(Translated from Portuguese)
COVERAGE
Insurance
Policies
This insurance provides coverage for Death, over 50% Permanent
Disablement, and Medical Expenses in the treatment of accidental
injuries to the Person Insured of professional and nonprofessional
risk, including the use of regular means of transportation and
the practice of amateur sports.
Accident is defined as a contingent, abrupt and abnormal event,
produced by an external cause alien to the will of the Person
Insured, resulting in body injury to the latter.
GUARANTEED BENEFITS
DEATH OR DISABLEMENT COVERAGE: In case of death or over 50% disablement
resultant from accident involving the Person Insured, the Beneficiary
shall be paid the benefit amounts according to the elected option.
MEDICAL EXPENSES: An allowance up to the limit established guarantees
the reimbursement of expenses incurred with the treatment of accidental
injuries.
REIMBURSEMENT
The benefit amount for Death or Permanent Disablement is cumulative
with any other insurance with the same guarantee.
In relation to Medical Expenses, if the Person Insured holds
other policies, reimbursement is provided through all policies
in proportion to the respective Benefit amount elected. Reimbursement
is provided to whomsoever shows evidence to have paid the medical
expenses.
ACCEPTANCE
The "..... Family Protection Plan" is limited to one
insurance per person or per couple and is destined to ..... clients
from 14 to 65 years of age.
MOST RELEVANT EXCLUSIONS
* Accidents resulting from crime and other intentional actions
(namely gross infraction and imprudence) self-inflicted by the
Person Insured, including suicide.
* Accidents resulting from actions of the Person Insured when
under the effect of alcohol or the use of drugs without medical
prescription.
* Accidents resulting from the practice of professional sports
or, if amateur, in championship events and respective training.
* Accidents resulting from natural disasters, acts of war, terrorism,
public unrest, and the use or transport of radioactive material,
* Accidents resulting from the practice of parachuting, bullfighting,
hang-gliding, plane gliding, and other similarly dangerous sports.
* Accidents with persons who work on bridges, scaffoldings, professional
pilots and other flight personnel, whether or not in service of
commercial airlines, as well as other professions involving similar
risk.
* Accidents in regions of the world in risk of eminent conflict
(i.e. war, civil war, terrorism, hostility).
***
In the terms of the General Conditions clause of the Accident
Insurance Policy of the ..... Company, model number 838 275, the
following Special Conditions are applicable to the present agreement:
1. Definitions
To the effect of the present agreement:
The Company - the ..... Company
Applicant - "....., S.A."
Person Insured - The client(s) of the ..... branches in Macau,
whose particulars have been previously indicated to the .....
Company.
Beneficiaries: The person(s) to whom the benefits are to be paid
2. Description of Agreement and Definition of Accident
The present agreement guarantees coverage for accidental body
injuries to the Person Insured of professional and non-professional
risk, including the use of regular means of transportation and
the occasional practice of amateur sports. Accident is defined
as a contingent, abrupt and abnormal event, produced by an external
cause alien to the will of the Person Insured, resulting in body
injury to the latter. Accidental Death or Permanent Disablement
occurred during the cross over between Macau and Hong Kong by
ferry, are payable double indemnity benefits. Accidents resulting
from riding 2-wheel vehicles are covered.
3. Excluded Accidents
- Accidents resulting from crime and other intentional actions
(namely gross infraction and imprudence) self-inflicted by the
Person Insured, including suicide.
- Accidents resulting from actions of the Person Insured under
the effect of alcohol or the use of drugs without medical prescription.
- Accidents resulting from natural disasters, acts of war, terrorism,
public unrest, and the use or transport of radioactive material.
- Accidents resulting from the practice of parachuting, bullfighting,
hang-gliding, plane gliding, and other similarly dangerous sports.
- Accidents involving persons who work on bridges, scaffoldings,
professional pilots and other flight personnel, whether or not
in service of commercial airlines, as well as other professions
involving similarly dangerous risk.
- Accidents in regions of the world in risk of possible conflict
(war, civil war, terrorism, hostility).
