0861 000 672


The Main member + 4 x dependent (M+4) will have Private Hospital Cover and Medical Expenses up to R100,000

per member per annum

Private Hospital Cover & Medical Expenses

Medical Expenses


R100,000 accidental medical expense cover

R25,000 life support equipment cover in hospital

R1,000 per day for 90 days hospitalisation benefit

R50,000 relocation cost cover (repatriation)



Remaining benefits applicable on the cover:

R100,000 accidental death cover

R100,000 accidental disability cover

R15,000 additional accidental death cover (final expense cover)

R60,000 per annum cover for childcare

R25,000 claims preparation cost cover (legal assistance)

5% of death and disability cover if the event is as a result of a crime

Death benefit becomes payable in the event of disappearance

In the event of disfigurement disability benefit becomes payable

R20,000 family medical expenses if travel with the insured

R100,000 mobility cost cover

R100,000 rehabilitation cost cover

Seat Belt benefit – 10% of death and disability cover

Terrorism – covered under this policy

Trauma Counselling R10,000 per event


OPERATIVE CLAUSE

If during the period of insurance an Insured Person sustains bodily injury as the result of an accident which directly and independently of any other cause results, within 24 calendar months, in Death, Disability or the incurring of Medical Expenses the Insurers will pay to the Insured or his legal personal representatives the Compensation stated in the Schedule up to the maximum limits of liability therein.

DEFINITIONS

The following words or phrases shall bear the meaning stated below:

"Annual Earnings" means the annual rate of wage, salary and cost of living allowance being paid or allowed by the Insured to such Insured Person at the time of accidental bodily injury, plus overtime, house rents, food allowances, commissions and other considerations of a constant character paid or allowed by the Insured to such Insured Person during the 12 months preceding the date of accidental bodily injury.

"Average Weekly Earnings" shall mean one fifty second part of the annual earnings of the Insured Person. In respect of casual workers with less than twelve consecutive months’ service with the Insured, prior to the date of loss, the one fifty second part shall be calculated by applying the total of all earnings received from the Insured divided by the total number of consecutive weeks’ service.

"Accident" means a fortuitous unexpected event occurring at an identifiable place and time.

"Bodily Injury" means traumatic bodily injury caused by an accident and shall be deemed to include bodily injury caused by starvation, thirst and exposure to the elements as a result of an accidental occurrence.

"Loss" used in reference to limb, hand, thumb, fingers, foot or toes means the loss by physical severance or total and permanent loss of use of such member.

"Permanent Total Disability" means bodily injury resulting in total and absolute disability preventing the Insured Person from following his/her usual occupation, or any other occupation for which he or she is suited by education or training, for 24 consecutive months and which, at the expiry of that period, is beyond hope of improvement.

"Permanent Partial Disability" means bodily injury which causes a permanent disability but not causing inability to work

"Temporary Total Disability" means bodily injury temporarily and totally preventing the Insured Person from engaging in or giving attention to his or her usual occupation.

"Medical Expenses" means expenses necessarily incurred within 24 months of the date of the accident for medical, surgical, dental, ophthalmic and hospital treatment and emergency travel costs reasonably and necessarily incurred.


PROVIS

1. Compensation shall only be payable under one of the items 1 and 2 of the Table of Benefits

2. Compensation for Temporary Total Disability and/or Medical Expenses shall be paid in addition to any Compensation paid or payable under Items 1 or 2 of the Table of Benefits.

3. The Compensation specified for Temporary Total Disability shall cease as soon as the Bodily Injury causing the incapacity has healed insofar as it is reasonably possible notwithstanding that Permanent Disability may remain but shall in any event not be payable for more than the number of weeks stated in the Schedule to this Policy.

4. Any Compensation payable by the Insurers for any period of Temporary Total Disability or for the reimbursement of Medical Expenses shall be reduced by an amount equal to the Compensation received or receivable by or on behalf of the Insured Person under the terms of the Compensation for Occupational Injuries and Diseases Act, 1993 for Temporary Disability (partial or total) for the same or a lesser period and/or in respect of Medical Expenses.

