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Friends Life Individual Protection
Critical Illness Cover and Critical Illness with Life CoverMembership handbook
FLIP/4564/May14
Membership handbook
Contents Welcome 3
General definitions 5
Critical illness definitions 9
Your membership 19
Additional options 22
What you are covered for 30
What you are not covered for 39
Changes to your membership 42
Premium options 48
How to make a claim 51
Your right to cancellation 55
General information 57
Getting in touch 60
Welcome
| 3
Welcome
Thank you for choosing Friends Life Individual Protection
Thank you for choosing critical illness cover
or critical illness with life cover from
Friends Life Individual Protection.
Friends Life Individual Protection products
are provided by Friends Life and Pensions
Limited, part of the Friends Life group.
With this membership we aim to provide you
and your dependants with protection should
serious illness or incapacity affect the
member’s ability to work and cause you
financial hardship, and help secure your
dependants’ financial future if a member is
to die.
The membership has been designed to offer
you the flexibility to provide you with the right
level of financial health protection to match
your circumstances.
Friends Life flexible financial protection is the
umbrella plan which provides cover through a
series of separate memberships for different
types and levels of cover.
Your registration certificate will show which
type of membership you have. Each
membership will have a separate handbook.
This handbook explains what is covered by
Friends Life Individual Protection Critical
Illness and Friends Life Individual Protection
Critical Illness with Life Cover and what to do
if you need to make a claim.
Using the membership handbook
The terms and conditions of this membership
handbook are the terms and conditions on
which we intend to rely. For your own benefit
and protection, you should read the terms
and conditions carefully. If you do not
understand any point please ask us for further
information.
Where the words ‘we’, ‘us’ or ‘our’ are used,
this refers to Friends Life and Pensions
Limited. The words ‘you’ or ‘your’ refer to the
person, or people, who are entitled to receive
the benefits of the membership. Where we
refer to the member(s), this refers to the
person, or people, covered under the same
membership. The terms you and member may
refer to the same people or different people.
Words printed in bold type in this handbook
are defined terms. Defined terms have a
specific meaning explained in the definition
section below or later on in the terms of this
handbook.
Welcome
Where we refer to you or to the member and
this refers to two people, we mean both
people jointly unless we say otherwise. For
example, where we say we will pay the
benefit to you, we mean both schemeholders
jointly, we will not pay the benefit twice.
Fairness of Terms(a) In making decisions and exercising
discretions given to us under the terms and
conditions of this membership handbook,
Friends Life will act reasonably and with
proper regard to the need to treat you and
our other customers fairly.
(b) The terms and conditions in your
membership handbook will only apply
provided that they are not held by a relevant
court or viewed by the Financial Conduct
Authority or by us to be unfair contract terms.
If a term is unfair it will, as far as possible, still
apply but without any part of it which causes
it to be unfair.
4 |
General definitions
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6 |
General definitions
General definitionsPlease refer to the definition explanations
below for further information on their
meanings.
Average Weekly Earnings
The measure used by the Office of National
Statistics which has replaced the average
earnings index. This measure is an indicator
of short-term earnings growth and provides
a monthly estimate of the level of average
weekly earnings per employee. Alternatively,
if this measure is not published during any
period of your membership the ‘average
weekly earnings measure’ will be any
substituted index or index of figures
published by that Office.
Benefit
The critical event benefit shown on your
registration certificate excluding the
terminal illness benefit. However, where
benefit is used in this handbook as being of
general application to all benefits covered by
this handbook, it shall be read so as to read
‘the benefit or the terminal illness benefit
as appropriate’.
Friends Life Individual Protection approved hospital
A centre of treatment which is registered, or
recognised under the local country’s laws, as
existing primarily for:
• carrying out major surgical operations; or
• providing treatment which only
consultants can provide
and which has been approved by Friends Life
Individual Protection.
Child / children
Any natural child or adopted child of you or
your spouse, partner or civil partner or any
child for which either you or your spouse,
partner or civil partner are the legal guardian.
Childcover benefit
The childcover benefit as defined in the ‘What
you are covered for’ section in this handbook.
Child funeral benefit
The child funeral benefit as defined in the
‘What you are covered for’ section in this
handbook.
Commencement date
The date your membership starts, as shown
on your registration certificate.
Consultant
A surgeon, anaesthetist or physician who:
• is legally qualified to practice medicine or
surgery following attendance at a
recognised medical school; and
• is recognised by the relevant authorities in
the country in which the treatment takes
place as having specialised qualification in
the field of, or expertise in, the treatment
of the disease or illness being treated.
By recognised medical school we mean a
medical school which is listed in the World
Directory of Medical Schools, as published
from time to time by the World Health
Organisation.
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General definitions
Critical illness(es)
Any of the illnesses and operations as defined
in the ‘Critical illness definitions’ section in this
handbook relate to any illness or operation
separately, not all of them together.
Endorsement(s)
Change(s) that you require and we agree to
be made to your membership after it
commences which are recorded in the
endorsement section of your registration
certificate.
Fracture
The fractures defined in ‘Black’s Medical
Dictionary’ (39th edition), comminuted,
complicated, compound, depressed,
greenstick, pathological and simple. The
fracture definition does not include any other
type of fracture.
Full time employment
Working a minimum of 35 hours a week.
Handbook
This handbook setting out the general terms
and conditions of your membership.
Irreversible
Cannot be reasonably improved upon by
medical treatment and/or surgical
procedures used by the NHS in the UK at the
time of the claim.
Member
The person (or people) named as a member in
your registration certificate. This is the
person (or people) for whom cover is provided.
Membership
The agreement between you and us to
provide the benefit on the terms set out in
the handbook and the documents referred
to in the section ‘Your membership’.
Mental impairment
Mental disorder causing incapacity which has
failed to respond to a minimum of two years
optimal treatment by a consultant
psychiatrist and requires the need for
continuous psychotropic medication,
supervision and care from a consultant and
results in severe dysfunctioning and the
prognosis is considered poor or worse.
NHS
National Health Service.
Occupation
A trade, profession or type of work
undertaken for profit or pay. It is not a
specific job with any particular employer and
is independent of location and availability.
Permanent
Expected to last throughout the life of the
person covered, irrespective of when the
membership ends or the member expects
to retire.
Permanent neurological deficit with persisting clinical symptoms
Symptoms of dysfunction in the nervous
system that are present on clinical
examination and expected to last throughout
the member’s life.
Symptoms that are covered include
numbness, hyperaesthesia (increased
sensitivity), paralysis, localised weakness,
dysarthria (difficulty with speech), aphasia
(inability to speak), dysphagia (difficulty in
swallowing), visual impairment, difficulty in
walking, lack of coordination, tremor, seizures,
lethargy, dementia, delirium and coma.
The following are not covered:
• an abnormality seen on brain or other
scans without definite related clinical
symptoms
• neurological signs occurring without
symptomatic abnormality, eg. brisk
reflexes without other symptoms
• symptoms of psychological or psychiatric
origin.
Registration certificate
The most recent registration certificate, we
issue to you.
Renewal date
If your registration certificate states that
your ‘Type of Cover’ is ‘Renewable Term (five
years)’, the renewal date will be the fifth
anniversary of the commencement date and
the end date of every following five year period.
If your registration certificate says the ‘Type
of Cover’ you have is ‘Renewable Term (ten
years)’, the renewal date will be the tenth
anniversary of the commencement date and
the end date of every following ten year period.
Retail Price Index
The general index of retail prices published by
the Office for National Statistics. Alternatively,
if that index is not published during any period
of your membership, the ‘retail price index’
will be any substituted index or index of
figures published by that Office.
Special condition
Any condition we set to limit your
entitlement under your membership, as
shown in the ‘Special Conditions’ section of
your registration certificate.
Suited occupation
Any work you could do for profit or pay
taking into account your employment history,
knowledge, transferable skills, training,
education and experience, and is irrespective
of location and availability.
Terminal illness benefit
The equivalent benefit in value to the benefit
but only relating to a member being
diagnosed with a terminal illness under a
Critical Illness with Life Cover membership.
UK
England, Northern Ireland, Scotland and Wales.
We / us / our
Refers to Friends Life and Pensions Limited.
You / your
Refers to the person (or people) named as
the schemeholder on your registration
certificate or any person (or people) to
whom your membership is validly assigned.
This is the person (or people) who hold the
membership.
8 |
General definitions
Critical illness definitions
| 9
Critical illness definitions
Alzheimer’s disease
A definite diagnosis of Alzheimer’s disease by
a consultant neurologist, psychiatrist or
geriatrician. There must be permanent
clinical loss of the ability to do all of the
following:
• remember
• reason; and
• perceive, understand, express and give
effect to ideas.
The following are not covered:
• other types of dementia.
Aorta graft surgery
The undergoing of surgery to the aorta with
excision and surgical replacement of a
portion of the affected aorta with a graft. The
term aorta includes the thoracic and
abdominal aorta but not its branches.
The following are not covered:
• any other surgical procedure, for example,
the insertion of stents or endovascular
repair.
Aplastic anaemia
Confirmation by a consultant haemotologist
of a definite diagnosis of complete bone
marrow failure which results in anaemia,
neutropenia and thrombocytopenia and
requires as a minimum, one of the following
treatments:
• blood transfusion
• bone-marrow transplantation
• immunosuppressive agents
• marrow stimulating agents.
All other forms of anaemia are specifically
excluded.
