800 TC-UMB Version 9 Effective 06 March 2017
TOTALCAREMAX
Contents
What are your policy benefits
1
2
2
Guaranteed Enhancement Benefit
2
2
What are your cover options
3
> Benefit indexation type (applicable to non-health benefits only)
Level cover
>
Inflation cover
>
Voluntary alterations to cover
>
Your premiums.
3
4
Premium
>
Method of paying premiums
>
> What happens if you do not pay the premium on time?
When can the premium change?
>
Premium type
>
Health premiums
>
How will you know what to pay?
>
> Other circumstances that can change your premium
5
How to make a claim
4
When can your policy be cancelled?
4
6
When can you cancel your policy?
>
When can Sovereign cancel your policy?
>
Important Information.
5
7
What forms part of this policy contract?
>
> Law changes affecting Sovereign or the policy
Sovereign Statutory Fund
>
Policy subject to laws of New Zealand
>
Notices
>
Transfer of ownership
>
Information about your policy
>
World wide cover
>
How do you make a complaint?
>
No surrender value
>
8
Key Terms
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> Enhancements will not be passed back to built-in benefit
1. What are your policy benefits?
sections and/or conditions that have subsequently become optional benefits within an appendix or no longer exist.
Your Sovereign TotalCare Max policy can provide financial assistance in the event of death, disability, redundancy, a critical condition or if a life assured incurs specialist or diagnostic testing expenses. Details of the benefits you have chosen and the names of the people insured for the benefits (called the life or lives assured) are shown in the schedule . The terms of your benefits are contained in the relevant appendix . Sovereign will pay all benefits to the policy owner, to the Registered Medical Practitioner ( health benefits only), or to the policy owner’s estate. If more than one person owns the policy then Sovereign will pay all benefits to the policy owners jointly or as they jointly direct, to the Registered Medical Practitioner or facility ( health benefits only) or to the survivor(s) of the policy owners. Your cover starts on the risk commencement date .
For the avoidance of doubt, where the definition of a condition or conditions is enhanced under this benefit, the enhancement will only be applied in respect of that condition or the conditions you are making a claim for. If the nature of the change to a section and/or condition means that it cannot be determined at the time of submitting a claim whether the change will be clearly favourable to you or not, you will need to elect whether or not the change will apply to the claim. After you have made the election, this election cannot be changed.
3. What are your cover options?
Your cover starts on the risk commencement date .
Benefit indexation type (Applicable to non-health benefits only)
Your policy contains options on the type of cover, and premium types and guarantees which are detailed below.
Level cover (specified in the schedule as Level)
If there is any inconsistency between these terms and your appendix , then the appendix will prevail.
The amount of cover under the relevant benefit will remain constant. Inflation cover (specified in the schedule as CPI Linked) The amount of cover under the relevant benefit will increase on each anniversary date , by the same percentage as the percentage increase in the consumer price index for the preceding year ending 30 September. If the consumer price index falls in any year, the inflation-linked benefit amounts will not decrease. You can write to Sovereign if you do not want the amount of cover under the relevant benefits to be increased for a particular year. Voluntary alterations to cover You may apply to Sovereign in writing to increase or reduce the amount of cover for existing benefits, or add other benefits to the policy. Sovereign does not have to accept an application for any increase in existing cover. Any acceptance will depend on a number of factors, including the state of health of the life assured. You may add other benefits so long as the life assured meets Sovereign’s usual requirements for those benefits. Any increase or reduction in cover will start from the next premium due date after Sovereign accepts your application.
