clinical claims definitions: medical impairment standard
TRANSCRIPT
Cancer
11
13
12
Activities of Daily Living14
Clinical claims definitions: Medical Impairment Standard
BrightRock has worked in partnership with international clinical and risk experts to ensure our clinical claims criteria are objective, transparent and industry-leading. To give you and your clients peace of mind that our claims definitions are comprehensive and clinically objective, we provide a full list of our claims definitions and criteria, divided by body system.
This document applies to your permanent expenses cover for the following needs:
Cover for illness or injury with a financial impact
Additional expense needs
BrightRock Life Ltd, an authorised financial services provider and registered insurer (FSP 11643, Registration number: 1996/014618/06). Sanlam Life Insurance Ltd, an authorised financial services provider and registered insurer (FSP 2759, Registration number: 1998/021121/06). Copyright ©November 2019 BrightRock. All rights reserved. Terms and conditions apply. Document number: 30000007648.
Please note: In this document, we’ve provided our clinical claims definitions accompanied with explanatory text for ease of understanding. The information provided in the columns labelled with the words “layman’s explanation” is provided purely for information purposes. If there is any uncertainty or ambiguity, then the wording provided under the column labelled “BrightRock clinical definitions” will prevail.
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Refractory pancytopaenia resulting from an irreversible, treatment-resistant disorder with any two of the following: 1. Persistent haemoglobin levels of ≤ 8g/dl OR 2. Neutropenia of < 1x109 WBC/l OR 3. Thrombocytopenia of < 100x109/l
Pancytopaenia (a lack of all types of blood cells) that persists as a results of an irreversible disorder that doesn’t respond to treatment and occurs with any two of the following:
1. Persistent haemoglobin levels of 8g/dl or less (haemoglobin is the oxygen-carrying protein in red blood cells) OR 2. Neutropenia (a lack of white blood cells) of 1x109 WBC/l or less OR 3. Thrombocytopenia (a lack of platelets) of 100x109/l or less
100%
Total % pay-out
Cancer
11
13
14
12
Medically certified institutionalisation for a mental and behavioural disorder1 of more than six months continuously
Medically certified admission to a recognised mental health facility for a mental or behavioural1 problem
For more than six months at a time 100%
Confirmed diagnosis of schizophrenia1 with evidence of all of the following criteria in the last year: 1. Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND 2. Admission to a psychiatric in-patient facility for three months or longer in total
Confirmed diagnosis of schizophrenia With evidence of the following in the last year 1. Consistent taking of psychotropic medication (which treats the psychiatric disorder), as prescribed by a psychiatrist AND 2. Admission to a psychiatric hospital or clinic for at least three months at a time
100%
Documented treatment-resistant mental and behavioural disorder1 with evidence of all of the following criteria in the last two years: 1. Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND 2. Admission to a psychiatric in-patient facility for four weeks or longer in total AND 3. A full course of ECT
Documented mental and behavioural disorder1 that doesn’t respond to treatment
With evidence of all of the following in the last two years: 1. Consistent taking of psychotropic medication (which affects the mental state), as prescribed by a psychiatrist AND 2. Admission to a psychiatric hospital or clinic for at least four weeks AND 3. A full course of ECT (electroconvulsive or shock therapy)
100%
Documented treatment-resistant mental and behavioural disorder1 with evidence of all of the following criteria in the last year: 1. Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND 2. Admission to a psychiatric in-patient facility for 12 weeks or longer in total AND 3. A full course of ECT
Documented mental and behavioural disorder1 that doesn’t respond to treatment
With evidence of all of the following in the last year: 1. Consistent taking of psychotropic medication (which treats the psychiatric disorder), as prescribed by a psychiatrist AND 2. Admission to a psychiatric hospital or clinic for at least 12 weeks AND 3. A full course of ECT (electroconvulsive or shock therapy)
100%
Total % pay-out
Cancer
11
13
14
12
Medical Impairment Standard Definition sets B(V7.0), C(V7.0), D(V6.0)
1. Documented treatment-resistant generalised epilepsy5 of at least three months’ duration (despite optimal treatment and patient compliance), with more than two seizures per week AND 2. Documented neurological deficit as a result of the epilepsy, defined as two or more of the following permanent (of more than six months’ duration) findings: • Motor deficit (power < 3/5) • Cognitive deficit (MMSE < 19/30) • Speech deficit and/or visual/hearing deficit, all confirmed by a neurologist
Epilepsy 1. Documented generalised epilepsy5 of two fits per week for at least three months. The fits do not respond to treatment, despite taking the right medicine as prescribed by the treating doctor AND 2. Documented permanent damage to the nervous system, caused by the epilepsy and exhibiting two or more of the following for at least six months (confirmed by a neurologist): • Impaired muscle power measurement of less than 3 out of 5 • Impaired cognitive skills (the ability to think, remember and judge clearly) with a Mini-Mental State Examination (MMSE) score of less than 19 out of 30 • Impaired speech, vision and/or hearing, all confirmed by a neurologist
100%
Non-traumatic organic cognitive disorder (excluding psychological disorders) resulting in irreversible cognitive impairment2 as evidenced by Mini Mental State Examinations (MMSE) < 19/30
Cognitive disorder Any condition affecting cognitive function (the brain’s capacity to think, remember and judge clearly) that is not due to physical injury (but that excludes psychological disorders). The condition also leads to permanent cognitive impairment2 with a Mini-Mental State Examination (MMSE) score of less than 19 out of 30
100%
Vestibular dysfunction3 presenting with attacks of nausea, vomiting, vertigo and dizziness with at least 10 episodes per month resulting from brainstem causes including: 1. Vascular lesions OR 2. Tumours of the cerebellum or fourth ventricle OR 3. Demyelination disorders
Neurological vestibular (balance) disorder Results in attacks of nausea, vomiting, dizziness and vertigo (a sense of falling), with at least 10 episodes per month due to problems in the base of the brain, including: 1. Disease of the blood vessels OR 2. Tumours of the cerebellum or fourth ventricle of the brain OR 3. Demyelination disorders (caused loss of the insulating sheath around nerves)
100%
Central respiratory failure (a life-threatening problem with breathing due to damage to the parts of the brain that control breathing)
Confirmed permanent central respiratory failure, with the need for a life support system
100%
Total % pay-out
Cancer
11
13
14
12
The irreversible loss of language comprehension and production6 resulting from damage to the portions of the brain responsible for language
Aphasia/dysphasia (communication disorders)
Permanent loss of the ability to understand, produce and/or use words6, caused by damage to the parts of the brain that are responsible for language
100%
Documented treatment-resistant sleep disorder7 (excluding sleep apnoea) resulting in abnormal sleep cycles and sustained cognitive impairment as evidenced by MMSE of less than 24/30
Sleep disorders A documented sleep disorder7 (excluding sleep apnoea) that does not respond to treatment. The disorder is characterised by abnormal sleep cycles and reduced mental functioning, evidenced by a Mini-Mental State Examination (MMSE) of less than 24 of a possible 30
100%
Disorders of cranial nerve VIII (the vestibulocochlear nerve)
Permanent vestibulocochlear nerve palsy4 (paralysis) on one side, causing hearing-loss and vestibular dysfunction (balance disorder) resulting in attacks of nausea, vomiting, dizziness and vertigo (a sense of falling)
100%
Irreversible bulbar palsy4 as a result of bilateral impairment of function of cranial nerves V, IX, X and XII that presents with loss of facial sensation including dysarthria, dysphagia, dysphonia, regurgitation and/or aspiration
Bulbar palsy (paralysis of the lower cranial nerves, which arise from the brain itself)
Impaired function of cranial nerves V, IX, X and XII that leads to permanent bulbar palsy4 (paralysis) on both sides, and includes loss of facial sensation, dysarthria (the inability to speak clearly), dysphagia (difficulty swallowing), dysphonia (impaired voice sound production), regurgitation and/or aspiration (inhaling stomach contents)
100%
Irreversible cerebellum dysfunction4 resulting in the inability to stand without assistive devices
Disorders of the cerebellum (part of the brain responsible for coordination and balance)
Permanent cerebellar dysfunction4 causing an inability to stand without a cane or other supportive device
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Confirmed diagnosis of any stage 4 cancer, including any cancer classified by SCIDEP as level A. Includes: 1. Acute myeloid leukaemia; 2. Chronic lymphocytic leukaemia, stage 3 or 4 on the
Rai classification, or Binet C; 3. Chronic myeloid leukaemia (requiring bone marrow
transplant); 4. Acute lymphocytic leukaemia (adults); 5. Hodgkin’s/non-Hodgkin’s lymphoma stage 4 on Ann
Arbor classification system; 6. Multiple myeloma stage 3 on the Durie- Salmon
scale; 7. WHO grade 3 or 4 brain tumour.
Any stage 4 cancer (includes any cancer classified by SCIDEP as level A)
Includes: 1. Acute myeloid leukaemia (a type of cancer
characterised by an overproduction of immature white blood cells, called myeloblasts);
2. Chronic lymphocytic leukaemia (a type of slow growing leukaemia that affects developing white blood cells called B-lymphocytes), stage 3 or 4 on the Rai classification, or Binet C;
3. Chronic myeloid leukaemia (a cancer where the bone marrow produces too many white cells called granulocytes) requiring bone marrow transplant;
4. Acute lymphocytic leukaemia in adults (a type of cancer characterised by an overproduction of immature white blood cells called lymphoblasts);
5. Hodgkin’s/non-Hodgkin’s lymphoma (cancerous tumour of the lymph nodes) stage 4 on Ann Arbor classification system;
6. Multiple myeloma (a cancer that forms in a type of white blood cell called a plasma cell) stage 3 on the Durie-Salmon scale;
7. Brain tumour that is considered WHO (World Health Organisation) grade 3 or 4
100%
Confirmed diagnosis of any stage 3 cancer or WHO grade 2 brain tumour (including any cancer that is classified by SCIDEP as level B such as Hodgkin’s or non-Hodgkin’s lymphoma stage 3 on the Ann Arbor classification system) for which the insured life has undergone continuous cancer treatment for a perod of 12 months or longer. This specifically excludes anti- hormonal treatments.
