This appendix only applies if cover under the schedule includes the Severe Trauma Benefit (standalone or accelerated). This appendix forms part of and is incorporated into your AIA Living policy, the terms of which apply to this appendix. This Severe Trauma Benefit may be standalone or accelerated. Details of the benefit and the life/lives assured are shown in the schedule.
AIA LIVING - BUSINESS PERSONAL OPTIONAL BENEFIT APPENDIX
Severe Trauma Benefit
This appendix only applies if cover under the schedule includes the Severe Trauma Benefit (standalone or accelerated). This appendix forms part of and is incorporated into your AIA Living policy, the terms of which apply to this appendix .
This Severe Trauma Benefit may be standalone or accelerated. Details of the benefit and the life/lives assured are shown in the schedule .
1. When will AIA pay a Severe Trauma Benefit?
AIA will pay you a Severe Trauma Benefit if the life assured suffers for the first time after the risk commencement date any of the conditions listed in the table below and survives for at least 14 days thereafter. An exception is the Optional Total Permanent Disablement condition , for which a 90 day survival period applies.
What stand down periods apply?
If, after the risk commencement date but within the first 90 days of the receipt of application , any of the conditions marked in the table below as having a 90 day stand down period occur, or symptoms or signs which lead to any of those conditions (whether or not a registered medical practitioner has been consulted) occur, then AIA will not pay a benefit for the life assured or any child of the life assured covered by the Built-in Children’s Trauma Benefit..
Cover added under the Optional Business Safeguard Facility
A 180 day stand down period applies to increases made under the Optional Business Safeguard Facility, except where the claim is due to an accident , as outlined in Section 14. Where the claim is due to an accident , the 90 day stand down period is waived on such increases, provided the life assured has already served the 90 day stand down period on the original Severe Trauma Benefit policy.
Medical Advancements Provision
If the medical diagnostic techniques and investigations used in our definitions of medical conditions have been superseded due to medical advancements, we will consider other appropriate and medically recognised methods or tests that conclusively diagnose the condition to at least the same severity. The following requirements must be met for a claim to be considered: The new diagnostic techniques and investigations are not experimental and are medically necessary and medically equivalent or superior to the original diagnostic technique or investigation. Any new diagnostic techniques and investigations must be deemed medically acceptable based on medical standards and medically recognised in Australia or New Zealand by specialist medical practitioners.
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Table of conditions
Refer to Section 17 for the definition of each of these medical conditions , including the full description of the criteria and severity required to give rise to a claim.
90 day stand down period
90 day stand down period
Condition
Condition
Loss of independent existence
Cancer
-
Paraplegia
Cancer
-
Permanent blindness
Heart
✓
Permanent loss of hearing
Cardiomyopathy
-
-
Permanent loss of speech
Heart attack
-
✓
Permanent loss of use of limbs (including sight)
Primary Pulmonary hypertension
-
-
Quadriplegia / Tetraplegia
Major neurological disease
-
Other key conditions
Alzheimer’s disease
-
Advanced AIDS
-
Coma
-
Advanced diabetes
Creutzfeldt-Jakob disease
✓
-
Aplastic anaemia
Dementia
-
-
Chronic liver failure
Encephalitis
✓
-
Chronic lung disease
Idiopathic Parkinson’s disease
✓
-
Chronic renal failure
Major head trauma
-
-
Cognitive impairment
Meningitis
-
-
Intensive care
Motor neurone disease
-
-
Major transplant surgery
Multiple sclerosis
-
✓
Severe burns
Muscular dystrophy
-
-
Systemic sclerosis
Peripheral neuropathy
-
-
Terminal illness
Stroke
-
✓
Optional condition (not applicable to the Built-in Children’s Trauma Benefit)
Paralysis and loss of functionality
Diplegia
-
Total Permanent Disablement
-
Hemiplegia
-
If you receive a payment for a claim that reduces the sum assured for a life assured to nil under this Severe Trauma Benefit, cover will cease for that life assured .
If the life assured suffers more than one condition (including the Optional Total Permanent Disablement condition ), AIA will pay a maximum of the Severe Trauma Benefit sum assured for all claims (in total).
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2.
What effect does payment of an accelerated Severe Trauma Benefit have on the Life Cover Benefit?
4.
Built-in Children’s Trauma Benefit
What is the Built-in Children’s Trauma Benefit?
AIA will pay a Built-in Children’s Trauma Benefit if a child of a life assured suffers one of the applicable conditions listed in Section 1 of this appendix .
This section applies only if an accelerated Severe Trauma Benefit is shown in the schedule .
When AIA pays an accelerated Severe Trauma Benefit, the Life Cover Benefit for the life assured will decrease by the same amount. Any other accelerated benefits relating to that Life Cover Benefit will also be reduced, if necessary, so that those accelerated benefits do not exceed the decreased Life Cover Benefit. If the Life Cover Benefit is reduced to nil, all accelerated benefits relating to that Life Cover Benefit will be removed. The maximum combined amount payable under the Life Cover Benefit, Specified Terminal Conditions Benefit, Terminal Illness Benefit, Bereavement Support Benefit, Repatriation Benefit, accelerated Severe Trauma Benefit and, if applicable, the accelerated Critical Conditions Benefit, the accelerated Progressive Care Benefit and the accelerated Total Permanent Disablement Benefit is the amount of the Life Cover Benefit for that life assured .
