1 clinical claims definitions: temporary expenses cover€¦ · introduction – clinical...

Temporary Expenses Cover

Criteria for specific conditions:

Introduction

• Fractures

• Hospitalisation and surgery

• Child claims

• Impairments (by body system):

3

Blood production disorders

Brain and nerves

Cancer

Digestive system

Heart and blood vessels

HIV/AIDS

Hormones

Kidney and genital/urinary tract

Lungs and breathing

Muscles, bones and joints

Sensory system

Skin and soft tissue disorders

Trauma

Sickness criteria2

1

Appendix

Reference notes

Assessment criteria

Definition sets A(v5), B(v5), C(v5), D(v5), E(v1)

Activities of Daily Living

Reference notes

This document applies to your temporary expense cover.

Clinical claims definitions: Temporary Expenses Cover

Cover for illness or injury with a financial impact

Additional expense needs

Death-related needs

Debt needs

Healthcare needs

Childcare needs

Household needs

BrightRock Life Ltd, an authorised financial services provider (FSP 11643, Registration number: 1996/014618/06) is an underwriting management agency ofSanlam Life Insurance Ltd, an authorised financial services provider and registered insurer (FSP 2759, Registration number: 1998/021121/06).Copyright © May 2018 BrightRock. All rights reserved. Terms and conditions apply.

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.

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.

Introduction – clinical definitions for temporary expenses cover claims


Introduction

• Fractures


• Child claims


3


Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria2

1

Appendix

Reference notes

Assessment criteria


Definition sets A(v5), B(v5), C(v5), D(v5), E(v1)Temporary Expenses Cover

We will pay valid claims for the pay-out period you chose if you meet our claims criteria. You will only qualify for a pay-out once your chosen waiting period has passed. For most conditions, we’ll pay your claim if you meet our sickness criteria. BrightRock will also pay your claim if you meet the clinical criteria we’ve set for the following specific conditions: impairment, fractures, hospital admissions and surgical procedures.

For more information about your cover and the choices you made, please check your BrightRock Owner’s manual.

Please note that the information provided in this clinical definitions document applies only to your cover for temporary expenses cover claims under an illness or injury that you can recover from. It does not apply to your claims for additional expense needs, or to permanent claims under your cover for an illness or injury with a financial impact that’s permanent.

1. We’ll pay you out if you meet our sickness criteria

• If you’re booked off for 14 days or less:

Subject to the waiting period you chose, we’ll pay your cover out if your doctor books you off for 14 days. All we need is a completed claims form and a valid sick note from your doctor.

• If you’re booked off for more than 14 days After the first 14 days of your illness or injury, we’ll ask you for a

completed claims form and a BrightRock Sick Note completed by your doctor. You can receive pay-outs for 12 or 18 months (the first half of the pay-out period you chose of either 24 months or 36 months) based on the BrightRock Sick Note. If you’re still booked off work after this period, we’ll ask you to do a Personal Job Fitness Test. If you fail the Personal Job Fitness Test, you can continue receiving pay-outs for up to another 12 or 18 months (the second half of the pay-out period you chose of either 24 or 36 months).

See the section titled “Sickness criteria” for further information.

2. We’ll pay you out if you meet our clinical definitions for specific conditions or events

• If you suffer a fracture, get admitted to hospital or have a specific surgical procedure, as defined in this document. If you meet the criteria set out in this clinical definitions document for Fractures, Hospital admissions or Surgical procedures, we’ll pay your claim as shown. You also have the peace of mind that, if you don’t recover, you can continue receiving monthly payments if you meet the sickness criteria under point 1 above.

• If your child qualifies for a claim under your child additional expense needs cover. If you have cover for additional expense needs and childcare needs on your policy, and we approve a claim for child additional expense needs, we’ll pay your claim as shown in the section titled “Child claims”. We won’t apply your waiting period to child claims.

• If you’re diagnosed with a condition, as listed in the impairments section of this clinical definitions document. If you’re diagnosed with any of the conditions listed under impairments, we’ll pay you 100% of your regular monthly amount. How long you’ll receive the pay-out depends on how serious your condition is – you might qualify for a pay-out for only the first half of the maximum pay-out period (12 or 18 months) or for the full period (24 or 36 months). If you’ve received pay-outs for only the first half of the maximum pay-out period and you’ve still not recovered, you can continue receiving monthly payments if you meet the sickness criteria under point 1 above.

If you also have cover for the same financial needs for an illness or injury with a financial impact that’s permanent

If you qualify for a claim for the same condition and for the same financial needs under your cover for an illness or injury with a financial impact that’s permanent, we’ll apply the following rules.

• If your cover for temporary claims is lower or equal to your recurring pay-outs from your cover for an illness or injury with a financial impact that’s permanent, you’ll receive the permanent pay-outs only.

• If your cover for temporary claims is higher than your recurring pay-outs from your cover for an illness or injury with a financial impact that’s permanent, you’ll receive the permanent pay-outs PLUS the difference between the two cover amounts. This ensures that you get the maximum benefit from your cover. The pay-out of this additional amount (the difference between your temporary and permanent pay-outs) will continue for the pay-out period specified in this document. In the case of a 100% permanent claim not contained in this explicit list of conditions (for example, if you qualify for a pay-out under the Personal Job Fitness Test), the pay-out of this additional amount will continue for the selected maximum pay-out period, unless the cover comes to an end earlier. The effect of this is to put you in the same position that you would have been if we’d paid your full cover for the temporary claim for the pay-out period specified in this document, and then followed it with a pay-out of your full cover for an illness or injury with a financial impact that’s permanent.

