Covered Loss means a critical disease, accidental death or accidental dismemberment covered under this benefit. The covered loss must occur prior to your 65th birthday for critical disease or the termination age indicated in the schedule of benefits for other covered losses, and while you are insured for this benefit. In the case of a covered loss, which qualifies under the accidental death and/or accidental dismemberment benefit, the loss must occur within 365 days of your injury. The amount of insurance is indicated in the schedule of benefits.
Critical Disease Benefit
We will pay you an amount equal to 10% of the amount of insurance (maximum $50,000) if you:
- have been medically diagnosed with one of the covered critical diseases after the effective date of your coverage under this benefit and prior to age 65, and
- you have been totally disabled (from any and all occupations as defined in the policy) from that critical disease for at least 9 months.
Benefits are limited to the first covered critical disease in your lifetime. Covered critical diseases are: Poliomyelitis, Parkinson’s Disease, Huntington’s Chorea, Multiple Sclerosis, Alzheimer’s Disease, Type I Diabetes (Insulin Dependent), Amyotrophic Lateral Sclerosis (ALS), Peripheral Vascular Disease and Necrotizing Fasciitis.
Accidental Death Benefit
If your death occurs as a direct result of accidental bodily Injuries occasioned solely through external, violent, and accidental means without gross negligence on your part, we will pay your beneficiary an amount equal to 100% of the amount of insurance.
Accidental Dismemberment Benefit Schedule
If you sustain one of the following losses, resulting directly and independently of all other causes from an injury occasioned solely through external, violent and accidental means, without gross negligence on your part, we will pay:
AD&D Schedule of Losses
200% of the amount of insurance for:
- paraplegia (total paralysis of both lower limbs), or
- hemiplegia (total paralysis of one side of the body), or
- quadriplegia (total paralysis of all four limbs), or
- loss of use of both arms, or
- loss of use of both legs, or
- loss of use of one arm and one leg on the same side of the body.
100% of the amount of insurance for:
- loss of both hands or both feet, or
- loss of both arms or both legs, or
- loss of sight of both eyes, or
- loss of one hand and one foot, or
- loss of use of both hands, or
- loss of use of both feet, or
- loss of speech and hearing in both ears, or
- loss of use of one hand or arm and one leg, or
- loss of sight of one eye and one hand or one foot.
75% of the amount of insurance for:
- loss of one arm, or
- loss of use of one arm, or
- loss of one leg, or
- loss of use of one leg.
66 2/3% of the amount of insurance for:
- loss of one hand, or
- loss of one foot, or
- loss of speech, or
- loss of hearing in both ears, or
- loss of sight of one eye, or
- loss of use of one hand, or
- loss of use of one foot.
33 1/3% of the amount of insurance for:
- loss of the thumb and index finger of the same hand, or
- loss of four fingers of one hand, or
- loss of hearing in one ear.
We will pay 25% of the amount of insurance if you lose all toes on one foot.
Surgical Reattachment
If you lose a limb or thumb and index finger and the limb, thumb, and/or index finger is surgically reattached, we will pay 50% of the amount that would have been payable as indicated in the schedule of losses if the loss had been permanent, regardless of the amount of use regained. The balance of the benefit will be payable if the reattachment fails within 1 year after the reattachment was performed.
Rehabilitation Benefit
If within 2 years from the date of the accidental injury, you participate in a rehabilitation program in order to be qualified to engage in an occupation in which you would not have engaged except for such injury. We will pay the reasonable and customary expenses incurred while you are participating in a formal occupational training program approved by us. Payment for the total of all expenses incurred will not exceed $10,000 as the result of any one injury. No benefits will be payable for charges for room and board, ordinary living, travelling, or clothing expenses.
Family Transportation Benefit
If you sustain an accidental injury and are confined as an inpatient in an approved hospital located at least 150 kilometres from your residence and you are receiving reasonable and customary treatment from a physician or surgeon, we will pay the reasonable and customary expenses incurred by all members of your immediate family for hotel accommodation in the vicinity of the approved hospital and return transportation by the most direct route to and from the hospital.
