1158 ALB-BC version 3 Effective 23 July 2021
AIA LIVING - BUSINESS OPTIONAL BENEFIT APPENDIX
Business Continuity Benefit This appendix only applies if cover under the schedule for your policy includes the Business Continuity Benefit. This appendix forms part of and is incorporated into your AIA Living policy, the terms of which apply to this appendix . This is a Business Continuity Benefit. Details of the benefit and the life/lives assured are shown in the schedule .
1. When will AIA pay a Business Continuity Benefit? To qualify for a Business Continuity Benefit, the life assured must be actively involved in the business on the date of becoming totally disabled .
the amount that AIA will pay monthly is the low e r of: – 1/12 th of the benefit amount shown in the schedule less any offsets as described below; or – 1/12 th of the gross profit as earned by the business in the 12 months immediately prior to
2.
When will AIA pay a Total Disablement Benefit?
the disablement date , multiplied by the replacement ratio calculated at application time and shown in the schedule , less any offsets as described below.
AIA will pay a Total Disablement Benefit if, in AIA’s opinion, at any time during the benefit term , the life assured : > has been totally disabled or partially disabled during the waiting period ; and > is totally disabled at the end of the waiting period . We will pay you the benefit monthly in advance from the end of the waiting period until the earliest of: > the life assured is no longer totally disabled ; or > the benefit term ends; or > the cover ends. Where the life assured has a waiting period of 8 weeks or less, is totally disabled due to injury and the nature of the injury is such that the life assured is expected to recover within a set period of time, AIA may choose to make a lump sum payment of up to 3 monthly benefit payments (after the waiting period and any offsets have been taken into account) and close the claim. This payment may be made during the waiting period . If the life assured is still totally disabled or partially disabled at the end of the expected recovery period corresponding with the lump sum payment, then AIA will reopen the claim and pay either the Total Disablement Benefit or (if applicable) an Optional Partial Disablement Benefit in accordance with this appendix . 3. What amount will AIA pay for a Total Disablement Benefit? > If the “Business Agreed Value Benefit” has been chosen, the amount that AIA will pay monthly is 1/12 th of the benefit amount shown in the schedule less any offsets as described below. > If the “Business Indemnity Benefit” has been chosen
Offsets Any other business income, farm protection, key person or income protection benefit(s) that any person receives or is entitled to receive from any sources in relation to the life assured and in respect of the same or a related disability . This does not include ACC benefits received, or entitled to be received. Where the life assured is covered by insurance policies held with more than one provider, AIA will negotiate with the other provider(s) to determine the amount to be offset. 4. What does totally disabled mean? In AIA’s opinion, the life assured is totally disabled , if as a direct result of sickness or injury, he or she is: > under the regular and personal care of a registered medical practitioner ; and > unable to: – engage in the occupation or carry on the business they were involved in immediately before the disablement date for more than ten hours per week; or – perform at least one income producing duty of
the role they were involved in immediately before the disablement date and is not working in that role; and not working or engaged in any other occupation or business.
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5. When will AIA pay an Optional Partial Disablement Benefit? The Optional Partial Disablement Benefit only applies if shown in the schedule . AIA will pay an Optional Partial Disablement Benefit if in AIA’s opinion, at any time during the benefit term , the life assured : > is in an occupation class other than occupation class five at the time of becoming totally disabled or partially disabled ; and > has been partially disabled during the waiting period, and is partially disabled at the end of the waiting period ; or > becomes partially disabled , following a period of receiving a Total Disablement Benefit under this appendix and the life assured is no longer totally disabled , provided: − the period in respect of which a Total Disablement Benefit has been paid in advance has expired; and/or
7. What is the amount of the Optional Partial Disablement Benefit? The amount that AIA will pay monthly is calculated in the following way:
( working hours at application time less post-disability working hours ) working hours at application time
monthly benefit as calculated in Section 3
X
For example: If the monthly benefit as calculated in Section 3 is $10,000, the working hours at application time are 50 hours and the post-disability working hours are 20 hours, the amount paid will be $6,000 per month.
$10,000 x (50 hours less 20 hours) 50 hours
$6,000 per month
=
8. What is the Partial Disablement Bridging Benefit and when will AIA pay it? Where the Optional Partial Disablement Benefit applies as shown in the schedule , AIA will pay you a Partial Disablement Bridging Benefit if: > you have been receiving a Total Disablement Benefit under this appendix ; and > the life assured is no longer totally disabled ; and > based on the information provided to, and requested by AIA , we reasonably expect that an Optional Partial Disablement Benefit (as set out in Section 5) will be payable for that life assured for the first month after the life assured ceased to be totally disabled . The Partial Disablement Bridging Benefit is a lump-sum payment equivalent to 1/3 rd (33.3%) of the final monthly Total Disablement Benefit paid before the life assured ceased to be totally disabled . The Partial Disablement Bridging Benefit is paid at the end of the final month in respect of which a Total Disablement Benefit was paid for the life assured . Payment of the Partial Disablement Bridging Benefit does not affect the amount of the Optional Partial Disablement Benefit (as set out in Section 7). The Partial Disablement Bridging Benefit is payable once for all claims resulting from the same or a related injury or illness. The Partial Disablement Bridging Benefit is not payable where a lump sum payment has been made in lieu of monthly benefit payments, as set out in Section 2.
where a lump sum payment has been made in lieu of monthly benefit payments as set out in Section 1, the benefit period to which the lump sum corresponds has expired.