Reference notes

BrightRock’s sickness criteria


Introduction

• Fractures


• Child claims


3


Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

Assessment criteria


Definition sets A(v5), B(v5), C(v5), D(v5), E(v1)Temporary Expenses CoverReference notes

We will pay valid claims for the pay-out period you chose if you meet our claims criteria. You will only qualify for a pay-out once your chosen waiting period has passed. For most conditions, we’ll pay your claim if you meet our sickness criteria. Elective cosmetic surgery, corrective eye surgery and routine pregnancy don’t qualify for a pay-out.

1. BrightRock’s sickness criteria for the first half of the maximum pay-out period (the first 12 or 18 months)

To qualify for the regular monthly pay-outs during the first half of the pay-out period you selected, you need only prove that you meet our sickness criteria and that you were receiving a regular income at the time of your claim.

You must provide us with:

• A valid doctor’s certificate. The doctor’s certificate must show that you have suffered a specific illness or injury that prevents you from being able to work or function at your usual, full capacity. It must also show the period for which your doctor has booked you off work.

If your doctor has cleared you to return to work but only for part of the day, we will reduce your pay-out accordingly. This means your pay-out will only cover that portion of the day for which you have been booked off work.

• A BrightRock Sick Note, completed by your treating doctor. Our claims department will send your doctor a BrightRock Sick Note to complete. If the information your doctor provides in this Sick Note provides sufficient proof – in our view – of your illness or injury, we’ll approve your pay-out. We’ll pay you out even if you are still receiving any active earnings in the period for which your doctor has booked you off for this illness or injury

Depending on the information we receive in the completed BrightRock Sick Note, we may call for further medical evidence. This could include proof that you are receiving optimal medical treatment and that you’re complying fully with the treatment your doctor has prescribed.

Your doctor has a 14-day grace period to fill in the BrightRock Sick Note. If you receive any pay-outs during this grace period and we later reject your claim after receiving the Sick Note, you won’t receive any further pay-outs for this specific claim or for any related conditions. We also won’t allow any further grace periods for future claims.

• Proof of employment. We’ll ask that you provide us with proof that you were employed at the time you suffered the illness or injury. If you weren’t employed just before your illness or injury, you don’t qualify for cover. However, we’ll waive this requirement if you were on special leave at the time of your illness or injury.

• Proof of income. We’ll also ask you for proof of your income at the time of your illness or injury. If the cover you’ve taken out with us is more than the net income you were earning at the time of the claim, we’ll pay you out the net income amount you can prove and not the full cover amount. This

is in line with industry practice, to prevent over-insurance. You can prove your income by submitting bank statements, giving us a copy of your latest payslip or, if you’re self-employed, a completed “BrightRock confirmation of income and benefits” form. It’s important to note that we don’t require you to prove that you’ve lost any income as a result of the illness or injury. We can waive this requirement for proof of income if you were on special leave at the time of your claim.

We’ll also ask you to provide us with a completed BrightRock claims form. This form includes questions about your personal details, medical condition and the doctors who’ve been treating you. It ensures that we ask you for everything we need upfront, so we don’t have to ask you for more information later on.

2. BrightRock’s sickness criteria for the second half of the maximum pay-out period (the second 12 or 18 months)

After receiving pay-outs for the first half of the pay-out period you selected, you can qualify for another set of monthly pay-outs if you meet our sickness criteria and you fail a Personal Job Fitness Test.

If you have not recovered after the first half of your maximum pay-out period, you can still receive further pay-outs for the same claims event if you meet the criteria. If you fail a Personal Job Fitness Test administered by a BrightRock-accredited occupational therapist, we’ll approve pay-outs for a further 12 or 18 months (depending on whether you chose 24 or 36 months as your maximum pay-out period). The Personal Job Fitness Test assesses your ability to perform the key duties linked to the specific job that we have on record for you. This is the job you put on your proposal form when you first applied for cover with us, or that you later updated with us. If you fail the Personal Job Fitness Test, we’ll pay you out even if you’re receiving any regular active earnings.

However, if the Personal Job Fitness Test shows that you not able to perform the key tasks and duties for your specific occupation, but can still perform elements of your job (but not all), we will make a partial Personal Job Fitness Test payment. The amount paid will depend on how much of your job you can and can’t perform.

BrightRock clinical definition

Condition or medical procedure

How serious it is


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

Seven-day waiting period

One-month waiting period

With layman’s explanation Payment period (months)

2

3

Assessment criteria



Spine (compression fracture of more than 50% of the vertebral body or burst fracture)

Fractures or compression of the vertebrae of the spine

At least 50% of a vertebral body (disc) is compressed or fractured (broken or collapsed), or has burst

3 2

Fracture or fracture dislocation of spine requiring surgery

Fracture of a backbone or dislocation of the spine (between two backbones) caused by a fracture

Has undergone surgical repair 3 2

Fracture of the body of a spinal vertebra Fracture of the main part of the vertebra: the thick, oval-shaped piece of bone at the front

A spinal body is fractured (broken or collapsed)

3 2

Facial bones fracture – Le Fort III Fractures of the bones of the face The fracture is classified as Le Fort III. This means that the bones of the upper jaw (maxilla) have separated from the cranial bones, which make up the skull

3 2

Fracture of the pelvis Fracture of one or more bones of the pelvis, a group of bones at the base of the spine

One or more of the pelvic bones are fractured

3 2

Fracture of the thigh Fracture of the femur (thigh bone) The thigh bone is fractured (broken) 3 2

Fractures of bony elements of a spinal vertebra, other than the vertebral body

Fracture of the bony elements of the spinal discs, other than the body of the disc. These bony elements may include fractures of the spinous processes (bony protrusions at the back of the disc), transverse processes (bony protrusions from the side of the disc), lamina (arched part of the spinal disc) or pedicle (stub-shaped bone that connects the lamina to the vertebral body).

