1 Trauma Cover Guide.
2 Dr John Clubb Dr John Clubb is the Chief Medical Officer of Life Underwriting at CommInsure. Dr Clubb is highly respected throughout the medical and life insurance industries. He joined CommInsure on a full-time basis in 2006, having worked as a general practitioner for over 40 years, combining this with 31 years as both senior and chief medical officer roles for various life insurance companies. Dr Clubb provides valuable contributions in the following areas: development of underwriting philosophy and guidelines training and mentoring of underwriters acts as a referral point for all medical technical issues within underwriting as an active member of the product committee. Important information This information is provided by CommInsure, a registered business name of The Colonial Mutual Life Assurance Society Limited ABN AFSL (CMLA), a wholly owned but non-guaranteed subsidiary of Commonwealth Bank of Australia ABN Layperson explanations are to be used as a guide only. All claims will be assessed under the definitions outlined in the Policy Document. Issued by: The Colonial Mutual Life Assurance Society Limited ABN This guide is for the information of advisers and Commonwealth Bank Group employees only.
3 Contents 2 Trauma Cover 5 Heart Disorders 9 Nervous System Disorders 15 Body Organ Disorders 22 Blood Disorders 24 Other Events 25 Glossary of terms 30 CommInsure s credentials 1
4 Trauma Cover The rise in popularity of Trauma Cover has been considerable over the last ten years; it has evolved from a little known and understood benefit to one that many advisers now specialise in selling. Accompanying this popularity have been never-ending requests for a guide that provides layperson definitions and relevant sales facts which are easily understood by adviser and client alike. This guide accompanies CommInsure s extensively revised policy definitions, which keep pace with new developments in treatments and diagnoses in medical science. History and background Trauma insurance was first developed in the early 1980s by Marius Barnard, brother of the acclaimed cardiac surgeon, Dr Christiaan Barnard. Christiaan s job was to make sure that people survived heart disease; Marius job was to make sure they could afford to survive! This resulted in the creation of a policy that paid a lump sum if the life insured contracted any one of a number of defined critical conditions. With diseases such as cancer and heart disease now touching almost everyone in some way, this new approach to risk protection has steadily grown in popularity. What is Trauma Cover? Trauma Cover, also known as critical illness insurance or living assurance, pays a lump sum in the event of a specified medical condition. Examples of critical illness include cancer, Parkinson s disease, heart attack and stroke. Trauma Cover is an important tool in wealth protection and risk planning and should be considered as part of a client s needs. It can alleviate financial pressure in a period of intense shock and trauma, giving the client and their family time to adjust to the crisis and rethink their future. What are the chances of contracting a critical illness? A stroke occurs every eleven minutes in Australia 1. Approximately 44,000 Australians suffer a stroke each year, with strokes being the leading cause of long-term disability in adults 1. Males have a two in five chance of suffering a critical illness between age 30 and Females have a one in four chance of suffering a critical illness between age 30 and It has also been shown that one in three men and one in four women will contract cancer before age The leading cause of death for Australians is cardiovascular disease (heart, stroke and blood vessel disease) at 39%, followed by cancer (30%) 4. Trauma Cover is about survival Trauma Cover gives your clients the opportunity to create real options at a traumatic time it pays out a lump sum not because they are going to die, but because they are going to live. Australians are suffering an increasing incidence of cancer and we are still experiencing high levels of heart disease and stroke. Due to advances in medical science, we have greater chances of surviving a serious medical condition. In many cases this survival period can be measured in years. It is important to understand that where in the past a serious medical condition often led to a swift death, this is no longer the case with consequential effects on lifestyle, family and work. While the critical condition sufferer may recover medically, the impact on their finances can be devastating. Many people depend on the continued success of their career or business to achieve their financial goals. Whilst many people make some sort of medical recovery, the likelihood of making a financial recovery is less certain, especially if they are unable to continue to work in their previous employment, or if they are forced to stop work completely for medical reasons. Trauma Cover can make a significant contribution towards the financial survival of families and businesses by providing cash for the insured to use as they see fit. Your clients need to consider Trauma Cover if: they have a mortgage or other debt they have a family and associated responsibilities they have a business or business partners they are company directors, key employees or self-employed they have insufficient cash reserves to cover unexpected medical and hospital bills. 2 1 Source Australian Institute of Health and Welfare (AIHW) Heart, Stroke and Vascular Diseases: Australian Facts General Cologne Life Re Australia, AIHW and Australasian Association of Cancer Registries, Cancer in Australia 2001, AIHW, 2002 and Heart Foundation of Australia, November 2003.