Any stage 3 cancer or WHO grade 2 brain tumour (includes any cancer classified by SCIDEP as level B such as Hodgkin’s or non- Hodgkin’s lymphoma stage 3 on the Ann Arbor classification system) that:
1. Has undergone continuous cancer treatment for 12 months or longer AND
2. Excludes anti-hormonal treatments
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Chronic gastrointestinal tract and/or liver and/or biliary disorders1 resulting in: 1. Unintentional treatment-resistant weight-loss of at least 25% over a 5 month period OR 2. Unintentional treatment-resistant weight-loss resulting in a BMI of less than 16
Digestive disorders, defined as: Chronic gastrointestinal tract and/or liver and/ or biliary (relating to bile, the bile ducts or the gallbladder) disorders1 resulting in: 1. Unintentional weight-loss of at least 25% that
doesn’t respond to treatment in five months OR
2. Unintentional weight-loss that doesn’t respond to treatment and that leads to a Body Mass Index (BMI) below 16
100%
Chronic irreversible liver disease1 with at least two of the following: 1. Serum bilirubin > 51µmol/l 2. Serum albumin < 30g/dl 3. Prolonged prothrombin time of > 6 seconds or INR > 2.3 4. Ascites requiring ongoing surgical drainage 5. Hepatic encephalopathy
Digestive disorders, defined as: Chronic, permanent liver disease1 with at least two of the following: 1. Serum bilirubin levels of more than 51µmol/l
(bilirubin is a bile pigment formed in the liver) 2. Serum albumin levels lower than 30g/dl
(albumin is a protein that’s produced by the liver and circulates in the blood)
3. Prolonged prothrombin time (how long it takes for blood to clot) of more than 6 seconds, or an international normalised ratio (INR) of more than 2.3 seconds (INR is a standardised version of the prothrombin time)
4. Ascites (free fluid in the abdominal cavity) that needs ongoing draining through surgery
5. Hepatic encephalopathy (a state of mental confusion caused by liver failure)
100%
Confirmed diagnosis of chronic irreversible liver failure¹ confirmed by a gastroenterologist (PLUS inclusion on a recognised transplant list) with one of the following: 1. Serum bilirubin more than 51 μmol/l 2. Serum albumin lower than 30g/dl 3. Prolonged prothrombin time of more than six
seconds or INR more than 2.3 4. Ascites requiring ongoing surgical drainage 5. Hepatic encephalopathy
Digestive disorders, defined as: Chronic, permanent liver failure¹ (PLUS inclusion on a recognised transplant list) with one of the following: 1. Serum bilirubin levels of more than 51μmol/l
(bilirubin is a bile pigment formed in the liver) 2. Serum albumin levels lower than 30g/dl
(albumin is a protein that’s produced by the liver and circulates in the blood)
3. Prolonged prothrombin time (how long it takes for blood to clot) of more than six seconds, or an international normalised ratio (INR) of more than 2.3 seconds (INR is a standardised version of the prothrombin time)
4. Ascites (free fluid in the abdominal cavity) that needs ongoing draining through surgery
5. Hepatic encephalopathy (a state of mental confusion caused by liver failure)
1 2
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
100%
Irreversible biliary tract obstruction1 with clinical evidence of cholestasis in the form of: 1. Ascending cholangitis 2. Jaundice AND 3. Deranged liver enzymes (a two-fold increase or more)
Digestive disorders, defined as: Permanent blockage in the biliary tract1, which transports bile from the liver to the small intestine, with clinical evidence of cholestasis (blocked bile ducts) in the form of: 1. Ascending cholangitis (inflammation of the biliary tract) 2. Jaundice (a condition involving yellowing of the skin and eyes caused by a build-up of pigment usually due to liver or bile duct problems) AND 3. At least a two-fold increase in liver enzymes
100%
Irreversible total dysphagia1 that has: 1. Resulted from organic disease AND 2. Undergone more than one surgical and/ or radiotherapeutic intervention
Digestive disorders, defined as: Permanent dysphagia1 (difficulty swallowing): 1. Caused by an organic disease (any condition that’s been confirmed by physical examination, lab tests or other diagnostic studies) AND 2. That’s undergone more than one operation and/or received radiation treatment
100%
Irreversible faecal incontinence1 treated by permanent colostomy
Digestive disorders, defined as: Permanent faecal incontinence1 (loss of bowel control) treated by permanent colostomy (surgery that brings the end of the large intestine out through an opening in the abdominal wall)
100%
Irreparable abdominal or inguinal hernia (where surgery is now contraindicated1) with documented persistent malabsorption syndrome resulting from previous bowel loss
Digestive disorders, defined as: 1. Irreparable abdominal or inguinal (groin) hernia, where surgery is not advised1 AND 2. Documented persistent malabsorption syndrome (a problem absorbing nutrients from food) that has been caused by previous bowel loss
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Any recognised cardiovascular or cardio-pulmonary disorder1 that results in the following cardiovascular assessments: 1. New York Heart Association Functional Classification (NYHA) III/IV AND 2. Permanent Ejection Fraction (EF) < 35% OR 3. Metabolic Equivalents (METS) < 2
Any recognised heart, circulation and/ or lung disorder1 that meet the following severity criteria:
1. A New York Heart Association Functional Classification (NYHA) of III or IV AND
3. Metabolic Equivalents (METS) of less than 2 (METS is a measure of the energy you burn and oxygen you use during exercise)
100%
Chronic peripheral arterial insufficiency (also known as ischaemia) presenting with: 1. No palpable pulses AND 2. Doppler readings of Ankle Brachial systolic pressure Index (ABI) ≤ 0.5 AND 3. Rest pain OR 4. Ulceration OR 5. Gangrene with or without amputation
Chronic peripheral arterial insufficiency or ischaemia (due to blockages in blood vessels to the upper and lower limbs) that leads to:
1. No pulse felt on physical examination) AND 2. Doppler readings of an Ankle Brachial Pressure Index (ABI) of 0.5 or less (a test that measures the difference in blood pressure between the arteries of your arm and ankle) AND 3. Pain in the limb when resting OR 4. Vascular ulcers (loss of skin) OR 5. Gangrene (tissue death) with or without complete surgical removal (amputation)
100%
* *
2. Permanent Ejection Fraction (EF) of less than 35% (the permanent ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction) OR
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Documented treatment-resistant hypertension2 complicated by at least two of the following: 1. Chronic kidney disease (CKD) stage 4 or 5, with an estimated glomerular filtration rate (eGFR) of < 30ml/min OR 2. Radiological evidence of a stroke (CVA) OR 3. Grade III or IV hypertensive retinopathy OR 4. Documented left ventricular hypertrophy (septal wall thickness to posterior LV wall thickness of 1:1.3 on ECHO) OR 5. Congestive cardiac failure (CCF) defined as: • New York Heart Association Functional Classification (NYHA) II AND • Permanent Ejection Fraction (EF) < 45% OR • Metabolic Equivalents (METS) 2 - 5
Documented high blood pressure2 that doesn’t respond to treatment and is complicated by at least two of the following:
1. Advanced and severe chronic kidney disease (CKD) of stage 4 or 5, with an estimated glomerular filtration rate (eGFR) of less than 30ml/min (eGFR is an indication of overall kidney function) OR
2. Evidence of a stroke on any brain scan OR 3. Grade III or IV hypertensive retinopathy (significant damage to the retina of the eye) OR 4. Thickening or increased size of the muscle wall of the heart’s left ventricle measured as 1:13 on a heart sonogram (ECHO) OR 5. Congestive cardiac failure (CCF) defined as: • New York Heart Association Functional Classification (NYHA) II AND • Permanent Ejection Fraction (EF) of less than
45% (the permanent ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction) OR
• Metabolic Equivalents (METS) of 2 to 5 (METS is a measure of the energy you burn and oxygen you use during exercise)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Advanced AIDS1, confirmed by: 1. A positive HIV antibody test AND 2. A current CD4 cell count of less than 200, despite optimal anti-retroviral combination therapy AND 3. A confirmed diagnosis of at least one of the following diseases: • Kaposi’s sarcoma • Pneumocystis carinii pneumonia • Progressive multifocal leukoencephalopathy • Extrapulmonary or MDRD/XDR pulmonary tuberculosis • Pulmonary cryptococcus
Advanced AIDS, confirmed by: 1. A positive HIV antibody test AND 2. A current CD4 cell count of less than 200, even with optimal anti-retroviral medication AND 3. Confirmed diagnosis of at least one of the following conditions: • Kaposi’s sarcoma (a cancer that causes lesions in the skin or internal organs ) • Pneumocystis carinii pneumonia (an infection of the lungs caused by a fungus) • Progressive multifocal leukoencephalopathy (a viral infection that causes progressive damage to the white matter of the brain) • Extrapulmonary tuberculosis (TB infection in organs other than the lungs), multidrug resistant pulmonary tuberculosis (MDR-TB), or extensively drug-resistant pulmonary tuberculosis (XDR-TB) - the latter two refer to TB infection in the lungs that doesn’t respond to standard TB treatment • Pulmonary cryptococcus (a fungal infection of the lungs)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Signs of established endocrine disorders1, including documented diabetes mellitus type 1 or 2, complicated by at least two of the following: 1. Chronic kidney disease (CKD) stage 3B with an estimated glomerular filtration rate (eGFR) of 30 to 44ml/min OR 2. Radiological evidence of a stroke (CVA) OR 3. Grade III diabetic retinopathy OR 4. Coronary artery disease which has undergone coronary artery bypass
Established endocrine disorder (problems with hormone-secreting glands)1
Documented type 1 or 2 diabetes, complicated by at least two of the following: 1. Chronic kidney disease (CKD) stage 3B, with an estimated glomerular filtration rate (eGFR, an indication of overall kidney function) of 30 to 44ml/min OR 2. Evidence of a stroke (cerebrovascular accident or CVA) on a scan OR 3. Grade III diabetic retinopathy (damage to the retina in the eye) OR 4. Coronary artery disease (disease of the heart’s blood vessels) that has undergone a coronary artery bypass
100%
Documented diabetes mellitus type 1 or 2 complicated by: • Grade IV or V diabetic retinopathy
Documented type 1 or 2 diabetes complicated by:
Grade IV or V diabetic retinopathy (damage to the retina of the eye)
100%
Cushing’s syndrome as evidenced by at least two of the following: 1. Documented profound proximal myopathy resulting in the permanent use of assistive devices
OR 2. New-onset persistent diabetes mellitus diagnosed after the diagnosis of Cushing’s syndrome and requiring ongoing insulin OR 3. Refractory hypertension (blood pressure > 140/90
in four or more separate readings taken at least two months apart within the last 12 months) and with newly diagnosed ischaemic heart disease
(angina, MI, stent or CABG) OR 4. Newly diagnosed psychotic disorder treated with continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)
Cushing’s syndrome (a condition caused by high levels of cortisol in the blood), evidenced by at least two of the following:
1. Documented serious proximal myopathy (weakness and wasting of the limb muscles closest to the body) leading to the permanent use of walking or supporting aids OR 2. New-onset, persistent diabetes mellitus that is diagnosed after the Cushing’s syndrome and requires ongoing insulin treatment OR 3. Refractory hypertension (high blood pressure that does not respond to treatment), with levels higher than 140/90 in four or more separate readings taken at least two months apart within the last 12 months AND with newly diagnosed ischaemic heart disease (reduced blood flow to the heart), in the form of angina, a heart attack, a stent or Coronary Artery Bypass Graft procedure (CABG) OR 4. New-onset psychotic disorder needing continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Refractory syndrome of inappropriate antidiuretic hormone secretion (SIADH) with: 1. Na+ < 130mmol/l AND 2. No evidence of hypovolaemia AND 3. Normal blood pressure, pulse and serum
