821 TCP-AIC Version 1 Effective 1 September 2017
TOTALCAREMAX PERSONAL
OPTIONAL BENEFIT APPENDIX
Accidental Injury Cover
This appendix only applies if cover under the policy schedule includes Accidental Injury Cover. This appendix forms part of and is incorporated into your TotalCareMax policy, the terms of which apply to this appendix . This is an agreed value benefit. Details of the benefit and the names of the people insured under the benefit (called the life or lives assured) are shown in the schedule .
1.
When will Sovereign pay Accidental Injury Cover?
The Accidental Injury Cover is not subject to any offsets.
Only one Accidental Injury Cover will be paid for the same event. If the life assured suffers more than one specified injury from the same event, Sovereign will pay the specified injury that provides the greatest benefit. However, if Sovereign pays a specified injury that provides a lower benefit and subsequently the same accidental injury would qualify for a specified injury providing a higher benefit, then Sovereign will pay the difference between the higher benefit and any lower benefit already paid for the same accidental injury.
Sovereign will pay Accidental Injury Cover if a life assured suffers an accidental injury after risk commencement date which falls within one of the Accidental Injury Categories in the table in Section 2 below ( “ specified injury ” ) and survives for at least 14 days thereafter. An Accidental Injury Cover claim must be supported by medical evidence acceptable to Sovereign confirming the specified injury giving rise to the claim. No waiting period applies and the Accidental Injury Cover will be paid once evidence of the specified injury is accepted by Sovereign.
3.
How to make a claim
To make a claim, the relevant procedures in the section of your TotalCareMax policy entitled ‘How to make a claim’ must be followed. In addition, Sovereign will not pay a claim under this Accidental Injury Cover until Sovereign has received medical evidence of the specified injury from a Registered Medical Practitioner (at your expense).
2.
What amount will Sovereign pay for Accidental Injury Cover?
If a life assured suffers a specified injury Accidental Injury Cover will be paid as a lump sum payment equal to the monthly benefit amount set out in the schedule multiplied by the applicable number of months set out in the table below.
Table of specified injuries .
4.
When will this appendix terminate for a life assured?
Number of Months’ Benefit as Lump Sum
Category Number
Accidental Injury Categories
This appendix will terminate and eligibility for the Accidental Injury Cover will cease for a life assured at the earliest of when:
An accidental injury that leads to a fracture that requires immobilisation other than a cast
The life assured dies.
1
2
The life assured reaches age 70.
The benefit is cancelled.
An accidental injury that leads to a fracture that requires a cast
2
3
All of the life assured’s other TotalCareMax benefits with Sovereign are cancelled.
An accidental injury that requires surgery under general anaesthesia An accidental injury that leads to amputation of a limb , permanent total blindness , permanent total loss of hearing , or permanent paralysis (diplegia, hemiplegia, paraplegia, quadriplegia)
3
3
4
12
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821 TCP-AIC Version 1 Effective 1 September 2017
5.
Exclusions – When Sovereign won’t pay a benefit?
Sovereign will not pay Accidental Injury Cover if a specified injury arises directly or indirectly from any of the following:
Any illness, disease or degenerative condition.
Any act or omission by the life assured intended to cause harm to him or herself. Sovereign will not pay any Accidental Injury Cover if the life assured participates in any criminal activity or suffers a specified injury when under the influence of alcohol or drugs, except where the drugs were prescribed by and were being used in accordance with the directions of a Registered Medical Practitioner.
6.
Key terms
limb(s)
An arm, leg, hand or foot. In respect of this definition:
accidental injury
Bodily injury caused solely, suddenly and directly by violent, accidental, external and visible means.
the arm starts from the shoulder joint and ends at the wrist joint; the hand starts from the wrist joint; the leg starts from the hip joint and ends at the ankle joint; and the foot starts from the ankle joint.
fracture
The disruption in continuity of bone, with or without displacement.
general anaesthesia
The induction of a state of unconsciousness with the absence of pain sensation over the entire body, through the administration of anaesthetic drugs. Means a Registered Medical Practitioner has certified that, as part of the recommended medical treatment for that fracture , the life assured requires a:
permanent total blindness
Irrecoverable loss of the sight of both eyes (whether aided or unaided). This is evidenced by:
immobilisation
visual acuity of 6/36 or less in both eyes; or field of vision reduced to 10 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.
moon boot;
halo;
surgical wires;
externally or internally fixed plates and/or screws;
wrist guard;
permanent total loss of hearing
The life assured loses all hearing in both ears (aided or unaided). The loss must be total and permanent as assessed three months after the accidental injury .
splint;
support;
crutches;
sling;
you/your
The 'Policy Owner' named in the schedule .
wheelchair; and/or
other mobility equipment, aid or device.
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821 TCP-AIC Version 1 Effective 1 September 2017
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