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The Optional Partial Disablement Benefit will be paid monthly in arrears until, in AIA’s opinion, after considering the advice of a registered medical practitioner and other relevant information, the disability is no longer preventing the life assured from working at least 75% of their working hours at application time , or until the end of the benefit payment period , whichever is the earlier. A Partial Disablement Bridging Benefit (as set out in Section 8) will also be paid if you have been receiving a Total Disablement Benefit under this appendix before you commence receiving an Optional Partial Disablement Benefit. 6. What does partially disabled mean? In AIA’s opinion, the life assured is partially disabled, if as a direct result of sickness or injury, he or she: > has a reduction in work capacity resulting from the continuation of the disability ; and > because of the reduction in work capacity, the life assured is working less than 75% their working hours at application time.
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9. What is the Recurrent Disablement Benefit? The waiting period will be waived if not later than 12 months after the benefit payments related to the original claim ceased, the life assured becomes disabled again and, in AIA’s opinion, after considering the advice of a registered medical practitioner and other relevant information, this is caused by the same or a related illness or injury as the original period of total or partial disablement (if applicable). The provisions of Sections 2, 3, 4, 5 and 6 of this appendix will apply to any benefit claimed. All claims resulting from the same or a related illness or injury will be considered to be the same claim in respect of the benefit payment period . 10. What is the Business Mentors Benefit? Business Mentors is available to the policy owner following an accepted claim for a life assured under this appendix . Business Mentors provides independent, impartial advice on your business by one of over 1,700 mentors around the country. If a claim is approved under this appendix , AIA will pay the costs of a two year membership to Business Mentors. Business Mentors is independent of AIA and Business Mentors terms and conditions and eligibility criteria apply. AIA may withdraw access to the service or change the terms on which access to the service is made available with 90 days’ notice. Neither AIA , its related companies, nor their directors, officers or employees accept any liability whatsoever for any loss or damage arising out of the use of the Business Mentors service, or the unavailability of Business Mentors. AIA is not responsible for any cost associated with becoming eligible to use, or use of, the Business Mentors service (including without limitation the cost of any travel, lodging, telephone calls, faxes or mail), unless covered by an AIA policy. AIA will only pay one Business Mentors Benefit for each business . 11. Rehabilitation and Support On receiving notification of a new or potential claim, we will appoint the life assured a Case Manager, who will work with the life assured to understand their personal situation and assist them with the claims process. They will work with the life assured to consider what rehabilitation or functional support could assist the life assured’s return to work or improve their capacity to work, either during or after the waiting period as appropriate in the opinion of AIA . Acceptance of any costs associated with the agreed rehabilitation and functional support by AIA does not mean that we will accept liability for any other benefit under this appendix and are accepted at the sole discretion of AIA .
12. How to make a claim To make a claim, the relevant procedures in the section of your AIA Living policy entitled ‘How to make a claim’ must be followed. In addition, for a Business Continuity claim, AIA will require: > the life assured to be examined by a registered medical practitioner acceptable to AIA , before accepting liability for a claim; and
an AIA claims form completed by the life assured and a registered medical practitioner (at your expense); and other information which AIA may reasonably request to help assess the claim; and where the “Business Indemnity Benefit” has been chosen, you will be required to provide AIA with financial information and accounts for the 12 months immediately prior to the disablement date ; and 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; and
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any other information that AIA may deem relevant to the assessment of the claim.
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13. Ongoing Claims Requirements For ongoing claims AIA will require: >
Completion of a monthly medical certificate by a registered medical practitioner (at your expense) in a form from time to time approved by AIA for the purposes of determining ongoing entitlement to payment of a Business Continuity Benefit. Completion of a monthly individual declaration by the life assured in a form from time to time approved by AIA , which may include completion of daily activity logs detailing the life assured’s functional activities for the purposes of determining ongoing entitlement to payment of a Business Continuity Benefit. Proof of any remunerated or non-remunerated work completed during the claim period. Any other information that AIA may deem relevant to the ongoing assessment of the claim.
