TABLE OF CONTENTS
Definitions.................................................................................................................................................... 3
Insured's Effective and Termination Dates................................................................................................. 3
Insured Dependent's Effective and Termination Dates.............................................................................. 4
Benefits and Coverages.............................................................................................................................. 4
Principal Sum.............................................................................................................................................. 4
Limitation on Multiple Benefits.................................................................................................................... 4
Accidental Death Benefit............................................................................................................................ 4
Accidental Dismemberment Benefit........................................................................................................... 5
Exposure and Disappearance..................................................................................................................... 5
Emergency Evacuation Benefit.................................................................................................................. 6
Repatriation of Remains Benefit................................................................................................................. 7
Exclusions................................................................................................................................................... 8
Claims Provisions........................................................................................................................................ 8
General Provisions.................................................................................................................................... 10
DEFINITIONS
Eligible Dependent - means an Eligible Spouse or an Eligible Dependent Child.
Family Coverage - means coverage in force under the Policy on an Insured’s Eligible Dependents for whom premium has been paid.
Injury - means bodily injury caused by an accident occurring while the Policy is in force as to the person whose injury is the basis of claim and resulting directly and independently of all other causes in a covered loss.
Insured - means and for whom premium has been paid while covered under the Policy.
Insured Dependent - means an Insured Spouse or an Insured Dependent Child.
Insured Dependent Child(ren) - means the Insured’s Eligible Dependent Child(ren): (1) whom the Insured has elected to cover under the Policy; (2) for whom premium has been paid; and (3) while covered under the Policy.
Immediate Family Member - means a person who is related to the Insured Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild).
Insured Person - means an Insured or an Insured Dependent.
Insured Spouse - means the Insured’s Eligible Spouse: (1) whom the Insured has elected to cover under the Policy; (2) for whom premium has been paid; and (3) while covered under the Policy.
Physician - means a licensed practitioner of the healing arts acting within the scope of his or her license who is not: (1) the Insured Person; (2) an Immediate Family Member; or (3) retained by the Policyholder.
Schedule - means the schedule found on the face page of this certificate.
INSURED'S EFFECTIVE AND TERMINATION DATES
Effective Date. The Insured's coverage under the Policy begins on the Effective Date of Coverage as shown in the Schedule.
Termination Date. An Insured’s coverage under the Policy ends on the earliest of: (1) the date the Policy is terminated; (2) the premium due date if premiums are not paid by the Policyholder when due; (3) the date the Insured requests, in writing, that his or her coverage be terminated; or (4) the date the Insured ceases to be eligible for coverage under the Policy.
Termination of coverage will not affect a claim for a covered loss that occurred while the Insured’s coverage was in force under the Policy.
INSURED DEPENDENT'S EFFECTIVE AND TERMINATION DATES
Effective Date. An Insured Dependent's coverage under the Policy begins on the latest of: (1) the date the Insured's coverage begins; (2) the date the first premium for the Insured Dependent’s coverage is paid when due; (3) if individual enrollment is required, the date the insured enrolls the dependent for Family Coverage (4) the date the person becomes an Eligible Dependent.
If additional premium is required to provide coverage for a newborn child or adopted child from the moment of birth or placement in the home of the Insured, the Insured must notify the Company of the birth or placement of the child within 30 days.
Termination Date. An Insured Dependent’s coverage under the Policy ends on the earliest of: (1) the date the Insured's coverage ends; (2) the premium due date if premiums for the Insured Dependent are not paid when due; (3) the date the Insured requests, in writing, that coverage for the Insured Dependent be terminated; or (4) the date the Insured Dependent ceases to be an Eligible Dependent.
Termination of coverage will not affect a claim for a covered loss which is incurred while the Insured Dependent's coverage was in force under the Policy.
BENEFITS AND COVERAGES
Principal Sum. As applicable to each Insured, Principal Sum means the amount of insurance in force under the Policy as described in the Schedule.
As applicable to an Insured Dependent, Principal Sum means the amount of insurance in force under the Policy as described in the Schedule.
Limitation on Multiple Benefits
If an Insured Person suffers one or more losses from the same accident for which amounts are payable under more than one of the following Benefits provided under the Policy, the maximum amount payable under all of the Benefits combined will not exceed the amount payable for one of those losses, the largest: Accidental Death Benefit, Accidental Dismemberment Benefit.
Accidental Death Benefit
If Injury to the Insured Person results in death within 365 days of the date of the accident that caused the Injury, the Company will pay 100% of the Principal Sum.
