Income Protection Insurance - Policy wording (Certificate of Insurance)

Introduction

This document contains the details of the Income Protection Policy. The policy provides cover if You become Incapacitated or Unemployed. However, You are only covered as long as You meet the conditions of eligibility described below and You have paid the required premium.

This document should be read in conjunction with Your Policy Schedule which will detail Your personally selected level and details of cover. Copies policy can be made available, on request, in alternative media forms as required under the Disability Discrimination Act 1995.

SECTION 1 Eligibility

You are covered under this insurance if, on the Start Date

• You are over 18 but under 65 at the End Date (if applicable)

• and You are Working and have been in continuous employment for 6 months when You apply and this policy commences

• and You have agreed to pay the Premium(s) for cover

• and You have met the underwriting criteria set out in the application

• You are resident in the UK and We have accepted Your application.

• You must not be aware of any illness, disease, condition or injury before the Start Date that may cause You to make a claim for Incapacity benefits and You must not be aware of any impending Unemployment. We may still insure You if You are aware of any of these events. However, We will not pay benefits directly relating to that Unemployment which You were aware of in the 6 months before the Start Date nor will We pay benefits directly relating to the illness, disease, condition or injury which You were aware of or received treatment for before the Start Date.

• If You are a Contract Worker and employed under a fixed term contract of employment, We will only consider Your cover under the Unemployment section in accordance with the following:

  • If at the Start Date You have been Working for the same employer for at least two years and if You have an annual contract, which has been renewed at least once and has at least six months remaining on the contract, then We will consider any claim as if You had been in permanent employment;

  • However if at the Start Date you have been working for the same employer for at least six months and your contract has been renewed at least once, we will consider a claim only if your current contract is terminated prior to its expiry date. Benefit will only be paid until that contract would have expired.

SECTION 2 Benefits

Please refer to Your Policy Schedule for full details of Your particular level of cover. The following benefits are only covered if they are selected and stated on Your Policy Schedule:

Incapacity If You are Working and become Incapacitated after the Start Date and before the End Date for at least 30 continuous days We will pay Your Monthly Benefit. You will continue to receive an amount equal to 1/30th of Your Monthly Benefit (payable monthly in arrears) for each further day that You remain off Work until the End Date or, You stop being Incapacitated or, We pay 12 Monthly Benefits for each Incapacity claim whichever is the sooner. Incapacity benefits will not start until You consult a Doctor. However, if You complete a self-certification form (from Your employer) for the first 7 days of Incapacity, You will be classified as Incapacitated for those 7 days. We will only pay You Incapacity benefit if a Doctor is regularly treating You for the condition causing Your Incapacity. If You have made an Incapacity claim which ends for whatever reason, You will not be able to make another Incapacity claim until You have been in continuous work for 30 days if the Incapacity is different or, 180 days if the Incapacity is the same.

Unemployment If You are Working and become Unemployed after the Start Date and before the End Date for at least 30 continuous days and register with the Job Centre Plus within fifteen days of Your Unemployment, We will pay Your Monthly Benefit. You will continue to receive an amount equal to 1/30th of Your Monthly Benefit (payable monthly in arrears) for each further day that You remain off Work until the End Date or, You stop being Unemployed or, We pay 12 Monthly Benefits for each Unemployment claim.

• If two periods of Unemployment are separated by 3 months or less We will treat this as one continuous claim. We will not pay any benefit during any time You were Employed between these periods. If the two periods of Unemployment are separated by more than 3 months, You must return to Work for a total of 6 continuous months before You can make another Unemployment claim.
  
• If You are receiving Unemployment benefit and want to start temporary Work which will continue for less than 6 months, please let Us have details in writing before You start this Work. We will not pay any benefit during the period that You are not Unemployed. However, when the temporary Work finishes, Your Unemployment claim may continue and We will treat this as one continuous claim. The most We will pay for this continuous claim is 12 times the Monthly Benefit in total.
  