5 Summary Trauma Cover Option Trauma Cover provides a lump sum on the occurrence of a specified medical condition, regardless of whether you are prevented from working or not. It is available either on its own (stand-alone Trauma), or in conjunction with Life Care (but cannot exceed the amount of Life Care). The lump sum is the amount for which you are insured. Trauma Plus Cover Option If you select this option, a partial Trauma Cover benefit will be payable for an additional ten trauma conditions, namely Diabetes Complication, Melanoma, Carcinoma in situ of the Cervix Uteri, Carcinoma in situ of the Vulva or Perineum of limited extent, Carcinoma in situ of the Vagina, Chronic Lymphocytic Leukaemia, Hydatidiform Mole, Partial Blindness, Partial Loss of Hearing and Severe Osteoporosis. Child Cover Option CommInsure also provides the option to attach a Trauma Cover policy on your child s life to your own Life Care or stand-alone Trauma policy, helping to ease the financial strain and stress caused in the event of a child s illness. If you have a child between the ages of two and 16 inclusive, you are able to apply for up to $100,000 worth of Child Cover for that child. You can cover more than one child under this option, but each child must be insured for the same amount. What is provided under Trauma Cover, Trauma Plus Cover Option and Child Cover Option? Medical condition Trauma Cover Additional Trauma Plus Cover Child Cover Heart Disorders Heart Attack 4 4 Out of Hospital Cardiac Arrest 4 4 Coronary Artery Disease Requiring By-pass Surgery 4 4 Coronary Artery Angioplasty 4 4 Coronary Artery Angioplasty Triple Vessel 4 4 Repair and Replacement of a Heart Valve 4 Surgery of the Aorta 4 4 Cardiomyopathy 4 4 Primary Pulmonary Hypertension 4 Open Heart Surgery 4 4 Nervous System Disorders Stroke 4 4 Major Head Trauma 4 4 Motor Neurone Disease 4 Multiple Sclerosis 4 Multiple Sclerosis of limited extent 4 Muscular Dystrophy 4 4 Paraplegia 4 4 Quadriplegia 4 4 Hemiplegia 4 4 Diplegia 4 4 Tetraplegia 4 4 Dementia and Alzheimer s Disease 4 Coma 4 4 Encephalitis 4 4 Parkinson s Disease 4 Bacterial Meningitis 4 Subacute Sclerosing Panencephalitis 4 3
6 Trauma Cover Medical condition Trauma Cover Additional Trauma Plus Cover Child Cover Body Organ Disorders Cancer 4 4 Melanoma 4 Chronic Lymphocytic Leukaemia 4 Cancer of the Vulva or Perineum 4 Removal of Carcinoma in situ of the Breast 4 Carcinoma in situ of the Cervix Uteri 4 Carcinoma in situ of the Vulva or Perineum of limited extent 4 Carcinoma in situ of the Vagina 4 Hydatidiform Mole 4 Benign Brain Tumour 4 4 Blindness 4 4 Partial Blindness 4 Chronic Kidney Failure 4 4 Major Organ or Bone Marrow Transplant 4 4 Placement on a Waiting List for Major Organ Transplant 4 4 Severe Burns 4 4 Loss of Speech 4 4 Loss of Hearing 4 4 Partial Loss of Hearing 4 Chronic Liver Disease 4 4 Chronic Lung Disease 4 4 Severe Rheumatoid Arthritis 4 4 Severe Osteoporosis 4 Blood Disorders Occupationally Acquired HIV 4 Medically Acquired HIV 4 4 Aplastic Anaemia 4 4 Advanced Diabetes 4 Diabetes Complication 4 Other Events Serious Injury 4 4 Critical Care 4 4 Loss of Limbs or Sight 4 4 Loss of Independent Existence 4 Loss of One Hand or One Foot 4 4 4
7 Heart Disorders Heart Attack The death of part of the heart muscle (myocardium) as a result of inadequate blood supply. The diagnosis must be based on either: the following medical evidence: i) elevation of cardiac enzyme CK-MB, or ii) elevation in levels of Troponin I greater than 2.0 mcg/l or Troponin T greater than 0.6 mcg/l or their equivalent and iii) confirmatory new electrocardiogram (ECG) changes, or iv) medical evidence satisfactory to us that the heart attack reduced the Left Ventricular Ejection Fraction to below 50% when measured at least six weeks after the heart attack, or any other medical evidence satisfactory to us which demonstrates that myocardial damage has occurred to at least the same degree of severity as would be evidenced by the medical evidence required under the first bullet point. Coronary arteries carry blood to the heart muscle. This blood is rich in oxygen, needed for the good health of the heart. In a heart attack, the blood supply to the heart muscle is reduced. As a result, some of the heart muscle dies. There may be only a small amount of heart muscle that dies. If this is the case, the medical evidence for such a heart attack doesn t fulfil the criteria given below for a Trauma claim to be made. However, in most heart attacks, three things may result, namely: The dead muscle releases enzymes into the blood stream. These enzymes are called CK-MB and Troponins. Enzymes are proteins that occur in most tissues of the body and allow the metabolism of those tissues to perform normally. An electrocardiogram (ECG), which records the electrical activity of the heart. The heart may not be able to pump properly. When a normal heart beats, it pumps out more than 50% of blood being held in the heart. When it doesn t pump properly, the heart