TCM Personal Essential Living Assurance Policy Wording

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TOTALCAREMAX PERSONAL

OPTIONAL BENEFIT APPENDIX

Essential Living Assurance Benefit

This appendix only applies if cover under the schedule includes the Essential Living Assurance Benefit (standalone or accelerated). This appendix forms part of and is incorporated into your TotalCare Max policy, the terms of which apply to this appendix .

Details of the benefit and the names of the people insured for the benefit (called the life or lives assured) are shown in the schedule .

1. When will Sovereign pay an Essential Living Assurance Benefit?

Sovereign will pay you (subject to the provisions of this policy) a Living Assurance Benefit if the life assured suffers for the first time after the risk commencement date any of the following conditions and survives for at least 14 days thereafter.

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If the medical diagnostic techniques and investigations used in our definitions of medical conditions have been superseded due to medical advancements, we will consider other appropriate and medically recognised methods or tests that conclusively diagnose the condition to at least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.

90 day stand down period

Full Payment

Partial payment

Children’s Trauma Benefit

Cancer

✓

Carcinoma-in-situ

✓

Carcinoma-in-situ radical surgery

Malignant tumours and blood cancers

✓

Prostate Cancer

Heart

✓

Angioplasty

✓

Aortic surgery

✓

Cardiomyopathy

✓

Coronary artery bypass surgery

✓

Heart attack

✓

Heart valve surgery

✓

Out-of-hospital cardiac arrest

✓

Pulmonary hypertension

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90 day stand down period

Full Payment

Partial payment

Children’s Trauma Benefit

Major neurological disease

✓

Alzheimer’s disease

✓

Benign brain or spinal cord tumour

✓

Coma

✓

Creutzfeldt-Jakob disease

✓

Dementia

✓

Encephalitis

✓

Idiopathic Parkinson’s disease

✓

Major head trauma

✓

Meningitis

✓

Motor neurone disease

✓

Multiple sclerosis

✓

Muscular dystrophy

✓

Peripheral neuropathy

✓

Stroke

Paralysis and loss of functionality

✓

Diplegia

✓

Hemiplegia

✓

Loss of independent existence

✓

Paraplegia

✓

Permanent blindness

✓

Permanent loss of hearing

✓

Permanent loss of speech

✓

Permanent loss of use of limbs

✓

Quadriplegia / Tetraplegia

Other key conditions

✓

Advanced AIDS

✓

Aplastic anaemia

✓

Chronic liver failure

✓

Chronic lung disease

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90 day stand down period

Full Payment

Partial payment

Children’s Trauma Benefit

✓

Chronic renal failure

✓

HIV

✓

Intensive care benefit

✓

Major transplant surgery

✓

Severe burns

(Refer to Section 15 for a full description of these conditions .)

If you receive a full payment claim for a life assured under this Living Assurance Benefit, cover will cease for that life assured.

If you receive a partial payment of this Living Assurance Benefit for a life assured, cover will continue for that life assured with the sum assured being reduced by the amount of the partial payment amount. The premium will reduce with the reduction in sum assured.

What stand down periods apply?

If, within the first 90 days after the risk commencement date , any of the conditions marked in the above table as having a 90 day stand down period occur, or symptoms or signs which lead to any of those conditions (whether or not a r egistered medical practitioner has been consulted) occur, then Sovereign will not pay a benefit for the life assured or any child of the life assured covered by the Children’s Trauma Benefit.

Cover added under the Essential LAB Future Insurability Benefit or the Special Events Increase Facility

A 180 day stand down period applies to increases made under the Essential LAB Future Insurability Benefit or the Special Events Increase Facility, except where the claim is due to an accident , as outlined in Sections 10 and 11. Where the claim is due to an accident , the stand down period is waived on such increases provided the life assured has already served the 90 day stand down period on the original Essential Living Assurance Benefit policy.

Cover added under the Special Events TPD/Trauma Facility

A 180 day stand down period applies to any accelerated Living Assurance Benefit cover added for the life assured using the Special Events TPD/Trauma Facility under the Life Cover Benefit, except where the claim is due to an accident , as outlined in the Life Cover Benefit appendix . Where the claim is due to an accident , the 90 day stand down period applies to the added cover from the date the added cover commences, for any of the conditions marked in the above table as having a 90 day stand down period.

