1. welcome 3 []...3 1. welcome 1.1 welcome to fedgroup life fedgroup life limited is a member...

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1. Welcome 3

2. Group Risk Cover 3

2.1 How are benefits expressed? 5

2.2 What is Life Cover? 6

2.3 What benefit payments are provided by Life Cover? 6

2.4 What is Accidental Life Cover? 6

2.5 What benefit payments are provided by Accidental Life Cover? 6

2.6 A free Will service is included with Life Cover 6

2.7 What is Education Trust Cover? 6

2.8 What benefit payments are provided by Education Trust Cover? 7

2.9 Fedgroup Trust administers the Education Trust Cover benefit payments 8

2.10 The Education Trust Cover benefit may be augmented 8

2.11 What is Funeral Cover? 9

2.12 What benefit payments are provided with Funeral Cover? 9

2.13 What is Burial Repatriation? 9

2.14 What is Grocery Cover? 9

2.15 What is Spouse and Children’s Pension Cover? 9

2.16 What benefit payments are provided by Spouse and Children’s Pension Cover?

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2.17 What is Capital Disability Cover? 10

2.18 What benefit payments are provided by Capital Disability Cover? 10

2.19 How is the date of disability determined for Capital Disability Cover? 11

2.20 A waiting period is applied before a Capital Disability Cover benefit is paid

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2.21 What is Income Disability Cover? 11

2.22 How is disability assessed? 12

2.23 How is the date of disability determined for Income Disability Cover? 12

2.24 What benefit payments are provided by Income Disability Cover? 12

2.25 A waiting period is applied before Income Disability Cover benefit pay-ments are made

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2.26 What is vocational rehabilitation? 13

2.27 What is the recovery bonus? 14

2.28 When do the Income Disability Cover benefit payments terminate? 14

2.29 Retirement fund contribution waiver 15

2.30 Medical scheme premium waiver 15

2.31 Continuation of Life Cover and/or Funeral Cover during disability 16

2.32 Increasing Life Cover during disability 16

2.33 Aggregation of Income Disability Cover claims 16

2.34 What is Critical Illness Cover? 16

2.35 What benefit payments are provided by Critical Illness Cover? 17

2.36 What critical illnesses are protected? 17

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2.37 An objective and fair system is used to assess a critical illness 17

2.38 How many benefit payments can be made under Critical Illness Cover? 18

3. How is a spouse defined? 18

4. How is a child defined? 18

5. How is a parent defined? 19

6. Underwriting 20

7. How to claim and receive your benefits 21

8. When does Group Risk Cover terminate? 23

9. Premiums 24

10. What is a continuation option? 25

11. General legal provisions, definitions and rules 26

12. Beneficiaries 30

13. Discontinuance 31

Appendix 1 – Critical Illness Cover 33

Appendix 2 – Activities of daily living 47

Appendix 3 – Disability income benefits 48

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1. Welcome

1.1 Welcome to Fedgroup Life

Fedgroup Life Limited is a member company of Fedgroup, a leading independent South African financial services group, offering clients a simple, yet distinct range of financial products and services. Fedgroup Life is a licensed insurer in terms of the Long-Term Insurance Act 52 of 1998 and a licensed financial services provider in terms of the Financial Advisory and Intermediary Services Act 37 of 2002. This policy is issued by Fedgroup Life in terms of the aforementioned legislation.

Fedgroup is continually expanding its range of financial services offerings to enable the group to better provide for the financial needs of its clients. The Fedgroup product range includes investments, insurance, education savings, trust services, property finance, estate planning and wills. This range is backed up by Fedgroup’s cutting-edge administration system, which enables it to respond to customer needs at industry-leading speeds.

The group was established in 1990 as a family-owned investment and trust company. It has grown into a well-established, secure, professional organisation offering products and services of the highest standard.

Our head office is strategically based in Sandton with branches offering nationwide representation in Western Cape, Eastern Cape and KwaZulu-Natal.

1.2 The policy consists of the Fedgroup Life Risk policy and the Benefit Schedule

The Fedgroup Life Risk policy provides comprehensive information on the Group Risk Cover offered by Fedgroup Life and the protection given to employee’s by the benefits that have been chosen by the policyholder. Details of the Fedgroup Life benefits selected on the Fedgroup Life Risk Cover application form appear on the Benefit Schedule accompanying this Fedgroup Life Risk policy.

It is important to check the benefit schedule carefully to ensure that the benefits selected are correctly recorded. The benefit schedule and the Fedgroup Life risk policy are read together when determining the benefits payable under this policy.

1.3 The policyholder can cancel this policy within 30 days

The cooling-off period enables the policyholder to re-evaluate the policy purchased and cancel the policy by sending a written cancellation notice to Fedgroup Life within 30 days of the policy having been issued. The cooling-off period only applies if no benefits have been paid or an event insured against has not yet occurred. Any premiums paid will be refunded after the deduction of any reasonable costs incurred.

1.4 Need more information on this policy?

We look forward to assisting you in resolving any problems that you may have and encourage you to contact us if necessary.

For any event, you are welcome to contact your financial adviser as indicated on your benefit schedule.

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Fedgroup Life Public Officer:Phone: 011 305 2300

Fax: 011 305 2500

Email: [email protected]

Web address: www.fedgroup.co.za

Mail: Fedgroup Life PO Box 782823 Sandton 2146

Fedgroup Life Compliance Officer:Email: [email protected]

Phone: 011 305 2323

Fax: 011 305 2523

1.5 How to lodge a complaint

If you have received inadequate information or unsatisfactory service or have complaints about the advice you have received, please contact the Fedgroup Life Compliance Officer on [email protected] or 011 305 2323.

If Fedgroup Life does not resolve your complaint to your satisfaction, you may contact the parties mentioned below for assistance:

The Ombudsman for Long-Term InsurancePostal address: Private Bag X45

Claremont Cape Town 7735

Physical address: 3rd floor, Sanclare Building 21 Dreyer Street Claremont Cape Town

Telephone: 021 657 5000

Fax: 021 674 0951


Website: www.ombud.co.za

The FAIS OmbudsmanPostal address: PO Box 74571

Lynnwood Ridge 0040

Physical address: Sussex Office Park Ground Floor,Block B, 473 Lynnwood Road Cnr Lynnwood Road & Sussex Ave Lynnwood

Telephone: 012 470 9080

Fax: 086 764 1422


Website: www.faisombud.co.za

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The Pension Funds AdjudicatorPostal address: PO Box 580 Menlyn 0063

Physical address: 4th Floor Riverwalk Office Park Block A, 41 Matroosberg Road Ashlea Gardens, Pretoria

Telephone: 012 346 1738

Fax: 086 693 7472


Website: www.pfa.org.za

1.6 Fedgroup Life Limited is an authorised financial services provider

Registration Number: 2007/018003/06

FAIS Number 40607

Postal address: PO Box 782823 Sandton 2146

Physical address: 89 Bute Lane Sandown 2196

2. Group Risk Cover

The Fedgroup Life risk policy provides cover for groups of employees or members, and includes death, critical illness and disability cover. There are various combinations of cover that can be selected by the policyholder. These combinations assist the policyholder in providing employees and members with benefits that meet their risk needs.

Where an employer funds the benefits selected for its employees, the policyholder is the employer. A retirement fund may select Group Risk Cover. In this instance, the policyholder is the retirement fund that funds the benefits selected for its members. A policyholder may select cover, which is the minimum level of Group Risk Cover that is compulsory and applicable to all employees.

Group Risk Cover consists of:

• Life Cover• Accidental Life Cover• Education Trust Cover• Funeral Cover• Spouse and Children’s Pension Cover• Capital Disability Cover• Income Disability Cover• Critical Illness Cover

2.1 How are benefits expressed? The benefit schedule indicates the benefits selected by the policyholder. Group Risk Cover is defined as a multiple or percentage of the employee’s annual salary, or as a fixed rand amount, or as a variation thereof.

Group Risk Cover is subject to such maximum as may be set by Fedgroup Life from time to time.

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2.2 What is Life Cover?

Life Cover provides cover on the death of an employee or a spouse.

2.3 What benefit payments are provided by Life Cover?

On the death of an employee or an employee’s spouse, a lump-sum benefit payment equal to the amount of the Life Cover as indicated in the benefit schedule will be made.

2.4 What is Accidental Life Cover?

Accidental Life Cover provides cover on the accidental death of an employee.

An accident is defined as an unforeseen event, which could not reasonably have been expected to occur. The event must result in death caused directly and independently of all other causes by some external and visible means arising from this event, and excludes death by natural causes.

2.5 What benefit payments are provided by Accidental Life Cover?

On the accidental death of an employee, a lump-sum benefit payment equal to the amount of the Accidental Life Cover as indicated in the benefit schedule will be made.

2.6 A free Will service is included in the Life Cover

A free Will service is provided by Fedgroup Trust for every life insured that has Life Cover.

The free Will service includes the following:

• A 20-minute Will drafting consultation• The safe custody of the Will• Two Will updates

The free Will service is not compulsory and a Life Insured may choose not to make use of the service. 2.7 What is Education Trust Cover?

Education Trust Cover provides a lump-sum benefit payment after the death of an employee to assist in the education of an employee’s children. The cover is provided by Fedgroup Life and the education payments are administered by Fedgroup Trust.

This ensures that the education payments that were being made by the employee immediately before his or her death in respect of his or her children’s education can be continued.

Education Trust Cover is an optional benefit that may be selected at policy level by the policyholder as a standalone benefit that is independent from any other Group Risk Cover.

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The Education Trust Cover benefit amount is a percentage of the employee’s annual salary based on the child’s grade at the date of employee’s death.

Two education Trust Cover options are available:

Child’s grade Comprehensive(Percentage of employee’s annual salary)

Core(Percentage of employee’s annual salary)

Not schoolgoing 69% 41%

Grade 0 66% 40%

Grade 1 63% 38%

Grade 2 60% 36%

Grade 3 57% 34%

Grade 4 54% 32%

Grade 5 51% 31%

Grade 6 48% 29%

Grade 7 45% 27%

Grade 8 42% 25%

Grade 9 39% 23%

Grade 10 36% 22%

Grade 11 33% 20%

Grade 12 30% 18%

1st year of tertiary study 20% 12%

2nd year of tertiary study 10% 6%

An employee must nominate the children covered for the Education Trust Cover in writing within three months of the inception of the policy or entering the policy as a new member after the commencement date. The employee can change the nominated children covered for the Education Trust Cover at any time thereafter on birth, marriage or adoption, but must do so in writing within three months of the birth, marriage or adoption.

The Education Trust Cover benefit amount is calculated per qualifying, nominated child at the date of the employee’s death. 2.8 What benefit payments are provided by Education Trust Cover?

The benefit pays for education and education-related costs for children, if and when these expenses are incurred.