Bacterial meningitis
Bacterial meningitis causing inflammation of
the membranes of the brain or spinal cord
resulting in permanent neurological deficit
with persisting clinical symptoms. The
diagnosis must be confirmed by a consultant
neurologist.
The following are not covered:
• all other forms of meningitis, not
mentioned above, including viral
meningitis.
Benign brain tumour
A non-malignant tumour or cyst originating in
the brain, cranial nerves or meninges within
the skull, resulting in any of the following:
• permanent neurological deficit with persisting clinical symptoms; or
• undergoing invasive surgery to remove
part or all of the tumour; or
• undergoing either stereotactic
radiosurgery or chemotherapy treatment
to destroy tumour cells.
The following are not covered:
• tumours in the pituitary gland
• tumours originating from bone tissue
• angiomas and cholesteatoma.
10 |
Critical illness definitions
Benign spinal cord tumour
A non-malignant tumour in the spinal canal,
involving the meninges or the spinal cord.
This tumour must be interfering with the
function of the spinal cord which results in
permanent neurological deficit with
persisting clinical symptoms. The diagnosis
must be made by a relevant consultant and
must be supported by CT, MRI or
histopathological evidence.
The following are not covered: cysts,
granulomas, malformations in the arteries or
veins of the spinal cord, haematomas,
abscesses, disc protrusions and osteophytes.
Blindness
Permanent and irreversible loss of sight to
the extent that even when tested with the
use of visual aids, vision is measured at 6/60
or worse in the better eye using a Snellen eye
chart, or visual field is reduced to 20 degrees
or less of an arc, as certified by an
ophthalmologist.
Cancer
Any 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 except
cutaneous lymphoma (lymphoma confined to
the skin).
The following are not covered:
• all cancers which are histologically
classified as any of the following:
– pre-malignant
– non-invasive
– cancer in situ
– having either borderline malignancy; or
– having low malignant potential
• all tumours of the prostate unless
histologically classified as having a
Gleason score greater than six or having
progressed to at least clinical TNM
classification T2N0M0
• chronic lymphocytic leukaemia unless
histologically classified as having
progressed to at least Binet Stage A
• any skin cancer (including cutaneous
lymphoma) other than:
– malignant melanoma that has been
histologically classified as having
caused invasion beyond the epidermis
(outer layer of skin); or
– the occurrence of a malignant basal
cell carcinoma or malignant squamous
cell carcinoma positively diagnosed
with histological confirmation and
characterised by the uncontrolled
growth of malignant cells and invasion
of tissue. To satisfy the definition of
skin cancer in this bullet point, the skin
cancer must have invaded and spread
to lymph nodes or metastasised to
distant organs.
| 11
Critical illness definitions
Cardiac arrest
Sudden loss of heart function with
interruption of blood circulation around the
body resulting in unconsciousness and
resulting in either of the following devices
being surgically implanted:
• Implantable Cardioverter-Defibrillator
(ICD); or
• Cardiac Resynchronization Therapy with
Defibrillator (CRT-D).
Cardiomyopathy
The unequivocal diagnosis by a consultant
cardiologist of cardiomyopathy resulting in
one or more of the following:
• impaired ventricular function and marked
limitation of physical activity where the
member is unable to progress beyond
stage two of a treadmill exercise test using the standard Bruce protocol; or is
• classified as Stage III under the New York
Heart Association (NYHA) Functional
Classification.
For the purpose of this definition NYHA
Stage III is classified as a marked limitation in
activity due to symptoms even during less
than ordinary activity. The patient is only
comfortable at rest.
The following are not covered:
• all other forms, other than those specified
above, of heart disease, heart
enlargement and myocarditis are
specifically excluded.
Chronic rheumatoid arthritis
A definite diagnosis by a consultant
rheumatologist of chronic rheumatoid
arthritis as evidenced by widespread joint
destruction with major clinical deformity.
In addition the member must permanently
satisfy three of the four following criteria:
Bending - The inability to bend or kneel to
pick up something from the floor and stand
up again and the inability to get into and out
of a standard saloon car.
Dexterity - The inability to use hands and
fingers to pick up and manipulate small
objects such as cutlery, including being
unable to write using a pen or pencil.
Lifting - The inability to lift, carry or otherwise
move everyday objects by hand. Everyday
objects include a kettle of water, a bag of
shopping and an overnight bag or briefcase.
Mobility - The inability to walk a distance of
200 metres on flat ground, with or without
the aid of a walking stick and without having
to rest or experiencing severe discomfort.
Coma
A state of unconsciousness with no reaction
to external stimuli or internal needs which:
• requires the use of life support systems;
and
• results in permanent neurological deficit with persisting clinical symptoms.
12 |
Critical illness definitions
| 13
Critical illness definitions
The following are not covered:
• medically induced coma
• coma secondary to alcohol or drug abuse.
Coronary artery by-pass grafts
The undergoing of surgery requiring
thoracotomy (keyhole surgery or median
sternotomy) on the advice of a consultant
cardiologist to correct narrowing or blockage
of one or more coronary arteries with
by-pass grafts.
Creutzfeldt-Jakob disease
Confirmation by a consultant neurologist of a
definite diagnosis of Creutzfeldt-Jakob
disease resulting in permanent neurological
deficit with persisting clinical symptoms.
Crohn’s disease
A definite diagnosis by a consultant
gastroenterologist of Crohn’s disease.
There must have been two or more bowel
segment resections on separate occasions.
There must also be evidence of continued
inflammation with current symptoms.
Deafness
Permanent and irreversible loss of hearing
to the extent that loss is greater than 95
decibels across all frequencies in the better
ear using a pure tone audiogram.
Dementia
A definite diagnosis of dementia by a
consultant neurologist, psychiatrist or
geriatrician. There must be permanent
clinical loss of the ability to do all of the
following:
• remember
• reason; and
• perceive, understand, express and give
effect to ideas.
The following is not covered:
• Alzheimer’s disease.
Diabetes mellitus type 1
A definite diagnosis of diabetes mellitus type 1
with first diagnosis over age 40, with abrupt
onset requiring the permanent use of insulin
injections that must have continued for a
period of at least 12 months.
The following are not covered:
• gestational diabetes
• type 2 diabetes (including type 2 diabetes
treated with insulin)
• latent autoimmune diabetes of adulthood
We will not pay the benefit for type 1 insulin
dependent diabetes mellitus, as defined
above, if the diagnosis is made within the 12
months before the date on which your
membership will end and may not be
renewed.
Heart attack
Death of heart muscle, due to inadequate
blood supply, that has resulted in all of the
following evidence of acute myocardial
infarction:
• the characteristic rise of cardiac enzymes
or Troponins
• new characteristic electrocardiographic
changes or other positive findings on
diagnostic imaging tests.
The evidence must show a definite acute
myocardial infarction.
The following are not covered:
• other acute coronary syndromes
• angina without myocardial infarction.
Heart valve replacement or repair
The undergoing of surgery requiring
thoracotomy (keyhole surgery or median
sternotomy) on the advice of a consultant
cardiologist to replace or repair one or more
heart valves.
HIV infection
Infection by Human Immunodeficiency Virus
resulting from:
• a blood transfusion given as part of
medical treatment;
• a physical assault; or
• an incident occurring during the course of
performing normal duties of employment
from the eligible occupations listed below:
– ambulance workers
– chiropodists
– dental nurses
– dental surgeons
– district nurses
– fire brigade firefighters
– general practitioners
– hospital caterers
– hospital cleaners
– hospital doctors, surgeons and
consultants – hospital laboratory technicians
– hospital laundry workers
– hospital nurses
– hospital porters
– midwives
– nurses employed by general
practitioners
– occupational therapists
– paramedics
– physiotherapists
– podiatrists
– policemen and policewomen
– prison officers
– radiologists
– refuse collectors
– social workers
after the start of the policy and satisfying all
of the following:
• the incident must have been reported to
appropriate authorities and have been
investigated in accordance with the
established procedures
14 |
Critical illness definitions
• where HIV infection is caught through a
physical assault or as a result of an
incident occurring during the course of
performing normal duties of employment,
the incident must be supported by a
negative HIV antibody test taken within
five days of the incident
• there must be a further HIV test within 12
months confirming the presence of HIV or
antibodies to the virus.
The following are not covered:
• HIV infection resulting from any other
means, including sexual activity or drug
misuse.
Kidney failure
Chronic and end stage failure of both kidneys
to function, as a result of which regular
dialysis is permanently required.
Liver failure
Chronic liver disease, being end stage liver
failure due to cirrhosis and resulting in all of
the following:
• permanent jaundice
• ascites
• encephalopathy.
Loss of hands or feet
Permanent physical severance of any
combination of one or more hands or feet at
or above the wrist or ankle joints.
Loss of independence
The total and permanent loss of the ability
to perform routinely at least three of the
specified six ‘activities of daily living’ without
the continual assistance of someone else,
even with the use of special devices or
equipment.
The following are activities of daily living:
Washing - this means being able to wash and
bathe unaided, including getting into and out
of the bath or shower.
Dressing - this means being able to put on,
take off, secure and unfasten all necessary
items of clothing.
Feeding - this means being able to eat
pre-prepared foods unaided.
Continence - this means being able to
control bowel or bladder functions, whether
with or without the use of protective
undergarments and surgical appliances.
Moving - this means being able to move from
one room to another on level surfaces.
