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AIA LIVING - BUSINESS OPTIONAL BENEFIT APPENDIX
Progressive Care Benefit
This appendix only applies if cover the schedule for your policy includes the Progressive Care Benefit. This appendix forms part of and is incorporated into your AIA Living policy, the terms of which apply to this appendix .
This is a Progressive Care Benefit. Details of the benefit and the life / lives assured are shown in the schedule .
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, AIA 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 consumers price index , the sum assured (and premium ) and any balance of the sum assured will increase each year accordingly.
AIA 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:
(a) Any of the conditions marked in the table below as having a three month stand down period; or
2. Covered conditions
There are five categories of conditions :
(b) Symptoms or signs which lead to any of the conditions marked in the table below as having a three month stand
Cancer
down period (whether or not a registered medical practitioner or specialist has been consulted)
Heart and Arteries
after the risk commencement date but within the first three months of the receipt of application , then AIA will not pay a benefit for that condition .
Brain and Nerves
Loss of Function
Built-in Newborn Children’s Benefit
Other Health Events
A twelve month stand down period applies to the Built-in Newborn Children’s Benefit, meaning that AIA will only pay a claim for a child of a life assured, where the life assured is the biological parent, if the birth of the child with one of the applicable conditions occurs at least twelve months after the risk commencement date .
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 .
This twelve month stand down period applies anew to all added cover from the date the added cover commences.
Once a claim is paid under a category , the balance of the
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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
Any malignant tumour
✓
Any prostate cancer
✓
Any malignant melanoma
✓
Any carcinoma in situ
✓
Urinary bladder cancer
✓
Non-Hodgkin’s Lymphoma
✓
Hodgkin’s Lymphoma
✓
Any leukaemia
✓
Cancer
Any malignant brain tumour
Any benign brain or spinal cord tumour
✓
Any myeloma
Aplastic anaemia
✓
Any bone marrow or stem cell transplant
Transplant waiting list for bone marrow transplant
✓
Myelodysplastic syndrome
✓
CIN-3, VIN-3, PIN-3
Any heart attack
✓
Heart and arteries
Out of hospital cardiac arrest
Coronary artery bypass graft
✓
Angioplasty
✓
Aortic surgery
✓
Heart valve surgery
✓
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Category
Conditions
3 month stand down
Cardiac Defibrillator insertion
✓
Pacemaker insertion
✓
Minor heart valve surgery
✓
Cardiomyopathy
Severe congestive cardiac failure
Severe peripheral vascular disease
Any stroke
✓
Any Dementia and Alzheimer’s disease
Any Parkinson’s disease
Major head trauma
Motor neurone disease
Brain and nerves
Any multiple sclerosis
✓
Any muscular dystrophy
Encephalitis
Meningitis
Peripheral neuropathy
Cerebral Aneurysm
✓
Coma
Paralysis – Diplegia and Hemiplegia
Loss of independent existence
Severe burns/major burns/serious burns
✓
Any Loss of sight
Loss of function
Loss of sight in one eye and one limb
Any Loss of hearing
Loss of speech
Loss of limbs
Intensive Care Benefit
Paraplegia/Quadriplegia/Tetraplegia
Optional Total Permanent Disablement condition
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Category
Conditions
3 month stand down
Chronic liver failure
✓
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
✓
Other health conditions
Severe ulcerative colitis
✓
Severe Crohn’s disease
✓
Advanced Type 1 diabetes
Type 1 diabetes
✓
Advanced Type 2 diabetes
✓
Advanced AIDS
Pneumonectomy
Systemic sclerosis
Systemic lupus erythematosus with lupus nephritis
Severe illness or injury
✓
4. Standalone or accelerated 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. 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 Critical Conditions Benefit, the accelerated Severe Trauma Benefit and the accelerated Total Permanent Disablement Benefit is the amount of the Life Cover Benefit for that life assured .
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 AIA pays an accelerated Progressive Care Benefit,
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When AIA 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.
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.
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. AIA 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. More than 12 months after previous claim event date or related condition 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 AIA determines the amount to be paid for the subsequent claim as follows:
5. The severity level
The lump sum amount that AIA 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 . 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 AIA will pay you . The percentage of the sum assured for each severity level is shown below.
Severity Level
Percentage
1 (most severe)
100%
2
75%
3
50%
4
25%
1. AIA determines if the life assured has suffered the condition .
5 (least severe)
10%
2. AIA 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.
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
3. AIA determines the severity level percentage that applies for the condition :
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 AIA 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) 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.
a) First claim
The amount paid for the first claim for a life assured under this appendix is determined by AIA as follows:
1. AIA determines if the life assured has suffered the condition .
2. AIA identifies which category the condition falls under i.e. Cancer , Heart and Arteries, Brain and Nerves, Loss of Function or Other Health Events.
3. AIA 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.
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Within 12 months of the previous claim event date and a non- related condition
8. Built-in Children’s Trauma Benefit
AIA 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 .
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 AIA 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 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;
This deduction will not apply if the current or previous claim is/was for a condition that is the result of an accident.
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 .
