TCM Business Progressive Care Policy Wording

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TOTALCAREMAX BUSINESS

OPTIONAL BENEFIT APPENDIX

Progressive Care Benefit

This appendix only applies if cover for the Progressive Care Benefit is shown in the schedule . This appendix forms part of and is incorporated into your TotalCare Max policy, the terms of which apply to this appendix .

1. Progressive Care Benefit

sum assured for that category decreases by the claim payment to leave the revised balance of the sum assured as the maximum amount available for that category for any subsequent claims. There is no change in the balance of the sum assured for other categories. If an existing condition becomes more severe after payment of a claim, or if the life assured develops a non- related condition after payment of a claim, Sovereign will pay a subsequent claim in accordance with the terms of this appendix . For more about making subsequent claims see Section 6 below. The premium will not reduce after a claim payment, except that, where applicable, the premium for the Optional Total Permanent Disablement condition will cease following a severity level 1 claim payment. If you elected to increase your sum assured each year in line with the consumer price index , the sum assured (and premium ) and any balance of the sum assured will increase each year accordingly.

Sovereign will pay you a Progressive Care Benefit if the life assured meets all of the following criteria:

 Suffers a condition as exactly defined in one of the five Schedules of Categories below;

 Suffers the condition for the first time after the risk commencement date (and where a three month stand down period applies, after this period has expired also); and  Survives for at least 14 days after the claim event date for that condition , and where the life assured is being kept alive by a life support system, the life assured must survive for at least 14 days after the life support system is turned off.  For the Optional Total Permanent Disablement condition, survives for at least three months after the life assured became incapacitated. The amount you receive will be a percentage of between 10% and 100% of the sum assured . The percentage will be determined by the severity of the condition based on a scale from levels 1 to 4 for some conditions and 1 to 5 for others. For more about severity levels see Section 5 below.

3. Stand down periods

If the life assured or any child of the life assured covered by the Built-in Children’s Trauma Benefit or the Optional Children’s and Maternity Benefit suffers:

2. Covered conditions

(a) Any of the conditions shown in the table below as having a three month stand down period; or

There are five categories of conditions :

(b) Symptoms or signs which lead to any of the conditions marked as having a three month stand down period (whether or not a Registered Medical Practitioner or specialist has been consulted) within the first three months after the risk commencement date , then Sovereign will not pay a benefit for that condition .

Cancer



Heart and Arteries



Brain and Nerves



Loss of Function



Other Health Events



Each of these categories and the conditions that come within them are set out in the five Schedules of Categories below. At the risk commencement date , the sum assured is the same for each of these categories and is equal to the sum assured set out in the schedule .

Built-in Newborn Children’s Benefit

A twelve month stand down period applies to the Built-in Newborn Children’s Benefit, meaning that Sovereign will only pay a claim for a biological child of a life assured where the birth of the child with one of the applicable conditions occurs at least twelve months after the risk commencement date .

Once a claim is paid under a category , the balance of the

This twelve month stand down period applies anew to all added cover from the date the added cover commences.

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Medical Advancements Provision

If the medical diagnostic techniques and investigations used in our medical Key terms 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.

Category

Conditions

3 month stand down

✓

Chronic lung failure

✓

Chronic kidney failure

Primary pulmonary hypertension

Major organ transplant (or transplant waiting list)

Acute renal dialysis

✓

Chronic Obstructive Pulmonary Disease

✓

Removal of large bowel

✓

Severe osteoporosis

✓

Severe rheumatoid arthritis

✓

Severe ulcerative colitis

✓

Severe Crohn’s disease

Advanced Type 1 diabetes

✓

Type 1 diabetes

✓

Advanced Type 2 diabetes

HIV and Advanced AIDS

Pneumonectomy

Systemic sclerosis

Systemic lupus erythematosus with lupus nephritis

✓

Severe illness or injury

4. Standalone or accelerated benefit

The maximum combined amount payable under the Life Cover Benefit, Specified Terminal Conditions Benefit, Terminal Illness Benefit, Bereavement Support Benefit, Repatriation Benefit, accelerated Progressive Care Benefit and, if applicable, the accelerated Living Assurance Benefit and the accelerated Total Permanent Disablement Benefit is the amount of the Life Cover Benefit for that life assured . When Sovereign has paid the equivalent of the sum assured of the Life Cover Benefit, your cover under this benefit will change from accelerated to standalone. This will require you to pay an increased premium . This increase will be calculated on the rates applicable at the time to the standalone Progressive Care Benefit.

