PA 10 Plus Policy Document

For all intents and purposes where there is a conflict or ambiguity as to the meaning in the Bahasa Malaysia provisions of any part of the contract, it is hereby agreed th at the English version of the Contract shall prevail.

WHEREAS the Policyholder named in the Schedule and following the occupation stated in the Schedule is desirous of insuring in the manner hereinafter mentioned and has made a Proposal which shall form the basis of this Insurance and has paid to PACIFIC & ORIENT INSURANCE CO. BERHAD, (hereinafter called the “Insurance” and the “Company” respectively) the Premium as consideration for the Insurance stated herein.

NOW THIS POLICY WITNESSETH that if during the Period of Insurance the Insured Person stated in the Schedule shall sustain bodily injury caused by violent accidental external and visible means which injury shall solely and independently of any other cause result in the Insured Person’s death or disablement or necessitate medical treatment as provided. The Company will subject to the terms exclusions and conditions of and endorsed on this Policy pay the Sum Insured specified in the Schedule of Benefits.

Consumer Insurance Contracts 

This Policy is issued in consideration of the payment of premium as specified in the Policy Schedule and pursuant to the answers given in Your Proposal Form (or when you applied for this insurance) and any other disclosures made by you between the time of submission of your Proposal Form (or when you applied fo r this insurance) and the time this contract is entered into. The answers and any other disclosures given by you shall form part of this contract of insurance between you and us. However, in the event of any pre-contractual misrepresentation made in relation to your answers or in any disclosures given by you, only the remedies in Schedule 9 of the Financial Services Act 2013 will apply.

This Policy reflects the terms and conditions of the contract of insurance as agreed between you and us.

(A) DEFINITION 

1. ACCIDENT 

An event of violent, accidental external and visible nature that is unforeseen or unexpected which shall independently of any other cause be the sole cause of bodily injury.

2. COMATOSE 

A state of continuous unconsciousness for a period of (365) three hundred and sixty five days where the Insured Person cannot  be  awakened and the activity of the brain as a whole is depressed.

3. HOSPITAL 

• Any lawfully registered and operating facility which:

1. Has facilities for diagnosis and major surgery
2. Provides (24) twenty four hours nursing services by registered graduate nurses
3. Is under the supervision of one or more physicians at all time; and
4. Shall not primarily be a clinic, a place for alcoholics or drug addicts, a nursing, rest or convalescent home or homes for th e aged or similar establishment.

4. INJURY / KECEDERAAN

Bodily injury to an Insured person caused solely by an accident and not by sickness, disease or gradual physical or mental deterioration. Successive medical treatment or hospitalisation due to the same and/or related causes shall be considered as one injury.

5. INSURED PERSON

The person who has completed and/or whose spouse name is included on the Proposal and Declaration Form for this insurance and in  respect of whom commencement of cover has been confirmed through an Official Cover Note issued by the Company’s Authorised Representative. The insured shall not be less than 16 years of age nor more than 65 years of age.

6. PERMANENT TOTAL DISABLEMENT/ TOTAL DISABLEMENT /

Total and permanent disablement which prevents the Insured Person totally and absolutely from engaging in any employment or occupation of any description within twelve calendar months after the accident and without any hope of improvement beyond the expiry of such period. The opinion of the Company’s panel of physician(s) shall be final and conclusive.

7. PHYSICIAN OR SURGEON 

Registered allopathic medical practitioner legally licensed to render medical and surgical services. Practitioners of traditional medicines are excluded.

8. POLICYHOLDER

The person to whom the insurance contract is issued and who is responsible for payment of premiums and claims documentation

9. LICENSED COMMON CARRIER

A vehicle licensed for public conveyance and offering transport to any fare-paying passenger.

10. SPOUSE

The Policyholder’s legal husband or wife who is not separated or divorced at the commencement of each period of the insurance cover or at the material time of accident. Should there be more than one legal spouse, only the spouse named in the Policy Schedule will be covered

11. CHILD

Any unmarried child of the Policyholder who is at least 3 years old and less than 18 years old or twenty three (23) years old, if completing tertiary studies, is eligible. Those insured under this category are entitled to only 50% of the applicable benefits. Benefits 1, 6 (i) & (ii), 9 and 10 are not applicable. 

12. PERIOD OF INSURANCE

Shall mean the period of cover of the Policy and shall be as specified in this Policy and/or in the Schedule

SUMMARY OF BENEFITS

DOUBLE INDEMNITY 

In the event of an accident resulting in Death or Permanent Disablement whilst the Insured Person is travelling as a fare-paying passenger in any Licensed Common Carrier, the Company will pay to the Estate or the legal personal representative of the deceased Insured Person double the Principal Sum Insured (excluding any accumulated Renewal Bonus). For purposes of this extension, the Insured person is not entitled to this benefit if they travel as a fare paying passenger on a non-scheduled and/or chartered aircraft.