Newborn Children’s Benefit

A twelve month stand down period applies to the 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 . This stand down period applies anew to all added cover from the date the added cover commences, including cover added using the Essential LAB Future Insurability Benefit, the Special Events Increase Facility, or the Special Events TPD/Trauma Facility under the Life Cover Benefit.

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2. What effect does payment of an accelerated Essential Living Assurance Benefit have on the Life Cover Benefit?

Sovereign will pay this Benefit a maximum of once per child across all Sovereign policies .

What are the applicable conditions and how much will Sovereign pay?

This section applies only if an accelerated Essential Living Assurance Benefit is shown in the schedule .

Payments under this Benefit apply for those conditions where the criteria for a full payment are met as detailed in Section 15 below. For these conditions , the Benefit payable is the lower of $20,000 or 50% of the sum assured across all Essential Living Assurance Benefit policies for the life assured.

When Sovereign pays an accelerated Essential Living Assurance Benefit, the Life Cover Benefit for the life assured will decrease by the same amount. Any other accelerated benefits relating to that Life Cover 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. The maximum combined amount payable under the Life Cover Benefit, Specified Terminal Conditions Benefit, Terminal Illness Benefit, Bereavement Support, Repatriation Benefit, accelerated Living Assurance Benefit, and, if applicable, the accelerated Progressive Care Benefit and the accelerated Total Permanent Disablement Benefit is the amount of the Life Cover Benefit for that life assured.

No payments are made under this Benefit for those conditions where a partial payment applies.

Sovereign will pay a maximum of one claim per child under either the Children’s Trauma Benefit or the Newborn Children’s Benefit across all Sovereign policies . Payment of the Children’s Trauma Benefit will not affect the amount of any Living Assurance Benefit payable for the life assured.

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

3. Financial and Legal Advice Benefit

If Sovereign pays a full payment claim under this Living Assurance Benefit for a condition suffered by a life assured, 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 Living Assurance 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.

5. Newborn Children’s Benefit

What is the Newborn Children’s Benefit?

Sovereign will pay a 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:

Cleft palate;



Down’s syndrome;



Spina bifida;



Total blindness;



Absence of one or more limbs ;



4. Children’s Trauma Benefit

Tetralogy of Fallot;



Transposition of Great Vessels; or



What is the Children’s Trauma Benefit?

Deafness.



Sovereign will pay a Children’s Trauma Benefit if a child of a life assured suffers one of the applicable conditions listed in Section 1 of this appendix .

Please refer to Section 16 for the definitions of these conditions .

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

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

 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

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

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date that conclusive diagnosis is first possible.

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);



A claim is only payable under the 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.

 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 their standalone Essential Living Assurance Benefit. This includes any claim currently under assessment; and

How much will Sovereign pay?

The Benefit payable is the lower of $20,000 or 50% of the sum assured across all Essential Living Assurance Benefit policies for the life assured. Sovereign will pay a maximum of one claim per child under either the Newborn Children’s Benefit or the Children’s Trauma Benefit, across all Sovereign policies . The 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 Essential LAB Future Insurability Benefit, the Special Events Increase Facility, or the Special Events TPD/Trauma Facility under the Life Cover Benefit. Payment of the Newborn Children’s Benefit will not affect the amount of any Living Assurance Benefit payable for the life assured.

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

 The premiums for their standalone Essential Living Assurance Benefit are paid up to date; and

 The accelerated Essential Living Assurance Benefit sum assured must be less than or equal to the standalone Essential Living Assurance sum assured; and

 The Life Benefit sum assured does not exceed the accelerated Essential Living Assurance 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 Essential Living Assurance Benefit will be reinstated from the date of conversion.

6. Built-in Children’s Trauma Conversion Facility

The Built-in Children’s Trauma Benefit can be converted to a standalone Essential Living Assurance Benefit with a maximum sum assured of $20,000 or 50% of the life assured’s original sum assured whichever is the lesser. Where the life assured’s sum assured has reduced, the conversion will be calculated on the reduced amount, without further medical evidence.

