Critical illness insurance definitions

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Critical Illness Insurance Definitions

With critical illness insurance, you want to make sure your policy has the best definitions for the covered illnesses. When it comes time to make a claim, a looser definition of a critical illness means that it is easier to qualify for the claim and increases your approval rate.

The CLHIA benchmark critical illness definitions were developed in 2007 in an effort to standardize the definitions, providing a single source for insurance companies to adhere their products to, while ensuring there isn’t a large discrepancy amongst them. Benchmark definitions also help consumers by removing some of the perceived complexity around critical illness definitions.

Note that in the definitions listed below, diagnosis of an illness must be made by a medical specialist and surgery must be determined to be necessary by a medical specialist, if applicable.

Alzheimer’s disease

Definition: A definite diagnosis of a progressive degenerative disease of the brain. The insured person must exhibit the loss of intellectual capacity involving impairment of memory and judgement, which results in a significant reduction in mental and social functioning, and requires a minimum of eight hours of daily supervision.

Survival period: 30 days

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

Aortic surgery

Definition: The undergoing of surgery for disease of the aorta requiring excision and surgical replacement of the diseased aorta with a graft. Aorta refers to the thoracic and abdominal aorta but not its branches.

Survival period: 30 days

Aplastic anemia

Definition: Chronic persistent bone marrow failure, confirmed by biopsy, which results in anaemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following:

  • Marrow stimulating agents;
  • Immunosuppressive agents; or
  • Bone marrow transplantation

Survival period: 30 days

Bacterial meningitis

Definition: A definite diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of diagnosis.

Survival period: 90 days

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

Benign brain tumour

Definition: A non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgery or radiation treatment or cause irreversible objective neurological deficits.

Survival period: 30 days

Exclusion: No benefit will be payable for pituitary adenomas less than 10mm. No benefit will be payable for a recurrence or metastasis of an original tumour which was diagnosed prior to the effective date of coverage.

Blindness

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

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

Survival period: 30 days

Cancer

Definition: Cancer is defined as a definite diagnosis of a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue.

Survival period: 30 days

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

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

No benefit will be payable for a recurrence or metastasis of an original cancer which was diagnosed prior to the effective date of coverage.

Coma

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

Survival period: 30 days

Exclusion: No benefit will be payable for:

  • A medically-induced coma;
  • A coma which results directly from alcohol or drug use; or
  • A diagnosis of brain death

Coronary artery bypass surgery

Definition: The undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s).

Survival period: 30 days

Exclusion: Any non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of an obstruction.

Deafness

Definition: The definite diagnosis of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz.

Survival period: 30 days

Heart attack

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

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

Survival period: 30 days

Exclusion: Heart attack does not include:

  • Elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves; or
  • ECG changes suggesting a prior myocardial infarction, which do not meet the heart attack definition as described above

Heart valve replacement

Definition: The undergoing of surgery to replace any heart valve with either a natural or mechanical valve.

Survival period: 30 days

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

Kidney failure

Definition: A definite diagnosis of chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated.

Survival period: 30 days

Loss of independent existence

Definition: A definite diagnosis of:

  • A total inability to perform, by oneself, at least two of the following six activities of daily living, or
  • Cognitive impairment, as defined below,

For a continuous period of at least 90 days with no reasonable chance of recovery.

Activities of daily living are:

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

Cognitive impairment is defined as mental deterioration and loss of intellectual ability, evidenced by deterioration in memory, orientation and reasoning, which are measurable and result from demonstrable organic cause as diagnosed by a specialist. The degree of cognitive impairment must be sufficiently severe as to require a minimum of eight hours of daily supervision. Determination of a cognitive impairment will be made on the basis of clinical data and valid standardized measures of such impairments.

Survival period: 90 days

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

Loss of limbs

Definition: The definite diagnosis of the complete severance of 2 or more limbs at or above the wrist or ankle joint, as the result of an accidental injury or medically-required amputation.

Survival period: 30 days

Loss of speech

Definition: The definite diagnosis of the total and irreversible loss of the ability to speak as the result of accidental injury or disease for a period of at least 180 days.

Survival period: 180 days

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

Major organ failure on waiting list

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

Survival period: 30 days

Major organ transplant

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

Survival period: 30 days

Motor neuron disease

Definition: The definite diagnosis of one of the following:

  • Amyotrophic lateral sclerosis (ALS or Lou Gehrig disease);
  • Primary lateral sclerosis;
  • Progressive spinal muscular atrophy;
  • Progressive bulbar palsy; or
  • Pseudo bulbar palsy

and limited to these conditions.

Survival period: 30 days

Multiple sclerosis

Definition: A definite diagnosis of at least one of the following:

  • Two or more separate clinical attacks, confirmed by MRI of the nervous system, showing multiple lesions of demyelination; or
  • Well-defined neurological abnormalities lasting more than six months, confirmed by MRI of the nervous system, showing multiple lesions of demyelination; or
  • A single attack, confirmed by repeated MRI of the nervous system, which shows multiple lesions of demyelination which have developed at intervals at least one month apart.

Survival period: 30 days

Occupational HIV

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

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

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

Survival period: 30 days

Exclusion: No benefit will be payable for occupational HIV infection if:

  • The insured has elected not to take any available licensed vaccine offering protection against HIV; or
  • A licensed cure for HIV infection has become available prior to the accidental injury; or
  • HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

Paralysis

Definition: The definite diagnosis of the total loss of muscle function of 2 or more limbs as a result of accidental injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event.

Survival period: 90 days

Parkinson’s disease

Definition: A definite diagnosis of primary idiopathic Parkinson’s disease, which is characterized by a minimum of two or more of the following clinical manifestations:

  • Muscle rigidity,
  • Tremor, or
  • Bradykinesis (abnormal slowness of movement, sluggishness of physical and mental responses)

Survival period: 30 days

Exclusion: No benefit will be payable for all other types of Parkinson’s.

Severe burns

Definition: The definite diagnosis of third degree burns over at least 20% of the body surface.

Survival period: 30 days

Stroke

Definition: A definite diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with:

  • Acute onset of new neurological symptoms, and
  • New objective neurological deficits on clinical examination persisting for more than 30 days following the date of diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing

Survival period: 30 days

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

  • Transient ischaemic attacks; or
  • Intracerebral vascular events due to trauma; or
  • Lacunar infarcts which do not meet the definition of stroke as described above

Not every critical illness insurance product uses these standard definitions. Some companies use a more stringent definition of certain illnesses, which make them harder to qualify for when it comes time to make a claim. Compare your current policy to see if its definitions match the benchmark set by CLHIA. If not, consider obtaining a critical illness insurance policy that adheres to these definitions.


Source: 2012 Canadian Institute of Actuaries report, Critically Canadian: Canadian critical illness standalone base incidence tables.

Image courtesy of Vichaya Kiatying-Angsulee / FreeDigitalPhotos.net