One or more of the bony elements of the spine are fractured (broken)

2 1

Multiple rib fractures with unstable rib cage

Multiple fractured ribs More than one rib is fractured, and the rib cage is no longer properly aligned

2 1

Fracture of the shoulder blade Fracture of the triangle-shaped bone (scapula) at the back of the shoulder

The shoulder blade is fractured 2 1

Fracture of the upper arm Fracture of the humerus (upper arm), the bone between the elbow and the shoulder

The upper arm is fractured 2 1

1 2Reference notes



How serious it is


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

Seven-day waiting period

One-month waiting period


2

3

Assessment criteria


Definition sets A(v5), B(v5), C(v5), D(v5), E(v1)Temporary Expenses Cover 1 2Reference notes

Fracture of the knee cap Fracture of the patella/knee cap (the bone at the front of the knee)

The knee cap is fractured 2 1

Fracture of the leg between knee and foot Fracture of either the tibia or fibula, or a fracture of both (the bones that make up the lower leg between the knee and the foot)

The tibia, fibula or both are fractured 2 1

Compression fracture of a vertebral body <10%

Fracture with compression of the vertebrae of the spine

Less than 10% of a vertebral body (disc) is compressed and fractured (broken or collapsed), or has burst

1 0

Skull (except bones of the nose or face) fracture

Fracture of any of the bones that make up the skull, other than the nose or the face

The skull (excluding the nose or face) is fractured

1 0

Facial bones fracture – Le Fort II Fractures of the bones of the face The fracture is classified as Le Fort II. This means that the bones of the upper jaw (maxilla) have broken in a triangular shape, with the fractures meeting at the bridge of the nose.

1 0

Fracture of the collarbone Fracture of the clavicle (collarbone), the horizontal bone above the rib cage which makes up the front of the shoulders

The collarbone is fractured 1 0

Fracture of the forearm above the wrist Fracture of either the radius or ulna, or both, the bones that make up the forearm

The forearm is fractured 1 0

Fracture of the hand requiring plaster or surgery

Fracture of a bone in the hand Has been set in plaster or undergone surgery

1 0

Fractured hind foot (calcaneus, talus, navicularis, cuboid or any of the three cuneiform bones)

Fractures to the bones of the hind foot (including the heel bone, ankle bone or the bones of the mid foot)

One or more of the bones of the hind foot are fractured

1 0


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3



How serious it isSeven-day

waiting periodOne-month

waiting period


Assessment criteria



Surgical replacement of a hip joint An illness or injury of the hip joint Has undergone hip replacement surgery, where the hip joint is replaced with an artificial joint

4 3

Complete rotator cuff rupture Tear of the group of tendons and muscles that surround the shoulder joint

Complete rupture of all of the tendons of the rotator cuff

3 2

Complete achilles tendon rupture Injury to the Achilles tendon, the tendon that connects your calf muscle to the bone of your heel

Complete rupture of the Achilles tendon 3 2

Surgical replacement of a shoulder joint An illness or injury of the shoulder joint The shoulder joint is surgically replaced with an artificial joint

3 2

Surgical replacement of a knee joint An illness or injury of the knee joint The knee joint is surgically replaced with an artificial joint

3 2

Removal of the neck or lower back intervertebral discs, or fusion of the neck or lower back vertebrae

• Surgery to (removal of) the discs between the backbones of the neck or the lower back; or

• Fusion (joining together) of backbones of the neck or lower back to limit movement

Has undergone surgical removal or fusion 3 2

Surgical repair of rotator cuff syndrome of the shoulder

Injury to the muscles and tendons that surround the shoulder joint


Knee cruciate ligament reconstruction Injury to either of the anterior or posterior (front or back) cruciate ligaments inside the knee, which connect the upper and lower leg to each other

Has undergone surgical reconstruction (repair of the tear in the ligament)

2 1

Ankle ligament repair Injury to one of the ligaments of the ankle Has undergone surgical repair 2 1

Surgical replacement of an elbow joint Illness or injury of the elbow joint The elbow joint is replaced with an artificial joint

2 1

Surgical replacement of a wrist joint Illness or injury of the wrist joint The wrist joint is replaced with an artificial joint

2 1

Surgical replacement of an ankle joint Illness or injury of the ankle joint The ankle joint is replaced with an artificial joint

2 1

Reference notes1 2


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3



How serious it isSeven-day

waiting periodOne-month

waiting period


Assessment criteria



Penetrating gun shot wound into the chest, abdomen or neck

A gunshot wound to the chest, abdomen (lower stomach area) or neck

The bullet has pierced the skin and entered the tissue of the chest, abdomen or neck

2 1

Penetrating stab wound into the chest, abdomen or neck

A stab wound to the chest, abdomen (lower stomach area) or neck

The knife or other object has pierced the skin and entered the tissue of the chest, abdomen or neck

2 1

Knee medial or lateral ligament repair Injury to one of the ligaments on either side of the knee


Abdominal injury with liver rupture, spleen rupture or kidney damage requiring emergency surgical repair

Injury to the abdomen (lower stomach area) that has caused the liver or spleen to burst or has damaged the kidneys

Has undergone emergency surgical repair 1 0

Acute disc lesion of the spine Abnormal tissue changes to any of the intervertebral discs of the spine

Structural damage to at least one disc between back bones. The lesions are acute, meaning their onset is sudden .

