and permanent disability; or details of the member suffering a fracture; or details of any illness or injury the member or child suffers or evidence of a member s death and details of the diagnosis of a terminal illness relevant dates, eg the date the illness was diagnosed or date of death the registration number under which you are making a claim, this can be found on the registration certificate. However if you cannot locate this, we will be able to assist but will need to know: the name of the member, their date of birth and their address Once we have all this information, we will be able to confirm that a claim can be submitted to us to consider and we will then forward a claim form, reply paid envelope and a short aid detailing the next steps required for the claim to be assessed. You must return the claim form to us giving us any written information or proof we reasonably require to establish your claim. We will need evidence, where appropriate of: a diagnosis by a medical practitioner whose specialism is appropriate to the cause of the claim, where this is necessary it is explained in the definition of the particular critical illness; a medical report and other information about member s medical condition and medical history; or the results of any independent medical assessment which we may ask the member to undergo at our expense 52
How to make a claim In order to establish that a member has a critical illness, terminal illness, total and permanent disability, illness or injury, we may require that the member or child undergoes a medical assessment. We will pay for the cost of this assessment. Where we receive a claim from a member who is resident outside the UK, we may ask the member to attend a Friends Life Individual Protection approved hospital for medical assessment. In the event that we cannot obtain the medical information we require to assess the claim, we also reserve the right to request that they attend a Friends Life Individual Protection approved hospital in a different country or they return to the UK for the medical assessment. We will not pay for the member to travel to the UK or any other country for the medical assessment but will meet the costs of the medical assessment itself. We may also require evidence that you are entitled to the benefit. For example, in the event of a death of a the sole trustee of the policy we may need evidence of the appointment of personal representatives (or an executor) who will become the new trustee. Once we reasonably consider that we have enough information or proof to establish your claim, we will pay the benefit, childcover benefit, fracture cover benefit, premium waiver benefit or benefits as set out in What you are covered for section, to you as applicable. When you make your claim neither you nor a member must mislead us by either giving us any false information or keeping relevant information from us. If either you or a member does, we will end your membership and no benefit or childcover benefit will be paid. Replacement cover If your membership covers more than one member when we have paid the benefit to you for one member, or one member has died (without any benefit coming due), you may take out a new membership covering the other member, provided that: you tell us that you want to take out the new membership within three months of the date we paid the benefit to you your membership could have continued for at least five years after the commencement date of the new membership the member to be covered by the new membership must be under 50 years of age the amount of benefit to be provided by the new membership is not more than the benefit under your original membership the new membership will not continue beyond the date your original membership would have ended the total permanent disability option can only be included in the new membership if it was included in your original membership 53
How to make a claim we accepted your initial application for cover without increasing the premiums above our standard rates at that time or applying any special conditions to your membership the new membership is provided under the terms and conditions we apply at the time the new membership is taken out (excluding any option to increase the benefit) For information on replacement cover, please contact us at: Friends Life Individual Protection The Core 40 St Thomas Street Bristol BS1 6JX Or telephone us on 0845 600 3122* * Calls may be recorded and may be monitored 54
Your right to cancellation
Your right to cancellation Your right to cancellation You have the right to cancel the membership and have any premiums paid refunded if you cancel within 30 days from the date you receive your registration certificate and this handbook. Confirmation of your request to cancel should be in writing sent by post to the contact details below. Please note that if there are two schemeholders, we will require both schemeholders signatures on any cancellation correspondence. Please note that outside of the initial 30 day cancellation period: no refund of premiums will be due unless you have paid an annual premium and you cancel your cover before the next premium is due, in which case, we will give you a pro-rata refund but we will deduct the discount you would have received in that year for paying an annual premium Please note that Friends Life Individual Protection contracts have no surrender value. Once we have been notified of your request to cancel (within the 30 days period) we will refund any premiums that you have paid to us. If you wish to cancel your membership at any other time, please write to us at the address shown below. Friends Life Individual Protection The Core 40 St Thomas Street Bristol BS1 6JX Tel: 0845 600 3122* We will write to you to confirm the cancellation of your membership. * Calls may be recorded and may be monitored 56
General information
General information General information Changes to your registration certificate If we need to change any details on your registration certificate, or add new details to it, we will send you a new registration certificate or an endorsement, providing the most up to date details of your membership and will replace any earlier registration certificate (including any endorsements on it). Your registration certificate will show the date on which it replaced the earlier registration certificate. Assigning and surrendering your membership Your membership has no surrender value. You will not receive any benefit or refund of premiums when your membership ends. If you assign your membership, you or the assignee should provide us with written notification of this. Changes to your membership Only we can make any changes to your membership (in accordance with our rights under your membership), confirm any changes you have asked for or decide not to enforce any of our rights. Any change to your membership will come into force only when confirmed by us in writing. Written communication We will send any letters to you to the address you last gave us. If you change address you must always write and tell us. If you write to us, you must send that letter to: Friends Life Individual Protection The Core 40 St Thomas Street Bristol BS1 6JX You can also personally deliver your letter to this address. If we change this address we will write to you with details of where you should write to us. You and we can assume that a letter has been received: on the day after it was personally delivered; three days after it was sent by first class post; or Applicable law Your membership is governed by English law. Any dispute that you and we cannot settle will be dealt with exclusively by the courts in England. If we ever decide not to enforce our legal rights, this does not prevent us from enforcing those rights in the future. 58
Getting in touch
Getting in touch Getting in touch Our helpline is always the first number to call if you need help or support or if you have any comments or complaints. Please call us on 0845 600 3122*. Alternatively, you can write to us at: Friends Life Individual Protection The Core 40 St Thomas Street Bristol BS1 6JX Making a complaint If you have not been able to resolve a problem and you wish to take your complaint further, please write to Customer Relations at the address above. It is rare that we cannot settle a complaint, but if this does happen, you may refer your complaint to the Financial Ombudsman Service. You can write to them at: South Quay Plaza 183 Marsh Wall London E14 9SR Or call them on their consumer helpline on 0800 023 4567 (free if you call from a landline) or 0300 123 9123 (free if you call from a mobile phone). Please let us know if you want a full copy of our complaints procedure. If something has gone wrong, we want to do everything we can to put it right. But none of these procedures affect your legal rights. *Calls may be recorded and may be monitored The Financial Services Compensation Scheme (FSCS) In the unlikely event that we cannot meet our financial obligations, you may be entitled to compensation from the Financial Services Compensation Scheme. This will depend on the type of business and the circumstances of your claim. The FSCS may arrange to transfer your membership to another insurer, provide a new policy or, where appropriate, provide compensation. Further information about compensation scheme arrangements is available from the FSCS on 020 7892 7300 or on its website www.fscs.org.uk www.financial-ombudsman.org.uk 60
For more information, please contact us on: 0845 600 3122 Friends Life Individual Protection, The Core, 40 St Thomas Street, Bristol, BS1 6JX Calls may be recorded and may be monitored Friends Life Limited is authorised and regulated by the Financial Services Authority, register number 196142. Friends Life Limited is an incorporated company limited by shares and registered in England and Wales number 4096141. Registered Office: Pixham End, Dorking, Surrey RH4 1QA. www.friendslife.com Friends Life is a registered trade mark of the Friends Life group. PBHA/4564/AUG12 82072 UNI