P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
PERSONAL ACCIDENT & SICKNESS POLICY (INDIVIDUAL)
Version: PAI 06.10
(THIS IS AN IMPORTANT DOCUMENT WHICH YOU SHOULD READ CAREFULLY AND KEEP IN A SAFE PLACE)
This Policy provides cover for disablement caused by injury only or by injury and sickness and benefits are payable in accordance to the circumstances set out in this policy and the policy schedule.
In accordance with the provisions of the Insurance (Agents and Brokers) Act 1984, WINSURE Insurance Group Pty Ltd (WINSURE) gives notice that this contract has been effected under an Authority given to WINSURE by The Company. WINSURE has entered into the Contract as an agent of The Company and not an agent of the Insured.
If you are not entirely satisfied with this policy you may cancel it by returning it to us within fourteen (14) days of the date of receipt of your policy in accordance to the conditions of the “cooling off period” (8)
1. DEFINITIONS
For the purposes of this Policy the following important definitions apply:
“The Company” means certain Underwriters at Lloyds. You or your representative can obtain further details of the Underwriters numbers and the proportions upon request.
“Excess/Waiting Deferred Period" means the period of consecutive days stated in the Schedule during which no benefits are payable for Temporary Total or Temporary Partial Disablement of an Insured.
“Underwriter/Our, Us, We," means WINSURE Insurance Group Pty Ltd on behalf of various Underwriters at Lloyds.
"You, Your," means the Principal /Employers as applicable named in the Schedule.
"Accident" means a sudden, unexpected, unusual, specific event which occurs at an identifiable time and place.
"Commencement Date" means the date specified in the Schedule as the Commencement Date and the date specified in the Member Certificate with respect to each Insured.
"Earnings" are specified in the Benefit Certificate as either (a) or (b) and are defined as IF YOU ARE NOT AN EMPLOYEE
(a) the Insured's gross weekly rate of remuneration from the duties declared to Us on the Application form or,
IF YOU ARE AN EMPLOYEE
(b) the Insured's gross weekly rate of remuneration from personal exertion and declared to Us but exclusive of bonuses, commission, overtime payments special allowances and payments of a similar or irregular nature.
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
Earnings will be averaged over the prior period of twelve (12) months (excluding annual leave taken with respect to Definition (a) above) from the date that any benefit becomes payable or over such lesser period as the Insured may have been engaged/employed.
"Injury" means bodily injury resulting from an Accident to the Insured during the Period of Insurance and results in an Insured event within twelve (12) calendar months from the date thereof but does not include any consequence of an injury which are ordinarily described as being a disease.
"Insured" means such persons who are eligible to become an Insured person or as You shall have nominated from time to time for membership and We have accepted as an Insured
“Illness/Sickness" means illness or disease first manifesting itself during the Period of Insurance and results in Temporary Disablement within twelve (12) calendar months from the date thereof and must continue for a period of not less than seven (7) consecutive days from the date you first sought treatment for the sickness from a qualified medical practitioner.
“Loss of use” means loss by physical severance or total and permanent loss of the effective use of the part of the body referred to in the Schedule of Compensation.
“Loss of Limb or Limbs” means loss by permanent physical separation of a hand or hands at or above the wrist or of a foot or feet at or above the ankle or total and irrecoverable Loss of Use of a hand or hands or foot or feet.
"Period of Insurance" means the Period stated in the Schedule or such other period specified in the Member Certificate for an Insured who joins the Policy during the current Period of Insurance.
"Temporary Total Disablement" means disablement which entirely prevents the Insured by reason of Injury or Sickness from engaging in an occupation for which the Insured is suitably qualified by training education or experience.
"Temporary Partial Disablement" means disablement which prevents the Insured from carrying out a substantial part of the duties in an occupation for which the Insured is suitably qualified by training, education or experience.
"Permanent Total Disablement" means disablement resulting from an Injury and which has lasted for at least twelve (12) calendar months from the date of such Injury and which thereafter is beyond hope of improvement and which entirely prevents the Insured Person from carrying our any occupation for which the Insured Person is reasonably qualified by education training or experience.
2. CONSIDERATION
(i) A grace period of thirty (30) days will be granted for the payment of each premium or instalment of premium falling due, and after payment of the first premium and during such grace period the Policy shall remain in force.
(ii) An Insured's cover under this Policy shall cease immediately upon:
(a) the attainment of age sixty seven(67), but in respect in attaining of age sixty five (65) in respect to “Accident” benefits only with a Waiting Perod of 28 days.
(b) discontinuing service with the Principal /Employer as applicable named in the Policy Schedule.