• If You are Self Employed and wish to make an Unemployment claim, Your business must have permanently ceased trading and You must be registered with the Job Centre Plus within fifteen days of unemployment and informed the Inland Revenue that You are no longer in business.

SECTION 3 Payment of Benefits

• We will pay benefits into the account specified on Your claim form. Incapacity and Unemployment benefits are paid monthly in arrears in thirty day periods.

• We only pay You one type of Monthly Benefit (Incapacity or Unemployment) at a time. If You are Joint Applicants, We will pay to each of You in the percentages shown on Your application Schedule.

• The maximum combined benefit payable for Incapacity or Unemployment claims under this insurance will not be more than the sum of £1,000 per month or 50% of Your gross monthly income whichever is the less.

SECTION 4 Cover Exclusions

Incapacity We will not pay You any Incapacity benefits resulting from;

• if You did not elect to have Incapacity benefit on Your application form,

• the recurrence of any Incapacity, illness, symptom or related condition for which You sought medical advice before the Start Date, or for any chronic or continuing medical condition

• alcohol or drugs not taken under the advice or supervision of a Doctor,

• medical operations or treatments which are not medically necessary, including cosmetic or beauty treatment unless this is the result of an accident where Your Doctor recommends You have cosmetic treatment;

• self inflicted injuries caused while sane or insane,

• any Incapacity which occurs while You are Working outside of the United Kingdom unless You are Working for the British Armed Forces, or as a civil servant in a British embassy or consulate, or unless You are Working on a specific project for less than 30 days outside the United Kingdom and were actually outside the United Kingdom for less than 30 days,

• backache and related conditions unless there is additional medical evidence (for example an MRI scan) of abnormality which We will require to validate Your claim. If Your Incapacity arises directly or indirectly from a back related condition where there is no physical or radiological evidence of medical abnormality, unless a Consultant certifies that the condition prevents You from Working.

• any condition of a mental or nervous origin including stress, anxiety or stress related conditions including depression, unless We validate Your claim by reference to additional specialist medical evidence which We will require. The condition must have been diagnosed by a Consultant Psychiatrist who You should be under the continued supervision of and be receiving treatment from.

• normal pregnancy conditions causing morning sickness or fatigue, actual child birth or maternity leave. Pathological conditions lasting longer than 30 days and diagnosed by a member of the Royal College of Obstetricians are not excluded and neither are any other abnormalities during normal pregnancy.

Unemployment We will not pay You any Unemployment benefits resulting from the following;

• if You did not elect to have Unemployment benefit on Your application form,

• if You were not in continuous Work for 6 months immediately before Your employment ended. If You were not in Work for 2 weeks or less, We will not count this as a break in Your employment,

• if, at the Start Date, You knew You were to be made Unemployed or should reasonably have known that it was likely to happen,

• if Your employment ends or You are notified, verbally or in writing, of Your employment ending, within 120 days of the Start Date,

• if Your Work is seasonal or if Unemployment is a regular feature of Your Work,

• if You are Working on a specific project and this project finishes,

• if You are Self-Employed and Your business temporarily stops trading;

• if You become voluntarily Unemployed (which includes ending Your Work voluntarily during a period of notice given by Your employer) or voluntary redundancy,

• if You Work on a fixed contract which ends unless You meet the conditions explained in the definitions of Contract Worker. However, if You have been in continuous Work with the same employer for at least 2 years and Your contract has been renewed at least once and You had no reason to believe that it would not be renewed again, this exclusion will not apply,

• if Your work ends as a result of the expiry of an apprenticeship or training contract,

• Unemployment caused or resulting from:

  • Misconduct which contributes or leads to Your dismissal;

  • any wilful act by You;

  • dismissal due to the inability to pass a probationary period or perform any elements of Your job,

• if You are Working outside of the United Kingdom unless You are Working for the British Armed Forces, or as a civil servant in a British embassy or consulate, or unless You are Working for an employer that is a United Kingdom registered company who assigns You to Work in a member country of the European Union on the same terms and conditions,

• if You are dismissed by Your employer as a result of misconduct, breaking the terms of Your employment contract, criminal offence or failing to meet the standards or targets laid down by Your employer,

• if You do not make a genuine and continuing effort to get Work and provide satisfactory proof of this.