8. Built-in Premium Conversion Facility

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

The following conditions are applicable:

 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 Sovereign within 60 days of the anniversary date after the child’s 21st birthday; and

 Convert all or part of your Essential Living Assurance Benefit from the premium shown in the schedule to a Level premium structure. The Essential Living Assurance 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. We 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 us to the general public. Premiums will be calculated on the current age of the life assured . Any loading(s) and/or exclusion(s) that applied to your existing Essential Living Assurance Benefit will apply to your new Essential Living Assurance Benefit.

Your request must be received in writing.



An applicable premium will be payable on converted cover.

7. Built-in Standalone Conversion Facility

If the schedule shows the Essential Living Assurance Benefit as standalone you can convert this to an accelerated Essential Living Assurance Benefit with an equal amount of Life Cover without any further medical evidence subject to the following:

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9. Built-in Suspension of Premium Benefit

having a child (by birth or legal adoption);



 becoming married or entering into a civil union;

A life assured can suspend their cover under this Essential Living Assurance Benefit appendix for up to 12 months if they:

 becoming legally separated, divorced or the dissolution of the life assured’s civil union;

go on parental leave;



 financially supporting a dependent child through a first course of full-time tertiary education;  the commencement of secondary school for the first time by a child of the life assured;  taking out or increasing a home loan because the life assured has purchased a new home, a new residential investment property, a vacation home, or a bare block of land zoned as residential, or is making extensions to a residential property or residential investment property owned by the life assured;

go on leave without pay for any reason;



become unemployed or redundant;



 experience at least a 20% reduction in pay (comparing the most recent payslip against a previous payslip from the same year); or  if self-employed, experience a 30% reduction in revenue (by comparing one month’s revenue against the same month for the previous year),

provided that:

 becoming responsible for the full-time care or payment for long term care of a close relative ;

 you notify Sovereign within three months of one of the above listed suspension events occurring, and provide evidence to Sovereign of the suspension event; and

 receiving an annual salary increase (this special event is not available to a life assured who is self-employed); or

 Sovereign acknowledges in writing receipt of that notification.

 experiencing the death of a spouse or de facto partner,

you may write to Sovereign asking us to increase the Essential Living Assurance Benefit for that life assured.

Cover for the life assured will be suspended from the date set out in Sovereign’s written acknowledgment.

What is the maximum cover that can be added?

No premium will be payable during the period that the cover is suspended.

The maximum increase for each special event cannot exceed the lower of:  50% of the original Essential Living Assurance Benefit for the life assured; or

No claim under this Essential Living Assurance Benefit appendix will be payable for any condition that occurs during the period that the cover is suspended. A claim may only be payable if the life assured first meets the criteria for an eligible claim under this policy after their cover is reinstated. Cover under this Essential Living Assurance Benefit appendix may be reinstated at the end of the suspension period in accordance with this Section without the need to provide further medical evidence, provided that the benefit has been suspended for no longer than 12 months.

$250,000.



The total of all increases made under this Facility cannot exceed the lower of:  100% of the original Essential Living Assurance Benefit for the life assured; or

$750,000.



In the case of taking out or increasing a home loan, the individual increase cannot exceed the amount of the home loan or the increase in the home loan. In the case of an annual salary increase, the individual increase cannot exceed five times the annual salary increase. The maximum increases outlined above each apply in respect of all Living Assurance Benefits, Progressive Care Benefits, and similar benefits for that life assured across all Sovereign policies .

At the end of the suspension period, the benefit will be automatically reinstated for the life assured.

Cover for the life assured will be reinstated from the date set out in Sovereign’s written acknowledgement.

The premium payable for the reinstated benefit will be based on Sovereign’s premium rates at the time of the reinstatement.

10. Special Events Increase Facility

Both of the following maximum sum assured limits also apply across all Sovereign policies for each life assured:

What is the Special Events Increase Facility?

On each occasion when one of the following circumstances occurs for a life assured on the Essential Living Assurance Benefit:

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(b) the total of the sum assured for all trauma benefits combined must not exceed $2,000,000 and the total sum assured for all trauma and Total Permanent Disablement Benefits (and similar benefits) combined must not exceed $5,000,000.