The benefits are paid directly to the learning institutions and providers by Fedgroup Trust.

All South African schools and universities are included in this benefit, as well as universities of technology (technikons) and recognised institutions providing for a trade (such as plumbing and electrical).

All nominated children are eligible to benefit from the Education Trust Cover.

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Education-related costs include, but are not limited to:

• Cost of prescribed books• Cost of residence• Transport fees• Registration fees• Utensils or equipment required for studies• Excursion fees• Aftercare fees

The lump-sum benefit payment is defined as a fixed Rand amount and is subject to the benefit minimums and maximums determined by Fedgroup Life from time to time.

If both parents are members of different Risk Cover policies insured by Fedgroup Life and both die, then both Education Trust Cover benefit payments will be made to cover the cost of the children’s Education.

The term of Education is not limited and Fedgroup Trust will continue making benefit payments, provided there are sufficient funds held in trust for the child.

The Education Trust Cover benefit payments expire when the child reaches the age of 24 or dies. The expired Education Trust Cover benefits will be paid to the child or to the child’s estate in the event of death.

2.9 Fedgroup Trust administers the Education Trust Cover benefit payments

On an employee’s death, all nominated children are added to the FedTrust Voluntary Savings Control Trust (registration number: IT 2020/07) to receive benefit payments.

The surviving parent, guardian or child needs to make an application to the trustees if and when Education and education-related costs are an incurred and a benefit is claimed. The trustees will assess the application in terms of the rules of the trust and pay the benefits directly to the learning institution or provider, provided there are sufficient funds available for the child.

There is no limit on the years of education, and the years of education do not need to run consecutively.

Should a child change educational institutions after the death of the employee, Fedgroup Trust will continue to make benefits payments at the changed fee level, provided there are sufficient funds held in trust for the child.

Should a child fail to pass a year of education, the child can repeat the year of education and Fedgroup Trust will continue to make benefit payments, provided there are sufficient funds held in trust for the child.

2.10 The Education Trust Cover benefit may be augmented

The trustees of a retirement fund, who are responsible for the distribution of the employee’s death benefits, and the surviving parent or guardian, may augment the children’s Education benefit by making additional donations to the FedTrust Voluntary Savings Control Trust (registration number: IT 2020/07). No additional fees will be charged for the augmentation.

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2.11 What is Funeral Cover?

In the event of the death of an employee, spouse, child or parent Funeral Cover provides cover towards the cost of a funeral for the employee, spouse, child or parent.

Three Funeral Cover options are available:

• Employee only, providing Funeral Cover for the employee.• Employee and family, providing Funeral Cover for the employee, spouse and

children.• Employee and extended family, providing Funeral Cover for the employee,

spouse, children and parents. No medical evidence is required for Funeral Cover.

2.12 What benefit payments are provided by Funeral Cover?

On the death of the employee, spouse, child or parent, a lump sum benefit payment equal to the amount of the Funeral Cover, as indicated in the benefit schedule, will be made.

The lump-sum benefit payment is defined as a fixed rand amount and is subject to the benefit maximums determined by Fedgroup Life from time to time.

2.13 What is Burial Repatriation?

This benefit option is available on Life Cover or Funeral Cover. On the death of the employee, spouse, child or parent covered, the benefit provides for transport of the deceased life insured:

• From anywhere in South Africa, Lesotho, Swaziland, Zimbabwe, Botswana, Namibia or Mozambique (south of the 22o latitude).

• To the funeral home closest to the place of burial in South Africa.

One relative may accompany the body to the funeral home, and overnight accom-modation within specific limits will be provided at no additional cost if the death occurred within the borders of South Africa.

2.14 What is Grocery Cover?

This benefit option is available on Funeral Cover. On the death of the policyholder, spouse or children, the benefit pays a voucher benefit to help the beneficiary with family expenses. This benefit forms part of the total cover amount of Funeral Cover and is paid in addition to the Funeral Cover benefit amount.

2.15 What is Spouse and Children’s Pension Cover?

In the event of the death of an employee, the Spouse and Children’s Pension Cover provides cover towards the cost of purchasing an annuity for the spouse and/or children.

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Spouse and Children’s Pension Cover is an optional benefit that may be selected at policy level by the policyholder as a standalone benefit that is independent from any other Group Risk Cover.

2.16 What benefit payments are provided by Spouse and Children’s Pension Cover?

On the death of the employee, a lump-sum benefit payment equal to the amount of the Spouse and Children’s Pension Cover as indicated in the benefit schedule will be made.

The lump-sum benefit payment is defined as a percentage of the employee’s annual salary and is subject to the benefit maximums determined by Fedgroup Life from time to time. 2.17 What is Capital Disability Cover?

Capital Disability Cover provides cover in the event of the employee experiencing an injury or illness rendering him or her permanently and totally incapable of performing the material and substantial duties of his or her own or any occupation for which the employee could reasonably be expected to be qualified for, with his or her own or any employer (this includes self-employment), taking into account the knowledge, training, Education, ability, experience and age of the employee.

If an employee’s employment is dependent on him or her being in possession of a valid pilot’s or driver’s licence, no Capital Disability Cover claim will be recognised unless the injury or illness has rendered him or her incapable of engaging for remuneration or profit in any occupation for which he or she could reasonably be expected to be qualified for, taking into account the degree of disability as well as his or her knowledge, training, education, ability, experience and age.

Disability refers to injury, illness or disease that has resulted in a reduction in the employee’s functionality.

The Capital Disability Cover for an employee will be reduced pro rata over the last five years before the normal retirement age.

Capital Disability Cover can be selected at policy level by the policyholder as:

• A standalone benefit that is independent from any other Group Risk Cover or• An acceleration of the Life Cover. With this selection, the Life Cover for an

employee will always be discontinued once a Capital Disability Cover claim has been paid.

2.18 What benefit payments are provided by Capital Disability Cover?

On the disability of an employee a lump-sum benefit payment equal to the amount of the Capital Disability Cover as indicated in the benefit schedule will be made. The lump-sum benefit payment is defined as a multiple of the employees’ annual salary or a flat rand amount and is subject to the benefit maximums determined by Fedgroup Life from time to time.

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2.19 How is the date of disability determined for the Capital Disability Cover?

The date of disability means the date upon which the employee was last able to perform the material and substantial duties of his or her own or any occupation with his or her own or any employer (this includes self-employment), for which the employee could reasonably be expected to be qualified or suited, taking into account the degree of disability as well as the knowledge, training, education, ability, experience and age of the employee, as assessed by Fedgroup Life, based on objective medical evidence received.

Capital Disability Cover will not become payable if the date of disability occurs before the employee becomes eligible for Capital Disability Cover or after the employee ceases to be eligible for Capital Disability Cover.

2.20 A waiting period is applied before a Capital Disability Cover benefit is paid

In order to be considered for a lump-sum benefit payment under Capital Disability Cover an employee must:

• Have been continuously disabled for the waiting period, after consulting a registered medical practitioner, and

• Be alive at the end of the waiting period.

The waiting period may be six months, 12 months or 24 months. Please refer to the benefit schedule for the waiting period that applies to the Capital Disability Cover. Fedgroup Life can waive the waiting period at its sole discretion. 2.21 What is Income Disability Cover?

Income Disability Cover provides cover in the event of the employee experiencing a loss of income, total or partial, upon injury or illness, rendering him or her incapable of being able to perform the functions of his or her occupation, regardless of whether the condition is temporary or permanent, until the employee recovers, dies or reaches the benefit expiry age, as defined below.

Income Disability Cover can be selected for a temporary/limited term. The limited- term monthly Income Disability benefit is paid out for a maximum period of 24 months on the disability of an employee.

Vocational Rehabilitation Services is automatically included in the Income Disability Cover even when it is selected for a temporary/limited term.

If an employee’s employment is dependent on him or her being in possession of a valid pilot’s or driver’s licence, no Income Disability Cover claim will be recognised unless the injury or illness has rendered him or her incapable of engaging for remuneration or profit in any occupation for which he or she could reasonably be expected to be qualified or suited, taking into account the degree of disability as well as his or her knowledge, training, education, ability, experience and age.

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2.22 How is disability assessed?

For the initial period (12 or 24 months as indicated in the benefit schedule), the employee will be assessed in terms of the effect that the disability has on his or her inability to perform with reasonable continuity the material and substantial duties of his or her regular occupation with his or her own employer (including self-employment).

Thereafter, Fedgroup Life will assess the employee’s disability based on his or her inability to perform with reasonable continuity the material and substantial duties of his or her own or any occupation with his or her own or any employer (this includes self-employment), for which the employee could reasonably be expected to be qualified or suited, taking into account the degree of disability as well as the knowledge, training, Education, ability, experience and age of the employee.

Disability refers to injury, illness or disease that has resulted in a reduction in the employees’s functionality. All other alternatives resulting in an inability to access gainful employment or earn an income are excluded from this benefit, and include retrenchment and redundancy.

2.23 How is the date of disability determined for Income Disability Cover?

The date of disability means the date upon which the employee was last able to perform the material and substantial duties of his or her normal employment with his or her employer as assessed by Fedgroup Life, based on objective medical evidence received.

2.24 What benefit payments are provided by Income Disability Cover?

Income Disability Cover pays a monthly disability benefit payment in the event of the employee experiencing a loss of income upon injury or illness rendering him or her incapable of being able to perform the functions of his or her occupation, as defined. The monthly disability benefit payment is defined as a percentage of the employee’s monthly salary and is subject to a maximum benefit of 100% of the employee’s after tax income prior to the date of disability.

The monthly disability benefit payment is subject to maximums determined by Fedgroup Life from time to time.

An employee will be eligible for a partial monthly disability benefit payment if:

• The employee is capable of performing the functions of his or her own occupation or, as a result of rehabilitation practices, any other suitable occupation, but the employee’s earnings are less than the benefit level selected, or

• The employee earns an income whilst eligible for a monthly disability benefit payment in terms of the definition of disability.

The disability benefit payments are made on or before the last business day of each calendar month. Each monthly disability benefit payment will be pro-rated according to that portion of the month for which the employee qualifies for a disability benefit payment.

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The payment of a monthly disability benefit under Income Disability Cover has no impact on Life Cover.

An employee must notify Fedgroup Life if he or she starts earning an income while a disability benefit is in payment. The employee’s income will be reduced by any actual income earned (excluding annuities, interest, rent and dividends) calculated on a monthly basis, notwithstanding his or her disability.

Should Fedgroup Life determine that it was not notified of this while a disability benefit was in payment, Fedgroup Life may recover any amount that was paid (including interest) in excess of the amount that would have been paid if the employee had notified Fedgroup Life that he or she was earning an income.