This Benefit is only payable if the child of the life assured :
first suffers a condition after the risk commencement date , subject to the applicable stand down period provisions where these apply;
is aged from three months up to their 21 st birthday at the time he or she first suffers from that condition ; and
survives for at least 14 days after suffering from the condition .
What are the applicable conditions and how much will AIA pay?
For those conditions where the criteria for a full payment are met as detailed in Section 17 below the Benefit payable is the lower of $50,000 or 50% of the sum assured across all Severe Trauma Benefit policies for the life assured . No payments are made under this Benefit for the Optional Total Permanent Disablement condition . AIA will pay a maximum of one claim per child under the Built-in Children’s Trauma across all AIA policies . Payment of the Built-in Children’s Trauma Benefit will not affect the amount of any Severe Trauma Benefit payable for the life assured . AIA will not pay a benefit under the Built-in Children’s Trauma Benefit that arises as a direct or indirect consequence of:
3.
Built-in Financial and Legal Advice Benefit
If AIA pays a full payment claim under this Severe Trauma Benefit for a condition suffered by a life assured , then AIA will reimburse you for fees incurred up to $2,500 including GST (in total) that you pay for financial planning you receive from an accredited Adviser or legal advice received from a legal professional approved by AIA , subject to the following conditions: You must pay for the financial planning or legal advice within the 12 months following AIA paying the Severe Trauma Benefit claim. AIA will only pay one Financial and Legal Advice Benefit per life assured across all AIA policies . This is in addition to the sum assured. The Built-in Financial and Legal Advice Benefit is not payable for a claim for a child of the life assured under the Built-in Children’s Trauma Benefit or the Built-in Parents Grieving Benefit.
a pre-existing condition ; or
any congenital condition .
The Built-in Children’s Trauma Benefit ceases on the child’s 21 st birthday.
5.
Built-in Children’s Trauma Conversion Facility
The Built-in Children’s Trauma Benefit can be converted to:
a standalone Severe Trauma Benefit; or
an accelerated Severe Trauma Benefit with an equal amount of Life Cover Benefit,
with a maximum sum assured of $50,000 or 50% of the life assured’s original sum assured whichever is the lesser, without further medical evidence. Where the life assured’s sum assured has reduced, the conversion will be calculated on the reduced amount.
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7.
Built-in Premium Conversion Facility
The following conditions are applicable to the Children’s Trauma Conversion option:
You may at any time prior to the life assured reaching age 65:
A conversion cannot occur if the child has claimed or was eligible to claim under the Built-in Children’s Trauma Benefit; and Your request for conversion must be received by AIA within 60 days of the anniversary date after the child’s 21 st birthday; and
Convert all or part of your Severe Trauma Benefit from the premium type shown in the schedule to a Level premium structure; or Convert a Level premium structure to an alternate Level premium structure, of which term duration may be the same or less than current Level premium structure.
Your request must be received in writing.
An applicable premium will be payable on converted cover.
AIA will not require you or the life assured to produce further medical evidence at the time of conversion.
6.
Built-in Standalone Conversion Facility
You will be issued a new policy for the sum assured amount of the Severe Trauma Benefit being converted, in which case:
If the schedule shows the Severe Trauma Benefit as standalone you can convert this to an accelerated Severe Trauma Benefit with an equal amount of Life Cover Benefit without any further medical evidence subject to the following:
The Severe Trauma Benefit under this policy will be reduced by the sum assured amount converted;
The life assured was accepted with standard underwriting terms (e.g. there are no special terms, exclusions or premium loadings applicable to the life assured );
The new policy will be issued based on the information provided at the time of conversion, together with the information provided in the original proposal; The terms and conditions of the new policy will be those which are then offered by us to the general public;
The life assured is only eligible for the standalone Conversion Facility where the conversion occurs before age 60; The life assured has not made a claim, with AIA or any other insurer, and is not eligible to make a claim under their standalone Severe Trauma Benefit. This includes any claim currently under assessment;
Premiums will be calculated on the current age of the life assured ;
Any special terms, exclusion or premium loadings that applied to your existing Severe Trauma Benefit under this policy will apply to your new Severe Trauma Benefit under the new policy.
The premiums for their standalone Severe Trauma Benefit are paid up to date;
8.
Built-in Return Home Benefit
The accelerated Severe Trauma Benefit sum assured must be less than or equal to the standalone Severe Trauma Benefit sum assured; and
We will pay a Return Home Benefit if the life assured is outside of New Zealand and suffers, for the first time, a covered condition . The Return Home Benefit will reimburse the cost of a standard economy flight back to New Zealand for the life assured and one support person. You will need to provide evidence of the transport costs satisfactory to us before a claim under the Return Home Benefit will be paid. In total the maximum we will pay over the life of the policy under the Return Home Benefit is $10,000. A Return Home Benefit is paid in addition to the Severe Trauma Benefit.