Transferring - this means being able to get on
and off the toilet, in and out of bed and move
from a bed to an upright chair or wheelchair
and back again.
Loss of speech
Total permanent and irreversible loss of the
ability to speak as a result of physical injury
or disease.
| 15
Critical illness definitions
Major organ transplant
The undergoing as a recipient from another
donor, or inclusion on an official UK waiting
list for any of the following:
• transplant of a bone marrow, or
• transplant of a complete heart, kidney,
liver, lung or pancreas, or
• transplant of a lobe of liver, or
• transplant of a lobe of lung.
The following are not covered:
• transplant of any other organs, parts of
organs or cells.
Motor neurone disease
A definite diagnosis of one of the following
motor neurone diseases by a consultant
neurologist:
– Amyotrophic lateral sclerosis (ALS)
– Primary lateral sclerosis (PLS)
– Progressive bulbar palsy (PBP)
– Progressive muscular atrophy (PMA).
There must also be permanent clinical
impairment of motor function.
Multiple sclerosis
A definite diagnosis of multiple sclerosis by a
consultant neurologist, that has resulted in
either of the following:
• clinical impairment of motor or sensory
function, which must have persisted for a
continuous period of at least three
months; or
• two or more attacks of impaired motor or
sensory function together with findings of
clinical objective evidence on Magnetic
Resonance Imaging (MRI).
All of the evidence must be consistent with
multiple sclerosis.
Open heart surgery
The undergoing of open heart surgery
requiring thoracotomy on the advice of a
consultant cardiologist.
The following is not covered:
• any percutaneous, transluminal or
investigative procedure.
Paralysis of limbs
Total and irreversible loss of muscle function
to the whole of any one limb.
Parkinson’s disease
A definite diagnosis of Parkinson’s disease by
a consultant neurologist.
There must be permanent clinical
impairment of motor function with associated
tremor or muscle rigidity.
The following are not covered:
• Parkinsonian syndromes/Parkinsonism
Progressive supranuclear palsy
Confirmation by a consultant neurologist of a
definite diagnosis of progressive
supranuclear palsy.
16 |
Critical illness definitions
There must be permanent clinical
impairment of all of the following:
• motor function
• eye movement disorder; and
• postural instability.
Respiratory failure
Confirmation by a consultant physician of
severe lung disease which is evidenced by all
of the following:
• the need for continuous daily oxygen
therapy on a permanent basis;
• evidence that oxygen therapy has been
required for a minimum period of six
months;
• FEV1 being less than 40 percent of
normal; and
• vital capacity less than 50 percent of
normal.
Stroke
Death of brain tissue due to inadequate
blood supply or haemorrhage within the skull
resulting in either:
• permanent neurological deficit with persisting clinical symptoms;
or
• definite evidence of death of tissue or
haemorrhage on a brain scan; and
• neurological deficit with persistent clinical
symptoms lasting at least 24 hours.
The following are not covered:
• transient ischaemic attack
• death of tissue of the optic nerve or
retina/eye stroke.
Systemic lupus erythematosus (SLE)
A definite diagnosis of systemic lupus
erythematosus (SLE) by a consultant
rheumatologist resulting in:
• permanent impaired renal function
evidenced by a glomerular filtration rate
below 30 ml/min/1.73m2; and
• urinalysis showing proteinuria or
haematuria;
or
• permanent neurological deficit
evidenced by one of the following
persisting clinical symptoms - paralysis,
localised weakness, dysarthria (difficulty
with speech), dysphagia (difficulty in
swallowing), difficulty in walking or lack of
co-ordination.
For the purposes of this definition seizures,
headaches, fatigue, lethargy or any
symptoms of psychological or psychiatric
origin will not be accepted as evidence of
permanent neurological deficit.
| 17
Critical illness definitions
Critical illness definitions
18 |
Terminal illness
A definite diagnosis by the attending
consultant of an illness that satisfies both of
the following:
• the illness either has no known cure or has
progressed to the point where it cannot be
cured; and
• in the opinion of the attending consultant,
the illness is expected to lead to death
within 12 months.
Third degree burns
Burns that involve damage or destruction of
the skin to its full depth through to the
underlying tissue and covering at least 20
percent of the body’s surface area or 20
percent loss of surface area of the face which
for the purposes of this definition includes the
forehead and ears.
Traumatic brain injury
Death of brain tissue due to traumatic injury
resulting in permanent neurological deficit
with persisting clinical symptoms.
Ulcerative colitis
A definite diagnosis of ulcerative colitis which
is treated with total colectomy (removal of
entire large bowel).
A definite diagnosis of ulcerative colitis must be
confirmed by a consultant gastroenterologist.
Your membership critical illness cover or critical illness with life cover
| 19
Your membership - critical illness cover or critical illness with life coverYour membership is made up of the
following documents:
• your application for cover
This includes your initial application and
any further applications you make where
your membership is varied. It also
includes any declarations you made at
our request when you applied for cover.
• your registration certificate and any
endorsements
These set out the current details of your
membership. The ‘Special conditions’
section of your registration certificate
shows any special conditions we apply
to your membership.
Your registration certificate may also
refer to other memberships you have
under the Friends Life flexible financial
protection plan.
We explain how your registration certificate may change in the ‘General
information’ section.
• this handbook
This contains all the general terms and
conditions of your membership. It is
referred to as the ‘Friends Life Individual
Protection Critical Illness and Friends Life
Individual Protection Critical Illness with
Life Cover’ membership handbook,
reference number FLIP/4564/May14.
When your membership starts and ends
Your membership starts on the
commencement date and is subject to you
paying your first premium.
The date your membership ends depends
on the type of cover you have.
If your registration certificate shows that
the type of cover you have is ‘Renewable
term’ (either five years or ten years), your
membership will end on the earliest of the
following:
• any renewal date on which you do not
renew your membership or we end your
membership
• where the renewal term is five years the renewal date is before the member’s 65th birthday (or the eldest member if more than one)
• where the renewal term is ten years, the renewal date is before the member’s 70th birthday (or the eldest member if more than one)
• where you have a critical illness cover membership, the death of a member
20 |
Your membership
• the date we pay you the benefit
• 30 days after the premium due date, we will allow your membership to continue if you pay any outstanding amount within
the 30 day period after it became due.
If you do not have ‘Renewable term’ cover
your membership will end on the earliest of
the following:
• the ‘expiry date’ shown on your registration certificate
• where you have a critical illness cover membership, the death of a member
• the date we pay you the benefit
• 30 days after the premium due date
where you do not pay any amounts. We will allow your membership to continue if you pay any outstanding amounts within
the 30 day period after it became due.
Failure to disclose a fact, giving false
information or failing to tell us of a change in
your health or circumstances in relation to
any question in your application before cover
starts where done deliberately or recklessly
gives us the right to cancel from the start any
membership issued as a result and may
invalidate a future claim. However, where that
information was given carelessly, or the
failure to disclose relevant information was
careless, then we will amend the terms of
your membership to be consistent with
what the terms should have been based on
the correct information, unless we would not
have offered any terms for the membership
applied for, in which case we have the right
to cancel the membership from the start
and return any premiums.
Your membership will end regardless of
whether it was you or a member or both
who misled us.
You can end your membership by writing to
us providing 30 days notice to tell us at the
address stated in the ‘General information’
section.
| 21
Your membership
Additional options
22 |
| 23
Additional options
Additional optionsYour registration certificate will show
whether we have provided any of the
following additional options to you. If there is
more than one member, your registration
certificate will show to which member the
option applies or whether it applies to both.
The following are the full list of additional
options. These are only applicable if you
have selected and we have agreed to
provide the option:
• indexation options
• fracture cover option
• premium waiver option
• total permanent disability option
• reinstatement option.
Indexation options
For each of these options, on each
anniversary of the commencement date,
we will increase the benefit under your
membership. The amount the benefit
increases by will depend on the indexation
option applicable.
If we have agreed to provide this option,
your registration certificate will show
which indexation option you have of the
following:
• RPI (Retail Price Index)
• AWE (Average Weekly Earnings)
• five percent
• three percent.
The increases for each indexation option are
as follows:
RPI (Retail Price Index) option
On the anniversary of the commencement
date, we will increase the benefit in
proportion to the increase in the RPI during
the first 12 months of the 15 month period
immediately before the anniversary of the
commencement date.
The maximum increase on any anniversary
will be 10 percent of the benefit.
AWE (Average Weekly Earnings) option
On the anniversary of the commencement
date we will increase the benefit in
proportion to the increase in the AWE
measure over the first 12 months of the 17
month period immediately before that
anniversary of the commencement date.
Five percent option
On the anniversary of the commencement
date, we will increase the benefit by five
percent a year.
Three percent option
On the anniversary of the commencement
date, we will increase the benefit by three
percent a year.
24 |
Additional options
How does indexation affect your premiums?
You will have to pay an increased premium
for any increase in the benefit. Your premium
will increase at a higher rate than your
benefit as we will allow for member’s age
and remaining term at the time of the
increase in the benefit. For guaranteed and
reviewable premiums the increase will be
based on our premium rates at the
commencement date. For renewable
premiums, the increase will be based on our
premium rates applicable at the later of the
commencement date or at the last renewal.
When we write to tell you about the increase
in the benefit, we will tell you about the
increase in your premium.
Cancelling an increase
You can cancel the increase in the benefit
and your premium by writing to us within 30
days of the date of our letter telling you
about the increase. If you cancel any
increases we will cancel your indexation
option and no further increases will be made
(this will not affect previous increases).
