Tryg Key Employee Insurance Insurance Terms and Conditions no

Transcription

1 Tryg Key Employee Insurance Insurance Terms and Conditions no Contractual basis Tryg Key Employee Insurance consists of the insurance agreement, any endorsements to the insurance agreement and the insurance terms and conditions. In addition, the insurance is subject to Danish legislation, including the Danish Financial Business Act (Lov om finansiel virksomhed) and the Danish Insurance Contracts Act (Lov om forsikringsaftaler) unless the latter is derogated from. Supervision and Guarantee Fund for Non-life Insurance Companies Tryg is subject to the supervision of the Danish Financial Supervisory Authority and is a member of the Guarantee Fund for Non-life Insurance Companies. Processing of personal data and consent At you can read more (in Danish) about how we process your personal data. For example, you will find information about the purposes for which we process data about you, where the data is registered and to whom the data may be disclosed. You are always welcome to contact us if you want to know more. Further information You can find further information about the insurance cover at or We recommend that you read these insurance terms and conditions so that you are acquainted with them if you need Tryg Key Employee Insurance. 1/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no Tryg Klausdalsbrovej 601 DK-2750 Ballerup Tryg Forsikring A/S CVR-no

2 Know your insurance Your Key Employee Insurance comprises your insurance agreement (policy) and your insurance terms and conditions. Tryg Key Employee Insurance A Key Employee Insurance protects your business if you, as the owner, or one of your employees becomes temporarily incapacitated for work due to illness or an accident that occurs during the policy period. The insurance does not cover diseases which have occurred in the first six months after the insurance was purchased. In the event of an accident, the insurance provides cover from the date on which the insurance was purchased. If one of the persons insured meets the requirements in Section 7 of the Danish Sickness Benefits Act (Sygedagpengeloven), your business is entitled to disbursement after two consecutive weeks of incapacity for work if the total period of incapacity for work exceeds four weeks. The premium is tax deductible, and you can read more about the statement of income at Your responsibilities You have a number of responsibilities which may have an impact on your right to indemnity: You must report the claim to us as soon as you receive reimbursement of sickness benefits for an insured person. A financial claim for indemnity must be reported to us no later than 12 months from the insured person's first day of illness. You must be able to document the reimbursement of sickness benefits for the insured person's incapacity for work, for example confirmation of notification from nemrefusion.dk. Any claim for financial indemnity must be documented, and we recommend that your financial statements and advice on the preparation hereof are drawn up and provided by an authorised accountant. This will make your claim clearer and your notice of claim quicker to process. Written consent from the insured person is a requirement for processing the claim and disbursing indemnity. We will send a consent form to the insured person. Special requirements for registration and deregistration of insured persons An insured person may, at the earliest, be covered by the insurance from the date on which we receive notice hereof. You cannot register insured persons under the insurance agreement retroactively. We will only disburse indemnity for persons who are stated in the insurance agreement, and we recommend that you check regularly that the insurance agreement is correct. If an insured person is no longer to be covered by the insurance, you must notify us immediately. Special requirements for the insured person The insured person must collaborate on reestablishing a situation in which he/she can return to the labour market. The object of such collaboration is to ensure that the period of absence due to illness is as short as possible, and the collaboration may, for example, be between the insured person s workplace, general practitioner and us. In addition, the insured person must grant his or her consent for us to obtain relevant information in order to process the claim. Contact our Claims Department on tel on all weekdays from 8am-5pm or at sygedriftstab@tryg.dk 2/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

3 Contents 1. The policyholder The insured Persons who can be covered 4 2. Commencement of insurance cover Scope of insurance cover Cover exclusions Chronic diseases 5 3. The company s right to indemnity Conditions for indemnity Waiting period Period of Indemnity Termination of indemnity 6 4. The amount of indemnity to which the company is entitled Indemnity principles Payroll costs for employees 6 Side Side Side 4.3 Business interruption loss for employees Payroll costs and business interruption loss for owners Limitation of indemnity Sum insured 7 5. Determination of indemnity Principles for calculation of payroll costs Principles for calculation of the company's business interruption loss Costs for auditor Partial incapacity for work 7 6. Documentation requirements Special requirements for indemnity for payroll costs Special requirements for indemnity for business interruption loss 8 7. Duty of disclosure The policyholder s and the insured's obligation Consent Changes in insurance matters 8 8. General terms and conditions Maximum cover Insurance with another company Transfer of insurance and seniority from another company Termination of the insurance Payment of the insurance Term and termination of the insurance Amendment of terms and conditions and premium changes Fees Complaints 10 3/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

