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TOTALCAREMAX BUSINESS OPTIONAL BENEFIT APPENDIX
Rural Continuity Benefit
This appendix only applies if cover under the policy schedule includes the Rural Continuity Benefit. This appendix forms part of and is incorporated into the TotalCare Max policy, the terms of which apply to this appendix . This is a Rural Continuity Benefit. 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 a Rural Continuity Benefit?
be received. Where the life assured is covered by insurance policies held with more than one provider, Sovereign will negotiate with the other provider(s) to determine the amount to be offset. Only one Rural Continuity Benefit will be paid per farm at any one time. If you have chosen the optional ACC offset and it is shown in the schedule then any ACC payments in respect of the same or a related disability will be included in offsets. If the life assured is entitled to receive a benefit from ACC but is not receiving that benefit because the life assured has either not applied for the benefit, or has not provided all of the requirements necessary to assess the benefit, or the benefit has been stopped due to any non-compliance with ACC requirements, Sovereign will offset the full ACC entitlement regardless of whether the life assured is receiving a payment or not. 4. What does totally disabled mean? In Sovereign’s opinion, the life assured is totally disabled , if as a direct result of sickness or injury, he or she is: > under the regular and personal care of a registered medical practitioner ; and > unable to: -- engage in farming they were involved in immediately before the disablement date for more than ten hours per week; or -- perform one important income producing duty of the role they were involved in immediately before the disablement date and is not working in that role; and > not working or engaged outside the farm or in any other business.
To qualify for a benefit, the life assured must be actively involved in farming in New Zealand on the date of becoming totally disabled . 2. When will Sovereign pay a Total Disablement Benefit? Sovereign will pay a Total Disablement Benefit if, in Sovereign’s opinion, at any time during the benefit term , the life assured has become totally disabled and remains so for a continuous period greater than the waiting period . The benefit is paid monthly in advance from the end of the waiting period until the life assured, in Sovereign’s opinion, ceases to be totally disabled , or until the occurrence of any one or more of the events set out in Sections 12 or 13. Where the life assured has a waiting period of 8 weeks or less, is totally disabled due to injury and the nature of the injury is such that the life assured is expected to recover within a set period of time, Sovereign may choose to make a lump sum payment of up to 3 monthly benefit payments (after the waiting period and any offsets have been taken into account) and close the claim. This payment may be made during the waiting period . If the life assured is still totally disabled or partially disabled at the end of the expected recovery period corresponding with the lump sum payment, then Sovereign will reopen the claim and pay either the Total Disablement Benefit or (if applicable) an Optional Partial Disablement Benefit in accordance with this appendix . 3. What amount will Sovereign pay for a Total Disablement Benefit? The amount that Sovereign will pay monthly is 1/12 th of the benefit amount shown in the schedule , less offsets shown below. Offsets: Any other farm protection, business income, key person or income protection benefit(s) that any person receives or is entitled to receive from any sources in relation to the life assured and in respect of the same or a related disability . This does not include ACC benefits received, or entitled to
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5. When will Sovereign pay an Optional Partial Disablement Benefit? The Optional Partial Disablement Benefit only applies if shown in the schedule . If the life assured has been totally disabled or partially disabled and then immediately thereafter carries on farming at a reduced work capacity than was the case immediately before becoming totally disabled or partially disabled , an Optional Partial Disablement Benefit may apply. The following conditions must be satisfied: > the reduction in work capacity results from the continuation of the disability ; and > because of the reduction in work capacity, the life assured is working less than 20 hours per week; and > the waiting period is over; and > the life assured is no longer totally disabled ; and > if applicable, the period in respect of which a Total Disablement Benefit has been paid in advance has expired; and > where a lump sum payment has been made in lieu of monthly benefit payments as set out in Section 2, the benefit period to which the lump sum corresponds has expired. The Optional Partial Disablement Benefit will be paid monthly in arrears until, in Sovereign’s opinion, after considering the advice of a registered medical practitioner and other relevant information, the disability is no longer preventing the life assured from working at least 20 hours per week, or until the occurrence of any one or more of the events set out in Sections 12 or 13. A Partial Disablement Bridging Benefit (as set out in Section 7) will also be paid if you have been receiving a Total Disablement Benefit under this appendix before you commence receiving an Optional Partial Disablement Benefit. Any claim for a subsequent Optional Partial Disablement Benefit must be immediately preceded by a 14 day period of total disability . Refer to Section 8 for “What is the Recurrent Disablement Benefit?”. What is the amount of the Optional Partial Disablement Benefit? The amount that Sovereign will pay monthly is calculated in the following way: (50% x 1/12 th of the benefit amount shown in the schedule ) less offsets as defined in Section 3. 6. For example, for a benefit amount shown in the schedule of $60,000 per annum ($5,000 per month) with offsets of $1,000, the amount that Sovereign will pay monthly is: ($5,000 x 50%) - $1,000 = $1,500
