Disability

• Comprehensive Disability

  These benefit descriptions on this policy provide an overview of important definitions and exclusions in the insured’s policy benefits. The insured will receive a detailed policy contract once the company has accepted his or her application, and all claims will solely be based on the information supplied in the original contract.

• Own Occupation Disability

  In the event of a valid claim, the company will pay the claim amount, provided that the benefit is still in force.

  The claim events under this benefit are divided into two groups. The insured life can qualify for a claim under occupational disability or :-
   

  • Functional impairment
  • Occupational disability
    • Disability caused by a bodily injury or an illness to the extent that the insured life is permanently and totally unable to perform the normal duties of his own occupation.
    • Disability caused by a bodily injury or an illness to such an extent that the insured life is permanently and totally unable to perform the normal duties of his own occupation. The insured will not be able to claim under occupational disability after the policy anniversary before the insured life’s 70th birthday.

• Comprehensive Disability Benefit

  In the event of a valid claim, the company will pay the claim amount, provided that the benefit is still in force.

  The claim events under this benefit are divided into two groups. The insured life can qualify for a claim under occupational disability or functional impairment.

• Occupational Disability

  Functional Impairment

  A medical impairment that occurs after the start date of the benefit as diagnosed by an appropriate specialist, registered with the Health Professions Council of South Africa (HPCSA) and resulting in the specified functional restrictions :-

  Cardiovascular system; arrhythmia; peripheral arterial disease; hypertension; red blood cell disorders; white blood cell disorders; clotting disorders; respiratory system; gastro intestinal tract and liver and biliary disease; anorectal impairment; impairment of the bladder; renal system; endocrine system; Diabetes mellitus type 1 and 2; impairment of consciousness and awareness; psychiatric condition; epilepsy; dementia; aphasia; hearing; visual; speech; facial disorders and/or disfigurement; Cranial nerve Vll (Facial nerve); Cranial nerve Vlll (Vestibulocochlear nerve); Cranial nerves lX, X, Xll; neurological impairment of respiration; cancer; paraplegia; quadriplegia; hemiplegia; diplegia; locomotor system; major burns and activities of daily living.

  The company will base the claim amount on the severity of a medical impairment that occurs after the inception date of the benefit, as diagnosed by an appropriate specialist, registered with the Health Professions Council of South Africa

  Occupational disability

  • Disability caused by a bodily injury or illness to such an extent that the insured life is totally and permanently unable to perform the normal duties of his own occupation (up to the policy anniversary before the insured life’s 65th birthday).

   
  Functional impairment
   

  • The claim amount is based on the severity of a medical impairment that occurs after the starting date of the benefit as diagnosed by an appropriate specialist (registered with the Health Professions Council of South Africa (HPCSA) and resulting in the specified functional restrictions.
  • The claim events are not in any way linked to the insured life’s ability to perform occupational activities.
  • The insured life must undergo reasonable optimal treatment and his or her functional impairment will be determined after he or she has reached (reasonable) Maximal Medical Improvement (MMI). At this stage, a specialist that the company has approved must declare the functional impairment total, permanent and continuous for the foreseeable future. The insured life will not be required to undergo reasonable optimal treatment if a specialist, that the company has approved, has established that the functional impairment is permanent and that further treatment will not lessen the severity of the condition.
  • Reasonable optimal treatment: this is the treatment that the company may reasonably expect the insured life to undergo according to the guidelines for the specific condition under the generally accepted medical practice at claim stage. It is expected that the insured life comply with his treatment routine.
  • Maximal Medical Improvement (MMI): A condition or state that is well stabilised and unlikely to change substantially in the next year with or without medical treatment. There may be some change over time, but further recovery is not expected.
  • A panel of accredited medical specialists will determine how many Activities of Daily Living (ADL) the insured life is able to perform.
  • A claim will be admitted only if the claim event is a permanent condition.

• Claim Amount

  Occupational disability

  • The claim amount is the full benefit amount.