4 1. The policyholder The policyholder is the company with which we have entered into the insurance agreement. The company must be registered with an active Central Business Registration (CVR) number in Denmark. Companies registered in Greenland or on the Faroe Islands cannot take out a key employee insurance policy. 1.1 The insured The insured are the persons who are stated with their civil registration (CPR) number in the insurance agreement. 1.2 Persons who can be covered The insurance may cover persons who are employed with the company and who actively perform work for the company. Disbursement can be made under this insurance when the insured persons are entitled to disbursement of sickness benefits, see the Danish Sickness Benefits Act, in connection with full or partial incapacity for work. Roles under the insurance The policyholder is the company that takes out the insurance. The company is the party that will receive the indemnity. The insured are the persons who are stated in the insurance agreement with their civil registration number. If an insured person is declared incapacitated for work, we can disburse indemnity. Persons residing in Greenland or on the Faroe Islands cannot be covered by the insurance not even if the person in question has his or her registered address in Denmark. 2. Commencement of insurance cover The insurance enters into force from the date on which we approve the registration, see, however, Sub-clause 3.2 on waiting period. 2.1 Scope of insurance cover The insurance covers the insured person s incapacity for work. The incapacity for work must have been directly caused by the insured person being afflicted by illness or involved in an accident. 2.2 Cover exclusions The insurance does not cover incapacity for work directly or indirectly caused by: Existing disorders, predisposition to disease or diseases that have produced symptoms before the insurance entered into force. Discomfort which is solely experienced by the insured person, but cannot be ascertained by the insured person s own general practitioner or a relevant specialist. Illness or accident caused by the insured person with intent or by gross negligence. Self-induced intoxication or influence of alcohol, drugs or other euphoriants. Attempted suicide. Participation in criminal acts. Pregnancy, fertility treatments or discomfort resulting from this. Cosmetic treatments or bariatric surgery. Performance of professional sports*. Performance of dangerous sports*. Military service. War, warlike acts, infringement of neutrality, civil war, riot, civil unrest, confiscation or revolution. Epidemics or pandemics as defined by the Danish State Serum Institute (Statens Serum Institut). Illness means conditions, symptoms, diagnoses, discomfort and sequelae which result in incapacity for work. Accident means a sudden event that causes personal injury and results in incapacity for work. Dangerous sports We define dangerous sports as sports in which the object is of a particularly dangerous nature. Such sports include, but is not limited to: parachuting, rappelling, mountain climbing, boxing against an opponent etc. Dangerous sports do not include fitness-based sports such as fitness boxing, crossfit, running, wall climbing, ball sports etc. Please contact us if you would like to have an overview of all sports on the list. Professional sports Professional sports comprise persons who are predominantly able to make a living from their sport. Voluntary association work, leisurebased sport or minor cash payments for referees, coaches or other sports-related tasks are not included in our definition of professional sports. 4/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

5 2.3 Chronic diseases The insurance covers chronic diseases, chronic conditions, chronic discomfort or sequelae ascertained during the policy period. Insurance event An insurance event covers a complete course based on the same illness or accident. Chronic diseases, conditions, discomfort or complications resulting in incapacity for work are regarded as one single insurance event*, irrespective of the frequency of the resulting incapacity for work. 3. The company s right to indemnity 3.1 Conditions for indemnity You are entitled to indemnity if the insured person meets four conditions: 1. The illness or accident that results in incapacity for work must have occurred during the policy period, and 2. the insured person must have been declared fully or partly incapacitated for work in accordance with the rules in Section 7 of the Danish Sickness Benefits Act, and 3. the insured person must be entitled to full or partial sick benefits or a job clarifying scheme with payment of resource programme benefits in accordance with the Danish Sickness Benefits Act, and 4. the insured must have undergone a medical examination with his or her own general practitioner or a relevant specialist in which objective signs of injury or illness can be documented. The company must also meet the following two conditions: 1. It must be documented that reimbursement of sickness benefits is received, see the Danish Sickness Benefits Act. 2. A claim for indemnity must be reported no later than 12 months from the insured person's first day of illness. 3.2 Waiting period The insurance may, at the earliest, cover incapacity for work due to illness six months after the date on which an insured person becomes covered by the insurance. The insured person s incapacity for work which is ascertained during the waiting period and which continues after the end of the waiting period will not be covered by the insurance. The waiting period will lapse if the insurance is transferred from another insurance company, as described in Sub-clause 8.3. There is no waiting period applicable to accidents that occur during the policy period. 3.3 Period of Indemnity We disburse indemnity after two consecutive weeks of full or partial incapacity for work if the incapacity for work exceeds four weeks. We disburse indemnity retroactively when the relevant documentation has been received and processed Maximum indemnity period The indemnity period for incapacity for work cannot exceed a maximum of 50 weeks per insurance event, regardless of whether the incapacity for work continues beyond the 50 weeks Incapacity for work on several occasions for the same insurance event If the insured person is reported fit for work during the indemnity period, but is subsequently deemed incapacitated for work for the same insurance event, the indemnity period will be calculated from the original first day of illness. Sub-clauses 3.3 and will still apply Sequelae of the insurance event Physical and mental problems or sequelae of a disease, treatment of illness or an accident do not constitute the basis for a new insurance event under this insurance. 5/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

