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Glossary
A
Accident Means a sudden unexpected and specific event which occurs at an identifiable time (moment or point in time) and place and which results in Injury.
Accidental Death In the event that an Insured Person should sustain Bodily Injury during the period of this insurance and such injury results in death of the Insured Person within 12 months from the date of the accident, Underwriters agree to indemnify the Insured Person’s executors or administrators the sum as stated in the Schedule of Benefits contained herein.
Air Travel Means being in or on or boarding an aircraft for the purpose of flying therein or alighting there from following a flight.
Accumulation Limit Means the maximum liability We will pay under this Policy in respect of any one Accident or number of Accidents arising from one source or cause.
Aids Means an opportunistic infection, or a malignant neoplasm. For the purpose of this definition the term "Acquired Immune Deficiency Syndrome" will have the meaning assigned to it by the World Health Organisation. Opportunistic infection will include but not be limited to Pneumonia caused by Pneumocystis Carini, the organism of chronic enteritis virus and or disseminated fungal infections. Malignant Neoplasm will include but not be limited to Kaposi's Sarcoma, lymphoma of the central nervous system and or other malignancies now known or which became known as immediate causes of Death or Illness in the presence of Acquired Immune Deficiency Syndrome. Acquired Immune Deficiency Syndrome will include HIV (Human Immune Deficiency Virus), Encephalathy (dementia) or HIV wasting syndrome.
Ambulance Costs Means the Benefit paid for emergency road transportation to and from Hospital in the event of an Accident necessitating such transportation but not exceeding the amount shown in the Table of Benefits provided that such costs are not recoverable from any other source.
B
Bodily Injury Means an identifiable physical injury, which is caused by accidental and visible means, but shall also include exposure resulting from mishap to the conveyance in which an Insured Person is travelling.
Benefit Means the amount paid at the rate shown in the Table of Benefits.
Beneficiary/ies Means the person or persons nominated by You and named in the application form.
C
Congenital Abnormality Means a condition that is recognised at birth or that is believed to have been present at birth.
Child/ren Means:
- any natural children,
- lawfully adopted children,
- step children by marriage,
- foster children who have in terms of the provisions of any legislation relative to
the protection of children been placed in the custody of the policyholder as foster
children, or any children who are living with the policyholder in the same household
in a relationship which is not casual or impermanent and as if they were the lawful
children of the policyholder, who are over the ages of 6 months and under 18 years
of age (or under 25 years of age and are full-
time students at an accredited institution for higher learning), not pregnant, unmarried and primarily dependent on You for maintenance and support.
D
Date of loss Means for Injury, the date of the Accident.
Diagnosis Means the primary cause for the health condition of the Insured Person shall be deemed to be the defined diagnosis. In the event two health conditions cause the Insured Person’s health to deteriorate then the primary diagnosis shall qualify for benefits.
E
Economical Impairment Shall mean a reduction in the Life insured’s ability to work at his nominated occupation as a result of a physiological impairment. The degree of economical impairment is related to the nominated occupation of the Life insured, and his rehabilitation in a lucrative activity conforming to his knowledge, previous activities and social status.
Effective Date Means the date stated in the application form.
Eligible Dependent Means the people named in the document of insurance that are unmarried dependent children under 18 years of age. A child who is a full time student will be covered providing they have not yet attained their 26th birthday.
Emergency Means the use of emergency services whether on the road, sea or air ambulance conveyance in the event of a medical or other evacuation, including repatriation and the use of fire tenders at the scene of an accident or premises, in which an insured person requires immediate medical treatment in order to sustain or preserve life.
Emergency services Means registered transport and personnel used specifically for the attendance of emergency situations.
Exposure Shall mean if death or permanent total disablement is caused as a direct result of exposure to the elements of nature, death or permanent total disablement shall be deemed to have been caused by bodily injury.
F
Family Means your nominated Spouse and Your Children.
H
Health benefits Means the stated benefit in respect of medical treatment, diagnosis or advice provided to the Insured Person, Spouse or an Eligible dependent whilst hospital confined as an inpatient in the Republic of South Africa. Such benefits will be restricted to the Health & Accident rate.
Holder Means H&A that has arranged for the insurance herein contained and who has the ownership, possession or use of the insurance herein defined and who has the legal right to enforce same and negotiate on behalf of the Insured Person in this respect.
Hospital Means a legally constituted establishment that operates pursuant to the laws of the country in which it is based and which meets the following requirements:
- it operates primarily for the reception, medical care and treatment of sick, ailing
or injured persons on a resident in-
patient basis; - it admits resident in-
patients only under the supervision of a Medical Practitioner; - it maintains organised facilities for the medical diagnosis and treatment of such persons and provides (where appropriate) facilities for major surgery within the confines of the establishment or facilities controlled by the establishment;
- it provides a full-
time nursing service by or under the supervision of a staff of nurses; - it is not a day clinic, health hydro or nature clinic, a mental institution, an institution confined primarily to the treatment of psychiatric disease, the psychiatric department of a hospital, a place for the treatment of chemical dependence, an establishment or a special unit of a hospital used primarily as a place for treatment of drug addicts or alcoholics, a hospice, frail care centre, a rest or nursing home, convalescent, rehabilitation, assisted living or extended care centre.
Hospitalisation Means admission to Hospital as an in-
I
Illness Means the Insured Person becoming fortuitously (suddenly and unexpectedly) ill during the period of the certificate.