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
3. ADDITIONAL BENEFITS DISAPPEARANCE
If after a reasonable time has elapsed of not less than one (1) year and having examined all evidence available We shall have no reason to suppose other than an accident has occurred, the disappearance of an Insured shall be considered to constitute a claim under the Policy. It is understood and agreed that if at any time after payment has been made by Us in settlement of the claim the Insured is found to be living any sums paid by Us in settlement of the claim shall be refunded to Us.
EXPOSURE
If as a result of an Injury occurring during the Period of Insurance you are exposed to the elements and suffer from any of the Insured Events set out in the Table of Benefits as a direct result of that exposure, we will pay compensations accordingly.
4. BENEFITS PAYMENTS
(i) No benefit is payable unless the Insured seeks medical advice and undertakes treatment from a registered medical practitioner and continues to do so whilst remaining Totally or Partially Disabled
(ii) Written notice of claim must be given to Us within thirty (30) days after the occurrence of any circumstance giving rise to a claim or as soon thereafter as is reasonably possible.
(iii) No Benefit shall be payable unless We are furnished with such evidence as We require with respect to the Insured's age, state of health and circumstances in which the Temporary Total or Temporary Partial Disablement arose. We must be furnished at the Insured’s expense such certificates as We may require signed by the Insured’s medical practitioner
(iv) At Our own expense We may require the Insured to be medically examined by a medical practitioner or other practitioner nominated by Us.
(v) The Benefit Period of an Insured will commence from the first date of treatment by a qualified medical practitioner.
(vi) Weekly Benefits shall be payable to the Insured fourteen (14) days in arrears and will be calculated from the end of the Waiting Period at one-seventh (1/7th) of the Weekly Benefit for each day of Temporary Total or Partial Disablement.
(vii) Where Benefits have been paid in respect of an Insured and Temporary Total or Temporary Partial Disablement recurs from the same or related cause or causes within six (6) months of the cessation of payments, the recurring Temporary Total or Temporary Partial Disability will be deemed to be a continuation of the previous Temporary Total or Temporary Partial Disability for the purposes of determining the Benefit Period and no Waiting Period shall apply.
5. BENEFIT LIMITATIONS
(i) The Weekly Benefit for Temporary Total or Temporary Partial Disablement of an Insured shall be reduced by:
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
(a) any earnings, salary, wage or other payment receivable from any employer or principal:
(b) the amount of any worker's compensation payment or any other statutory benefits which the Insured receives or is entitled to receive;
(c) Amounts to the value of income an Insured receives or is due to receive as a consequence of letting out, hiring or sub contracting the business and/or plant and equipment of the business.
(d) Any entitlement under any policy of insurance, cover for which includes contingencies relating to any form of disability, permanent and total or partial disablement, injury, accident, sickness or absence from work rendering the Insured unable to carry out duties normally undertaken in connection with an Insured's usual occupation or business;
(ii) No Weekly Benefit shall be payable during the Waiting Period.
(iii) Any Capital Benefit payable under this Policy shall be reduced by the amount of any other Capital or Weekly Benefit we have paid in connection with the same injury.
(iv) Benefits shall cease upon the earliest of
(a) the expiration of the Benefit Period referred to in the Schedule; (b) the death of an Insured;
6. EXCLUSIONS
No Benefits are payable under this Policy for any conditions resulting from the Injury or Sickness of an Insured which:
(i) is deliberately self-inflicted or intentionally caused by the Insured.
(ii) occurs, caused by, resulting from or in connection with any war, hostilities or warlike operations (whether war be declared or not), invasion, act of any enemy foreign to the nationality of the Insured person or the country in, or over, which the act occurs, civil war, riot, rebellion, insurrection, revolution, overthrow of the legally constituted Government, civil commotion assuming the proportions of, or amounting to an uprising, military or usurped power, explosions of war weapons, release of weapons of mass destruction that do not involve an explosive sequence, murder or assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured person whether war be declared with that State or not and/or terrorist activity . For the purpose of this exclusion an act of terrorism means an act, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), which from its nature or context is done for, or in connection with political, religious, ideological, ethnic or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
This exclusion also excludes any loss of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to any act of terrorism.
(iii) results from engaging in or taking part in or training for professional sports of any kind, an occupation other sports and/or pastimes or activity of a hazardous nature not declared to the Underwriter.
(iv) is attributable wholly or partly to childbirth or pregnancy or the complications of these.
(v) is attributable wholly or partly to AIDS or the HIV virus in any of their forms and any disease or injury associated with them.
(vi) results from any aerial activity unless as a passenger in a properly licensed aircraft.
