Exclusions and Limitations
Exclusions
A Claim will not be deemed a valid Claim, and thus not be paid, if the event that led to the Claim is a direct or indirect result of an Exclusion. Such Exclusions are:
- Willful participation in any riot, illegal strike, civil commotion or usurpation of power, or any act of and/or participation in military, war, hostilities and/ or war-like operations, insurrection and invasion by a foreign enemy;
- Willful participation in any riot, illegal strike, civil commotion or usurpation of power, or any act of and/or participation in military, war, hostilities and/ or war-like operations, insurrection and invasion by a foreign enemy;
- A Self-Inflicted Death, including but not limited to suicide or euthanasia, at any time during the first two (2) years of a Plan, or of Reinstatement of a Plan. Where such a Death occurs any time after the first two (2) years of a Plan or its Reinstatement, then the amount that will be paid in respect of those Benefits due to be paid in cash is limited to 30% of the total cash payable Benefit amount, subject to an overall maximum of R1 million. Where a medical practitioner had previously declared that there was no reasonable prospect of the Insured Person’s recovery from any physical illness or Impairment that would render them capable of rational existence without the assistance of artificial means, then the Exclusions in this section b will not apply. At any time during the life of a Plan, any Claim against the MyAbility Cover™ Benefit that arises in any way from Self-Inflicted harm is excluded;
- Knowing use of nuclear, biological or chemical weapons, or any radioactive contamination;
- Willful participation in any criminal act or any act in violation of the law with the exception that this Exclusion shall not be used to refute an otherwise valid Claim in the event the said criminal act or violation of the law relates to the driver of a private motor vehicle being in breach of alcohol limits; or
- Participating in at least one (1) of the following activities: flying in any form of non-commercially operated aircraft; any form of skydiving (including parachuting, paragliding and winged suit flying); and scuba diving, in each case either as part of one’s work or more than once in any twelve (12) consecutive month period as a leisure pursuit.
All the Exclusions in this section apply whether the Insured Person was declared medically or legally sane or not.
Claims
Valid claims
For a Claim to be deemed a valid Claim, the Claim Event Date must occur during the term of your Plan (except those specific situations as provided under the Cover Commencement section) and while the relevant Benefit being claimed is In Force. A Claim for a Death or Impairment Benefit (where one’s Plan provides Death or Impairment cover respectively) that has an Initial Waiting Period will not be deemed a valid Claim for that Benefit if it is a Natural Death or a Natural Impairment which occurred within the Initial Waiting Period stated on the Plan Schedule (Natural Deaths and Natural Impairments are defined in these Plan Terms and Conditions but are broadly Deaths and Impairments that occurred naturally rather than by accidental means).
A Claim will also not be deemed a Valid Claim if:
- the Plan or Benefit is not In Force at Claim Event Date;
- it is a Claim for Impairment and Impairment cover is not provided by any of the selected Benefits;
- Death occurs, or the Impairment suffered is, as a result of an Exclusion;
- Misrepresentation has been made;
- the Claim Event Date occurred before the Cover Commencement Date (with limited exceptions, see the Cover Commencement section); or
- the Claim Event Date occurred after any Maximum Benefit Term, Cover Cease Age or any Termination Date.