2. Guaranteed Enhancement Benefit
If at any time in the future, we make a change to a section and/or condition within a section of our Sovereign TotalCare Max policy and the change is favourable to you , the enhanced section and/or condition will automatically be applied to this policy, subject to the following: > At claim time Sovereign will compare the enhanced section and/or condition in the latest version of Sovereign TotalCare Max with this policy and will apply the section and/or condition that is most favourable to you . Sovereign will not apply changes to sections and/or conditions set out in earlier versions of Sovereign TotalCare Max which are not included in the latest version. > The enhanced section and/or condition will only be applied to this policy if it relates to a benefit for which you have cover under this policy. > The enhanced section and/or condition will be ‘applied’ to this policy with effect from the pass back date . > The enhanced section and/or condition will only apply if the claim event first occurs on or after the pass back date . Eligibility criteria for individual benefits will still apply. > If the claim event first occurred before the pass back date , then the claim will not be assessed or reassessed using the new wording. > Any underwriting exclusions or special terms that apply to this policy will not be altered by any enhanced section and/or condition . > Any associated increase in premium required will be applied when your premiums are next reviewed. > Enhancements to sections and/or conditions that relate to optional benefits within an appendix will not be passed back.
4. Your premiums
Premium
> To ensure your policy remains in force you must pay the premium on a regular basis as agreed with Sovereign.
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> The initial premium is shown in the schedule , the first payment is due to Sovereign on the first premium due date . > The premium comprises the cost of the benefits chosen plus the policy fee if any. > The premium amount may change from time to time (as described below) and you will need to pay the new premium on the agreed regular basis. Sovereign will advise you of the new premium before the change. > The enclosed policy illustration gives details of the likely changes.
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Sovereign’s underlying premium rates at that time.
> Where a premium type of 10 years, to age 65 or to age 80 has been selected and all benefits are Level, your premium has been calculated over the selected period and Sovereign will only change your premiums over the selected period if the underlying premium rates change. If the underlying premium rates change, then at the next anniversary date Sovereign will recalculate the premium to apply for the remainder of the selected period (subject to any further underlying premium rates changes). At the end of the selected period, the premium type will convert to Rate for Age. Notwithstanding the above, for Life Cover, Family Protection and Accidental Death benefits, Sovereign guarantees the underlying premium rates (subject to relevant changes in taxation or legislation). > Where a premium type of 10 years, to age 65 or to age 80 has been selected and the benefits are CPI linked, your premium has been calculated over the selected period and in addition to any underlying premium rate changes (see above) your premium will increase annually in line with any increase in your benefit. The increase in premium will be based on the increase in the sum assured and the current age of the life or lives assured.
Method of paying premiums
You must pay all premiums to Sovereign. Premiums can be paid by direct debit, credit card or debit card. Premium payments are not effective until after they have been credited and cleared to Sovereign’s bank account. What happens if you do not pay the premium on time? You have 30 days’ grace in respect of any premium due. Sovereign will be entitled to cancel your policy by written notice to you at your last known address if a premium remains outstanding 31 days after a premium due date . If you want to have the policy reinstated, you must write to Sovereign. Sovereign does not have to reinstate the policy but may do so on any conditions it considers appropriate. If Sovereign has to pay a non-health benefit under the policy when a premium is overdue, the overdue premium may be deducted from the claim payment. If Sovereign has to pay a health benefit under the policy when a premium is overdue, the overdue premium must be paid before Sovereign makes the health claim payment.
Irrespective of the type of premium you have selected:
> All changes to your premium as described above will take effect from the anniversary date . > Whenever the premium is recalculated, the premium will not be affected by any change in health of a life assured which has occurred since the benefits were first added to the policy. > Premiums will always be based on premium rates adopted by Sovereign for each benefit so that no single client can have his or her premium recalculated in isolation. Any policy fee will normally increase annually in line with the consumer price index . However, if all benefits for all lives assured are Level and the premium type selected is 10 years, to age 65 or to age 80 then the policy fee will also remain unchanged until the end of the selected period. Premium increases will always be applied across a class of business. No increase in premium will apply to your own policy based on your own claim experience.
When can the premium change?
There are a number of circumstances that can change the premium you pay.
Premium type Sovereign calculates the premium for each of your benefits based on the premium type chosen and whether the benefits are Level or CPI linked. Premiums can be structured in the following ways:
Rate for Age;
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10 years; To age 65; To age 80.