(vii) For any loss that occurs as a result of ionising radiation’s or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel, the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof.
(viii) results directly or indirectly from neurosis, psychoneurosis, psychosis, mental, emotional, depression, stress or anxiety condition, disease or disorder.
(ix) arises from the consumption of alcohol by the Insured or the taking of drugs or narcotics otherwise than under the direction of a registered medical practitioner provided that such direction is not given due to treatment of the insured person for drug addiction or dependence.
(x) is attributable to any pre-existing sickness or injury for which an Insured has received treatment, advice or taken prescribed medicines or drugs in the period specified in the Policy Schedule before commencement of the insurance.
7. GENERAL CONDITIONS
(i) Alterations to the terms, clauses and/or conditions of this policy are not valid unless agreed by Us in writing.
(ii) This Policy is issued on the basis of the information disclosed by You to Us in the application form. (iii) Enquiry/Dispute Resolution:-
Underwriters at Lloyd’s proudly support the General Insurance Code of Practise. The purpose of the Code is to raise standards and service in the general insurance industry. Any enquiry or complaint relating to this insurance should be referred to the Coverholder shown in the first instance. If this does not resolve the matter or you are not satisfied with the way a complaint has been dealt with, you should write to:-
Lloyd’s Underwriters’ General Representative in Australia Suite 2, Level 21, Angel Place
123, Pitt Street, SYDNEY, NSW 2000 Telephone Number:- (02) 9223 1433
If your claims dispute remains unresolved you will be referred to the Financial Ombudsman Service under the terms of the General Insurance Code of Practice. For other disputes you will be referred
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
to other proceedings for resolution. Details are available from Lloyd’s Underwriters General Representative in Australia at the address above.
(iv) The Underwriters hereon agree that:-
(i) In the event of a dispute arising under this Policy, Underwriters at the request of the Insured (or reinsured) will submit to the jurisdiction of any competent Court in the Commonwealth of Australia. Such dispute shall be determined in accordance with the law and practise applicable in such Court.
(ii) Any summons notice or process to be served upon the Underwriters may be served upon:
Lloyd’s Australia Ltd ABN 49 080 862 291 Suite 2, Level 21, Angel Place 123, Pitt Street, SYDNEY, NSW 2000
who has authority to accept service and to enter an appearance on Underwriters’ behalf, and who is directed at the request of the Insured (or reinsured) to give a written undertaking to the Insured (or reinsured) that he will enter an appearance on Underwriters’ behalf.
(iii) If a suit is instituted against any one of the Underwriters all Underwriters herein will abide by the final decision of such Court or any competent Appellate Court
In the event of a claim arising under this insurance IMMEDIATE NOTICE should be given to the Coverholder:-
MECON Winsure Insurance Group Pty Ltd P O Box R1789
Royal Exchange NSW 1225 PH: 02 9252 1040 Fax: 02 9252 1050
(v) The Policy Certificate is issued by the Coverholder shown above in accordance with the authority granted to them by Certain Underwriters at Lloyds under the Agreement referred to in the
schedule.
(vi) The subscribing Insurers’ obligations under Contracts of insurance to which they subscribe are several and not joint and are limited solely to the extent of their individual subscriptions. The subscribing insurers are not responsible for the subscription of any co-subscribing insurer who for any reason does not satisfy all or part of its obligation.
(vii) This Policy may be cancelled by You at any time by giving us written notice. We shall retain a portion of the premium calculated at our usual short-term rates for the time the Policy has been in force. We may cancel this Policy at any time if You have been in breach of any of its conditions or for any other reason available to us at law. Upon cancellation by Us, We shall refund a proportion of the premium paid calculated by reference to the unexpired period of insurance.
(viii) We must be immediately notified of a change in occupation of an Insured from the occupation declared in the Application. If the Insured person engages in any occupation in which greater risk may be incurred than in the occupation disclosed in the proposal form without first notifying Us
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
and obtaining Our written agreement to the amendment of the Insurance (subject to the payment of such additional premium as We may reasonably require), then no claim will be payable in respect of any Accident arising out of or in the course of such other occupation.
(ix) In the event of a claim the Insured Person will be required to show proof of income and payment of any weekly benefit will not commence until adequate proof of income has been supplied to Us.
8. COOLING – OFF INFORMATION
You have a cooling off period. During the cooling-off period, you may return your insurance contract to your Broker or Financial Service Provider and obtain a refund.