urea:creatinine ratio demonstrated by two or more readings taken at least two months apart within the last six months) AND
4. As a result of any of the following: • Small cell lung cancer • Mesothelioma • GI tract malignancy • Pancreatic malignancy • Asbestosis • Progressive multiple sclerosis
Syndrome of inappropriate antidiuretic hormone secretion (SIADH), a problem with the secretion of the antidiuretic hormone
With evidence of the following: 1. Sodium (Na+) level of less than 130mmol/l AND 3. No evidence of hypovolaemia (reduced blood volume) AND 4. Normal blood pressure, pulse and serum urea:creatinine ratio shown by two or more readings taken at least two months apart within the last six months AND 5. Caused by any of the following: • Small cell lung cancer OR • Mesothelioma (cancer of the tissue that lines the chest, abdomen or around the heart) OR • Cancer of the gastrointestinal tract • Cancer of the pancreas • Asbestosis (a lung condition caused by inhaling asbestos fibres) • Progressive multiple sclerosis (a condition involving increasing damage to the nerves in the brain and spinal cord and affecting all body functions)
100%
Refractory hypocalcaemia resulting from parathyroid disorders with evidence of the following: Chronic hypocalcaemia (serum calcium < 2.3mmol/l, as evidenced by three or more separate readings taken at least two months apart within the last six months) and with any of the following: • New-onset seizure disorder on permanent
anti-convulsant medication (diagnosed and treated by a neurologist) OR • Raised intracranial pressure necessitating surgical intervention OR • Refractory new-onset prolonged QT interval on ECG OR • Osteomalacia OR • New-onset psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)
Refractory hypocalcaemia (a lack of calcium that doesn’t respond to treatment) caused by disorders of the parathyroid glands and with evidence of the following:
Chronic hypocalcaemia (too little calcium), with levels below 2.3mmol/l in three or more separate tests taken at least two months apart within the last six months. These results must be accompanied by any of the following: • Newly-diagnosed seizure disorder that requires permanent anti-seizure medication (diagnosed and treated by a neurologist) OR • Raised intracranial pressure (increased pressure within the brain) that requires surgical correction OR • New-onset prolonged QT interval (a conduction disturbance in the heart) that’s seen on an electrocardiogram (ECG) and doesn’t respond to treatment OR • Osteomalacia a (bone disorder that leads to bone softening) OR • Newly-diagnosed psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Refractory hypercalcaemia resulting from parathyroid disorders with evidence of the following: Chronic hypercalcaemia (serum calcium ≥ 3.0mmol/l as evidenced by three or more separate readings, following correction for serum albumin, taken at least two months apart within the last six months) and with any of the following: • Chronic pancreatitis OR • New-onset irreversible dementia (confirmed by MMSE of < 24/30 on three separate tests at least three months apart over the preceding 12 months, and diagnosed and treated by a psychiatrist) OR • New-onset psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist) OR • Unintentional treatment resistant weight-loss of at
least 15% in a three month period, or unintentional weight-loss resulting in a BMI of < 18 within the last year OR
• Cardiac arrhythmias necessitating a permanent pacemaker
Refractory hypercalcaemia (a surplus of calcium that doesn’t respond to treatment) caused by disorders of the parathyroid glands and with evidence of the following:
Chronic hypercalcaemia (too much calcium), with levels of at least 3.0mmol/l in three or more separate tests after correction for albumin levels. The tests must have been taken at least two months apart within the last six months, and the results must be accompanied by any of the following: • Chronic pancreatitis (inflammation of the pancreas) OR • New-onset, permanent dementia (loss of brain function), confirmed by Mini-Mental State Examination (MMSE) score of less than 24 out of 30 in three separate tests that were taken at least three months apart over the last 12 months (diagnosed and treated by a psychiatrist) OR • New-onset psychotic disorder that needs continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist) OR • Unintentional weight-loss of at least 15%
over three months that does not respond to treatment or unintentional weight-loss leading to a Body Mass Index (BMI) score of less than
18 within the last year OR • Cardiac arrhythmias (disorders of the heart rhythm) that require a permanent pacemaker
100%
Panhypopituitarism, defined as more than 80% loss of the anterior pituitary gland as evidenced by: 1. Growth hormone deficiency AND 2. Gonadotrophin deficiency AND 3. TSH deficiency AND 4. ACTH deficiency
Panhypopituitarism (reduced production of all or most pituitary gland hormones)
Defined as more than 80% loss of the anterior (front portion) pituitary gland, shown by: 1. Growth hormone (a hormone that promotes growth of the body) deficiency AND 2. Gonadotrophin (a hormone that stimulate the ovaries or testes) deficiency AND 3. Thyroid (TSH - a hormone that stimulates the thyroid gland) stimulating hormone deficiency AND 4. Adrenocorticotropic (the hormone that stimulates the adrenal gland) hormone (ACTH) deficiency
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Any of the following endocrine conditions1: 1. Polyglandular autoimmune syndrome II 2. Multiple endocrine neoplasia I or II
Any of the following hormonal conditions1: 1. Polyglandular autoimmune syndrome II - a condition where the immune system attacks several hormone-secreting glands including the thyroid, adrenal glands and the pancreas 2. Multiple endocrine neoplasia I or II - tumours of several hormone-secreting glands including the parathyroids, pituitary, and pancreas (multiple endocrine neoplasia I) or the thyroid, parathyroids and adrenal glands (multiple endocrine neoplasia II)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Lifelong haemo- or peritoneal dialysis Lifelong haemo- or peritoneal dialysis A lifelong need for dialysis (treatment for severe kidney failure where fluid and body waste products are filtered and removed by a dialysis machine). This can be either haemodialysis (which filters blood through a vein) or peritoneal dialysis (which filters blood through the abdominal cavity)
100%
Irreversible chronic kidney disease (CKD) stage 4 or 5 with eGFR < 30ml/min
Irreversible chronic kidney disease (CKD) Permanent stage 4 or 5 chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of below 30ml/min (eGFR is an indication of overall kidney function)
100%
Urinary incontinence or urethral dysfunction resulting in a permanent indwelling catheter
Incontinence Urinary incontinence (loss of bladder control) or urethral dysfunction (abnormal flow of urine in the bladder outflow tract), leading to the insertion of a permanent catheter tube
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Documented respiratory disorder1 resulting in irreversible respiratory impairment of: • FEV1 ≤ 40% OR • FVC ≤ 40% OR • DCO ≤ 40%
A documented respiratory problem1 that leads to irreversible impairment and the following measurements:
1. A Forced Expiration Volume or FEV1 (the volume of air that can be blown out in the first second) of 40% or less, indicating reduced lung function OR
2. A Forced Vital Capacity or FVC (the volume of air that can be blown out after inhaling fully) of 40% or less, indicating reduced lung function OR
3. A Diffusion Capacity or DCO of 40% or less, indicating the lungs’ reduced ability to transfer oxygen
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Paraplegia Paralysis from the waist down Permanent and complete 100%
Quadriplegia Paralysis from the neck down Permanent and complete 100%
Hemiplegia Paralysis on one side of the body, including the arm, leg and trunk
Permanent and complete 100%
Diplegia Paralysis of the upper or lower limbs on both sides of the body
Permanent and complete 100%
Loss or complete loss of use of both lower limbs (defined as the lower limb from above the ankle)
Loss of both legs above the ankle, or the complete loss of the ability to use them
Permanent and complete 100%
Loss or complete loss of use of one or both upper limb(s) above the elbow, or one or both lower limb(s) above the knee
Loss of one or both arms above the elbow, or one or both legs above the knee, or the complete loss of the ability to use them
Permanent and complete 100%
Loss or complete loss of use of an entire hand Loss of a hand, or the complete loss of the ability to use it
Permanent and complete 100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Persistent documented neurological impairment1, despite optimal treatment, and with evidence of the following: 1. 50% or more compression fracture of a vertebral body or multiple level compression fractures AND 2. Two or more spinal operations including laminectomy AND/OR discectomy AND/OR fusion AND/OR surgical motion-preserving technologies such as discarthroplasty and dynamic stabilisation techniques on separate occasions within a five-year period
Spinal disorder Nerve damage that persists even after optimal treatment, and with evidence of the following: 1. A compression fracture that has collapsed 50% or more of the vertebral body (the largest, central part of a vertebra), or compression fractures of several vertebrae AND 2. Two or more spinal operations within the last five years, including a laminectomy (removal of the back of a vertebral bone to relieve pressure on the spinal cord), AND/OR a discectomy (removal of part or all of a cartilage disc between vertebrae), AND/OR a fusion (surgical joining of two or more vertebrae to reduce pain and abnormal movement), AND/OR non fusion (motion-preserving) techniques, such as discarthroplasty (replacement of a damaged disc with an artificial one) and dynamic stabilisation (insertion of a device that stabilises the spine without eliminating its ability to move)
100%
Persistent documented neurological impairment1, despite optimal treatment, and with evidence of the following: 1. Corresponding clinical and radiological evidence of a radiculopathy, defined as motor and sensory deficit, muscle atrophy and clinical signs of nerve tension AND 2. Two or more spinal operations including laminectomy AND/OR discectomy AND/OR fusion AND/OR surgical motion-preserving technologies such as discarthroplasty and dynamic stabilisation techniques on separate occasions within a five-year period
Spinal disorder Nerve damage that persists even after optimal treatment, and with evidence of the following: 1. Evidence of a radiculopathy, (a “pinched nerve”) on examination and an X-ray. Symptoms include motor and sensory damage, muscle atrophy and clinical signs of nerve tension 2. Two or more spinal operations within the last five years, including a laminectomy (removal of the back of a vertebral bone to relieve pressure on the spinal cord), AND/OR a discectomy (removal of part or all of a cartilage disc between vertebrae), AND/OR a fusion (surgical joining of two or more vertebrae to reduce pain and abnormal movement), AND/OR non fusion (motion-preserving) techniques, such as discarthroplasty (replacement of a damaged disc with an artificial one) and dynamic stabilisation (insertion of a device that stabilises the spine without eliminating its ability to move)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
A disorder of the spine resulting in a diagnosis of bladder incontinence with a permanent indwelling catheter or bowel incontinence with a permanent colostomy