Fracture cover option
If we have agreed to provide the fracture
cover option, your registration certificate
will show this option. If there is more than
one member we may have agreed to cover
one or both members and this will also show
on your registration certificate. If the
member suffers one of the fractures shown
in the table below, we will pay fracture cover
benefit to you. The amount of the fracture
cover benefit we will pay is shown in the
table below:
To make a claim for fracture cover benefit
you must:
• contact us to ask for a claim form; and
then
• fill in the claim form and return it to us.
You must make your claim as soon as
reasonably practicable.
Fracture cover benefitFracture
closed fracture of the skull
open fracture of the skull
fracture of the vertebra
fracture of the shoulder blade
fracture of the jaw
fracture of the sternum
fracture of the pelvis
fracture of the wrist
fracture of the hand
fracture of the upper leg
fracture of the knee
fracture of the lower leg
fracture of the arm
fracture of the cheekbone
fracture of the foot
fracture of the ankle
fracture of the ribs
fracture of the collar bone
£1,200
£2,100
£900
£900
£900
£900
£1,200
£900
£900
£2,100
£2,100
£1,200
£1,200
£900
£900
£1,200
£600
£600
| 25
Additional options
We will only pay the benefit to you for the
following fractures as defined in ‘Black’s
Medical Dictionary’ (39th edition);
comminuted, complicated, compound,
depressed, greenstick, pathological and
simple. We will not pay the benefit for any
other type of fracture.
Where more than one of the above fractures
occurs at any time, we will only pay fracture
cover benefit for one of the fractures. You
can decide which fracture you claim for.
We will not pay fracture cover benefit to you
if the fracture arises out of the same event
as that for which we have paid the benefit
to you.
We will only pay fracture cover benefit to
you for one fracture suffered during any 12
month period. The first 12 month period will
start on the commencement date and then
each subsequent 12 month period will begin
on each anniversary of the commencement
date.
We will not pay fracture cover benefit for a
fracture suffered by a child.
Total permanent disability option
This is only applicable if you have selected
and we have agreed to provide the total
permanent disability option, this will show on
your registration certificate. If there is more
than one member we may have agreed to
cover one or both members and this will also
show on your registration certificate. This
option ends when your membership ends.
With this option we will pay the benefit if the
member that the option applies to becomes
totally and permanently disabled as defined
in this handbook. Any disability must
continue for a minimum of six months before
we will consider whether it is a ‘total
permanent disability’ for the purpose of your
membership.
What is total permanent disability?
Your registration certificate will show
whether the definition of total permanent
disability for a particular member is ‘own’,
‘suited’ or ‘activities of daily work’. The
definitions are as follows:
‘Own’ definition
Loss of the physical or mental ability through
an illness or injury to the extent that the
member is unable to do the essential duties
of their own occupation ever again. The
essential duties are those that are normally
required for, and form a significant and
integral part of, the performance of the
member’s own occupation that cannot
reasonably be omitted or modified.
The relevant consultant must reasonably
expect that the disability will last throughout
life with no prospect of improvement,
irrespective of when the cover ends or the
member expects to retire.
‘Suited’ definition
Loss of the physical or mental ability through
an illness or injury to the extent that the
member is unable to do the essential duties
26 |
Additional options
of a suited occupation ever again. The
essential duties are those that are normally
required for, and form a significant and
integral part of, the performance of a suited
occupation that cannot reasonably be
omitted or modified.
The relevant consultant must reasonably
expect that the disability will last throughout
life with no prospect of improvement,
irrespective of when the cover ends or the
member expects to retire.
‘Activities of daily work’ definition
Loss of the physical ability through an illness
or injury to do at least three of the six work
tasks listed below ever again.
The relevant consultant must reasonably
expect that the disability will last throughout
life with no prospect of improvement,
irrespective of when the cover ends or the
member expects to retire.
The member must need the help or
supervision of another person and be unable
to perform the task on their own, even with
the use of special equipment routinely
available to help and having taken any
appropriate prescribed medication.
‘Activities of daily work’
The work tasks are:
Walking
The ability to walk more than 200 metres on
a level surface.
Climbing
The ability to climb up a flight of 12 stairs and
down again, using the handrail if needed.
Lifting
The ability to pick up an object weighing 2kg
at table height and hold for 60 seconds
before replacing the object on the table.
Bending
The ability to bend or kneel to touch the floor
and straighten up again.
Getting in and out of a car
The ability to get into a standard saloon car,
and out again.
Writing
The manual dexterity to write legibly using a
pen or pencil, or type using a desktop
personal computer keyboard.
Premium waiver option
This is only applicable if you have selected
and we have agreed to provide the premium
waiver option, this will show on your
registration certificate. If there is more than
one member we may have agreed to cover
one or both members and this will also show
on your registration certificate.
This option ends when your membership
ends.
If the member that the option relates to is in
an occupation and was on the
commencement date, we will waive your
premiums for the period the member is
unable to do their normal occupation, as a
| 27
Additional options
result of illness and injury, provided that the
member is not doing any other occupation.
If the member that the option relates to is
not in an occupation or was not on the
commencement date, we will waive your
premiums for the period that the member is,
as a result of illness or injury, unable to do at
least three of the daily activities listed below:
Daily activities
Shopping
Being able to get to and from the nearest
shops and carry a small bag of shopping.
Cooking
Being able to prepare and cook a basic meal.
Housework
Being able to carry out light housework such
as dusting, washing dishes and making beds.
Handling money
Being able to handle basic household
finances and recognise the value of money.
Taking medicine
Being able to take routine medication
prescribed by a recognised medical
practitioner.
Child minding
Being able to care for, feed, wash and dress a
child under the age of five.
We will waive your premiums until:
• the member can do their occupation; or
• the member starts any paid work; or
• the member becomes capable of doing
four or more of the daily activities shown
above (if the member was not in an
occupation); or
• your membership ends.
If, as a result of illness or injury, the member
becomes unable to do their occupation or
unable to do at least three of the daily
activities listed above, you must make a
claim to us to waive your premiums before
you are entitled to any waiver. To do this you
must:
• contact us to ask for a claim form; and
then
• fill in the claim form and return it to us.
You must give us any information or proof
we reasonably require to consider your claim
both at the time of your claim and at any
time when we are waiving your premiums.
If we accept your claim, we will not waive
your premiums until the end of the three
month period following either the date the
member became unable to do their
occupation or the date they became unable
to do at least three of the daily activities as
appropriate.
You must make your claim within six months
of the illness or injury arising or as soon as
reasonably practicable. If you do not, we
may not waive your premiums for the period
of delay in making your claim.
During any period where we waive your
premiums, you must notify us as soon as
practicable of the member:
• starting an occupation
• no longer being incapable of doing three
or more of the daily activities
• being capable of doing their occupation.
If you fail to do so, we may end your
membership.
Reinstatement option
This is only applicable if you have selected
and we have agreed to provide you with the
reinstatement option.
If we have provided the reinstatement option
and we pay the benefit to you in the event
of a member suffering or undergoing a
critical illness, you can take out a new
membership subject to all of the following:
• you tell us in writing that you want to take
out the new membership
• if the benefit was paid due to a member having cancer, the new membership can
only be taken out within five years of the
date we paid the benefit and you must
provide us with all of the following:
– the written confirmation of the doctors
who treated the member that the
member made a full recovery at least
one year prior to you applying to us for
the new membership; and
– evidence that the member has not
undergone any tests that show the
presence of cancer since the full
recovery from cancer was made; and
– evidence that the member has
attended all consultations and check
ups and undergone all tests
recommended by the medical
specialist for cancer
• if the benefit was paid due to a critical illness other than cancer, the new membership can only be taken out
between 12 and 24 months after the date
we paid the benefit
• the only critical illnesses to be covered
under the new membership are the
following (the illnesses and definitions of
these will be those we apply at the time
the new agreement is taken out):
– aorta graft surgery
– aplastic anaemia
– bacterial meningitis
– cancer
– cardiomyopathy
– heart attack
– HIV/AIDS
– kidney failure
– liver failure
– major organ transplant
– motor neurone disease
– multiple sclerosis
– Parkinson’s disease
– progressive supranuclear palsy
– stroke
– systemic lupus erythematosus
– third degree burns
28 |
Additional options
| 29
Additional options
• claims for the same event for which we paid benefit to you will be excluded from
the new membership
• we will only consider claims under the
new membership for events or illnesses
occurring or being diagnosed after the
commencement of your new membership
• the new membership will cover the same
member (or both if more than one) as
under this membership
• the new membership will not continue
beyond the date your membership would
have ended
• the membership must have been capable
of continuing for at least five years after
the date we receive the request for your new membership
• the amount of benefit provided will be the
lower of £100,000 or the benefit we paid
under your membership
• the member to be covered by the new membership (or eldest member if more
than one) is under 50 years of age
• life cover will only be provided under the
new membership where your original
membership is for critical illness with life
cover
• no additional options can be included in
the new membership
• no claim for terminal illness benefit will
be included in the new membership
• the terms and conditions of the new membership will be those we apply at the
time the new membership is taken out
• we accepted the initial application for
cover without increasing the premiums
above our standard rates at that time or
applying any special conditions to the membership.
The premiums you will have to pay for the
new membership will be based on our
premium rates and the member’s age on the
commencement date of the new
membership.