General Exclusions

No benefit will be paid if Your Incapacity or Unemployment results directly or indirectly from the following circumstances

• civil unrest, war, radiation and radioactive contamination, or any related event,

• strike or lock-out or Your involvement in such,

• Human Immunodeficiency Virus (HIV) and/or any HIV related illness including Acquired Immune Deficiency Syndrome (AIDS) however such may be defined.

SECTION 5 Maximum Cover

The amount of cover You select is known as the Monthly Benefit. The maximum Monthly Benefit available, under this insurance is £1,000 or 50% of gross monthly income whichever is the lower, less any other form of income but excluding State Benefits.

In addition, the maximum Monthly Benefit allowed under all similar insurances (including this insurance) is 50% of gross monthly income less any other form of income including payments in lieu of notice and employers’ sick pay but excluding State Benefits. All benefits over 50% of gross monthly income will be deducted in the event of a claim.

SECTION 6 Claims Conditions

• You should contact Our Administrator, Adminicle Limited, Callidus House, Cirencester Business Park, Love Lane, Cirencester GL7 1XD or telephone 01285 886109 to request a claim form.

• You must complete the claim form fully and accurately and return it to Us at the address above. This claim form should be received by Us within 60 days of the date Your Incapacity or Unemployment began, or as soon as possible after this.

• We may ask You to fill in a continuing or supplementary claim form at Your own expense for each month You are claiming. You must send this to Us within 60 days of the date We last paid Your Monthly Benefit or as soon as possible after this.

• When You make a claim, You must give Us all the evidence that We need (at Your own expense) to prove Your claim. You must give Us this evidence in the way We ask. We may also ask You for additional information during Your claim such as (but not limited to) being examined by a Doctor (at Our expense) or, certificates from Your employer stating that You are not presently working or, a copy of the Jobseekers Agreement that You signed with Your local Job Centre Plus office and a certificate from Your last employer stating that You no longer Work for them.

• We will not pay Your claim if We cannot validate it because You are late sending Us Your claim form or any additional information that We may reasonably request. Any attempt to falsify any information provided to Us may invalidate Your claim and may result in Us cancelling this insurance immediately.

• If We start to pay Monthly Benefit because You are Incapacitated and You become Unemployed, or Unemployed and You become Incapacitated, You must write and advise Us straight away. When deciding if Your claim is still valid, We will take into consideration the fact that You have not been Working because of Your Unemployment or Incapacity. We will continue to pay Your Incapacity benefit while it remains valid. If You are still Unemployed once a Doctor says You are fit to return to Work, You must tell Us and We will ask You to complete an Unemployment claim form. If You change Your claim, the most We will pay for both Your Incapacity and Unemployment claims combined is 12 times the Monthly Benefit.

• If You are unable to meet Our conditions to claim for Incapacity benefit You can claim Unemployment benefit once You are fit to work. You must let Us know that You are no longer Incapacitated and You must meet Our conditions to claim Unemployment benefit. If Your claim is valid, the most We will pay is 12 times the Monthly Benefit which will include any Monthly Benefit We paid before Your Incapacity started.

• During Your claim We may arrange for an agent to visit You. The purpose of such visit will be to gather details regarding Your claim in order to ensure an accurate assessment. It is essential that You make Yourself available for such a visit. If You fail to do so no further benefit will be payable.

SECTION 7 General Conditions

• All cover under this insurance will end and all Monthly Benefit will stop automatically if You die or, when You reach the age of 65 or Permanently Retire or, when You miss paying any premium(s) which may be due to Us under this insurance.