Once the monthly disability benefit payments start, they will remain level unless the policyholder has elected for them to increase annually in line with the selected rate of increase. Please check the benefit schedule to see if this option has been selected. The policyholder can select the percentage by which the monthly disability benefit payments will increase. The monthly disability benefit payments may increase at any rate from 0% up to 10% per annum (integral percentage only), subject to the maximum year-on-year increase in the core consumer price index. These increases will be effective after each 12-month period from the date at which the monthly disability benefit payments started.

2.25 A waiting period is applied before Income Disability Cover benefit payments are made

In order to be considered for a monthly benefit payment under the Income Disability Cover an Employee must:

• Have been continuously disabled for the waiting period, after consulting a registered medical practitioner, and

• Be alive at the end of the waiting period.

This period is known as the waiting period. The waiting period may be one month, three months or six months. Please refer to the benefit schedule for the waiting period that applies to the Income Disability Cover.

Should the employee recover or be rehabilitated and claim again for the same cause within three months of recovery, the waiting period will be waived for this subsequent claim. This is known as the off-period. If an Income Disability Cover claim is reinstated in the off-period of the claim, then the monthly disability benefit payments will be at the same level as paid previously.

The employee’s premium for the Income Disability Cover will be waived from the end of the waiting period until disability benefit payments stop.

When the employee recovers and the monthly disability benefit payments end, the employee’s Income Disability Cover will be based on the Income Disability Cover selected by the employer and the employee’s new annual salary. Please refer to the benefit schedule for the amount of Income Disability Cover provided for the recovered employee.

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2.26 What is vocational rehabilitation?

If, in the opinion of Fedgroup Life’s claims committee, the disability claimant is deemed able to be rehabilitated through retraining and/or reskilling, Fedgroup Life will require that the claimant undergoes vocational rehabilitation. The purpose of the rehabilitation is to assist the claimant to achieve a level of performance to enable him or her to perform suitable gainful employment. After rehabilitation, the claimant may no longer be considered disabled based on the definition of disability.

Vocational rehabilitation is a set of services which prepares the disability claimant to achieve a standard of independence and integration into the workplace. It is offered to claimants with mental or physical disabilities. These services are designed to enable disability claimants to attain skills and resources needed to perform in gainful employment.

Fedgroup Life’s claims committee, which includes independent medical professionals, will determine the feasibility of vocational rehabilitation for a disability claimant. On acceptance of the rehabilitation programme, the claimant and the employer will be required to sign a written undertaking to indicate the claimant’s genuine intent to follow the rehabilitation programme.

The cost of the rehabilitation programme will be paid directly to the service providers by Fedgroup Life and will be limited to a maximum of the lesser of 24 times the monthly Income Disability Cover and R100 000.

A disability claimant that is a member of a medical aid scheme will be required to utilise his or her medical aid scheme benefits, if there are funds available, before the rehabilitation programme will pay the service providers.

Vocational rehabilitation will cease on the occurrence of any one of the following:

• The employee being deemed rehabilitated as determined by Fedgroup Life• The claimant failing to comply with the requirements detailed in the rehabilitation

programme• Fedgroup Life deciding at its own discretion that the rehabilitation programme is

not effective

2.27 What is the Recovery Bonus?

Upon the successful return to employment in his or her own or any occupation with his or her own or any employer, for a continuous period of at least six months, a disability claimant will be entitled to a Recovery Bonus equal to one additional month’s disability benefit payment.

2.28 When do the Income Disability Cover benefit payments terminate?

The payment of disability income benefits will be terminated in the following instances:

• If the employee recovers from his or her disability and is able to perform his or her own occupation in the initial period.

• If the employee recovers from his or her disability and is able to start working

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in his or her own occupation or any occupation (this includes self-employment), for which the employee could reasonably be expected to be qualified or suited, taking into account the degree of disability as well as the knowledge, training, education, ability, experience and age of the employee after the initial period.

• If the employee no longer suffers any loss of income from his or her nominated occupation despite his or her disability.

• If the employee unreasonably refuses to undergo recommended medical. treatment or vocational rehabilitation to reduce his or her disability.

• If the employee fails to provide Fedgroup Life with satisfactory proof of his or her disability within thirty (30) days of being requested to do so, and if he or she fails to submit to a physical examination and tests at Fedgroup Life’s request and expense.

• If the employee reaches the benefit expiry age.• On the employee’s death.• For temporary Income Disability Cover when the employee reaches the end of the

term. 2.29 Retirement Fund Contribution Waiver

The policyholder may choose to insure all or part of the obligation by the policyholder and/or employee to contribute towards retirement funding if the employee becomes disabled. The percentage of the employee’s salary insured at claim stage will be paid in respect of retirement funding.

The retirement fund contribution waiver will be paid as long as the employee is entitled to receive a monthly disability benefit payment under Income Disability Cover.

While an employee is in receipt of a partial monthly disability benefit the retirement fund will receive a partial retirement fund contribution waiver in the same proportion as the partial monthly disability benefit is to the full monthly disability benefit.

The retirement fund contribution waiver is an optional benefit that may be selected at policy level by the policyholder at the inception or renewal of the policy.

2.30 Medical scheme premium waiver

The medical scheme premium waiver will pay the medical scheme premiums (including the savings element, if applicable) on the disability of an employee, who is the principal member on a medical scheme, and is receiving a monthly disability income payment under Income Disability Cover. The savings element is calculated as the average of the savings premium for the three months before the date of disability.

The medical scheme premiums waived include the cost for the Employee, spouse, children and adult dependants. The cost for an unborn child will be covered, provided that the pregnancy is in the second or third trimester at the date of disability.

The medical scheme premium waiver is paid from the end of the waiting period, for the lesser of the benefit payment period and the initial period (12 or 24 months).

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The payment to the medical scheme will increase in the same month and at the same rate of increase that the medical scheme increases premiums for its members, subject to a maximum of a 20% increase for any one year. The medical scheme premium waiver cover will not cover the increased medical scheme premiums should an employee choose to upgrade their health plan, and will be based on the health plan type in the month before the date of disability. The medical scheme premium waiver will be paid to the medical scheme.

An employee who is in receipt of a partial monthly disability benefit will receive a partial medical scheme premium waiver in the same proportion as the partial monthly disability benefit.

The medical scheme premium waiver is an optional benefit that may be selected at policy level by the policyholder at the inception or renewal of the policy.

2.31 Continuation of Life Cover and/or Funeral Cover during disability

If chosen by the policyholder, an employee who receives a monthly disability benefit payment will be deemed an eligible employee, and the Life Cover and/or Funeral Cover which applied to the employee before the date of disability will remain in place with the payment of premiums up to the benefit expiry age. Premiums for Life Cover and/or Funeral Cover must continue to be paid on a monthly basis. This clause applies to all future Income Disability Cover claimants or ill-health retirements. Where Fedgroup Life is asked to take over Life Cover and/or Funeral Cover from other underwriters where there are existing disability claimants, the continuation of Life Cover and/or Funeral Cover during disability will be negotiated on a case-by-case basis.

2.32 Increasing Life Cover during disability

If chosen by the policyholder, Life Cover for future disability claimants will increase annually at the same percentage at which their monthly disability benefit payments increase.

2.33 Aggregation of Income Disability Cover claims

Aggregation will be applicable where a claimant receives an Income Disability Cover benefit from another source.

The maximum Income Disability Cover benefit is 100% of the employee’s after-tax income prior to the date of disability. If the total income disability benefit from all sources exceeds 100% of the employee’s after-tax income prior to the date of disability, then all the income disability benefits payable from each source will be reduced proportionately to their share of the total income disability benefit. The result will be that the sum of the income disability benefits paid to the claimant will not exceed 100% of their pre-claim net after-tax income.

Capital Disability Cover benefits are not aggregated with Income Disability Cover benefits.

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2.34 What is Critical Illness Cover?

Critical Illness Cover provides cover in the event of the employee or spouse contracting one of the life-threatening diseases or disorders as defined in the policy.If selected by the policyholder, Critical Illness Cover is a standalone benefit that is independent from any other Group Risk Cover.

Two Critical Illness Cover options are available:

• Core Critical Illness Cover, providing cover for eight critical illnesses.• Comprehensive Critical Illness Cover, providing cover for 15 critical illnesses.

2.35 What benefit payments are provided by Critical Illness Cover?

Critical Illness Cover provides a lump-sum benefit payment equal to the amount of the Critical Illness Cover as indicated in the benefit schedule to an employee or a spouse who meets the requirements of one of the defined critical illnesses listed in Appendix 1 of the risk policy.

The lump-sum benefit payment is defined as a multiple of the employee’s annual salary or a flat rand amount and is subject to the benefit maximums determined by Fedgroup Life from time to time.

2.36 What critical illnesses are protected?

Fedgroup Life’s Critical Illness Cover provides protection for a wide range of life-threatening diseases and disorders.

The diseases and disorders covered, subject to the detailed requirements set out in Appendix 1, are as follows:

1. Heart attack2. Cancer3. Stroke4. Coronary artery bypass graft5. Major organ transplant6. Blindness7. Paraplegia8. Coma9. Severe burns10. Multiple sclerosis11. End-stage kidney failure12. Advanced dementia including Alzheimer’s disease13. Parkinson’s disease14. Accidental brain injury15. Heart valve replacement surgery

Core Critical Illness Cover provides cover for the first eight critical illnesses. Comprehensive Critical Illness Cover provides cover for all 15 critical illnesses.

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2.37 An objective and fair system is used to assess a critical illness

The assessment of a critical illness is based on specific objective medical definitions and is detailed in Appendix 1.

Please refer to Appendix 1 for the detail of the medical definitions.

2.38 How many benefit payments can be made under Critical Illness Cover?

Critical Illness Cover does not fall away after the first benefit payment.

Related claims - a related claim is a claim where the claim event progressed from a previous claim event. A claim that is related to any previous claim in a different category is treated as if it is in the same category as that from which it progressed. Related claims will be treated as the progression of a previous claim and no subsequent benefit payments will be made.

Unrelated claims - An unrelated claim is a claim where the claim event did not progress from a previous claim event. The employee may claim for subsequent benefit payments for unrelated causes. In this case, the benefit payment for the subsequent claim will be treated independently of any previous claims.

A subsequent claim may occur which is not regarded as a progression of previous claims. In this case, the benefit payment for the subsequent claim will be treated independently of any previous claims. 3. How is a spouse defined?

A spouse is defined as the person with whom the employee is joined in marriage and includes:

• A marriage or union in accordance with the Marriage Act, 1961, the Recognition of Customary Marriages Act, 1998, or the Civil Union Act, 2006, or the tenets of a religion or

• A person living with the employee in the manner of a spouse, living in a relationship of mutual dependence with the employee, and running and sharing a common household with the employee.

Common-law and same sex-partners are included in the definition of spouse.