6 3.4 Termination of indemnity The indemnity will terminate at the earliest of the following times: When the insured person is reported fit for work*. When the right to sickness benefits ceases. On the insured person's death. On termination of the insured person s employment with the company. The date on which the insured person attains 70 years of age. If the company closes down its activities. On termination of the insurance. Reporting fit for work Reporting fit for work entails that the insured person is reported fit for work for both the labour market in general and for his or her specific occupation. If a person is reported fit for work on the labour market in general, this means that the person in question is able to work, but not in his or her previous function. If a person is reported fit for work in his or her specific occupation, this means that the person in question is able to work in the same function as previously The amount of indemnity to which the company is entitled 4.1 Indemnity principles We disburse the indemnity to the company stated as the policyholder on the policy. The company's loss resulting from an insured person's incapacity for work due to illness or an accident is thus the loss covered by the insurance. 4.2 Payroll costs for employees In the event of an employment contract with full pay during full periods of illness or parts thereof, the insurance will cover current disbursements corresponding to the payroll costs for the insured 4.3 Business interruption loss for employees If it can be documented that a business interruption loss has been incurred as a result of the insured person s incapacity for work, The indemnity is calculated on the basis of two indemnity principles: Costs for the insured person s net salary during the period in which he or she has been declared incapacitated for work. The company's business interruption loss as a result of a period of incapacity for work. person, less sickness benefits, sick pay, compensation from other parties etc. indemnity for such loss will be paid up to the agreed sum insured for the insured person. 4.4 Payroll costs and business interruption loss for owners If the insured person is the owner of a personally owned business, or if there is no employment contract regulating salary during illness, the insurance will cover the business interruption loss incurred as a result of the insured person s incapacity for work. Owners of a private limited company (ApS), an entrepreneurial limited company (IVS), a public limited company (A/S) or a company with limited liability (SMBA) who actively perform work in their own company can receive indemnity for the payroll costs disbursed. The payroll cost is calculated as the disbursed salary with the addition of the incapacitated person s share of the contribution margin. 4.5 Limitation of indemnity The indemnity must never exceed the company s actual loss. The company that has taken out the insurance is responsible for documenting and collaborating with us to ensure that the indemnity disbursed under the insurance does not exceed the actual loss incurred by the company. 6/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

