Critical Illness Benefit Wording

Here is an example of our Critical Illness Benefit wording. You can easily print the PDF version available by clicking this link. Please note that this is just a sample; you should carefully read the wording of your own policy once issued.

1. When Sovereign will pay a critical illness benefit

The critical illness benefit is a one-off lump sum amount. Sovereign will pay you a critical illness benefit in accordance with this policy if the life assured suffers any of the following conditions:

• Cancer
• Coronary artery bypass surgery
• Heart attack
• Stroke

and meets all of the following criteria:

• the life assured suffers from one of the conditions for the first time;
• the life assured suffers the condition not less than 6 months after the risk commencement date;
• the life assured survives for at least 56 days after first suffering the condition;
• the life assured is
• prevented from undertaking active employment by the condition for at least 56 days; or
• if unemployed at the time of suffering the condition, is, as a result of the condition, for at least 56 days after first suffering from the condition, unable to perform at least three of the following activities without assistance:
  1. Bathing and showering
  2. Dressing and undressing
  3. Eating and drinking
  4. Using a toilet
  5. Moving from place to place by walking, in a wheel chair or with a walking aid.
• the life assured is under medical treatment and following the advice of a Registered Medical Practitioner at the time you make the claim.

Sovereign will only make one payment for a critical illness benefit for each life assured.

2. The effect of a critical illness benefit on life cover

The critical illness benefit will be treated as an early payment of your life cover benefit. When Sovereign pays a critical illness benefit, the life cover benefit for that life assured will decrease by the amount paid for the critical illness benefit.

The maximum combined amount payable under the life cover benefit, bereavement support benefit, critical illness benefit and if applicable total permanent disablement benefit is the amount of the life cover benefit for that life assured.

3. When Sovereign will not pay a benefit

Sovereign will not pay any benefit where the life assured participates in any criminal act, which (either directly or indirectly) causes or contributes to the condition of the life assured.

4. Making a critical illness claim

To make a claim for a critical illness benefit, please call the Sovereign claims team on 0800 500 103 for assistance.

Sovereign will require information from you including:

• a completed claim form; and
• medical evidence and reports, showing proof of the condition giving rise to the claim.

Sovereign may also require the life assured to have an examination by a Registered Medical Practitioner appointed by Sovereign before accepting the claim.

Sovereign is under no obligation to pay a critical illness benefit until we have received all the information we have requested.

5. Definitions of medical conditions

Cancer
The presence of one or more malignant tumours, characterised by uncontrolled growth and spread of malignant cells, with the invasion and destruction of normal tissue for which major interventionist treatment or surgery is considered medically necessary.

In addition, the following tumours are covered:

• Intra-ductal carcinoma of the breast where mastectomy has been performed to arrest spread of malignancy.
• Malignant melanoma, which is covered if it is at least a Clark level 3, or greater than 1.5mm thickness as measured using the Breslow histological classification.

The following tumours are excluded:

• Tumours classified as carcinoma in situ (including intraepithelial neoplasia).
• Prostate tumours with a Gleason score of less than 6.
• All skin cancers unless there is evidence of metastases.
• Papillary micro-carcinoma of thyroid or bladder.
• Chronic Lymphocyctic Leukaemia less than RAI stage 3.

Coronary Artery Bypass Surgery
Open heart bypass surgery to correct or treat coronary artery disease.

Heart attack
The death of a portion of the heart muscle arising from the inadequate blood supply to the relevant area. The diagnosis shall be based on the following criteria being present and consistent with a heart attack:

• Clinical features (including but not limited to chest pain, nausea and dizziness); and
• Confirmatory new electrocardiogram (ECG) changes; and
• Diagnostic elevation of cardiac enzymes. Specifically a rise in CK-MB, or a rise in Troponin I greater than 2.0 microgram/l, or a rise in Troponin T greater than 0.6 microgram/l.

If any of the above criteria are not met then we will consider a claim based on evidence that the event produced a permanent reduction in the Ejection Fraction to 50% or less (as measured one year after the event).

Stroke
A cerebrovascular incident producing neurological sequelae and causing at least 25% impairment of whole person functioning, as measured at 6 months after diagnosis. This requires evidence of:

• Infarction of brain tissue; or
• Intracerebral or subarachnoid haemorrhage; or
• Embolisation from an extracranial source.

Excluded from this definition are transient ischaemic attacks (TIA), reversible ischaemic neurological deficit (RIND), cerebral symptoms due to migraine, cerebral injury from trauma or systemic hypoxia and vascular disease affecting the eye or optic nerve.

6. Key Terms

appendices
The appendix or appendices that forms part of the policy document and contains the terms of any benefit you have chosen.

condition(s)
A treatment, illness, surgical procedure or event as specified in this appendix which leads to a claim being paid under the specified definition.

whole person functioning
As defined in the "Guides to the Evaluation of Permanent Impairment - 4th Edition"(or subsequent editions), produced by the American Medical Association.

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:

• You;
• The life assured;
• A member of the life assured's family or your immediate family;
• The life assured's or your business partner or associate.

risk commencement date
The commencement date of the policy, being the date on which the policy was issued.

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