4. Guaranteed Coverage
4.1 Benefit guaranteed in case of Death - In case of death occurred
immediately or within the term of two years counted from the date
of the accident, the ..... Company shall pay the indemnity benefit
to the beneficiaries appointed by the Person Insured on the application
form.
4.2 Permanent Disablement - This agreement guarantees a benefit
correspondent to 100% disablement as long as the accident resulted
in a greater than 50% (>50%-100%) disablement, thus, no indemnity
benefit is paid in case of temporary disablement.
4.3 In case of the death of the Person Insured as a result of
an accident covered by the present agreement, an allowance of
MOP5,000.00 is provided to cover funeral expenses.
4.4 In case of a death covered by the present agreement, all benefits
granted to the Applicant (the ".....") through the application
of Article 7, paragraph 2, shall be transferred in favor of the
legal heirs of the Person Insured.
4.5 Medical Expenses: Medical expenses incurred with the treatment
of accidental injuries shall be reimbursed up to the maximum benefit
amount guaranteed, provided admission in hospital was longer than
24 hours. The annual maximum benefit amount for medical expenses
is MOP/HK$30,000.00.
5. Beginning and Cessation of Guaranteed Benefits
Guaranteed benefits, when the client applies before its 66th anniversary,
shall take effect from the date of acceptance of the Application
Form, and shall cease to take effect:
- With the revocation of the Insurance Agreement by the Person
Insured;
- When the Person Insured ceases to be a client of the Applicant,
or upon the voidance of the Policy;
- When the Person Insured reaches the age of 70.
6. Alteration of Benefits
Another certificate shall be issued in case of alteration to the
benefits elected by the Person Insured.
7. Payment of Indemnity Benefits
Indemnity benefits shall be paid to the appointed Beneficiaries
under the precise terms provided in the Beneficiaries' Clause
of the Application Form.
Reimbursement of Medical Expenses shall be paid to the Person
Insured or, if missing, whomsoever shows evidence to have paid
the expenses. Claim for indemnity benefits for death, permanent
disablement or medical expenses must be filed with the Insurance
Company within a term of 12 months following the accident.
8. Former Disease or Illness
If the consequences of an accident become aggravated due to disease
or illness already manifested before the accident, the liability
of the ..... Company shall not exceed the liability the Company
would have if the accident had occurred to a person clear of such
disease or illness.
****
GENERAL CONDITIONS
GUARANTEED BENEFITS
Article One
1. By means of the present Policy, under the terms of present
General Conditions and the Special and Particular Conditions drawn
from the statements contained in the Insurance Proposal, the Company
hereby guarantees to pay the relevant Indemnity Benefits in consequence
of accident involving the Person Insured according to the elected
coverage, namely:
a) Death;
b) Permanent Disablement;
c) Temporary Total Disablement;
d) Medical Expenses and Repatriation;
e) Funeral Expenses.
2. Accident is defined as a contingent, abrupt and abnormal event,
produced by an external cause alien to the will of the Person
Insured, resulting in body injury to the latter.
COVERAGE
Article Two
1. The present insurance covers accidents that occur in any part
of the world provided they occur in result of:
1.1 Professional or nonprofessional risk or only nonprofessional
risk as expressly provided in the Particular Conditions. Nonprofessional
risk is considered the risk taken in any activity that is not
covered by public or private industrial accident insurance or
not susceptible of such coverage.
1.2 The use of normal means of transportation including commercial
and private airplanes but excluding motorized two-wheeled vehicles.
1.3 Sporadic practice of amateur sports, including sport events
that are not part of championships and respective training, with
the exclusion of "Hunting ferocious animals", "Winter
sports", "Box", "Karate" and other martial
arts, "Parachuting", "Bullfighting", and other
similarly dangerous sports.
2. Accidents emerging from the following activities may be covered
only when dully expressed under the Particular Conditions:
2.1 Professional sports or, in case of amateur sports, any sport
event integrated in its respective championship and correspondent
training.
2.2 Hunting of ferocious animals, Winter sports, Box, Karate and
other martial arts, Parachuting, Bullfighting and other similarly
dangerous sports.