5. Any compensation payable by the Insurers for any period of Temporary Disability (partial or total) shall not exceed the average weekly earnings earned by the Insured Person at the time of the accident.

6. Where amounts recoverable from the Insurers are delayed pending finalisation of any claim, payments on account can be made to the Insured, at the Insurers' discretion, on receipt by the Insurers of certification by a medical doctor appointed by the Insurers.

7. Upon payment of a claim under Items 1 to 2.4 (other than 2.2.1) or of 100% under Item 3 of the Schedule of Permanent Disability this policy shall be terminated in respect of the Insured Person for whom such payment is made.




SCHEDULE OF PERMANENT DISABILITY

The following percentages shall be payable in the event of Bodily Injury resulting in:

1. Permanent Total Disability        100%

2. Permanent and total loss of:

2.1 speech          100%

2.2 hearing in both ears        100%

2.2.1 hearing in one ear       35%

2.3 one or more limbs at or above the wrist or ankle    100%

2.4 sight in one or both eyes         100%

2.5 four fingers of either hand       75%

2.6 thumb, either hand - both phalanges      30%

one phalanx          15%

2.7 index finger, either hand

three phalanges         15%

two phalanges         10%

one phalanx          5%

2.8 any other finger, either hand

three phalanges         8%

two phalanges         5%

one phalanx          2%

2.9 toes

all on one foot         35%

great, both phalanges        15%

great, one phalanx         5%

other than great, if more than one toe lost - each     5%

3. Permanent Disability not specified herein a percentage which in the opinion of the Insurers is consistent with the above insofar as possible.

In the event of Compensation being due under more than one of the benefits referred to above as a consequence of any one accident to any one Insured Person the maximum amount payable hereunder shall not exceed 100% in total under the Schedule of Permanent Disability Benefits.



EXTENSIONS

Subject to an Insured Person suffering accidental bodily injury which is the subject of a valid claim hereunder the following extensions are applicable:

Additional Death Benefit

The insurer will in addition to the accidental Death benefit and the production of a valid Death certificate of an insured Person pay the insured an amount of R15 000 per insured Person.

Childcare

In the event of accidental bodily injury to:

1. an Insured Person’s child resulting in disability which requires regular care and attendance;

2. an Insured Person or his spouse resulting in disability which prevents care being given to a child then the Insurers will pay to the Insured Person R150 per day during the period of such disability, provided that Insurers will:

3.   not be liable for the first seven days of each and every claim;

4.    only be liable for a period not longer than 28 days in respect of each and every claim;

5.   only be liable for a maximum of R7,500 in respect of any Insured Person in any one 12 month period of insurance, irrespective of the number of children the Insured Person has;

5.   only be liable for a maximum of R60,000 per Policy in any 12 month period of insurance;

6.   not be liable for any claim in respect of a child who is more than 16 years of age;

7. only be liable if continuous treatment and attendance by a qualified, registered medical practitioner is necessary for the condition rendering the child or parent(s) disabled;

8.  only be liable if the child is permanently resident with the Insured Person.


Claims Preparation Costs

This Policy is extended to include costs reasonably incurred by the Insured in producing and certifying any particulars or details required by the Insurers to substantiate a claim, provided that the liability of the Insurers for such costs in respect of any one claim shall not exceed R25,000 (Twenty five thousand rand).

Crime benefit

In the event that the insured Person’s Death or Permanent Disability is as a direct consequence of a crime, the insures will pay an additional 5% of the Insured Person’s Death or Permanent Disability Benefit up to a maximum amount of R25 000.

Disappearance

If after a suitable period of time of the disappearance of an Insured Person it is reasonable to believe that such person has died as a result of bodily injury the Death benefit shall be payable provided that if such belief is incorrect such benefit shall be repaid to the Insurers.