The reinstatement option is not available for
and will not include childcover benefit.
The reinstatement option can only be
effected once.
What you are covered for
30 |
| 31
What you are covered for
What you are covered for
Benefit
We will pay the benefit to you if, during the
period of your membership any of the
following happens:
• a member suffers or undergoes a critical illness; or
• a member becomes totally and
permanently disabled (if we have
provided the total permanent disability
option); or
• where you have a critical illness with life
cover membership, either of the following
happens;
– a member dies; or
– a member is diagnosed with a terminal
illness. The relevant benefit payable for
a terminal illness for a Critical Illness
with Life Cover membership will be
the terminal illness benefit.
Payment of the benefit is subject to:
• you complying with the requirements and
obligations set out in the ‘How to make a
claim’ section.
• your claim not being excluded by any of
the circumstances listed in the ‘What you are not covered for’ section.
We will only pay the benefit or the terminal
illness benefit once and not both under this
membership, on the first of the above events
to happen.
For any claim under the total permanent
disability option, we will only pay the benefit
after the disability has continued for six
months, subject to the additional terms of the
total permanent disability option set out in
the ‘Additional options’ section.
Carcinoma in situ of the cervix uteri – requiring hysterectomy
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member is
diagnosed with carcinoma in situ of the
cervix uteri (cervix) requiring treatment with
hysterectomy.
The hysterectomy must have been performed
on the advice of a consultant to treat
carcinoma in situ.
The following tumors are excluded:
• all grades of dysplasia;
• cervical squamous epithelial lesion (SIL);
and
• cervical intra-epithelial neoplasia (CIN),
unless carcinoma in situ is present.
The carcinoma in situ of the cervix uteri
requiring hysterectomy benefit is payable in
addition to the benefit you have under your
membership. We will only pay this benefit
once for each member regardless of the
number of memberships held.
Carcinoma in situ of the urinary bladder
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member is
diagnosed with carcinoma in situ of the
urinary bladder.
The diagnosis must be histologically
confirmed on a pathology report. This benefit
is payable only once. Non-invasive papillary
carcinoma, stage Ta bladder carcinoma and
all other forms of non-invasive carcinoma are
specifically excluded.
The carcinoma in situ of the urinary bladder
benefit is payable in addition to the benefit
you have under your membership. We will
only pay this benefit once for each member
regardless of the number of memberships
held.
Cerebral aneurysm - with surgical repair
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member undergoes
either of the following surgical procedures in
order to treat a cerebral aneurysm:
• surgical correction via craniotomy
(surgical opening of the skull); or
• endovascular treatment using coils or
other materials (embolisation).
The cerebral aneurysm benefit is payable in
addition to the benefit you have under your
membership. We will only pay this benefit
once for each member regardless of the
number of memberships held.
Cerebral arteriovenous malformation - with surgical repair
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member undergoes
either of the following surgical procedures in
order to treat a cerebral arteriovenous
malformation:
• surgical correction via craniotomy
(surgical opening of the skull); or
• endovascular treatment using coils or
other materials (embolisation).
The cerebral arteriovenous malformation
benefit is payable in addition to the benefit
you have under your membership. We will
only pay this benefit once for each member
regardless of the number of memberships
held.
Coronary angioplasty
We will pay the lower of 25 percent of the
benefit and £25,000 if a member undergoes
any of the following:
• balloon angioplasty
• atherectomy
• rotablation
• laser treatment, or
• insertion of stents.
The above operations must have been carried
out on the advice of a consultant cardiologist
to treat severe coronary artery disease in two
or more main coronary arteries. The above
operation must be to treat at least 70 percent
diameter narrowing. If an operative procedure
is only performed on one main coronary artery
there must be at least 70 percent diameter
narrowing in another main coronary artery.
For the purposes of this definition main
coronary arteries are described as one or
more of the following:
• right coronary artery
• left main stem
32 |
What you are covered for
| 33
What you are covered for
• left anterior descending
• circumflex.
The following is not covered:
• procedures to any branches of any of the
main coronary arteries.
The coronary angioplasty benefit is payable
in addition to the benefit you have under
your membership. We will only pay this
benefit once for each member regardless of
the number of memberships held.
Crohn’s disease – treated with surgical intestinal resection
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member is
diagnosed with Crohn’s disease and has
undergone surgical intestinal resection.
A definite diagnosis of Crohn’s disease must be
confirmed by a consultant gastroenterologist.
Crohn’s disease treated with surgical
intestinal resection benefit is payable in
addition to the benefit you have under your
membership. We will only pay this benefit
once for each member regardless of the
number of memberships held.
We will not pay this benefit to you if we have
already paid the benefit to you for Crohn’s
disease - of specified severity, as defined in
the ‘Critical illness definitions’ section of this
handbook.
Ductal carcinoma in situ of the breast - with specified treatment
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member is
diagnosed with ductal carcinoma in situ
(DCIS), histologically confirmed, and as a
result requires total mastectomy,
segmentectomy or lumpectomy.
DCIS of the breast treated by other methods
and lobular carcinoma in situ are specifically
excluded.
DCIS of the breast benefit is payable in
addition to the benefit you have under your
membership. We will only pay this benefit
once for each member regardless of the
number of memberships held.
Low-grade prostate cancer
We will pay the lower of 25 percent of the
benefit and £25,000 if a member is
diagnosed with a tumour of the prostate
histologically classified as having a Gleason
score between 2 and 6 inclusive provided:
• the tumour has progressed to at least
clinical TNM classification T1N0M0; and
• treatment included the complete removal
of the prostate or external beam or
interstitial implant radiotherapy.
For clarity, cases treated with cryotherapy,
other less radical treatment (eg. transurethral
resection of the prostate), experimental
treatments or hormone therapy are not
included.
34 |
What you are covered for
The low-grade prostate cancer benefit is
payable in addition to the benefit you have
under your membership. We will only pay
this benefit once for each member
regardless of the number of memberships
held.
Non-malignant pituitary adenoma - with specified treatment
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member is
diagnosed with a non-malignant pituitary
tumour requiring radiotherapy or surgical
removal.
Non-malignant tumours of the pituitary gland
treated by other methods are specifically
excluded.
This benefit is payable in addition to the
benefit you have under your membership.
We will only pay this benefit once for each
member regardless of the number of
memberships held.
Removal of one or more lobe(s) of the lung – for disease and trauma
We will pay the lower of 12.5 percent of the
benefit and £12,500 if a member undergoes
the removal of one or more lobes of the lung
due to underlying disease or trauma. The
surgery must be carried out on the advice of
a consultant physician. The removal of one or
more lobe(s) of the lung – for disease and
trauma benefit is payable in addition to the
benefit you have under your membership.
We will only pay this benefit once for each
member regardless of the number of
memberships held.
Significant visual loss
We will pay the lower of 25 percent of the
benefit and £25,000 if a member suffers
permanent and irreversible loss of sight to
the extent that even when tested with the
use of visual aids, vision is measured at 6/24
or worse in the better eye using a Snellen eye
chart, or visual field is reduced to 45 degrees
or less of an arc, as certified by an
ophthalmologist.
Significant visual loss benefit is payable in
addition to the benefit you have under your
membership. We will only pay this benefit
once for each member regardless of the
number of memberships held.
We will not pay this benefit to you if we have
already paid the benefit to you for blindness
as defined in the ‘Critical illness definitions’
section of the membership handbook.
Acceleration payment benefit for specified surgical treatments
We will make an advance payment if a
member is on the NHS waiting list for one of
the following types of surgical treatments, as
defined in ‘Critical illness definitions’ section
of this handbook:
• aorta graft surgery
• coronary artery by-pass grafts
• heart valve replacement or repair
• open heart surgery.
| 35
What you are covered for
We will pay the lower of 25 percent of the
benefit and £25,000.
To be eligible for this acceleration payment
benefit, the member must be on the relevant
NHS waiting list for the hospital where it is
proposed the surgical treatment is to take
place.
When an advance payment is made under
this acceleration payment benefit for
specified surgical treatments, your benefit
will be reduced by the amount of the
accelerated payment we make to you.
This accelerated payment is also applicable
for eligible children.
We will always pay the benefit in respect of
carcinoma in situ of the cervix requiring
hysterectomy; carcinoma in situ of the urinary
bladder; Crohn’s disease treated with surgical
intestinal resection; ductal carcinoma in situ of
the breast - with specified treatment;
low-grade prostate cancer; coronary
angioplasty; cerebral aneurysm - with surgical
repair; cerebral arteriovenous malformation
- with surgical repair; non-malignant pituitary
adenoma - with specified treatment; removal
of one or more lobe(s) of the lung – for disease
and trauma; significant visual loss or surgical
treatments, as a lump sum, with the lump sum
calculated by reference to the benefit.
Childcover benefit
We will pay childcover benefit to you, if
during the period of the agreement, a child
suffers or undergoes a critical illness, suffers
cerebral palsy, cystic fibrosis, hydrocephalus,
muscular dystrophy or spina bifida as defined
below, requires intensive care as defined
below or suffers or undergoes one of the
conditions as defined in the ‘What you are
covered for’ section of this handbook,
subject to you complying with the
requirements and obligations set out in the
‘How to make a claim’ section, unless your
claim is excluded by any of the
circumstances listed in the ‘What you are not
covered for’ section.