is only able to pump out less than 50% of the blood held in the heart. The amount of blood pumped out with each heart beat is called the ejection fraction. A Trauma claim will be paid if: either the CK-MB or the Troponins reach a certain high level in the blood stream indicative of a heart attack, and either the electrocardiogram shows a classical heart attack pattern or the ejection fraction noted in an echocardiogram falls to less than 50%. During hospital stays for heart attacks, about one in eight of these patients proceed to also have coronary artery angioplasty (see page 6) and one in 20 need coronary by-pass surgery. Source: Australian Institute of Health and Welfare, September Out of Hospital Cardiac Arrest Cardiac arrest which is not associated with any medical procedure and is documented by an electrocardiogram, occurs out of hospital and is due to: cardiac asystole, or ventricular fibrillation with or without ventricular tachycardia. Cardiac arrest means the heart is not able to pump out blood sufficiently to maintain life. As a result, the person collapses suddenly into unconsciousness and without resuscitation within minutes will die. In all cases the pulse cannot be felt. Cardiac asystole means the heart has stopped beating completely. Ventricular tachycardia means that the heart is beating regularly but at such a very fast heart rate that each beat is insufficient in pumping out blood. Ventricular fibrillation means that the heart is beating irregularly and very fast so that each beat is insufficient in pumping out blood. It is necessary for the episode to be proven by an electrocardiograph. This is because there are other changes in the rhythm of the heart that can also produce unconsciousness and difficulty in recording a pulse but which are not as life threatening as those listed causing cardiac arrest. In patients with ventricular fibrillation, there is a high success rate with immediate defibrillation but for every minute of delay, 10% of patients who might have been saved are lost. By having defibrillators readily available in cardiac arrest, the survival rate can go up 40% to 50%. Source: New England Journal of Medicine, 26 October
8 Heart Disorders Coronary Artery Disease Requiring By-pass Surgery The actual undergoing of by-pass surgery (including saphenous vein or internal mammary graft/s) for the treatment of coronary artery disease. Any other operations are specifically excluded from this definition. Coronary artery disease means that there is a narrowing of one or more of the coronary arteries that supply blood to the muscle of the heart. This narrowing reaches a degree where the blood flow is insufficient to maintain normal vitality of the heart muscle so that the heart muscle is damaged or actually dies. By-pass surgery is designed to send blood to the damaged heart muscle by another route. In by-pass surgery, the surgeon opens into the chest and can therefore directly visualise the heart. The surgeon identifies the blockage or blockages causing the heart attack. The blockages are not removed. Rather, a vein is taken from a lower limb and connected above and below the blockages, thus by-passing the blockage. Sometimes, instead of using a vein, an artery that lies behind the breastbone is used in the same way. Up to four new routes may be needed. After surgery, patients are encouraged to gradually increase their exercise level. Those who achieve a high level of activity have the best long-term results. Patients in sedentary office jobs can be back at work in four to six weeks. In , there were 15,321 coronary artery by-pass graft operations carried out in Australia. Source: Australian Institute of Health and Welfare, Coronary Artery Angioplasty The undergoing of coronary artery angioplasty, that is considered necessary by a cardiologist to treat coronary artery disease. The cardiologist s opinion that the procedure is necessary must be supported by angiographic evidence. Coronary Artery Angioplasty Triple Vessel Undergoing, in the same procedure, coronary artery angioplasty to three or more coronary arteries, where the procedure is considered necessary by a cardiologist to treat coronary artery disease. The degree of coronary artery narrowing is determined by coronary artery angiography (this is what is meant by angiographic evidence). A catheter (flexible tube) is continuously fed through an artery (usually in the groin but may be in the arm) until it can be passed into the main coronary artery and a dye is then passed through this catheter. Photographs are then taken of this dye and these give an excellent picture of the inside of the arteries, demonstrating the extent of plaques of fat that are causing obstruction in the coronary arteries. With angioplasty, it is not necessary for the surgeon to open into the chest. Rather, a small inflatable balloon on a long flexible catheter is continuously fed through an artery (usually in the groin but may be in the arm) until it can be passed into the blocked coronary artery that is preventing the heart muscle from receiving adequate blood. The balloon is then inflated and the narrow artery stretched back to its normal diameter. Sometimes the artery is kept open by placing a fine metallic mesh tube into the artery. This tube is called a stent. It is left in place when the balloon is deflated and removed. The patient, after angioplasty, stays in hospital for up to one day usually, and is then allowed to go home. In , there were 30,906 coronary angioplasty procedures performed in Australia. Source: Australian Institute of Health and Welfare, Saphenous vein graft Internal mammary artery graft Coronary by-pass. 6