7 4.6 Sum insured Each insured person has a sum insured linked to the insured person's civil registration (CPR) number. The sum insured is individual and cannot be transferred to other insured persons under the insurance agreement. The sum insured is a first-risk sum*, and we only cover up to the maximum of the sum chosen. Under-insurance will not be claimed. The sum insured is not indexed Waiting period for increase in sum insured If the company increases the sum linked to an insured person, there is a waiting period of three months after the sum has been increased. For incapacity for work due to illness or accident ascertained in the waiting period, indemnity is disbursed in accordance with the originally agreed sum insured. First-risk sum First-risk sum means that the indemnity can never exceed the sum insured stated on the policy. If you have a sum insured of, for example, DKK 75,000 a month and have a claim, we will cover maximum DKK 75,000 per month, regardless of whether you have a claim with a value of DKK 100,000 per month. 5. Determination of indemnity 5.1 Principles for calculation of payroll costs We base our calculation of indemnity on the documented average payroll costs from the preceding three months. We will deduct saved payroll costs or pay subsidies, for example sickness benefits, sick pay or compensation from other parties, from the indemnity. 5.2 Principles for calculation of the company's business interruption loss The business interruption loss is assessed as the difference between: the expected and probable net revenue less the expected consumption of commercial goods purchased for resale as well as raw materials and consumables, semi-manufactures, product-related packaging, and the actual net revenue less the actual consumption of commercial goods purchased for resale as well as of raw materials and consumables, semi-manufactures and productrelated packaging, and saved costs and payroll costs or pay subsidies, for example, sickness benefits, sick pay or compensation from other parties, which will be deducted from the indemnity. Revenue is defined as invoiced revenue exclusive of VAT, discounts, bonuses and other sales reductions granted. 5.3 Costs for auditor The insurance covers reasonable, necessary and documented costs of up to DKK 10,000 per claim, incl. VAT, for an auditor for determination of the illness-related business interruption loss. We must approve the use of an auditor if the costs are to be paid by us. The sum is not indexed. In addition, we cover any necessary, reasonable and documented additional costs incurred for loss-limiting measures with a view to maintaining the company s operations, for example expenses for temporary staff or overtime. The size and nature of such additional costs must be agreed with us in each individual case. We can disburse the additional costs periodically every third month. Such costs cannot exceed the business interruption loss which would otherwise have been incurred, and are only covered for that part of the costs which has effect in the period of cover. Disbursement of indemnity is subject to the condition that the company s financial statements are up to date and are presented in accordance with generally accepted accounting principles. 5.4 Partial incapacity for work If the insured person is partially incapacitated for work, the indemnity will be calculated based on the ratio between the number of working hours in which the insured person is working and the full-time working hours (equal to 37 hours/week). The indemnity disbursement period cannot, however, exceed 50 weeks, regardless of whether the insured person is working on a full-time basis, a part-time basis or just a few hours a week. 7/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

8 6. Documentation requirements For use for determination of the indemnity, you must document that the illness or accident has affected the insured person s working capacity. Medical documentation must always be provided for full or partial incapacity for work. When you report your claim to us, we will provide you and the insured person with further details about the information necessary for us to consider the case. You and the insured person are obliged to send the documentation and information we request to enable us to consider the case. We pay the expenses for a medical certificate and medical reports that we find necessary to enable us to consider the case. We must always receive: A signed consent form from the insured person. Documentation that the right to sickness benefits has been met. Confirmation that reimbursement of sickness benefits is received. Medical documentation. 6.1 Special requirements for indemnity for payroll costs When you report a claim for payroll costs to us, we will require: Payroll cost documentation for the preceding three months from the first day of illness. We may also request further information, including: Employment contract Documentation for payroll liability 6.2 Special requirements for indemnity for business interruption loss When you report a claim for indemnity to us, you must also submit a business interruption loss statement with the indemnity claim. We may also request further documentation, including: Documentation of the company s financial statements for the past 12 months prior to the incapacity for work. Documentation of the company's budget for the current year. Documentation that shows, on a balance of probabilities, that the insured person s incapacity for work has had a direct impact on the business interruption loss. If disbursement of additional costs is required, you must also submit the following: A statement showing that a periodic disbursement of additional costs does not exceed the business interruption loss which would otherwise be incurred. 7. Duty of disclosure 7.1 The policyholder s and the insured's obligation As the policyholder, you have an obligation to provide the information that we find necessary for deciding if and to which extent we are liable to pay indemnity. This information may be of an accounting nature or concern the right to sickness benefits. The insured person is under an obligation to provide the information that we find necessary for deciding if and to which extent we are liable to pay indemnity. 7.2 Consent Disbursement of indemnity is subject to the condition that the insured person provides written consent allowing us to obtain information in order to process the claim and provides information about the name, address and telephone number of the hospital, doctors and other health care providers or job centre etc. that have or will have knowledge of the insured s health and/ or sick leave. 7.3 Changes in insurance matters It is important that you notify us if there are changes in any of the matters mentioned below, as this may affect the cover or the insurance premium. Incorrect information in the insurance agreement (the policy). If you or the company moves Changes to the billing address. Change in ownership of the company If the company's primary DB07 code (stated on the policy) is changed Change in the number of persons insured under the policy. We may only obtain further medical information regarding the insured person s incapacity for work with the insured person s written consent. If we are not notified of the change, and the change would have resulted in a higher insurance premium, you will receive indemnity corresponding to the ratio between the premium paid and the premium that should have been paid. Moreover, if you fail to notify us, the right to indemnity may lapse entirely. We determine, based on the changes, whether and on what terms and conditions the insurance may continue. 8/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