The Employee must nominate their spouse in writing within three months of the inception of the policy or entering the policy as a new member after the commencement date. An employee can change the spouse covered at any time thereafter on marriage, divorce or death, but must do so in writing within three months of the marriage, divorce or death.

If an employee has more than one spouse, then the spouse that qualifies first for a benefit is the spouse the employee married first, or the spouse that the employee nominated.

A maximum of one spouse per eligible employee will be covered at any point in time. If an eligible employee has more than one spouse then the employee must nominate the additional spouse(s) in order for the spouse(s) to be covered under the policy. Additional premiums will be charged for every additional spouse.

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4. How is a child defined?

A child is defined as an unmarried person who is financially dependent on the employee and is described as:

• A child, born of the employee.• A dependent stepchild of the employee.• A foster child of the employee.• A child, legally adopted by the employee.• A stillborn child, being a child that has had at least 26 weeks of intra-uterine

existence but showed no sign of life after complete birth. Stillborn shall exclude the intentional termination of the life of the child.

• A grandchild, being a child of the employee’s children, where both the child’s parents are deceased or the child is dependent on the employee.

Proof of dependency must be submitted to Fedgroup Life.

The employee must nominate the children covered in writing within three months of the inception of the policy or entering the policy as a new member after the commencement date. The employee can change the nominated children covered at any time thereafter on birth, marriage or adoption, but must do so in writing within three months of the birth, marriage or adoption.

A child of the employee who studies full-time at a recognised Educational institution and who has not reached the benefit expiry age is considered a child for purposes hereof.

No age limit will apply to a child who is incapacitated by mental or physical infirmity and unable to maintain themselves, provided that such child is wholly dependent on the employee for support and maintenance, disregarding any state grant that they may receive.

Once a child has become partially independent of the employee for support and maintenance, dependency cannot be revived at a later date and he or she will not be considered a child for the purposes of the Fedgroup Life Risk Cover policy at any future date.

A maximum of five children per eligible employee will be covered at any point in time.

5. How is a parent defined?

A parent is defined as a parent of the employee or as a parent of the nominated spouse who depends on the employee for financial assistance. The parent may be the biological or adoptive parent of the employee or nominated spouse.

In addition:

• There is a three-month waiting period for parents for death due to natural causes• A parent must be nominated at the date the employee joins the policy The employee must nominate the parent(s) covered in writing within three months of the inception of the policy or entering the policy as a new member after the

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commencement date. An employee can change the parent(s) covered at any time thereafter on marriage or divorce, but must do so in writing within three months of the marriage or divorce.

A maximum of four parents per eligible employee will be covered at any point in time.

6. Underwriting

6.1 Medical information required

All cover under the Fedgroup Life Risk policy is limited to the free cover limits as set out in the benefit schedule.

No medical evidence is required for Group Risk Cover that is less than or equal to the free cover limit. Group Risk Cover in excess of the free cover limit will only be granted once the required medical evidence has been submitted to the satisfaction of Fedgroup Life. On receipt of medical evidence, Fedgroup Life will give the employee an underwriting decision in writing.Any subsequent increases in Group Risk Cover up to the advance cover will not be subject to further underwriting.

When new or additional benefits are selected, the employee will be required to comply with Fedgroup Life’s medical underwriting policies applicable at the time.Fedgroup Life will meet the costs of all medical underwriting required.

No free cover limits are set for spouses’ Group Risk Cover. However, Fedgroup Life can decide to provide a free cover limit for spouses’ Group Risk Cover at its sole discretion.

6.2 Accident cover during the medical evidence period

The medical evidence period is a 90-day period from the date the medical evidence was requested, during which time the medical evidence must be obtained, submitted and considered.

Fedgroup Life will provide cover below the free cover limit for an employee at the standard rates, terms and conditions of this policy.

During the medical evidence period, Fedgroup Life will provide accident cover in excess of the free cover limit for claims arising due to accidents only. The accident cover provided during the medical evidence period is provided at the standard rates, terms and conditions of this policy.

This accident cover in excess of the free cover limit will terminate on the earlier of the expiry of the medical evidence period and the policyholder being advised of Fedgroup Life’s underwriting decision.

Fedgroup Life reserves the right to refuse accident cover claims when:

• The disability or critical illness was self-inflicted.• Failure to disclose information about physical disabilities or medical conditions

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that affect the employee or any dependants at the time that cover commences.• The claim arose from participation in a hazardous occupation which was not

disclosed to Fedgroup Life at any point in time and is not normally associated with the industry in which the employee is employed.

• The claim arose as a consequence of participation in a hazardous sport or pursuit, including, (but without limiting the generality of the foregoing) rock climbing, scuba diving, hang-gliding, and speed contests of any kind.

• Fedgroup Life is unable to obtain sufficient medical evidence from the employee or any dependant or treating medical practitioner to fulfil the criteria to make a benefit payment.

Fedgroup Life reserves the right to refuse accident cover disability or critical illness claims as a result of:

• Wilful and deliberate breaking of any law or wilful involvement in any riot, insurrection, usurpation of power, martial law or war.

• Intentional and negligent consumption of poisons, alcohol, drugs and narcotics, unless prescribed by a registered medical practitioner. Neither the member nor his or her dependants may perform the role of a registered medical practitioner in these circumstances.

• Excessive consumption of alcohol.

6.3 What is advance cover?

The written underwriting decision provided by Fedgroup Life includes advance cover.

Advance cover is an annual percentage increase in Group Risk Cover that does not require additional medical underwriting. Provided that the life insured’s Group Risk Cover does increase in any one year beyond the advance cover percentage, no additional medical evidence will be required by Fedgroup Life. 7. How to claim and receive your benefits

7.1 How to receive a benefit payment

In the event of an insured event, Fedgroup Life will provide the prescribed forms that must be completed and the protocols needed for the benefit payment. Fedgroup Life may, from time to time, insist on further requirements in writing before considering a claim.

7.2 When must Fedgroup Life be notified of claims?

Fedgroup Life must be notified of a claim and provided with the claim requirements within a certain time in order for the claim to be assessed. Failing to do so may result in the claim being repudiated.

For Life Cover, Education Trust Cover, Funeral Cover and Spouse and Children’s Pension Cover claims:

• The policyholder needs to notify Fedgroup Life in writing within six months of a Life Insured’s death.

• All requirements must be received within nine months of the Life Insured’s death for the claim to be paid.

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For Capital Disability Cover and Income Disability Cover claims:

• For any impending disability claim the policyholder needs to notify Fedgroup Life in writing within three months of the earlier of the date of the occurrence of the event which may give rise to a disability claim, or the life insured’s last day at work.

• All requirements must be received within nine months for the claim to be paid.

For Critical Illness Cover claims:

• For any impending critical illness claim the policyholder needs to notify Fedgroup Life in writing within three months of the earlier of the date of the occurrence of the event which may give rise to a critical illness claim, or the life insured’s last day at work.

• All requirements must be received within nine months from the date of the occurrence of the event that may give rise to a disability claim, or the life insured’s last day at work for the claim to be paid.

Upon receipt of the notification of a claim Fedgroup Life shall provide the necessary forms and protocols needed in order to assess the claim.

7.3 What is required for a claim to be assessed?

The policyholder is required to furnish Fedgroup Life with such information and evidence as may reasonably be required. In addition to the necessary forms and protocols required, the employee may be required to submit the necessary initial medical evidence or any other information required by Fedgroup Life to establish whether the claim is valid in terms of the risk policy. The cost of obtaining the initial medical evidence will be paid by the employee.

The employee may be required to submit to further medical examinations by medical practitioners and experts as may reasonably be required by Fedgroup Life. The cost of providing any further medical evidence or expert opinions to consider the claim shall be borne by Fedgroup Life.

Fedgroup Life may defer the assessment of a claim until all the medical evidence has been produced.

The policyholder may appeal to Fedgroup Life to reconsider a claim if he or she is not satisfied with the claim assessment. If the policyholder wants the assessment reviewed, he or she must submit a motivation for the appeal and any pertinent additional reports or information that may be relevant to the appeal within 90 days of Fedgroup Life’s assessment, unless a longer period is agreed to in writing by Fedgroup Life.

The costs of the review will be borne by the policyholder. However, if the review results in the claim being admitted, Fedgroup Life shall reimburse the policyholder for the cost of the new medical evidence. Fedgroup Life will have the final discretion in deciding whether a claim should be admitted and will communicate its final decision to the policyholder in writing.

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7.4 Payment of the Group Risk Cover

Fedgroup Life will pay the Group Risk Cover as set out in the benefit schedule in respect of the Life Insured to the policyholder (or another party if so requested by the policyholder).

Payment by Fedgroup Life to the policyholder, or to another party as requested by the policyholder, will be the final settlement of Fedgroup Life’s obligations in terms of each life insured under this policy. However, where Fedgroup Life believes that the policyholder could jeopardise the certainty of the employee’s benefit expectations or the benefit expectations of the employee’s beneficiaries, Fedgroup Life shall have the right to pay a benefit directly to the employee or the employee’s beneficiaries. 7.5 When can a claim be refused?

Fedgroup Life reserves the right to refuse claims when:

• The disability or critical illness was self-inflicted.• Failure to disclose information about physical disabilities or medical conditions

that affect the employee or any dependants at the time that cover commences.• The claim arose from participation in a hazardous occupation that was not

disclosed to Fedgroup Life at any point in time and is not normally associated with the industry in which the employee is employed.

• The claim arose as a consequence of participation in a hazardous sport or pursuit, including, (but without limiting the generality of the foregoing) rock climbing, scuba diving, hang-gliding and speed contests of any kind.

• Fedgroup Life is unable to obtain sufficient medical evidence from the employee or any dependant or treating medical practitioner to fulfil the criteria to make a benefit payment.

Fedgroup Life reserves the right to refuse disability or critical illness claims as a re-sult of:

• Wilful and deliberate breaking of any law or wilful involvement in any riot, insurrection, usurpation of power, martial law or war.

• Intentional and negligent consumption of poisons, alcohol, drugs and narcotics, unless prescribed by a registered medical practitioner. Neither the member nor his or her dependants may perform the role of a registered medical practitioner in these circumstances.

• Excessive consumption of alcohol.

8. When does Group Risk Cover terminate?

Group Risk Cover in respect of any life insured will terminate at the selected benefit expiry age. The benefit expiry age is selected by the policyholder and is generally the age at which the employee would attain their normal retirement age in terms of their contract of employment or the rules of the retirement fund. This means that should the employee die in service before the benefit expiry age, the claim will be assessed and paid, but claims after the benefit expiry age will not be accepted. Premiums will not be charged for Group Risk Cover after employee reaches the benefit expiry age.

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8.1 Funeral Cover will terminate:

• At the date the employee reaches the benefit expiry age or dies, whichever occurs first.

