CI definitions: Covered conditions, explained (Part 2)

Last week we discussed an industry initiative led by Munich Re, that brought CI insurers together to create a new set of benchmark definitions for the Canadian marketplace. The language might be a bit much to get through, but this week we give you the new set of benchmark definitions created by committee members from firms that generate more than 80% of the Canadian CI insurance market’s new business premiums.

See also: Demystifying CI definitions (Part 1).

Generally, all contracts will include wording that requires diagnosis and treatment of any covered condition be undertaken by a specialist or physician licensed in Canada, the United States of America or other specifically approved jurisdiction.

A specialist is a licensed medical practitioner who has been trained in the specific area of medicine relevant to the covered illness for which benefit is being claimed, and who has been certified by a specialty examining board. If a specialist is not available, a condition may be diagnosed by a qualified medical practitioner practising in Canada or the United States of America if the arrangement is approved by the insurer.

The term specialist includes, but is not limited to, cardiologist, neurologist, nephrologist, oncologist, ophthalmologist, burn specialist and internist. The specialist must not be the policy owner, the insured or a relative of or business associate of the policy owner or of the insured.

Diagnosis under the policy means complete fulfillment of the condition definition as described under the policy. The date of diagnosis must occur while the policy is in force. All contracts generally have a survival period.

Survival period is the period starting on the date of diagnosis of the critical condition and ending 30 days following the date of diagnosis of the critical condition, except where this time frame is modified under the policy. The survival period does not include the number of days on life support. The insured person must be alive at the end of the survival period and must not have experienced irreversible cessation of all brain functions.

Life support means the insured person is under the regular care of a licensed physician for nutritional, respiratory and/or cardiovascular support when irreversible cessation of all brain functions has occurred.

Please note that certain terms, such as irreversible and surgery, used in the definitions below should be defined in your client’s contract.

Benchmark definitions and 26 critical illness conditions explained

See also: Demystifying CI definitions (Part 1).

Alzheimer’s disease: A definite diagnosis of a progressive degenerative disease of the brain. The insured person must exhibit the loss of intellectual capacity involving impairment of memory and judgment, which results in a significant reduction in mental and social functioning, and require a minimum of eight hours of daily supervision. The diagnosis of Alzheimer’s disease must be made by a specialist.

Exclusion: No benefit will be payable under this condition for all other dementing organic brain disorders and psychiatric illnesses.

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

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

• marrow stimulating agents; • immunosuppressive agents; • bone marrow transplantation.

The diagnosis of aplastic anemia must be made by a specialist.

Bacterial meningitis: A definite diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of diagnosis. The diagnosis of bacterial meningitis must be made by a specialist.

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

Benign brain tumour: A definite diagnosis of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgical or radiation treatment or cause irreversible objective neurological deficit(s). Diagnosis of benign brain tumour must be made by a specialist.

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

Moratorium period exclusion: No benefit will be payable under this condition if, within the first 90 days after the later of: • the effective date of the policy, or • the effective date of last reinstatement of the policy, the insured person has any: • signs, symptoms or investigations that lead to a diagnosis of benign brain tumour, regardless of when the diagnosis is made, • a diagnosis of benign brain tumour.

This medical information as described above must be reported to the company within six months of the date of the diagnosis. If this information is not provided, the company has the right to deny any claim for benign brain tumour or any critical illness caused by benign brain tumour or its treatment.

Blindness: A definite diagnosis of the total and irreversible loss of vision in both eyes, evidenced by:

• the corrected visual acuity being 20/200 or less in both eyes; or • the field of vision being less than 20 degrees in both eyes.

The diagnosis of blindness must be made by a specialist.

Cancer (life-threatening): A definite diagnosis of a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The diagnosis of cancer must be made by a specialist.

Exclusion: No benefit will be payable under this condition for the following non-life-threatening cancers:

• carcinoma in situ or • stage 1A malignant melanoma (melanoma less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion), or • any non-melanoma skin cancer that has not metastasized or • stage A (T1a or T1b) prostate cancer.

Moratorium period exclusion: No benefit will be payable under this condition if, within the first 90 days after the later of: • the effective date of the policy, or • the effective date of last reinstatement of the policy, the Insured Person has any of the following: • signs, symptoms or investigations, that lead to a diagnosis of cancer (covered or excluded under the policy), regardless of when the diagnosis is made, • a diagnosis of cancer (covered or excluded under the policy).

This medical information as described above must be reported to the company within six months of the date of the diagnosis. If this information is not provided, the company has the right to deny any claim for cancer or any critical illness caused by any cancer or its treatment.

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

Exclusion: No benefit will be payable under this condition for: • a medically induced coma or • a coma that results directly from alcohol or drug use or • a diagnosis of brain death.

Coronary angioplasty: The undergoing of an interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood. The procedure must be determined to be medically necessary by a specialist.

Coronary artery bypass surgery: The undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s), excluding any non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of an obstruction. The surgery must be determined to be medically necessary by a specialist.

Deafness: A definite diagnosis of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The diagnosis of deafness must be made by a specialist.

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

• heart attack symptoms • new electrocardiogram (ECG) changes consistent with a heart attack • development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.

The diagnosis of heart attack must be made by a specialist.

Exclusion: No benefit will be payable under this condition for: • elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves; or • ECG changes suggesting a prior myocardial infarction, which do not meet the heart attack definition as described above.

Heart valve replacement: The undergoing of surgery to replace any heart valve with either a natural or mechanical valve. The surgery must be determined to be medically necessary by a specialist.

Exclusion: No benefit will be payable under this condition for heart valve repair.

