Friends Life Group Critical Illness Flex Scheme Guide to the Cover

Transcription

1 Friends Life Group Critical Illness Flex Scheme Guide to the Cover Reference BGR/6721/JUL12 This document contains important information about the Friends Life Group Critical Illness Standard (Silver) and Comprehensive (Gold) Flex Schemes. It should be read along with the Policy Summary of the Friends Life Group Critical Illness Flex Scheme and should be kept in a safe place afterwards. Please note that it does not give the full terms and conditions and exclusions of cover, which are contained in the policy document issued to your employer. Nothing in the policy confers any contractual rights on you. Its aims To provide the amount of cover you elect. To provide a lump sum benefit which is payable if you or your child: are diagnosed with one of the specified medical conditions or undergo one of the listed operations covered under the option you have elected (ie Standard (Silver) cover or Comprehensive (Gold) cover); and survive for at least 14 days; and the medical condition or operation meets the definition in the policy conditions. The full list of medical conditions and operations covered is given in the Which critical illnesses are covered? section later in this document, and the definitions are available in the Conditions covered brochure. Your commitment You must do the following: notify us of potential claims within three months of first diagnosis being made, or of undergoing surgery read the Conditions covered brochure, which is available from your employer. Risk factors If we do not receive the premiums from your employer your cover will end 30 days after the due date of the last premium paid. The rates used to calculate your premiums are reviewed every two years and may go up. In addition, the rates used to calculate premiums are based on your age each year and will go up when you enter a new age band. The same level of critical illness cover will therefore increase in cost as you get older, which may reduce your scope for electing other options within the flexible benefits scheme. We will not pay out in the circumstances described under When will the cover not pay out? later in this document. Cover is designed to provide a lump sum benefit on survival of one of the specified medical conditions or operations covered under the option you have elected (ie Standard (Silver) cover or Comprehensive (Gold) cover) and no others, and has no surrender value. We have the right to change the conditions of cover at any time for benefits coming into force in the future and for all benefits at any time after the group policy taken out by your employer has been in force for five years.

2 How does the cover work? You choose the cover you want by electing one of the option levels offered through your employer s flexible benefit scheme. In order for benefit to be payable the medical condition diagnosed or operation undergone must, in the reasonable opinion of our chief medical officer, meet the definition in the policy conditions. The benefit will be paid if you survive for at least 14 days from when you are diagnosed with one of the specified medical conditions or undergo one of the operations listed under the option you have elected (ie Standard (Silver) cover or Comprehensive (Gold) cover). Please note that in order for some of the definitions to be met there is a requirement for symptoms to have persisted for a prolonged period (eg multiple sclerosis). Full details are contained in the Conditions covered brochure. How much does the cover cost? Your employer pays the premiums to keep the cover in force. The premiums paid by your employer for this cover are calculated according to the amount of your cover and your age at the start of each scheme year. As you get older and continue to be covered, you will move into different premium age bands and the cost per unit of cover will usually increase. In addition the premiums payable are reviewed every two years and so may increase. Sample rates can be found on HM Revenue and Customs will treat the premium paid on your behalf as a benefit in kind, so it will be added to your taxable income. Who can be covered? If you are eligible for cover under your employer s flexible benefit scheme, you can elect this benefit. You will not have to complete an application form but all cover (including any increases in cover) will be subject to the pre-existing conditions exclusion which is described in When will the cover not pay out? later in this document, from the date that cover commences. Under the rules of the scheme you will be able to elect benefit for your spouse/partner if they satisfy the following definition. Your spouse/partner is: someone who you are married to (or a civil partner): or someone you are not married to (or a civil partner) but, in the reasonable opinion of the insurer: is financially dependent on you; or his or her financial relationship with you is one of mutual dependence at the date of diagnosis. The definition specifically excludes: your children, and anyone who at no time has been in a relationship with you which resembles marriage or civil partnership. Your spouse/partner can only be covered for this benefit if you also elect the cover for yourself and their benefit cannot be higher than your benefit and is restricted to a maximum limit of 100,000 or, if you are paid in Euros, 100,000. Can children have critical illness cover? Your children (including stepchildren and legally adopted children) aged between six months and 18 years are automatically covered free of charge. There is no upper limit to the number of children who can be covered. For a child who meets the claim requirements for one of the specified medical conditions or undergoes one of the listed operations we will pay the lower of 25% of your benefit; or 20,000 or, if you are paid in Euros, 20,000. When does cover start? You will normally have the opportunity to join the scheme on a fixed date each year or shortly after your employment starts. Your employer will be able to confirm the date that your cover can start but this will always be after the election date. No cover will be in place before the start date. You will not have to fill out an application form in order for cover to begin. However, all cover will be subject to a pre-existing conditions exclusion (please refer to the When will cover not pay out? section later in this document). When does cover cease? Cover will cease on the earlier of: you reaching the scheme expiry age you ceasing to be eligible for the RBSelect programme even if still an employee of RBS you leaving service (in which case, cover will cease on the last working day of the month in which you leave) you de-selecting this benefit as an option under your employer s flexible benefits scheme your contract of employment ending your death benefit being paid in respect of a claim for you= 2

