Assurance maladie grave

These are the 2013 Critical Illness Benchmark Definitions published by the Canadian Life and Health Insurance Association (CLHIA).  If you are insured under a Special Markets Solutions group critical illness insurance plan, please refer to your Insurance Benefits Summary or booklet wording for the definitions currently in force under your group insurance plan.

 

 

Aortic Surgery

 

Aortic Surgery means the undergoing of surgery for disease of the aorta requiring excision and surgical replacement of any part of the diseased aorta with a graft. Aorta means the thoracic and abdominal aorta but not its branches. The Surgery must be determined to be medically necessary by a Specialist.

 

Exclusion: No benefit will be payable under this condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

 

 

Aplastic Anemia

 

Aplastic Anemia means a definite Diagnosis of a chronic persistent bone marrow failure, confirmed by biopsy, which results in anemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following:

 

• marrow stimulating agents;

• immunosuppressive agents;

• bone marrow transplantation.

 

The Diagnosis of Aplastic Anemia must be made by a Specialist.

 

 

Bacterial Meningitis

 

Bacterial Meningitis means a definite Diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of Diagnosis. The Diagnosis of Bacterial Meningitis must be made by a Specialist.

 

Exclusion: No benefit will be payable under this condition for viral meningitis.

 

 

Benign Brain Tumour

 

Benign Brain Tumour means a definite Diagnosis of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgical or radiation treatment or cause Irreversible objective neurological deficit(s). The Diagnosis of Benign Brain Tumour must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition if, within the first 90 days following the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

 

• signs, symptoms or investigations that lead to a Diagnosis of Benign Brain Tumour (covered or excluded under the Policy), regardless of when the Diagnosis is made; or

• a Diagnosis of Benign Brain Tumour (covered or excluded under the Policy).

 

Medical Information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Benign Brain Tumour or any Critical Illness caused by any Benign Brain Tumour or its treatment.

 

No benefit will be payable under this condition for pituitary adenomas less than 10mm.

 

 

Blindness

 

Blindness means a definite Diagnosis of the total and Irreversible loss of vision in both eyes, evidenced by:

 

• the corrected visual acuity being 20/200 or less in both eyes; or

• the field of vision being less than 20 degrees in both eyes.

 

The Diagnosis of Blindness must be made by a Specialist.

 

 

Cancer (Life-Threatening)

 

Cancer (Life-Threatening) means a definite Diagnosis of a tumour, which must be characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Types of cancer include carcinoma, melanoma, leukemia, lymphoma, and sarcoma. The Diagnosis of Cancer (Life Threatening) must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition if, within the first 90 days following the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

 

• signs, symptoms or investigations that lead to a Diagnosis of cancer (covered or excluded under the Policy), regardless of when the Diagnosis is made; or

• a Diagnosis of cancer (covered or excluded under the Policy).

 

Medical Information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Cancer (Life Threatening) or any Critical Illness caused by any cancer or its treatment.

 

No benefit will be payable for the following:

 

• lesions described as benign, pre-malignant, uncertain, borderline, non-invasive, carcinoma in-situ (Tis), or tumours classified as Ta;

• malignant melanoma skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;

• any non-melanoma skin cancer, without lymph node or distant metastasis;

• prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;

• papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis;

• chronic lymphocytic leukemia classified less than Rai stage 1; or

• malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than AJCC Stage 2.

 

For purposes of the Policy, the terms Tis, Ta, T1a, T1b, T1 and AJCC Stage 2 are to be applied as defined in the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th Edition, 2010.

 

For purposes of the Policy, the term Rai staging is to be applied as set out in KR Rai, A Sawitsky, EP Cronkite, AD Chanana, RN Levy and BS Pasternack: Clinical staging of chronic lymphocytic leukemia. Blood 46:219, 1975.

 

 

Coma

 

Coma means a definite Diagnosis of a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least 96 hours, and for which period the Glasgow coma score must be 4 or less. The Diagnosis of Coma must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for:

 

• a medically induced coma; or

• a coma which results directly from alcohol or drug use; or

• a diagnosis of brain death.

 

 

Coronary Artery Bypass Surgery

 

Coronary Artery Bypass Surgery means the undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s). The Surgery must be determined to be medically necessary by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

 

 

Deafness

 

Deafness means a definite Diagnosis of the total and Irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The Diagnosis of Deafness must be made by a Specialist.