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, AIA will only pay one claim. For each condition , AIA 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 .
What are the applicable conditions and how much will AIA pay?
The Benefit payable is the lower of $50,000 or 50% of the sum assured across all Progressive Care policies for the life assured . AIA 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 AIA 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). AIA will not pay a benefit under the Built-in Children’s Trauma Benefit that arises as a direct or indirect consequence of:
7. Built-in Financial and Legal Advice Benefit
If AIA pays a claim under this Progressive Care Benefit for a life assured for a condition of severity level 1, then AIA 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 AIA , subject to the following conditions: You must pay for the financial planning or legal advice within the 12 months following AIA paying the Progressive Care Benefit claim. AIA will only pay one Financial and Legal Advice Benefit per life assured across all AIA 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.
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.
9. Built-in Newborn Children’s Benefit
What is the Built-in Newborn Children’s Benefit?
AIA will pay a Built-in Newborn Children’s Benefit if a child of a life assured, where the life assured is the biological parent, 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;
Tetralogy of Fallot;
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11. Built-in Parents Grieving Benefit
Transposition of Great Vessels; or
Deafness.
When is a Parents Grieving Benefit payable?
Please refer to Section 29 for the definitions of these conditions .
AIA will pay a Parents Grieving Benefit if:
a child of a life assured dies prior to birth but after at least 24 weeks gestation; or
In order for AIA 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.
a child of a life assured dies.
AIA will not make any payment if the death occurs within 12 months of the risk commencement date except where it is an accidental death. This Parents Grieving Benefit ceases on the child’s 21 st birthday.
How much will AIA pay for the Parents Grieving Benefit?
The Benefit payable:
if the child is under 10 years of age AIA will pay a maximum of one claim of $2,000 per child under the Parents Grieving Benefit across all AIA policies ; or if the child is 10 years of age or over AIA will pay a maximum of one claim of $15,000 per child across all 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 .
How much will AIA pay?
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. AIA 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 AIA 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 .
12. Built-in Counselling Benefit
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 a registered medical practitioner AIA 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 AIA paying the Progressive Care Benefit claim; and AIA must be provided with a receipt for the consultation and/or counselling being claimed. The $2,500 is payable once per life assured per policy. This is in addition to the sum assured .
10. Built-in Return Home Benefit
AIA 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. 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.
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.
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b. Pregnancy Complications Benefit
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. The Optional Total Permanent Disablement condition is only available before the life assured attains age 65.
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 . AIA 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 .
14. Optional Children’s and Maternity Benefit
The Optional Children’s and Maternity Benefit applies only if shown in the schedule .
What Pregnancy Complication Benefit conditions are covered?
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.
Disseminated intravascular coagulation.
Eclampsia.
Hydatidiform mole.
a. Children’s Critical Conditions Benefit
See Section 29 for a full description of these Pregnancy Complication conditions .
What is the Children’s Critical Conditions Benefit?
AIA 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 .
How much will AIA pay for the Pregnancy Complications Benefit?
The benefit payable is $10,000.
This Benefit is only payable if the child of the life assured :
Payment of the Pregnancy Complications Benefit will not reduce the sum assured or the balance of the sum assured for any of the categories .
first suffers a condition after the risk
commencement date , and subject to the stand down period provisions where these apply;
c. Children’s Congenital Conditions Benefit
When is the Children’s Congenital Conditions Payable?
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 . AIA will pay a maximum of one claim per child under the Children’s Critical Conditions Benefit across all AIA 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.
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.
How much will AIA pay for the Children’s Critical Conditions Benefit?
Congenital diaphragmatic hernia.
Tracheo-oesophageal fistula.
The Benefit payable is the lower of $75,000 or 50% of the sum assured .
Truncus arteriosis.
Retinopathy of prematurity.
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. Cover for a child will only commence once we have confirmation of the child’s details in writing.
How much will AIA pay for the Children’s Congenital Conditions Benefit?
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The Benefit payable is $5,000, regardless of the number of congenital conditions diagnosed. AIA will pay a maximum of one claim for a child under the Children’s Congenital Conditions Benefit across all AIA 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 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 Children’s Congenital Conditions Benefit will not reduce the sum assured or the balance of the sum assured for any of the categories. When will AIA not pay a claim under the Optional Children’s and Maternity Benefit? AIA will not pay a benefit under the Optional Children’s and Maternity Benefit that arises as a direct or indirect consequence of:
Your request must be received in writing.
An applicable premium will be payable on converted cover.
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 AIA 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;
a pre-existing condition ; or
any congenital condition , except where expressly covered under the Children’s Congenital Conditions Benefit.
The life assured is not terminally ill or suffering from a terminal illness;
The Optional Children’s and Maternity Benefit ceases on the child’s 21 st birthday.
The premiums for their standalone Progressive Care Benefit are paid up to date;
15. Built-in Children’s Trauma Conversion Facility
The accelerated Progressive Care sum assured must be less than or equal to the standalone Progressive Care sum assured ; and
The Built-in Children’s Trauma Facility can be converted to:
a standalone Progressive Care Benefit; or
The Life Cover Benefit sum assured does not exceed the accelerated Progressive Care sum assured .
an accelerated Progressive Care Benefit with an equal amount of Life Cover Benefit,
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 you are issued a new policy for the amount of the standalone Progressive Care Benefit being converted the new policy will be issued based on the information provided at the time of conversion, together with the information provided in the original proposal. 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 .