You may do this by notifying your Brokers or Financial Service Provider in writing or electronically. You may only exercise this right during the period of fourteen (14) days starting on the earlier of:
the time you received confirmation of the insurance transaction:
OR the end of the 5th day after the day on which this insurance contract was issued to you. You can not exercise your right at any time after:
you have exercised a right or power under your insurance contract (e.g. you have made a claim): OR
your rights or powers under your insurance contract have ended.
If your insurance contract is for an event that will start and finish within the 14 day cooling-off period, you can only exercise your right before the event starts or the expiry of the cooling-off period, whichever is the earlier.
If you exercise your right to return this insurance contract then it is cancelled with effect from that time.
Your Broker or Financial Service Provider will give you a pro-rata refund. Your Broker or Financial Service Provider may deduct from your refund:
any tax or duty which we have been paid and which is not refundable: AND
any reasonable administrative and transaction costs. 9. OUR PRIVACY PROMISE
New privacy legislation took effect from 21st December 2001. The legislation will regulate the way private sector organisations can collect, use, keep secure and disclose personal information. WINSURE has developed a privacy policy which explains what sort of personal information we hold about you and what we do with that information. A copy of the brochure may be obtained from WINSURE office or from our Website at www.winsure.com.au
IN WITNESS WHEREOF THIS POLICY IS SIGNED BY THE DULY AUTHORISED OFFICER OF WINSURE INSURANCE GROUP PTY LTD:
Matthew Boon Managing Director
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
BENEFIT SCHEDULE
For Fishing Industry – (Continental Scale)
The compensation for such events shall be payable as a percentage of the Capital Sum Insured specified in the Schedule.
THE EVENT – as a result of an injury CAPITAL BENEFIT
1. Death 100%
2. Permanent Total Disablement which results in an Insured being unable to engage in any occupation For which the Insured is reasonably qualified by
Education, training or experience. 100%
3. Permanent and incurrable paralysis of all limbs 100% 4. (a) Permanent total loss of sight of both eyes 100% (b) Permanent total loss of sight of one eye 100% 5. (a) Permanent total loss of use of two limbs 100% (b) Permanent total loss of use of one limb 100%
6. Permanent & incurrable insanity 100%
7. Permanent total loss of hearing in:
(a) both ears 100%
(b) one ear 20%
8 Permanent total loss of the lens of one eye 60% 9. Permanent total loss of use of four fingers & thumb of
Either hand 70%
10. Permanent total loss of use of four fingers of either hand 40% 11. Permanent total loss of use of either thumb
(a) both joints 30%
(b) one joint 15%
12. Permanent total loss of use of fingers of either hand
(a) three joints 10%
(b) two joints 8%
(c) one joint 5%
13 Permanent total loss of use of toes of either foot
(a) all- one foot 15%
(b) great – both joints 5%
(c) great – one joint 3%
(d) other than great, each toe 1%
14. Fractured leg or patella with established non-union 10%
15. Shortening of leg by at least 5cm 20%
16. Thrid degree burns to 40% of the entire body 50% 17 Permanent disability not otherwise provided for under
Events 3 & 15 inclusive The percentage as We will, in Our Absolute discretion, determine & being in Our opinion not inconsistent with the Compensation provided for other Capital Benefits.
WEEKLY BENEFITS AS A RESULT OF AN INJURY
18. Weekly benefits so long as such } Temporary Schedule weekly benefit or 85%
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
Disablement continues but not exceeding } Total of gross Earnings whichever is the 104 weeks for any single disablement. } Disablement lesser.
Per week
19 Temporary Partial up to 40% of the amount payable for Disablement Temporary Total Disablement Per week
WEEKLY BENEFIT AS A RESULT OF A SICKNESS
20 Permanent total loss of sight of both eyes or Permanent paralysis of any 2 limbs by disease
(other than general paralysis of the insane) 100%
21 Weekly benefit so long as such disablement } Temporary Schedule weekly benefit or 85% Continues but not exceeding } Total of gross Earnings whichever
104 weeks for any single disablement } Disablement is the lesser. Per week
22 Temporary Partial No compensation is payable
Disablement for Temporary Partial per week Disablement resulting from
Illness
Note:- Loss of Limb or Limbs means:- loss by permanent physical separation of a hand or hands at or above the wrist or of a foot or feet at or above the ankle or total and irrecoverable loss of use of a hand or hands or foot or feet. Loss of Use means: loss by permanent physical severance or permanent loss of the effective use of the part of the body referred to in the Schedule of Compensation.
AGGREGATE LIMIT is $2,000,000. The benefits payable to each individual insured person are limited to the amount shown in the schedule but, in addition, the maximum amount which will be paid for all claims in any one period of insurance is $2,000,000. If this amount is insufficient to pay all claims in full, then we will reduce proportionally the compensation payable to each insured person.
