CLAIMS CONDITIONS

Compliance The Insured Person must follow the Company’s advice or instruction otherwise the Company may decline to pay the whole or any part of the claim.

Legal action  If the Company denies liability for any claim and the Insured Person does not institute legal action and serve summons on the Company (or initiate arbitration proceedings if the Company has agreed to submit to arbitration) within 12 months after such repudiation, all benefits of such claim shall be forfeited.

Notice of claim and proof of loss

The Insured Person must give the Company notice in writing:

  a)  Within 60 days of an Accident which may give rise to a claim under section 2 of this Policy.  Any benefit related to death will only be payable if the Company receives written notification of the death within 30 days. The Company shall have the right to have a post mortem examination of the body conducted.

 b)  Within 30 days of any other occurrence which may give rise to a claim under this Policy.

The Insured Person must, at his own cost, provide whatever certificates, information and documented evidence (“Evidence”) is required by the Company regarding the Insured Event.

Recoveries All recoveries net of the Company’s actual recovery costs will be distributed firstly to the Company for all amounts paid and any remainder will be paid to the Insured Person.

Fraudulent Claims If the Insured Person or anyone acting on his behalf uses any fraudulent means or devices to obtain any benefit, then any amount payable in respect of such claim shall be forfeited.

General

- The Insured Person shall submit to medical examination at the expense of the Company as often as shall be required in connection with any claim. Any report generated as a result of such examination shall be the property of the Company and shall be deemed to be confidential information of the Company.

- Medical Treatment shall be sought and followed promptly on the occurrence of an Injury or Illness and the Company shall not be liable for that part of any claim which in the opinion of a Medical Practitioner arises from the unreasonable or willful neglect or failure of any Insured Person to seek and remain under the care of a qualified Medical Practitioner.

- All claims arising from criminal incidents are to be supported and accompanied by a certified police report.

- The due observance and fulfillment of the Policy insofar as it relates to anything being done or complied with by the Insured Person, shall be a condition precedent to liability to make any payment under this Policy.

- The Company shall have the right to access any current or prior medical records of the Insured Person in order to finalize and/or proceed with the assessment of a claim and/or render medical assistance.  By virtue of this clause, the Insured Person shall be deemed to have given the Company written consent to access any of the Insured Person’s current or prior medical records.

- No amount payable in terms of this Policy shall bear any interest.

GENERAL EXCLUSIONS

The Company will not be liable to pay any benefit caused by or arising directly or indirectly from:

1. War, invasion, act of foreign enemy, hostilities, civil war, rebellion, revolution, insurrection or military or usurped power, labor disturbances, riot, strike or lock-out. However, the Insured Person will continue to be entitled to be covered for 7 calendar days from the start of the hostilities in case he is surprised by such events abroad and insofar as he does not actively participate in them.; nor

2. The intentional use of military force to intercept, prevent, or mitigate any known or suspected Terrorist Act; nor

3. Any Terrorist Act or bomb incident or threat thereof; nor

4. The use, release or escape of nuclear materials that directly or indirectly results in ionizing, radiation or contamination by radioactivity from any nuclear fuel or from nuclear weapons materials. For the purpose of this exclusion only combustion shall include any self-sustaining process of nuclear fission; nor

5. The release, the dispersal or application of pathogenic or poisonous biological or chemical materials; or

6. Being in service or on duty with or undergoing training with any military or police force, or militia or paramilitary organization; nor

7. Engaging in occupational activities underground or requiring the use of explosives; nor

8. Willful or deliberate exposure to danger (except in an attempt to save human life), intentional self inflicted injury, suicide or attempt thereat; nor

9. Deliberate violation of criminal law; nor

10. Traveling by air except as a passenger on a legally licensed aircraft or where the Insured Person is acting as part of the aircraft crew; nor

11. Mental disorders including, but not limited to anxiety disorders, eating disorders, psychotic disorders, affective disorders, personality disorders, substance use disorders, somatoform disorders, dissociate disorders, psychosexual disorders, adjustment disorders, organic mental disorders, mental retardation and autism; nor

12. Pregnancy and all related conditions, including services and supplies related to the diagnosis or treatment of infertility or other problems related to inability to conceive a child;  birth control, including surgical procedures and devices; nor

13. Sexually transmitted diseases and the conditions commonly known as AIDS or HIV and/or any related illness or condition including derivatives or variations thereof, howsoever, acquired or caused; nor

14. Chronic fatigue syndrome or myalgic encephalomyelitis (M.E.) (anticardiolipin antibody positively) or the Illness commonly referred to as yuppie flu; nor 

15. a) An Insured Person being under the influence of alcohol with more than the legal limit of alcohol in his blood or breath or  b) An Insured Person being under the influence of drugs or narcotics unless such drugs or narcotics were administered by a Medical Practitioner or unless prescribed by and taken in accordance with the directions of a Medical Practitioner; or  c) An Accident occurring whilst an Insured Person was driving a motor vehicle with more than the legal limit of alcohol in his blood or breath or  d) Alcohol abuse, alcoholism, substance abuse, solvent abuse, drug abuse or addictive conditions of any kind; nor

16. a) Any Pre-existing Medical Condition; or b)  Any cardiac or cardio vascular or vascular or cerebral vascular illness or conditions or sequelae thereof or complications   that, in the opinion of a Medical Practitioner appointed by the Company, can reasonably be related thereto, if the Insured Person has received medical advice or treatment (including medication) for hypertension 2 years prior to the commencement of the Insured Journey; nor

17. Congenital anomalies and conditions arising out of or resulting there from, and hernia; nor

18. Flying in any aircraft owned, leased or operated by or on behalf of an Insured Person or any member of an Insured Person's household; nor

19. An Insured Person traveling against medical advice or to seek medical attention or advice or with a terminal condition which was diagnosed prior to the Insured Journey or when he is unfit to do so; nor

20. Any cardiac or cardio vascular or vascular or cerebral vascular illness or conditions or sequelae thereof or complications that, in the opinion of a Medical Practitioner appointed by the Company, can reasonably be related thereto, for persons over the age of 69 years; nor”

21. Employment involving Manual Labor, other than off duty; or b) undertaking employment on a permanent or contract basis which is not casual, other than whilst on a leisure trip; nor

22. Participating in any sport as a Professional Player; or b) school sports (unless an Endorsement has been issued and additional premium charged and authorized by the Company and paid by the Insured Person); nor

23. Any hazardous pursuits, sports or activities which introduce or increase the possibility of a loss including but not limited to engaging in motor cycling (where the engine capacity exceeds 200cc or the cycle is under control of an unlicensed driver), steeple-chasing, polo or horseback riding, hunting, bungee jumping, abseiling, white water rafting, hiking (unless accompanied by a recognized guide or on a clearly marked route), mountaineering requiring the use of ropes or equipment, scuba diving (unless licensed or accompanied by a qualified instructor), potholing, fighting (except in bona fide self defense), racing (other than on foot or under sail in inland waters), being a crew member on a ship or boat traveling from one country to another, speed or endurance racing or practice thereof (other than athletics), or training for or engaging in contact sports where physical contact between players is an accepted part of play unless an Endorsement has been issued and additional premium charged and authorized by the Company and paid by the Insured Person. This remains at the discretion of the Company; nor

24. Consequential loss of any kind or financial loss and/or expense not otherwise specifically covered; nor

25. Default or insolvency of the carrier; nor

26. The Insured Person’s intention to emigrate, unless agreed previously in writing by the Company.

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