Disfigurement

The Schedule of Permanent Disability Benefits is hereby extended to include Bodily Injury resulting in permanent disfigurement of:

 The head, neck and hands - provided the total area affected exceeds 20% of the total area

 All other areas of the Body - provided the total area affected exceeds 5% of the total area of the Body. Compensation payable hereunder is a percentage of the compensation in direct proportion to the area affected. The benefits payable in terms of i) and ii) above shall apply independently and be cumulative, but the overall liability of the Insurers for permanent disfigurement resulting from an accident or series of accidents arising from one cause for any one Insured Person shall be limited to 50% (Fifty per cent) of the amount payable for Permanent Total Disability in respect of i) above. Compensation shall not be payable under this extension in addition to compensation payable for the same bodily injury under the Schedule of Permanent Disability Benefits and shall be limited to 100% of the compensation provided for Permanent Total Disability.



Hospitalization

In the event of an insured being hospitalised as in in-patient in an Hospital as a result of Accidental Body injury the insured will pay R1,000 per day up to a maximum of 90 days per insured Person per policy. The insurers will not indemnify the insured against

1. Treatment of an insured for any nervous or mental conditions whatever the classification.

2. Pregnancy or childbirth or any complications that may arise thereof

3. Rest or recovery periods in retirement homes, convalescence homes or detoxification or alcohol rehabilitation centres

4. Voluntary procedures of any nature

5. The first 24 hours in any covered medical facility



Family Medical Expenses

In the event of accidental bodily injury to any spouse, dependent child or domestic servant of an Insured Person (referred to in this extension as such person) as a result of a motor vehicle accident while such person is travelling with the Insured Person in any private motor vehicle owned, leased or hired by the Insured Person, Insurers will pay any consequent medical expenses incurred by such person, provided that:

1. The maximum amount payable by Insurers will be R20,000 any one such person each and every claim,  and subject to a maximum of R100,000 in any one 12 month period of insurance;

2. The Insurers will not be liable for the first R250 of each and every claim;

3. The Insurers will only be liable for the amounts in excess of amounts paid or payable under any other policy of insurance or under any Medical Aid Scheme, or Road Accident Fund or otherwise known, or as may be amended by legislation;

4. If the Business Hours Limitation is applicable, this extension does not apply.




Life Support Equipment

The Insurers will, pay reasonable costs and expenses incurred as a result of accidental Bodily Injury in respect of hire costs for life support machinery, equipment or apparatus provided that the liability of the Insurers under this Extension in respect of any one Insured Person shall be limited to R25,000 (Twenty five thousand rand).



Mobility Costs

When Insurers have admitted a claim for Permanent Disability, if as a direct result of that disability the Insured Person is permanently dependent on a wheelchair for mobility, the Insurers will, in addition to any amount payable for Permanent Disability, pay for:

1. a self-propelled wheelchair;

2. the fitting of wheelchair loading equipment and alterations to the Insured Person’s residence to facilitate the use of such wheelchair;

3. the modification of the controls of the Insured Person’s motor vehicle


Provided that the liability of the Insurers for such costs in respect of any one claim shall not exceed R100, 000 (one hundred thousand rand).

Per insured person.

Relocation Costs

In the event that it is necessary to replace as employee a deceased or permanently disabled Insured Person the Insurers will indemnify the Insured for the following costs not exceeding R50,000 incurred by the Insured in relation to any one Person who is required to move more than 100 km:

1. Relocation costs for such person, his family, furniture and pets; and

2. 75% (seventy five percent) of the actual loss caused following the forced sale of such person’s private dwelling subject to such loss being determined by an impartial valuer appointed and paid by the Insurers.


Rehabilitation Costs

In the event that the Insured demonstrates, to the reasonable satisfaction of the Insurers, that an Insured Person has suffered Permanent Disability such that he/she cannot continue to be employed in the occupation in which he or she was employed at the time of the accident but may be retrained by the Insured, or by any registered training centre, the Insurers will contribute 80% (Eighty per cent) of such retraining costs up to a maximum liability of R100,000 (One hundred thousand rand) per person.