ACCIDENTAL DEATH 

If bodily injury sustained as a result of an accident shall, within 12 months from the date of the Accident, result in death, the Estate of the deceased Insured Person will receive a lump sum equivalent to the Accidental Death Benefit inclusive of any Renewal bonus accumulated as stated in the Schedule upon submission of all the relevant claim documents as required by the Company.

PERMANENT DISABLEMENT

If bodily injury sustained as a result of an accident shall, within 12 months from the date of the accident, result in Permanent Disablement to the Insured Person, a lump sum Benefit in accordance to the Schedule of Benefits specified hereunder is payable to the Injured Person.

In the event of a claim under permanent disablement, the decision of the company’s panel of physicians shall be final and conclusive.

Any permanent disablement not specified above other than loss of sense of taste or smell:

such percentage to be assessed by Company in accordance with the opinion of the Company’s panel of physicians, consistent with the percentages specified above and without regard to the Insured Person’s employment or occupation.

a. Comatose cases – The Company will pay the Principal Sum upon certification by a Medical Specialist that the Insured Person has been in a state

b. Shortening of leg – The measure for shortening of leg must be certified by Orthopaedic medical report

c. Permanent total loss of use of limb shall be treated as loss of limb. Loss of speech shall mean total permanent inability to communicate verbally

The aggregate of all percentage payable in respect of any one accident shall not exceed (100%) one hundred percent. In the event of a total of (100%) one hundred percent having been paid. This Policy shall immediately cease to be in force. In the event of claims having paid for losses not exceeding (100%) one hundred percent, the coverage shall be reduced by the amount paid from the date of accident until the expiration of the Policy.

MEDICAL EXPENSES 

The Company will reimburse the Insured Person for the necessary and reasonable expenses incurred for:-

1. Hospital outpatient treatment. However, the first (RM50.00) Fifty Ringgit shall be borne by the Insured Person. The first expense must be incurred within 45 days following the date of accident, or failing which the expenses incurred thereafter are not reimbursable.
2. The actual cost of hospitalisation subject to the limit set out in the schedule. Follow-up outpatient treatment within 31 days of discharge in respect of the same. Accident shall, subject to the limits set out in the schedule be reimbursable.

DAILY HOSPITAL INCOME

A daily cash allowance is payable for each day of hospitalisation as stated in the Benefits Schedule up to a maximum of 100 days per year subject to a one (1) day excess for each claim. 

i. TEMPORARY TOTAL DISABLEMENT from engaging in or giving attention to the Insured’s profession or occupation: Weekly Compensation at the rate stated in the schedule hereto  shall be payable.

ii. TEMPORARY PARTIAL DISABLEMENT from engaging in or giving attention to the Insured’s profession or occupation: Weekly Compensation at the rate stated in the Schedule hereto shall be payable.

Compensation under Benefits (i) or (ii) alternatively (i) & (ii) running consequently shall be payable on a weekly basis up to a maximum of 104 weeks calculated from the date the Insured was first examined by a duly qualified Medical Practitioner.

DEATH WHILST OVERSEAS 

In the event of accidental death of the Insured Person whilst overseas the Company will reimburse the Estate and/or the legal personal representative of the deceased Insured Person the actual necessary and reasonable expenses for a return air ticket (economy class) incurred by a member of the Insured Person’s immediate family, in having to travel to the place where the death occurred for the sole purpose of arranging for repatriation of the deceased’s body. This benefit shall not be applicable to death occurring in Malaysia, Singapore, Brunei and Thailand.

COMPASSIONATE DEATH ALLOWANCE 

In the event of accidental death the Company will pay the amount specified in the Summary of Benefits to the Estate and/or the legal personal representative of the deceased Insured Person. 

PERSONAL LIABILITY 

In the event the Insured Person is legally liable to pay for compensation to a third party in respect of accidental bodily injury and loss of or accidental damage to property of any persons (unless excepted) anywhere in the world and which is first made in writing against the Insured (or any other party entitled to indemnity under this policy)

• during 

OR 

• within 30 days after expiry of the same period of insurance as defined in the Schedule of this policy.

The Company will subject to the limits set out in the Schedule pay all legal cost and expenses incurred with their written consent if the first instance proceeding are filed in the Malaysian courts and are subject to the Laws of Malaysia. For the avoidance of doubt, legal fees incurred will be included in the calculation of the said limit.