Children’s intensive care benefit – requiring mechanical ventilation for 7 days
We will pay childcover benefit to you, if
during the period of the agreement, a child
due to sickness or injury is requiring
continuous mechanical ventilation by means
of tracheal intubation for 7 consecutive days
(24 hours per day) unless it is as a result of
the child being born prematurely (before 37
weeks). Please refer to ‘What you are not
covered for’ section for exclusions and
limitations of the cover.
Cerebral palsy
We will pay childcover benefit to you if the
child receives a definite diagnosis of cerebral
palsy made by an attending consultant.
Cystic fibrosis
We will pay childcover benefit to you if the
child receives a definite diagnosis of cystic
fibrosis made by an attending consultant.
Hydrocephalus - treated with the insertion of a shunt
We will pay childcover benefit to you if the
child suffers hydrocephalus if the
hydrocephalus is treated with an insertion of
a shunt.
Muscular dystrophy
We will pay childcover benefit to you if the
child receives a definite diagnosis of
muscular dystrophy made by a consultant
neurologist.
Spina bifida
We will pay childcover benefit to you if the
child receives a definite diagnosis of spina
bifida myelomeningocele or rachischisis by a
paediatrician.
The following are not covered:
• spina bifida occulta
• spina bifida with meningocele.
Childcover benefit is the lower of 50
percent of the benefit and £25,000 unless;
• the child suffers:
– coronary angioplasty;
– low-grade prostate cancer; or
– significant visual loss;
then the childcover benefit will be the
lower of 25 percent of the benefit and
£25,000, or;
• the child suffers:
– carcinoma in situ of the cervix requiring
hysterectomy;
– carcinoma in situ of the urinary
bladder;
– cerebral aneurysm - with surgical
repair;
– cerebral arteriovenous malformation
- with surgical repair;
– Crohn’s disease treated with surgical
intestinal resection;
– ductal carcinoma in situ - with
specified treatment;
– non-malignant pituitary adenoma with
specified treatment; or
– removal of one or more lobe(s) of the
lung - for disease and trauma;
in which case the childcover benefit will
be the lower of 12.5 percent of the benefit
and £12,500.
The childcover benefit will be payable once
per child. The maximum benefit payable is
the lower of 50 percent of the benefit and
£25,000, regardless of the number of
memberships held by you.
We will only pay childcover benefit where
the child is under 18 years of age, or under 21
years of age if not in full time employment,
when the child suffers or undergoes a
critical illness, any of the conditions listed in
the ‘What you are covered for’ childcover
benefit section and children’s intensive care
benefit.
We will only pay childcover benefit where
the member is either the parent or legal
guardian of the child or if the member is the
spouse, partner or civil partner of the parent
or legal guardian of the child.
36 |
What you are covered for
| 37
What you are covered for
We will pay the childcover benefit as a lump
sum, with the lump sum calculated by
reference to the benefit.
Child funeral benefit
We will pay £5,000 towards the cost of a
funeral, if during the period of the agreement,
a child dies, subject to you complying with
the requirements and obligations set out in
the ‘How to make a claim’ section, unless
your claim is excluded by any of the
circumstances listed in the ‘What you are not
covered for’ section.
Child funeral benefit is payable in addition
to childcover benefit.
The child funeral benefit payable is £5,000.
The benefit is payable once per child,
regardless of the number of memberships
held by you. We will only pay child funeral
benefit where the member is either the
parent or legal guardian of the child or if the
member is the spouse, partner or civil partner
of the parent or legal guardian of the child.
We will pay the child funeral benefit as a
lump sum.
Family income benefit
We will pay the benefit to you as an annual
income where the benefit is a family income
benefit, subject to you complying with the
requirements and obligations set out in
the ‘How to make a claim’ section, unless
your claim is excluded by any of the
circumstances listed in the ‘What you are not
covered for’ section. We will pay the benefit
annually on each anniversary of the payment
until the last anniversary before the expiry
date set out in your registration certificate.
If you select the indexation option your
benefit will stop increasing once we pay
your claim.
If your registration certificate shows that
you have family income benefit, the benefit
figure that will be used for the lump sum
calculation for these benefits will be the
annual benefit as per the following
calculations:
The annual benefit as shown on your
registration certificate x the remaining
number of years of your membership x 12.5
percent, up to a maximum of £12,500, for the
following benefits:
• carcinoma in situ of the cervix requiring
hysterectomy;
• carcinoma in situ of the urinary bladder;
• cerebral aneurysm - with surgical repair;
• cerebral arteriovenous malformation
- with surgical repair;
• Crohn’s disease treated with surgical
intestinal resection;
• ductal carcinoma in situ of the breast-
with specified treatment;
• non-malignant pituitary adenoma - with
specified treatment;
• removal of one or more lobe(s) of the lung
– for disease and trauma.
38 |
What you are covered for
Each of these benefits is defined in the
‘What you are covered for’ section of this
handbook.
The annual benefit as shown on your
registration certificate x the remaining
number of years of your membership x 25
percent, up to a maximum of £25,000, for the
following benefits:
• low-grade prostate cancer
• coronary angioplasty
• acceleration payment benefit for specified
surgical treatments
• significant visual loss.
Each of these benefits is defined in the ‘What
you are covered for’ section of this handbook.
The annual benefit as shown on your
registration certificate x the remaining
number of years of your membership x 50
percent, up to a maximum of £25,000, for the
following benefits:
• childcover benefit.
This benefit is defined in the ‘What you are
covered for’ section of this handbook.
What you are not covered for
| 39
What you are not covered forWe will not pay the benefit, childcover
benefit, fracture cover benefit, premium
waiver benefit or any of the benefits set out
in section ‘What you are covered for’ in any of
the following circumstances:
• where your claim is excluded by any
special condition
• where your claim, other than a claim for
the death or terminal illness benefit of a
member, in whole or part, results directly
or indirectly from a self inflicted injury
• where your claim is for critical illness,
unless the member survives for 14 days
after undergoing that critical illness or
being diagnosed with that critical illness
(unless the benefit is claimed under a
critical illness with life cover membership)
• failure to disclose a fact, giving false
information or failing to tell us of a change
in your health or circumstances in relation
to any question in your application before
cover starts where done deliberately or
recklessly gives us the right to cancel
from the start any membership issued as
a result and may invalidate any future
claim. However, where that information
was given carelessly or the failure to
disclose relevant information was
careless, then we will amend the terms of
your membership to be consistent with
what the terms should have been based
on the correct information, unless we
would not have offered any terms for the
membership applied for, in which case
we have the right to cancel the
membership from the start and return
any premiums.
• we will not pay any claim in relation to a
member:
– if it relates to any operation, or intended
operation, unless it was, or is, medically
necessary and was performed by a
consultant in a hospital in which such
operations are routinely carried out.
Additional terms apply to fracture cover
benefit and the premium waiver benefit and
are found in the ‘Additional options’ section.
We will not pay childcover benefit in the
additional following circumstances:
• if symptoms first arose, the underlying
condition was first diagnosed or either
parent received counselling or medical
advice in relation to the condition before:
– the commencement date– your legal adoption or legal
guardianship of the child
• if the condition is brought about by
intentional harm inflicted on the eligible
child by you
• if the child is over 18 years of age and in
full time employment, or over the age of
21 when the child suffers or undergoes; a
critical illness; any of the conditions
listed in the ‘what you are covered for’
childcover benefit section; and children’s
intensive care benefit.
What you are not covered for
40 |
| 41
What you are not covered for
• if the child suffers a total permanent
disability
• if the child dies before 14 days after
undergoing a critical illness or being
diagnosed with a critical illness
We will not pay child funeral benefit in the
following circumstances:
• if the child dies before reaching 30 days
old
• if the cause of death first arose before:
– the commencement date
– your legal adoption or legal
guardianship of the child
• if the death is brought about by intentional
harm inflicted on the eligible child by you.
Changes to your membership
42 |
| 43
Changes to your membership
Changes to your membershipThere are various changes that can be made
to your membership by you and by us.
Changes we can make
If you have ‘Renewable term’ cover, you need
to renew your membership on each
renewal date. Renewal is subject to our
entitlement to change the terms and
conditions of your membership and/or your
cover (including your premiums).
At least 60 days before each renewal date,
we will write to tell you either about any
changes we will make to the terms and
conditions of your membership or your
cover on renewal or if we intend to end your
membership.
If we do not end your membership and you
continue to pay your premiums, your
membership will automatically be renewed
and any changes to your membership will
come into effect upon renewal.
Changes you can make
At any time you may write and ask us to
change the terms of your membership, we
will consider your request at our discretion.
If you ask us to increase the benefit you
have, we can ask you to give us extra
medical, financial or other information to
allow us to consider your application.
If we accept your application, we will
provide the increase either:
• under a new membership governed by the
terms and conditions we apply at the
time; or
• as an increase to the benefit under your membership.
Any increase in the benefit will increase your
premiums.
You may want to increase the benefit you
have when the member, or either member if
more than one:
• gets married or becomes a civil partner
• gets divorced or separated
• obtains a dissolution of a civil partnership
• has a child or adopts a child or becomes
the legal guardian of a child
• takes out a larger mortgage due to
moving house or undertaking home
improvements
• is promoted by their current employer or
starts a new job with a different employer
and their salary increases.