Immediate Medical Treatment Means a Medical Practitioner’s treatment, consultations and prescribed or repeat maintenance medication in respect of treatment commencing within 24 hours of the time and date of the Injury.
Incident Means a Hospitalisation necessitating the occupation of a bed for a minimum of 6 hours.
Injury Means a bodily injury or physical trauma to an Insured Person resulting from an Accident occurring solely, directly and independently of any other cause or any other physical defect or infirmity existing prior to the Accident in an Insured Event within 24 months of the date of the Accident. Exposure to the elements of nature as a direct result of an Accident will be deemed to be Injury.
Insured Person Means You or Your Spouse, or Your Children.
Insured Event Shall mean any benefit covered in terms of this policy.
L
Legal Representative/s Means the person or persons who manage the legal affairs of the Insured Person as a result of incapacity or Death.
Limit any one Life Means the maximum amount payable to any one Insured Person specified in the Table of Benefits.
M
Maternity Means the period in which a woman carries a developing foetus.
Medical Expenses Means the reasonable and customary charges levied from a registered Medical or paramedical practitioner for actual costs incurred up to the maximum limit stated in the Schedule of Benefits as a result of an Accident if an Insured Persons medical condition requires Immediate Medical Treatment but excluding any amount of any compensation recoverable by or on behalf of an Insured Person under any occupational injury enactment or workmen’s compensation enactment or any other insurance policy Medical Expenses include the cost of necessary medical or surgical treatment, services, or supplies, including necessary hospital, nursing and ambulance services. Medical Expenses in respect of dental charges are limited to treatment of Bodily Injuries sustained to sound natural teeth and received within 30 days of the Date of Loss.
Medical Practitioner Means a person currently legally licensed and registered to practice medicine other than You under this Policy or a member of any Insured Person’s immediate family.
Medical Treatment Means a Medical Practitioner’s medical advice, treatment, consultations, and prescribed or repeat maintenance medication.
Motor Vehicle Accident Means an Accident involving the vehicle in which the insured person is travelling as the driver or as a passenger, and a third party.
N
Nominated Occupation Shall mean the occupation as detailed on the application form.
O
Occupational Therapist Shall mean a person currently legally licensed and registered to practice occupational therapy (other than the Life Insured under this policy or a member of any Life Insured’s immediate family).
P
Partial Total Disablement Means Disablement as a result of an Accident which partially prevents the Principal insured from attending to any business or occupation of any and every kind.
Period of Insurance Means the period for which Underwriters have received monthly premium in accordance with the Terms and Conditions section of this insurance.
Permanent and Incurable Insanity Shall mean the insured being diagnosed as permanently insane according to the usual and customary standards of the registered medical profession by two practitioners who are not related in any way whatsoever.
Permanent Total Disablement Means Disablement as a result of an Accident which entirely prevents the Principal insured from attending to any business or occupation of any and every kind and which lasts for 12 months and which at expiry of that time is beyond hope of improvement.
Policy Means this document embodying the contract of insurance and will include any subsequent endorsements, amendments, declarations and application form and correspondence issued to You.
Principal insured Means the insured person named in the application form as the Principal Member.
Procedure In the event the Insured Person is hospitalised and treatment is required following a defined diagnosis then the benefit applicable to that procedure shall be payable. If the primary procedure results in a further defined diagnosis or procedure, then the benefit payable shall be for the initial procedure only.
Professional Player Means an Insured Person earning in excess of 50% of his income from playing sport.
Professional Sport Means a sport which remunerates a player as a means of livelihood.
Physiological Impairment Shall mean a reduction in the integrity of the body of the Insured
Physician or Medical Practitioner Shall mean a person currently legally licensed and registered to practice medicine.
R
Reasonable and Customary Charges Means a charge which:
- is charged for treatment, supplies or medical services medically necessary to treat an Insured Person’s condition;
- does not exceed the usual level of charges for similar treatment, supplies or medical services in the locality where the expenses are incurred; and
- does not exceed charges for treatment that would not have been made if no insurance existed.
Retrospective Payment Shall mean that for the seven day waiting period, claims will be paid retrospectively back to day One.
S
Spouse Means the husband, wife, partner in a permanent same sex life partnership or any de facto partner with whom the Insured Person has permanently and continuously lived in the same household in a relationship which is not casual or impermanent for a period longer than 12 consecutive months and as if he or she were Your lawful spouse. Only one Spouse shall be eligible for cover under a Policy.
T
Temporary Disablement Means hospitalisation as a result of an unforeseen illness or injury. Such illness or Injury shall be sole cause for the Insured person to be hospitalised.
Temporary Total Accidental Disablement Means disablement as a result of Bodily injury which entirely prevents the Principal insured from attending to their usual occupation for a period of not less than 7 (seven) days.
Terrorist Act Means active involvement in any actual or threatened use of force or violence directed at or causing damage, Injury, harm or disruption, or commission of an act dangerous to human life or property, against any individual, property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator/s and victim/s will not be considered Terrorist Acts.Terrorism will also include any act which is verified or recognized by any relevant Government as an act of terrorism.
W
War Means war, whether declared or not, or any warlike activities, including use of military force by any sovereign nation to achieve economic, geographic, nationalistic, political, racial, religious or other ends.
Waiting Period Shall mean the initial period during which no benefit is payable.
We / Our/ Us Means the company.
Y
You/Your Means the policyholder who is under the age of 55 years, who has applied for this insurance and who is responsible for the payment of the premium and has completed an application form incorporating a premium deduction authority satisfactorily.
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