 

 

Dementia, including Alzheimer’s Disease

 

Dementia, including Alzheimer’s Disease means a definite Diagnosis of dementia, which must be characterized by a progressive deterioration of memory and at least one of the following areas of cognitive function:

 

• aphasia (a disorder of speech)

• aphraxia (difficulty performing familiar tasks);

• agnosia (difficulty recognizing objects); or

• disturbance in executive functioning (e.g. inability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior), which is affecting daily life.

 

The Insured Employee must exhibit

 

• Dementia of at least moderate severity, which must be evidenced by a Mini Mental State Exam of 20/30 or less, or equivalent score on another generally medically accepted test or tests of cognitive function; and

• Evidence of progressive worsening in cognitive and daily functioning either by serial cognitive tests or by history over at least a 6 month period.

 

The Diagnosis of Dementia, including Alzheimer’s Disease must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for affective or schizophrenic disorders, or delirium.

 

For purposes of the Policy, reference to the Mini Mental State Exam is to Folstein MF, Folstein SE, McHugh PR, J Psychiatr Res. 1975;12(3):189.

 

 

Heart Attack

 

Heart Attack means a definite Diagnosis of the death of heart muscle due to obstruction of blood flow, that results in a rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:

 

• heart attack symptoms

• new electrocardiogram (ECG) changes consistent with a heart attack

• development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.

 

The Diagnosis of Heart Attack must be made by a Specialist.

 

Exclusions: No benefit will be payable under this covered condition for:

 

• elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or

• ECG changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition as described above.

 

 

Heart Valve Replacement or Repair

 

Heart Valve Replacement or Repair means the undergoing of Surgery to replace any heart valve with either a natural or mechanical valve or to repair heart valve defects or abnormalities. The Surgery must be determined to be medically necessary by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for angioplasty, inter-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

 

Kidney Failure

Kidney Failure means a definite Diagnosis of chronic Irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated. The Diagnosis of Kidney Failure must be made by a Specialist.

 

Loss of Independent Existence

Loss of Independent Existence means a definite Diagnosis of the total inability to perform, by oneself, at least 2 of the following 6 Activities of Daily Living for a continuous period of at least 90 days with no reasonable chance of recovery. The Diagnosis of Loss of Independent Existence must be made by a Specialist.

 

Activities of Daily Living are:

 

bathing – the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of assistive devices;

dressing – the ability to put on and remove necessary clothing, braces, artificial limbs or other surgical appliances with or without the aid of assistive devices;

toileting – the ability to get on and off the toilet and maintain personal hygiene with or without the aid of assistive devices;

bladder and bowel continence – the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained;

transferring – the ability to move in and out of a bed, chair or wheelchair, with or without the aid of assistive devices; and

feeding – the ability to consume food or drink that already has been prepared and made available, with or without the use of assistive devices.

Loss of Limbs

Loss of Limbs means a definite Diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation. The Diagnosis of Loss of Limbs must be made by a Specialist.

 

Loss of Speech

Loss of Speech means a definite Diagnosis of the total and Irreversible loss of the ability to speak as a result of physical injury or disease, for a period of at least 180 days. The Diagnosis of Loss of Speech must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for all psychiatric related causes.

 

Major Organ Failure on Waiting List

Major Organ Failure on Waiting List means a definite Diagnosis of the Irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under Major Organ Failure on Waiting List, the Insured Employee must become enrolled as the recipient in a recognized transplant center in Canada or the United States of America that performs the required form of transplant Surgery. For the purpose of the Survival Period, the Date of Diagnosis is the date of the Insured Employee’s enrolment in the transplant centre. The Diagnosis of the major organ failure must be made by a Specialist.

 

Major Organ Transplant

Major Organ Transplant means a definite Diagnosis of the Irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under Major Organ Transplant, the Insured Person must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The Diagnosis of the major organ failure must be made by a Specialist.

 

Motor Neuron Disease

Motor Neuron Disease means a definite Diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy, or pseudo bulbar palsy, and limited to these conditions. The Diagnosis of Motor Neuron Disease must be made by a Specialist.