The schedule will specify if you have chosen a standalone or an accelerated benefit.

Standalone

If you have chosen a standalone benefit, a payment under this benefit does not reduce the sum assured under your Life Cover Benefit (if any).

Accelerated

If you have chosen an accelerated benefit, the sum assured for this Progressive Care Benefit cannot be greater than the sum assured for your Life Cover Benefit. When Sovereign pays an accelerated Progressive Care 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 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.

5. The severity level

The lump sum amount that Sovereign will pay at claim time will depend on the severity level of the life assured's condition and your sum assured/balance of the sum assured you have available under the applicable category .

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The severity level of the life assured's condition determines the percentage of the sum assured that is used to determine the lump sum benefit that Sovereign will pay you. The percentage of the sum assured for each severity level is shown below.

If the subsequent claim's claim event date is more than 12 months after the preceding claim's claim event date or if the subsequent claim is for a related condition , then Sovereign determines the amount to be paid for the subsequent claim as follows: 1. Sovereign determines if the life assured has suffered the condition . 2. Sovereign identifies the category that the condition falls under i.e. Cancer , Heart and Arteries, Brain and Nerves, Loss of Function or Other Health Events. A subsequent claim can be made in the same category or a different category to the previous claim. 3. Sovereign determines the severity level percentage that applies for the condition : (a) For a condition that is not a related condition, the severity level percentage is then multiplied by the sum assured . This will be the amount paid for the subsequent claim, unless the balance of the sum assured for the category that the condition falls under is less, in which case the balance of the sum assured for the category will be the amount paid for the subsequent claim. (b) For a related condition , the severity level percentage of the related condition must be higher than the severity level percentage of the previous condition that it relates to. The amount by which the severity level percentage increases from the previous severity level percentage is then multiplied by the sum assured . This will be the amount paid for the subsequent claim, unless the balance of the sum assured for the category is less, in which case the balance of the sum assured for the category will be the amount paid for the subsequent claim. For the avoidance of doubt, you cannot claim more than the sum assured in total for the life assured’s first claim and all subsequent related claims to that first claim.

Severity Level

Percentage

1 (most severe)

100%

75%

50%

25%

5 (least severe)

10%

The severity level of a condition is stated in the Schedule of Categories for the category the condition comes within.

Some of the conditions do not have all five severity levels.

6. The amount of cover

The sum assured is the maximum amount of cover you have for each category. After the first claim is paid under a category , the balance of the sum assured is the maximum amount Sovereign will pay you for any subsequent claim under that category . Once the balance of the sum assured is exhausted for a category , no further claims will be paid under that category .

a) First claim

The amount paid for the first claim for a life assured under this appendix is determined by Sovereign as follows: 1. Sovereign determines if the life assured has suffered the condition . 2. Sovereign identifies which category the condition falls under i.e. Cancer , Heart and Arteries, Brain and Nerves, Loss of Function or Other Health Events. 3. Sovereign determines the severity level percentage that applies to the condition . 4. The severity level percentage is then multiplied by the sum assured . This is the amount paid for the first claim. 5. The balance of the sum assured available for future claims under the category that the claim is paid under is then calculated as the sum assured minus the amount paid for the first claim.

Within 12 months of the previous claim event date and not a related condition

If you make a subsequent claim, where the claim event date is within 12 months of the immediately preceding claim's claim event date and the subsequent claim is not for a related condition , then Sovereign will deduct all claims paid under this appendix for that life assured within the previous 12 months from the amount determined in accordance with steps 1 to 3 immediately above. This may mean that no benefit is payable. This deduction will not apply if the current or previous claim is/was for a condition that is the result of an accident.

b) Subsequent claims

Any claim made for a life assured after the first claim paid to you under this appendix for that life assured is a subsequent claim. Sovereign will determine whether or not the condition relied upon for a subsequent claim is a related condition to a previous Progressive Care Benefit claim for that life assured . The way subsequent claims are determined depends upon the length of time that has passed since the previous claim event date and whether the condition claimed for is a related condition or not.

c) Two or more claims for conditions arising simultaneously from one event

If a single event causes the life assured to have one or more simultaneously arising conditions, Sovereign will only pay one claim. For each condition , Sovereign will determine the amount in accordance with steps 1 to 3 in b) above and the amount paid will be the highest of these amounts. The balance of the sum assured will reduce for the category that the condition with the highest amount falls under, while the balance of the sum assured will be unchanged for other categories .