> the life assured is no longer totally disabled ; and > based on the information provided to, and requested by Sovereign, we reasonably expect that an Optional Partial Disablement Benefit (as set out in Section 5) will be payable for that life assured for the first month after the life assured ceased to be totally disabled . The Partial Disablement Bridging Benefit is a lump-sum payment equivalent to 1/3 rd (33.3%) of the final monthly Total Disablement Benefit paid before the life assured ceased to be totally disabled . The Partial Disablement Bridging Benefit is paid at the end of the final month in respect of which a Total Disablement Benefit was paid for the life assured. Payment of the Partial Disablement Bridging Benefit does not affect the amount of the Optional Partial Disablement Benefit (as set out in Section 6). The Partial Disablement Bridging Benefit is payable once for all claims resulting from the same or a related injury or illness. The Partial Disablement Bridging Benefit is not payable where a lump sum payment has been made in lieu of monthly benefit payments, as set out in Section 2. 8. What is the Recurrent Disablement Benefit? The waiting period will be waived if in Sovereign’s opinion, after considering the advice of a registered medical practitioner and other relevant information, the life assured becomes totally disabled again and this is caused by the same or a related illness or injury as the original period of total disability , not later than 12 months after benefit payments related to the original claim ceased. The provisions of Sections 2, 3, 4, 5 and 6 of this appendix will apply to any benefit claimed. All claims resulting from the same or a related illness or injury will be considered to be the same claim in respect of the benefit payment period . 9. What is the Optional Peak Season Upgrade Benefit and when will Sovereign pay it? The Optional Peak Season Upgrade Benefit applies only if shown in the schedule . If you have chosen the Optional Peak Season Upgrade Benefit, then Sovereign will pay an additional 25% of the monthly benefit while the life assured is in receipt of a Total Disablement Benefit during the nominated 3 month peak season period as defined in the schedule , in any year. The nominated peak season period may only be changed with Sovereign’s written consent. There will be a 90 day stand down from the date the peak season period is changed on the schedule before any Optional Peak Season Upgrade Benefit is payable during the new peak season period. During this stand down period your previous peak season period will remain in force.
7.
What is the Partial Disablement Bridging Benefit and when will Sovereign pay it?
Where the Optional Partial Disablement Benefit applies as shown in the schedule , Sovereign will pay you a Partial Disablement Bridging Benefit if: > you have been receiving a Total Disablement Benefit under this appendix ; and
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10. How to make a claim To make a claim, the relevant procedures in the section of your TotalCare Max policy entitled ‘How to make a claim’ must be followed. In addition, for a Rural Continuity Benefit claim, Sovereign will require: > the life assured to be examined by a registered medical practitioner acceptable to Sovereign before accepting liability for a claim; and > a Sovereign claims form completed by the life assured and a registered medical practitioner (at your expense); and > other information which Sovereign may reasonably request to help assess the claim; and > the life assured to undergo medical and/or surgical treatment (including any operation or vocational, medical and/or social rehabilitation programme) at your expense which the life assured’s registered medical practitioner or a registered medical practitioner approved by Sovereign considers necessary; and > any other information that Sovereign may deem relevant to the assessment of the claim. 11. Ongoing claim requirements For ongoing claims Sovereign will require: > Completion of a monthly medical certificate by a registered medical practitioner (at your expense) in a form from time to time approved by Sovereign for the purposes of determining ongoing entitlement to payment of a Rural Continuity Benefit. > Completion of a monthly individual declaration by the life assured in a form from time to time approved by Sovereign, which may include completion of daily > activity logs detailing the life assured’s functional activities for the purposes of determining ongoing entitlement to payment of a Rural Continuity Benefit. > Proof of any remunerated or non-remunerated work completed during the claim period. > Any other information that Sovereign may deem relevant to the ongoing assessment of the claim. 12. When will Sovereign cease paying a benefit? Sovereign will cease paying a benefit if: a) The life assured fails to undergo and complete: -- any surgical operation; and/or -- any medical rehabilitation programme; and/or -- any social rehabilitation programme; and/or -- any vocational rehabilitation programme, which a registered medical practitioner approved by Sovereign considers reasonably necessary. b) The life assured fails to undertake any medical examinations that Sovereign requires the life assured to have, at our expense.