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14. When will AIA cease paying a benefit? AIA will cease paying a benefit if: (a) The life assured fails to undergo and complete: – any surgical operation; and/or
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any medical rehabilitation; and/or any social rehabilitation; and/or
in force until the end of the benefit payment period for that life assured . When the benefit is cancelled by the policy owner . In addition, this appendix cannot be assigned to another policy owner , unless consent is given by AIA in writing. Termination will take effect upon receipt of written notification from the policy owner . > 16. When will this appendix terminate for the life assured ? This appendix will terminate and eligibility for the Business Continuity Benefit will cease for a life assured : > At the expiry of the benefit term for that life assured as shown in the schedule . > When the life assured dies. > If the life assured is no longer actively involved in the business for more than 60 days for reasons other than total disability , unless AIA has been notified in writing and its written consent has been given for the continuation of the appendix .
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– any vocational rehabilitation, which a registered medical practitioner approved by AIA considers reasonably necessary. (b) The life assured fails to undertake any medical examinations that AIA requires the life assured to have, at our expense. (c) The life assured fails to comply with the requirements of Section 13 above. (d) AIA determines that the life assured is no longer totally disabled or partially disabled . (e) The benefit payment period expires in relation to the life assured . (f) The life assured or anyone acting on behalf of the life assured makes a false or fraudulent statement in respect of a claim or supports any claim with false evidence. (g) The life assured is no longer actively involved in the business , unless the reason for this is related to a claim. (h) The life assured is in prison or sentenced to home detention for any reason. (i) The life assured dies. If AIA ceases paying a benefit in accordance with paragraphs (a), (b) or (c) and the life assured subsequently complies with the relevant requirement(s), then: > The date that the life assured complied with the > The waiting period will be waived for the new claim. > The original claim and the new claim will be considered to be the same claim in respect of the benefit payment period . > No monthly benefit payments will be payable retrospectively for any period of time before the date that the life assured subsequently complies with the relevant requirement(s). 15. When will this appendix terminate for the policy owner ? This appendix will terminate for the policy owner : > At the expiry of the benefit term as shown in the schedule . > If the business is wound-up or liquidated unless AIA has been notified in writing and its written consent has been given for the continuation of the appendix . However, if a life assured is on claim and the reason for the business being wound-up or liquidated is due to the total disability or partial disability of the life assured , the benefit will remain relevant requirement(s) will, subject to the provisions of this appendix, be treated as the disablement date for a new claim.
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If the business is wound-up or liquidated unless AIA has been notified in writing and its written consent has been given for the continuation of the appendix . However, if a life assured is on claim and the reason for the business being wound-up or liquidated is due to the total disability or partial disability of the life assured , the benefit will remain in force until the end of the benefit payment period for that life assured . When the benefit is cancelled by the policy owner .
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17. Exclusions – when AIA won’t pay a benefit AIA will not pay a benefit where any of the following directly or indirectly cause or contribute to the total disability or partial disability : > The life assured deliberately injures himself or herself or attempts to do so. > The life assured engages in or is part of any conduct that is criminal. > The life assured does not comply with the treatment recommended by the attending treatment providers. > Pregnancy of, or childbirth by, the life assured , unless the disability lasts for more than 90 days after the end of pregnancy, in which case the waiting period will start from the 91 st day. If the life assured is imprisoned or sentenced to home detention for any reason, no monthly benefit will be payable during the term of imprisonment or home detention.
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18. Key terms
The replacement ratio shown in the schedule , calculated as the monthly benefit multiplied by 12, divided by the gross profit for the business . See Section 4 of this appendix for the meaning of this key term. Total disability has a corresponding meaning. The period stated as such in the schedule for which no Total Disablement Benefit or Optional Partial Disablement Benefit is payable. The number of hours working as stated at application time for the life assured .
replacement ratio
Working an average of more than 30 hours per week in the six months prior to the disablement date , inclusive of any periods of approved leave. The date as declared on the original application form applying for the Business Continuity Benefit for the life assured . The term for which the life assured is insured for the Business Continuity Benefit as stated in the schedule. The maximum term for which the Business Continuity Benefit is payable as stated in the schedule . The benefit payment period commences at the end of the waiting period and ceases either 6, 12 or 24 months (whichever is stated in the schedule ) later or when the life assured reaches the end of the benefit term as stated in the schedule , whichever is the earlier. The 6, 12 or 24 month period (whichever is stated in the schedule ) is the total period for which benefits will be payable for all claims arising from the same or a related cause illness or injury.
actively involved
totally disabled
application time
waiting period
benefit term
benefit payment period
working hours
The business of the ‘policy owner ’ named in the schedule .
business
The illness or injury giving rise to the claim for total disability or partial disability.
disability/disabled
The date the life assured became totally disabled or partially disabled .
disablement date
See Section 6 of this appendix for the meaning of this key term. Partial disability has a corresponding meaning. An individual, employer, company, partnership, association, organisation or trust. The number of hours per week that the life assured is able to work as stated by a registered medical practitioner . AIA may request the second opinion of another registered medical practitioner.
partially disabled
person
post-disability working hours
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1158 ALB-BC version 3 Effective 23 July 2021
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