More than 12 months after previous claim event date or related condition

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7. Built-in Financial and Legal Advice Benefit

9. Built-in Newborn Children’s Benefit

Sovereign will pay a Built-in Newborn Children’s Benefit if a biological child of a life assured is born with one of the following conditions and survives for thirty days after birth:

If Sovereign pays a claim under this Progressive Care Benefit for a life assured for a condition of severity level 1, then Sovereign 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 Sovereign, subject to the following conditions:  You must pay for the financial planning or legal advice within the 12 months following Sovereign paying the Progressive Care Benefit claim.  Sovereign will only pay one Financial and Legal Advice Benefit per life assured across all Sovereign 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, the Built-in Parents Grieving Benefit, the Optional Children’s and Maternity Benefit or the Built-in Newborn Children’s Benefit.

Cleft palate;



Down’s syndrome;



Spina bifida;



Total blindness;



Absence of one or more limbs;



Tetralogy of Fallot;



Transposition of Great Vessels; or



Deafness.



Please refer to Section 29 for the definitions of these conditions .

In order for Sovereign to pay a claim under this Benefit, we will require medical information from a registered medical practitioner acceptable to us that conclusively evidences the condition . In circumstances where a conclusive diagnosis cannot be made at birth, we will defer our assessment of the claim until sufficient evidence can be supplied. For example, this might apply in the case of total blindness or deafness, where a conclusive diagnosis may not be possible until later in the child’s life. In these cases, the claims assessment will be based on the child’s sight or hearing impairment at the date that conclusive diagnosis is first possible. A claim is only payable under the Built-in Newborn Children’s Benefit if cover remains in effect for the life assured up to the date that the conclusive diagnosis for the child occurs.

8. Built-in Children’s Trauma Benefit

Sovereign will pay a Built-in Children’s Trauma Benefit if a child of a life assured suffers a condition of severity level 1, 2 or 3, except for the Optional Total Permanent Disablement condition .

This Benefit is only payable if the child of the life assured :

 First suffers a condition after the risk commencement date, subject to the three month 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

How much will Sovereign pay?

 Survives for at least 14 days after suffering from the condition .

The Benefit payable is the lower of $50,000 or 50% of the sum assured across all Progressive Care policies for the life assured . The Built-in Newborn Children’s Benefit is only payable where the birth of the child with one of the applicable conditions occurs at least twelve months after the risk commencement date . This requirement applies anew to all added cover from the date the cover commences, including cover added using the Progressive Care Future Insurability Benefit, the Special Events Increase Facility, or the Special Events TPD/Trauma Facility under the Life Cover Benefit. Sovereign will pay a maximum of one claim per child under either the Built-in Newborn Children’s Benefit or the Built-in Children’s Trauma Benefit across all Sovereign policies . Payment of the Built-in Newborn Children’s Benefit will not affect the amount of any Progressive Care Benefit payable for the life assured . 10. Built-in Return Home Benefit Sovereign 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.

The Benefit payable is the lower of $50,000 or 50% of the sum assured across all Progressive Care policies for the life assured . Sovereign will pay a maximum of one claim per child under either the Built-in Children’s Trauma Benefit or the Built-in Newborn Children’s Benefit across all Sovereign policies . The Built-in Children’s Trauma Benefit or the Built-in Newborn Children’s Benefit is payable in addition to the Optional Children’s and Maternity Benefit (if applicable). Sovereign will not pay a 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 .

 

Payment of the Built-in Children’s Trauma Benefit will not affect the amount of any Progressive Care Benefit payable for the life assured .

The Built-in Children’s Trauma Benefit ceases on the child’s 21 st birthday.

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13. 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 severity level 1 condition within the Loss of Function category . The Optional Total Permanent Disablement condition will cease to apply, and premiums for this condition will cease, following any severity level 1 claim payment. Premiums for the Optional Total Permanent Disablement condition will not be affected by a claim payment for a condition of any other severity level. 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 or the Optional Children’s and Maternity Benefit.

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 Progressive Care Benefit. No payment will be made if the life assured is covered for the same event with a travel insurance provider.

11. Built-in Parents Grieving Benefit

When is a Parents Grieving Benefit payable?

Sovereign will make a Parents Grieving Benefit payment if:

 a child of a life assured dies prior to birth but after at least 24 weeks gestation; or

The Optional Total Permanent Disablement condition is only available before the life assured attains age 65.

 a child of a life assured dies. Sovereign will not make any payment if the death occurs within 12 months of the risk commencement date except where it is an accidental death.