9 Repair and Replacement of Heart Valve Surgery to replace or repair heart valves but does not include percutaneous valvuloplasty, trans-arterial procedures or other non-surgical techniques. There are four one-way heart valves in the heart. They stop the blood flowing in the wrong direction. Unfortunately, one or more of the heart valves can become narrowed or fail to close properly. If this happens, the circulation of the blood through the heart can become impaired. This impairment gradually worsens so that eventually surgery has to be undertaken. This may involve repairing or replacing one of these four valves completely: mitral tricuspid aortic pulmonary. It does not include key-hole surgery techniques. In these cases, a minimal hole is made into the chest and indirect visualisation via a camera is used to operate on the valve (percutaneous valvuloplasty). Similarly some valve repairs are carried out with the surgeon passing a camera into the heart via an artery and indirectly visualising the valve (trans-arterial procedure). Again, payment is not made for such a procedure. Approximately 300,000 people worldwide have heart valve repair or replacement surgery each year. Source: Medical-News.net, 15 March Surgery of the Aorta Surgery to correct a narrowing, dissection or aneurysm of the thoracic or abdominal aorta but not its branches. The aorta is the biggest artery in the body and carries blood from the heart to all parts of the body via a system of branching arteries. The thoracic aorta is in the chest and continues through the diaphragm (the muscle that separates the chest from the abdomen) into the abdomen, where it is called the abdominal aorta. Narrowing: This means the aorta is narrowed in one or more places by an accumulation of fatty deposits or by a blood clot on its wall. Because this causes decreased blood flow to the lower limbs, usually on walking or exercising, the client usually complains of pain or cramping at these times. Surgery is used either to remove the fatty plaques or to by-pass the blockages. Dissection: This is a sudden emergency when the wall of the artery can split. Surgery is designed to release the pressure building up in the dissected layers, and to try to avoid a progression of the dissection. Aneurysm: This is a weakening in the wall of the artery which slowly bulges, even to the size of a grapefruit. Larger aneurysms are surgically repaired to avoid complications. A sudden rupture of an aneurysm may also occur, when urgent surgery will again be needed. The aorta is the most common major vessel to be injured following blunt chest trauma. Source: Diseases of the Aorta in the Critically Ill, M. Chinthamuneedi, Intensive Care Unit, St Andrew s Hospital, Adelaide, South Australia, Aorta Prosthetic valve Aortic valve replacement. 7
10 Heart Disorders Cardiomyopathy Condition of impaired ventricular function of variable aetiology (often not determined) resulting in significant physical impairment, i.e. Class 3 on the New York Heart Association classification of cardiac impairment (see page 28). Blood is pumped out of the heart into the largest artery in the body (the aorta) and from there is carried to all the tissues of the body (except the lungs). The chamber of the heart that pushes out this blood is called the left ventricle. A cardiomyopathy affects the muscle of this left ventricle, causing it to perform less and less efficiently. The amount of blood the left ventricle pumps out with each beat is called the ejection fraction and in a normal heart is 50% or more of the blood held in the left ventricle. As the heart pumping action fails with the cardiomyopathy, this ejection fraction falls more and more. Three different types of cardiomyopathy are recognised: Dilated cardiomyopathy is the most common. The cavity of the heart is enlarged and the walls are stretched. The heart is so weak it does not pump normally. Hypertrophic cardiomyopathy the muscle mass in the left ventricle enlarges. Restrictive cardiomyopathy the walls of the heart become rigid and hard to move. This type is usually caused by another disease process. Cardiomyopathy may be inherited or can be caused by viral infections; heart attacks; alcoholism; long-term, severe high blood pressure; or by other reasons not yet known. Source: Department of Cardiology, Henry Ford Hospital, Detroit, September