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>
Health premiums
>
It is Sovereign’s normal business practice to review premiums for health benefits on a regular basis. This is usually done each year on the anniversary date . Please note that: > Premium increases will always be applied across the policy type. > There will not be an increase in premium for your own policy based on your claim history or experience.
The premium type(s) you have selected are shown in the schedule . How this affects the premium you pay is explained below: > Where Rate for Age has been selected, your premium will be recalculated at each anniversary date based on: - the age of the life or lives assured; - the amount of cover for each benefit (for non- health benefits only); and
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> Premiums for health benefits are related to the life assured’s age, unless otherwise agreed to by Sovereign. > Premiums will increase each year and the premium increase will usually take effect from the anniversary date .
Information that may be required for each different type of benefit is detailed in the benefit appendix. Sovereign will tell you about any other information that may be required once notice of the claim has been received. You must give Sovereign written notice of a claim as soon as practicable but at least within 12 months of the event giving rise to the claim. Sovereign is under no obligation to consider a claim unless all of the information requested is provided. Furthermore, Sovereign is under no obligation to assess or pay a claim prior to receiving notification. Sovereign may also ask any life assured to undergo further medical examinations throughout the life of the claim. Any requests made by Sovereign for further medical information will be at our expense.
Any policy fee will increase each year on the anniversary date in line with the consumer price index .
>
The other circumstances in which your premium will change are as follows: > When you add or remove optional health benefits or adjust the excess. > When you add or delete a life or lives assured to or from this policy.
You will be given at least 30 days’ written notice of such premium increase prior to the increase taking effect.
6. When can your policy be cancelled?
How will you know what to pay?
When can you cancel your policy or individual benefits? If for any reason you are not happy with your policy or individual benefits you may return it to us within 15 days from the date your policy document is received. You will be deemed to have received your policy document three days after postage from Sovereign. Sovereign will promptly refund any premiums paid under your policy provided that no benefit has been paid or any claim has been made. Alternatively changes to your policy or individual benefits may be made and a replacement policy document issued. You can cancel your policy or individual benefits at any time by giving Sovereign notice in writing. If you have elected to pay premiums less frequently than monthly, we will refund any part of a premium already paid for this policy or the cancelled benefits to cover any period of more than one month beyond the date of cancellation (being the date we receive the cancellation notice). Otherwise, we do not have to refund any premiums or part of premiums already paid. You will remain liable to pay any premium due on the policy before Sovereign received the cancellation notice. From (and including) the date Sovereign receives notice of cancellation of your policy, you will not be entitled to any benefits under the policy, unless otherwise agreed in writing by Sovereign. From (and including) the date Sovereign receives notice of cancellation of any individual benefits, you will not be entitled to any of the cancelled benefits under the policy, unless otherwise agreed in writing by Sovereign. When can Sovereign cancel your policy? Sovereign can cancel this policy if the premium has not been paid within 31 days of the premium due date . If Sovereign issues you this policy with the understanding that it is to replace a policy you already have then you must cancel your existing policy. If you fail to cancel your existing policy, Sovereign can cancel this policy or decline liability for any claims made under this policy. A Business Replacement Advice (BRA), application form, illustration or
Each year prior to the anniversary date Sovereign will write to you and tell you how much the premium will need to be to maintain your existing cover. If Sovereign tells you that your non-health benefit premiums need to increase to maintain your existing benefit amounts, you can choose to: > increase the premium to maintain the existing benefit amounts; or > reduce the benefits to the amount which your existing premium will cover.
Other circumstances that can change your premium
The other circumstances in which your premium will change are as follows: > When you add other benefits to the policy or increase or reduce the amount of benefits under the policy. > When you add or delete a life or lives assured to or from this policy. > When you request, and we agree to, a change in premium type. > When a claim is paid and the benefit ceases as a result of the payment being made. > When a benefit ceases due to the life assured covered for that benefit attaining the benefit expiry age as specified in the schedule . > Any changes to the tax treatment of any premium payable or claims receivable in respect of the policy (such as changes to GST).