14. Optional Children’s and Maternity Benefit

The Optional Children’s and Maternity Benefit applies only if shown in the schedule .

This Parents Grieving Benefit ceases on the child’s 21 st birthday.

The benefit is payable in addition to any benefit payable under the Built-in Children’s Trauma Benefit or the Built-in Newborn Children’s Benefit.

How much will Sovereign pay for the Parents Grieving Benefit?

The Benefit payable:

Children’s Critical Conditions Benefit

 if the child is under 10 years of age Sovereign will pay a maximum of one claim of $2,000 per child under the Parents Grieving Benefit across all Sovereign policies and AIA policies ; or  if the child is 10 years of age or over Sovereign will pay a maximum of $15,000 per child across all Sovereign policies and AIA policies for a life assured . Payment of the Parents Grieving Benefit will not reduce the sum assured of the Progressive Care Benefit for the life assured .

What is the Children’s Critical Conditions Benefit?

Sovereign will pay a Children’s Critical Conditions Benefit if a child of a life assured suffers a condition of severity level 1, 2, 3, 4 or 5, except for the Optional Total Permanent Disablement condition .

This Benefit is only payable if the child of the life assured :

 first suffers a condition after the risk commencement date , and subject to the 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

12. Built-in Counselling Benefit

 survives for at least 14 days after suffering from the condition .

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 Progressive Care Benefit. After referral by an appropriate specialist Sovereign 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 Sovereign paying the Progressive Care claim; and  Sovereign must be provided with a receipt for the consultation and/or counselling being claimed. The $2,500 including GST (in total) is payable once per life assured per policy. This is in addition to the sum assured .

Sovereign will pay a maximum of one claim per child under the Children’s Critical Conditions Benefit across all Sovereign policies for a life assured. In cases where two policies each name a distinct parent of the child as a life assured, both policies are eligible to claim under the Children’s Critical Conditions Benefit for that child, provided the Optional Children’s and Maternity Benefit is shown in the schedule of both policies.

How much will Sovereign pay for the Children’s Critical Conditions Benefit?

The Benefit payable is the lower of $75,000 or 50% of the sum assured .

Before cover for a child can commence under the Children’s Critical Conditions Benefit, you must advise us in writing of the child’s name, date of birth and gender.

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Cover for a child will only commence once we have confirmation of the child’s details in writing.

How much will Sovereign pay for the Children’s Congenital Conditions Benefit?

The Benefit payable is $5,000, regardless of the number of congenital conditions diagnosed. Sovereign will pay a maximum of one claim for a child under the Children’s Congenital Conditions Benefit across all policies for a life assured where AIA New Zealand Limited is the insurer. In cases where two policies each name a distinct parent of the child as a life assured , both policies are eligible to claim under the Children’s Congenital Conditions Benefit for that child , provided the Optional Children’s and Maternity Benefit is shown in the schedule of both policies. Payment of the Congenital Conditions Benefit will not reduce the sum assured or the balance of the sum assured for any of the categories. Sovereign will not pay a benefit under the Optional Children’s and Maternity Benefit that arises as a direct or indirect consequence of:

Pregnancy Complications Benefit

When is a Pregnancy Complications Benefit payable?

This benefit is payable if a life assured suffers for the first time and at least 12 months after the risk commencement date one of the defined Pregnancy Complication Benefit conditions . Sovereign will not pay this benefit if the life assured suffers the condition or has any symptom or signs leading to the condition (whether or not a registered medical practitioner has been consulted) within 12 months after the risk commencement date .

What Pregnancy Complication Benefit conditions are covered?

Disseminated intravascular coagulation.



a pre-existing condition ; or



Eclampsia.



 any congenital condition , except where expressly covered under the Children’s Congenital Conditions Benefit.

Hydatidiform mole.



See Section 29 for a full description of these Pregnancy Complication conditions .

The Optional Children’s and Maternity Benefit ceases on the child’s 21 st birthday.

How much will Sovereign pay for the Pregnancy Complications Benefit?

The benefit payable is $10,000. Payment of the Pregnancy Complications Benefit will not reduce the sum assured or the balance of the sum assured for any of the categories .