44 |
Changes to your membership
In these circumstances, we will provide the
increase to you without asking the member
to provide extra medical evidence subject to
all of the following:
• you write to us asking for the increase
within six months of the event, supplying
written evidence to us to show that the
particular circumstance has happened
eg. a marriage certificate or mortgage
loan offer
• the maximum increase in the benefit for
each of the above is the lower of 25
percent of the benefit on the
commencement date and £50,000 or if
the member has family income benefit cover the lower of 25 percent of the
annual benefit and £8,000 per annum
• the total of all increases in the benefit under this option is not more than the
lower of 100 percent of the benefit on the
commencement date and £125,000
• for family income benefit, the total
increases will not exceed £125,000 as
calculated by the annual benefit multiplied by the remaining term under
this membership
• if you want to increase the benefit due to
a mortgage loan, increase must be due to
the member either moving home or
undertaking home improvements
• if you want to increase the benefit because a member’s salary has
increased, the percentage increase is not
more than the percentage increase in
their salary
• we still offer this type of membership at
the time you ask for the increase in benefit
• the member (or eldest member, if more
than one) is under 55 years of age at the
time we receive your request for an
increase
• when we accepted your initial application
for cover we did not apply premiums
above one and a half times our standard
rates at that time or apply any special conditions to your membership
• the increase in the benefit is provided
under a new membership governed by the
terms and conditions (excluding any
option to increase the benefit) that we apply when you ask for the increase or, at our option, as an increase in the benefit under your membership
• the amount by which your premiums will
rise for any increase, is more than the
minimum premium for this type of membership at the time you ask for the
increase
• you may only increase the benefit once
for each of the reasons set out above
• any increase due to a change made is
based on the original benefit on the
commencement of the original membership
• no changes to the membership will be
made or will be effective in the event that
a critical illness has already arisen.
| 45
Changes to your membership
Any increase in benefit will increase your
premiums. Your premiums will increase by
the cost of providing the extra benefit, based
on the member’s age and our premium rates
at the time of the increase in benefit.
Changes applicable for key person/shareholder protection only
Where you have taken out the membership
as a business on a person working in your
business (a “key person”) or as protection for
your interest in a business (“shareholder/
partnership cover”) or if you are a sole trader,
you may wish to increase the benefit you
have to reflect changes in your business or
the levels of cover you need.
We will allow you to increase the cover you
have without providing extra medical
information where one of the events set out
below occurs and the reason you took out
the cover was one which applies for that
event. We will only allow this subject to the
applicable conditions which are set out in this
section.
In all cases the following conditions must be
met:
• you write to us asking for the increase
within three months of the event,
supplying written evidence to us to show
that the particular circumstance has
happened
• the member is under 55 years of age at
the time we receive your request for an
increase
• when we accepted the initial application
for cover we did not apply premiums
above one and a half times our standard
rates at that time or add any special conditions to your membership
• the increase in the benefit is provided
under a new membership governed by the
terms and conditions (excluding any
option to increase the benefit) that we apply when you ask for the increase or, at our option, as an increase in the benefit under your membership
• the amount by which your premiums will
rise for any increase is more than the
minimum premium for this type of membership at the time you ask for the
increase
• we still offer this type of membership at
the time you ask for the increase in benefit
• the membership was taken out for one of
the reasons specified as applying for the
event in which you are seeking to exercise
the option
• only one increase will be allowed for the membership.
The events on which this option may be
exercised together with the reasons for
taking out the membership which must
apply are as follows:
46 |
Changes to your membership
• the member is employed by you and their
salary has increased – the reason for
taking out cover for this event must have
been to protect you against losses you
would suffer to your business or the costs
your business would incur if the member
could not continue in their employment
(“key person cover”)
• a business loan you have is increased
– the reason for taking out cover for this
event must have been to provide security
for the loan and have been a requirement
of the lender in making the loan, but
excludes applications from sole traders on
their own lives (“loan cover”)
• the value of your interest in a business you own has increased – the reason for
taking out cover for this event must have
been to provide funds to purchase your interest in the business which has
increased in value (“shareholder/
partnership cover”)
• where you are a sole trader and either your net relevant earnings have increased
or a business loan you have is increased
– the reason for taking out cover for this
event must have been to provide funds for your dependants to replace the earnings
from your trade or to provide security for
the business loan and have been a
requirement of the lender in making the
loan (“sole trader cover”).
The following conditions must be met for
increases in relation to the different types of
cover:
Key person cover
• the maximum increase in the benefit is
the lower of 50 percent of the benefit on
the commencement date and £250,000
• the increase does not exceed five times
the increase in salary to which the request
relates
• any request for an increase greater than
£150,000 is subject to the member making a true declaration that they are in
good health and our agreement that the
financial evidence supports the request
for the increase
• you cannot extend the term of your membership.
Loan cover or shareholder/partnership cover
• the maximum increase in the benefit is
the lower of 50 percent of the benefit on
the commencement date and £250,000
• you cannot extend the term of your membership.
| 47
Changes to your membership
Sole trader cover
• the maximum increase in the benefit is
the lower of 50 percent of the benefit on
the commencement date and £150,000
• if you want to increase the benefit because your net relevant earnings have
increased the increase does not exceed
five times the increase in net relevant
earnings
• any request for an increase greater than
£150,000 is subject to the member making a health declaration and our agreement that the financial evidence
supports the request for the increase
• you cannot extend the term of your membership.
Any increase in benefit will increase your
premiums. Your premiums will increase
based on the cost of providing the extra
benefit, based on the member’s age and
our premium rates at the time of the increase
in benefit.
Premium options
48 |
| 49
Premium options
Premium options
Paying your premiums
You must pay your premiums in advance
throughout your membership (except whilst
you are receiving the premium waiver
benefit). The amount you must pay, and how
often, are shown on your registration
certificate and any endorsements to it.
If you cannot pay your premiums, contact us
immediately.
Changing premiums
This section explains how your premiums
may change (except for yearly increases if
we have provided an indexation option – see
the ‘Additional options’ section).
Whenever we change your premium we will
write to tell you about this at least 60 days
before the date the changes take effect.
We may increase your premium if there is a
change in law, regulatory requirements or
taxation and it is reasonable for us to
increase your premium as a result. In these
circumstances, the increase in your
premiums will be limited to the amount
necessary to cover the increase in cost to us
of providing cover.
Your membership is subject to the payment
of a monthly plan fee, which we collect as
part of your premium. If you have more than
one Friends Life flexible financial protection
membership we will only charge you a plan
fee with your premiums on one membership.
If any other Friends Life flexible financial
protection membership you have ends (for
any reason) we have the right to increase the
premium on your membership. We will only
increase the premium by the amount of any
plan fee forming part of the premium of the
membership which has ended.
Your registration certificate will show
whether your premium option is ‘guaranteed’,
‘reviewable’ or ‘renewable’. The effect of
these different options is explained below.
Guaranteed premiums
• if your premium option is guaranteed, your premium will remain the same for the
term of the membership unless:
– changes in law, regulatory
requirements or taxation mean that it is
reasonable for us to increase the cost
of your cover as a result
– premium increases if the benefit is
increased, for example, if an indexation
option is selected.
50 |
Premium options
Reviewable premiums
• if your premium option is reviewable, we may increase or decrease your premiums
on the fifth anniversary of the
commencement date and at the end of
every following five year period
• when we decide what premiums we charge under this option, we make
assumptions about the future level of
inflation, claim costs, expenses,
investment returns, taxes and levies. When
we review your premiums under this
option, we consider if the combined effect
of these factors is better or worse than
we had assumed and if, as a result, the
cost of the benefit needs to account for
this. We may, as a result, increase or
reduce your premiums by the amount we reasonably believe is necessary
• we may also increase your premiums
under this premium option if there is a
change in law, regulatory requirements or
taxation and it is reasonable for us to
increase your premium as a result
• we will write to tell you about any change
to your premiums at least 60 days
beforehand
• as a result of our review, if your premium
needs to increase, you can tell us to keep
the premium the same and reduce the
amount of benefit instead. Alternatively, you can cancel the membership and
stop paying premiums altogether.
Renewable premiums
• if your premium option is renewable your premiums may increase or decrease at
each renewal without the need for further
medical evidence based on the age of the
member and our premium rates at that
time. Your premiums will almost certainly
increase on each renewal date because
of an increase in age of the member
• renewable premiums are only available
with renewable term
• we will write to tell you about any change
to your premiums at least 60 days
beforehand
• if your premium needs to increase, you can tell us to keep the premium the same
and reduce the amount of benefit instead.
Alternatively, you can cancel the membership and stop paying premiums
altogether
• we may also increase your renewable
premium on the renewal date as set out
above and if there is any change in law,
regulatory requirements or taxation and it
is reasonable for us to do so.
How to make a claim
| 51
How to make a claimIf you wish to make a claim in relation to
your membership, please contact:
Friends Life Individual Protection – Claims
department
PO Box 569
Friends Life Centre
Bristol
BS34 9FE
Or telephone us on 0845 600 3122*
*Calls may be recorded and may be monitored
You must make your claim as soon as you
reasonably can.
When initially notifying us of a claim, you
must provide the following information:
• details of the person(s) dealing with the
claim, their name(s), address, and
telephone number. In some instances this
may be a third party eg. solicitor, next of
kin or executor
• the nature of the illness, disability,
operation or cause of death
• details of the member’s total permanent
disability; or
• details of the member suffering a
fracture; or
• details of any illness or injury the member or child suffers; or
• evidence of a member’s death and
details of the diagnosis of a terminal
illness; or
• evidence of a child’s death
• relevant dates, eg. the date the illness was
diagnosed or date of death
• the registration number under which you are making a claim, this can be found on
the registration certificate. However if
you cannot locate this, we will be able to
assist but will need to know:
– the name of the member, their date of
birth and their address.