1 0

Hospitalisation longer than a week but less than a month

Admission to a hospital ward The stay in hospital is longer than a week and shorter than a month

1 0

1 2


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

With layman’s explanation



How serious it isPayment period

(months)

Assessment criteria



Child receives a 75% additional expense needs claim An illness or injury that's permanent 1

Child receives a 100% additional expense needs claim An illness or injury that's permanent 3

Your chosen waiting period will not apply to any pay-outs made under this cover for child claims.

Reference notes


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria



How serious it is24-month

option36-month

option




Refractory pancytopaenia resulting from an irreversible, treatment-resistant disorder with any two of the following:1. Persistent haemoglobin levels

of ≤ 8g/dl OR2. Neutropenia of < 1x10⁹ WBC/l OR3. Thrombocytopenia of < 100x10⁹/l

Pancytopaenia (a lack of all types ofblood cells) that persists as a results of anirreversible disorder that doesn’t respondto treatment and occurs with any two ofthe 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

24 36

Irreversible treatment-resistant haematological disorder that requires monthly blood product transfusion for at least six continuous months and manifests with any of the following:

1. Persistent haemoglobin levels of ≤ 8g/dl

OR

2. Neutropenia of < 1x10⁹ WBC/l OR

3. Thrombocytopenia of < 100x10⁹/l

Irreversible blood disorder that doesn’trespond to treatment, requires monthlyblood or blood product transfusions for atleast six continuous months and presentswith any 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

12 18


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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 behavioural problem

For more than six months at a time 24 36

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

24 36

Documented treatment-resistant mental and behavioural disorder¹ with evidence of all of the following criteria in the last two years:


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)

24 36

Documented treatment-resistant mental and behavioural disorder¹ with evidence of all of the following criteria in the last year:


2. Admission to a psychiatric in-patient facility for 12 weeks or longer in total AND

3. A full course of ECT


With evidence of all of the following in the last year:


2. Admission to a psychiatric hospital or clinic for at least 12 weeks AND

3. A full course of ECT (electroconvulsive or shock therapy)

24 36

1 2 3 4 5

*

*

*

*

* *


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Documented treatment-resistant mental and behavioural disorder¹ with evidence of all of the following criteria in the last two years:


2. Admission to a psychiatric in-patient facility for four weeks or longer in total


With evidence of all of the following in the last two years:


2. Admission to a psychiatric hospital or clinic for at least four weeks

12 18

Documented treatment-resistant mental and behavioural disorder¹ with evidence of all of the following criteria in the last year:


2. Admission to a psychiatric in-patient facility for 12 weeks or longer in total


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

12 18

Medically certified institutionalisation for a mental and behavioural disorder of at least three months continuously

Admission to a recognised mental healthfacility for a mental and behavioural1

problem

For a continuous period of at least three months

12 18

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

24 36

*

*

*

*

*

*

1 2 3 4 5


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Documented treatment-resistant generalised epilepsy⁵ of least three month’s duration (despite optimal treatment and patient compliance), with more than two seizures per week

Epilepsy Documented generalised epilepsy⁵ of more than 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

12 18

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 or 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

24 36

Non-traumatic organic cognitive disorder (excluding psychological disorders) resulting in irreversible cognitive impairment² as evidenced by Mini Mental State Examinations (MMSE) < 21/30

Cognitive disorder Any condition affecting cognitive function (the brain’s capacity to think, remember and judge clearly) that is not due to physical injury or psychological disorders. The condition also leads to permanent cognitive impairment² with a Mini-Mental State Examination (MMSE) score of less than 21 out of 30

12 18

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)

24 36

Confirmed irreversible central respiratory failure (on a life-support system)

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

24 36

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

24 36

*

*

*

*

*

*

*

*

1 2 3 4 5


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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

24 36

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 dysfunction causing an inability to stand without a cane or other supportive device

24 36

Irreversible cerebellum dysfunction⁴ resulting in the inability to walk without assistive devices

Disorders of the cerebellum (part of the brain responsible for coordination and balance)

Permanent cerebellar dysfunction⁴ causing an inability to walk without a cane or other walking device

12 18

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 cranialnerves, 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)

24 36

Irreversible unilateral vestibulocochlear nerve palsy⁴ resulting in hearing-loss and vestibular dysfunction manifesting as attacks of nausea, vomiting, vertigo and dizziness

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)

24 36

Irreversible unilateral trigeminal nerve palsy⁴ resulting in permanent absent corneal reflex, loss of facial sensation and impairment of mastication

Disorders of cranial nerve V (the trigeminal nerve)

Permanent trigeminal nerve palsy⁴ (paralysis) on one side of the face causing permanent absence of a corneal reflex (the blink reflex), loss of facial sensation, and impaired chewing ability

12 18

Irreversible unilateral facial nerve palsy⁴ resulting in the total inability to control eyelid closure

Disorders of cranial nerve VII (the facial nerve)

Permanent facial nerve palsy⁴ (paralysis) on one side, causing a complete inability to control closing the eyelid

12 18

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• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Irreversible unilateral glossopharyngeal nerve palsy⁴ resulting in dysarthria, dysphagia, dysphonia, regurgitation and/or aspiration

Disorders of cranial nerve IX (the glossopharyngeal nerve)