5. How to make a claim
For any claims enquiries, advice about submitting a claim or before incurring any costs in respect to a claim, please phone the Sovereign Claims Team or your adviser for assistance.
Sovereign Claims Hotline: 0800 500 108
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quote which indicates this policy is intended to replace an existing policy will be sufficient evidence that your policy was issued on the basis that you would cancel the existing policy. Sovereign can cancel this policy and decline liability for any claims made under this policy if you or any life assured, or anyone acting on your or any life assured’s behalf, makes a claim under this policy that is false or fraudulent in any respect. In the event that a false or fraudulent claim is established after payment of a claim, all amounts paid in relation to the false or fraudulent claim must be repaid by you to Sovereign.
Nothing else forms part of this contract.
Law changes effecting Sovereign or the policy If changes in the law occur after the risk commencement date and Sovereign believes on reasonable grounds that those changes will affect:
Sovereign’s liability to pay any tax; or
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> The tax treatment of any premiums payable or claims receivable in respect of the policy (such as GST); or > The way in which the policy works or the amount which can be paid under benefits; then Sovereign can change the provisions of the policy or the benefits, but only to take into account the effect of the law change. Sovereign Statutory Fund Your insurance policy is part of the ‘Sovereign Statutory Fund Number 1’, effective 1 July 2013. This is a requirement under the Insurance (Prudential Supervision) Act 2010, for policy holder protection.
Non-disclosure or the provision of false or misleading information
Any information you or any life assured gives us, and any information given to us on your behalf, must be complete, true and correct.
If you or any life assured:
> fails to disclose material information to Sovereign prior to inception of this policy or any variation or reinstatement of this policy;, or > has made a statement on the faith of which the policy was issued, renewed, varied or reinstated that was substantially incorrect .
Policy subject to laws of New Zealand
The laws of New Zealand govern this policy, which has been issued in New Zealand.
Sovereign may, at its complete discretion either:
Notices
> subject to the Insurance Law Reform Act 1977, avoid your entire policy from its inception (this means the policy is deemed to have never existed); or > avoid from its inception any individual benefits provided by your policy (this means the individual benefit(s) are deemed to have never existed); or > alter the terms upon which cover is provided under your policy (such alteration of terms will be effective from the risk commencement date or such date of our choosing, at our discretion); or > remove from cover any life assured from inception but leave the policy in force for the remaining lives assured. If this policy is avoided or any terms altered or a life assured is removed from cover, we are entitled to retain all premiums paid in relation to the policy or that life assured.
When you write to Sovereign about this policy, you must send the letter to Sovereign’s head office in New Zealand or a substitute address Sovereign gives you .
The postal address of Sovereign’s head office is:
Freepost Sovereign Private Bag Sovereign Victoria Street West Auckland 1142 New Zealand
The street address of Sovereign’s head office is:
Sovereign Assurance Company Limited Sovereign House 74 Taharoto Road Takapuna Auckland 0622 New Zealand
7. Important information
What forms part of this policy contract? All the terms of this policy are contained in and based on: > This policy document including the schedule and any alterations made as permitted under the policy.
If more than one person owns this policy, all the policy owners must sign any letter or notice to Sovereign. However, Sovereign will not be liable to any policy owner if we act on a letter or notice signed by one or more, but not all, of the policy owners. Sovereign is not bound by anything contained in a letter or notice you send unless we actually receive the letter or notice at the relevant address. When Sovereign writes to you about this policy, we will send the letter or notice to the address for the policy owner shown in the schedule , or a substitute address you give us.
The relevant benefit appendix .
>
> Any application forms and declarations made by you and any life/lives assured, at any time, concerning this policy. > All statements which anybody who is insured under this policy has made to Sovereign. > Any provisions which any legislation states must be included in this contract, unless those provisions can be contracted out of, in which case they are not included.
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You must immediately notify Sovereign of any changes to your postal or residential address. Every notice required to be given to you by Sovereign shall be deemed to be delivered three days after having been posted. Transfer of ownership You may transfer the ownership of your policy at any time. To be valid the transfer must be on a transfer of ownership form and registered with us. If ownership of your policy has been transferred, references in this policy document to you , your and the policy owner(s) are references to the most recent transferee(s).