After an increase under this Facility has been made, Sovereign will not pay the increased benefit amount if, before the increase, or within six months of the Facility being exercised, the life assured:  suffers any condition for the first time other than due to an accident under the Essential Living Assurance Benefit; or  has any symptoms or signs leading to a condition (whether or not a registered medical practitioner has been consulted) that may result in a claim for anything other than an accident under the Essential Living Assurance Benefit.

What are the other conditions applying to this Facility?

You do not need to produce any medical evidence regarding the life assured when you request this increase, but any Special Events Increase is subject to the following conditions:  You must make the request within 60 days either side of the relevant special event and provide Sovereign with suitable evidence of the occurrence of the event.  A life assured is only eligible for special events increases where the special event occurs before age 55.  If, at any time before you seek to exercise the Facility, a claim for the life assured had been accepted by us or notified to us, Sovereign will have discretion in determining whether the Facility can be exercised. In exercising discretion, we will consider whether the life assured represents an increased risk of claim for the benefit being added under this Facility.  Only one of the following is available in any 12 month period:

Increases in sum assured issued as an additional new policy

Where this policy or any part of the sum assured under it, has been issued as the result of an increase under the Special Events Increase Facility, then:  the Special Events Increase Facility will not be available under this policy for the proportion of the sum assured that represents the increase.  Sovereign will not pay the increased benefit amount if, before the increase, or within six months of the increase, the life assured: − suffers any condition for the first time other than due to an accident under the Essential Living Assurance Benefit; or − has any symptoms or signs leading to a condition (whether or not a r egistered medical practitioner has been consulted) that may result in a claim for anything other than an accident under the Essential Living Assurance Benefit.

An Essential LAB Future Insurability Benefit increase (see Section 11 below);

−

A Special Events Increase under a Living Assurance Benefit or Progressive Care Benefit; or (If applicable) exercising the Special Events TPD/Trauma Facility under the Life Cover Benefit and/or similar benefits to add an accelerated Living Assurance Benefit or an accelerated Progressive Care Benefit.

−

11. Essential LAB Future Insurability Benefit

Sovereign will increase the Essential Living Assurance Benefit for a life assured from the date we accept your request. Each increase will require an increase in premium . This increase will be calculated on the rates applicable at the time the Special Events Increase Facility is exercised. Any loadings, exclusions or special terms on the original Essential Living Assurance Benefit sum assured will be applied to the increased amount. If you have the Optional Life Cover Buyback benefit selected on the policy for your original Essential Living Assurance Benefit, you can choose to add this benefit to the portion of the increased sum assured when you exercise the Special Events Increase Facility.

At every third policy anniversary date you may write to Sovereign asking us to increase the Essential Living Assurance Benefit for a life assured. You do not need to produce any medical evidence regarding the life assured when you request this increase, but any increase in sum assured under this Benefit is subject to the following conditions:  You must request the increase by providing written advice to Sovereign within 60 days either side of the applicable anniversary date .  Each individual increase cannot exceed 20% of the original Essential Living Assurance Benefit sum assured or $200,000, whichever is the lesser.  The total of all Essential LAB Future Insurability Benefit increases for a life assured cannot exceed 100% of the original Essential Living Assurance Benefit for that life assured or $500,000, whichever is the lesser.

When will Sovereign not pay a claim for an increase under this Facility?

Increases in sum assured added to this policy

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 Both of the following maximum sum assured limits also apply across all Sovereign policies for each life assured:

the increased sum assured when you exercise the Essential LAB Future Insurability Benefit.

(a) the total of the sum assured for all Living Assurance Benefits, Progressive Care Benefits, and similar trauma benefits (combined), including increases under this Facility must not exceed $2,000,000; and (b) the total of the sum assured for all trauma benefits combined must not exceed $2,000,000 and the total sum assured for all trauma and Total Permanent

When will Sovereign not pay a claim for an increase under this Benefit?

a. Increases in sum assured added to this policy

After an Essential LAB Future Insurability Benefit increase has been made, Sovereign will not pay the increased amount if, before the increase, or within six months of the increase, the life assured:  suffers any condition for the first time other than due to an accident under the Essential Living Assurance Benefit; or  has any symptoms or signs leading to a condition (whether or not a r egistered medical practitioner has been consulted) that may result in a claim for anything other than an accident under the Essential Living Assurance Benefit.

Disablement Benefits (and similar benefits) combined must not exceed $5,000,000.