Permanent glossopharyngeal nerve palsy⁴ (paralysis) on one side, causing dysarthria (the inability to speak clearly), dysphagia (difficulty swallowing), dysphonia (difficulty producing sound), regurgitation and/or aspiration (inhaling stomach contents)

12 18

Irreversible unilateral vagus nerve palsy⁴ resulting in dysarthria, dysphagia, dysphonia, regurgitation and/or aspiration

Disorders of cranial nerve X (the vagus nerve)

Permanent vagus nerve palsy⁴ (paralysis) on one side, causing dysarthria (the inability to speak clearly), dysphagia (difficulty swallowing), dysphonia (impaired voice sound production), regurgitation and/or aspiration (inhaling stomach contents)

12 18

Irreversible unilateral hypoglossal nerve palsy⁴ resulting in dysarthria, dysphagia, regurgitation and/or aspiration

Disorders of cranial nerve XII (the hypoglossal nerve)

Permanent hypoglossal nerve palsy⁴ (paralysis) on one side, causing dysarthria (the inability to speak clearly), dysphagia (difficulty swallowing), regurgitation and/or aspiration (inhaling stomach contents)

12 18

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• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

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3

Assessment criteria




option36-month

option




Any stage IV cancer (which includes a lymphoma Ann Arbor stage 4, leukaemia RAI stage 3 or 4 or Binet C, brain tumour WHO grade III or Multiple Myeloma stage III)

1. Any stage IV cancer

2. Ann Arbor stage IV lymphoma (a cancerous tumour of the lymph nodes) that has spread extensively

3. Advanced leukaemia (cancer of the blood cells) considered RAI stage III or IV, or Binet C

4. Brain tumour that is considered WHO (World Health Organisation) grade III

5. Multiple Myeloma (a cancer that forms in a type of white blood cell called a plasma cell) which has progressed to stage III

Confirmed diagnosis 24 36

Any stage III cancer or WHO grade II brain tumour that has undergone continuous cancer treatment for 12 months or longer. This specifically excludes anti-hormonal treatments

1. Lymphoma (a cancerous tumour of the lymph nodes) that has spread extensively and is considered Ann Arbor stage IV

2. Leukaemia (cancer of the blood cells) that is advanced and is considered RAI stage III or IV, or Binet C

3. Brain tumour that is considered WHO (World Health Organisation) grade III

Cancer that has been treated for a continuous period of at least 12 months. This does not include anti-hormonal treatments

24 36

Any stage III cancer or WHO grade II brain tumour that is permanent and non-responsive, despite the life insured undergoing medical treatment for a continuous period of six months or longer. It must be confirmed by a specialist oncologist that remission has not been achieved after six months of optimal treatment, and the life insured is unable to function independently.

Any stage III cancer or WHO grade II braintumour that:

1. Is permanent, AND

2. Hasn’t responded to treatment, despite being treated for six months, or more continuously

3. A specialist oncologist has confirmed that the cancer has not gone into remission even after six months of the best available treatment, AND

4. A specialist oncologist has confirmed that the person cannot function with the help of a caregiver.

12 18


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

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Assessment criteria




option36-month

option



Definition sets A(v5), B(v5), C(v5), D(v5), E(v1)Temporary Expenses Cover 1 2 3Reference notes

Chronic gastrointestinal tract and/or liver and/or biliary disorders¹ resulting in:

1. Unintentional treatment-resistant weight-loss of at least 25% over a five-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 that doesn’t respond to treatment of at least 25% 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

24 36

Chronic gastrointestinal tract and/or liver and/or biliary disorders¹ resulting in:

1. Unintentional treatment-resistant weight-loss of at least 15% over a three month period OR

2. Unintentional treatment-resistant weight-loss resulting in a BMI of less than 18

Digestive disorders, defined as: Chronic gastrointestinal tract and/or liver and/or biliary (disorders of the bile ducts or the gallbladder) disorders¹ resulting in:

1. Unintentional weight-loss of at least 15% within three months OR

2. Unintentional weight-loss that does not respond to treatment and that leads to a Body Mass Index (BMI) below 18

12 18

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)

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Appendix

Reference notes

1

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Assessment criteria




option36-month

option




Chronic irreversible liver disease1 with at least two of the following:

1. Serum bilirubin of 34 to 51μmol/l

2. Serum albumin of 30 to 35g/dl

3. Prolonged prothrombin time of 4 to 6 seconds or INR of 1.7 to 2.3

4. Ascites controlled by medication

Digestive disorders, defined as: Chronic, permanent liver disease1 with at least two of the following:

1. Serum bilirubin levels of 34 to 51μmol/l (bilirubin is a bile pigment formed in the liver)

2. Serum albumin levels of 30 to 35g/dl (albumin is a protein that’s produced by the liver and circulates in the blood)

3. Prolonged prothrombin time (a measure of how long it takes for blood to clot) of 4 to 6 seconds, or an international normalised ratio (INR) of 1.7 to 2.3 seconds (INR is a standardised version of the prothrombin time)

4. Ascites (free fluid in the abdominal cavity) that is treated with medication

24 36

Primary sclerosing cholangitis¹ Digestive disorders, defined as: Primary sclerosing cholangitis1 (inflammation and scarring of the biliary tract, which transports bile from the liver to the small intestine)

24 36

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

24 36

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

24 36*

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1

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Assessment criteria




option36-month

option




Irreversible total dysphagia¹ that has:

1. Resulted from organic disease AND

2. Undergone at least one surgical and/or radiotherapeutic intervention

Digestive disorders, defined as: Permanent dysphagia1 (difficulty swallowing):

1. Caused by an organic disease (any condition confirmed by physical examination, lab tests or other diagnostic studies) AND