The Life Cover Benefit sum assured does not exceed the accelerated Severe Trauma Benefit sum assured.
The premium for the conversion will be based on the age of the life assured and our premium rates at the date of conversion . If you are issued a new policy for the amount of the standalone Severe Trauma Benefit being converted, the new policy will be issued based on the information provided at the time of conversion, together with the information provided in the original proposal. If the death of the life assured occurs within three months of the date of conversion , other than by accidental death , then this conversion is void and the standalone Severe Trauma Benefit will be reinstated from the date of conversion.
No payment will be made if the life assured is covered for the same event with a travel insurance provider.
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9.
Built-in Counselling Benefit
The Optional Total Permanent Disablement condition does not apply once the life assured attains age 65.
The Counselling Benefit covers the cost of a Psychiatrist or Psychologist consultation and/or counselling for the life assured and/or a close relative of the life assured where the support treatments and/or consultations directly relate to a claim under the Severe Trauma Benefit. After referral by a registered medical practitioner we will reimburse up to $2,500 including GST (in total) per life assured , subject to the following conditions: The consultation and/or counselling must be paid for within 12 months following AIA paying the Severe Trauma Benefit claim; and
12. Optional Life Cover Buyback Benefit
What is the Optional Life Cover Buyback Benefit?
The Optional Life Cover Buyback Benefit applies only if shown in the schedule and if you have selected an accelerated Severe Trauma Benefit. Where an Optional Life Cover Buyback Benefit is selected, this allows the Life Cover Benefit to be reinstated without the need to provide further medical evidence following an accelerated Severe Trauma Benefit claim, subject to the following conditions: The Life Cover Benefit can be reinstated to the level applying immediately before the accelerated Severe Trauma Benefit claim.
AIA must be provided with a receipt for the consultation and/or counselling being claimed.
The $2,500 is payable once per life assured per policy. This is in addition to the sum assured.
The Optional Life Cover Buyback Benefit can be exercised:
10. Built-in Parents Grieving Benefit
When is a Parents Grieving Benefit payable?
− within 60 days of the accelerated Severe Trauma Benefit claim payment; or
AIA will pay a Parents Grieving Benefit if:
a child of a life assured dies prior to birth but after at least 24 weeks gestation; or
− within 60 days of the life assured surviving a period of six months after an accelerated Severe Trauma claim payment for one of the following conditions:
a child of a life assured dies.
AIA will not make any payment if the death occurs within 12 months of the risk commencement date except where it is an accidental death. This Parents Grieving Benefit ceases on the child’s 21 st birthday.
▪
Paraplegia.
▪
Quadriplegia.
▪
Diplegia.
▪
Hemiplegia.
▪
Alzheimer’s disease.
How much will AIA pay for the Parents Grieving Benefit?
▪
Permanent blindness.
The Benefit payable:
▪
Permanent loss of hearing.
if the child is under 10 years of age AIA will pay a maximum of one claim of $2,000 per child under the Parents Grieving Benefit across all AIA policies; or if the child is 10 years of age or over AIA will pay a maximum of one claim of $15,000 per child across all AIA policies for a life assured . Payment of the Parents Grieving Benefit will not reduce the sum assured of the Severe Trauma Benefit for the life assured .
▪
Dementia.
▪
Permanent loss of use of limbs (including sight)
▪
Multiple sclerosis.
▪
Idiopathic Parkinson’s disease.
− within 60 days of the life assured surviving a period of 12 months after an accelerated Severe
Trauma Benefit claim payment for all other conditions (including the Optional Total Permanent Disablement condition, where applicable).
11. Optional Total Permanent Disablement condition
The Optional Total Permanent Disablement condition applies only if shown in the schedule and, subject to the provisions of this appendix , is included as a condition under the Severe Trauma Benefit. The Optional Total Permanent Disablement condition does not apply to any child of a life assured covered under the Built-in Children’s Trauma Benefit.
Only one Life Cover Buyback reinstatement will apply per life assured per policy.
The maximum Life Cover Benefit that can be reinstated is 100% of the accelerated Severe Trauma Benefit claim or $2,000,000, whichever is the lesser.
What other conditions apply to cover reinstated under
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When can the life assured exercise the Optional Severe Trauma Buyback Benefit?
the Optional Life Cover Buyback Benefit?
No reinstated Life Cover Benefit is payable:
The Optional Severe Trauma Buyback can be exercised:
− within six months (for the conditions listed above that require a six month survival period); or
within 60 days of the Severe Trauma Benefit claim payment, or within 60 days of the first anniversary of the Severe Trauma Benefit claim payment.
within twelve months (for all other conditions , including the Optional Total Permanent Disablement condition, where applicable),
−
The Benefit(s) can only be reinstated on one occasion.
from the date of the accelerated Severe Trauma Benefit claim payment, except where the claim event is for accidental death. No Life Cover Buyback Benefit is available if the life assured has suffered a claim event under a Terminal Illness Benefit or a Specified Terminal Conditions Benefit under any AIA policy , whether or not a claim has been made. Any exercise of the Life Cover Buyback Benefit may require an increase in premium . This premium increase will be calculated on the rates applicable at the time the Life Cover Benefit is reinstated. Any accelerated benefits relating to the Life Cover Benefit for the life assured that have been reduced or removed as a result of an accelerated Severe Trauma Benefit claim will not be reinstated.
