approved by Sovereign considers necessary; and > any other information that Sovereign may deem relevant to the assessment of the claim. 4. Ongoing Claim Requirements For ongoing claims Sovereign 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 Sovereign for the purposes of determining ongoing entitlement to a Waiver of Premium Benefit. > Completion of a monthly individual declaration by the life assured in a form from time to time approved by Sovereign, which may include completion of daily activity logs detailing the life assured’s functional activities for the purposes of determining ongoing entitlement to a Waiver of Premium Benefit. > Proof of any remunerated or non-remunerated work completed during the claim period. > Any other information that Sovereign may deem relevant to the ongoing assessment of the claim. 5. When will Sovereign cease waiving the regular premiums payable under this TotalCareMax policy? Sovereign will cease waiving the regular premiums payable under this policy if: (a) The life assured fails to undergo and complete: > any surgical operation; and/or > any medical rehabilitation programme; and/or > any social rehabilitation programme; and/or > any vocational rehabilitation programme, which a Registered Medical Practitioner approved by Sovereign considers reasonably necessary. (b) The life assured fails to undertake any medical examinations that Sovereign requires the life assured to have, at our expense. (c) The life assured fails to comply with the requirements of Section 4 above. (d) Sovereign determines that the life assured is no longer totally disabled or a partial disability benefit is no longer payable in respect of the life assured under this TotalCare Max policy. (e) The waiver of premium term 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 in prison for any reason. (h) The life assured dies.
If Sovereign ceases waiving the regular premiums payable under this policy 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 relevant requirement(s) will, subject to the provisions of this appendix, be treated as the disablement date for a new claim. > The waiting period will be waived for the new claim. > Sovereign will not waive the regular premiums payable under this TotalCare Max policy retrospectively for any period of time before the date that the life assured complies with the relevant requirement(s). 6. Exclusions – when Sovereign won’t waive the regular premiums Sovereign will not waive the regular premiums payable under this TotalCare Max policy where any of the following directly or indirectly cause or contribute to the 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. > 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. > The life assured does not comply with the treatment prescribed by the attending treatment providers. If the life assured is imprisoned for any reason, regular premiums will not be waived during the term of imprisonment.
7. Key terms
disablement date
The date the life assured became totally disabled .
full-time care
Care for 16 hours per day or more, provided by a nursing service approved by Sovereign whose profession it is to provide nursing services or provided by a Registered Medical Practitioner .
totally disabled/ total disablement
See Section 2 of this appendix for the meanings of these key terms.
unemployed
A person who is not engaged in remunerated work or business activities for 10 hours or more a week. This definition does not include a person on leave without pay.
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812 TCP-WOP version 4 Effective 19 October 2015
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