In the event of death of the Insured Person the Company will in respect of the liability incurred by the Insured Person indemnify the Insured Person’s legal personal representatives in the terms of and subject to the limitations of this Section and the Schedule provided that such representatives shall as though they were the Insured Person observe fulfil and be subject to the terms conditions and exceptions of this section insofar as they can apply.

Territorial Limits 

1. Malaysia and Singapore 
2. Elsewhere in the World during temporary visits excluding United States of America, Canada and South American Countries.

SPECIAL CONDITIONS applying to the Personal Liability Section

1. The Insured shall exercise reasonable care and shall take all reasonable precautions to prevent accidents and shall comply wi th all statues, regulations, by laws and/or rules.
2. The Insured Person shall give notice to the Company of any injury loss or damage as soon as possible after it comes to the knowledge of the Insured Person or of the Insured Person’s representatives for the time being. The Insured Person shall forward to the Company forthwith after receipt thereof every wri tten notice of information as to any verbal notice of claim and shall also give written notice to the Company immediately upon becoming aware of or being informed of any proceeding. The Insured Person shall use his best endeavours to preserve any damaged or defective machinery or other appliances or things or records of such damage and defect which might prove necessary or useful by way of evidence in connection with any claim and so far as may be reasonably practicable no alteration or repair shall be made without the consent of the Company after any accident occurring in connection therewith until the Company shall have had an opportunity to inspect or to waive in writing such right to inspect. The Insured Person shall give all necessary information and all such assistance as the Company may deem necessary and forward all documents to enable the Insurers to investigate settle or resist any claim as the Insurers may think fit.
3. The Insured Person shall not incur any expense whether by litigation or otherwise or make any payment settlement arrangement or admission of liability in respect of any claim for which the Company may be liable under this Section without the written authority of the Company. The Company shall be entitled to use the name of the Insured Person for all purposes in connection with this Section including bringing defending enforcing or settling of legal proceedings for the benefit of the Company and the Insured Person shall provide to the Company all such  assistance as the Company may deem neccessary. In connection with any one claim or number of claims arising out of any one ca use for indemnity against liability as defined in this Section the Company may at any time pay to the Insured the Limit of Liability (after deduction of any sum or sums already paid as compensation and/or legal fees) or say less amount for which such claim or claims can be settled and upon such payment being made the Company shall relinquish the conduct and control of and be under no further liability in respect of such claim except the payment of costs and expenses of litigation recoverable or incurred in respect of matters prior to the date of such payment and the Company shall not be responsible for any loss alleged to have been sustained by the Insured Person in consequent of any action or omission of the Company in connection with such claim or proceedings.
4. If at the time any claim arises under this Section and there is any other existing insurance covering the same liability the Company shall not be liable to pay or contribute more than their ratable proportion of such claim.
5. While the Insured Person is driving any vehicle.

10. RENEWAL BONUS 

Provided no claim has been incurred under any session the Company agrees on each anniversary date of the policy, to grant a renewal bonus of (5%) five percent on the original sum insured for Accidental Death and Permanent Disablement Benefits upon renewal of the policy each year up to a maximum of five years and in total not more than (25%) twenty-five percent of the original sum insured. Written instruction must be received by the Company within (30) thirty days from each anniversary date. If renewal instruction is received after the stipulated (30) thirty days Accumulated renewal bonus shall not be applied if the Insured upgrades the policy / plans on renewal.

This Policy does not cover any claims directly or indirectly caused:

(a) By war (whether declared or undeclared), act of foreign enemy, hostilities, civil war, rebellion, revolution, mutiny or unsurped power, military or popular uprising, proclamation or maintenance of martial law or state of emergency, seizure, quarantine, or customs regulations or nationalisation by or under the order of any government or public or local authority.

(b) By provoked murder or provoked assault.

(c) By insanity, suicide or any attempt thereat, intentional self-inflicted injury or any attempt thereat.

(d) By pregnancy, childbirth, miscarriage, hernia or any complications thereof.

(e) While the driver of any vehicle occupied by the Insured Person is under influence of liquor or drugs (unless administered under the order of a qualified medical practitioner and which does not affect his ability to drive or ride)

(f) Through HIV (Human Immunodeficiency Syndrome) and/or any HIV related illness including AIDS (Acquired Immune Deficiency Syndrome) or AIDS related Complex (ARC) howsoever caused any contagious disease and/or any mutant derivatives, variations or treatment thereof and/or all sexually transmitted diseases.

(g) By ionising radiation or contamination by readioactivity from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any sustaining process of nuclear fission, and nuclear weapons materials.