What other conditions apply to cover reinstated under the Optional Severe Trauma Buyback Benefit? On AIA’s acceptance of an application for reinstatement of the Severe Trauma Benefit, you will be issued a new policy for the Benefit(s) and sum assured amount(s) being reinstated in which case: The new policy will be issued based on the information provided at the time of buyback, together with the information provided in the original proposal.
The terms and conditions of the new policy will be those which are then offered by us to the general public, with the exception that no further reinstatements under an Optional Severe Trauma Buyback Benefit will be available in respect of the reinstated Benefit(s). The reinstated Benefit(s) may require an increase in premium . This premium increase will be calculated at the rates applicable at the time the Benefit(s) are reinstated. However, where the Benefit(s) are reinstated after a Severe Trauma Benefit claim has been paid for cancer, stroke or heart attack – a discount will be applied to the Severe Trauma Benefit premium .
13. Optional Severe Trauma Buyback Benefit
What is the Optional Severe Trauma Buyback Benefit?
The Optional Severe Trauma Buyback Benefit applies only if shown in the schedule .
Where an Optional Severe Trauma Buyback Benefit is selected, this allows the Severe Trauma Benefit to be reinstated without the need to provide further medical evidence following a Severe Trauma Benefit claim, subject to the following conditions: The life assured must have had a claim paid on their Severe Trauma Benefit that has reduced the sum assured to a nil balance. No Severe Trauma Buyback Benefit is available if the life assured has suffered a claim event under a Terminal Illness Benefit or a Specified Terminal Conditions Benefit under any AIA policy , whether or not a claim has been made. A life assured can only exercise the Severe Trauma Buyback Benefit for the cover provided under this policy once.
Any special terms, exclusions or premium loadings that applied to the original Benefit(s) will also apply to the reinstated Benefit(s) under the new policy. If you had selected the Optional Total Permanent Disablement condition at the time of the first Severe Trauma Benefit claim, this condition will be included under the reinstated Severe Trauma Benefit, except where the Optional Total Permanent Disablement condition was the subject of the Severe Trauma Benefit claim.
In the event of a claim in respect of the reinstated Severe Trauma Benefit, no claim will be paid for:
Any condition for the subsequent claim that is a related condition to the condition which was the subject of the first Severe Trauma Benefit claim, as determined by AIA . The same condition for which AIA has paid a claim under a Severe Trauma Benefit for the life assured , unless the original claim was for any of the conditions under the category of cancer, in which case: o any subsequent claims under the category of cancer will be excluded if the condition occurs
What is the maximum amount of cover that can be reinstated?
The maximum Severe Trauma Benefit that can be reinstated is 100% of the Severe Trauma Benefit claim payment or $2,000,000, whichever is the lesser.
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within the 36 months immediately following the original claim event date; and following this period the same condition shall include any cancer that is either:
The Severe Trauma Benefit for a life assured under this policy after the use of this Facility cannot exceed the Life Cover Benefit for that life assured . After the use of this Facility, the Severe Trauma Benefit for a life assured under this policy plus any other Severe Trauma type cover held on the life assured with any insurer cannot exceed $2,000,000. The Optional Business Safeguard Facility cannot be exercised within six months of the risk commencement date . In any 12 month period you can make only two increases under this Facility.
o
of the same organ system as the original cancer;
−
− considered by the treating oncologist as likely to be a secondary cancer of the original cancer; or
a related cancer .
−
Any heart (or heart-related) condition if the original claim was for a heart condition or a stroke, except where the claim in respect of the reinstated Severe Trauma Benefit is for pulmonary hypertension, and it has not previously been claimed for and is not considered by an appropriate specialist as likely to be secondary or directly resulting from the original condition . Stroke, or any condition directly resulting from a stroke, if the original claim was for a heart (or heart- related) condition , except where the original claim was for pulmonary hypertension. Any exclusion which applied to the original Severe Trauma Benefit.
You must make the request within three months of the relevant business event.
To apply for the increase in cover, you need to write to AIA to satisfy us that the value of the life assured 's financial interest is at least equal to the requested increase to the amount of cover. You must include: - a valuation of the business or valuation of the life assured to the business (as provided by an independent qualified accountant or business valuer); and/or
- evidence of the loan guarantee, and any other contractual or financial evidence we may request.
Any increase is subject to approval by AIA .
14. Optional Business Safeguard Facility
The method chosen to value the business or life assured must be in accordance with established business valuation practice for the industry. The independent qualified accountant or business valuer cannot be a family member, business partner, employee or employer of you or the life assured . The method of valuation and valuer must be satisfactory to AIA . In the first six months following an increase, the life assured will only be covered for the amount of the increase if the life assured ’s condition occurs as a direct and sole result of an accident . You cannot apply for an increase under this Facility at any time when you have made, or are entitled to make, a claim under your Life Cover Benefit or Severe Trauma Benefit.