Accidental Dismemberment Benefit
If Injury to the Insured Person results, within 365 days of the date of the accident that caused the Injury, in any one of the Losses specified below, the Company will pay the percentage of the Principal Sum shown below for that Loss:
For Loss of Percentage of Principal Sum
Both Hands or Both Feet...................................................................... 100%
Sight of Both Eyes................................................................................ 100%
One Hand and One Foot...................................................................... 100%
One Hand and the Sight of One Eye................................................... 100%
One Foot and the Sight of One Eye..................................................... 100%
Speech and Hearing in Both Ears ....................................................... 100%
One Hand or One Foot........................................................................... 50%
Sight of One Eye.................................................................................... 50%
Speech or Hearing in Both Ears ............................................................ 50%
Hearing in One Ear................................................................................. 25%
Thumb and Index Finger of Same Hand............................................... 25%
"Loss" of a hand or foot means complete severance through or above the wrist or ankle joint. "Loss" of sight of an eye means total and irrecoverable loss of the entire sight in that eye. "Loss" of hearing in an ear means total and irrecoverable loss of the entire ability to hear in that ear. "Loss" of speech means total and irrecoverable loss of the entire ability to speak. "Loss" of thumb and index finger means complete severance through or above the metacarpophalangeal joint of both digits.
If more than one Loss is sustained by an Insured Person as a result of the same accident, only one amount, the largest, will be paid.
Exposure and Disappearance
If by reason of an accident occurring while an Insured Person's coverage is in force under the Policy, the Insured Person is unavoidably exposed to the elements and as a result of such exposure suffers a loss for which a benefit is otherwise payable under the Policy, the loss will be covered under the terms of the Policy.
If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking or wrecking of a conveyance in which the person was an occupant while covered under the Policy, then it will be deemed, subject to all other terms and provisions of the Policy, that the Insured Person has suffered accidental death within the meaning of the Policy.
Emergency Evacuation Benefit
If the Insured Person suffers an Injury or Emergency Sickness that warrants his or her Emergency Evacuation while he or she is outside a 100 mile radius from his or her current place of primary residence, the Company will pay for Covered Emergency Evacuation Expenses reasonably incurred, up to a maximum of $50,000 for all Emergency Evacuations due to all Injuries from the same accident or all Emergency Sicknesses from the same or related causes.
The Physician ordering the Emergency Evacuation must certify that the severity of the Insured Person's Injury or Emergency Sickness warrants his or her Emergency Evacuation. All Transportation arrangements made for the Emergency Evacuation must be by the most direct and economical conveyance and route possible.
Family Travel Benefit. Following an Emergency Evacuation for which an Emergency Evacuation benefit is payable under the Policy, the Company will pay for expenses reasonably incurred:
1. to return to their current place of primary residence, with an attendant if necessary, any of the Insured Person’s Children who were accompanying the Insured Person when the Injury or Emergency Sickness occurred; but not to exceed the cost of a single one-way economy airfare ticket less the value of applied credit from any unused return travel tickets per Child; and
2. to bring one person chosen by the Insured Person to and from the hospital or other medical facility where the Insured Person is confined if the Insured Person is alone and if the place of confinement is outside a 100 mile radius from the Insured Person’s place of primary residence; but not to exceed the cost of one round-trip economy airfare ticket.
AIG Assist must make all arrangements and must authorize all expenses in advance for any such benefits to be payable. The Company reserves the right to determine the benefit payable, including reductions, if it is not reasonably possible to contact AIG Assist in advance.
The Exclusions section of this Certificate does not apply with respect to this benefit(s).
"Children" - for purposes of this benefit, means unmarried children, including natural, step, foster or adopted children from the moment of placement in the Insured Person’s home, under age 19 and primarily dependent on the Insured Person for support and maintenance. However, the age limit does not apply to a child who: (1) otherwise meets the definition of Children; and (2) is incapable of self-sustaining employment by reason of mental or physical incapacity.
"Covered Emergency Evacuation Expense(s)" - means an expense that: (1) is charged for a Medically Necessary Emergency Evacuation Service; (2) does not exceed the usual level of charges for similar Transportation, treatment, services or supplies in the locality where the expense is incurred; and (3) does not include charges that would not have been made if no insurance existed.
"Emergency Evacuation" - means, if warranted by the severity of the Insured Person’s Injury or Emergency Sickness: (1) the Insured Person's immediate Transportation from the place where he or she suffers an Injury or Emergency Sickness to the nearest hospital or other medical facility where appropriate medical treatment can be obtained; (2) the Insured Person's Transportation to his or her current place of primary residence to obtain further medical treatment in a hospital or other medical facility or to recover after suffering an Injury or Emergency Sickness and being treated at a local hospital or other medical facility; or (3) both (1) and (2) above. An Emergency Evacuation also includes medical treatment, medical services and medical supplies necessarily received in connection with such Transportation.