15. Built-in Children’s Trauma Conversion Facility

The Built-in Children’s Trauma Facility can be converted to:

a standalone Progressive Care Benefit; or



Children’s Congenital Conditions Benefit

an accelerated Progressive Care Benefit with an equal amount of Life Cover Benefit,



When is the Children’s Congenital Conditions Payable?

with a maximum sum assured of $50,000 or 50% of the life assured’s original sum assured whichever is lesser, without further medical evidence. Where the life assured’s sum assured has reduced, the conversion will be calculated on the reduced amount. If the Optional Children’s and Maternity Benefit is shown on the schedule , it can also be converted to a standalone Progressive Care Benefit or an accelerated Progressive Care Benefit with an equal amount of Life Cover Benefit, with a maximum sum assured of $75,000, without further medical evidence. The following conditions are applicable to both Children’s Trauma Conversion options:  A conversion cannot occur if the child has claimed or was eligible to claim under the Built-in Children’s Trauma Benefit and/or the Optional Children’s or Maternity Benefit; and  Your request for conversion must be received by Sovereign within 60 days of the anniversary date after the child’s 21 st birthday; and

This Benefit is payable if at least 12 months after the risk commencement date a child of a life assured is unequivocally diagnosed by an appropriate specialist and undergoes treatment or therapy for one of the conditions below.

What congenital conditions are covered?

Coarctation of the Aorta.



Infantile Hydrocephalus.



Anal atresia.



Oesophageal atresia.



Congenital diaphragmatic hernia.



Tracheo-oesophageal fistula.



Truncus arteriosis.



Retinopathy of prematurity.



Your request must be received in writing.



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An applicable premium will be payable on converted cover.

Premiums will be calculated on the current age of the life assured . Any loading(s) and/or exclusion(s) that applied to your existing Progressive Care Benefit will apply to your new Progressive Care Benefit.

16. Built-in Standalone Conversion Facility

If the schedule shows the Progressive Care Benefit as standalone you can convert your cover to an accelerated Progressive Care Benefit with an equal amount of Life Cover Benefit without any further medical evidence, subject to the following:  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 life assured is only eligible for the Standalone Conversion Option where the conversion occurs before age 60;  The life assured has not made a claim with Sovereign or any other insurer, and is not eligible to make a claim under the standalone Progressive Care Benefit, this includes any claim currently under assessment;

18. Reducing your sum assured

You can write to Sovereign at any time to reduce your sum assured . You can make a reduction to your sum assured before you make a claim or after you have made a claim. In either case, the balance of the sum assured you have in each category will be reduced in proportion to the reduction in the sum assured . Sovereign will send you an endorsement letter, confirming the reduced sum assured and this will form part of your appendix . 19. Exclusions: When Sovereign will not pay a benefit Sovereign will not pay a benefit under this appendix if any of the exclusions that are set out in each Schedule of Categories applies to the condition listed in that category . Sovereign will not pay any benefit under this appendix where any of the following directly or indirectly causes or contributes to the condition (whether or not the condition is a related condition ):  The life assured (or a child in the case of a Built-in Children’s Trauma Benefit or the Optional Children’s and Maternity Benefit) deliberately injures himself or herself or attempts to do so.  The life assured (or a child in the case of a Built-in Children’s Trauma Benefit, the Built-in Parents Grieving Benefit or the Optional Children’s and Maternity Benefit) engages in or is part of any conduct that is criminal. Sovereign will not pay any benefit under 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, the Built-in Parents Grieving Benefit or the Optional Children’s and Maternity Benefit) reaches age 21, and (in each case either directly or indirectly) causes or contributes to a claim for that life assured (or child ):

 The life assured is not terminally ill or suffering from a terminal illness;

 The premiums for their standalone Progressive Care Benefit are paid up to date;

 The accelerated Progressive Care sum assured must be less than or equal to the standalone Progressive Care sum assured ;

 The Life Cover Benefit sum assured does not exceed the accelerated Progressive Care 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 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 Progressive Care Benefit will be reinstated from the date of conversion .

any intentional act by you or by any parent or guardian of the life assured, or child .



any intentional act by someone who lives with or supervises the life assured, or child .



17. Built-in Premium Conversion Facility

You may at any time prior to the life assured reaching age 65:

Sovereign will not pay any benefit under this appendix for:

Any condition ; or



 Convert all or part of your Progressive Care Benefit from the premium shown in the schedule to a Level premium structure. The Progressive Care Benefit under your policy will be reduced by the sum assured amount converted; or  Convert a Level premium Term to a further Level premium Term, of which duration may be the same or less than current Level premium Term.