The Optional Business Safeguard Facility applies only if shown in the schedule and if you have selected an accelerated Severe Trauma Benefit. On each occasion that the financial interests of a life assured in the business increases, or their loan guarantee increases, or their value to the business increases, you may write to AIA asking us to increase the Severe Trauma Benefit for that life assured without the need to provide medical evidence, subject to the following conditions: The Severe Trauma Benefit for a life assured under this policy after the use of this Facility cannot exceed the lesser of five times the original Severe Trauma Benefit or $2,000,000. Example 1: Original benefit = $100,000 Original benefit x 5 = $500,000 Cover available after the use of this Facility cannot exceed $500,000 Total increase under this Facility cannot exceed $400,000
Each Optional Business Safeguard Facility increase will require an increase in premium . This increase will be
calculated on the rates applicable at the time the Optional Business Safeguard Facility is used.
Example 2: Original benefit = $500,000 Original benefit x 5 = $2,500,000 Cover available after the use of this Facility cannot exceed $2,000,000 Total increase under this Facility cannot exceed $1,500,000.
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15. Exclusions – when AIA won’t pay a benefit
16. How to make a claim
To make a claim, refer to the section in your AIA Living policy entitled ‘How to make a claim’.
AIA will not pay any benefit described in this appendix where any of the following (and in each case either directly or indirectly) causes or contributes to the claim: The life assured (or the child in the case of a Built-in Children’s Trauma Benefit) deliberately injures himself or herself or attempts to do so. The life assured (or the child in the case of a Built-in Children’s Trauma Benefit or the Built-in Parents Grieving Benefit) engages in or is part of any conduct that is criminal. Any condition or any symptom or signs leading to the condition (whether or not a registered medical practitioner has been consulted) that existed before the risk commencement date , unless AIA is satisfied that you or the life assured could not have known of the existence of the condition or symptom or signs leading to the condition , or the condition or symptom or signs leading to the condition were declared on your application and accepted by AIA . AIA will not pay any benefit described in this appendix where any of the following occurs before a life assured (or any child in the case of a Built-in Children’s Trauma Benefit or the Built-in Parents Grieving Benefit) reaches age 21, and (in each case either directly or indirectly) causes or contributes to a claim for that life assured (or child ):
In addition, for a Severe Trauma Benefit claim, AIA will require information acceptable to us, including medical evidence and reports, showing proof of the condition giving rise to the claim. AIA may require the life assured or his or her child (if applicable) to have an examination by a registered medical practitioner appointed by AIA before accepting liability for a claim.
Where the Optional Total Permanent Disablement condition is the condition giving rise to the claim, AIA will also require:
An AIA claims form completed by the life assured and a registered medical practitioner (at your expense).
Other information which AIA may reasonably request to help assess the claim, which may include evidence of earnings, taxable income, business accounts, ACC details or similar. The life assured to undergo medical and/or surgical treatment (including any operation or vocational, medical and/or social rehabilitation) at your expense which the life assured ’s registered medical practitioner or a registered medical practitioner approved by AIA considers necessary.
Any other information that AIA may deem relevant to the assessment of the claim.
any intentional act by you or by any parent or guardian of the life assured , or child.
For advice about submitting a claim you can phone AIA on 0800 500 108 or your Adviser. Find claim information online at AIA.co.nz
any intentional act by someone who lives with or supervises the life assured, or child.
AIA will not pay a children’s benefit under the Built-in Children’s Trauma Benefit that arises as a direct or indirect consequence of:
a pre-existing condition ; or
any congenital condition.
These exclusions apply to any subsequent benefit increase you make.
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17. Definitions of medical conditions
Heart attack Heart attack resulting in permanent and irreversible left ventricular ejection fraction of less than 40% (two measurements at least six months apart) whilst on ongoing optimal therapy for a minimum of six months, and significant and irreversible physical impairment to the degree of at least Class III (3) of the New York Heart Association Functional Classification System of cardiac impairment. Heart attack means the death of a portion of the heart muscle (myocardium) as a result of inadequate blood supply to the relevant area, confirmed by a cardiologist or general physician and evidenced by: Typical rise and/or fall of cardiac biomarkers with at least one value above the 99 th percentile of the upper reference limit;
Cancer
The life assured has suffered or undergone one of the following conditions :
Cancer
Any metastatic cancer classified as, Stage III (3) based on TNM classification, where all treatment modalities have failed and been exhausted and where no other therapies are available and where progression of the cancer can be identified, or Stage IV (4) based on TNM classification; or Advanced lymphoma classified as, Ann-Arbor Stage III (3) where all treatment modalities have failed and been exhausted and where no other therapies are available and where progression of the cancer with resultant ongoing and continuous symptomatology can be identified, or Ann-Arbor Stage IV (4) classification; or Leukaemia where all treatment modalities have failed and been exhausted and where no other therapies are available, where progression of the cancer can be identified, and where there is resultant ongoing and continuous symptomatology; or Malignant brain tumour classified as Grade III (3) based on the WHO grading system for malignant neuroepithelial tumours of the central nervous system, where all treatment modalities have failed and been exhausted and where no other therapies are available and where progression of the cancer can be identified, or Grade IV (4) based on the WHO grading system for malignant neuroepithelial tumours of the central nervous system; or Multiple myeloma where all treatment modalities have failed and been exhausted and where no other therapies are available, where progression of the cancer can be identified, and where there is resultant ongoing and continuous symptomatology.