 Where this Essential Living Assurance Benefit is shown in the schedule as accelerated against the Life Cover Benefit, the Essential Living Assurance Benefit, including the total of all Essential LAB Future Insurability Benefit increases, cannot exceed the sum assured of the Life Cover Benefit. See Section 2 “What effect does payment of an accelerated Essential Living Assurance Benefit have on the Life Cover Benefit” for details.

 A life assured is only eligible for Essential LAB Future Insurability Benefit increases before age 55.

b. Increases in sum assured issued as an additional new policy

 Sovereign will increase the Essential Living Assurance Benefit for a life assured from the date we accept your request.  If, at any time before you seek to exercise an increase under this Benefit, a claim for the life assured had been accepted by us or notified to us, Sovereign will have discretion in determining whether the increase will be accepted. In exercising discretion, we will consider whether the life assured represents an increased risk of claim for the cover being added under this Benefit.

Where this policy or any part of the sum assured under it, has been issued as the result of an increase under the Essential LAB Future Insurability Benefit, then:  the Essential LAB Future Insurability Benefit under this policy will not be available for the proportion of the sum assured that represents the increase.  Sovereign will not pay the increased amount if, before the increase, or within six months of the increase, the life assured: - suffers any condition for the first time other than due to an accident under the Essential Living Assurance Benefit; or - has any symptoms or signs leading to a condition (whether or not a r egistered medical practitioner has been consulted) that may result in a claim for anything other than an accident under the Essential Living Assurance Benefit.

 Only one of the following is available in any 12 month period:

- an Essential LAB Future Insurability Benefit increase; or

- a Special Events Increase under a Living Assurance Benefit or Progressive Care Benefit; or

- (if applicable) exercising the Special Events TPD/Trauma Facility under the Life Cover Benefit and/or similar benefits to add an accelerated Living Assurance Benefit or an accelerated Progressive Care Benefit. Each Essential LAB Future Insurability Benefit increase in sum assured will require an increase in premium . This increase will be calculated on the rates applicable at the time the Essential LAB Future Insurability Benefit is exercised. Any loadings, exclusions or special terms on the original Essential Living Assurance Benefit sum assured will be applied to the increased amount. If you have the Optional Life Cover Buyback benefit selected on the policy for your original Essential Living Assurance Benefit, you can choose to add this benefit to the portion of

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 Essential Living Assurance 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 Essential Living Assurance Benefit claim, subject to the following conditions:

 The Life Cover Benefit can be reinstated to the level

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Life Cover Benefit is reinstated.

applying immediately before the accelerated Essential Living Assurance Benefit claim.

 Any accelerated benefits relating to the Life Cover Benefit for the life assured that have been reduced or removed as a result of the accelerated Living Assurance Benefit claim will not be reinstated.

 The Optional Life Cover Buyback can be exercised:

− within 60 days of the accelerated Essential Living Assurance Benefit claim payment; or

13. Exclusions – when Sovereign won’t pay a benefit

within 60 days of the life assured surviving a period of six months after an accelerated Essential Living Assurance Benefit claim payment for one of the following conditions:

−

Sovereign 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 children’s benefit) deliberately injures himself or herself or attempts to do so.  The life assured (or the child in the case of a children’s 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 Sovereign 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 Sovereign.

▪

Paraplegia;

▪

Quadriplegia;

▪

Diplegia;

▪

Hemiplegia;

▪

Alzheimer’s disease;

▪

Permanent blindness;

▪

Permanent loss of hearing;

▪

Dementia;

▪

Permanent loss of use of limbs ;

▪

Multiple sclerosis;

▪

Idiopathic Parkinson’s disease; or

within 60 days of the life assured surviving a period of twelve months after an accelerated Essential Living Assurance Benefit claim payment for all other conditions.

−

Sovereign will not pay a Children’s Trauma Benefit that arises as a direct or indirect consequence of:

a pre-existing condition ; or



 The Life Cover Benefit can be reinstated following a full payment claim or a partial payment claim.

any congenital condition .



 Only one Life Cover Buyback reinstatement will apply per life assured per policy.

These exclusions apply to any subsequent benefit increase you make.