Seat Belt Benefit

The Insurers will pay an additional 10% of the Insured Person’s Death or Permanent Disability benefit, up to a maximum amount of R50, 000 (fifty thousand Rand), provided that the Insured Person was wearing a properly factory installed seat belt while operating or travelling as a passenger in a private motor vehicle when the Accident causing the Death or Total Disability occurs.


Verification of the actual use of the seat belt at the time of the accident must be a part of an official report of the accident or must be certified in writing by the investigating officer(s).



Terrorism

This policy is extended to cover Accidental Death or Disability of an Insured Person arising from acts of "terrorism" as defined in the Defence Act 1957 or as amended; provided that Insurers shall not be liable to pay compensation for Death or Disablement arising from:

1. The performance by such person of obligations in terms of the Defence Act or the Police Services Act of any country or at a place from which military or police actions are carried out, or

2. Consequent upon such person's engagement in any military or police actions against an enemy of the republic, combating "terrorism" as defined in the Defence Act or "operations in defence of the Republic” as defined in the Defence Act, 1957.




TRAUMA COUNSELLING

In the event of an Insured Person being subjected to an act of violence or a traumatic accident, the Insurers will reimburse such person for counselling fees actually incurred by such person as a result of the act of violence or traumatic accident, provided that:

1. the maximum amount payable by Insurers will be R500 per visit and R10,000 per annum for each Insured Person; and R100.000 in any one 12 month period of insurance;

2. act of violence shall mean an assault, robbery, rape or armed car hijack,

3. for the purpose of this extension only, Insured Person shall include immediate family members of such Insured Person, who are subjected to the same incident or occurrence of violence or traumatic accident as the Insured Person;

4. the act of violence has been reported to the police and a case number obtained.




TERRITORIAL LIMITS

Coverage applies anywhere in the World unless otherwise restricted by an endorsement and/or memorandum to this Policy.


OPERATING TIME

Coverage applies 24 hours a day, 7 days a week unless otherwise restricted by endorsement and/or memorandum to this Policy.


EXCLUSIONS

The Insurers shall not be liable to pay Compensation for Bodily Injury in respect of any Insured Person:

1. caused by such person's suicide, attempted suicide or intentional self-injury or deliberate exposure to obvious risk or injury (unless in an attempt to save human life).


2. Whose death or disability is directly or indirectly caused by, arising or resulting from or traceable to any physical defect or infirmity which existed prior to the accident, provided that if the disability of the Insured Person is merely aggravated by such pre-existing condition, the Insurers may in their discretion pay an amount which they consider would have been payable but for such aggravation.


3. under 16 or over 70 years of age.


4. whilst the Insured Person is travelling by air other than as a passenger (and a ‘passenger’ does not include a member of the crew or any person being conveyed for the purpose of any trade or technical operation relating to the aircraft)


5. as a direct result of the Insured person:

(a) being under the influence of alcohol, drugs or narcotics unless such drugs or narcotics were administered lawfully by a medical practitioner (other than the Insured Person) or unless prescribed by and taken in accordance with the directions of a medical practitioner (other than the Insured Person)

(b) driving a motor vehicle and having more than the legal limit of alcohol in his/her blood.


6. whilst participating in any riot, strike, civil commotion, public disorder, or as a result of deliberately committing a criminal offence.


7. a) arising from war, invasion, act of foreign enemy, hostilities or warlike operations (whether war be declared or not), civil war, mutiny, insurrection, rebellion, revolution, military or usurped power, or any events or causes which determine the proclamation or maintenance of martial law;

b) Whilst such Insured Person is on active service with the military, naval air or police services of any nation provided that this Insurance shall continue to apply in respect of Accidental Bodily Injury sustained independently of such contingencies


8. whose death or disability is directly or indirectly attributable to Human Immunodeficiency Virus (HIV and/or any HIV related illness) or Acquired Immune Deficiency Syndrome (AIDS) including derivatives or variations thereof howsoever caused. The onus of proof shall always be upon the Insured to show that death or disability of an Insured Person did not arise through or was not caused by AIDS or HIV.


