Limitations and Restrictions (Accimum)
- An insured age 65 or older on the date of the accident is only eligible for 50% of the amounts indicated in the TABLE OF BENEFITS.
- If, following an accident, an insured has incurred more than one of the losses set out in the TABLE OF BENEFITS, the insurer shall only pay a benefit for one loss. The benefit paid shall correspond to the highest amount set out in the TABLE OF BENEFITS for said loss.
If, following an accident, an insured:
- has incurred more than one of the losses set out in the TABLE OF BENEFITS; and
- dies as a result of the accident in the 365 days immediately following the accident, the insurer shall only pay the benefit stipulated for accidental death in the TABLE OF BENEFITS.
- This policy does not provide for any benefit while an insured is in a coma.
- In the event of death from natural causes, no benefit shall be payable if the death occurs in the 12 months following the effective date of the policy and is the result of suicide or an illness for which the insured was treated in the 6 months preceding the effective date. In such a case, the insurer shall reimburse the insured for premiums paid since the effective date of the contract. These conditions also apply during the 12 months following any increase to the amount of benefits under the contract, if such increase is requested by the contractholder, and following any reinstatement of the contract following its termination.
Restrictions and exclusions
The insurer shall not pay any benefits in the following cases:
- The accident is a direct or indirect result of voluntarily self-inflicted injuries, suicide or attempted suicide, whether or not the insured is of sound mind.
- The accident is a result of the participation of the insured in a criminal act, including driving a motor vehicle while under the influence of drugs or alcohol in excess of the legal limit. A vehicle, whether moving or stationary, is defined as any means of transportation by land, air or water moved by any force, including muscular force.
- The accident is a result of a physical or mental illness, a medical or surgical treatment, anesthesia or an infection other than an infection caused by an injury sustained during the accident.
- The accident is a result of a military operation, a revolution, an act of terrorism, war, whether declared or undeclared, a riot or an insurrection.
- The accident is a result of injuries that produced no visible wounds or contusions on the surface of the body, except in the case of accidental drowning.
- The accident is a direct or indirect result of the abusive consumption of medication, drugs or narcotics, or gas inhalation, whether voluntary or not.
- The accident is the result of the insured's participation in a flight, other than as a regular passenger on a regularly scheduled flight operated by a public carrier, or the participation of the insured in a dangerous sport such as scuba diving, hang-gliding, skydiving, free falling, mountaineering or climbing.
- The accident is the result of the participation of the insured in a sporting activity for which he or she is compensated, his or her participation in a motor vehicle competition, or in training for such a competition.
- The expenses are incurred more than 104 weeks following the accident.
- The care or services were administered by a relative of the insured or policyholder.
- The loss resulting from said injury occurs more than 365 days following the date of the accident. However, this exclusion does not apply if the insured is in a comatose state at the end of this period. In such a case, the insurer determines the benefits payable, if applicable, at the end of the coma.
Coordination of benefits
If an insured is covered by several insurance policies (private or public), the total amount of benefits receivable cannot exceed expenses actually incurred.
If an insured is covered by one or more plans that do not include coordination of benefits with other plans, the insured must be reimbursed by these other plans first. The insurer's responsibility is limited to the portion of the expenses that are not reimbursed by the other plans.
If the other plans include coordination of benefits, benefits are paid proportionally between these plans and that of the insurer, in accordance with the amounts that should have been paid by each insurance plan.
If the insured is covered under more than one Accimum contract, the insurer shall only pay one benefit per covered loss, i.e. the highest benefit from among all such policies.