Spinal disorder Disorder has caused bladder or bowel incontinence and the need for a permanent catheter or colostomy
100%
Diagnosis of cauda equina syndrome Cauda equina syndrome (a serious condition caused by compression of the nerves in the lower portion of the spinal canal, which leads to permanent loss of bowel and bladder control, and paralysis of the legs)
Diagnosed 100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Irreversible binaural loss of hearing1 of greater than 85%
as measured by audiometry at hearing thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and with a speech discrimination threshold of less than 60%
Hearing loss Permanent hearing loss1 of more than 85% in both ears (binaural), measured at hearing thresholds (sound levels) of 500Hz, 1000Hz, 2000Hz and 3000Hz, with a speech discrimination threshold (ability to hear and understand speech) of less than 60%
100%
Irreversible and complete loss of hearing1 in both ears (total loss of hearing bilaterally)
Hearing loss Total and permanent hearing loss1 in both ears 100%
Bilateral loss of visual acuity as evidenced by a Snellen chart reading of 20/200 or worse in the best eye after full correction
Visual loss Loss of clear vision in both eyes, with a Snellen chart (eye-testing chart) reading of 20/200 or worse in the better-functioning eye, even after fully correcting your eyesight with the strongest available lens
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Full-thickness burns of more than 18% of the body surface
Burns Full-thickness burns (involving all the layers of the tissue) of more than 18% of the body surface
100%
Full-thickness burns of 9% to 18% of the body surface including the palms of both hands or soles of both feet
Burns Full-thickness burns (involving all the layers of the tissue) of 9 to 18% of the body surface, including the palms of both hands or soles of both feet
100%
Full-thickness burns of more than 25% of the face Burns Full-thickness burns (involving all the layers of the tissue) of more than 25% of the face
100%
Irreversible disfigurement of more than 50% of the body surface caused by a chronic treatment-resistant skin disorder and accompanied by systemic organ involvement of the central nervous system OR the heart OR lungs OR liver OR kidneys, due to the chronic treatment-resistant skin disorder itself
Skin disorders 1. Permanent disfigurement of more than 50% of the body surface, caused by a chronic skin disorder that does not respond to treatment AND 2. That has affected another internal organ, namely the central nervous system, heart, lungs, liver or kidneys
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
A state of unresponsiveness, as evidenced by a Glasgow Coma Scale of 8 and less, which persists for more than 96 hours. (medically-induced comas are excluded)
Coma (being unconscious) A coma that lasts longer than four days and scores 8 and less on the Glasgow Coma Scale (a scale for measuring the level of unconsciousness or severity of a brain injury) (medically-induced comas are excluded)
100%
A traumatic injury to the brain, with resultant documented Glasgow Coma Scale of less than 12/15, caused by an external physical force with: 1. Irreversible cognitive impairment of MMSE < 21/30 OR 2. Permanent neurological deficit (motor and/ or sensory impairment) resulting in continuous professional care and supervision of more than four hours a day
Traumatic (physical) brain injury Caused by an external physical force and leading to a Glasgow Coma Scale (which quantifies the level of unconsciousness or severity of a brain injury) score of less than 12 out of 15, as well as: 1. Permanently reduced mental function with a Mini–Mental State Examination (MMSE) score of less than 21 of a possible 30 OR 2. Permanent damage to the nervous system that impairs movement and/or sensation and requires professional care and supervision for more than four hours per day
100%
Irreversible anatomical distortion of 25% to 50% of the face caused by an external physical force, and which has undergone multi-stage facial reconstructive surgery
Facial injury Permanent distortion of 25% to 50% of the anatomy of the face, caused by an external physical force, and which has undergone several stages of reconstructive surgery
100%
Irreversible anatomical distortion of more than 50% of the face caused by an external physical force
Facial injury Permanent distortion to more than 50% of the anatomy face, which was caused by an external physical force
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Permanent failure of 4 out of 5 BrightRock Activities of Daily Living (excluding cognitive failure)
ADL failure Has resulted in permanent inability to perform four out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is where the brain’s capacity to think, remember and judge clearly is reduced)
100%
Permanent failure of cognitive BrightRock Activities of Daily Living (see definition) with an irreversible MMSE of ≤ 18
ADL failure Has resulted in permanent inability to perform the cognitive BrightRock Activities of Daily Living (this refers to the brain’s capacity to think, remember and judge clearly) and a permanent score of 18 or less when a neurologist tests the person’s cognitive (thinking) skills with the Mini Mental State Examination (MMSE)
100%
BrightRock Activities of Daily Living (ADLs)
1. Washing: You rely entirely on someone else to help you wash, bath or shower.
2. Dressing Skills: You need the help of another person to help you fasten clothes (open/close zips, fasten/unfasten buttons, close belts, tie laces) and, if applicable,
attach and fasten any braces, prosthetics or other surgical appliances that you usually wear.
3. Eating and feeding: You’re physically unable to feed yourself and need someone’s help.
4. Mobility: You need physical help when moving between rooms on a level surface, despite the use of an assistive device such as a walking cane or wheelchair.
5. Transferring: You need someone’s help when moving between a bed and a chair.
6. Cognitive Impairment: You have suffered irreversible brain damage, and can no longer perform the Activities of Daily Living without medical help or supervision.
This must be confirmed by a neurologist or psychiatrist and formally tested by a neuropsychologist.
Permanence will be established not less than three months after the event
Appendix
Cancer
11
13
12
Activities of Daily Living14
Reference notes
Brain and nerves 1. Examples of mental and behavioural disorders that result in the severity criteria as specified here include but are not limited to:
• Dementia
• Anxiety disorders
2. Irreversible cognitive impairment must be confirmed by a neuropsychologist assessment.
3. The diagnosis of vestibular dysfunction must be confirmed by a neurologist with supporting investigations (i.e. brain imaging studies). Neurological vestibular conditions excluded from this benefit include vasospastic conditions, such as migraines.
4. Must be confirmed by a neurologist with supporting investigations.
5. The diagnosis of treatment-resistant generalised epilepsy is defined as the failure to control seizure activity by surgery or an adequate trial (despite full patient compliance) of at least three antiepileptic medications. At least two must have been used in combination (confirmed by therapeutic blood levels where possible). This diagnosis must be confirmed by a neurologist, with supporting investigations i.e. EEG and brain imaging studies. Non-Epileptic Attack Disorder (NEAD) and psychogenic non-epileptic seizure (PNES) are excluded from this benefit category.
6. Loss of language comprehension and production must be confirmed by a neurologist with radiographic evidence in keeping with the clinical findings.
7. The diagnosis of treatment-resistant sleep disorder must be confirmed by formal neurophysiological testing as performed in an accredited sleep laboratory.`
The following mental and behavioural disorders are specifically excluded from this benefit category:
• Factitious disorders
• Substance-use disorders.
Digestive system
1. Eating and functional disorders are excluded from this benefit category.
Heart and blood vessels
1. Examples of cardiovascular or cardio-pulmonary disorders that result in the severity criteria we’ve specified include, but are not limited to:
• Myocardial infarction
• Aortic disease, e.g. aneurysm.
2. Treatment resistant hypertension is high blood pressure that is treated with more than four medicines.
HIV/AIDS
1. For these conditions, claims for insured lives who have already been diagnosed as HIV-positive prior to taking out their cover with BrightRock are excluded.
1 2 3
Cancer
11
13
12
Activities of Daily Living14
Reference notes
Hormones 1. The endocrine disorders (as confirmed by an endocrinologist) must be supported by the relevant laboratory and radiological investigations and shown to be persistent despite full compliance with optimal medical and surgical treatment. Psychogenic polydipsia is excluded.
Lungs and breathing
1. Examples of respiratory disorders that result in the severity criteria as specified here include but are not limited to:
• Chronic obstructive airways disease
Muscles, bones and joints
1. Neurological impairment must include evidence of a lower motor neuron lesion with evidence of:
• Motor weakness of the muscles corresponding to the nerve level involved AND
• Prominent muscle wasting.
Sensory system
1. The hearing loss must be permanent and completely uncorrectable by surgery or a fitted hearing aid/device.
2. Vestibular conditions excluded from this benefit include:
• Viral labyrinthitis
• Vestibular neuronitis
1 2 3
* Condition-specific alcohol exclusion:
For the conditions marked with the * symbol, claims for injuries or illnesses related to long-term alcohol or drug abuse are excluded.
** Our optimal treatment requirement doesn’t apply to these conditions
We won’t apply the requirement for optimal treatment to a claim on clinical definitions marked with the ** symbol.
** Our optimal treatment requirement doesn’t apply to these conditions
We won’t apply the requirement for optimal treatment to a claim on clinical definitions marked with the ** symbol, but only where the limb(s) or finger(s) have been amputated.
Appendix
Cancer
11
13
12
Activities of Daily Living14
Appendix
BrightRock has the right to ask for a second opinion if the medical information we initially receive is not sufficient to prove conclusively that the client has met the claims criteria. For example, if the information provided is not sufficient to confirm the client’s diagnosis. Depending on the case, BrightRock may recommend a medical professional for the second opinion or the client may consult a medical professional of their own choosing.
“Confirmed” means that the diagnosis has been made with appropriate and supporting medical evidence in the form of reports, blood tests, histological findings, imaging, scans or any other relevant investigations.
BrightRock has no explicit general survival or general waiting periods on our permanent expenses cover (condition-specific waiting periods, however, do apply for certain conditions. Please refer to the clinical definitions contained in this document to see which ones have this type of waiting period). This gives you greater certainty of claim. If the insured life has a valid permanent expenses claim that meets our clinical criteria but dies before we have made the pay-out, BrightRock will still pay the claim out. This applies as long as the insured life was alive at the time of the diagnosis that led to the permanent expenses claim.
Unless otherwise specified, if you become ill or injured, you must get medical treatment as soon as possible to qualify for a claim against your permanent expenses cover on your BrightRock policy. You must fully comply with your doctor’s advice and finish your full treatment regime. If you don’t seek and receive optimal treatment and fail to comply with your treatment, the claim will be invalid.
