three months, you must advise us in writing of the child’s name, date of birth and gender. If you provide these details to us within this three month period, the child will automatically be accepted for cover under this benefit without the need to provide evidence of good health. Details received outside this period will result in the child having to be medically assessed. If a child is added to your benefit and the child is the first child to be covered under this benefit, a premium increase will be required. No premium increase will be necessary if one or more children are already covered under this benefit. If an additional adult is added then the appropriate premium will need to be calculated and paid. The additional adult will need to provide evidence of good health. B) REMOVING A FAMILY MEMBER / DEALING WITH ADULT DEPENDANT CHILDREN >> Under normal circumstances children listed on the schedule are covered under this benefit until the first anniversary date after their 21 st birthday. You will receive written notification from Sovereign advising you that a child’s cover under this policy is soon to expire prior to that anniversary date. >> On reaching the age of 21 each child covered under this benefit can elect to purchase their own Specialist and Diagnostic Testing Benefit from the range of policies being offered at that time by Sovereign to customers. The child must make written application to Sovereign within three months after the anniversary date following his/her 21 st birthday to be able to purchase the benefit without providing evidence of good health. >> If a child insured under the policy has reached the age of 21 and is a dependant, then you can apply to have them remain on this benefit until the anniversary date following his/her 25 th birthday. Sovereign may request you to provide proof to establish that a child insured under this policy is a dependant. You will be charged the appropriate age related premium for each dependant. On reaching the age of 25 each dependant can elect to purchase their own Specialist and Diagnostic Testing Benefit from the range of policies being offered at that time by Sovereign to retail customers. The dependant must make written application to Sovereign within three months after the anniversary date following his/her 25th birthday to be able to purchase the benefit without providing evidence of good health. You may remove any life assured under this policy with effect from an anniversary date. You must advise us that you wish to remove a life assured from this policy at least 30 days before the applicable anniversary date. C) ADJUSTING YOUR EXCESS You may make a request to Sovereign in writing to change the excess . Sovereign is not under any obligation to agree to any change to the excess unless we are satisfied that the life assured is in good health. The life assured may be required to provide further health information before a change to the excess is made. Any change to the excess may result in a change to your premium . Any change to your premiums or excess will start from the date notified to you by Sovereign in the applicable policy endorsement.
6 Claims on other insurers
Where another insurer, including but not limited to ACC, may have responsibility in respect of a claim the following provisions apply: >> It is the policy owner’s or the life assured’s responsibility to advise Sovereign that another insurer is involved in a claim that has been submitted to Sovereign. >> Before Sovereign accepts a claim under this policy, you or the life assured must firstly make a claim to the other insurers for any expense recoverable from a third party or under any contract of indemnity or insurance. Any expenses recoverable in this way will be deducted from the reimbursement provided by Sovereign under this policy. For the purposes of this policy, ACC is defined as another insurer.
7 For claims involving ACC
a) It is the life assured’s or the policy owner’s responsibility to submit any accident related claim to ACC in the first instance. b) In respect of any accident related hospital treatment, Sovereign will not pay for MRI or CT scans or other specialised imaging procedures required within seven days of the injury occurring. c) If, due to the policy owner’s or life assured’s failure to comply with ACC’s requirements, ACC refuses to cover the claim or ceases claim cover, the policy owner or life assured will be deemed by Sovereign to not have made a reasonable effort to secure cover and will therefore be ineligible to claim under this benefit. d) If ACC declines cover for private hospital treatment of an accident related condition, Sovereign reserves the right to insist that the policy owner or life assured applies to ACC for a review of that decision before Sovereign accepts any claim. Where ACC reverses a decision for a previously declined claim, Sovereign reserves the right to seek reimbursement from ACC or the policy owner of any related claims paid by Sovereign. e) Sovereign will not be liable for any additional costs where a lead care provider of ACC is used to provide private hospital medical treatment or procedures.
8 How can you amend this benefit?
A) ADDING FAMILY MEMBERS You may apply to Sovereign in writing to extend cover under this benefit at any time to include: >> the spouse, civil or de facto partner of the policy owner; >> any child under the age of 21. Sovereign is not under any obligation to add any additional life assured unless we are satisfied that the life assured is in good health. Children are automatically covered under this benefit for the first three months after being born. For a child’s cover to continue after the first
865 TCB-ST version 3 Effective 25 May 2015
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