 Any symptom or sign that leads to a condition

that existed before the risk commencement date (whether or not a registered medical practitioner has been consulted), unless Sovereign is satisfied that:  You and the life assured could not have known of the existence of the condition or the symptom or sign that led to the condition ; or  The condition or symptom or sign that led to the condition was declared on your application and accepted by Sovereign. Sovereign will not pay a benefit under the Built-in Children’s Trauma Benefit or the Children’s Critical Conditions Benefit in the Optional Children’s and Maternity

Sovereign will not require you or the life assured to produce further medical evidence at the time of conversion.

The terms and conditions of the new policy will be those which are then offered by Sovereign to the general public.

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Benefit that arises as a direct or indirect consequence of:

a pre-existing condition ; or



 any congenital condition , except where expressly covered under the Children’s Congenital Conditions Benefit

These exclusions also apply to any subsequent sum assured increase you make.

20. How to make a claim

To make a claim, refer to the section in your Sovereign TotalCare Max policy entitled ‘How to make a claim’.

In addition, for a Progressive Care Benefit claim, Sovereign will require information acceptable to us, including medical evidence and reports, showing proof of the condition giving rise to the claim. Sovereign may require the life assured to have an examination by a registered medical practitioner or specialist appointed by Sovereign before accepting liability for a claim. Where the Optional Total Permanent Disablement condition is the condition giving rise to the claim, Sovereign will also require:  A Sovereign claims form completed by the life assured and a registered medical practitioner (at your expense).  Other information which Sovereign may reasonably request to help assess the claim, which may include evidence of earnings, taxable income, business accounts, Accident Compensation Corporation details or similar.  The life assured to undergo medical and/or surgical treatment (including any operation or vocational, medical and/or social rehabilitation programme) at your expense which the life assured ’s registered

medical practitioner or a registered medical practitioner approved by Sovereign considers necessary.

 Any other information that Sovereign may deem relevant to the assessment of the claim.

For advice about submitting a claim you can phone Sovereign on 0800 500 108 or your Adviser. Find claim information online at sovereign.co.nz

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21. Key terms

or other surgical appliance.

Feeding/eating - The ability to eat independently once food has been prepared and made available. Continence - The ability to manage bowel and bladder functions such that an adequate level of personal hygiene can be maintained. Mobility - The ability to move independently between indoor rooms on a level surface with the assistance of a walking aid, including a wheelchair. Transferring - The ability to independently transfer from the bed to a chair with the assistance of a walking aid.

Injury caused by violent, accidental, external and visible means.

accident

accidental death

Death which is the result of external or internal bodily injury caused directly by violent external visible means, not attributable to any other event. Either an Adviser with a current financial adviser agreement with Sovereign Services Limited or a member of a financial

accredited Adviser

services industry body approved by Sovereign.

activities of daily living

The total and irreversible disablement of the life assured with the effect that he or she is unable to perform without the physical assistance of someone else, at least one of the following activities for himself or herself (if the life assured can perform the activity on his or her own by using special equipment Sovereign will treat the life assured as being able to perform that activity):

category

One of five categories of conditions as set out in the Schedule of Categories below.

child/children

Any biological child/children, adopted child/children or child/children under the legal guardianship of:

A life assured ; or



Bathing and showering;



The spouse, civil or de facto partner of a life assured .



Dressing and undressing;



Eating and drinking;



claim event date

The date the medical treatment or event occurred, or the date the condition was diagnosed by a specialist . A relative who is the life assured 's spouse, civil or de facto partner, mother, father, step mother, step father, brother, sister, step brother, step sister, child , grandfather or grandmother.

Using a toilet;



Moving from place to place by walking, in a wheelchair, or with a walking aid.



close relative

annual salary

Regular remuneration that is subject to PAYE, excluding allowances in lieu of non- monetary remuneration and extra income such as, but not limited to, bonuses and overtime payments. The amount of the sum assured remaining under each category after deduction of all claim payments already made under that category to date. Washing - The ability to wash oneself without physical assistance or supervision. This includes transferring in and out of the bath or shower.

condition(s)

Any:

balance of the sum assured

medical treatment;



event; or



illness as diagnosed by a specialist



basic activity of daily living

that exactly matches one of the definitions listed in any of the five Schedules of Categories attached to this appendix .

congenital condition

A health anomaly or defect, regardless of whether diagnosed or not:

Dressing - The ability to independently put on or take off

all garments, including the securing and unfastening

which is present at birth; and



thereof. Where appropriate, this includes any braces, prosthesis

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therapies administered outside of a clinical setting are excluded. An invasive procedure occurring in a hospital operating theatre involving the incision, excision, manipulation, or suturing of tissue, under general anaesthesia, spinal anaesthesia or epidural. Elective cosmetic procedures are excluded. A service or supply provided by a registered medical practitioner or specialist that Sovereign deems on reasonable grounds is necessary for the treatment of the disease, illness, or injury involved. Under no circumstances shall the following services or supplies be considered medically necessary:

for which the individual had signs or symptoms within three months of birth.



major invasive surgery

Includes health anomalies or defects inherited or due to external environmental factors such as drugs, alcohol, or complications during pregnancy or delivery. The later of the effective date or the actual date from which we receive the increased premium for the Life Cover Benefit and accelerated Progressive Care Benefit cover. Working to generate income through personal efforts by using the life assured ’s time and skills. He or she can be self-employed, employed, earning fees, under contract, receiving commissions, working

medically necessary

date of conversion

gainful employment

Those services or supplies that do not require the skills or services of a registered medical practitioner or specialist ; and Those services or supplies provided mainly for the comfort or convenience of the life assured.



on contract or otherwise remunerated for his or her efforts.

A specially staffed and equipped section of an intensive care complex that provides a level of care intermediate between intensive care and general ward care. Patients may be admitted to the high dependency unit:  from the intensive care unit



high dependency unit

pre-existing condition

Any disease or medical condition for which, prior to becoming covered under this policy, the individual consulted a registered medical practitioner , received treatment or services from a registered medical practitioner , or took prescribed drugs and medicines. Any condition that Sovereign, in its sole discretion, deems to be directly or indirectly related to a previous claim's condition . This includes:

as a step-down prior to transfer to the ward; or directly from the ward, recovery or emergency areas.



life assured

A ‘ Life assured ’ named in the schedule .

related condition

limb(s)

An arm, leg, hand or foot. In respect of this definition:

the arm starts from the shoulder joint and ends at the wrist joint;



any increase in severity level of the same condition ; and any condition that is a recognised outcome and/or complication of a previous claim or a recognised complication of any



the hand starts from the wrist joint;



the leg starts from the hip joint and ends at the ankle joint; and



treatment administered in relation to a previous claim. Any two conditions that are both related conditions of a third condition will be treated as related conditions to each other for calculating the amount payable. The Schedule of Related Conditions detailed in Section 22 outlines some of the

the foot starts from the ankle joint.



Non-surgical procedures or treatments initiated to treat the claimed medical condition including but not limited to: stereotactic radiosurgery, laser therapy, ultrasonic aspiration, chemotherapy, radiotherapy, or immunotherapy. Pharmaceutical

major interventional treatment

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conditions that are deemed to be related conditions of other conditions . The list is not exhaustive. Means mental deterioration and loss of intellectual ability, evidenced by deterioration in memory, orientation and reasoning, which are measurable and result from demonstrable organic cause as diagnosed by a specialist . The degree of cognitive impairment must be sufficiently severe to require a minimum of 16 hours of daily supervision by a nursing service approved by us. Determination of a cognitive impairment will be made on the basis of clinical data and valid standardised measures of such impairments.

sum assured

The ‘Sum Assured’ shown in the schedule for the Progressive Care Benefit. This includes any increase by the consumers price index if your benefit indexation type is specified in the schedule as CPI Linked. As defined in the ‘Guides to the Evaluation of Permanent Impairment – 4th Edition’ (or subsequent editions), produced by the American Medical Association and measured six months beyond initial diagnosis. Personal effort using the life assured ’s time and skills, whether or not income is generated for the life assured . Worked and working have similar meaning.

significant cognitive impairment

whole person functioning

work

Sovereign policies

Any policy or policies where Sovereign is the insurer.

you/your

The 'Policy Owner' named in the schedule .

specialist

A registered medical practitioner who has an approved fellowship in one of the approved surgical, anaesthetic or traditional non- surgical colleges and who is registered with the New Zealand Medical Council. These include, but are not limited to, the following disciplines: general surgery, orthopaedic surgery, urology, neurosurgery, anaesthesiology, cardiology, endocrinology, gastroenterology, haematology, paediatrics, gynaecology, obstetrics, neurology, oncology, renal specialists and rheumatology.

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22. Schedule of related conditions

The table below sets out some of the conditions that Sovereign deems to be related conditions to earlier conditions suffered by the life assured .

This list of related conditions is not exhaustive.