1 2 3
Blood production disorders
HIV/ AIDS 1
Sensory System 1
Trauma
11
13
12
Activities of Daily Living14
Clinical claims definitions: Medical Impairment Standard
BrightRock has worked in partnership with international clinical and risk experts to ensure our clinical claims criteria are objective, transparent and industry-leading. To give you and your clients peace of mind that our claims definitions are comprehensive and clinically objective, we provide a full list of our claims definitions and criteria, divided by body system.
This document applies to your permanent expenses cover for the following needs:
Cover for illness or injury with a financial impact
Additional expense needs
BrightRock Life Ltd, an authorised financial services provider and registered insurer (FSP 11643, Registration number: 1996/014618/06). Sanlam Life Insurance Ltd, an authorised financial services provider and registered insurer (FSP 2759, Registration number: 1998/021121/06). Copyright ©November 2019 BrightRock. All rights reserved. Terms and conditions apply. Document number: 30000007648.
Please note: In this document, we’ve provided our clinical claims definitions accompanied with explanatory text for ease of understanding. The information provided in the columns labelled with the words “layman’s explanation” is provided purely for information purposes. If there is any uncertainty or ambiguity, then the wording provided under the column labelled “BrightRock clinical definitions” will prevail.
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Refractory pancytopaenia resulting from an irreversible, treatment-resistant disorder with any two of the following: 1. Persistent haemoglobin levels of ≤ 8g/dl OR 2. Neutropenia of < 1x109 WBC/l OR 3. Thrombocytopenia of < 100x109/l
Pancytopaenia (a lack of all types of blood cells) that persists as a results of an irreversible disorder that doesn’t respond to treatment and occurs with any two of the following:
1. Persistent haemoglobin levels of 8g/dl or less (haemoglobin is the oxygen-carrying protein in red blood cells) OR 2. Neutropenia (a lack of white blood cells) of 1x109 WBC/l or less OR 3. Thrombocytopenia (a lack of platelets) of 100x109/l or less
100%
Total % pay-out
Cancer
11
13
14
12
Medically certified institutionalisation for a mental and behavioural disorder1 of more than six months continuously
Medically certified admission to a recognised mental health facility for a mental or behavioural1 problem
For more than six months at a time 100%
Confirmed diagnosis of schizophrenia1 with evidence of all of the following criteria in the last year: 1. Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND 2. Admission to a psychiatric in-patient facility for three months or longer in total
Confirmed diagnosis of schizophrenia With evidence of the following in the last year 1. Consistent taking of psychotropic medication (which treats the psychiatric disorder), as prescribed by a psychiatrist AND 2. Admission to a psychiatric hospital or clinic for at least three months at a time
100%
Documented treatment-resistant mental and behavioural disorder1 with evidence of all of the following criteria in the last two years: 1. Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND 2. Admission to a psychiatric in-patient facility for four weeks or longer in total AND 3. A full course of ECT
Documented mental and behavioural disorder1 that doesn’t respond to treatment
With evidence of all of the following in the last two years: 1. Consistent taking of psychotropic medication (which affects the mental state), as prescribed by a psychiatrist AND 2. Admission to a psychiatric hospital or clinic for at least four weeks AND 3. A full course of ECT (electroconvulsive or shock therapy)
100%
Documented treatment-resistant mental and behavioural disorder1 with evidence of all of the following criteria in the last year: 1. Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND 2. Admission to a psychiatric in-patient facility for 12 weeks or longer in total AND 3. A full course of ECT
Documented mental and behavioural disorder1 that doesn’t respond to treatment
With evidence of all of the following in the last year: 1. Consistent taking of psychotropic medication (which treats the psychiatric disorder), as prescribed by a psychiatrist AND 2. Admission to a psychiatric hospital or clinic for at least 12 weeks AND 3. A full course of ECT (electroconvulsive or shock therapy)
100%
Total % pay-out
Cancer
11
13
14
12
Medical Impairment Standard Definition sets B(V7.0), C(V7.0), D(V6.0)
1. Documented treatment-resistant generalised epilepsy5 of at least three months’ duration (despite optimal treatment and patient compliance), with more than two seizures per week AND 2. Documented neurological deficit as a result of the epilepsy, defined as two or more of the following permanent (of more than six months’ duration) findings: • Motor deficit (power < 3/5) • Cognitive deficit (MMSE < 19/30) • Speech deficit and/or visual/hearing deficit, all confirmed by a neurologist
Epilepsy 1. Documented generalised epilepsy5 of two fits per week for at least three months. The fits do not respond to treatment, despite taking the right medicine as prescribed by the treating doctor AND 2. Documented permanent damage to the nervous system, caused by the epilepsy and exhibiting two or more of the following for at least six months (confirmed by a neurologist): • Impaired muscle power measurement of less than 3 out of 5 • Impaired cognitive skills (the ability to think, remember and judge clearly) with a Mini-Mental State Examination (MMSE) score of less than 19 out of 30 • Impaired speech, vision and/or hearing, all confirmed by a neurologist
100%
Non-traumatic organic cognitive disorder (excluding psychological disorders) resulting in irreversible cognitive impairment2 as evidenced by Mini Mental State Examinations (MMSE) < 19/30
Cognitive disorder Any condition affecting cognitive function (the brain’s capacity to think, remember and judge clearly) that is not due to physical injury (but that excludes psychological disorders). The condition also leads to permanent cognitive impairment2 with a Mini-Mental State Examination (MMSE) score of less than 19 out of 30
100%
Vestibular dysfunction3 presenting with attacks of nausea, vomiting, vertigo and dizziness with at least 10 episodes per month resulting from brainstem causes including: 1. Vascular lesions OR 2. Tumours of the cerebellum or fourth ventricle OR 3. Demyelination disorders
Neurological vestibular (balance) disorder Results in attacks of nausea, vomiting, dizziness and vertigo (a sense of falling), with at least 10 episodes per month due to problems in the base of the brain, including: 1. Disease of the blood vessels OR 2. Tumours of the cerebellum or fourth ventricle of the brain OR 3. Demyelination disorders (caused loss of the insulating sheath around nerves)
100%
Central respiratory failure (a life-threatening problem with breathing due to damage to the parts of the brain that control breathing)
Confirmed permanent central respiratory failure, with the need for a life support system
100%
Total % pay-out
Cancer
11
13
14
12
The irreversible loss of language comprehension and production6 resulting from damage to the portions of the brain responsible for language
Aphasia/dysphasia (communication disorders)
Permanent loss of the ability to understand, produce and/or use words6, caused by damage to the parts of the brain that are responsible for language
100%
Documented treatment-resistant sleep disorder7 (excluding sleep apnoea) resulting in abnormal sleep cycles and sustained cognitive impairment as evidenced by MMSE of less than 24/30
Sleep disorders A documented sleep disorder7 (excluding sleep apnoea) that does not respond to treatment. The disorder is characterised by abnormal sleep cycles and reduced mental functioning, evidenced by a Mini-Mental State Examination (MMSE) of less than 24 of a possible 30
100%
Disorders of cranial nerve VIII (the vestibulocochlear nerve)
Permanent vestibulocochlear nerve palsy4 (paralysis) on one side, causing hearing-loss and vestibular dysfunction (balance disorder) resulting in attacks of nausea, vomiting, dizziness and vertigo (a sense of falling)
100%
Irreversible bulbar palsy4 as a result of bilateral impairment of function of cranial nerves V, IX, X and XII that presents with loss of facial sensation including dysarthria, dysphagia, dysphonia, regurgitation and/or aspiration
Bulbar palsy (paralysis of the lower cranial nerves, which arise from the brain itself)
Impaired function of cranial nerves V, IX, X and XII that leads to permanent bulbar palsy4 (paralysis) on both sides, and includes loss of facial sensation, dysarthria (the inability to speak clearly), dysphagia (difficulty swallowing), dysphonia (impaired voice sound production), regurgitation and/or aspiration (inhaling stomach contents)
100%
Irreversible cerebellum dysfunction4 resulting in the inability to stand without assistive devices
Disorders of the cerebellum (part of the brain responsible for coordination and balance)
Permanent cerebellar dysfunction4 causing an inability to stand without a cane or other supportive device
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Confirmed diagnosis of any stage 4 cancer, including any cancer classified by SCIDEP as level A. Includes: 1. Acute myeloid leukaemia; 2. Chronic lymphocytic leukaemia, stage 3 or 4 on the
Rai classification, or Binet C; 3. Chronic myeloid leukaemia (requiring bone marrow
transplant); 4. Acute lymphocytic leukaemia (adults); 5. Hodgkin’s/non-Hodgkin’s lymphoma stage 4 on Ann
Arbor classification system; 6. Multiple myeloma stage 3 on the Durie- Salmon
scale; 7. WHO grade 3 or 4 brain tumour.
Any stage 4 cancer (includes any cancer classified by SCIDEP as level A)
Includes: 1. Acute myeloid leukaemia (a type of cancer
characterised by an overproduction of immature white blood cells, called myeloblasts);
2. Chronic lymphocytic leukaemia (a type of slow growing leukaemia that affects developing white blood cells called B-lymphocytes), stage 3 or 4 on the Rai classification, or Binet C;
3. Chronic myeloid leukaemia (a cancer where the bone marrow produces too many white cells called granulocytes) requiring bone marrow transplant;
4. Acute lymphocytic leukaemia in adults (a type of cancer characterised by an overproduction of immature white blood cells called lymphoblasts);
5. Hodgkin’s/non-Hodgkin’s lymphoma (cancerous tumour of the lymph nodes) stage 4 on Ann Arbor classification system;
6. Multiple myeloma (a cancer that forms in a type of white blood cell called a plasma cell) stage 3 on the Durie-Salmon scale;
7. Brain tumour that is considered WHO (World Health Organisation) grade 3 or 4
100%
Confirmed diagnosis of any stage 3 cancer or WHO grade 2 brain tumour (including any cancer that is classified by SCIDEP as level B such as Hodgkin’s or non-Hodgkin’s lymphoma stage 3 on the Ann Arbor classification system) for which the insured life has undergone continuous cancer treatment for a perod of 12 months or longer. This specifically excludes anti- hormonal treatments.