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 and Maternity Benefit; and Your request for conversion must be received by AIA within 60 days of the anniversary date after the child’s 21 st birthday; and
17. Built-in Premium Conversion Facility
You may at any time prior to the life assured reaching age 65:
Convert all or part of your Progressive Care Benefit from the premium type shown in the schedule to a Level premium structure; or
Convert a Level premium structure to an alternate Level premium structure, of which term duration may be the
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same or less than current Level premium structure.
life assured (or child ):
AIA will not require you or the life assured to produce further medical evidence at the time of conversion.
any intentional act by you or by any parent or guardian of the life assured, or child .
You will be issued a new policy for the sum assured amount of the Progressive Care Benefit being converted, in which case:
any intentional act by someone who lives with or supervises the life assured, or child .
AIA will not pay any benefit under this appendix for:
The Progressive Care Benefit under this policy will be reduced by the sum assured amount converted;
Any condition ; or
Any symptom or sign that leads to a condition
The new policy will be issued based on the information provided at the time of conversion, together with the information provided in the original proposal;
that existed before the risk commencement date (whether or not a registered medical practitioner has been consulted), unless AIA 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 AIA . AIA 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 Benefit that arises as a direct or indirect consequence of:
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 special terms, exclusions or premium loadings that applied to your existing Progressive Care Benefit under this policy will apply to your new Progressive Care Benefit under the new policy.
18. Reducing your sum assured
You can write to AIA at any time to reduce y our 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 . AIA will send you an endorsement letter, confirming the reduced sum assured and this will form part of your appendix .
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
19. Exclusions: When AIA will not pay a benefit
To make a claim, refer to the section in your AIA Living policy entitled ‘How to make a claim’.
AIA 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 . AIA 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. AIA 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
In addition, for a Progressive Care Benefit claim, AIA will require information acceptable to us, including medical evidence and reports, showing proof of the condition giving rise to the claim. AIA may require the life assured to have an examination by a registered medical practitioner or specialist appointed by AIA before accepting liability for a claim.
Where the Optional Total Permanent Disablement condition is the condition giving rise to the claim, AIA will also require:
An AIA claims form completed by the life assured and a registered medical practitioner (at your expense).
Other information which AIA may reasonably request to help assess the claim, which may include evidence of earnings, taxable income, business accounts, ACC details or similar. The life assured to undergo medical and/or surgical treatment (including any operation or vocational, medical and/or social rehabilitation) at your expense which the life assured ’s registered medical practitioner
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21. Key terms
or a registered medical practitioner approved by AIA considers necessary.
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. 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 AIA will treat the life assured as being able to perform that activity):
Any other information that AIA may deem relevant to the assessment of the claim.
For advice about submitting a claim you can phone AIA on 0800 500 108 or your Adviser. Find claim information online at aia.co.nz
activities of daily living
Bathing and showering;
Dressing and undressing;
Eating and drinking;
Using a toilet;
Moving from place to place by walking, in a wheelchair, or with a walking aid.
balance of the sum assured
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. Dressing - The ability to independently put on or take off all garments, including the securing and unfastening thereof. Where appropriate, this includes any braces, prosthesis 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.
basic activity of daily living
Mobility - The ability to move independently between indoor
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working on contract or otherwise remunerated for his or her efforts.
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.
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 as a step-down prior to transfer to the ward; or
high dependency unit
One of five categories of conditions as set out in the Schedule of Categories below.
Category
Categories has the corresponding meaning.
directly from the ward, recovery or emergency areas.
claim event date
The date the medical treatment or event occurred, or the date the condition was diagnosed by a specialist .
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;
condition(s)
Any:
medical treatment;
the hand starts from the wrist joint;
event; or
illness as diagnosed by a specialist
the leg starts from the hip joint and ends at the ankle joint; and
that exactly matches one of the definitions listed in any of the five Schedules of Categories attached to this appendix .
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 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 AIA 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:
major interventional treatment
congenital condition
A health anomaly or defect, regardless of whether diagnosed or not:
which is present at birth; and
for which the individual had signs or symptoms within
three months of birth.
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,
major invasive surgery
date of conversion
medically necessary
gainful employment
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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.
significant cognitive impairment
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.
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.
AIA policies
Any policy or policies where AIA is the insurer.
receipt of application
Means the date the application for cover is received by AIA along with a valid payment instruction.
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.
related condition
Any condition that AIA , in its sole discretion, deems to be directly or indirectly related to a previous claim's condition .
whole person functioning
This includes:
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
Work
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 23 outlines some of the conditions that are deemed to be related conditions of other conditions . The list is not exhaustive.
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22. Schedule of related conditions
The table below sets out some of the conditions that AIA 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, AIA 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.
1
2
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).
3
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
4
– 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.
5
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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