 

Multiple Sclerosis

Multiple Sclerosis means a definite Diagnosis of one of the following:

 

two or more separate clinical attacks, confirmed by a magnetic resonance imaging (MRI) of the nervous system, showing multiple lesions of demyelination; or,

well-defined neurological abnormalities lasting more than 6 months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination; or,

a single attack, confirmed by repeated MRI imaging of the nervous system, which shows multiple lesions of demyelination which have developed at intervals at least one month apart.

The Diagnosis of Multiple Sclerosis must be made by a Specialist.

 

Occupational HIV Infection

Occupational HIV Infection means a definite Diagnosis of infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the Insured Person’s normal occupation, which exposed the person to HIV contaminated body fluids.

 

The accidental injury leading to the infection must have occurred after the later of the Issue Date or latest Reinstatement Date of such Insured Person’s coverage.

 

Payment under this condition requires satisfaction of all of the following:

 

a) The accidental injury must be reported to the Company within 14 days of the accidental injury;

 

b) A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative;

 

c) A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;

 

d) All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America;

 

e) The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines.

 

The Diagnosis of Occupational HIV Infection must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition if:

 

the Insured Person has elected not to take any available licensed vaccine offering protection against HIV; or,

a licensed cure for HIV infection has become available prior to the accidental injury; or

HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

Paralysis

Paralysis means a definite Diagnosis of the total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event. The Diagnosis of Paralysis must be made by a Specialist.

 

Parkinson’s Disease and Specified Atypical Parkinsonian Disorders

Parkinson’s Disease and Specified Atypical Parkinsonian Disorders means a definite Diagnosis of either a) Parkinson’s Disease or b) Specified Atypical Parkinsonian Disorders, as defined below.

 

a) Parkinson’s Disease means a definite Diagnosis of primary Parkinson’s disease, a permanent neurological condition which must be characterized by bradykinesia (slowness of movement) and at least one of the following: muscular rigidity or rest tremor. The Insured Person must exhibit objective signs of progressive deterioration in function for at least one year, for which the treating neurologist has recommended dopaminergic medication or other generally medically accepted equivalent treatment for Parkinson’s Disease.

 

b) Specified Atypical Parkinson’s Disorders means a definite Diagnosis of progressive supranuclear palsy, corticobasal degeneration, or multiple system atrophy.

 

The Diagnosis of Parkinson’s Disease or a Specified Atypical Parkinsonian Disorder must be made by a Specialist.

 

Exclusions: No benefit will be payable for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders if, within the first year following the later of the Issue Date or the latest Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

 

signs, symptoms or investigations that lead to a Diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of parkinsonism, regardless of when the Diagnosis is made; or

a Diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of Parkinsonism.

Medical information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or its treatment.

 

No benefit will be payable under Parkinson’s Disease and Specified Atypical Parkinsonian Disorders for any other type of Parkinsonism.

 

Severe Burns

Severe Burns means a definite Diagnosis of third-degree burns over at least 20% of the body surface. The Diagnosis of Severe Burns must be made by a Specialist.

 

Stroke

Stroke (Cerebrovascular Accident) means a definite Diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with:

 

acute onset of new neurological symptoms, and

new objective neurological deficits on clinical examination,

persisting for more than 30 days following the Date of Diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing. The Diagnosis of Stroke must be made by a Specialist.

 

Exclusion: No benefit will be payable under this covered condition for:

 

Transient Ischaemic Attacks; or

Intracerebral vascular events due to trauma; or

Lacunar infarcts which do not meet the definition of stroke as described above.

 

AdvanceCare Benefit Conditions

“AdvanceCare Benefit Conditions” are medical conditions for which an AdvanceCare Benefit is paid under the Group Policy with respect to an Insured Employee or Insured Spouse. These are coronary angioplasty or Early Stage Cancer as defined in this document.

 

Coronary angioplasty means the undergoing of an interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood.

 

The procedure must be determined to be medically necessary by a Specialist.

 

“Early Stage Cancer” refers to one of the following conditions:

 

malignant melanoma skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;

any non-melanoma skin cancer, without lymph node or distant metastasis;

prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;

papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis;

chronic lymphocytic leukemia classified less than Rai stage 1;

malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than AJCC Stage 2; or

Ductal Carcinoma in situ of the Breast

The Diagnosis of an Early Stage Cancer must be made by a Specialist.