9. whilst participating in sport as a professional player, hang gliding or micro lighting.


10. whose occupation involves underground mining or tunnelling or involving the use or handling of explosives or explosive devices.



CONDITIONS

1. This Policy may be cancelled at any time by the Insurers giving 30 days' notice in writing (or such other period as may be mutually agreed) or by the Insured giving immediate notice. From date of cancellation the Insured shall be entitled to a refund of premium paid pro rata for the unexpired Period of Insurance, subject to condition 10.


2. Cover under this Policy shall terminate immediately upon the non-payment of premium. If a monthly premium debit is dishonoured, all cover under this Policy shall cease at 24H00 on the last day of the month for which the premium has been paid.


3. This Policy is not assignable. Compensation shall be payable only to the Insured whose receipt shall effectually discharge the Insurers


4. No sum under this Policy shall carry interest.


5. This Policy shall be voidable in the event of misrepresentation, or miss-description or non-disclosure by or on behalf of the Insured or an Insured Person in any particular material to this Insurance.


6. Notice must be given to the Insurers in writing on the prescribed claim form as soon as practicable within three calendar months of any occurrence which may give rise to a claim under this Policy but notice of death must be given forthwith and the Insurers shall have the right to have a post mortem examination of the body.


All certificates, information and evidence required by the Insurers shall be furnished without expense to the Insurers within 30 days of the Insurers notifying the Insured of their requirements. After incurring Bodily Injury for which Compensation may be payable under this Policy, the Insured Person shall, when reasonably required by the Insurers so to do, submit to medical examination on behalf of and at the expense of the Insurers and undergo any treatment specified. The Insurers shall not be liable to make payment unless this Condition is complied with to their satisfaction. Qualified medical advice shall be sought and followed promptly on the occurrence of any Bodily Injury and the Insurers shall not be liable for any part of any claim which in the opinion of their medical adviser arises from the unreasonable or wilful neglect or failure of an Insured Person to seek and remain under the care of a qualified member of the medical profession.


7. If any difference shall arise as to the amount to be paid under this Policy (liability being otherwise admitted) such difference shall be referred to arbitration in accordance with the statutory provisions for the time being in force and the making of an award shall be a condition precedent to any liability for the Insurers to make any payment under this Policy.


8. In the event of the Insurers disclaiming liability in respect of any claim and an action or suit not being commenced within twelve months after such disclaimer or, in the case of an arbitration taking place, within twelve months after the Arbitrator shall have made his award, all benefits under this Policy in respect of such claim shall be forfeited.

Medical Evacuation Scheme 1 Sept 2013 7


9. If any claim under this Policy be in any respect fraudulent or intentionally exaggerated or if any fraudulent means or devices are used by the Insured or Insured Person or anyone acting on his or her behalf to obtain any benefit under this Policy all benefit thereunder shall be forfeited in respect of such claim.


10. If the Premium is calculated on estimates supplied by the Insured an accurate record containing all relevant particulars must be maintained by the Insured to which the Insurers shall have the right of access. The Insured shall furnish such information within one month of the expiry of each Period of Insurance and the Premium shall be adjusted accordingly.

10.1 The estimates and declaration of total wages, earnings or salaries on which the premium hereunder is based shall include all items of remuneration which fall under the definition of "Annual Earnings" within this policy.

10.2 In the event that such allowances are not included in the estimated or declared earnings these amounts will not be included in the computation of any claim.


11.  This Policy will be governed by the laws of the Republic of South Africa, whose courts shall have jurisdiction in any dispute arising hereunder.






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