Primary Pulmonary Hypertension Primary Pulmonary Hypertension associated with right ventricular enlargement established by cardiac catheterisation resulting in significant permanent physical impairment to the degree of at least Class 3 of the New York Heart Association classification of cardiac impairment (see page 28). The word primary means that the underlying cause of this rare disease is unknown. Primary pulmonary hypertension means that the very small arteries in the lungs become narrowed or blocked. There is therefore a resistance to the flow of blood through the lungs. As a result, there is a bank-up of blood in the larger arteries in the lungs (pulmonary arteries) as these larger arteries try to push harder and harder against these small blocked arteries. As a result, there develops hypertension (high pressure) in the larger pulmonary arteries. This high pressure finally affects the chamber of the heart which delivers blood to the pulmonary arteries. This chamber is called the right ventricle. Finally this chamber, which has become bigger and bigger as it works harder and harder, weakens and is unable to pump properly. Finally it fails altogether and then a transplant is the only cure available. Despite doctors inability to cure primary pulmonary hypertension, advances in its treatment over the past decade have markedly improved survival and the quality of life for sufferers. Source: American Heart Association. Primary or Unexplained Pulmonary Hypertension, Open Heart Surgery Open Heart Surgery for treatment of cardiac defect/s, cardiac aneurysm or benign cardiac tumour/s. Open heart surgery is any surgery where the chest is opened and surgery is performed on the heart. The term open refers to the chest, not the heart itself (which may or may not be opened depending on the type of surgery). Open heart surgery includes surgery on the heart muscle, valves, arteries or other structures. A heart-lung machine (also called heart-lung by-pass) is usually used to help provide oxygen-rich blood to the brain, heart muscle and other vital body areas. It pumps the blood, supplies oxygen to the blood and removes carbon dioxide from the blood. Right atrium Left atrium Left ventricle Between 2001 and 2002, there were 23,279 procedures which required open heart surgery in Australia. Source: AIHW, Heart, Stroke and Vascular Diseases; Australian Facts Right ventricle 8 An enlarged heart.
11 Nervous System Disorders Stroke A cerebrovascular accident or incident producing neurological sequelae. This includes infarction of brain tissue, intracranial and/or subarachnoid haemorrhage, or embolisation from an extracranial source. The following are excluded: Cerebral symptoms due to: transient ischaemic attacks reversible ischaemic neurological deficit migraine. Cerebral injury resulting from: trauma hypoxaemia vascular disease affecting the eye, optic nerve or vestibular function. The blood circulation to the brain is called the cerebrovascular circulation. A cerebrovascular accident does not relate to any injury but rather to a clot cutting off the blood supply to part of the brain, resulting in partial brain death (cerebral infarction), or to a rupture of a blood vessel, causing bleeding either into the brain (cerebral or intracranial haemorrhage) or into the space surrounding the brain (subarachnoid haemorrhage). Whatever type of cerebrovascular accident occurs, we call it a stroke. Each year, over 40,000 Australians have a stroke, with 70% of these being first ever strokes. Source: Australian Institute of Health and Welfare, Infarction of brain tissue Major Head Trauma Injury to the head resulting in neurological deficit causing either: a permanent loss of at least 25% whole person function (as defined in the edition of the American Medical Association publication Guides to the Evaluation of Permanent Impairment current as at the preparation date of the Personal Insurance Portfolio PDS), or the permanent and irreversible inability to perform without the assistance of another person any one of the Activities of Daily Living (as defined under Loss of Independent Existence on page 24), as certified by a consultant neurologist. Neurological deficit here refers to symptoms that may result from damage to brain cells as a result of an injury to the head. Loss of 25% of whole body function is determined by a neurologist who has detailed tables as to what constitutes 25% loss of total body function. A blow to the outside of the skull can result in the brain moving and hitting the hard skull or tearing. Both cause bleeding and bruising, resulting in damage to brain cells. Major head injury may result in permanent disability. Fatigue and headache are by far the most common complaints. Depending on which area in the brain is damaged there can be: memory loss loss of time and space sense behaviour disturbances and personality changes paralysis or weak limb movements changes in hearing, vision, taste, touch and smell speech problems and/or difficulty understanding speech. Improvements in function can occur up to two years following the injury. Subarachnoid haemorrhage Motor vehicle crashes account for 50% of all Traumatic Brain Injuries (TBI). This includes autos, trucks, motorcycles, bicycles and pedestrians hit by vehicles. The leading causes of TBI vary by age: falls are the leading cause of TBI among persons aged 65 years and older; transportation is the leading cause of TBI among persons under the age of 65 years. Source: International Brain Injury Association, A stroke. 9