ENDORSEMENT:- It is noted that weekly benefits shall not exceed 52 weeks for an Insured person over 66 years of age, accident benefits and no cover is applicable for illness benefits, when selected, for persons 65 years of age or older.
:- TERRITORIAL LIMIT – WORLD WIDE
:- In respect to earned income that varies within strictly defined seasonal periods such income will be regarded as earned annually (52 weeks).
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
BENEFIT SCHEDULE
For all Industries Excluding the Fishing Industry (Please refer to separate benefit schedule)
The Compensation for such events shall be payable as a percentage of the Capital Sum Insured specified in the Schedule.
THE EVENT – as a result of an injury CAPITAL BENEFIT
1. Death 100%
2. Permanent Total Disablement which results In an Insured being unable to engage in any Occupation for which the Insured is reasonably
Qualified by education, training or experience. 100%
3. Permanent Quadriplegia 100%
4. Permanent Paraplegia 100%
5. Permanent and incurable paralysis of all limbs 100% 6. Permanent total loss of sight to one or both eyes 100% 7. Permanent total loss of hearing in both ears 100%
8. Permanent total loss of the lens of one eye 70%
9. Permanent total loss of hearing in one ear 50%
10. Loss of or loss of use of both hands 100%
11. Loss of or loss of use of both arms 100%
12. Loss of or loss of use of both feet 100%
13. Loss of or loss of use of both legs 100%
14. Loss of or loss of use of one hand and one foot 100% 15. Loss of or loss of use of one hand and one arm 100% 16. Loss of or loss of use of one foot or one leg 100% WEEKLY BENEFITS AS A RESULT OF AN INJURY
17 Weekly benefits so long as such } Temporary Schedule weekly benefit or 85% Disablement continues but not } Total of gross Earnings, whichever is Exceeding 104 weeks for any } Disablement the lesser.
Single disablement } Per week
18 Temporary Partial up to 40% of the amount payable
Disablement for Temporary Total Disablement. Per week
WEEKLY BENEFIT AS A RESULT OF SICKNESS
19 Permanent Total loss of sight of both eyes or } Schedule weekly benefits or 85% Permanent paralysis of any 2 limbs by disease } of gross earnings whichever if the (other than general paralysis of the Insane) } lesser.
20 Weekly benefits so long as such disablement } Continues but not exceeding 104 weeks for } Any single disablement and excluding the 1st }
14 days of disablement. }
21 Temporary Partial up to 40% of the amount payable for
Disablement Temporary Total Disablement. Per week
P O Box R1789 ABN: 29 059 310 904
Royal Exchange, NSW 1225 AFS Lic No: 253106
Ph: 02 9252 1040 ACN: 059 310 904
ENDORSEMENT:- It is noted that weekly benefits shall not exceed 52 weeks for an Insured person over 66 years of age
For consideration for adding to policy section “Additional Benefits”
These Benefits are only applicable when you have applied for and we have confirmed in writing and you have paid the additional premium applicable.
ADDITIONAL BENEFITS MODIFICATION
Where a Capital Benefit is payable under conditions 2 to 5 inclusive of the Benefit Schedule , We will also pay for the cost necessarily incurred by You and agreed by Us in modifying Your motor vehicle or home or in relocating You to a suitable home, up to a maximum sum in all of $10,000.
REHABILITATION
If You are paid a Weekly Benefit We will also pay for the costs incurred by You for Your participation in a return to work program if We consider them reasonable, and Your medical practitioner agrees, up to a maximum of
$5,000.
Rehabilitation costs are costs you incur to improve Your ability to live, or assist You in living, as normal a life as possible. For example, they could include special equipment, or modification of Your home or car. However, rehabilitation costs do not include expenses incurred by You for excluded health services and excluded benefits.
EXCLUDED HEALTH BENEFITS
Excluded health services are expenses for surgical, diagnostic, nursing, dental, chiropody, chiropractic, eye therapy, occupational therapy, physiotherapy, speech therapy or similar medical services or treatment. EXCLUDED BENEFITS
Excluded benefits are services involving the supply, alteration, maintenance or repair of hearing aids, spectacles, contact lenses, artificial teeth, artificial eyes or limbs or other medical or surgical prosthetic or dental aids, equipment or appliances, drugs or medical preparations, ambulance services and other care services.
Additional Benefits for Voluntary Workers (When Insured and shown on the Certificate Schedule)
Capital Benefit limited to be limited to a maximum of $20,000 Fulltime Student Tutorial Costs limited to $500
Funeral expenses incurred due to death whilst undertaking insured voluntary work $5,000