A trust cannot be the owner of this policy. No charge is payable for a transfer of ownership of the policy.
Information about your policy Shortly before each anniversary date , Sovereign will send you a letter containing information about your policy.
You may at any time write to Sovereign or your Sovereign financial adviser for further information about your policy.
World wide cover This policy and benefits cover the lives assured anywhere in the world except for health benefits where cover will only apply while the life assured is in New Zealand. All payments Sovereign makes under this policy will be in New Zealand dollars. How do you make a complaint? Complaints by policy owners to Sovereign must be made in writing. If the policy owner is not satisfied with the outcome of the complaint they may have the right to refer the complaint to the Insurance and Financial Services Ombudsman . The Ombudsman can only deal with a complaint after Sovereign’s internal complaints procedure has been exhausted and a letter acknowledging this has been sent to the complainant.
You can obtain more information about the Ombudsman from the website: www.ifso.nz
The Ombudsman’s address is:
Insurance and Financial Services Ombudsman PO Box 10-845 Wellington 6143 Phone: (04) 499 7612 or 0800 888 202
No surrender value This policy does not participate in the profits of Sovereign. The policy has no surrender value or cash value if it is cancelled.
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8. Key terms
premium
The amount payable by you to Sovereign under this policy, comprising the cost of the benefits chosen by you , plus the policy fee , if any.
In this policy document and optional benefit appendices some words have special meanings:
ACC
The Accident Compensation Corporation of New Zealand.
premium due date
The date on which the premium is payable under the policy, as agreed with Sovereign.
anniversary date
The anniversary in each year of the first premium due date.
Registered Medical Practitioner(s)
A person, acceptable to Sovereign, who is registered and practising as a medical practitioner in New Zealand or Australia, other than:
appendix
The appendix contains the terms of any benefit you have chosen.
You ;
>
The life assured;
claim event
The death, illness, injury, condition , redundancy, or (for health benefits only) specialist consultation or diagnostic tests that you are claiming for under your Sovereign TotalCare Max policy. As defined in the Optional Benefit Appendix for Comprehensive Living Assurance Benefit, Progressive Care Benefit, Essential Living Assurance Benefit and Essential Disability Income Benefit. The consumer price index (all groups) issued by the Government Statistician or any index which may replace that index.
>
A member of the life assured’s family or your immediate family; The life assured’s or your business partner or associate.
>
>
Sovereign reserves the right to accept the advice of a medical practitioner practising outside New Zealand or Australia with qualifications equivalent to New Zealand or Australian standards.
condition(s)
risk commencement date
The commencement date of the benefit, as shown in the schedule .
consumer price index
Sovereign policy / policies
Any policy or policies where Sovereign is the insurer.
health benefit(s)
The Specialist and Diagnostic Testing Benefit.
substantially incorrect
A statement is substantially incorrect only if the difference between what was stated and what is actually correct would have been considered material by a prudent insurer.
material
A statement is material only if that statement would have influenced the judgment of a prudent insurer in fixing the premium or in determining whether he/she would have taken or continued the risk upon substantially the same terms.
the schedule
The most recent schedule for your policy and:
any notice of a change to premiums ; and any policy alteration or endorsement documents recording a change to your policy.
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non-health benefit(s)
Any benefit shown on the schedule , excluding the health benefits .
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pass back date
The date that the relevant change to Sovereign’s TotalCare Max policy comes into effect, as determined by Sovereign.
transfer of ownership form
Sovereign’s standard form for an assignment of a policy by way of ordinary transfer.
policy fee
The administration fee charged by Sovereign as detailed in the policy illustration.
you/your
The 'Policy Owner' named in the schedule.
The Sovereign TotalCare Max illustration enclosed with this policy document.
policy illustration
policy year
The period from the risk commencement date to (but
excluding) the first anniversary date , or from an anniversary date to (but excluding) the next anniversary date .
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