• At the date that the employee leaves the employment of the employer.• For the spouse, child or parent, if they no longer meet the definitions as defined in

this document.• For the spouse at the date the spouse reaches the benefit expiry age or dies,

whichever occurs first.• For the child at the date the child reaches the benefit expiry age or dies,

whichever occurs first.• For the parent at the date the parent reaches the benefit expiry age or dies, or at

the date the employee reaches the benefit expiry age or dies, whichever occurs first.

8.2 Life Cover, Spouse and Children’s Pension Cover, Capital Disability Cover and Critical Illness Cover will terminate:


• At the date that the employee leaves the employment of the employer.• For the spouse if they no longer meet the definition of spouse as defined in this

document.• For the spouse at the date the spouse reaches the benefit expiry age or dies,

whichever occurs first.

8.3 Income Disability Cover will terminate:


• At the date that the employee leaves the employment of the employer.

8.4 Education Trust Cover will terminate:

• At the date the employee reaches the benefit expiry age or age 65, whichever occurs first.

• At the date that the employee leaves the employment of the employer.• For the child if they no longer meet the definition of child as defined in this

document.• For the child at the date the child reaches the benefit expiry age or dies,

whichever occurs first. 9. Premiums

9.1 Who is responsible for paying premiums?

The policyholder is responsible for paying the premiums. A period of two months grace is allowed for the payment of premiums, unless otherwise arranged with Fedgroup Life in writing. Any claim arising during the period of grace will not be paid until all outstanding premiums have been paid by the policyholder. If the full amount of premiums due is not received by the date of expiry of the period of grace, no benefit will be payable and all cover will cease from the last date the full amount of

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premiums has been paid. The last date the full amount of premiums has been paid is the last day of the month for the month that the premiums due were paid.

9.2 When can Fedgroup Life alter the existing premium rates?

The rates and calculation basis are effective from the commencement date until the first policy anniversary. A longer premium guarantee term may be granted in specific cases. This will be reflected in the benefit schedule. Fedgroup Life reserves the right to change the rate and calculation basis by giving one month’s written notice if:

• There is a change in membership of more than 15% or a new associated company joins the policyholder or there is a change to the benefit under this policy.

• The policyholder becomes involved in another business activity that substantially affects the risk under this policy.

Each year, on the anniversary date, the premiums and benefits will be reviewed. The review will include a recalculation of premiums based on the benefits, the employee’s age at time of review, previous claims experience of the policy and any other factor that has affected the risk of insuring the benefits.

10. What is a continuation option?

A continuation option may be chosen by the policyholder to enable employees and spouses to continue their Group Risk Cover with Fedgroup Life in their individual capacity for the same benefits as enjoyed under the Fedgroup Life Risk policy. The continuation option is not available on Education Trust Cover and Spouse and Children’s Pension Cover.

An employee may exercise the continuation option for the Group Risk Cover as a result of the employee leaving service on or before the earlier of the benefit expiry age or age 65.

A spouse may exercise the continuation option for the Group Risk Cover as a result of the employee leaving service or the employee’s death on or before the earlier of the benefit expiry age or age 65.

The employee must have at least 12 consecutive months’ insured service with his employer. An employee who leaves service as the result of a successful Capital Disability Cover claim will not be allowed to continue their Life Cover. Any condition or illness that resulted in a successful Capital Disability Cover, Income Disability Cover or Critical Illness Cover claim is permanently excluded from any Group Risk Cover that is continued.

The continuation option may be exercised on the termination of the policyholder’s participation in the policy, provided that the policyholder ceases to operate as a going concern and/or the policyholder is not transferring the insurance cover to another insurer that provides life, funeral, disability and/or critical illness insurance.

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The employee and spouse will be required to complete a Fedgroup Life Individual Risk Application Form. Under the employee’s and spouse’s Individual Risk Cover application, no medical underwriting will be required except for the requirements, conditions or exclusions in respect of the acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV), as Fedgroup Life may specify at the time of exercising the continuation option. Additional underwriting may be required if the employee or spouse adds benefits that he or she did not have cover for as part of the Fedgroup Life risk policy.

The premium rate applicable at the time the continuation option is exercised and the risk class of the employee or spouse will determine the premium payable on a voluntary group risk policy.

Any pre-existing condition provisions continue to apply. Waiting periods, where applicable, will not be shorter than those applicable to the Fedgroup Life risk policy and maximum cover age shall not be later than the benefit expiry age initially chosen, according to the benefit schedule.

The employee and spouse will have 30 days from the date the employee left his or her employer to request the continuation option in writing.

If an employee or spouse who has requested the continuation option dies or becomes medically impaired within 30 days of the employee leaving his or her employer, then the maximum benefit that the employee or spouse would have obtained without proof of good health in terms of the continuation option will be paid to his or her dependants, nominees or estate, as decided by Fedgroup Life on his or her death, or it will be paid on medical impairment. 11. General legal provisions, definitions and rules

11.1 Exclusions

Fedgroup Life will not pay any Group Risk Cover claim as a consequence of:

11.1.1 Pre-existing conditions

In the case of Capital Disability Cover, Critical Illness Cover and Income Disability Cover, Fedgroup Life will not pay a claim during the first 12 months of the life insured joining the Fedgroup Life risk policy, should it be the opinion of Fedgroup Life that the claim is directly or indirectly attributable to an injury or illness, which the life insured sought medical advice for, or knew about (or could reasonably be expected to have known of), during the six months prior to becoming a life assured under the risk policy.

The pre-existing conditions clause will not be waived for a new Fedgroup Life risk policy where the provisions of this clause have not been fulfilled.

The pre-existing conditions clause will be waived by Fedgroup Life in cases where a life insured is actively in the service of an employer and has previously satisfied these provisions under a

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group risk policy issued by any insurer that was insuring the same benefits immediately prior to the commencement date of the risk policy. This is only allowed for conditions covered by the previous insurer and is a partial waiver.

If the clause has been waived, an endorsement to the Fedgroup Life risk policy will be issued, reflecting the benefits for which the clause has been waived.

11.1.2 War and riot exclusion

An employee, spouse, child or parent will not be entitled to receive a Group Risk Cover benefit payment for any claim arising as a direct or indirect consequence of war, invasion, acts of foreign enemies, hostilities, warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power.

11.1.3 Atomic, biological and chemical exclusion

Fedgroup Life will not be liable for any Group Risk Cover claim arising as a direct or indirect consequence of:

• The use of nuclear, biological or chemical weapons, or any radioactive contamination or• Attacks on or sabotage of facilities (including, but not limited to, nuclear power plants, reprocessing plants, final repository sites and research reactors) and storage depots, which lead to the release of radioactivity or nuclear, biological or chemical warfare agents, irrespective of whether any of the aforesaid has been performed with the specific use of information technology.

If Fedgroup Life alleges that by reason of this exclusion, any loss, damage, cost or expense is not covered under this policy, the burden of proving the contrary will lie with the policyholder.

11.1.4 War and riot exclusion partial waiver

A policyholder may choose to have the war and riot exclusion partially waived for an additional premium. If this option is chosen the war and riot exclusion above is replaced by:

An employee, spouse, child or parent will not be entitled to receive a Group Risk Cover benefit payment for any claim arising as a direct or indirect consequence of active participation in war, invasion, acts of foreign enemies, hostilities, warlike operations (whether war is declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military action or usurped power.Fedgroup Life will provide written confirmation of the partial waiver of the war and riot exclusion in the benefit schedule.

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11.2 Documentation to be received

The Fedgroup Life risk policy read in conjunction with the benefit schedule and applicable documentation constitutes the entire agreement between Fedgroup Life and the policyholder. Alterations to these documents will be treated as an endorsement signed by an authorised official of Fedgroup Life.

11.3 Currency and law

Benefit payments and premiums are payable in the lawful currency of the Republic of South Africa. Any questions of law arising under this policy will be decided according to the laws of the Republic of South Africa.

11.4 Life insured

Life insured means a person who is insured in terms of this policy. 11.5 Eligibility

Eligible employee means a permanent, active, full-time employee who has not reached the benefit expiry age and who is employed for no less than 25 hours a week and member means members admitted to a retirement fund in terms of its rules.

Any employee who becomes eligible for membership after the commencement date shall become a member on the first day of the month on which he or she first became eligible.

11.6 Actively at work

An employee must be actively at work, attending to and capable of fulfilling his or her normal daily duties on the first working day on which his or her cover commences. If not, the employee’s entry will be deferred until such time as eight consecutive weeks of uninterrupted service is completed.

An employee who is on annual or maternity leave at commencement will have this clause waived, provided that he or she did not receive medical treatment for a condition that led to his or her disability or critical illness within eight weeks of his or her intended date of return to work.

The actively at work clause may be waived where the Employees have complied with the provisions of the clause under a previous group risk policy, provided that there has been no break between the policies.

Fedgroup Life will provide written confirmation of the waiver of the actively at work clause in the benefit schedule.

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11.7 Take-over of existing policies

The cover of employees who have already provided proof of insurability to the previous insurer will be taken over on the same terms and conditions as those that applied with the previous insurer, subject to any maximum limits determined by Fedgroup Life and on receipt of written proof from the previous insurer.

11.8 Particulars of the insured lives

The policyholder will be required to provide Fedgroup Life with all documentation and proof of the particulars of the lives insured, as required from time to time, to determine the benefits and premiums. If it transpires that any of this information is incorrect, Fedgroup Life will be entitled to make appropriate benefit and premium adjustments.

11.9 Evidence of age

Fedgroup Life will request evidence of the employee’s age before making a benefit payment. Should the date of birth previously provided to Fedgroup Life by an employee prove to be incorrect, Fedgroup Life will determine the premiums that should have been paid and adjust the premiums retrospectively to the date on which the employee became entitled to the assurance in terms of this policy. Any adjustment of premium will be reflected in the next premium statement to the policyholder.

11.10 Temporary absence

If an employee is temporarily absent from the service of the employer other than by reason of disability, the following provisions shall apply:

• Provided that payment of premiums continues, the benefits will be provided for a period of six months.• By application from the policyholder and approval by Fedgroup Life, the period of absence can be extended to 24 months, with cover ceasing thereafter.• If the employee resumes active employment after cover has terminated, he or she will be treated by Fedgroup Life as a new employee.

11.11 Territorial limitations

Employees must be resident and physically present in the Republic of South Africa to qualify for admission to the policy in terms of the eligibility requirements. If an employee is temporarily absent from the Republic, the following provisions shall apply:

• The benefits will be underwritten in accordance with Fedgroup Life’s territorial loadings for foreign countries and is subject to change from time to time.

• Provided that payment of premiums continues, the benefits will be provided for a period of six months.