Kidney failure: A definite diagnosis of chronic irreversible failure of both kidneys to function, as a result of which regular hemodialysis, peritoneal dialysis or renal transplantation is initiated. The diagnosis of kidney failure must be made by a specialist.

Loss of independent existence: A definite diagnosis of:

a) a total inability to perform, by oneself, at least two of the following six activities of daily living; or b) cognitive impairment, as defined below

[…]for a continuous period of at least 90 days with no reasonable chance of recovery. The diagnosis of loss of independent existence must be made by a specialist.

Activities of daily living are:

• Bathing — the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of equipment. • Dressing — the ability to put on and remove necessary clothing including braces, artificial limbs or other surgical appliances. • Toileting — the ability to get on and off the toilet and maintain personal hygiene. • Bladder and bowel continence — the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained. • Transferring — the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment. • Feeding — the ability to consume food or drink that already has been prepared and made available, with or without the use of adaptive utensils.

Cognitive impairment is defined as mental deterioration and loss of intellectual ability, evidenced by deterioration in memory, orientation and reasoning, which are measurable and result from demonstrable organic cause as diagnosed by a specialist. The degree of cognitive impairment must be sufficiently severe as to require a minimum of eight hours of daily supervision.

Determination of a cognitive impairment will be made on the basis of clinical data and valid standardized measures of such impairments.

Exclusion: No benefit will be payable under this condition for any mental or nervous disorder without a demonstrable organic cause.

Loss of limbs: A definite diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation. The diagnosis of loss of limbs must be made by a specialist.

Loss of speech: A definite diagnosis of the total and irreversible loss of the ability to speak as the result of physical injury or disease, for a period of at least 180 days. The diagnosis of loss of speech must be made by a specialist.

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

Major organ failure on waiting list: A definite diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under major organ failure on waiting list, the insured person must become enrolled as the recipient in a recognized transplant centre in Canada or the United States of America that performs the required form of transplant surgery.

For the purposes of the survival period, the date of diagnosis is the date of the insured person’s enrolment in the transplant centre. The diagnosis of the major organ failure must be made by a specialist.

Major organ transplant: A definite diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under major organ transplant, the insured person must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The diagnosis of the major organ failure must be made by a specialist.

Motor neuron disease: A definite diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy or pseudo bulbar palsy. The diagnosis of motor neuron disease must be made by a specialist.

Multiple sclerosis: A definite diagnosis of at least one of the following:

• two or more separate clinical attacks, confirmed by magnetic resonance imaging (MRI) of the nervous system, showing multiple lesions of demyelination or • well-defined neurological abnormalities lasting more than six months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination; or • a single attack, confirmed by repeated magnetic resonance imaging of the nervous system, which shows multiple lesions of demyelination that have developed at intervals at least one month apart.

The diagnosis of multiple sclerosis must be made by a specialist.

Occupational HIV infection: A definite diagnosis of infection with human immunodeficiency virus (HIV) resulting from accidental injury during the course of the insured person’s normal occupation, which exposed the person to HIV-contaminated body fluids. The accidental injury leading to the infection must have occurred after the later of the effective date of the policy or the effective date of last reinstatement of the policy.

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

a) The accidental injury must be reported to the insurer within 14 days of the accidental injury; b) A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative; c) A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive; d) All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America; e) The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines.

The diagnosis of occupational HIV infection must be made by a specialist.

Exclusion: No benefit will be payable under this condition if: • The insured person has elected not to take any available licensed vaccine offering protection against HIV or • A licensed cure for HIV infection has become available prior to the accidental injury; or • HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

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

Parkinson’s disease: A definite diagnosis of primary idiopathic Parkinson’s disease, which is characterized by a minimum of two or more of the following clinical manifestations: muscle rigidity, tremor or bradykinesis (abnormal slowness of movement, sluggishness of physical and mental responses). The insured person must require substantial physical assistance from another adult to perform at least two of the following six activities of daily living. The diagnosis of Parkinson’s Disease must be made by a specialist.

Activities of daily living are:

• Bathing — the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of equipment. • Dressing — the ability to put on and remove necessary clothing including braces, artificial limbs or other surgical appliances. • Toileting — the ability to get on and off the toilet and maintain personal hygiene. • Bladder and bowel continence — the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained. • Transferring — the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment. • Feeding — the ability to consume food or drink that already has been prepared and made available, with or without the use of adaptive utensils.

Exclusion: No benefit will be payable under this condition for all other types of Parkinsonism.

Severe burns: A definite diagnosis of third-degree burns over at least 20% of the body surface. The diagnosis of severe burns must be made by a specialist.

Stroke (cerebrovascular accident): A definite diagnosis of an acute cerebrovascular event caused by intracranial thrombosis or hemorrhage, or embolism from an extra-cranial source, with:

• acute onset of new neurological symptoms and • new objective neurological deficits on clinical examination

[…] persisting for more than 30 days following the date of diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing. The diagnosis of stroke must be made by a specialist.

Exclusion: No benefit will be payable under this condition for: • transient ischemic attacks or • intracerebral vascular events due to trauma; or • lacunar infarcts that do not meet the definition of stroke as described above.

The authors: Hélène Michaud is the assistant vice-president, marketing, at Munich Reinsurance Company; Dr. Tim Meagher, Munich Re medical director and director of clinical development at the McGill University Health Centre, was an active participant in the CI Benchmark Definition committee; Nick Kirwan was chairman of the Association of British Insurers (ABI) Protection Committee, which produced the standard CI definitions in the U.K. He is currently ABI’s assistant director of head of health and protection.

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(03/25/09)