The amount payable under this benefit will not exceed the aggregate amount of $3,000 for all accommodation and transportation expenses. If transportation occurs in a vehicle or device other than one operated under a license for the conveyance of passengers for hire, then reimbursement of transportation expenses will be limited to $0.30 per kilometre travelled.
Home Alteration and Vehicle Modification Benefit
If you sustain an accidental injury and subsequently require the use of a wheelchair to be ambulatory, we will pay the reasonable and customary expenses incurred for the purpose of making your home and vehicle wheelchair accessible. Benefits are payable for the cost of alterations to your principal residence and the cost of modifications to 1 motor vehicle utilized by you when such modifications are approved by licensing authorities where required. The expenses must be incurred within 2 years from the date of your injury and are limited to a lifetime maximum of $10,000.
Continuation of Education Benefit
If you die as a direct result of an accidental injury, we will pay your beneficiary the education benefit stated below for each of your dependent children who are, at the time of your death enrolled as full-time students:
- in an institution for higher learning above the secondary school level as defined in the province or territory of residence, or
- at the secondary school level but who will enroll as a full-time student in an institution for higher learning within 365 days after your death.
The education benefit is equal to the reasonable and customary expenses actually incurred for tuition and books, subject to the lesser of a maximum of 5% of the amount of insurance or $5,000, for each year the dependent child continues the education, but not to exceed 4 years, which must run consecutively, with respect to any one dependent child.
This benefit will be paid each year on receipt of satisfactory proof that the dependent child is enrolled as a full-time student in an institution for higher learning. Payment will not be made for expenses incurred prior to your death or for room, board, or other ordinary living, travelling, or clothing expenses. If none of your dependent children satisfy the above requirements, we will pay $2,500 to your beneficiary.
Spousal Occupational Training Benefit
If your death occurs as a direct result of an accidental injury, we will pay the reasonable and customary expenses actually incurred for tuition and books for your insured spouse to participate in a formal occupational training program to become qualified for active employment in an occupation for which your spouse would not otherwise be qualified. Expenses must be incurred within 2 years from the date of your death and are subject to a maximum lifetime payment of $10,000.
Repatriation Benefit
If you die, from any cause outside of Canada, or if in Canada, you die at least 150 kilometres from your normal place of residence, we will pay your beneficiary the reasonable and customary expenses incurred for the preparation of the body and its transportation to the funeral home or the place of internment in proximity to your normal place of residence in Canada. Benefits will not exceed $10,000 for all eligible expenses.
Seat Belt Benefit
If you die or become injured as a direct result of an accident, which results in a benefit payable under the schedule of losses, while driving or riding in a vehicle and wearing a properly fastened seat belt, the benefit payable under the schedule of losses will be increased by 10%.
At the time of the accident, the driver of the vehicle, must hold a valid driver’s license and must not have been under the influence of drugs, or have been driving the vehicle with blood alcohol in their blood in excess of 80 milligrams of alcohol per hundred millilitres of blood or have had their ability to operate the vehicle impaired by drugs or alcohol or a combination of the two.
The person claiming the benefit must establish that you were wearing a seat belt at the time of the accident.
Maximum Benefit
In no case will an amount greater than the amount of insurance indicated in the schedule of benefits be paid for all losses identified in the schedule of losses sustained by you resulting directly or indirectly from the same accident with the exception of: paraplegia, hemiplegia, quadriplegia, loss of use of both arms, loss of use of both legs, or loss of use of one arm and one leg on the same side of the body, where the benefit payable is 200%.
Exposure
If you are exposed to the elements following the disappearance, forced landing, stranding, sinking or wrecking of a conveyance in which you were an occupant, such exposure will be deemed an injury by accidental means.
Disappearance
If your body has not been found within one year of the disappearance, forced landing, stranding, sinking or wrecking of a conveyance in which you were an occupant, then it will be deemed that you have suffered a loss of life within the meaning of this coverage.
Total Disability Waiver of Premium
If premiums for your basic life insurance coverage are being waived, then premiums for the accidental death and dismemberment benefit will also be waived, but only so long as this benefit and your plan sponsor’s coverage under this benefit, remains in force.
AD&D Definitions
- loss of a hand will mean complete severance at or above the wrist.
- loss of an arm will mean complete severance through or above the elbow joint.
- loss of a leg will mean complete severance through or above the knee joint.