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• By application in writing from the policyholder and approval by Fedgroup Life, the period of absence from the Republic can be extended to 12 months, with cover ceasing thereafter.

• Upon return to the Republic by the employee after cover has terminated, he or she will be treated by Fedgroup Life as a new employee.

11.12 Alterations to the policy

Policy alterations are subject to three months’ written notice from either the policyholder or Fedgroup Life, unless a shorter period is agreed upon. If the amendment is the result of changes to legislation or regulations, Fedgroup Life may alter the policy from the effective date of the change without giving notice to the policyholder.

11.13 Precedent

No decision by Fedgroup Life in regard to any matter concerning the policy may be interpreted as a precedent.

11.14 Misrepresentation

The information given to Fedgroup Life in the Fedgroup Life Risk Cover Application Form, or any other documentation that was provided in support of the application, forms the basis upon which the policy is issued.

If the policyholder or employee fails to disclose any information, or provides false information or distorts information when applying for the policy, Fedgroup Life will be entitled to discontinue their cover from the inception date of the policy. In addition to this, Fedgroup Life will also be entitled to:

• Refuse to pay out any current or future claims that are related to the misrepresentation or non-disclosure.• Adjust the premium from the date of the misrepresentation or non- disclosure.• Recover monies already paid to the employee for claims that relate to the misrepresentation or non-disclosure.• Cancel certain benefits or the entire policy with immediate effect, and retain any premiums paid to Fedgroup Life.

11.15 Fraud

Fedgroup Life shall not be liable for any claim under this policy if the policyholder or life insured or employer commits any act of dishonesty or fraud relating to any provisions contained in this policy.

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The policy and all its benefits may be cancelled should the policyholder or the employee:

• Submit a fraudulent claim.• Use any fraudulent means or devices to make claims.• Provide false information in order to obtain a benefit.• Knowingly allow anyone acting on their behalf to provide false information in order to obtain a benefit.

12. Beneficiaries

The Group Risk Cover provided through the Fedgroup Life Risk policy may not be ceded to a third party.

Fedgroup Life will pay the Group Risk Cover as set out in the benefit schedule in respect of a deceased employee to the beneficiaries as nominated by the Employee in the Fedgroup Life beneficiary nomination form. Should there be no completed and signed Fedgroup Life beneficiary nomination form then Fedgroup Life will pay the Group Risk Cover to the policyholder or as instructed by the policyholder.

13. Discontinuance

13.1 Discontinuance by the policyholder

The policyholder must give Fedgroup Life one calendar month’s written notice should the policyholder wish to discontinue the policy. If this occurs, the policyholder will not be entitled to resume premium payments and all benefits will end at the expiry of the notice period unless otherwise agreed by Fedgroup Life in writing.

13.2 Discontinuance of benefits for an employee

The benefits in respect of a particular employee and his or her family may fully or partially terminate as soon as any of the following events occur:

• Full or partial discontinuance of premium payments in respect of a particular employee.• The employee reaching any benefit expiry age.• The employee ceasing to be an eligible employee or member.

13.3 Discontinuance by Fedgroup Life

Fedgroup Life has the right to discontinue the benefits provided to Employees and dependants in terms of this policy if:

• The policyholder is placed under judicial management or liquidation, or has been liquidated, or effects a compromise with its creditors or• There is any material non-compliance by the policyholder regarding any of the provisions of this policy or• The policy no longer meets the policy and benefit minimums

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determined by Fedgroup Life from time to time or• Fedgroup Life loses its reinsurance cover.

Fedgroup Life will give the policyholder one calendar month’s written notice of the discontinuance of the policy.

This policy will be discontinued on the date of termination of the last remaining employee’s participation in this policy.

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Appendix 1 – Critical Illness Cover

Fedgroup Life subscribes to the ASISA standard on disclosures for critical illness products known as the Standardised Critical Illness Definitions Project (SCIDEP). This means that Fedgroup Life will honour claims according to the SCIDEP definitions, for the severity levels of each of the four core diseases (heart attack, cancer, stroke and coronary artery bypass graft) according to the payout percentages as listed in the table below.

Below are the payout percentages for our Critical Illness Cover as measured against the ASISA critical illness definitions:

Level A Most Severe

Level B Moderate Impairment

Level C Mild Impairment

Level DAlmost Full Recovery

1. Heart attack 100% 75% 50% 25%

2. Cancer 100% 75% 50% 25%

3. Stroke 100% 75% 50% 25%

4. Coronary artery bypass graft 100% 75% 50% 25%

General provisions:

• Any diseases or disorders must be shown to be a new event since the date of commencement of the policy with evidence of acute signs or symptoms compatible with the event.

• Any change in activities of daily living must be shown to be a new change since diagnosis of the disease or disorder.

• Any definition pertaining to a transplant will include being on the official South African or official international waiting list for the relevant transplant.

Fedgroup Life requires proof that the medical impairment definitions in the Fedgroup Life Risk policy have been met according to general accepted medical practice.

Specific critical illnesses that qualify for a benefit payment:

Below are detailed medical descriptions of the various critical illnesses for which Critical Illness Cover claims may be made. Because a medical specialist must be involved in diagnosing and submitting any claim, specific protocols for each critical illness claim will be sent to the specialist who treats the life insured at the time of the claim.

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1. Heart Attack

Level A: Heart attack with severe permanent impairment in function

A heart attack that meets the criteria as defined under Level C, with permanent impairment in one or more of the following functional criteria, as measured six weeks post-infarction:

Criterion ValueNYHA classification Class 4

METS 1 or less

LVEF < 30%

LVEDD > 72

Ultrasound FS in % < 16%

Level B: Heart attack with mild permanent impairment in function

A heart attack that meets the criteria as defined under Level C, with permanent impairment in one or more of the following functional criteria, as measured six weeks post-infarction:

Criterion ValueMETS 2-7

LVEF 30%-50%

LVEDD 59-72

Ultrasound FS in % 16%-25%

Level C: Moderate heart attack of specified severity

This is defined as the death of heart muscle, due to inadequate blood supply, as evidenced by any of the following combinations of criteria:

• Compatible clinical symptoms AND raised cardiac biomarkers, OR• Compatible clinical symptoms AND new pathological Q-waves on ECG as defined

in Annexure A (b), OR• New pathological Q-waves on ECG as defined in Annexure A (b) AND raised

cardiac biomarkers, OR• ST-segment and T-wave changes on ECG indicative of myocardial injury as

defined in Annexure A (a), AND raised cardiac biomarkers.

Where raised cardiac biomarkers are referenced above, they are defined as any one of the following troponin or non-troponin markers:

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Sensitive Troponin Markers

Marker Value**

*Assay (test) Troponin Type Unit: ng/L Unit: ng/mlRoche hsTnT TnT > 1 000 > 1.0

Abbott ARCHITECT TnI > 3 000 > 3.0

Beckman AccuTnI TnI > 5 000 > 5.0

Siemens Centaur Ultra TnI > 6 000 > 6.0

Siemens Dimension RxL TnI > 6 000 > 6.0

Siemens Stratus CS TnI > 6 000 > 6.0

*Use the relevant manufacturer’s assay (test) or equivalent as it appears on the laboratory report.**Values represent multiples of the World Health Organisation (WHO) MI rule in levels and not the

99th percentile values (upper limit of normal) as quoted on the laboratory result.

Conventional Troponin Markers

Marker Value

Assay (test) Troponin Type Unit: ng/L Unit: ng/mlConventional TnT TnT > 1 000 > 1.0

Conventional AccuTnI***

TnI > 500 > 0.5

*** or equivalent threshold with other Troponin I methods

Non-Troponin Markers

Marker ValueRaised CK-MB mass Raised two times or more the upper limit of normal laboratory

reference range in acute presentation phase

Total CPK elevation Raised two times or more the upper limit of normal laboratory reference range in acute presentation phase, with at least 6% being CK-MB

Level D: Mild heart attack of specified severity

This is defined as the death of heart muscle, due to inadequate blood supply, as evidenced by all three of the following criteria:

• Compatible clinical symptoms AND• Characteristic ECG changes indicative of myocardial ischaemia or myocardial

infarction as per Annexure A (a) AND• Raised cardiac biomarkers defined as any one of the following troponin or non-

troponin markers:

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Sensitive Troponin Markers

Marker Value**

*Assay (test) Troponin Type Unit: ng/L Unit: ng/mlRoche hsTnT TnT > 500 >0.5

Abbott ARCHITECT TnI > 1 500 >1.5

Beckman AccuTnI TnI > 2 500 >2.5

Siemens Centaur Ultra TnI > 3 000 >3.0

Siemens Dimension RxL TnI > 3 000 >3.0

Siemens Stratus CS TnI > 3 000 >3.0

*Use the relevant manufacturer’s assay (test) or equivalent as it appears on the laboratory report.**Values represent multiples of the World Health Organisation (WHO) MI rule in levels and not the

99th percentile values (upper limit of normal) as quoted on the laboratory result.

Conventional Troponin Markers

Marker Value

Assay (test) Troponin Type Unit: ng/L Unit: ng/mlConventional TnT TnT > 500 > 0.5

Conventional AccuTnI***

TnI > 250 > 0.25

*** or equivalent threshold with other Troponin I methods Non-Troponin Markers

Marker ValueRaised CK-MB mass Raised above the upper limit of normal laboratory reference

range but not meeting the severity C definition (i.e. below two times the upper limit of normal laboratory reference range) in acute presentation phase

Total CPK elevation Raised above the upper limit of normal laboratory reference range but not meeting the severity C definition (i.e. below two times the upper limit of normal laboratory reference range) in acute presentation phase, with at least 6% being CK-MB

The evidence must show a definite acute myocardial infarction. Other acute coronary syndromes, including but not limited to angina, are not covered by this definition. Post coronary artery intervention myocardial infarction (MI)

• Confirmed acute MI that has occurred post percutaneous coronary intervention (PCI) with a detection of cardiac biomarkers as follows:

Marker ValueCardiac troponin assay As it appears in the definition of at least a heart attack of mild

severity (Level D) post intervention

Raised CK-MB mass Raised above the upper limit of normal laboratory reference range but below four times the upper limit of normal laboratory reference range post intervention

• Confirmed acute MI that has occurred post coronary artery bypass graft (CABG) with a detection of cardiac biomarkers as follows:

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Marker ValueCardiac troponin assay As it appears in the definition of at least a heart attack of

moderate severity (Level C) post intervention

Raised CK-MB mass Raised four times or more the upper limit of normal laboratory reference range post intervention

Definitions of ECG changes:

a. ECG changes indicative of myocardial ischaemia that may progress to myocardial infarction:

• Patients with ST-segment elevation:• New or presumed new ST segment elevation at the J point in two or

more contiguous leads with the cut-off points greater than or equal to 0.2mV in leads V1, V2 or V3, and greater than or equal to 0.1mV in other leads.