12 Nervous System Disorders Motor Neurone Disease Motor Neurone Disease diagnosed by a consultant neurologist. Motor neurone disease (MND) is the name given to a group of related diseases which affect the motor neurones which control muscles. The motor neurones degenerate and cause a progressive weakness and muscle-wasting. Motor neurones are nerve cells that allow our muscles to function normally. There are two types of motor neurones. One group (called upper motor neurones) run from the brain to the spinal cord. The other group (called lower motor neurones) run from the spinal cord to the muscles. These two groups link up in the spinal cord. There are three main types of motor neurone disease. In one type, both the upper and lower neurones degenerate. In the other two, just the upper or the lower neurones degenerate. However, whatever the type, the end result is muscle-wasting and progressive weakness. There is no specific test to diagnose MND, so in its early stages it can be confused with other diseases. However, measuring the electrical activity in a muscle and/or a muscle biopsy will usually give the diagnosis. The cause is unknown. The cause is unknown. There is no cure. Clients with this disease need physical and psychological support with aids to help them overcome disabilities. The average life expectancy is three to four years from diagnosis, although some patients have survived 20 years. Source: Neurological Resource Centre, United States, Multiple sclerosis is twice as common in women than men and can affect people as early as age 20. The cause is still unknown. Source: Mayo Clinic, United States, An estimated 2.5 million people in the world have the disease MS. The National Health Survey of 2001 indicated that there were approximately 15,000 Australians with MS. Source: MS Australia, Muscular Dystrophy The unequivocal diagnosis of Muscular Dystrophy by a consultant neurologist. Muscular dystrophy is a group of diseases, usually genetic, that cause progressive weakness and degeneration of muscles that control movement. Some forms appear in infancy and others do not appear until middle age or later. Sometimes the heart and other organs are involved. Some forms of muscular dystrophy are mild, and are only very slowly progressive, and sufferers may have a normal lifespan. There is no specific treatment. All therapy is aimed at stopping the affected muscles from shortening around joints. Corrective orthopaedic surgery may be necessary. Source: NINDS Muscular Dystrophy Information, page 27, June Multiple Sclerosis The unequivocal diagnosis of Multiple Sclerosis as confirmed by a consultant neurologist and characterised by demyelination in the brain and spinal cord evidenced by Magnetic Resonance Imaging or other investigations acceptable to us. There must have been more than one episode of well defined neurological deficit with persisting neurological abnormalities. Multiple Sclerosis of limited extent The unequivocal diagnosis of Multiple Sclerosis as defined above but without the existence of persisting neurological abnormalities. In multiple sclerosis (MS), nerve cells lose their myelin coating, which acts like the insulation on electrical wiring. The myelin is destroyed and replaced by hard scar tissue. When nerve impulses reach a damaged area, they are blocked or delayed in travelling to or from the brain. Symptoms vary depending on where the damage is. Early signs are blurred vision, numbness in hands or legs, weakness, fatigue and loss of coordination and balance. The disease may gradually worsen until there is loss of vision, bladder problems, bowel problems and paralysis. Motor neurone disease. Nerve cell Loss of myelin coating in MS
13 Paraplegia The permanent loss of use of both legs or both arms, resulting from spinal cord sickness or injury. Hemiplegia The total loss of function of one side of the body due to sickness or injury, where such loss of function is permanent. There are more than 8,000 people with spinal cord injuries in Australia, at a cost to the community of $470 million each year. One eighth are children. Source: Spinal Research Fund of Australia Inc., Quadriplegia The permanent loss of use of both arms and both legs, resulting from spinal cord sickness or injury. If the spinal cord is injured or develops disease, the muscles of both the arms and both the legs become paralysed. The main causes of spinal cord injury are: motor vehicle accidents 44% violence 24% falls 