"Emergency Sickness" - means an illness or disease, diagnosed by a Physician, which meets all of the following criteria: (1) there is present a severe or acute symptom requiring immediate care and the failure to obtain such care could reasonably result in serious deterioration of the Insured Person’s condition or place their life in jeopardy; (2) the severe or acute symptom occurs suddenly and unexpectedly; and (3) the severe or acute symptom occurs while the Policy is in force as to the person suffering the symptom.
"Medically Necessary Emergency Evacuation Service" - means any Transportation, medical treatment, medical service or medical supply that: (1) is an essential part of an Emergency Evacuation due to the Injury or Emergency Sickness for which it is prescribed or performed; (2) meets generally accepted standards of medical practice; and (3) either is ordered by a Physician and performed under his or her care or supervision or order, or is required by the standard regulations of the conveyance transporting the Insured Person.
"Transportation" - means moving the Insured Person during an Emergency Evacuation by a land, water or air conveyance. Conveyances include, but are not limited to, air ambulances, land ambulances and private motor vehicles.
Repatriation of Remains Benefit
If an Insured Person suffers loss of life due to Injury or Emergency Sickness while outside a 100 mile radius from his or her current place of primary residence, the Company will pay for covered expenses reasonably incurred to return his or her body to his or her current place of primary residence, up to a maximum of $25,000.
Covered expenses include, but are not limited to, expenses for: (1) embalming or cremation; (2) the most economical coffins or receptacles adequate for transportation of the remains; and (3) transportation of the remains by the most direct and economical conveyance and route possible.
AIG Assist must make all arrangements and must authorize all expenses in advance for this benefit to be payable. The Company reserves the right to determine the benefit payable, including any reductions, if it was not reasonably possible to contact AIG Assist in advance.
"Emergency Sickness" – means an illness or disease, diagnosed by a Physician, which meets all of the following criteria: (1) there is a present severe or acute symptom requiring immediate care and the failure to obtain such care could reasonably result in serious deterioration of the Insured Person’s condition or place his or her life in jeopardy; (2) the severe or acute symptom occurs suddenly and unexpectedly; and (3) the severe or acute symptom occurs while the Policy is in force as to the Insured Person suffering the symptom.
Exclusion 2 in the Exclusions section of the Policy does not apply with respect to this benefit.
EXCLUSIONS
The Policy does not cover any loss caused in whole or in part by, or resulting in whole or in part from, the following:
1. suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt at intentionally self‑inflicted injury;
2. sickness, disease or infections of any kind; except bacterial infections due to an accidental cut or wound, botulism or ptomaine poisoning;
3. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured Person is:
a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or
b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or
c. riding as a passenger in an aircraft owned, leased or operated by the Policyholder.
4. declared or undeclared war, or any act of declared or undeclared war;
5. full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Insured Person is not covered due to his or her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty for regularly scheduled training purposes is not excluded.); or
6. the Insured Person being under the influence of drugs, unless taken under the advice of a Physician.
CLAIMS PROVISIONS
Notice of Claim. Written notice of claim must be given to the Company within 20 days after an Insured Person's loss, or as soon thereafter as reasonably possible. Notice given by or on behalf of the claimant to the Company at American International Companiesâ, Accident and Health Claims Division, P. O. Box 15701, Wilmington, DE 19850-5701, with information sufficient to identify the Insured Person, is deemed notice to the Company.
Claim Forms. The Company will send claim forms to the claimant upon receipt of a written notice of claim. If such forms are not sent within 15 days after the giving of notice, the claimant will be deemed to have met the proof of loss requirements upon submitting, within the time fixed in the Policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. The notice should include the Insured's name, the Policyholder's name and the Policy number.
Proof of Loss. Written proof of loss must be furnished to the Company within 90 days after the date of the loss. If the loss is one for which the Policy requires continuing eligibility for periodic benefit payments, subsequent written proofs of eligibility must be furnished at such intervals as the Company may reasonably require. Failure to furnish proof within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required.
Payment of Claims. Upon receipt of due written proof of death, payment for loss of life of an Insured Person will be made to the Insured Person's beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section.
Upon receipt of due written proof of loss, payments for all losses, except loss of life, will be made to (or on behalf of, if applicable) the Insured Person suffering the loss. If an Insured Person dies before all payments due have been made, the amount still payable will be paid to his or her beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section.
If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee's property. If the payee has no legal guardian for his or her property, a payment not exceeding $1,000 may be made, at the Company's option, to any relative by blood or connection by marriage of the payee, who, in the Company's opinion, has assumed the custody and support of the minor or responsibility for the incompetent person's affairs.
Any payment the Company makes in good faith fully discharges the Company's liability to the extent of the payment made.