• Contiguity in the frontal plane is defined by the lead sequence AVL, I and II, AVF, III.

• Patients without ST-segment elevation:• ST-segment depression of at least 0.1 mV• T-wave abnormalities only

b. Definition of new pathological Q-waves:

• Any new Q-wave in leads V1 through V3.• A Q-wave greater than or equal to 40 ms (0.04s) in leads I, II, AVL, AVF, V4, V5

or V6.• The Q-wave changes must be present in any two contiguous leads, and be greater

than or equal to 1mm in depth.• Appearance of new complete bundle branch block.

Reference:

Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction: “Myocardial Infarction Redefined – A Consensus Document”; Journal of the American College of Cardiology, Vol. 36, No 3, 2000, p959-968. Table 3 & 4, p962.

Layman’s description

Four levels of severity of heart attacks are defined:

• Level D is the mildest and Level A the most severe.• In both levels C and D the patient recovers fully and the heart function returns to

normal.• In levels A and B, more permanent damage has resulted, which means the heart

function is less than 100% after recovery.• The effect of the heart attack on heart function should be measured six weeks

after the heart attack.

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Level A: Heart attack with severe impairment in function These are heart attacks where a significant proportion of the heart muscle was damaged. The same tests are used to measure the damage as under Level B but the results would show a more serious level of impaired function. This person will have difficulty coping with normal activities of daily living, and will most likely not be able to work. Level B: Heart attack with mild permanent impairment in function.

This is usually a heart attack that does not recover 100% of normal function. The degree of permanent damage can be measured by a heart sonar, an exercise tolerance test or a measurement of physical abilities. These measurements should be performed six weeks after the heart attack.

A person with this level of heart damage should still be able to manage normal daily activities and even his/her occupation, if the occupation does not involve strenuous physical work. However, this person’s insurability will be adversely affected, and the future risk for a repeat cardiac event is high. Significant lifestyle adaptation and risk factor modification are indicated.

Level C: Moderate heart attack of specified severity

In this case damage to the heart muscle is more than in Level D. In some cases a cardiologist will intervene early and reverse the potential damage. This intervention may include administration of drugs to dissolve the blood clot in the coronary artery(ies), balloon stretching of the coronary artery, with or without a stent. Because the clinical methods of diagnosing this level of heart attack are unambiguous, only two of the three criteria are required:

• Typical chest pain or other symptoms typically associated with a heart attack.• Certain defined ECG changes. At this level the changes are more marked and

more specific to a heart attack.• Elevated blood test results greater than required for Level D.

Level D: Mild heart attack with full recovery

This is a heart attack where the ECG changes and blood test results are mildly abnormal. Therefore, all three criteria are required, i.e.

• Typical chest pain or other symptoms associated with a heart attack, and• Certain defined ECG changes, and• An elevation in certain blood test results.

2. Cancer

A malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, lymphoma and sarcoma.

The following conditions are excluded from this definition:

• All cancers in situ and all pre-malignant conditions or conditions with low malignant potential, or classified as borderline malignancy.

• All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0.

• All skin cancers are excluded. The only exception is malignant melanoma that has been histologically classified as T1N0M0 or worse.

Cancers are generally classified by severity into four stages. However brain and prostate cancer, leukaemia and lymphoma do not conform to this general classification. Therefore additional tiering levels are proposed for these cancers.

Tiering of all cancers except prostate, leukemia, lymphoma and brain tumours:

The levels are correlated to the general classification used by the American Joint Committee for Cancer for the type of cancer involved:

• Level A – Stage 4 cancer• Level B – Stage 3 cancer• Level C – Stage 2 cancer• Level D – Stage 1 cancer

Tiering of prostate cancer

Stage 1 T1a, N0, M0, Gleason ≤ 4 Excluded

Stage 2 T1a, N0, M0, Gleason 5-6 Excluded

T1b-c, N0, M0, Gleason 2-6 Excluded

T1a-c, N0, M0 Gleason ≥7 Severity D

T2, N0, M0 any Gleason Severity D

Stage 3 T3, N0, M0 any Gleason Severity C

Stage 4 T4, N0, M0 any Gleason Severity B

Any T, N1 – 3, M0 any Gleason Severity A

Any T, any N, M1, any Gleason Severity A

Tiering of leukemia and lymphoma

Level A - This benefit will pay for any one of the following diagnoses:• Acute myeloid leukaemia• Chronic lymphocytic leukaemia, stage III or IV on the Rai classification• Chronic myeloid leukaemia (requiring bone marrow transplant);• Acute lymphocytic leukaemia (adults)• Hodgkins/non-Hodgkins lymphoma stage IV on Ann Arbor classification system• Multiple myeloma Stage III on the Durie-Salmon Scale Level B - This benefit will pay for the following diagnoses:• Hodgkins and non-Hodgkins Lymphoma stage III on Ann Arbor Classification

System

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Level C - This benefit will pay for any one of the following diagnoses:• Chronic lymphocytic leukaemia (stage II on the Rai classification)• Acute lymphocytic leukaemia (children)• Chronic myeloid leukaemia (no bone marrow transplantation)• Hodgkins/non-Hodgkins lymphoma Stage II on Ann Arbor classification system• Multiple myeloma Stage I and II on the Durie-Salmon scale

Level D - This benefit will pay for any of the following:• Chronic lymphocytic Leukaemia (Stage 0 or 1)• Hairy cell leukaemia• Hodgkins/non-Hodgkins lymphoma Stage 1 on Ann Arbor classification Tiering of brain tumours

WHO grade II Without neurological deficit Severity D

WHO grade II With neurological deficit Severity C

WHO grade III On diagnosis Severity B

WHO grade IV On diagnosis Severity A

WHO Grades of CNS Tumors

Grades I II III IVAstrocytic tumors

Subependymal giant cell astrocytoma X

Pilocytic astrocytoma X

Pilomyxoid astrocytoma X

Diffuse astrocytoma X

Pleomorphic xanthoastrocytoma X

Anaplastic astrocytoma X

Glioblastoma X

Giant cell glioblastoma X

Gliosarcoma X

Oligondendroglial tumors

Oligodendroglioma X

Anaplastic oligodendroglioma X

Oligoastrocytic tumors

Oligoastrocytoma X

Anaplastic oligoastrocytoma X

Ependymal tumors

Subependymoma X

Myxopapillary ependymoma X

Ependymoma X

Anaplastic ependymoma X

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Grades I II III IV

Choroid plexus tumors

Choroid plexus papilloma X

Atypical choroid plexus papilloma X

Choroid plexus carcinoma X

Other neuroepithelial tumors

Angiocentric glioma X

Chordoid glioma of the third ventricle X

Neuronal and mixed neuronal-glial tumors

Gangliocytoma X

Ganglioglioma X

Anaplastic ganglioma X

Desmoplastic infantile astrocytoma and ganglioglioma X

Dysembryoplastic neuroepithelial tumor X

Central neurocytoma X

Extraventricular neurocytoma X

Cerebellar liponeurocytoma X

Paraganglioma of the spinal cord X

Papillary glioneuronal tumor X

Rosette-forming glioneural tumor of the fourth ventricle X

Pineal tumors

Pineocytoma X

Pineal parenchymal tumor of intermediate differentiation X

Pineoblastoma X

Papillary tumor of the pineal region X

Embryonal tumors

Medulloblastoma X

CNS primitive neuroectodermal tumor (PNET) X

Atypical teratoid/rhabdoid tumor X

Tumors of the cranial and paraspinal nerves

Schwannoma X

Neurofibroma X

Perineurioma X

Malignant peripheral nerve sheath tumor (MPNST) X

Meningeal tumors

Meningioma X

Atypical meningioma X

Anaplastic/malignant meningioma X

Hemangiopericytoma X

Anaplastic hemangiopericytoma X

Hemangioblastoma X

Tumors of the sellar region

Craniopharyngioma X

Granular cell tumor of the neurohypophysis X

Pituicytoma X

Spindle cell oncocytoma of the adenohypophysis X41

Layman’s description

Cancer is an uncontrolled growth that spreads into the normal tissue surrounding the organ where the cancer originates. The diagnosis must be supported by tests where a pathologist confirms the presence of cancer cells using a microscope. Some cancers have been specifically excluded because:

• The long-term outcome is good and the effect on quality of life is minimal.• Treatment is neither expensive nor extensive.

There are specific exclusions to this definition that include:• Cancerous cells that have not invaded the surrounding or underlying tissue.• Early cancer of the prostate gland and breast.• All cancers of the skin except cancerous moles that have invaded underlying

tissue.

Staging of cancer

As a general rule there are four stages of cancer.

Stage 1 cancer is defined by an invasive cancer confined to the tissue or organ of origin.Stage 2 cancer is defined by the involvement of adjacent structures or organs.Stage 3 cancer involves spreading to regional lymph nodes.Stage 4 cancer is characterized by distant metastasis.

However, each type of cancer is staged specifically by the American Joint Committee for Cancer (AJCC). This staging is based on the outcome of the specific cancer and does not always follow the general rule as stated above. In order to standardise staging we have used the AJCC system which is the same system used in clinical practice by specialists who treat cancer. 3. Stroke

Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in neurological deficit lasting longer than 24 hours, confirmed by neuro-im-aging investigation and appropriate clinical findings by a specialist neurologist. For the above definition, the following are not covered:

• Transient ischaemic attack• Vascular disease affecting the eye or optic nerve• Migraine and vestibular disorders• Traumatic injury to brain tissue or blood vessels

Severity levels will be assessed by a full neurological examination by a specialist neurologist any time after three months. Level A: Stroke with severe impairment. Needs constant assistance, as measured by:

• The inability to do three or more basic ADLs, or

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• A Whole Person Impairment (WPI) of greater than 35%.

Level B: Stroke with moderate impairmentCannot function independently, as measured by:

• The inability to do 6 or more advanced ADL’s, or• A WPI of 21% to 35%.

Level C: Stroke with mild impairmentCan function independently, but has impairment as measured by:

• The inability to do 3 or more advanced ADL’s, or• A WPI of 11% to 20%.

Level D: Stroke with almost full recoveryAlmost full recovery, with little residual symptoms or signs, as measured by:

• The ability to do all basic and advanced ADLs, or• A WPI of 10% or less.

Whole Person Impairment (WPI) figures are calculated as per the American Medical Association Guides to the Evaluation of Permanent Impairment 6th edition. The claim will be considered valid if the member can function independently, but has impairment as measured by the inability to do 3 or more advanced ADLs (see Appendix 2).

Layman’s Definition

A stroke occurs when the blood supply to a portion of the brain is obstructed and this part of the brain tissue dies. It can also happen when there is bleeding into the brain tissue due to a weakening or abnormality of the blood vessel wall. A common cause of the rupture of a brain blood vessel is longstanding uncontrolled high blood pressure.