and at least one of the following:
Signs and symptoms of ischaemia which are consistent with myocardial infarction; or Confirmatory new (or presumed new) ECG changes associated with myocardial infarction with the development of any one of the following:
ST changes;
−
T wave inversion;
−
Left bundle branch block (LBBB);
−
Pathological Q waves; or
−
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. A rise in cardiac biomarkers resulting from a percutaneous procedure for coronary artery disease is excluded unless the baseline value is normal and the elevation is greater than five times the 99 th percentile of the upper reference limit. If the above evidence is inconclusive or superseded by technological advances, we will consider other appropriate and medically recognised tests that unequivocally diagnose that a myocardial infarction of the degree of severity or greater as outlined above has occurred. Other acute coronary syndromes including but not limited to angina pectoris are excluded. Primary pulmonary hypertension Primary pulmonary hypertension means the presence of irreversible raised pressure in the pulmonary arteries. The measurement reported must be the average level measured by cardiac catheterisation and be at least 30mmHG (mm of mercury) at rest. There must also be right ventricular dilatation and hypertrophy on echocardiogram with characteristic ECG changes.
Heart
The life assured has suffered or undergone one of the following conditions :
Cardiomyopathy Cardiomyopathy means impaired ventricular function of variable aetiology, resulting in permanent and irreversible left ventricular ejection fraction of less than 40% (two measurements at least six months apart) whilst on ongoing optimal therapy for a minimum of six months, and significant and irreversible physical impairment to the degree of at least Class III (3) of the New York Heart Association Functional Classification System of cardiac impairment.
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Major neurological disease
Major head trauma An accidental cerebral injury diagnosed by an appropriate specialist approved by AIA . The life assured must have also sustained a neurological deficit resulting in total and irreversible inability to perform one of the activities of daily living .
The life assured has suffered or undergone one of the following conditions :
Alzheimer’s disease The unequivocal diagnosis of Alzheimer's disease, resulting in significant cognitive impairment or permanent irreversible inability to perform two activities of daily living . The diagnosis is confirmed by an appropriate specialist in psychogeriatrics, psychiatry, neurology or geriatrics. Coma Means a state of unconsciousness with no reaction to external stimuli or internal needs which, at the recommendation of an appropriate specialist , results in continuous mechanical ventilation by means of tracheal intubation for at least seven days or the admission to the intensive care ward of a hospital for at least fifteen consecutive days.
Major head trauma arising from drug and alcohol abuse is specifically excluded.
Meningitis The diagnosis of meningitis by an appropriate specialist approved by AIA . The life assured must have also sustained a neurological deficit resulting in total and irreversible inability to perform one of the activities of daily living .
Motor neurone disease The unequivocal diagnosis of motor neurone disease diagnosed by an appropriate specialist approved by AIA .
Coma caused by alcohol or drug abuse is specifically excluded.
Multiple sclerosis The unequivocal diagnosis of multiple sclerosis as confirmed by an appropriate specialist and resulting in total and irreversible inability of the life assured to perform at least one of the activities of daily living .
Creutzfeldt-Jakob disease The diagnosis of Creutzfeldt-Jakob disease confirmed by an appropriate specialist neurologist. The life assured must exhibit signs and symptoms of cerebellar dysfunction, severe progressive dementia, uncontrolled muscle spasm, tremor and athetosis, resulting in the life assured requiring permanent and continual medical supervision. Dementia The unequivocal diagnosis of dementia, resulting in significant cognitive impairment or permanent irreversible inability to perform two activities of daily living . The diagnosis is confirmed by an appropriate specialist in psychogeriatrics, psychiatry, neurology or geriatrics. Encephalitis The unequivocal diagnosis of severe inflammatory disease of the brain diagnosed by an appropriate specialist approved by AIA . The life assured must have also sustained a neurological deficit resulting in total and irreversible inability to perform one of the activities of daily living . Idiopathic Parkinson’s disease The unequivocal diagnosis of Idiopathic Parkinson’s disease as confirmed by an appropriate specialist and resulting in total and irreversible inability of the life assured to perform one of the activities of daily living.
Multiple sclerosis means a disease characterised by demyelination in the brain and/or spinal cord.