2. That’s been operated on at least once and/or received radiation treatment

12 18

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)

24 36

Irreversible faecal incontinence1 managed conservatively (i.e. where surgical intervention has failed or is contraindicated), resulting from any of the following:

1. History of 3rd and 4th degree obstetric injury OR

2. Current rectal or pelvic organ prolapse

OR

3. Previous history of pelvic radiotherapy, colonic resection or anorectal surgery

Digestive disorders, defined as: Permanent faecal incontinence1 (loss of bowel control) that is managed conservatively (meaning surgery has failed or is not advised), and that was caused by any of the following:

1. History of 3rd and 4th degree obstetric injury (severe tearing of the vagina and anus during childbirth) OR

2. A rectal or pelvic organ is currently prolapsed (slipping of a body part from its usual position) OR

3. Previous history of radiation therapy to the pelvis, colonic resection (surgery to remove all or part of the colon) or anorectal surgery (surgery to the anus and rectum)

12 18

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

24 36

Irreparable abdominal or inguinal hernia (where surgery is now contraindicated1) with documented evidence of previous bowel obstruction

Digestive disorders, defined as: 1. Irreparable abdominal or inguinal (groin) hernia, where surgery is not advised1 AND

2. There is documented evidence of a previous blockage of the bowel

12 18

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Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

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Assessment criteria




option36-month

option




1 2 3

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

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

3. Metabolic Equivalents (METS) of less than 2 (METS is a measure of the energy you burn and oxygen you use during exercise)

24 36

Any recognised cardiovascular or cardio-pulmonary disorder¹ that results in the following cardiovascular assessments:

1. New York Heart Association Functional Classification (NYHA) II AND

2. Permanent Ejection Fraction (EF) < 45% OR

3. Metabolic Equivalents (METS) 2 – 5

Any recognised heart, circulation and/or lung disorder¹ with the following scores:

1. A New York Heart Association Functional Classification (NYHA) of II AND

2. 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

3. Metabolic Equivalents (METS) of 2 to 5 (METS is a measure of the energy you burn and oxygen you use during exercise)

12 18

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)

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Appendix

Reference notes

1

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3

Assessment criteria




option36-month

option




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) < 0.7 AND

3. Intermittent claudication (pain on walking caused by restriction in blood flow) OR

4. Rest pain

Chronic peripheral arterial insufficiency or ischaemia (poor blood flow or blockages in blood vessels to the upper and lower limbs) that leads to:

1. No pulses felt on physical examination AND

2. Doppler readings of an Ankle Brachial Pressure Index (ABI) of 0.7 or less (a test that measures the difference in blood pressure between the arteries of your arm and ankle) AND

3. Intermittent claudication (pain in the limb while walking and that eases with rest) OR

4. Pain when at rest caused by restricted arterial blood flow

12 18

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



• 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)

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Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Documented treatment-resistant hypertension² complicated by at least one of the following:

1. Chronic kidney disease (CKD) stage 4 or 5, with an estimated glomerular filtration rate (eGFR) of < 30ml/min 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



• 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 one 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 X-ray or scan OR

3. Grade III or IV hypertensive retinopathy (damage to the retina in the eye due to high blood pressure) OR

4. Thickening or increased size of the muscle wall of the heart’s left ventricle measured as 1:13.1 on a sonogram (ECHO) OR



• 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)

12 18

Non-healing venous ulcer of more than three months’ duration, despite treatment by a vascular surgeon and with documented evidence of deep venous insufficiency

A non-healing venous ulcer (loss of skin), with the following features:

The ulcer persists for longer than three months, even after treatment from a vascular surgeon. There is also clinical evidence of poor blood flow in the deep vein system of the legs

12 18

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Hormones


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Appendix

Reference notes

1

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3

Assessment criteria




option36-month

option




Advanced AIDS4, 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)

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Appendix

Reference notes

1

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Assessment criteria




option36-month

option




Diagnosis of any of the following HIV treatment-related disorders1+4:

1. Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI) lactic acidosis, defined as venous lactate level > 10mmol/l with signs and symptoms including nausea, vomiting, abdominal pain, tachycardia, fatigue and weight-loss where sepsis has been excluded OR

2. Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI) lactic acidosis, defined as a venous lactate level of 5 - 10mmol/l with signs and symptoms including nausea, vomiting, abdominal pain, tachycardia, fatigue and weight-loss where sepsis has been excluded, as well as one of the following:

• Lipodystrophy2 OR

• Irreversible peripheral neuropathy3 (duration of more than six months) OR

3. Lipodystrophy2 and new-onset diabetes mellitus requiring oral hypoglycaemic medication and/or insulin OR

4. Chronic pancreatitis with:

• Documented malabsorption syndrome

OR

• New-onset diabetes mellitus requiring oral hypoglycaemic medication and/or insulin hypoglycaemic medication and/or insulin

Diagnosis of any of the following disorders related to HIV treatment¹:

1. Lactic acidosis (a build-up of lactic acid in the bloodstream) caused by an anti-retroviral drug called a Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI). This leads to a blood lactate level of more than 10mmol/l, and some or all of the following: nausea, vomiting, abdominal pain, tachycardia (racing pulse), fatigue and weight-loss, where sepsis (inflammation due to infection) has been excluded OR

2. Lactic acidosis (a build-up of lactic acid in the bloodstream) caused by an anti-retroviral drug called a Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI). This leads to a blood lactate level of 5 to 10mmol/l, and some or all of the following: nausea, vomiting, abdominal pain, tachycardia (racing pulse), fatigue and weight-loss, where sepsis (inflammation due to infection) has been excluded. One of the following will also be present:

• Lipodystrophy2 (abnormality of the body’s fat tissue) OR

• Permanent peripheral neuropathy3 (damage to the nerves of the peripheral nervous system) for longer than six months OR

3. Lipodystrophy2 (loss of fat tissue and new-onset diabetes that requires oral medication and/or insulin OR

4. Chronic pancreatitis (inflammation of the pancreas) with:

• Documented malabsorption syndrome (poor absorption of the nutrients from food leading to malnutrition or other dietary problems) OR

• New-onset diabetes that requires oral medication and/or insulin medication and/or insulin

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Brain and nerves

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Hormones


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Sickness criteria

Appendix

Reference notes

1

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Assessment criteria




option36-month

option




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


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

24 36

Signs of established endocrine disorders¹, including documented diabetes mellitus type 1 or 2, complicated by at least one of the following:

1. Chronic kidney disease (CKD) stage 3B with an estimated glomerular filtration rate (eGFR) of 30 to 44ml/min OR


3. Grade III diabetic retinopathy

Established endocrine disorder (problems with hormone-secreting glands):

Documented type 1 and type 2 diabetes mellitus, complicated by at least one 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 of the eye)

12 18

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)

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option36-month

option




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)

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1

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Assessment criteria




option36-month

option




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 AND2. No evidence of hypovolaemia (reduced

blood volume) AND3. 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

4. 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)

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3

Assessment criteria




option36-month

option




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)

24 36

1 3 4 5 62


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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% over 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 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

24 36

1 3 4 5 62


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Panhypopituitarism, defined as more than 80% loss of the anterior pituitary gland as evidenced by:1. Growth hormone deficiency AND2. Gonadotrophin deficiency AND3. TSH deficiency AND4. 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

24 36

Any of the following endocrine conditions¹:1. Polyglandular autoimmune syndrome II2. 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)

24 36

Phaeochromocytoma¹ presenting with documented recurrent hypertensive crises defined as:• Three or more hospital admissions for

phaeochromocytoma-related hypertensive crises within the last 12 months, with each admission lasting longer than 48 hours

Established endocrine disorder (problems with hormone-secreting glands⁴):

A phaeochromocytoma (a hormone-secreting tumour, most commonly found in the adrenal glands) that has resulted in three or more hospital admissions for high blood-pressure crises. All of the admissions must have occurred in the last 12 months and each episode lasted longer than 48 hours

12 18

1 3 4 5 62


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria



How serious it is24 month

option36 month

option




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)

24 36

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)

24 36

Irreversible chronic kidney disease (CKD) stage 3B with eGFR of 30 to 44ml/min

Irreversible chronic kidney disease (CKD) Permanent stage 3B chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of 30 to 44ml/min (eGFR is an indication of overall kidney function)

12 18

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

24 36

Treatment-resistant nephrotic range proteinuria (> 3g/24 hours) of more than one year duration and with evidence of irreversible impaired renal function(eGFR < 50ml/min)

Nephrotic range proteinuria (large amountsof protein in the urine) that does not respond to treatment

An abnormal amount of protein found in the urine of more than 3g in a 24-hour period present for longer than a year. The kidney function must also be permanently damaged with an estimated glomerular filtration rate or eGFR below 50ml/min

12 18


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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

24 36

Documented respiratory disorder¹ resulting in irreversible respiratory impairment of:• FEV1 ≤ 50% OR• FVC ≤ 50% OR• DCO ≤ 50%

A documented respiratory problem¹ thatleads to irreversible impairment and thefollowing measurements:

1. A Forced Expiration Volume or FEV1 (the volume of air that can be blown out in the first second) of 50% 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 50% or less, indicating reduced lung function OR

3. A Diffusion Capacity or DCO of 50% or less, indicating the lungs’ reduced ability to transfer oxygen

12 18


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Paraplegia Paralysis from the waist down Permanent and complete 24 36

Quadriplegia Paralysis from the neck down Permanent and complete 24 36

Hemiplegia Paralysis on one side of the body, including the arm, leg and trunk

Permanent and complete 24 36

Diplegia Paralysis of the upper or lower limbs on both sides of the body


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


Loss or complete loss of use of a lower limb above the ankle (the ankle is defined as including the ankle, foot and all toes)

Loss of a leg above the level of the ankle, or the complete loss of the ability to use it

The loss must include all of the toes, the foot and the ankle

12 18

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


Loss or complete loss of use of an entire hand

Loss of a hand, or the complete loss of the ability to use it


Loss or complete loss of use of thumb and two fingers of the non-dominant hand

Loss of the thumb and two fingers on the non-dominant hand, or the complete loss of the ability to use them


Loss or complete loss of use of thumb and index finger of the dominant hand

Loss of the thumb and index finger on the dominant hand, or the complete loss of the ability to use them


1 2 3 4


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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)

24 36

1 2 3 4


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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)

24 36

1 2 3 4


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Persistent documented neurological impairment¹, despite optimal treatment, and with evidence of at least two of the following:1. One spinal operation including

laminectomy AND/OR discectomy AND/OR fusion AND/OR surgical motion preserving technologies such as discarthroplasty and dynamic stabilisation techniques within a five-year period

2. A 50% or more compression fracture of a vertebral body, or multiple level compression fractures

3. Corresponding clinical and radiological evidence of a radiculopathy, defined as motor and sensory deficit, muscle atrophy and clinical signs of nerve tension