Condition for which a claim was paid

Related condition of a subsequent claim

Any second primary cancer arising in the same organ, or pair of organs, or tissue as a prior cancer

Any of the conditions in the category of cancer

Any Dementia and Alzheimer’s Disease

Loss of independent existence

Dementia and Alzheimer’s Disease, Loss of independent existence

Any multiple sclerosis

Any muscular dystrophy

Cardiomyopathy

Dementia and Alzheimer’s Disease, Loss of independent existence

Any Parkinson’s disease

Parkinson's disease, Dementia and Alzheimer’s Disease, Loss of independent existence, Heart attack

Any stroke

Any heart attack

Any stroke

Major head trauma

Coma

Major organ transplant, Chronic kidney failure, Acute renal dialysis, Loss of sight in one eye, Permanent blindness, Loss of sight in one eye and loss of a limb or limbs , Stroke , Heart attack , Coronary artery bypass graft

Advanced type 1 diabetes

Any severity level 1 condition

Optional Total Permanent Disablement condition

23. Schedule of categories – cancer category

Cancer – solid tumours

Key term

Cancer means any malignant tumour, positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasive and destruction of normal tissue. The term malignant tumour includes leukaemia, sarcoma and lymphoma except cutaneous lymphoma (lymphoma confined to skin).

When a cancer is determined by the life assured 's treating specialist to be a recurrence, local or regional spread, or metastasis of the life assured 's prior cancer claim, then this will be assessed as part of the life assured 's original claim.

The severity of cancer is measured by staging at first diagnosis and this diagnosis stage does not usually change over time. For the purposes of paying claims, if the cancer progresses, Sovereign will assess the severity of the cancer using the same staging criteria as if the cancer is reclassified at time of claim. For example, a Stage II breast cancer with bone metastasis will qualify for claim as Stage IV breast cancer .

Metric for the conditions in the table immediately below:

TNM Classification is an internationally recognised standardised method of staging cancers , where:

 Tumour (T): a scale of 0 to 4 is used to record the size and extent of spread of the primary tumour (T0 means no evidence of a primary tumour).

 Nodes (N): a scale of 0 to 3 is used to record the extent of spread to regional lymph nodes (N0 means lymph nodes are not involved).

 Metastases (M): M0 means no distant metastasis and M1 means distant spread of the cancer .

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Severity Level

Conditions

 Any metastatic cancer or Stage III or above cancer based on TNM classification, classified as Stage III or above 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.

 Advanced cancer classified as Stage III or above based on TNM classification.

 Advanced cancer classified as Stage II based on TNM classification.

 Carcinoma in situ of the breast requiring the removal of the entire breast (total mastectomy).

 Cancer classified as Stage I based on TNM classification requiring the removal of the entire breast (total mastectomy).

 Prostate cancer where the tumour is described histologically as TNM Classification T2 or greater.

 Malignant melanoma of Clark level 3 or above; or more than 2mm Breslow thickness; or showing evidence of ulceration.

Cancer classified as Stage I based on TNM classification.



 Carcinoma in situ (Tis) with organ removal. Tumours showing the malignant changes of carcinoma in situ or which are histologically described as pre-malignant, resulting directly in the removal of the entire organ.

 Carcinoma in situ of the breast requiring any of the following:

– Breast conserving surgery (lumpectomy, quadrantectomy, segmental mastectomy) and radiotherapy or

– Breast conserving surgery and chemotherapy and/or immunotherapy

 Prostate cancer which is histologically described as both TNM Classification T1 and Gleason score of 5 or less, requiring major treatment (including but not limited to prostatectomy, radiotherapy, chemotherapy, or immunotherapy).

 Prostate cancer where the tumour is described histologically as TNM Classification T1 and has a Gleason score of 6 or greater.

 Malignant melanoma of Clark level 2; or of less than or equal to 2mm and greater than 1mm Breslow thickness.

 Carcinoma in situ (Tis) - equivalent of ”In Situ” summary staging. The presence of malignant/cancerous cells at a stage of development such that they have not spread into surrounding healthy tissue. The tumour must be classified as Tis according to the TNM Classification or FIGO Stage 0.

 Cervical, vaginal or prostatic intraepithelial neoplasia (dysplasia) with histology showing CIN-3, VIN-3 or PIN-3.

 Malignant melanoma of Clark level 1 or melanoma in situ; or of less than 1mm Breslow thickness.

 Prostate cancer where the tumour is described histologically as TNM Classification T1 and has a Gleason score of 5 or less.

Cancer of the urinary bladder – Stage Ta.



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