There must be more than one episode of well-defined neurological deficit with persisting neurological abnormalities. Neurological investigations such as lumbar puncture, MRI (Magnetic Resonance Imaging) evidence of lesions in the central nervous system, evoked visual responses, and evoked auditory responses are required to confirm diagnosis. Muscular dystrophy The unequivocal diagnosis of muscular dystrophy diagnosed by an appropriate specialist approved by AIA and resulting in total and irreversible inability of the life assured to perform at least one of the activities of daily living. Peripheral neuropathy Irreversible inflammation or degradation of a peripheral nerve, diagnosed by an appropriate specialist approved by AIA . The life assured must have also sustained a neurological deficit resulting in total and irreversible inability to perform one of the activities of daily living . Stroke Stroke resulting in total and irreversible inability of the life assured to perform one of the activities of daily living . If required, the assessment may need to be deferred until all
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rehabilitation has been completed, or until any other appropriate time necessary to determine permanency, at which point a specialist can determine the irreversibility of the condition . Stroke means a cerebrovascular event producing neurological deficit. This requires clear evidence on CT, MRI (Magnetic Resonance Imaging) or similar appropriate scan or investigation that a stroke has occurred. This requires evidence of:
Permanent loss of hearing Means irreversible, and profound (defined in accordance with the Clark 1981 Scale of Hearing Impairment), hearing loss in both ears which cannot be corrected medically or mechanically. Permanent loss of speech The life assured , as a result of sickness or injury, loses the ability to produce intelligible speech, both natural and assisted. This loss must be total and permanent and the unequivocal diagnosis reaffirmed after a continuous period of three months of such loss by an appropriate specialist . Loss of speech related to any psychological cause is excluded.
infarction of brain tissue; or
intracranial or subarachnoid haemorrhage.
Excluded from this definition are transient ischaemic attacks (TIA), cerebral symptoms due to migraine, cerebral injury from trauma or hypoxia and vascular disease affecting the eye, optic nerve or vestibular functions.
Permanent loss of use of limbs (including sight)
The life assured , as a result of sickness or injury, permanently loses the use of: both hands; or
Paralysis and loss of functionality
both feet; or
The life assured has suffered or undergone one of the following conditions :
one hand and one foot; or
one hand and the sight of one eye (to the extent of 6/60 or less); or one foot and the sight of one eye (to the extent of 6/60 or less). Quadriplegia/Tetraplegia Total and permanent loss of function of both upper and lower limbs due to injury or disease of the spinal cord.
Diplegia Total and permanent loss of function of both arms or both legs due to injury or disease of the spinal cord.
Hemiplegia Total and permanent loss of function of one side of the body due to brain injury or disease.
Total Permanent Disablement (Optional condition ) A life assured has suffered Total Permanent Disablement if in AIA’s opinion the life assured before attaining age 65:
Loss of independent existence The life assured is totally and irreversibly disabled, with the effect that he or she is unable, as a result of sickness or injury, to perform at least two activities of daily living . Alternatively, the life assured is totally and irreversibly unable to perform one of the activities of daily living and his or her intellectual capacity has reduced or deteriorated to such an extent that the life assured requires full-time care .
A. becomes totally and permanently incapacitated by illness or accident and, as a result of that incapacity:
is completely unable to engage in the occupation, or carry on the business, he or she was involved in immediately before becoming incapacitated; and
for the three consecutive months after that incapacity began, has not worked in that occupation or carried on that business; and is, in AIA ’s opinion, after consideration of the medical and any other evidence satisfactory to AIA , so incapacitated that it is unlikely he or she will ever be able to resume work in that occupation or carry on in that business; or
Paraplegia Total and permanent loss of function of both legs due to injury or disease of the spinal cord.
Permanent blindness
Irrecoverable loss of sight of both eyes as a result of sickness or injury. This is evidenced by:
B. suffers by illness or accident the total and permanent loss of meaningful use of:
visual acuity on the Snellan Scale after correction by suitable lenses is less than 6/60 in both eyes; field of vision is reduced to 20 degrees or less of arc in the better eye; or a combination of visual defects resulting in the same degree of visual impairment as either of the points above.
both feet (entire feet); or
both hands (entire hands); or
the sight in both eyes (to the extent that visual acuity is reduced to 6/36 or less in the better eye and/or the field of vision is reduced to 10 degrees or less of arc in the better eye); or
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any combination of two of: a hand, a foot or sight in an eye (to the extent that visual acuity is reduced to 6/36 or less and/or the field of vision is reduced to 10 degrees or less of arc); or
Any condition that AIA has reasonable grounds to expect can be reversed or improved by surgery or other treatment will not be considered as having met this Optional Total Permanent Disablement condition . AIA will not pay a benefit under the Optional Total Permanent Disablement condition if the life assured dies within three months of the date that the life assured became incapacitated.
C. is totally and permanently unable to perform at least two of the activities of daily living .
Alternatively, the life assured has suffered Total Permanent Disablement if he or she is unable to perform one of the activities of daily living and his or her intellectual capacity has reduced or deteriorated to such an extent that the life assured requires permanent and constant supervision. If the life assured commences full-time domestic duties, the definition of the Optional Total Permanent Disablement condition will change by replacing paragraph A. above with:
Other key conditions
The life assured has suffered or undergone one of the following conditions :
Advanced Acquired Immunodeficiency Syndrome (AIDS) The life assured has been unequivocally diagnosed by an appropriate specialist with Advanced Acquired Immunodeficiency Syndrome in the clinical setting, evidenced by the presence of HIV infection with a persistent CD4 cell count of less than 200/ul despite appropriate continuous antiretroviral therapy.