• If Joint Applicants are covered under this insurance and one of You reaches 65 or Permanently Retires, that person will no longer be covered. If You write and tell Us about this however, the other person can then receive all the Monthly Benefit if a claim needs to be made provided this does not exceed 50% of Your income.

• You may not transfer or assign Your rights or interest in this insurance to any other person. This insurance does not have any value at the End Date nor does it acquire any surrender value during the period of insurance.

• We reserve the right to amend the terms of a monthly premium renewable insurance contract by giving You notice of Our intention to do so as follows; to withdraw, terminate or cancel the cover, 90 days notice, to vary the cover provided, 30 days notice, to alter the rates of premium (other than any statutory tax changes) charged during the period of cover, 30 days notice. The minimum period between consecutive changes will be 180 days. If You do not have a monthly premium renewable insurance contract, then You will not be affected by these possible changes.

• If You are not satisfied that this insurance is suitable for Your requirements, You may write to Us within 14 days of the Start Date and We will cancel Your cover from the Start Date without charge provided no claims have been made.

SECTION 8 – Definitions

In this Certificate, Your application and Insurance Schedule or anything attached to or subsequently endorsed hereon, the following words and expressions have the following meaning(s) wherever they may appear

Administrator Adminicle Ltd, Callidus House, Cirencester Business Park, Love Lane, Cirencester GL7 1XD

Chronic Condition A condition that occurs prior to the policy Start Date and that continues indefinitely, or cannot be cured or eradicated and that recurs or requires treatment.

Consultant a senior medical practitioner registered and practising in the UK. This does not include You or Your relatives.

Contract Worker You are employed on a regularly renewable or individually negotiated employment contract which is periodical and has been renewed at least once, or You have been under contract with the same employer for at least 24 months. You will be defined as being in Work, if You have been employed for at least 6 months with the same employer and Your contract has been renewed at least twice, Unemployment benefit is payable if the contract is terminated early but only up to the end of the contract term.

Deferred Period The 30-day period before any benefit is paid.

Doctor A medical practitioner registered and, practising in the UK. This does not include You or Your relatives except when disclosing a pre-existing condition as detailed in Sections 1 and 4 of this Certificate.

Employment, Employed Any Work (including self-employment) of at least 16 hours a week. You must also be paying the correct class of National Insurance Contributions.

End Date The date that cover ceases under this insurance as detailed in Section 7 of this Certificate.

Exclusion Period The period shown in Section 4 above and on Your schedule of insurance. This period immediately follows the Start Date of Your insurance

Incapacity, Incapacitated An illness, disease, condition or injury, which stops You from doing Your job or any similar job. It must also stop You from doing any paid Work that Your experience, education or training reasonably qualifies You to do. If You are Self Employed, an Incapacity must stop You from helping, managing or carrying out any part of the day-to-day running of a business.

Joint Applicants Two people who are responsible for the regular monthly payments stated in the application Schedule.

Misconduct Means being dismissed from Your Employment as a result of, but not limited to, theft, fraud, alcohol abuse, sex offences, harassment and/or discriminatory behavior.

Monthly Benefit The amount equal to the payments that You must make every month under any Mortgage, Rental and/or Loan agreement(s) plus all other regular payments as stated on Your application Schedule up to a total of £1,000 or 50% of Your gross monthly income whichever is the less (unless Your schedule of Insurance shows a different amount). If You are Joint Applicants, the MonthlyBenefit will be the percentage shown in Your application and Insurance Schedule.

Permanently Retire When You have stopped Working and You have no intention of returning to Work in the future.

Self Employed Means that You are helping with, managing or carrying on a business in the UK and are liable to pay tax under Schedule D Case I, II, IV and V of the Income and Corporation Taxes Act 1988. We will also consider You to be self employed if You are a partner in a partnership or, a person who exercises direct or indirect control over a company (but not necessarily the majority shareholder or holder of the majority voting rights) or, if You are Working for a business or company which is in any way connected with a relative (by blood or marriage) who has control over that business or company.