Any stage 3 cancer or WHO grade 2 brain tumour (includes any cancer classified by SCIDEP as level B such as Hodgkin’s or non- Hodgkin’s lymphoma stage 3 on the Ann Arbor classification system) that:
1. Has undergone continuous cancer treatment for 12 months or longer AND
2. Excludes anti-hormonal treatments
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Chronic gastrointestinal tract and/or liver and/or biliary disorders1 resulting in: 1. Unintentional treatment-resistant weight-loss of at least 25% over a 5 month period OR 2. Unintentional treatment-resistant weight-loss resulting in a BMI of less than 16
Digestive disorders, defined as: Chronic gastrointestinal tract and/or liver and/ or biliary (relating to bile, the bile ducts or the gallbladder) disorders1 resulting in: 1. Unintentional weight-loss of at least 25% that
doesn’t respond to treatment in five months OR
2. Unintentional weight-loss that doesn’t respond to treatment and that leads to a Body Mass Index (BMI) below 16
100%
Chronic irreversible liver disease1 with at least two of the following: 1. Serum bilirubin > 51µmol/l 2. Serum albumin < 30g/dl 3. Prolonged prothrombin time of > 6 seconds or INR > 2.3 4. Ascites requiring ongoing surgical drainage 5. Hepatic encephalopathy
Digestive disorders, defined as: Chronic, permanent liver disease1 with at least two of the following: 1. Serum bilirubin levels of more than 51µmol/l
(bilirubin is a bile pigment formed in the liver) 2. Serum albumin levels lower than 30g/dl
(albumin is a protein that’s produced by the liver and circulates in the blood)
3. Prolonged prothrombin time (how long it takes for blood to clot) of more than 6 seconds, or an international normalised ratio (INR) of more than 2.3 seconds (INR is a standardised version of the prothrombin time)
4. Ascites (free fluid in the abdominal cavity) that needs ongoing draining through surgery
5. Hepatic encephalopathy (a state of mental confusion caused by liver failure)
100%
Confirmed diagnosis of chronic irreversible liver failure¹ confirmed by a gastroenterologist (PLUS inclusion on a recognised transplant list) with one of the following: 1. Serum bilirubin more than 51 μmol/l 2. Serum albumin lower than 30g/dl 3. Prolonged prothrombin time of more than six
seconds or INR more than 2.3 4. Ascites requiring ongoing surgical drainage 5. Hepatic encephalopathy
Digestive disorders, defined as: Chronic, permanent liver failure¹ (PLUS inclusion on a recognised transplant list) with one of the following: 1. Serum bilirubin levels of more than 51μmol/l
(bilirubin is a bile pigment formed in the liver) 2. Serum albumin levels lower than 30g/dl
(albumin is a protein that’s produced by the liver and circulates in the blood)
3. Prolonged prothrombin time (how long it takes for blood to clot) of more than six seconds, or an international normalised ratio (INR) of more than 2.3 seconds (INR is a standardised version of the prothrombin time)
4. Ascites (free fluid in the abdominal cavity) that needs ongoing draining through surgery
5. Hepatic encephalopathy (a state of mental confusion caused by liver failure)
1 2
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
100%
Irreversible biliary tract obstruction1 with clinical evidence of cholestasis in the form of: 1. Ascending cholangitis 2. Jaundice AND 3. Deranged liver enzymes (a two-fold increase or more)
Digestive disorders, defined as: Permanent blockage in the biliary tract1, which transports bile from the liver to the small intestine, with clinical evidence of cholestasis (blocked bile ducts) in the form of: 1. Ascending cholangitis (inflammation of the biliary tract) 2. Jaundice (a condition involving yellowing of the skin and eyes caused by a build-up of pigment usually due to liver or bile duct problems) AND 3. At least a two-fold increase in liver enzymes
100%
Irreversible total dysphagia1 that has: 1. Resulted from organic disease AND 2. Undergone more than one surgical and/ or radiotherapeutic intervention
Digestive disorders, defined as: Permanent dysphagia1 (difficulty swallowing): 1. Caused by an organic disease (any condition that’s been confirmed by physical examination, lab tests or other diagnostic studies) AND 2. That’s undergone more than one operation and/or received radiation treatment
100%
Irreversible faecal incontinence1 treated by permanent colostomy
Digestive disorders, defined as: Permanent faecal incontinence1 (loss of bowel control) treated by permanent colostomy (surgery that brings the end of the large intestine out through an opening in the abdominal wall)
100%
Irreparable abdominal or inguinal hernia (where surgery is now contraindicated1) with documented persistent malabsorption syndrome resulting from previous bowel loss
Digestive disorders, defined as: 1. Irreparable abdominal or inguinal (groin) hernia, where surgery is not advised1 AND 2. Documented persistent malabsorption syndrome (a problem absorbing nutrients from food) that has been caused by previous bowel loss
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Any recognised cardiovascular or cardio-pulmonary disorder1 that results in the following cardiovascular assessments: 1. New York Heart Association Functional Classification (NYHA) III/IV AND 2. Permanent Ejection Fraction (EF) < 35% OR 3. Metabolic Equivalents (METS) < 2
Any recognised heart, circulation and/ or lung disorder1 that meet the following severity criteria:
1. A New York Heart Association Functional Classification (NYHA) of III or IV AND
3. Metabolic Equivalents (METS) of less than 2 (METS is a measure of the energy you burn and oxygen you use during exercise)
100%
Chronic peripheral arterial insufficiency (also known as ischaemia) presenting with: 1. No palpable pulses AND 2. Doppler readings of Ankle Brachial systolic pressure Index (ABI) ≤ 0.5 AND 3. Rest pain OR 4. Ulceration OR 5. Gangrene with or without amputation
Chronic peripheral arterial insufficiency or ischaemia (due to blockages in blood vessels to the upper and lower limbs) that leads to:
1. No pulse felt on physical examination) AND 2. Doppler readings of an Ankle Brachial Pressure Index (ABI) of 0.5 or less (a test that measures the difference in blood pressure between the arteries of your arm and ankle) AND 3. Pain in the limb when resting OR 4. Vascular ulcers (loss of skin) OR 5. Gangrene (tissue death) with or without complete surgical removal (amputation)
100%
* *
2. Permanent Ejection Fraction (EF) of less than 35% (the permanent ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction) OR
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Documented treatment-resistant hypertension2 complicated by at least two of the following: 1. Chronic kidney disease (CKD) stage 4 or 5, with an estimated glomerular filtration rate (eGFR) of < 30ml/min OR 2. Radiological evidence of a stroke (CVA) OR 3. Grade III or IV hypertensive retinopathy OR 4. Documented left ventricular hypertrophy (septal wall thickness to posterior LV wall thickness of 1:1.3 on ECHO) OR 5. Congestive cardiac failure (CCF) defined as: • New York Heart Association Functional Classification (NYHA) II AND • Permanent Ejection Fraction (EF) < 45% OR • Metabolic Equivalents (METS) 2 - 5
Documented high blood pressure2 that doesn’t respond to treatment and is complicated by at least two of the following:
1. Advanced and severe chronic kidney disease (CKD) of stage 4 or 5, with an estimated glomerular filtration rate (eGFR) of less than 30ml/min (eGFR is an indication of overall kidney function) OR
2. Evidence of a stroke on any brain scan OR 3. Grade III or IV hypertensive retinopathy (significant damage to the retina of the eye) OR 4. Thickening or increased size of the muscle wall of the heart’s left ventricle measured as 1:13 on a heart sonogram (ECHO) OR 5. Congestive cardiac failure (CCF) defined as: • New York Heart Association Functional Classification (NYHA) II AND • Permanent Ejection Fraction (EF) of less than
45% (the permanent ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction) OR
• Metabolic Equivalents (METS) of 2 to 5 (METS is a measure of the energy you burn and oxygen you use during exercise)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Advanced AIDS1, confirmed by: 1. A positive HIV antibody test AND 2. A current CD4 cell count of less than 200, despite optimal anti-retroviral combination therapy AND 3. A confirmed diagnosis of at least one of the following diseases: • Kaposi’s sarcoma • Pneumocystis carinii pneumonia • Progressive multifocal leukoencephalopathy • Extrapulmonary or MDRD/XDR pulmonary tuberculosis • Pulmonary cryptococcus
Advanced AIDS, confirmed by: 1. A positive HIV antibody test AND 2. A current CD4 cell count of less than 200, even with optimal anti-retroviral medication AND 3. Confirmed diagnosis of at least one of the following conditions: • Kaposi’s sarcoma (a cancer that causes lesions in the skin or internal organs ) • Pneumocystis carinii pneumonia (an infection of the lungs caused by a fungus) • Progressive multifocal leukoencephalopathy (a viral infection that causes progressive damage to the white matter of the brain) • Extrapulmonary tuberculosis (TB infection in organs other than the lungs), multidrug resistant pulmonary tuberculosis (MDR-TB), or extensively drug-resistant pulmonary tuberculosis (XDR-TB) - the latter two refer to TB infection in the lungs that doesn’t respond to standard TB treatment • Pulmonary cryptococcus (a fungal infection of the lungs)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Signs of established endocrine disorders1, including documented diabetes mellitus type 1 or 2, complicated by at least two of the following: 1. Chronic kidney disease (CKD) stage 3B with an estimated glomerular filtration rate (eGFR) of 30 to 44ml/min OR 2. Radiological evidence of a stroke (CVA) OR 3. Grade III diabetic retinopathy OR 4. Coronary artery disease which has undergone coronary artery bypass
Established endocrine disorder (problems with hormone-secreting glands)1
Documented type 1 or 2 diabetes, complicated by at least two of the following: 1. Chronic kidney disease (CKD) stage 3B, with an estimated glomerular filtration rate (eGFR, an indication of overall kidney function) of 30 to 44ml/min OR 2. Evidence of a stroke (cerebrovascular accident or CVA) on a scan OR 3. Grade III diabetic retinopathy (damage to the retina in the eye) OR 4. Coronary artery disease (disease of the heart’s blood vessels) that has undergone a coronary artery bypass
100%
Documented diabetes mellitus type 1 or 2 complicated by: • Grade IV or V diabetic retinopathy
Documented type 1 or 2 diabetes complicated by:
Grade IV or V diabetic retinopathy (damage to the retina of the eye)
100%
Cushing’s syndrome as evidenced by at least two of the following: 1. Documented profound proximal myopathy resulting in the permanent use of assistive devices
OR 2. New-onset persistent diabetes mellitus diagnosed after the diagnosis of Cushing’s syndrome and requiring ongoing insulin OR 3. Refractory hypertension (blood pressure > 140/90
in four or more separate readings taken at least two months apart within the last 12 months) and with newly diagnosed ischaemic heart disease
(angina, MI, stent or CABG) OR 4. Newly diagnosed psychotic disorder treated with continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)
Cushing’s syndrome (a condition caused by high levels of cortisol in the blood), evidenced by at least two of the following:
1. Documented serious proximal myopathy (weakness and wasting of the limb muscles closest to the body) leading to the permanent use of walking or supporting aids OR 2. New-onset, persistent diabetes mellitus that is diagnosed after the Cushing’s syndrome and requires ongoing insulin treatment OR 3. Refractory hypertension (high blood pressure that does not respond to treatment), with levels higher than 140/90 in four or more separate readings taken at least two months apart within the last 12 months AND with newly diagnosed ischaemic heart disease (reduced blood flow to the heart), in the form of angina, a heart attack, a stent or Coronary Artery Bypass Graft procedure (CABG) OR 4. New-onset psychotic disorder needing continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Refractory syndrome of inappropriate antidiuretic hormone secretion (SIADH) with: 1. Na+ < 130mmol/l AND 2. No evidence of hypovolaemia AND 3. Normal blood pressure, pulse and serum