   
  Functional impairment

  • The functional impairment claim events are divided into categories. For certain categories, claim payments are divided into severity level subcategories, depending on the severity of the functional impairment event. Each level has an associated “percentage payout”.
  • For the first claim made under the benefit, the claim amount is calculated as the percentage payout multiplied by the benefit amount. The benefit amount will be reduced by the claim amount.
  • For a subsequent claim in a different category, the claim amount is calculated by multiplying the percentage payout by the reduced benefit amount. This amount is paid, irrespective of the relative severity level of the new claim and the original claim.
  • A subsequent claim in the same category will be paid only if the claim event is more severe than previous claims in the same category. The amount paid is based on the difference between the percentage payout for the new claim and the total percentage paid for that category (the “additional percentage payout”). In this case, the claim amount is calculated as the additional percentage payout, multiplied by the benefit amount (only adjusted for claims in other categories).
  • Related claims: A related claim is a claim where the claim event progressed from a previous claim event. A claim that is related to any previous claim in a different category is treated as if it is in the same category as that from which the claim progressed.
  • If more than one claim event occurs as a result of the same cause, a claim will be admitted for the claim event resulting in the highest payment.
  • For claims with a percentage payout of 100%, the balance of the benefit amount will always be paid.
  • The claim categories, severity levels and payout percentages are described below.

   
  Please note: Any outstanding debt will be deducted from the claim amount.

  If tapering is chosen: The lump sum benefit amount will be reduced to zero evenly from the benefit anniversary after the insured life’s chosen tapering age to the benefit anniversary before the insured life’s chosen expiry age.

  Survival period (Functional Impairment only)

  To qualify for a claim the insured life must survive for a period of 14 days that we calculate from the date of the diagnosis of the impairment. The company may, at its discretion, waive the survival period at claim stage.

  Waiting period (Own Occupation Disability only)

  The lump sum claim amount under occupational disability is paid only after the insured life has been disabled for at least 6 months, which is the waiting period. The company may waive the waiting period at claim stage, once permanency of the disability has been established, according to the company definition.

  If the insured life dies within the waiting period, a disability claim will not be paid. The policyholder is responsible for the payment of premiums during the waiting period.

  Functional Protector Conversion option

  The policyholder has the option to convert this benefit to a Functional Protector, which pays a monthly claim amount for the remainder of the insured’s life if he is permanently impaired (subject to the benefit limits that apply at the time of the conversion).

  If tapering was not chosen:

  • The monthly income for the benefit that is issued under this conversion option is limited to 1% of the benefit amount at the time of the conversion.

   
  If tapering was chosen:

  • The monthly income for the benefit that is issued under this conversion option is limited to 1% of:
    • the benefit amount at the time of the conversion if tapering has not started, or
    • the benefit amount before the tapering has started, subject to a declaration of health.
  • A declaration of health will be required if this benefit is an ancillary benefit.
  • Medical underwriting will be required if:
    • any specific exclusion applies to this benefit, or
    • a health or occupational loading applies to this benefit.
  • A claim will not be paid under the Functional Protector, taken out by way of a conversion from an existing disability or impairment benefit, if the claim event occurred before the conversion.

   
  Benefit termination events

  This benefit ends on the earliest of:

  The cancellation of the policy or benefit as a result of:

  • any event covered in the policy contract
  • notification from the policyholder.
  • The death of the insured life.
  • The end of the benefit term.
  • The payment of the full benefit amount.

   
  Benefits

  It is not the intention of the company to rely on an exclusion to avoid payment of claims which, at the company’s sole discretion, were not caused, accelerated or made more likely by conditions which gave rise to the exclusion or which existed before the start of the risk.

  • Physical Impairment Benefit
  • Functional Impairment Benefit
  • Own Occupation Disability Benefit
  • Comprehensive Disability Benefit
  • Income Protector
  • Temporary Income Replacer
  • Comprehensive Critical Illness Benefit
  • Comprehensive ADW Disability Benefit Income Protector
  • Temporary Income Replacer

   
  Benefit Exclusions

  The company will not admit the claim if the claim event is brought about or accelerated directly or indirectly by any of the following:
   

  • War (whether declared or not)
  • Participation in any terrorist activity, riots, civil commotion and/or rebellion
  • Radioactivity and nuclear explosion
  • Willful breaking of any law by the insured life
  • The insured life fails to disclose information before the cover starts
  • Intentional and grossly negligent self-inflicted injury
  • The excessive consumption of alcohol, intentional and negligent consumption of poisons, drugs, narcotics or medication unless prescribed by an independent medical practitioner and used as prescribed
  • The company also specifically excludes maternity leave

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