3 the scheme ending if we do not receive the premiums when they are due your cover will end 30 days after the due date of the last premium paid. = If benefit is paid in respect of a claim for you your cover will end. There is an option to re-enter the scheme one day after the cover has ended. You will be treated as a new member and the pre-existing conditions exclusion will be re-applied from the date that you re-enter the scheme. Please note that this option is not available to those who have claimed for the following conditions: Under Standard (Silver) cover - Alzheimer s disease, dementia, motor neurone disease or progressive supranuclear palsy. Under Comprehensive (Gold) cover - Alzheimer s disease, coma, Creutzfeldt-jakob disease, dementia, HIV infection, loss of independent existence, motor neurone disease, progressive supranuclear palsy, or traumatic head injury. If cover is also provided for your spouse/partner that cover will cease on the earlier of: your cover ending a claim becoming payable in respect of your spouse/partner your spouse/partner reaching the expiry age for spouse/partners your spouse/partner dying the definition of spouse/partner no longer being satisfied. Cover for a child will cease at the same time that your cover ceases, or earlier if a claim is payable in respect of the child or the child reaches age 18. If benefit is paid for a child, no further benefit will be paid for that particular child. However, your cover will continue along with that for any other children who have not claimed benefit. Please note that there is no option for your spouse/partner or child to re-enter the scheme once a benefit has been paid in respect of them. All cover will end if the scheme is terminated by your employer. Which critical illnesses are covered? Please note that although the Conditions covered brochure contains definitions for all the medical conditions and operations we can cover, under the terms of this scheme you will be covered only for the medical conditions and operations listed below under the option you have elected (ie Standard (Silver) cover or Comprehensive (Gold) cover). Standard (Silver) cover If you have elected Standard (Silver) cover the complete list of conditions and operations you are covered for is: Alzheimer s disease resulting in permanent symptoms cancer excluding less advanced cases coronary artery by-pass grafts with surgery to divide the breastbone dementia resulting in permanent symptoms heart attack of specified severity kidney failure requiring dialysis major organ transplant motor neurone disease resulting in permanent symptoms multiple sclerosis with persisting symptoms Parkinson s disease resulting in permanent symptoms progressive supranuclear palsy resulting in permanent symptoms stroke resulting in permanent symptoms The following cover is not available for spouse/partners covered under Standard (Silver) cover: children s benefit. Comprehensive (Gold) cover If you have elected Comprehensive (Gold) cover the complete list of conditions and operations you are covered for is: Alzheimer s disease resulting in permanent symptoms aorta graft surgery for disease aplastic anaemia with permanent bone marrow failure bacterial meningitis resulting in permanent symptoms benign brain tumour resulting in permanent symptoms blindness permanent and irreversible cancer excluding less advanced cases cardiomyopathy of specified severity coma resulting in permanent symptoms coronary angioplasty to two or more coronary arteries 3

