What the Personal Accident policy covers

The Personal Accident policy provides you with invaluable cover if you are injured and admitted to hospital or you are disabled or die as the result of an accident.

Benefits of the Personal Accident policy

• A discount on the additional premium if you add your partner/spouse.
• No medical examinations.
• Non-medical expense cover as a result of hospitalisation, commences on the first day of hospital admission for a maximum of 104 consecutive weeks.
• Tax-free payout in the event of disablement or death.
• Expo-Sure cover, which gives you access to HIV testing and treatment after accidental exposure.

Children’s Benefit

Children are also covered for the maximum amounts below:

• R10 000 for children unborn to 6 years old.
• R30 000 for children 7 to 14 years old.
• 25% of the main member’s cover for children between 15 and 21, and up to 25 if they are registered full-time students.

Please note that the cover selected by the main member determines the amount of cover available to children older than 15.

How do my payments work?

Your Personal Accident policy gives you monthly cover and your premium is deducted in advance on the date stated on your schedule. If in the month following the activation of your policy (and onwards) we do not receive your premium on the due deduction date, you will be allowed a 15-day period of grace in which to pay your premium. If we still do not receive your premium after these 15 days, you will not have cover for that month.

Premium obligations

For your premium obligations, refer to the paragraph headed “Payment details” on your schedule. This will give you details regarding the premium payable, the manner of payment of premiums and the due date for payment of your premiums. Your policy will only commence upon receipt of the first premium.

Please take note that we agreed to collect the monthly payment for your policy by debit order. A deduction will be made on the same date every month. We reserve the right to deduct the premium on an alternative date in an attempt to ensure cover. Should this date fall on a Sunday or public holiday, the deduction will be made either on the last working day prior to or the first working day after the weekend or public holiday. If we do not receive your premium on your preferred deduction date, we may attempt to collect your premium on a more suitable date in an effort to keep you covered. If payment is not received for three consecutive months, the policy will be cancelled immediately.

The definition of an accident

An accident is an unexpected and unintentional event, caused by violent, external and visible means, commonly leading to injury resulting in hospitalisation, disablement or death within 12 months of the event.

The definition of total permanent disablement

This is a disablement that entirely prevents the insured from gaining employment of any kind, and that is likely to last for the remainder of the insured’s life. This condition must be substantiated by medical evidence.

Scale of benefits for disablement

If you claim for more than one of the above injuries/losses, your total payout when added up will be limited to 100%.

Hospitalisation

If the insured is hospitalised as a result of an accident, cover will be provided from the first day of hospital admission, up to a maximum of 104 weeks. The claim will only be paid once the hospital records have been provided and authorised for payment. If compensation for disablement or death becomes payable, there will be no compensation under this benefit.

The benefit will only be payable to the policyholder and not to the hospital or provider of the health services.  Please note that this is not a medical scheme and the cover is not the same as that of a medical scheme.  This policy is not a substitute for a medical scheme membership.

Death cover

Should the insured die as a result of an accident, we will compensate his/her nominated beneficiary/ies or estate to the level of cover chosen. Compensation for total permanent disablement or death will be paid in one lump sum. Payment will be tax-free.

Total Permanent Disablement cover

Should the insured suffer disablement as a result of an accident, we will compensate him/her according to the scale of benefits and level of cover chosen – see the scale of benefits table above.

What the Personal Accident policy does not cover

• Self-inflicted injury.
• Injury due to mental disability.
• Hospitalisation, disablement or death as a result of a hazardous pursuit.
• Hospitalisation, disablement or death as a result of alcohol or drug abuse.
• Non-accident-related hospitalisation.
• Death and disability as a result of an accident or injury that occurred prior to the commencement of this policy.
• Suicide.
• Death and injury as a result of natural causes.

Your obligations

If you do not fulfil any of the following obligations, your cover may be cancelled. Your obligations are as follows:

• Incorrect information or non-disclosure, or misrepresentation of information, may influence the insurer on any claims arising from your contract of insurance and may influence the insurer’s decision to provide the benefits in terms of your policy, or to accept or terminate your policy.
• Inform us if any of the policy details or declarations are incorrect, or if any of these details or declarations change.

Disputed claims

After we inform you of our decision on a claim, we will allow you 90 days to make representations to us about our decision. If you do not comply with this time limit, we will not reconsider the disputed claim. If we do receive representations, the decision will then be reviewed and the outcome communicated to you.

If, after review, we do not compensate you for a claim or any part of it and you wish to challenge our decision, you must serve legal process on us within six months, calculated from the expiry of the 90-day period referred to above. If you do not comply with this time limit, you will be prevented from proceeding with legal process.

Expo-Sure

There is still a great deal of fear and ignorance surrounding HIV/Aids, which affects the way HIV-positive people are viewed by society. If you are accidently exposed to HIV, you will need as much support and guidance as possible.

The purpose of this product is to ensure that you and your family have full access to confidential HIV testing and treatment within the critical 72-hour window period after accidental exposure.

Accidental exposure to HIV

There are many ways in which accidental exposure can occur, including the following:

• Sexual transmission through assault and/or molestation.
• Blood transfusions and accidental contact with needles.
• Direct contact with bodily fluids of an infected person through incidents such as vehicle accidents.
• Occupational exposure, e.g. in the health-care industry.
• Mother-to-child transmission during pregnancy, at birth and through breastfeeding.

What to do in the event of accidental exposure

In the unfortunate event of accidental exposure, these are the steps that must be taken to ensure your safety:

1. Immediately call the Care Centre number (below).
2. You will be directed to the nearest doctor, clinic or hospital, where appropriate treatment will be given.
3. Blood tests will be done to determine your HIV status.

If the patient tests HIV-negative:

• Anti-retroviral treatment will be provided.
• Prophylactic therapy will be provided to prevent possible sexually transmitted infections (STIs).
• The ‘morning-after pill’ will be given in the event of sexual assault.
• He/she will be monitored over a three-month period and retested.
• If his/her status remains negative, the file will be closed.

If the patient tests HIV-positive:

• STI treatment and the ‘morning-after pill’ will be provided.
• The patient will be given the opportunity to join an HIV/Aids Disease Management Programme (treatment costs will be for his/her own account or medical aid).
• Lifelong telephonic advice and counselling will be offered to the patient.

Treatment benefits:

• Access to a 24-hour, 365 days a year care centre for HIV/Aids information, advice and counselling.
• Two blood tests and consultations after potential exposure cases.
• Anti-retroviral therapy to prevent infection.
• The ‘morning-after pill’ to prevent pregnancy.
• STI preventative medication (prophylaxis).

Sexual assault

If you are sexually assaulted, you have access to the following:

• An unlimited counselling benefit for the patient and immediate family. The patient may use R1 000 of this benefit for alternative therapy, e.g. reflexology, aromatherapy, etc. Please note that any service under this benefit must be provided by a registered practitioner. Original invoices must accompany all claims for reimbursement.
• A security benefit of R2 000 for reasonable security improvements after a sexual assault-related incident.Please note that any service under this benefit must be provided by a recognised company/individual. Original invoices must accompany all claims for reimbursement.

How to protect yourself:

• Always use a condom.
• Know about your partner’s lifestyle.
• Avoid contact with blood or other bodily fluids, syringes or needles.

Process followed after accidental sexual exposure

Sales, Admin and Claims
0860 10 95 71

This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for a medical scheme membership.