Benefits
When do benefit payments commence?
For Injury or Sickness benefits, once we admit liability in relation to an Insured Person’s claim, and the Waiting Period has expired, benefit payments start to accrue. Benefits are paid fourteen (14) days in arrears.
If Premiums are due for payment, benefits are not payable until all Premiums have been paid.
What if Statutory Benefits are commuted?
If an Insured Person is receiving Statutory Benefits and agrees to redeem or commute their Statutory Benefits entitlement to a lump sum payment, we will treat the commutation or redemption payment as Other Disability Income and offset it accordingly for the number of weeks that the commutation or redemption payment represents the payment of Statutory Benefits to the Insured Person. The number of weeks will be determined by dividing the commutation payment by the weekly Statutory Benefit that was paid to the Insured Person immediately before the commutation or redemption.
If a benefit is payable for less than a whole week (7 days), we will pay 1/7th of the weekly amount for each day the benefit is payable.
When do disability benefit payments reduce?
The Insured Person’s benefit will be reduced by Other Disability Income – which is other income benefits received from other sources in respect of the period of disability.
“Other Disability Income” means any income (other than any benefit received under this Policy) which a person may derive during a month, whether that income was actually received or not and includes:
a. any employment or other work income performed while Partially Disabled;
b. any benefit under any workers compensation, statutory compensation, pension, social security or similar schemes or other similar State, Federal or Territory legislation;
c. any benefit under state or federal legislation such as the Department of Veterans affairs;
d. any amounts received from other disability income insurance policies arising from the same Injury or Sickness for which an Insured Person is receiving benefits under this Policy; and
e. any employer funded sick leave entitlements and other income payments.
Where you have previously paid sick leave benefits to an Insured Person and use the benefit amounts paid by us as a reimbursement to either you or the Insured Person, the relevant sick leave amounts will not be offset.
If the Insured Person is capable of returning to work in a reduced capacity but refuses, weekly benefits will reduce to a maximum of 25% of the Total Disability benefit.
The Insured Person must undertake any treatment recommended by a treating Medical Practitioner and continue to do so during the currency of any period of Total Disability or Partial Disability. If the Insured Person fails to seek or follow medical advice or treatment or a rehabilitation programme for the relevant Injury or Sickness, our liability in respect of the claim will be reduced by the amount that fairly represents the extent to which our interests have been prejudiced as a result of that failure.
What happens if an Insured Person has a recurring disability?
If within six (6) months after the cessation of Total Disability or Partial Disability, the Insured Person again becomes Totally Disabled or Partially Disabled due to the same or a related Injury or Sickness, we will waive the Waiting Period and regard the Total Disability or Partial Disability as a continuation of the previous claim. The Maximum Benefit Period will be reduced by the period over which benefit payments were previously made.
If an Insured Person suffers a recurrence of Total Disability or Partial Disability for the same or a related Sickness or Injury, the subsequent period of Total Disability and/or Partial Disability will be deemed to have resulted from a new Injury or Sickness if the Insured Person worked on a full time basis for a period of 6 months performing all the duties of their usual occupation between such periods of Total Disability and/or Partial Disability. If this occurs, the Waiting Period will apply to the recurred Total Disability or Partial Disability.
When do benefit payments cease?
Benefits will cease at the earliest of when:
a. the Insured Person is no longer Totally Disabled or Partially Disabled;
b. the Benefit Period ends;
c. the Insured Person reaches age 70;
d. the Insured Person dies; or
e. where the Participating Employer has not elected to make the Mental Health benefit available for Insured Persons, and a claim is being paid for a Mental Illness, when Workers Compensation benefits cease; or
f. where cover for the Mental Health benefit has been obtained by the Participating Employer, in accordance with the end of the Mental Health benefit terms.
If an Insured Person suffers Total Disability or Partial Disability whilst residing or travelling outside Australia, the payment of benefits will cease six (6) months after the date the Insured Person was deemed Totally Disabled or Partially Disabled unless the Insured Person has permanently returned to Australia.
Payment of benefits
Benefits are paid by us. Coverforce ensures that these benefits are directed to the appropriate recipient, as outlined below.
Death benefits are payable to the nominated beneficiary or the estate of the deceased person.
All other benefits are paid to the Insured Person, unless payment to the Insured Person is not possible, or you request otherwise, in which case benefits will be paid to you.
Recovery of overpaid amounts
Where you or an Insured Person have been paid an amount under the Policy which we are entitled to reduce under applicable legislation, you or the Insured Person will be liable to repay the full amount of any overpayment to us.