The result of a stroke is usually paralysis of an arm and leg, sometimes with one half of the face affected as well. In some cases people also lose their ability to speak. The paralysis can recover to varying degrees. Some recover fully, whereas others may retain permanent weakness of a limb(s).

A transient ischaemic attack (TIA) occurs when the blood supply is momentarily interrupted, but restored before any permanent damage can occur. It usually results in one of more of the following symptoms:

• A loss of sensation• Dizziness• Lameness of a limb• Loss of speech

which only occur for a few minutes to hours and recovery is quick and spontaneous. 4. Coronary Artery Bypass Graft

The undergoing of surgery, regardless of method of surgical access, to correct the 43

narrowing of, or blockage to, one or more coronary artery(ies) by means of a by-pass graft.

The following are covered:

• Level A - The undergoing of surgery to correct the narrowing of, or blockage to, three or more coronary arteries, by means of a bypass graft.

• Level B - The undergoing of surgery to correct the narrowing of, or blockage to, two coronary arteries, by means of a bypass graft.

• Level C - The undergoing of surgery to correct the narrowing of, or blockage to, the left main or proximal left anterior descending coronary artery, by means of a bypass graft.

• Level D - The undergoing of surgery to correct the narrowing of, or blockage to, any one coronary artery, by means of a bypass graft.

Layman’s definition

Coronary artery bypass graft surgery, also called heart bypass or bypass surgery, is a surgical procedure performed to relieve chest pain and reduce the risk of death from heart disease.

Arteries or veins from elsewhere in the patient’s body (most commonly the leg) are joined to the coronary arteries of the heart to bypass the narrowing of the affected or diseased arteries. This improves the blood supply and circulation to the heart muscle. The terms “single bypass”, “double bypass”, “triple bypass”, “quadruple bypass” and “quintuple bypass” refer to the number of coronary arteries bypassed in the procedure.

This surgery is usually performed with the heart stopped necessitating the usage of highly specialised theatre equipment to keep the heart and the lungs working during the course of the operation.

5. Major Organ Transplant

The undergoing of a transplant of bone marrow or of a complete heart, kidney, liver, lung, or pancreas, or inclusion on an official waiting list for such a procedure.

For the above definition, the following is not covered:

• Transplant of any other organs, parts of organs, tissues or cells.

6. Blindness

Clinically proven irreversible reduction of sight in both eyes as a result of sickness or accident.

The corrected visual acuity must be less than 6/60 or 20/200 using, e.g. Snellen test types, or visual field restriction to 20° or less in both eyes. No benefit will be payable if in general medical opinion a device or implant could result in the partial or total restoration of sight.

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7. Paraplegia

Total and irreversible loss of the use of any two limbs as a result of a spinal cord injury.

8. Coma with residual impairment

A state of unconsciousness with no reaction to external stimuli or internal needs that:• Requires the use of life support systems for a continuous period of at least 96

hours, and• Results in permanent neurological deficit with persisting clinical symptoms. The

residual impairment will be assessed by a full neurological examination by a specialist neurologist any time after three months. The claim will be considered valid if the member can function independently, but has impairment as measured by the inability to do three or more advanced ADLs (see Appendix 2).

For the above definition, the following is not covered:

• Coma secondary to alcohol or drug abuse or medically induced coma.

9. Severe Burns Full thickness burns that involve at least 20% of the body surface area. This means tissue injury caused by thermal, electrical or chemical agents causing third-degree or full thickness burns to at least 20% of the body surface area as measured by The Rule of Nines or the Lund and Browder Body Surface Chart. 10. Multiple Sclerosis (with persisting symptoms)

A definite diagnosis of multiple sclerosis confirmed by a neurologist. There must be at least two separate events and current clinical impairment of motor or sensory function of an EDSS scale 3.0 or more, which must have persisted for a continuous period of at least six months. Benign multiple sclerosis will not be covered (see Appendix 2).

11. End-stage Kidney Failure (requiring ongoing dialysis)

Chronic end-stage failure of both kidneys to function, as a result of which regular dialysis is necessary.

12. Advanced Dementia including Alzheimer’s Disease

A definite diagnosis of Alzheimer’s disease or advanced dementia by a neurologist, psychiatrist or geriatrician. There must be permanent significant cognitive impairment resulting in an inability to remember, reason, perceive, understand, express and give effect to ideas as per standard testing procedures. The member is unable to do three or more Advanced Activities of Daily Living (see Appendix 2).

Exclusion: Dementia as a result of alcohol or drug abuse.

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13. Parkinson’s Disease (resulting in permanent symptoms)

A definite diagnosis of Parkinson’s disease by a neurologist. There must be permanent clinical impairment of motor function with associated tremor, rigidity of movement and postural instability.

Exclusion: Parkinson’s disease secondary to drug abuse.

14. Accidental Brain Injury (resulting in permanent symptoms)

Death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms. Can function independently, but has impairment as measured by the inability to do three or more Advanced Activities of Daily Living (see Appendix 2).

15. Heart Valve Replacement Surgery (with surgery to divide the breastbone)

The undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a cardiologist to replace or repair one or more heart valves.

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Appendix 2 – Activities of Daily Living

The Activities of Daily Living (ADLs) is a scoring system that assesses the functional ability of a person that takes into account the physical, social and interactive abilities of a person. Fedgroup Life looks at the total functioning ability of the life insured using the Basic and Advanced Activities of Daily Living, which are objective measurements of a life insured’s ability to carry out normal functions, to provide an objective assessment of the impact of diseases and disorders on the life insured.

Basic Activities of Daily Living

• Bathing – the ability to was/bathe oneself independently.• Transferring – the ability to move oneself from a bed to a chair or from a bed to a

toilet independently.• Dressing – the ability to take off and put on one’s clothes independently.• Eating - the ability to feed oneself independently. This does not include the

making of food.• Toileting – the ability to use a toilet and cleanse oneself thereafter, independently.• Locomotion on a level surface – the ability to walk on a flat surface,

independently.• Locomotion on an incline – the ability to walk up a gentle slope, or a flight of steps

independently.

Advanced Activities of Daily Living

• Driving a car – the ability to open a car door, change gears or use a steering wheel.

• Medical care - the ability to prepare and take the correct medication.• Money management – the ability to do one’s own banking and to make rational

financial decisions.• Communicative activities - the ability to communicate either verbally or written.• Shopping - the ability to choose and lift groceries from shelves as well as carry

them in bags.• Food preparation – the ability to prepare food for cooking as well as using kitchen

utensils.• Housework – the ability to clean a house or iron clothing.• Community ambulation with or without assistive device, but not requiring a

mobility device – the ability to walk around in public places using only a walking stick if necessary.

• Moderate activities - activities like moving a table, pushing a vacuum cleaner, bowling, golf.

• Vigorous activities - able to partake in running, heavy lifting, sports.

The Expanded Disability Status Scale (EDSS)

EDSS is frequently used by neurologists to measure Multiple Sclerosis dysfunction, and is a strong prognostic indicator. The EDSS is a widely used standard for the clinical assessment of MS.

The Functional System (FS) score determines the EDSS. Functional System refers to a specific area of neurological functioning. These areas include pyramidal (motor), cerebellar, brainstem, sensory, bowel, bladder, visual and cerebral (cognitive and mood) functions.

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Fedgroup Financial Services (Pty) Ltd (Reg. No. 2012/000697/07) FAIS Licence No: 45563. 89 Bute Lane, Sandton. PO Box 782823, 2146. T 011 305 2300 F 011 305 2500 [email protected] fedgroup.co.za For details on our directorate visit our website

At EDSS steps 1.0 to 4.0, patients are fully ambulatory, impairment to ambulation defines EDSS steps greater than or equal to 6.0.

0 – 1.0 No disability, minimal symptoms

1.5 – 2.5 Moderate disability in one functional system or mild disability 3 or 4 FS, remains fully ambulatory

3.0 – 5.5 Ambulatory without an aid and/or rest at least 100 metres, disability severe enough to impair full daily activities (may impair the ability to work a full day)

6.0 Ambulatory impairment such that a cane is needed to walk 100 metres

6.5 – 9.5 Constant bilateral assistance necessary to walk 20 metres up through inability to perform self-case

10 Death due to MS

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Fedgroup Financial Services (Pty) Ltd (Reg. No. 2012/000697/07) FAIS Licence No: 45563. 89 Bute Lane, Sandton. PO Box 782823, 2146. T 011 305 2300 F 011 305 2500 [email protected] fedgroup.co.za For details on our directorate visit our website

Appendix 3 – Disability income benefits

From 1 March 2015, a member will no longer be able to claim a tax deduction on the premium paid for a disability income benefit and the benefit will be paid out tax-free.

Currently, the premiums paid by an employer on self-standing insurance benefits such as death and disability for the benefit of the employee or their spouse, child, dependant or nominee, are deemed to be a taxable benefit granted by the employer to the employee. This means that these premiums have to be taxed as fringe benefits in the hands of the employee. A lump-sum benefit is paid out tax-free to the employee or their dependants or nominees in terms of section 10(1)(gG) of theIncome Tax Act. When the benefit is paid to the employer, it is included in the employer’s gross income. If the employer then on-pays this amount to the employee or their dependants or nominees, the employer must ask for a section 11(a) deduction for this payment. The employer’s tax position is ultimately neutral, but they first need to account for the accrual and subsequent deduction in their own records. Employer-provided disability income benefits on the other hand are treated differently. The employee is entitled to claim a tax deduction for the premium on which they paid fringe benefit tax. The employee’s tax position for the premium is neutral – they pay fringe benefit tax, but get a deduction for that. If the employee receives a benefit, it is taxed.

Position from 1 March 2015 for the employer-provided (unapproved) insurance benefits that are set up for the benefit of the employee or their spouse, child, dependant or nominee:

Death, disability, critical illness (whether the benefit is paid as a lump sum or annuity)

Employer Deduction for premiums paid on behalf of the employee.

Member Premiums taxed as fringe benefit. No tax deduction.

Benefit Tax-free – exemption will apply.

National Treasury has set out to align the tax position of lump sum disability and income disability insurance benefits. From 1 March 2015, an employee will no longer be able to claim a deduction on the premiums paid for disability income insurance benefits. These benefits will be treated the same as employer-provided lump-sum insurance benefits – the premiums will be taxed as fringe benefits in the hands of the employee and the benefit will be paid out to the employee tax-free. The premiums will still be deductible for the employer as long as the premiums have been taxed in the hands of the employee as a fringe benefit. The employer deduction will fall under section 11(w)(i) of the Income Tax Act. Section 11(w)(i) only relates to cover for employees or directors of the employer. If any other person is covered, the employer should ask for a deduction under the general deduction formula.

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