Start Date The requested date stated on Your application as shown on Your Schedule of Insurance.

Unemployment, Unemployed Being out of Work and receiving the correct class of National Insurance credits by reason of Unemployment, unless You have been entitled to make reduced National Insurance contributions in the past. You must be actively looking for Work. We will not consider You as Unemployed for any day that You receive pay in lieu of notice.

UK United Kingdom, Channel Islands and the Isle of Man.

We, Us, Our, Underwriters Bankers Insurance Company Limited (a subsidiary of Assurant Solutions)

Work, Working Permanent Employment or Self-Employment for 16 hours or more each week or on statutory maternity leave, adoption leave, parental leave or paternity leave from such Employment. You must also be paying the correct National Insurance Contributions.

You, Your, Insured The person or persons stated in the application, each satisfying the eligibility requirements set out in Section 1 of this Certificate.

SECTION 9 Important Notices

Data Protection. The data supplied by You will only be used for the purposes of processing Your policy of insurance, including underwriting, administration and handling any claim which may arise. The data supplied will not be passed to any other parties other than those which are mentioned below. It is important that the data You have supplied is kept up to date. You should therefore notify Us promptly of any changes so that We may update Our records.

You are reminded that it is essential You provide all material information likely to influence the acceptance and assessment of this insurance. If You have any doubts as to whether a fact is material, it should be disclosed. Failure to disclose any material facts may invalidate Your policy or may result in Your policy not operating fully. We may also respond to enquiries by the Police concerning Your policy in the normal course of their investigations. Where it is necessary to administer Your policy effectively or to protect Your interests, We may disclose the personal data You have supplied to other third parties such as solicitors, loss adjusters, other insurers etc. We may also if necessary contact other parties requesting sensitive data, these may include doctors, hospitals, consultants, employers etc., but We will ensure that We obtain Your consent to approach such other parties prior to doing so. You should show this notice to any person directly or indirectly insured under this Policy about whom personal information has been supplied.

If You are a resident of the European Union, then the parties completing this Contract are free to choose the law applicable to this Contract. However, unless it is specifically agreed to the contrary, the Contract shall be subject to English Law.

If You have given false information to Us on or before the Start Date, on Your claim form or in connection with this policy, or any claim made, We may cancel the policy immediately. We may demand You repay any benefits We have already paid You. We will keep the premium You have paid Us. We may also prosecute You.

SECTION 10 Customer Care

Any enquiry or complaint You may have about this contract should be addressed in the first instance to the Administrator Adminicle Ltd, Callidus House, Cirencester Business Park, Love Lane, Cirencester GL7 1XD Telephone No 01285 886109. Please be ready to quote Your Certificate Number so that Your enquiry or complaint may be dealt with promptly.

If You are still not satisfied with the way that Your enquiry or complaint has been dealt with, You may contact the Underwriters to review Your case without prejudice to Your rights in Law, the address is:

Assurant Solutions, The Operations Director, 117-119 Whitby Road, Slough, SL1 3DR.

If the matter remains unresolved and once the above have been contacted, then You can approach the Financial Ombudsman Service at South Quay Plaza, 183 Marsh Street, London E14 9SR. Phone 0845 080 1800.

SECTION 11 Financial Services Compensation Scheme

If We are unable to meet our liabilities, You may be entitled to compensation from the Financial Services Compensation Scheme, which was set up under the Financial Services and Markets Act 2000. There are maximum levels of compensation You can receive under the Financial Services Compensation Scheme and Your entire loss may not be covered. Further details are available on request. Most insurance contracts are covered for 100% of the first £2,000 and 90% of the remainder of the claim. Further information on this scheme can be obtained from the FSCS.

Choices Insurance Marketing Ltd, Adminicle Ltd, and Bankers Insurance Co Ltd are all authorised and regulated by the Financial Services Authority.