4 coronary artery by-pass grafts with surgery to divide the breastbone Creutzfeldt-jakob disease resulting in permanent symptoms deafness permanent and irreversible dementia resulting in permanent symptoms heart attack of specified severity heart valve replacement or repair HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation* kidney failure requiring dialysis loss of hands or feet permanent physical severance loss of independent existence permanent and irreversible loss of speech permanent and irreversible major organ transplant motor neurone disease resulting in permanent symptoms multiple sclerosis with persisting symptoms paralysis of limbs total and irreversible Parkinson s disease resulting in permanent symptoms progressive supranuclear palsy resulting in permanent symptoms respiratory failure of advanced stage terminal illness rheumatoid arthritis chronic and severe stroke resulting in permanent symptoms third degree burns covering 20 percent of the body s surface area traumatic head injury resulting in permanent symptoms * The eligible occupations for HIV infection caught at work are: the emergency services police, fire and ambulance the medical profession including administrators, cleaners, dentists, doctors, nurses and porters the armed forces The following cover is not available for spouse/partners covered under Comprehensive (Gold) cover: The following cover is not available for any children covered under Comprehensive (Gold) cover: HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation loss of independent existence. Please remember that the heading for each critical illness is only a guide to what is covered. For example, some types of cancer are not covered. The full definitions we will use are given in the Conditions covered brochure. If you are absent from work for a prolonged period it may be possible for cover to be maintained, subject to you continuing to be employed by your employer and the appropriate cover being selected by your employer when setting up the scheme. How much cover can I have? You decide how much cover you would like by electing one of the option levels offered through your employers flexible benefit scheme. The higher the level of benefit the higher the monthly cost will be. Your cover can be purchased in units of 25,000 up to a maximum limit of the lower of four times your ValueAccount or 250,000. Cover for your spouse/partner can be purchased in units of 25,000 up to a maximum limit of the lower of 100,000 or an amount equivalent to your level of cover. If you are paid in Euros your cover can be purchased in units of 25,000 up to a maximum limit of the lower of four times your ValueAccount or 250,000. Cover for your spouse/partner can be purchased in units of 25,000 up to a maximum limit of the lower of 100,000 or an amount equivalent to your level of cover. You may change the level of cover within certain limits upwards (if your employer has agreed to this) or by any amount downwards on the annual enrolment date, or following a lifestyle event. What is a lifestyle event? A lifestyle event is an event after which, under the terms of the scheme, you may change your cover within certain limits upwards or by any amount downwards. The pre-existing conditions exclusion will apply to any increase in benefit from the date that cover commences. Events that constitute lifestyle events with regard to this scheme may have been agreed between Friends Life and your employer, which could typically include such events as marriage and birth of a child. Your employer will be able to confirm the full list of any lifestyle events applicable. HIV infection caught at work in an eligible occupation children s benefit. 4

5 When will the cover not pay out? We will not pay a critical illness claim: if you have elected Standard (Silver) cover and you, your spouse/partner or child suffers a critical illness not included on the list under the Standard (Silver) cover in the section Which critical illnesses are covered? or if the condition or operation is listed but your diagnosis or treatment fails to meet the relevant definition in the Conditions covered brochure if you have elected Comprehensive (Gold) cover and you, your spouse/partner or child suffers a critical illness not included on the list under the Comprehensive (Gold) cover in the section Which critical illnesses are covered? or if the condition or operation is listed but your diagnosis or treatment fails to meet the relevant definition in the Conditions covered brochure if you, your spouse/partner or child die within 14 days (or such longer time as is specified in the definition) of meeting the definition of a critical illness if the cause of claim results from alcohol, drug or solvent abuse, failure to follow medical advice or self-inflicted injury. Full details are contained in the Conditions covered brochure and Clause 5 of the policy terms and conditions issued to your employer and can be found at A pre-existing conditions exclusion applies to all benefits under this scheme (ie benefits for you, your spouse/partner (if covered) and your children). This means that if you or your spouse/partner are suffering from, or have suffered from, or have any symptoms of, any critical illness or undergone any operation covered by the scheme at any time prior to entering the scheme then you or your spouse/partner will not be able to claim for that or any further incidence of that critical illness or operation, or for any other critical illness or operation which is directly or indirectly linked to the prior critical illness or operation. For your children the pre-existing condition exclusion means that they are not covered for any critical illness or operation linked directly or indirectly to any condition or illness suffered prior to cover commencing. In addition No benefit will be paid in respect of any critical illness or operation where you, your spouse/partner or your child has suffered from an associated condition (including but not limited to the examples listed in the Conditions covered brochure) prior to the commencement of your/their cover. This will apply whether or not any treatment has been administered and/or diagnosis made of the associated condition. For all critical illnesses or operations with the exception of loss of independent existence, paralysis of limbs and terminal illness, the associated conditions will be disregarded if you, your spouse/partner or child do not suffer a critical illness or operation covered by the policy within two years from the date of your/their entry to the scheme. Associated conditions for loss of independent existence, paralysis of limbs and terminal illness remain applicable indefinitely. Important For the purpose of this exclusion, the onset or occurrence of aorta graft surgery, coronary angioplasty, coronary artery by-pass graft, heart attack, heart transplant, heart valve replacement or repair, stroke or valvuloplasty will all be considered to be directly linked. No benefit will be paid in respect of blindness, coma, deafness, loss of independent existence, loss of speech, paralysis of limbs and terminal illness linked directly or indirectly to a prior critical illness or operation. If you, your spouse/partner or your child suffers from any malignant tumour(s) defined as cancer while covered by the policy or have suffered from cancer at any time in the past then no benefit shall be paid in respect of any subsequent cancer whether or not such cancer is connected or associated with the prior diagnosis of cancer. The pre-existing conditions exclusion applies from the date of commencement of cover and will also apply to any increases you elect to make to your cover. If you re-enter a scheme (including following a claim) you will be treated as a new member and the pre-existing conditions exclusion will be re-applied from the date of re-entry to the scheme. 5