22% sport 8%. Hemiplegia is the total paralysis of the arm, leg and trunk on the same side of the body. The most common cause is a stroke, usually in the elderly, but it can occur in babies or toddlers. Other causes are blood vessel disease, wounds, tumours or abscesses. The onset of hemiplegia is usually very sudden in stroke patients, and as well as not being able to move one side of the body, they are often unable to talk. Some patients can make a complete recovery after several days or weeks. The majority make only a partial recovery and are left with a severe weakness on one side for the rest of their lives. The most common cause of hemiplegia is a stroke. Source: Merck Manual, Diplegia The total loss of function of both sides of the body due to sickness or injury, where such loss of function is permanent. There are more than 8,000 people living with spinal cord injuries in Australia. Source: Spinal Cord Injuries Australia, Spastic Diplegia is one of the most common forms of cerebral palsy 1. In children, cerebral palsy is the most common cause of disability 2. Sources: 1. The Children s Hospital at Westmead Parents and Cerebral Palsy The Spastic Centre, Cerebral Palsy fact sheet Tetraplegia The total and permanent loss of use of both arms and both legs, together with loss of head movement, due to brain sickness or injury, or spinal cord sickness or injury. 11
14 Nervous System Disorders Dementia and Alzheimer s Disease Clinical diagnosis of Dementia (including Alzheimer s Disease) as confirmed by a consultant neurologist, psycho-geriatrician, psychiatrist or geriatrician. The diagnosis must confirm permanent, irreversible failure of brain function resulting in significant cognitive impairment for which no other recognisable cause has been identified. Significant cognitive impairment means a deterioration in the life insured s Mini-Mental State Examination scores to 24 or less, and deterioration would continue but for any effective treatments. Dementia related to alcohol, drug abuse or AIDS is excluded. The cause of Alzheimer s disease is still unknown. Symptoms of Alzheimer s disease are gradual memory loss, poor judgement, an inability to perform routine tasks and personality and mood changes. These symptoms gradually get worse over five to ten years, until the patient needs constant supervision so that they do not endanger themselves or others. Often the diagnosis is only confirmed by examination of the brain tissue after death. For a number of reasons, the brain can cease functioning normally and, as a result, the patient is unable to look after themselves or may be a danger to others. This is called dementia. The cause can be unknown, as in Alzheimer s disease, or may be known, such as multiple strokes. The Mini-Mental State Examination is too detailed to reproduce in this booklet. However, an excellent review of dementia, together with details of this examination, is given in (and easily brought up on the Internet): Pridmore S. Download of Psychiatry. Chapter 20. Last modified 7 November Coma A state of total unconsciousness with no reaction to external stimuli or internal needs, requiring continuous assisted ventilation to maintain life for at least 72 consecutive hours. Coma is best defined as a state of unresponsiveness from which an individual cannot be aroused. If a patient in a coma survives the first ten days following an injury to the brain, then long-term survival can be expected. Recovery can be partial or complete. Partial recovery occurs frequently after head injury. By far the most common cause of coma is head injury. Other causes can be: diabetes abscesses tumours stroke liver failure. Coma represents the last and lowest level of function of the brain prior to death. Head injuries are the most common cause of coma. Transportation accidents involving automobiles, motorcycles, bicycles and pedestrians account for half of all head injuries. Source: National Institute of Neurological Disorders and Stroke, October More than 162,000 Australians have a diagnosis of dementia, with perhaps as many again in the early stages of dementia. The average length of time a person will live with dementia is ten to 14 years. Source: Alzheimer s Australia,
15 Encephalitis The severe inflammation of brain substance which results in significant neurological sequelae, causing either: a permanent loss of at least 25% whole person function (as defined in the edition of the American Medical Association s publication Guides to the Evaluation of Permanent Impairment current as at the preparation date of the Personal Insurance Portfolio PDS), or the permanent and irreversible inability to perform without the assistance of another person any one of the Activities of Daily Living (as defined under Loss of Independent Existence, see page 24), as certified by a consultant neurologist. Encephalitis as a result of HIV infection is excluded. Encephalitis is an acute inflammation of the brain itself and the lining covering the brain, the