 The maximum Life Cover Benefit that can be reinstated is 100% of the accelerated Essential Living Assurance Benefit claim or $2 million, whichever is the lesser.

14. 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’.

No reinstated Life Cover Benefit is payable:



− within six months (for the conditions listed above that require a six month survival period); or

In addition, for a Living Assurance 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 or his or her child (if applicable) to have an examination by a registered medical practitioner appointed by Sovereign before accepting liability for a 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

− within twelve months (for all other conditions ),

from the date of the accelerated Essential Living Assurance 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 Sovereign 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

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15. Definitions of medical conditions .

classification and tumours classified as T1 or its equivalent will be excluded).

Cancer

All skin cancers unless they:



− are at least 1.0mm in maximum thickness as determined by histological examination using the Breslow thickness histological classification; or

The life assured has suffered or undergone one of the following conditions :

Carcinoma-in-situ

− are graded higher than Clark Level 2 depth of invasion; or

A focal autonomous new growth of carcinomatous cells which has not yet resulted in the invasion of normal tissues. ‘Invasion’ means an infiltration and/or active destruction of normal tissue beyond the basement membrane.

− show evidence of ulceration as determined by histological examination.

 Chronic lymphocytic leukaemia less than RAI Stage 1.

This benefit only covers carcinoma-in-situ of the following sites:

Prostate Cancer

Breast;



As a result of a prostate tumour, the entire prostate is removed to arrest spread of the malignancy and this is considered medically necessary by an appropriate specialist .

Cervix;



Vagina; and



Heart

Vulva.



The carcinoma-in-situ must be positively diagnosed by biopsy and be classified as TIS according to the TNM staging method or FIGO Stage 0. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

The life assured has suffered or undergone one of the following conditions :

Angioplasty

The actual undergoing of coronary artery angioplasty with or without a stent, laser or atherectomy, considered medically necessary by an appropriate specialist cardiologist, to correct a narrowing or blockage of one or more coronary arteries during the same procedure. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Carcinoma-in-situ radical surgery

As a result of a carcinoma-in-situ, an operation to arrest spread of the malignancy is performed which involves the removal of the entire organ (which includes: breast, cervix, ovary, fallopian tube, vagina, vulva, prostate, colon/rectal, bladder) affected or the organ requires systemic chemotherapy, radiotherapy, or immunotherapy, and that treatment is considered medically necessary by an appropriate specialist . The carcinoma-in-situ must be positively diagnosed by biopsy and be classified as TIS according to the TNM staging method or FIGO Stage 0.

Aortic surgery

Medically necessary surgery to correct or repair:

an aortic aneurysm;



an obstruction of the aorta;



a coarctation of the aorta;



a traumatic rupture of the aorta; or



Malignant tumours and blood cancers

an aortic dissection.



The presence of one or more malignant tumours, characterised by uncontrolled growth and spread of malignant cells, with the invasion and destruction of normal tissue for which major interventional treatment or surgery is considered medically necessar y by an appropriate specialist .

For the purpose of this definition aorta shall mean the thoracic and abdominal aorta.

The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

The following tumours are excluded:

 Tumours classified as carcinoma-in-situ (including intra- epithelial neoplasia).

Cardiomyopathy

Impaired ventricular function of variable aetiology due to primary disease of the heart muscle, resulting in permanent and irreversible physical impairments to the degree of at

 Prostate tumours with a Gleason score of less than 6. (If the Gleason score is unavailable, we will use the TNM

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least Class 3 of the New York Heart Association classification of cardiac impairment.

Out-of-hospital cardiac arrest

Cardiac arrest not associated with any medical procedure that occurs out of hospital, and is due to cardiac asystole, or ventricular fibrillation with or without ventricular tachycardia, documented by:

The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

 an electrocardiogram (ECG), or any other appropriate diagnostic test; or

Coronary artery bypass surgery

Medically necessary surgery to correct the narrowing of, or blockage to, one or more coronary arteries by means of a bypass graft.

 other evidence which unequivocally confirms a cardiac arrest, including but not limited to:

− defibrillation recorded by an Automated External Defibrillator (AED) or ambulance or hospital medical records; or − documented administration of cardiopulmonary resuscitation (CPR) provided by an attending ambulance officer or hospital clinical staff. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Heart attack

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 and at least one of the following:

 Signs and symptoms of ischaemia which are consistent with myocardial infarction; or

Pulmonary hypertension

Primary pulmonary hypertension with substantial right ventricular enlargement resulting in permanent and irreversible physical impairment to the degree of at least Class 3 of the New York Heart Association classification of cardiac impairment. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

 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

−

Major neurological disease

 Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.