Once we have all this information, we will be
able to confirm that a claim can be submitted
to us to consider and we will then forward a
claim form, reply paid envelope and a short
aid detailing the next steps required for the
claim to be assessed.
You must return the claim form to us giving
us any written information or proof we
reasonably require to establish your claim.
We will need evidence, where appropriate of:
• a diagnosis by a medical practitioner
whose specialism is appropriate to the
cause of the claim, where this is necessary
it is explained in the definition of the
particular critical illness;
• a medical report and other information
about the member’s medical condition
and medical history; or
• the results of any independent medical
assessment which we may ask the
member to undergo at our expense.
52 |
How to make a claim
In order to establish that a member has a
critical illness, terminal illness, total
permanent disability, illness or injury, we may
require that the member or child undergoes
a medical assessment. We will pay for the
cost of this assessment.
Where we receive a claim from a member
who is resident outside the UK, we may ask
the member to attend a Friends Life
Individual Protection approved hospital for
medical assessment. In the event that we
cannot obtain the medical information we
require to assess the claim, we also reserve
the right to request that they attend a Friends
Life Individual Protection approved
hospital in a different country or they return
to the UK for the medical assessment. We will
not pay for the member to travel to the UK or
any other country for the medical assessment
but will meet the costs of the medical
assessment itself.
We may also require evidence that you are
entitled to the benefit. For example, in the
event of a death of the sole trustee of the
policy we may need evidence of the
appointment of personal representatives (or
an executor) who will become the new
trustee.
Once we reasonably consider that we have
enough information or proof to establish your
claim, we will pay the benefit, childcover
benefit, fracture cover benefit, premium
waiver benefit or benefits as set out in ‘What
you are covered for’ section, to you as
applicable.
When you make your claim neither you nor
a member must mislead us by either giving
us any false information or keeping relevant
information from us. If either you or a
member does, we will end your
membership and no benefit or childcover
benefit will be paid.
Replacement cover
If your membership covers more than one
member when we have paid the benefit to
you for one member, or one member has
died (without any benefit coming due), you
may take out a new membership covering
the other member, provided that:
• you tell us that you want to take out the
new membership within three months of
the date we paid the benefit to you
• your membership could have continued
for at least five years after the
commencement date of the new membership
• the member to be covered by the new membership must be under 50 years of
age
• the amount of benefit to be provided by
the new membership is not more than the benefit under your original membership
• the new membership will not continue
beyond the date your original membership would have ended
• the total permanent disability option can
only be included in the new membership if
it was included in your original membership
| 53
How to make a claim
• we accepted your initial application for
cover without increasing the premiums
above our standard rates at that time or
applying any special conditions to your
membership
• the new membership is provided under
the terms and conditions we apply at the
time the new membership is taken out
(excluding any option to increase the
benefit).
For information on replacement cover, please
contact us at:
Friends Life Individual Protection
PO Box 569
Friends Life Centre
Bristol
BS34 9FE
Or telephone us on 0845 600 3122*
* Calls may be recorded and may be monitored
54 |
How to make a claim
Your right to cancellation
| 55
Your right to cancellationYou have the right to cancel the
membership and have any premiums paid
refunded if you cancel within 30 days from
the date you receive your registration
certificate and this handbook.
Confirmation of your request to cancel
should be in writing sent by post to the
contact details below. Please note that if
there are two schemeholders, we will require
both schemeholders’ signatures on any
cancellation correspondence.
Once we have been notified of your request
to cancel (within the 30 days period) we
will refund any premiums that you have paid
to us.
If you wish to cancel your membership at
any other time, please write to us at the
address shown below.
Friends Life Individual Protection
PO Box 569
Friends Life Centre
Bristol
BS34 9FE
Tel: 0845 600 3122*
We will write to you to confirm the
cancellation of your membership.
Please note that outside of the initial 30 day
cancellation period:
• no refund of premiums will be due unless you have paid an annual premium and
you cancel your cover before the next
premium is due, in which case, provided
no claim has been made, we will give you
a pro-rata refund but we will deduct the
discount you would have received in that
year for paying an annual premium, or you
cancel your membership in accordance
with with the section headed ‘Changes to
these terms and conditions’.
Please note that Friends Life Individual
Protection contracts have no surrender value.
56 |
Your right to cancellation
* Calls may be recorded and may be monitored
General information
| 57
General information
Changes to your registration certificate
If we need to change any details on your
registration certificate, or add new details
to it, we will send you a new registration
certificate or an endorsement, providing
the most up to date details of your
membership and will replace any earlier
registration certificate (including any
endorsements on it). Your registration
certificate will show the date on which it
replaced the earlier registration certificate.
Assigning and surrendering your membership
Your membership has no surrender value.
You will not receive any benefit or refund of
premiums when your membership ends.
If you assign your membership, you or the
assignee should provide us with written
notification of this.
Changes to these terms and conditions
a) We reserve the right from time to time by
giving you 60 days notice, so far as it is
practicable to do so, to make such changes
or additions to this membership handbook
as may reasonably be required:
• to reflect any change of law, regulatory
requirement or taxation; or
• because of circumstances outside of our control, which we could not reasonably
have forseen, which either significantly
add to the costs of providing any benefit
or of administering the policy, or which
would make it impractical to provide any
benefit or administer the policy;
• to allow us to provide benefits or
administer your policy more efficiently;
• to change anything which is unclear or
incorrect.
b) We reserve the right, from time to time, to
make changes or additions to this
membership handbook for any
administrative or other reason, which may or
may not have a detrimental effect on you
and which are not set out in a) above. If you
suffer a material detriment as a result of a
change or addition to this membership
handbook under this paragraph b), you may
notify us and you will be free to cancel your
policy. In that case, we will give you a
pro-rata refund of any premium you have
already paid for the period following the date
of cancellation, unless a claim has already
been made under your policy.
Changes to your membership
Only we can make any changes to your
membership (in accordance with our rights
under your membership), confirm any
changes you have asked for or decide not to
enforce any of our rights. Any change to your
membership will come into force only when
confirmed by us in writing.
58 |
General information
| 59
General information
If we ever decide not to enforce our legal
rights, this does not prevent us from
enforcing those rights in the future.
Written communication
We will send any letters to you to the
address you last gave us. If you change
address you must always write and tell us.
If you write to us, you must send that
letter to:
Friends Life Individual Protection
PO Box 569
Friends Life Centre
Bristol
BS34 9FE
If we change this address we will write to
you with details of where you should write
to us.
You and we can assume that a letter has
been received:
• three days after it was sent by first class
post.
Choice of law
Friends Life and you have a free choice
about the law that can apply to a contract.
Friends Life proposes to choose the law of
England and Wales and by entering into this
contract you agree that the law of England
and Wales applies.
Jurisdiction
The Courts of England and Wales have
non-exclusive jurisdiction over any claim,
dispute or difference which may arise out of,
or in connection with, the terms and
conditions of this membership handbook.
Getting in touch
60 |
Getting in touchOur helpline is always the first number to call
if you need help or support or if you have any
comments or complaints. Please call us on
0845 600 3122*.
*Calls may be recorded and may be monitored
Alternatively, you can write to us at:
Friends Life Individual Protection
PO Box 569
Friends Life Centre
Bristol
BS34 9FE
Making a complaint
If you have not been able to resolve a
problem and you wish to take your
complaint further, please write to Customer
Relations at the address above.
It is rare that we cannot settle a complaint,
but if this does happen, you may refer your
complaint to the Financial Ombudsman
Service. You can write to them at:
South Quay Plaza
183 Marsh Wall
London
E14 9SR
www.financial-ombudsman.org.uk
Or call them on their consumer helpline on
0800 023 4567 (calls to this number are
normally free for people ringing from a ‘fixed
line’ phone - but charges may apply if you
call from a mobile phone) or 0300 123 9123
(calls to this number are charged at the
same rate as 01 or 02 numbers on mobile
phone tariffs).
Please let us know if you want a full copy of
our complaints procedure.
If something has gone wrong, we want to do
everything we can to put it right. But none of
these procedures affect your legal rights.
The Financial Services Compensation Scheme (FSCS)
In the unlikely event that we cannot meet
our financial obligations, you may be entitled
to compensation from the Financial Services
Compensation Scheme. This will depend on
the type of business and the circumstances
of your claim. The FSCS may arrange to
transfer your membership to another
insurer, provide a new policy or, where
appropriate, provide compensation.
Further information about compensation
scheme arrangements is available from the
FSCS on 020 7741 4100 or on its website
www.fscs.org.uk
| 61
Getting in touch
Friends Life and Pensions LimitedAn incorporated company limited by shares and registered in England and Wales, number 475201.Registered office: Pixham End, Dorking, Surrey RH4 1QA. Authorised by the Prudential RegulationAuthority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Telephone 0845 600 3122 – calls may be recorded. www.friendslife.co.ukFriends Life is a registered trade mark of the Friends Life group.FL
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For more information, please contact us on:
0845 600 3122†
Friends Life Individual Protection, PO Box 569 Friends Life Centre, Bristol, BS34 9FE
†Calls may be recorded and may be monitored
This document is available in other formats.If you would like a Braille, large print or audio version of this document, please contact us.