urea:creatinine ratio demonstrated by two or more readings taken at least two months apart within the last six months) AND
4. As a result of any of the following: • Small cell lung cancer • Mesothelioma • GI tract malignancy • Pancreatic malignancy • Asbestosis • Progressive multiple sclerosis
Syndrome of inappropriate antidiuretic hormone secretion (SIADH), a problem with the secretion of the antidiuretic hormone
With evidence of the following: 1. Sodium (Na+) level of less than 130mmol/l AND 3. No evidence of hypovolaemia (reduced blood volume) AND 4. Normal blood pressure, pulse and serum urea:creatinine ratio shown by two or more readings taken at least two months apart within the last six months AND 5. Caused by any of the following: • Small cell lung cancer OR • Mesothelioma (cancer of the tissue that lines the chest, abdomen or around the heart) OR • Cancer of the gastrointestinal tract • Cancer of the pancreas • Asbestosis (a lung condition caused by inhaling asbestos fibres) • Progressive multiple sclerosis (a condition involving increasing damage to the nerves in the brain and spinal cord and affecting all body functions)
100%
Refractory hypocalcaemia resulting from parathyroid disorders with evidence of the following: Chronic hypocalcaemia (serum calcium < 2.3mmol/l, as evidenced by three or more separate readings taken at least two months apart within the last six months) and with any of the following: • New-onset seizure disorder on permanent
anti-convulsant medication (diagnosed and treated by a neurologist) OR • Raised intracranial pressure necessitating surgical intervention OR • Refractory new-onset prolonged QT interval on ECG OR • Osteomalacia OR • New-onset psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)
Refractory hypocalcaemia (a lack of calcium that doesn’t respond to treatment) caused by disorders of the parathyroid glands and with evidence of the following:
Chronic hypocalcaemia (too little calcium), with levels below 2.3mmol/l in three or more separate tests taken at least two months apart within the last six months. These results must be accompanied by any of the following: • Newly-diagnosed seizure disorder that requires permanent anti-seizure medication (diagnosed and treated by a neurologist) OR • Raised intracranial pressure (increased pressure within the brain) that requires surgical correction OR • New-onset prolonged QT interval (a conduction disturbance in the heart) that’s seen on an electrocardiogram (ECG) and doesn’t respond to treatment OR • Osteomalacia a (bone disorder that leads to bone softening) OR • Newly-diagnosed psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Refractory hypercalcaemia resulting from parathyroid disorders with evidence of the following: Chronic hypercalcaemia (serum calcium ≥ 3.0mmol/l as evidenced by three or more separate readings, following correction for serum albumin, taken at least two months apart within the last six months) and with any of the following: • Chronic pancreatitis OR • New-onset irreversible dementia (confirmed by MMSE of < 24/30 on three separate tests at least three months apart over the preceding 12 months, and diagnosed and treated by a psychiatrist) OR • New-onset psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist) OR • Unintentional treatment resistant weight-loss of at
least 15% in a three month period, or unintentional weight-loss resulting in a BMI of < 18 within the last year OR
• Cardiac arrhythmias necessitating a permanent pacemaker
Refractory hypercalcaemia (a surplus of calcium that doesn’t respond to treatment) caused by disorders of the parathyroid glands and with evidence of the following:
Chronic hypercalcaemia (too much calcium), with levels of at least 3.0mmol/l in three or more separate tests after correction for albumin levels. The tests must have been taken at least two months apart within the last six months, and the results must be accompanied by any of the following: • Chronic pancreatitis (inflammation of the pancreas) OR • New-onset, permanent dementia (loss of brain function), confirmed by Mini-Mental State Examination (MMSE) score of less than 24 out of 30 in three separate tests that were taken at least three months apart over the last 12 months (diagnosed and treated by a psychiatrist) OR • New-onset psychotic disorder that needs continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist) OR • Unintentional weight-loss of at least 15%
over three months that does not respond to treatment or unintentional weight-loss leading to a Body Mass Index (BMI) score of less than
18 within the last year OR • Cardiac arrhythmias (disorders of the heart rhythm) that require a permanent pacemaker
100%
Panhypopituitarism, defined as more than 80% loss of the anterior pituitary gland as evidenced by: 1. Growth hormone deficiency AND 2. Gonadotrophin deficiency AND 3. TSH deficiency AND 4. ACTH deficiency
Panhypopituitarism (reduced production of all or most pituitary gland hormones)
Defined as more than 80% loss of the anterior (front portion) pituitary gland, shown by: 1. Growth hormone (a hormone that promotes growth of the body) deficiency AND 2. Gonadotrophin (a hormone that stimulate the ovaries or testes) deficiency AND 3. Thyroid (TSH - a hormone that stimulates the thyroid gland) stimulating hormone deficiency AND 4. Adrenocorticotropic (the hormone that stimulates the adrenal gland) hormone (ACTH) deficiency
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Any of the following endocrine conditions1: 1. Polyglandular autoimmune syndrome II 2. Multiple endocrine neoplasia I or II
Any of the following hormonal conditions1: 1. Polyglandular autoimmune syndrome II - a condition where the immune system attacks several hormone-secreting glands including the thyroid, adrenal glands and the pancreas 2. Multiple endocrine neoplasia I or II - tumours of several hormone-secreting glands including the parathyroids, pituitary, and pancreas (multiple endocrine neoplasia I) or the thyroid, parathyroids and adrenal glands (multiple endocrine neoplasia II)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Lifelong haemo- or peritoneal dialysis Lifelong haemo- or peritoneal dialysis A lifelong need for dialysis (treatment for severe kidney failure where fluid and body waste products are filtered and removed by a dialysis machine). This can be either haemodialysis (which filters blood through a vein) or peritoneal dialysis (which filters blood through the abdominal cavity)
100%
Irreversible chronic kidney disease (CKD) stage 4 or 5 with eGFR < 30ml/min
Irreversible chronic kidney disease (CKD) Permanent stage 4 or 5 chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of below 30ml/min (eGFR is an indication of overall kidney function)
100%
Urinary incontinence or urethral dysfunction resulting in a permanent indwelling catheter
Incontinence Urinary incontinence (loss of bladder control) or urethral dysfunction (abnormal flow of urine in the bladder outflow tract), leading to the insertion of a permanent catheter tube
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Documented respiratory disorder1 resulting in irreversible respiratory impairment of: • FEV1 ≤ 40% OR • FVC ≤ 40% OR • DCO ≤ 40%
A documented respiratory problem1 that leads to irreversible impairment and the following measurements:
1. A Forced Expiration Volume or FEV1 (the volume of air that can be blown out in the first second) of 40% or less, indicating reduced lung function OR
2. A Forced Vital Capacity or FVC (the volume of air that can be blown out after inhaling fully) of 40% or less, indicating reduced lung function OR
3. A Diffusion Capacity or DCO of 40% or less, indicating the lungs’ reduced ability to transfer oxygen
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Paraplegia Paralysis from the waist down Permanent and complete 100%
Quadriplegia Paralysis from the neck down Permanent and complete 100%
Hemiplegia Paralysis on one side of the body, including the arm, leg and trunk
Permanent and complete 100%
Diplegia Paralysis of the upper or lower limbs on both sides of the body
Permanent and complete 100%
Loss or complete loss of use of both lower limbs (defined as the lower limb from above the ankle)
Loss of both legs above the ankle, or the complete loss of the ability to use them
Permanent and complete 100%
Loss or complete loss of use of one or both upper limb(s) above the elbow, or one or both lower limb(s) above the knee
Loss of one or both arms above the elbow, or one or both legs above the knee, or the complete loss of the ability to use them
Permanent and complete 100%
Loss or complete loss of use of an entire hand Loss of a hand, or the complete loss of the ability to use it
Permanent and complete 100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Persistent documented neurological impairment1, despite optimal treatment, and with evidence of the following: 1. 50% or more compression fracture of a vertebral body or multiple level compression fractures AND 2. Two or more spinal operations including laminectomy AND/OR discectomy AND/OR fusion AND/OR surgical motion-preserving technologies such as discarthroplasty and dynamic stabilisation techniques on separate occasions within a five-year period
Spinal disorder Nerve damage that persists even after optimal treatment, and with evidence of the following: 1. A compression fracture that has collapsed 50% or more of the vertebral body (the largest, central part of a vertebra), or compression fractures of several vertebrae AND 2. Two or more spinal operations within the last five years, including a laminectomy (removal of the back of a vertebral bone to relieve pressure on the spinal cord), AND/OR a discectomy (removal of part or all of a cartilage disc between vertebrae), AND/OR a fusion (surgical joining of two or more vertebrae to reduce pain and abnormal movement), AND/OR non fusion (motion-preserving) techniques, such as discarthroplasty (replacement of a damaged disc with an artificial one) and dynamic stabilisation (insertion of a device that stabilises the spine without eliminating its ability to move)
100%
Persistent documented neurological impairment1, despite optimal treatment, and with evidence of the following: 1. Corresponding clinical and radiological evidence of a radiculopathy, defined as motor and sensory deficit, muscle atrophy and clinical signs of nerve tension AND 2. Two or more spinal operations including laminectomy AND/OR discectomy AND/OR fusion AND/OR surgical motion-preserving technologies such as discarthroplasty and dynamic stabilisation techniques on separate occasions within a five-year period
Spinal disorder Nerve damage that persists even after optimal treatment, and with evidence of the following: 1. Evidence of a radiculopathy, (a “pinched nerve”) on examination and an X-ray. Symptoms include motor and sensory damage, muscle atrophy and clinical signs of nerve tension 2. Two or more spinal operations within the last five years, including a laminectomy (removal of the back of a vertebral bone to relieve pressure on the spinal cord), AND/OR a discectomy (removal of part or all of a cartilage disc between vertebrae), AND/OR a fusion (surgical joining of two or more vertebrae to reduce pain and abnormal movement), AND/OR non fusion (motion-preserving) techniques, such as discarthroplasty (replacement of a damaged disc with an artificial one) and dynamic stabilisation (insertion of a device that stabilises the spine without eliminating its ability to move)
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
A disorder of the spine resulting in a diagnosis of bladder incontinence with a permanent indwelling catheter or bowel incontinence with a permanent colostomy