9 8. General terms and conditions 8.1 Maximum cover The maximum cover per person per month is specified in the insurance agreement in the form of the agreed sum insured. Indemnity can be disbursed for up to maximum 100 weeks per insured person throughout the policy period, regardless of the number of insurance events. 8.2 Insurance with another company If you have taken out insurance against the same risk with another insurance company, this constitutes double insurance, and you must report the illness or accident to both companies. exclusions and restrictions will apply to this insurance. This means that we and the other insurance company will pay a proportionate indemnity. If the other insurance company excludes or restricts its liability to pay indemnity in the event of double insurance, the same 8.3 Transfer of insurance and seniority from another company We offer to take over seniority from previous equivalent insurance policies in connection with an uninterrupted insurance relationship. This means that the insurance must continue with us from the date on which it was terminated with your previous insurance company. If there is an interruption in the insurance relationship, the cover with us will be regarded as a completely new insurance policy with a waiting period. The insurance does not cover cases in progress with a previous insurance company when you take out Tryg Key Employee Insurance. 8.4 Termination of the insurance When the insurance terminates, you will concurrently lose the right to cover. The insurance will be terminated if: The company closes down its activities The company enters into bankruptcy or liquidation. 8.5 Payment of the insurance The insurance premium must be paid when the insurance enters into force, and subsequently on the dates specified in the insurance agreement. Together with the insurance premium, we charge any taxes and duties, for example general insurance duty, as well as any fees and other costs. We will send the invoice to the stated payment address via the direct debit system Betalingsservice or a payment form. All expenses related to collection and payment are payable by the policyholder. We must be notified immediately in case of a change of billing address. 8.6 Term and termination of the insurance On expiry of the policy period, the insurance will continue unchanged for a corresponding period. On expiry of a multi-annual policy period, the insurance can, however, only be renewed for a corresponding multi-annual period if we have notified the policyholder of such renewal at the earliest three months and at the latest one month before expiry of the period of notice. If we do not provide such notification, the insurance will be renewed for a period of one year at a time. If the premium is not paid on the due date, we will send a reminder with information that the insurance cover will cease if the invoice is not paid no later than 21 days after the reminder has been sent. In connection with a reminder, we are entitled to charge a handling fee, default interest and any other costs. We are also entitled to charge a fee for printing documents and other services that corresponds to our costs. If these costs increase, we are entitled to raise our fees correspondingly. later than one month before expiry of the policy period. You may terminate the insurance by telephone or in writing. The insurance must be terminated no later than one month before expiry of the policy period. When a claim has been reported, both you and we may terminate the insurance at 14 days notice, however, no later than one month after the indemnity has been disbursed or the claim has been rejected. Both you and we are entitled to terminate the insurance. If we terminate the insurance, this must be done in writing and no 9/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no

10 8.7 Amendment of terms and conditions and premium changes The premium for each pay category is adjusted once a year on the first insurance premium payment date in the policy year. The premium is calculated on the basis of the age of the insured persons, the sum insured for the insured persons and the company's Danish Industrial Classification (Dansk Branchekode), unless otherwise stated in the insurance agreement. The insurance premium is adjusted in line with the change in the Index of average earnings for the private sector published by Statistics Denmark. If this index ceases to be published, or if the basis of its calculation is changed, we are entitled to use a similar index from Statistics Denmark. Notice of significant amendments to the terms and conditions and/or changes of premiums will be given no later than 30 days before expiry of the policy period. When you pay the insurance premium for a new period, you also accept the amendments and changes, and the insurance will continue with the amended terms and conditions and/or changed premium. Indexation is not regarded as a change of the insurance premium. 8.8 Fees We are entitled to charge fees for full or partial cover of the costs of, for example, invoices, reminders, debt collection, disbursements, printing and processing of documents, summaries, inspections, administration and services in connection with insurance and claims handling etc. We may change the existing fees or introduce new fees when this is justified by: cost reasons if, for example, we digitise more of our processes or services, or introduce more self-service solutions. commercial reasons for example to utilise our resources or capacity in a more expedient manner, or to change our general fee structure. market reasons if, for example, the basis for the fee has changed, or if we see a change in customer behaviour. Notice of new fees and changes to existing fees will be given via our website at one month s notice to the first day of a month. We may reduce our fees without notice. You can always obtain information about our current fees by contacting us. 8.9 Complaints If you are not satisfied with a decision, you may always file a complaint. You may contact our Quality Department, which is responsible for handling complaints. The address is: Tryg Postkode J22 Klausdalsbrovej 601 DK-2750 Ballerup Kvalitet@tryg.dk ERH 045-1UK (06.17) 10/10 Tryg Tryg Key Employee Insurance Insurance Terms and Conditions no