Spinal disorder Nerve damage that persists even after optimal treatment, and with evidence of least two of the following:1. One spinal operation 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)

2. A compression fracture that has resulted in more than 50% collapse of the vertebral body (the largest, central part of a vertebral bone), or more than one compression fracture

3. Evidence of a radiculopathy (a “pinched nerve”) on examination and an X-ray. Symptoms include motor and sensory damage(reduced power and sensation), muscle atrophy (muscle wasting) and clear evidence of nerve compression

12 18

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

24 36

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 24 36

1 2 3 4


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Irreversible binaural loss of hearing¹ of greater than 85% as measured by audiometry at hearing thresholds of500Hz, 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%

24 36

Irreversible and complete loss of hearing¹ in both ears (total loss of hearing bilaterally)

Hearing loss Total and permanent hearing loss¹ in both ears

24 36

Irreversible loss of hearing¹ in one ear of an average of > 90dB (profound hearing loss) 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 an average of more than 90dB* (profound hearing loss) in one ear, 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%

12 18

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

24 36

Bilateral loss of visual acuity as evidenced by a Snellen chart reading of 20/125 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 20/125 or worse in the better-functioning eye, even after fully correcting your eyesight with the strongest available lens

12 18

Permanent hemianopia Visual loss Permanent hemianopia (loss of half the field of vision in one or both eyes)

12 18

Complete loss of sight in one eye with a Snellen chart reading of 20/200 or worse

Visual loss Total and permanent blindness in one eye, with a Snellen chart (eye-testing chart) reading of 20/200 or worse

12 18

1 2


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




Dysarthria, defined as the inability to produce coherent speech due to the dysfunction of anatomical structures responsible for the mechanical production of sound (e.g. mouth cavity, larynx, vocal cords)

Dysarthria (the inability to speak clearly) Caused by problems with sound-producing structures, such as the mouth cavity, voice box and vocal cords

12 18

Vestibular dysfunction² presenting with medically documented attacks of nausea, vomiting, vertigo, dizziness and tinnitus, with at least two episodes per week resulting from:1. Ménière’s disease OR2. Involvement of the vestibular labyrinth by

documented autoimmune disease

Vestibular (balance) problem Resulting in medically confirmed attacks of nausea, vomiting, dizziness, vertigo (a sense of falling) and tinnitus (ringing in the ears). You suffer at least two attacks per week due to:• Ménière’s disease (an inner ear condition

that impairs hearing and balance) OR• A known autoimmune condition that

affects the vestibular labyrinth (a part of the inner ear)

12 18

1 2


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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 surfac

24 36

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

24 36

Full-thickness burns of 9% to 18% of the body surface

Burns Full-thickness burns (involving all the layers of the tissue) of 9 to 18% of the body surface

12 18

Full-thickness burns of 8% of the body surface involving at least the palm of one hand or sole of one foot

Burns Full-thickness burns (involving all the layers of the tissue) of 8% of the body surface, including at least the palm of one hand or sole of one foot

12 18

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

24 36

Full-thickness burns of 10% to 25% of the face

Burns Full-thickness burns (involving all the layers of the tissue) of 10% to 25% of the face

12 18

Full-thickness burns of the entire genitalia Burns Full-thickness burns involving all the layers of the tissue of the entire genitalia

12 18

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

24 36

Irreversible disfigurement of more than 50% of the body surface caused by a chronic treatment-resistant skin disorder, which has necessitated hospital admission for at least two weeks within the last year

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. Which has resulted in hospital admission for at least two weeks within the last year

12 18


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria




option36-month

option




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)

24 36

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 OR2. 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

24 36

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

24 36

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

24 36


Introduction

• Fractures


• Child claims



Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma


Sickness criteria

Appendix

Reference notes

1

2

3

Assessment criteria 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 capacityto think, remember and judge clearly is reduced)

24 36

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 Activity 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)

24 36

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




option36-month

option




Introduction

• Fractures


• Child claims


3


Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria2

1

Appendix

Reference notes

Assessment criteria



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

• Depression and other mood disorders

• Schizophrenia and other psychotic disorders

• Anxiety disorders

The following mental and behavioural disorders are specifically excludedfrom this benefit category:

• Factitious disorders.

• Malingering

• Substance-use 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.

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

• Ischaemic heart disease

• Valvular heart disease

• Cardiomyopathy

• Coronary artery disease

• Hypertension

• Congenital heart disease

• Pericardial heart disease

• Arrhythmia

• Pulmonary arterial hypertension

• Pulmonary venous hypertension

• Cor pulmonale

• Aortic disease, e.g. aneurysm

2. Treatment reisistant hyper-tension is high blood pressure that is treated with more than four different medicines.

HIV/AIDS 1. To be confirmed by an HIV specialist with supporting laboratory and/or radiological investigations.

2. HIV-associated lipodystrophy refers to abnormal central fat accumulation (lipohypertrophy) and localised loss of fat tissue (lipoatrophy) in individuals with HIV infection on treatment with anti-retroviral medications.

3. Confirmed by neurophysiological tests.

4. 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


Introduction

• Fractures


• Child claims


3


Brain and nerves

Cancer

Digestive system


HIV/AIDS

Hormones


Lungs and breathing


Sensory system


Trauma

Sickness criteria2

1

Appendix

Reference notes

Assessment criteria



Appendix

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

• Restrictive lung disease.


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

• Benign positional vertigo.

1 2

* 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.

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 medi-cal professional for the second opinion or the client may consult a medical professional of their own choosing.

1 clinical claims definitions: temporary expenses cover€¦ · introduction – clinical...

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