Time of Payment of Claims. Benefits payable under the Policy for any loss other than loss for which the Policy provides any periodic payment will be paid immediately upon the Company's receipt of due written proof of the loss. Subject to the Company's receipt of due written proof of loss, all accrued benefits for loss for which the Policy provides periodic payment will be paid at the expiration of each month during the continuance of the period for which the Company is liable and any balance remaining unpaid upon termination of liability will be paid immediately upon receipt of such proof.
GENERAL PROVISIONS
Entire Contract; Changes. The Policy, the Master Application, and any attached papers make up the entire contract between the Policyholder and the Company. In the absence of fraud, all statements made by the Policyholder or any Insured Person will be considered representations and not warranties. No written and signed statement made by the Policyholder or an Insured Person will be used in any contest unless a copy of the statement is furnished to the Insured Person, Policyholder, his or her beneficiary or personal representative.
No change in the Policy will be valid until approved by an officer of the Company. The approval must be noted on or attached to the Policy. No agent may change the Policy or waive any of its provisions.
Incontestability. After an Insured Person has been insured under the Policy for two year(s) during his lifetime, no statement made by the Insured Person, except a fraudulent one, will be used to contest a claim under the Policy. The Company may only contest coverage if the misstatement is made in a written instrument signed by the Insured Person and a copy is given to the Policyholder, the Insured Person or the beneficiary.
Insured’s Beneficiary Designation and Change. The Insured’s designated beneficiary(ies) is (are) the person(s) so named by the Insured for the Policyholder’s group life insurance policy as shown on the Policyholder’s records kept on that policy, unless the Insured has named a beneficiary specifically for the Policy as shown on the Policyholder’s records kept on the Policy.
An Insured over the age of majority and legally competent may change his or her beneficiary designation at any time, unless an irrevocable designation has been made, without the consent of the designated beneficiary(ies), by providing the Policyholder with a written request for change. When the request is received by the Policyholder, whether the Insured is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment made by it prior to receipt of the request.
If there is no designated beneficiary or no designated beneficiary is living after the Insured’s death, the benefits will be paid, in equal shares, to the survivors in the first surviving class of those that follow: the Insured’s (1) spouse; (2) children; (3) parents; or (4) brothers and sisters. If no class has a survivor, the beneficiary is the Insured’s estate.
Insured Dependent’s Beneficiary Designation and Change. The Insured Dependent’s beneficiary is the Insured unless the Insured has named (a) different beneficiary(ies) for the Insured Dependent’s coverage as shown on the Policyholder’s records kept on the Policy.
An Insured over the age of majority and legally competent may change the beneficiary designation for an Insured Dependent’s coverage at any time, unless an irrevocable beneficiary designation has been made, without the consent of the Insured Dependent or the designated beneficiary(ies), by providing the Policyholder with a written request for change. When the request is received by the Policyholder, whether the Insured or the Insured Dependent is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment made by it prior to receipt of the request.
If no beneficiary is living on the date of an Insured Dependent’s death, the beneficiary is the Insured’s estate.
Physical Examination and Autopsy. The Company at its own expense has the right and opportunity to examine the person of any individual whose loss is the basis of claim under the Policy when and as often as it may reasonably require during the pendency of the claim and to make an autopsy in case of death where it is not forbidden by law.
Legal Actions. No action at law or in equity may be brought to recover on the Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the Policy. No such action may be brought after the expiration of the applicable statutes of limitations from the time written proof of loss is required to be furnished.
Noncompliance with Policy Requirements. Any express waiver by the Company of any requirements of the Policy will not constitute a continuing waiver of such requirements. Any failure by the Company to insist upon compliance with any Policy provision will not operate as a waiver or amendment of that provision.
Conformity With State Statutes. Any provision of the Policy which, on its effective date, is in conflict with the statutes of the state in which the Policy is delivered is hereby amended to conform to the minimum requirements of those statutes.
Workers' Compensation. The Policy is not in lieu of and does not affect any requirements for coverage by any Workers' Compensation Act or similar law.
Clerical Error. Clerical error, whether by the Policyholder or the Company, will not void the insurance of any Insured Person if that insurance would otherwise have been in effect nor extend the insurance of any Insured Person if that insurance would otherwise have ended or been reduced as provided in the Policy.
Assignment. An Insured may assign all of his or her rights, privileges and benefits under the Policy without the consent of his or her designated beneficiary. The Company is not bound by an assignment until the Company receives and files a signed copy. The Company is not responsible for the validity of assignments. The assignee only takes such rights as the assignor possessed and such rights are subject to state and federal laws and the terms of the Policy.
Misstatement of Age. If the benefits for which the Insured Person is insured are based on age and the Insured Person has misstated his or her age, there will be an adjustment of said benefit based on his or her true age. The Company may require satisfactory proof of age before paying any claim.