c) The life assured fails to comply with the requirements of Section 11 above. d) Sovereign determines that the life assured is no longer totally disabled or partially disabled . e) The benefit payment period expires in relation to the life assured. f) The life assured or anyone acting on behalf of the life assured makes a false or fraudulent statement in respect of a claim or supports any claim with false evidence. g) The life assured ceases to be actively involved in farming , unless the reason for this is related to the claim. The life assured is in prison for any reason. h) The life assured dies. If Sovereign ceases paying a benefit in accordance with paragraphs (a), (b) or (c) and the life assured subsequently complies with the relevant requirement(s), then: > The date that the life assured complied with the relevant requirement(s) will, subject to the provisions of this appendix, be treated as the disablement date for a new claim. > The waiting period will be waived for the new claim. > The original claim and the new claim will be considered to be the same claim in respect of the benefit payment period . > No monthly benefit payments will be payable retrospectively for any period of time before the date that the life assured subsequently complies with the relevant requirement(s). 13. When will this appendix terminate for a life assured? This appendix will terminate and eligibility for the Rural Continuity Benefit will cease for a life assured: > At the expiry of the benefit term for that life assured as shown in the schedule . > When the life assured dies. > If the life assured is no longer actively involved in the farm for more than 60 consecutive days for reasons other than total disability , unless Sovereign has been notified in writing and its written consent has been given for the continuation of the appendix . > If the farming business is wound-up or liquidated or the farm is sold or its lease ends, unless Sovereign has been notified in writing and its written consent has been given for the continuation of the appendix . However, if the life assured is on claim and the reason for the farming business being wound-up or liquidated is due to the total disability or partial disability of the life assured, the benefit will remain in force until the end of the benefit payment period . > When the benefit is cancelled by the policy owner.
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14. Exclusions – When Sovereign won’t pay a benefit Sovereign will not pay a benefit where any of the following directly or indirectly cause or contribute to the total disability or partial disability : > The life assured deliberately injures himself or herself or attempts to do so. > The life assured engages in or is part of any conduct that is criminal. > The life assured does not comply with the treatment recommended by the attending treatment providers. > Pregnancy of, or childbirth by, the life assured, unless the disability lasts for more than 90 days after the end of pregnancy, in which case the waiting period will start from the 91 st day. If the life assured is imprisoned for any reason, no monthly benefit will be payable during the term of imprisonment.
A n individual, employer, company, partnership, association, organisation or trust.
person
s haremilking
The provision of services under a Sharemilking Agreement as defined by the Sharemilking Agreements Act 1937 and any of its subsequent amendments including any replacement Act and/or Regulations.
See Section 4 of this appendix for the meanings of these key terms.
totally disabled / total disability
The period stated as such in the schedule for which no Total Disablement Benefit or Optional Partial Disablement Benefit is payable.
waiting period
The ‘Policy Owner’ named in the schedule .
you/your
15. Key terms
Farming for more than 30 hours per week in or on the farm .
actively involved
The term for which the life assured is insured for the Rural Continuity Benefit as stated in the schedule. The maximum term for which the Rural Continuity Benefit is payable as stated in the schedule. The benefit payment period commences at the end of the waiting period and ceases either 6, 12 or 24 months (whichever is stated in the schedule ) later or when the life assured reaches the end of the benefit term as stated in the schedule , whichever is the earlier. The 6, 12 or 24 month period (whichever is stated in the schedule ) is the total period for all claims arising from the same or related illness or injury. The illness or injury giving rise to the claim for total disability or partial disability.
benefit term
benefit payment
period
disability/disabled
The date the life assured became totally disabled .
disablement date
The area where the farming occurs.
farm
Owning or leasing the farm and/or animals and actively raising the animals for commercial purposes including sharemilking.
farming
See Section 5 of this appendix for the meaning of these key terms.
partially disabled / partial disability
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