6 Further information The provider The Friends Life Group Critical Illness Flex Scheme is provided under a group critical illness insurance scheme by Friends Life Limited, part of the Friends Life group. How to make a claim Claims should be submitted through your employer as soon as reasonably practicable and in any case within three months of first diagnosis being made or undergoing surgery. Claim forms can be obtained by writing to Friends Life Group Protection Claims Management Team, 2nd Floor, Anchorage 1, Anchorage Quay, Salford Quays M50 3YL Call us on Calls may be recorded and may be monitored. Making a complaint We want you to be entirely satisfied with your flex critical illness cover. If you have a query or complaint about anything other than a claim you should speak to your employer (the policyholder) who will contact us. If you are complaining about the decision we have made on a claim we will consider any new medical evidence submitted by you or your employer. The medical evidence should support the contention that you, your spouse/partner, or your child has been diagnosed with one of the specified medical conditions or undergone one of the listed operations. Information should be sent to the Friends Life Group Protection Claims Team at the address given in the How to make a claim section. Any appeal by you or your employer must be made in writing within three months of receipt of notification from us of a claim being rejected. If you disagree with the claim decision following such written appeal you may refer the question of whether you, your spouse/partner or your child has a valid claim under the policy to: Law The cover is issued subject to the law of England. Financial Services Compensation Scheme In the unlikely event that we cannot meet our financial obligations, you may be entitled to compensation from the Financial Services Compensation Scheme (FSCS). This will depend on the type of business and the circumstances of your claim. The FSCS may arrange to transfer the policy to another insurer, provide a new policy or where appropriate, provide compensation. Further information about compensation scheme arrangements is available from FSCS on or at its website Tax Under current HM Revenue and Customs practice, premiums paid by the employer for critical illness benefit are taxed at source through the usual payroll deduction process. As a result, the payment of any benefit payable is free of tax. HM Revenue and Customs rules regarding taxation of benefits and premiums may change in the future. For those outside the jurisdiction of HM Revenue and Customs different taxation rules on benefits and premiums may apply. This information is given for guidance only and is not intended to give definitive advice and you should seek clarification of the tax position for your specific circumstances. This document is a guide to the features of the group critical illness cover arranged by your employer. Full details of the insurance are contained in the policy document issued to your employer. If there is any discrepancy between the information contained in this document and the policy document the terms and conditions of the policy document will prevail. The Financial Ombudsman Service South Quay Plaza, Marsh Wall, London E14 9SR Telephone or Friends Life Limited An incorporated company limited by shares and registered in England and Wales, number Registered office: Pixham End, Dorking, Surrey RH4 1QA. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Calls may be recorded. Friends Life is a registered trade mark of the Friends Life group. BGR/6721/JUL12