(h) Whilst committing or attempting to commit any unlawful act or while resisting arrest.

(i) Whilst travelling in an aircraft except as a fare-paying passenger in an aircraft licensed for passengers service. For the purpose of this exclusion the Insured Person would not be covered if (i) they are involved in any technical operation or navigation whilst in the aircraft, (ii) travelling as a fare-paying passenger on any non-scheduled and/or chartered aircraft. (iii) travelling in any military, police, quasi-military aircraft for whatsoever reason.

(j) Whilst serving in the Police and Military Units of any Country or International Authority, fire brigade, uniformed security guards or of similar occupational hazards.

(k) Whilst engaging in racing of any kind (other than on foot).

(l) Whilst engaging in hunting, mountaineering, ice-hockey, polo-playing, steeplechasing, winter sports, parasailing, hand-gliding, underwater activities involving the use of breathing apparatus, parachuting, any professional/semi-professional games/sports and any other hazardous activities/sports.

(m) By any existing physical infirmity or any degree of mental instability.

(n) By any tasks carried out by offshore and onshore workers, fisherman, seaman, timber and logging operation workers/drivers

(o) Whilst traveling in any vehicle, vessel or craft which is not duly licensed by the appropriate authority.

ADDITIONAL EXCEPTIONS applying to the Personal Liability Section

The Company shall not be liable in respect of:

(a) Any liability directly or indirectly arising from

(i) The ownership or occupation of any building other than the ownership or occupation by the Insured Person of a private dwelling.

(ii) The pursuit or exercise by the Insured Person of any employment, business or profession.

(iii) The use of any animal used to carry a person, for hunting racing ot steeplechasing.

(iv) the use of vehicles (other than hand-propelled vehicles or pedal cycles not being used for racing) boats (sailing or mechanically-propelled aircraft or model aircraft owned by or in the custody or control of the Insured Person or his servants

(v) The commission by the Insured Person of any unlawful act, attempt to commit an unlawful act or whilst enroute to or from the commission the attempt to commit an unlawful act. 

(b) Liability for bodily injury to a member of the Insured’s family or to any person under a contract of service or apperenticeship with the Insured Person arising out of and/or in the course of employment of such person by the Insured Person.

(c) Liability for loss of or damages to:

1. Property belonging to or in the custody of the Insured.
2. Property belonging to or in the custody or control of any person in the service of the Insured.

Notwithstansing anything contained herein to the contrary, it is hereby declared and agreed that the following warranties, endorsements and clauses not applicable unless specified in the schedule. 

5P51 YACHTING / SCUBA DIVING 

5P52 PROFESSIONAL SPORTS/GAMES 

5P53 MARTIAL ART or SELF-DEFENCE (excluding competition) 

5P54 HUNTING / MEMBURU

5P56 USE OF WOODWORKING MACHINERY DRIVEN BY MECHANICAL POWER 

1. CONSTRUCTION 

This policy and the Schedule shall be read together as one contract and any word or expression to which a specific meaning has been attached in any part of this policy shall bear such meaning wherever it may appear.

2. ALTERATION

The policyholder shall give immediate notice in writing to the Company of any change in the Insured Person’s occupation as stated in the Policy Schedule. In the event of the failure to notify. The Company may disclaim all liability for any loss or injury as a result of the increased risk.

1. CLAIM 
1. Written notice must be given to the Company within (30) thirty days of any occurrence likely to give rise to a claim. Failure to give such notice will not invalidate the claim if it can be shown that such notice was given as soon as it is reasonably possible to do so.

(b) In the event of an Accident, the Insured Person shall procure and act on proper Medical or Surgical advice from a Physician or Surgeon as soon as possible.

(c) If the Policyholder or the Insured Person makes a fraudulent or exaggerated claim under this policy, or engages in any fraudulent activity as a means to obtain a benefit under this    Policy. all benefits payable in respect of this policy shall be forfeited and the policy shall become void.

(d) Compensation in respect of the benefits provided under the policy shall be payable only when the claim has been proved to the satisfaction of the Company.

(e) The Insured Person or the legal personal representative is required to prove the claim by providing all the necessary documents as required  by the Company. Any expense incurred for the purpose of proving the claim shall be borne by the Insured Person.

The Company shall be entitled at its own expenses, to require that the Insured Person be examined by the Company’s panel of physicians where the Company deems it necessary

4. DISCHARGE OF LIABILITY 

Any receipt of discharge which the Insured Person or his legal personal representative(s) grants to the Company in respect of a claim under this policy shall be deemed to be a complete and final discharge of all liabilities of the Company in respect of that claim.