2.3 Riding of aircraft not provided under the above subparagraph
1.2.
2.4 Use of motorized two-wheeled vehicles.
2.5 Natural disasters, acts of war, terrorism, public unrest and
transport of radioactive materials.
3. The following accidents are excluded from coverage:
3.1 Accidents resulting from actions of the Person Insured when
under the effect of alcohol or the use of drugs without medical
prescription.
3.2 Accidents resulting from crime and other intentional actions
self-inflicted by the Person Insured, including suicide.
3.3 Hernias of any kind.
ALTERATIONS
Article three
1. The contracting or alteration of other accident insurance by
the Person Insured, as well as any alteration to the place of
residence of the Person Insured or the Applicant, must be informed
to the Insurance Company.
2. Any change to the activities usually carried out by the Person
Insured, namely in profession or in the practice of activities
wherefore coverage through Particular Conditions is provided under
the present General Conditions (Article 2, number 2), should be
previously notified to the Company. Failure to provide such notice
shall result, in case of accident, that the correspondent indemnity
shall be reduced in proportion to the premium that would correspond
to the referred normal activity and the premium corresponding
to the activity that was not notified.
3. Alterations that have been duly notified, after being accepted
by the Company, are included in additional riders issued by the
Company.
START, DURATION AND TERMINATION
Article four
1. Insurance begins to take effect at 0 hours on the day following
the acceptance of the proposal by the Company or at any later
date expressly indicated in the proposal, unless otherwise determined
by the Company and informed in written within 15 days counted
from the date the proposal was received.
2. The insurance may be contracted for a term of up to one year,
or for successive terms of one year. In the latter case, it shall
be valid for secured terms of one year and tacitly renewed at
the end of each annuity.
3. The Applicant or the Company may call for the termination of
the agreement by means of a notice sent through certified mail
within a minimum of thirty days prior to the date when such termination
is intended to take effect.
4. Termination of the insurance agreement as provided under the
previous paragraph shall grant the Applicant the right to claim
reimbursement of 50% or 100% of the premium, corresponding to
the term of validity not yet passed, according to whether the
termination has been called by the Applicant or the Company.
PREMIUMS
Article Five
1. The Applicant is obliged to pay, at the beginning of each validity
term, the respective premium and corresponding additional fees.
2. If after being notified through certified mail to pay overdue
premiums and other additional fees, the Applicant fails to do
so within 30 days from the date of the notice, the insurance agreement
shall be considered terminated at the end of such term.
3. Notwithstanding, the Company shall always have the right to
claim premiums and correspondent additional fees for any term
wherein the insurance was in effect.
ACCIDENTS
Article six
1. In case of accident the Applicant and the Person Insured are
cumulatively obliged before the Insurance Company:
1.1. To take immediate action to avoid increasing consequences
of the accident.
1.2. To report the accident, in written, within eight days, indicating
the place, date, hour, causes, witnesses and consequences.
1.3. To provide, within eight days after the Person Insured was
clinically assisted, a statement from the doctor informing the
nature of the injuries, the diagnosis, the days expected of eventual
Temporary Total Disablement, as well as any possible Permanent
Disablement.
1.4. To inform, within eight days after clinic examination confirming
such fact, the healing from injuries, providing a medical statement
declaring the date of discharge, the number of days of temporary
total disablement and the percentage of any eventual Permanent
Disablement.
1.5. Provide all documents relevant to the Medical Expenses in
order to be reimbursed.
2. In case of accident, the Person Insured is obliged:
2.1. To follow medical prescription.
2.2. To undertake medical examination by doctor appointed by the
Company.
2.3. To authorize the doctors to reveal any information requested
by the Company.
2.4. To notify reinstatement of its activities.
3. If the accident results in the death of the Person Insured,
in addition to the notification of the accident, a death certificate
must be sent to the Company and, whenever deemed necessary, other
documents explaining the accident and its consequences.
4. When the Applicant or the Person Insured are unable to comply
with the obligations contained in the present article, the duty
to comply with such obligations falls on the Applicant, the Person
Insured or the Beneficiary - whoever is able to comply.