Spinal disorder Disorder has caused bladder or bowel incontinence and the need for a permanent catheter or colostomy
100%
Diagnosis of cauda equina syndrome Cauda equina syndrome (a serious condition caused by compression of the nerves in the lower portion of the spinal canal, which leads to permanent loss of bowel and bladder control, and paralysis of the legs)
Diagnosed 100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Irreversible binaural loss of hearing1 of greater than 85%
as measured by audiometry at hearing thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and with a speech discrimination threshold of less than 60%
Hearing loss Permanent hearing loss1 of more than 85% in both ears (binaural), measured at hearing thresholds (sound levels) of 500Hz, 1000Hz, 2000Hz and 3000Hz, with a speech discrimination threshold (ability to hear and understand speech) of less than 60%
100%
Irreversible and complete loss of hearing1 in both ears (total loss of hearing bilaterally)
Hearing loss Total and permanent hearing loss1 in both ears 100%
Bilateral loss of visual acuity as evidenced by a Snellen chart reading of 20/200 or worse in the best eye after full correction
Visual loss Loss of clear vision in both eyes, with a Snellen chart (eye-testing chart) reading of 20/200 or worse in the better-functioning eye, even after fully correcting your eyesight with the strongest available lens
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
With layman’s explanation
Total % pay-out
Cancer
11
13
12
Full-thickness burns of more than 18% of the body surface
Burns Full-thickness burns (involving all the layers of the tissue) of more than 18% of the body surface
100%
Full-thickness burns of 9% to 18% of the body surface including the palms of both hands or soles of both feet
Burns Full-thickness burns (involving all the layers of the tissue) of 9 to 18% of the body surface, including the palms of both hands or soles of both feet
100%
Full-thickness burns of more than 25% of the face Burns Full-thickness burns (involving all the layers of the tissue) of more than 25% of the face
100%
Irreversible disfigurement of more than 50% of the body surface caused by a chronic treatment-resistant skin disorder and accompanied by systemic organ involvement of the central nervous system OR the heart OR lungs OR liver OR kidneys, due to the chronic treatment-resistant skin disorder itself
Skin disorders 1. Permanent disfigurement of more than 50% of the body surface, caused by a chronic skin disorder that does not respond to treatment AND 2. That has affected another internal organ, namely the central nervous system, heart, lungs, liver or kidneys
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
A state of unresponsiveness, as evidenced by a Glasgow Coma Scale of 8 and less, which persists for more than 96 hours. (medically-induced comas are excluded)
Coma (being unconscious) A coma that lasts longer than four days and scores 8 and less on the Glasgow Coma Scale (a scale for measuring the level of unconsciousness or severity of a brain injury) (medically-induced comas are excluded)
100%
A traumatic injury to the brain, with resultant documented Glasgow Coma Scale of less than 12/15, caused by an external physical force with: 1. Irreversible cognitive impairment of MMSE < 21/30 OR 2. Permanent neurological deficit (motor and/ or sensory impairment) resulting in continuous professional care and supervision of more than four hours a day
Traumatic (physical) brain injury Caused by an external physical force and leading to a Glasgow Coma Scale (which quantifies the level of unconsciousness or severity of a brain injury) score of less than 12 out of 15, as well as: 1. Permanently reduced mental function with a Mini–Mental State Examination (MMSE) score of less than 21 of a possible 30 OR 2. Permanent damage to the nervous system that impairs movement and/or sensation and requires professional care and supervision for more than four hours per day
100%
Irreversible anatomical distortion of 25% to 50% of the face caused by an external physical force, and which has undergone multi-stage facial reconstructive surgery
Facial injury Permanent distortion of 25% to 50% of the anatomy of the face, caused by an external physical force, and which has undergone several stages of reconstructive surgery
100%
Irreversible anatomical distortion of more than 50% of the face caused by an external physical force
Facial injury Permanent distortion to more than 50% of the anatomy face, which was caused by an external physical force
100%
Total % pay-out
Cancer
11
13
12
Activities of Daily Living14
Permanent failure of 4 out of 5 BrightRock Activities of Daily Living (excluding cognitive failure)
ADL failure Has resulted in permanent inability to perform four out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is where the brain’s capacity to think, remember and judge clearly is reduced)
100%
Permanent failure of cognitive BrightRock Activities of Daily Living (see definition) with an irreversible MMSE of ≤ 18
ADL failure Has resulted in permanent inability to perform the cognitive BrightRock Activities of Daily Living (this refers to the brain’s capacity to think, remember and judge clearly) and a permanent score of 18 or less when a neurologist tests the person’s cognitive (thinking) skills with the Mini Mental State Examination (MMSE)
100%
BrightRock Activities of Daily Living (ADLs)
1. Washing: You rely entirely on someone else to help you wash, bath or shower.
2. Dressing Skills: You need the help of another person to help you fasten clothes (open/close zips, fasten/unfasten buttons, close belts, tie laces) and, if applicable,
attach and fasten any braces, prosthetics or other surgical appliances that you usually wear.
3. Eating and feeding: You’re physically unable to feed yourself and need someone’s help.
4. Mobility: You need physical help when moving between rooms on a level surface, despite the use of an assistive device such as a walking cane or wheelchair.
5. Transferring: You need someone’s help when moving between a bed and a chair.
6. Cognitive Impairment: You have suffered irreversible brain damage, and can no longer perform the Activities of Daily Living without medical help or supervision.
This must be confirmed by a neurologist or psychiatrist and formally tested by a neuropsychologist.
Permanence will be established not less than three months after the event
Appendix
Cancer
11
13
12
Activities of Daily Living14
Reference notes
Brain and nerves 1. Examples of mental and behavioural disorders that result in the severity criteria as specified here include but are not limited to:
• Dementia
• Anxiety disorders
2. Irreversible cognitive impairment must be confirmed by a neuropsychologist assessment.
3. The diagnosis of vestibular dysfunction must be confirmed by a neurologist with supporting investigations (i.e. brain imaging studies). Neurological vestibular conditions excluded from this benefit include vasospastic conditions, such as migraines.
4. Must be confirmed by a neurologist with supporting investigations.
5. The diagnosis of treatment-resistant generalised epilepsy is defined as the failure to control seizure activity by surgery or an adequate trial (despite full patient compliance) of at least three antiepileptic medications. At least two must have been used in combination (confirmed by therapeutic blood levels where possible). This diagnosis must be confirmed by a neurologist, with supporting investigations i.e. EEG and brain imaging studies. Non-Epileptic Attack Disorder (NEAD) and psychogenic non-epileptic seizure (PNES) are excluded from this benefit category.
6. Loss of language comprehension and production must be confirmed by a neurologist with radiographic evidence in keeping with the clinical findings.
7. The diagnosis of treatment-resistant sleep disorder must be confirmed by formal neurophysiological testing as performed in an accredited sleep laboratory.`
The following mental and behavioural disorders are specifically excluded from this benefit category:
• Factitious disorders
• Substance-use disorders.
Digestive system
1. Eating and functional disorders are excluded from this benefit category.
Heart and blood vessels
1. Examples of cardiovascular or cardio-pulmonary disorders that result in the severity criteria we’ve specified include, but are not limited to:
• Myocardial infarction
• Aortic disease, e.g. aneurysm.
2. Treatment resistant hypertension is high blood pressure that is treated with more than four medicines.
HIV/AIDS
1. For these conditions, claims for insured lives who have already been diagnosed as HIV-positive prior to taking out their cover with BrightRock are excluded.
1 2 3
Cancer
11
13
12
Activities of Daily Living14
Reference notes
Hormones 1. The endocrine disorders (as confirmed by an endocrinologist) must be supported by the relevant laboratory and radiological investigations and shown to be persistent despite full compliance with optimal medical and surgical treatment. Psychogenic polydipsia is excluded.
Lungs and breathing
1. Examples of respiratory disorders that result in the severity criteria as specified here include but are not limited to:
• Chronic obstructive airways disease
Muscles, bones and joints
1. Neurological impairment must include evidence of a lower motor neuron lesion with evidence of:
• Motor weakness of the muscles corresponding to the nerve level involved AND
• Prominent muscle wasting.
Sensory system
1. The hearing loss must be permanent and completely uncorrectable by surgery or a fitted hearing aid/device.
2. Vestibular conditions excluded from this benefit include:
• Viral labyrinthitis
• Vestibular neuronitis
1 2 3
* Condition-specific alcohol exclusion:
For the conditions marked with the * symbol, claims for injuries or illnesses related to long-term alcohol or drug abuse are excluded.
** Our optimal treatment requirement doesn’t apply to these conditions
We won’t apply the requirement for optimal treatment to a claim on clinical definitions marked with the ** symbol.
** Our optimal treatment requirement doesn’t apply to these conditions
We won’t apply the requirement for optimal treatment to a claim on clinical definitions marked with the ** symbol, but only where the limb(s) or finger(s) have been amputated.
Appendix
Cancer
11
13
12
Activities of Daily Living14
Appendix
BrightRock has the right to ask for a second opinion if the medical information we initially receive is not sufficient to prove conclusively that the client has met the claims criteria. For example, if the information provided is not sufficient to confirm the client’s diagnosis. Depending on the case, BrightRock may recommend a medical professional for the second opinion or the client may consult a medical professional of their own choosing.
“Confirmed” means that the diagnosis has been made with appropriate and supporting medical evidence in the form of reports, blood tests, histological findings, imaging, scans or any other relevant investigations.
BrightRock has no explicit general survival or general waiting periods on our permanent expenses cover (condition-specific waiting periods, however, do apply for certain conditions. Please refer to the clinical definitions contained in this document to see which ones have this type of waiting period). This gives you greater certainty of claim. If the insured life has a valid permanent expenses claim that meets our clinical criteria but dies before we have made the pay-out, BrightRock will still pay the claim out. This applies as long as the insured life was alive at the time of the diagnosis that led to the permanent expenses claim.
Unless otherwise specified, if you become ill or injured, you must get medical treatment as soon as possible to qualify for a claim against your permanent expenses cover on your BrightRock policy. You must fully comply with your doctor’s advice and finish your full treatment regime. If you don’t seek and receive optimal treatment and fail to comply with your treatment, the claim will be invalid.
1 2 3
Blood production disorders
HIV/ AIDS 1
Sensory System 1
Trauma