A. becomes totally and permanently incapacitated by illness or accident and, as a result of that incapacity:
For three consecutive months after that incapacity began, has not worked in any occupation or carried on any business or engaged in any other gainful employment ; and Following that three consecutive months is, in the opinion of AIA , after consideration of the medical and any other evidence satisfactory to AIA , so incapacitated that it is unlikely he or she will ever be able to work in any occupation or engage in any other gainful employment for which he or she may be reasonably suited by education, training or experience, which would pay remuneration at a rate
There must be an associated AIDS defining illness with AIDS resulting in at least one of the following:
Kaposi's Sarcoma or Lymphoma.
Pneumocystis Carinii infection, cryptococcal infection or any other opportunistic infection of the lungs or nervous system.
Tuberculosis or other mycobacterium infection at any site.
greater than 25% of the life assured ’ s earnings during his or her last 12 consecutive months of work .
Progressive multifocal leukoencephalopathy.
HIV Encephalopathy.
HIV wasting syndrome characterised by more than 10% weight loss, chronic intractable diarrhoea and chronic candidiasis of the respiratory tract or gastrointestinal tract. Advanced diabetes The life assured suffers severe diabetes mellitus, either insulin or non-insulin dependent, as certified by a consultant endocrinologist and resulting in at least two of the following:
AIA will at its discretion waive the three month waiting period when assessing Total Permanent Disablement if:
in AIA ’s opinion, the life assured has met all other requirements for payment under the Optional Total Permanent Disablement condition; and
AIA expects the life assured to survive beyond three months after the incapacity began.
In exercising this discretion, AIA will consider whether the medical condition of the life assured enables an assessment to be made immediately in respect of whether the life assured has met all other requirements of the Optional Total Permanent Disablement condition . AIA will not waive the three month waiting period if, in our opinion, after considering suitable medical evidence, we believe that the life assured may die within three months after the incapacity began. A decision not to waive the three month waiting period will not affect our consideration of a claim under the Optional Total Permanent Disablement condition if the life assured survives for three months after the incapacity began.
Severe diabetic retinopathy resulting in visual acuity uncorrected and corrected of 6/36 or worse in both eyes; Severe diabetic neuropathy causing motor and/or autonomic impairment;
Diabetic gangrene leading to surgical intervention; or
Severe diabetic nephropathy causing chronic irreversible stage 4 renal impairment.
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Aplastic anaemia The life assured has suffered the first occurrence of permanent and irreversible bone marrow failure which results in anaemia, neutropenia and thrombocytopenia, requiring treatment with at least one of the following:
Intensive care benefit Means continuous mechanical ventilation by means of tracheal intubation for at least seven days or the admission to the intensive care ward of a hospital for at least fifteen consecutive days at the recommendation of an appropriate specialist .
Blood product transfusion;
Unconsciousness caused by alcohol or drug abuse are specifically excluded.
Marrow stimulating agents;
Immunosuppressive agents;
Major transplant surgery The life assured has undergone, or been placed on the major organ transplant waiting list in New Zealand or Australia for a transplant from a human donor of one or more of the following organs or substances:
Bone marrow transplantation;
Haemopoietic stem cell transplantation.
Chronic liver failure The life assured suffers an unequivocal diagnosis of end- stage liver failure confirmed by an appropriate specialist and evidenced by one of the following conditions:
Kidney;
Heart;
permanent jaundice;
Lung;
ascites; or
Liver;
encephalopathy.
Pancreas;
Bone marrow; or
Chronic lung disease The life assured has irreversible chronic lung disease as confirmed by an appropriate specialist on the basis of respiratory function tests and which satisfies any one of the following criteria:
Intestine.
The transplant of all other organs or parts of any organ or of any other tissue or stem cell transplant is excluded.
The transplant must be considered medically necessary and the condition affecting the organ deemed untreatable by any means other than organ transplant, as confirmed by an appropriate specialist . Severe burns The life assured has suffered severe tissue injury caused by thermal, electrical or chemical agents. As a result, the life assured has full thickness or third-degree burns to:
Type 1 respiratory failure defined as O2 <60mm hg; or
Type 2 respiratory failure defined as CO2 >45 mm hg; or
the provision of home oxygen therapy according to clinical practice guidelines for hypoxia O2 <55 mm hg (or 60 mm hg in the presence of pulmonary hypertension); or
FEV1 <35% predicted; or
DLCO (diffusing capacity or gas transfer) < 40% predicted; or
at least 20% of the body surface area (as measured by age-appropriate use of The Rule of 9 or the Lund and Browder Body Surface Chart); or
is unable to perform at least one of the activities of daily living as a result of the respiratory failure.
Chronic renal failure The failure of both kidneys of the life assured having reached the end-stage of renal disease resulting in chronic irreversible failure of the kidneys to function, as a result of which regular renal dialysis is instituted or transplantation performed. Cognitive impairment A permanent and irreversible loss of cognitive function that requires the life assured to be under continual care and supervision by an appropriate carer for at least 8 hours per day, as certified by an appropriate specialist.
50% of both hands, requiring surgical debridement and/or grafting; or
25% of the face, requiring surgical debridement and/or grafting.
Systemic Sclerosis The life assured has been unequivocally diagnosed by an appropriate specialist with systemic sclerosis, causing the life assured to be totally and irreversibly unable to perform any one of the activities of daily living.
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