5. LOCAL JURISDICTION 

This policy is subject to the Laws of Malaysia and any provision of the policy which is in conflict is hereby amended to conform to the minimum requirement of such laws (or as amended from time to time)

6. RENEWAL

It shall not be incumbent on the Company to give notice that renewal is due.

The Company reserves the right to review the premium and scope of cover at any time prior to the renewal of the policy.

The Company shall not be bound to accept any renewal and the Policy shall not be renewable after the year of insurance in which the Insured Persons attains the age of 65 years. This policy is renewable at the option of the Company.

7. CANCELLATION 

The Company may by notice in writing send by registered post to the policyholder giving (14) fourteen days notice of their intention to terminate this policy returning a proportion of the premium corresponding to the unexpired Period of Insurance, subject to a minimum retained premium. By like notice to the Company. The Policyholder may at any time cancel this policy in which case the company will retain the premium for the time the policy has been in force or the minimum premium whichever is higher.

8. DISPUTES

All differences arising out of this policy shall be referred to:

1. The Insurance Mediation Bureau, Kuala Lumpur, within six months after the decision was made, if the amount claimed is RM100,000.00 and below.
2. Arbitration, if the amount claimed is above RM100,000.00 

ARBITRATION 

If any difference arises as to the amount of any loss or damage such difference shall independently of all other questions be referred to the decision of an Arbitrator, to be appointed in writing by the parties in difference, or, if they cannot agree upon a single Arbitrator, to the decision of two disinterested persons as Arbitrators, of whom one shall be appointed in writing by each of the parties within one (1) calendar month after having been required so to do in writing by the other party. In case either party shall refuse or fail to appoint an Arbitrator within one (1) calendar month after receipt of notice in writing requiring appointment, the other party shall be at liberty to appoint a sole Arbitrator; and in case of disagreement between the Arbitrators, the difference shall be referred to the decision of an Umpire who shall have been appointed by them in writing before entering on the reference, and who shall sit with the Arbitrators and preside at their meetings. The death of any party shall not revoke or affect the authority or powers of the Arbitrator, Arbitrators or Umpire respectively; and in the event of the death of an Arbitrator or Umpire, another shall in each case be appointed in his stead by the party or Arbitrators (as the case may be) by whom the Arbitrator or Umpire so dying was appointed. The costs of the reference and of the award shall be in the discretion of the Arbitrator, Arbitrators or Umpire making the award. And it is hereby expressly sti pulated and declared that it shall be a condition precedent to any right of action or suit upon this policy that the award by such Arbitrator, Arbitrators or Umpire of the amount of the loss or damage if disputed shall be first obtained. In no case whateve r shall the Company be liable for any loss or damage after the expiration of twelve (12) months from the happening of the loss or damage unless the claim is the subject of pending action or arbitration.

9. PREMIUM WARRANTY

It is fundamental and absolute special condition of this contact of insurance that the premium due must be paid and received by the Company within sicty (60) days from the inception date of this Policy/Endorsement/Renewal Certificate.

If this condition is not complied with then this Contact is automatically cancelled and the Company shall be entitled to the pro-rata premium for the period they have been on risk.

Where the premium payable pursuant to this warranty is received by an authorised agent of the Company, the payment shall be deemed to be received by the Company for the purposes of this warranty and the onus of proving that the premium payable was reveived by a person, including an insurance agent, who was not authorised to receive such premium shall lie on the Company.

10. CONDITION PRECEDENT CLAUSE

The due observance and fulfillment of the Terms, Provisions, Conditions, Clause and Endorsement of this Policy, in so far as they relate to anything to be done or complied with by the Insured (or the Insured’s legal personal representatives) shall be condition precedent to any liability of the Company to make any payment under the Policy. Failure to comply with any of the terms, provisions and conditions in this Policy shall invalidate all claims hereunder.

11. DUTY OF DISCLOSURE

Where you have applied for this Insurance wholly for purposes unrelated to your trade, business or profession, you had a du ty to take reasonable care not to make a misrepresentation in answering the questions in the Proposal Form (or when you applied for this insurance) i.e. you should have answered the questions fully and accurately. Failure to have taken reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance in accordance with the remedies in Schedule 9 of the Financial Services Act 2013. You were also required to disclose any other matter that you knew to be relevant to our decision in accepting the risks and determining the rates and terms to be applied.

You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in the Proposal Form (or when you applied for this insurance) is inaccurate or has changed.

This Policy with its terms and conditions should be studied carefully and in the event of any correction being found necessary, should be communicated to the Company at once Notice of every accident whether a claim is anticipated or not under this policy should be given immediately to the nearest office of the Company.