- loss of a foot will mean complete severance at or above the ankle.
- loss of a thumb will mean the complete loss of one entire phalanx of the thumb.
- loss of a finger will mean the complete loss of two entire phalanges of the finger.
- loss of a toe will mean the complete severance at or above the knuckle joining the toe to the foot.
- loss of sight, loss of hearing or loss of speech will mean total and irrecoverable loss of that faculty. If that faculty can be recovered or partially recovered by the use of some device or rehabilitative program, it will be deemed that there was no loss for the purposes of this provision.
- loss of use must be caused by tendon, nerve or bone damage as a result of an accidental injury. Such loss of use must be total and irrecoverable and must be continuous for a period of 12 months.
- No benefits will be payable for loss of use if benefits for loss by dismemberment are paid or payable as a result of the same injury.
- Paralysis will mean complete and irreversible paralysis caused by spine or brain damage as a result of an accidental injury which has continued for a period of 12 months from the date of the injury.
- Institution for higher learning for the education benefit includes any university, college or trade school.
- Immediate family, for the Family Transportation benefit, means a person who is your spouse, child, father, mother, brother or sister. Other relatives may be considered in the event that no immediate family is living.
Accidental Death and Dismemberment Exclusions
No benefits will be paid if the covered loss is caused by or results directly or indirectly from one or more of the following:
- suicide or attempted suicide or self-inflicted injury, regardless of mental state, or
- committing, attempting or provoking an assault or criminal offense, or
- a situation where the covered loss results from injuries sustained in, or directly or indirectly from, a vehicle accident where you were driving the vehicle involved in the accident and had either:
- alcohol in your blood in excess of 80 milligrams of alcohol per hundred millilitres of blood, or
- your ability to operate the vehicle was impaired by drugs or alcohol or a combination of the two, or
- disease or bodily or mental infirmity, or medical or surgical treatment of any kind, except surgical reattachment, or
- death where there is no visible contusion on the exterior of the body (except death by drowning), or
- any drug, poison, gas or fumes, voluntarily or otherwise taken administered, absorbed or inhaled, other than as a result of an occupational accident, or
- insurrection or war (whether war be declared or not) or participation in any riot, or active service in the armed forces of any country, or
- travel or flight in any aircraft, or descent from such aircraft, if you are a pilot or a member of the crew of the aircraft, or if such flight is made for the purpose of instruction, training or testing.
When to submit an AD&D claim
Accidental Death Claim
If the claim is the result of an accidental death, the claim must be submitted to us within 6 months from the date of death.
Critical Disease or Accidental Dismemberment Claims
If the claim is for a Critical Disease or Accidental Dismemberment benefit, the claim form must be submitted to us within 9 months from the date of total disability or 12 months from the date of the accidental dismemberment.
Failure to furnish proof within this time will not invalidate nor reduce any claim if it is shown not to have been reasonably possible to furnish the proof and that the proof was furnished as soon as was reasonably possible, but in no event will this be more than 12 months after first becoming eligible for accidental death benefits or Critical Disease benefits or 18 months for accidental dismemberment benefits.
Accidental Death & Dismemberment Conversion Privilege
If your Basic Accidental Death & Dismemberment Insurance coverage terminates on or before your 65th birthday, as a result of termination of employment or termination in a class of Member’s eligible for insurance under the Policy, then you may apply for Accidental Death and Dismemberment coverage of the type then being offered by the Insurance Company under Group Policy G. 6318.
The Accidental Death & Dismemberment coverage will not include any Total Disability benefit (or Critical Disease benefit) provisions. The maximum amount of Accidental Death & Dismemberment coverage you may covert will not exceed the amount of Accidental Death & Dismemberment Coverage in effect at the time of termination. The minimum amount of coverage available for conversion is $25,000.00.
The Conversion Policy will be issued only if a written application and the first 12 months’ premium is received by the Insurance Company at its Regina Office within 31 days after the date of termination of your insurance under this Policy. The Conversion Policy shall become effective on the day following the date the Insurance Company receives the application and premium.
The Insurance Company shall be under no obligation to advise eligible Members of their right to convert as stated in this provision.
If you are interested in applying for conversion, please contact a Co-operators office near you for an application form.