5. False statements in communications and notices to the Company
shall result in liability for any loss and damages resulting thereof.
INDEMNITIES
Article seven
1. The amounts corresponding to the guaranteed indemnities are
expressly listed in the Particular Conditions of the Policy.
2. In case of death that occurred immediately or within two years
counted from the date of the accident, the Company shall pay the
amount correspondent to the elected benefit to the appointed Beneficiary,
or, if the latter is deceased, the heirs thereof. If no Beneficiary
was appointed, the benefit amount shall be paid to the Applicant
or, if missing, to the heirs thereof.
3. In case of Permanent Disablement, duly attested clinically
and manifested within two years from the date of the accident,
the Company shall pay the correspondent benefit amount as determined
by the percentage Chart which constitutes an integral part of
the present General Conditions.
3.1 If no other entity is expressly indicated under the Particular
Conditions the indemnity benefits shall be paid to the Person
Insured.
3.2 Percentage loss in the Particular Conditions may be set at
different values from those listed in the Chart attached hereto.
3.3 Injuries not listed in the percentage Chart, even if of minor
importance, are indemnified in proportion to how serious they
are as compared with the cases listed in the Chart hereof, without
taking into account the profession of the injured.
3.4 If the person is left-handed, the percentage loss for the
disablement of right upper limb shall apply to the disablement
of upper left limb reciprocally.
3.5 Physical defects on any limb or organ of the Person Insured
before the accident shall be taken into consideration when fixing
the percentage loss resulting from the accident. The actual disablement
shall be the difference between the previous disablement and the
disablement after the accident.
3.6 Partial or total functional disablement of limb or organ is
comparable to correspondent partial or total loss thereof.
3.7 In relation to one and the same limb or organ, the accumulated
percentage disablement shall not exceed the percentage correspondent
to the total loss of that same limb or organ.
3.8 When an accident results in injuries to more than one limb
or organ, the overall indemnity amount is the sum of indemnity
amounts due for each one of the injuries, provided the total does
not exceed the Insured Benefit amount.
4. In case of Temporary Total Disablement, manifested within
180 days counted from the date of the accident, the Company shall
pay the daily guaranteed allowance for the duration of the disablement,
during up to 360 days counted from the date the disablement was
evidenced.
4.1 Temporary Total Disablement is defined as the temporary total
physical incapacity of the Person Insured to carry on normal activity,
susceptible of medical confirmation.
4.2 Unless otherwise provided under the Particular Conditions,
the payment of the daily allowance shall be made to the Person
Insured.
5. Medical Expenses and Repatriation. The Company shall reimburse,
up to the benefit amount established to that effect, the expenses
incurred with the treatment of injuries as well as extraordinary
expenses with repatriation through means of transportation clinically
suggested for the injuries sustained.
5.1. Reimbursement shall be made to whomsoever shows evidence
to have paid such expenses, against the submission of relevant
documents.
6. Expenses with Funeral. The Company shall reimburse, up to
the amount established to that effect, the expenses incurred with
the funeral of the Person Insured.
6.1. Reimbursement shall be made to whomsoever shows evidence
to have paid such expenses.
7. Reimbursement of Medical Expenses and Repatriation and Expenses
with Funeral, when equally guaranteed by other insurance policies
shall be paid through all other policies in proportion to the
respective insured benefit amounts.
8. Concerning Medical Expenses and Repatriation and Funeral Expenses,
the Applicant, the Person Insured, the Beneficiary and the Heirs,
hereby subrogate all their claims against third parties responsible
for the accident, up to the amount of benefits paid.
9. Except otherwise expressly provided under the Particular Conditions,
if the consequences of an accident are aggravated by disease or
illness manifested prior to the date of the accident, the responsibility
of the Company is limited to the liability the Company would have
with a person who did not suffer from such disease or illness.
JURISDICTION
Article eight
For any litigation emerging from the present agreement, the parties
hereof elect the jurisdiction of the District court wherein the
Policy is issued, in case of failure of regular private arbitration,
renouncing any other jurisdiction.