Alzheimer’s disease

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 5 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.

The unequivocal diagnosis of Alzheimer’s disease, which must confirm permanent irreversible failure of brain function. The diagnosis is confirmed by an appropriate specialist in psychogeriatrics, psychiatry, neurology or geriatrics. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Benign brain or spinal cord tumour

Other acute coronary syndromes including but not limited to angina pectoris are excluded.

A benign tumour of the brain or spinal cord where it is deemed appropriate and medically necessary to be:

Heart valve surgery

 treated using major interventional treatment necessary for the therapeutic management of the tumour; or

The undergoing of heart valve surgery performed to replace or repair one or more heart valves that cannot be repaired by intra-arterial procedures. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

 removed through surgery (whether it is able to be removed or not).

The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

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Coma

Idiopathic Parkinson’s disease

A definite diagnosis of a state of unconsciousness resulting in the following for at least 96 hours:

The unequivocal diagnosis of Idiopathic Parkinson’s disease as confirmed by an appropriate specialist .

The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

 a documented Glasgow Coma Score of 7 or less; and

the use of a life-support system.



The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . Coma arising from drug and alcohol abuse is specifically excluded. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Major head trauma

An accidental cerebral injury diagnosed by an appropriate specialist approved by Sovereign.

Creutzfeldt-Jakob disease

The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . Major head trauma arising from drug and alcohol abuse is specifically excluded. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

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. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Meningitis

The diagnosis of meningitis by an appropriate specialist approved by Sovereign. The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Dementia

The unequivocal diagnosis of dementia. The diagnosis must confirm permanent irreversible failure of brain function and result in significant cognitive impairment for which no other cause has been identified. Significant cognitive impairment means a deterioration or loss of intellectual capacity that results in a requirement for continual supervision to protect the life assured or others. The diagnosis is confirmed by an appropriate specialist in psycho geriatrics, psychiatry, neurology or geriatrics. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Motor neurone disease

The unequivocal diagnosis of motor neurone disease diagnosed by an appropriate specialist approved by Sovereign. The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Encephalitis

The unequivocal diagnosis of severe inflammatory disease of the brain diagnosed by an appropriate specialist approved by Sovereign. The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Multiple sclerosis

The unequivocal diagnosis of multiple sclerosis as confirmed by an appropriate medical specialist .

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.

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Paralysis and loss of functionality

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. The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

The life assured has suffered or undergone one of the following conditions :

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.

Muscular dystrophy

Loss of independent existence

The unequivocal diagnosis of muscular dystrophy diagnosed by an appropriate medical specialist approved by Sovereign.

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 without the physical assistance of someone else at least two 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):

Bathing and showering.



Dressing and undressing.



Eating and drinking.



Peripheral neuropathy

Using a toilet.



Irreversible inflammation or degradation of a peripheral nerve, diagnosed by an appropriate specialist approved by Sovereign. The life assured must have also sustained a neurological deficit causing at least 25% permanent impairment of whole person functioning or inability to perform one of the activities of daily living . The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

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

Alternatively, the life assured is unable to perform one of the above and his or her intellectual capacity has reduced or deteriorated to such an extent that the life assured requires full-time care . The benefit payable is 10% of the sum assured to a maximum of $20,000 across all Personal Sovereign policies for the life assured .

Stroke

Paraplegia

A cerebrovascular event producing neurological deficit. This requires clear evidence on CT, MRI or similar appropriate scan or investigation that a stroke has occurred. This requires evidence of:

Total and permanent loss of function of both legs due to injury or disease of the spinal cord.

Permanent blindness

infarction of brain tissue; or



Irrecoverable loss of sight of both eyes as a result of sickness or injury. This is evidenced by:

intracranial or subarachnoid haemorrhage.



 visual acuity on the Snellan Scale after correction by suitable lenses is less than 6/60 or less in both eyes; or

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.

 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.

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