meninges. The cause is usually a viral infection, but it can also result from exposure to certain bacteria, parasites, harmful chemicals or heavy metal poisoning. In some cases, recovery from encephalitis is slow and permanent brain damage occurs. Based on the American Medical Association (AMA) guidelines, illustrations of what constitutes 25% whole person impairment could be: inability to understand words or to produce understandable language for daily activities someone who mentally requires constant supervision someone who, after head injury, develops frequent epileptic fits, needing to be supervised reduced daytime alertness that significantly limits daily activities and requires supervision. Parkinson s Disease The unequivocal diagnosis of Parkinson s Disease by a consultant neurologist where the consultant neurologist confirms that the condition: is the established cause of two or more of the following: muscular rigidity resting tremor bradykinesia has caused significant progressive physical impairment, likely to continue progressing but for any treatment benefit. The life insured must be under the established care and following the advice of a specialist neurologist. Parkinson s disease causes trembling in hands, legs, jaws and face at rest; stiffness of limbs (called muscular rigidity); slowness of movements (called bradykinesia); and impaired balance and coordination. At present there is no cure for Parkinson s disease. However, there are a number of drugs which can control symptoms. As time goes on, the drugs gradually lose their effect and the patient becomes progressively impaired. Source: American Parkinson s Disease Association, Dengue fever is one of the most prevalent airborne diseases in the world today and can cause encephalitis. There has been an increase in Australian cases in recent years, but the disease is more prevalent in New Zealand. Source: New Zealand Ministry of Health, November
16 Nervous System Disorders Bacterial Meningitis The unequivocal diagnosis of Bacterial Meningitis resulting in a neurological deficit causing permanent and significant functional impairment. The Bacterial Meningitis must be caused by a proven organism. Meningitis means inflammation of the membranes or meninges lining the brain and spinal cord. There are many types of meningitis and while the symptoms are often similar, the causes, treatments and outcomes can vary greatly. The organisms that usually cause meningitis include bacteria, viruses, parasites and fungi. Bacterial meningitis is the most common life-threatening type of meningitis and can cause death within hours. Most cases of bacterial meningitis are caused by meningococcal and pneumococcal bacteria. Subacute Sclerosing Panencephalitis The unequivocal diagnosis of Subacute Sclerosing Panencephalitis. Subacute Sclerosing Panencephalitis is a late complication of measles, which causes progressive brain damage and death. Ten out of every 1 million children may experience SSPE. Source: National Health and Medical Research Council. The Australian Immunisation Handbook, Commonwealth of Australia, th edition. Canberra: Australian Government Department of Health and Ageing, Death occurs in about 5% to 15% of cases of bacterial meningitis and, in addition, about 20% of patients are left with a permanent disability including cerebral palsy, limb amputation, deafness or a learning difficulty. Source: The Meningitis Centre (Australia), the Meningitis Research Foundation and The Meningitis Trust (UK), April
17 Body Organ Disorders Cancer Any malignant tumour characterised by the uncontrolled growth and spread of malignant cells that requires treatment by surgery, radiotherapy, chemotherapy, biological response modifiers, or any other major interventionist treatment and includes cancers that are completely untreatable. The following are included: Leukaemia Hodgkin s Disease Malignant lymphoma Malignant bone marrow disorders Melanomas which have a depth of invasion of Clark Level 3 or 1.5mm or more in Breslow thickness Carcinoma in situ of the breast which results directly in the removal of the entire breast (with or without removal of lymph nodes). The procedure must be performed specifically to arrest the spread of malignancy and be considered the appropriate and necessary treatment. The following are excluded: Tumours showing the malignant changes of carcinoma in situ or which are histologically described as premalignant. The following are examples of tumours categorised as either being carcinoma in situ or premalignant and are excluded: i) Cervical dysplasia, CIN1, CIN2 and CIN3 ii) all non-melanoma skin tumours and cancers unless there has been evidence of metastatic spread Any colorectal cancer classified as TNM (Tumour, Nodes, Metastases) Stage 0 (Tis, NO, MO) Prostatic cancers which remain histologically described as TNM Classification T1a or T1b or are of another equivalent or lower classification Prostatic cancers which remain histologically described as TNM Classification T1c unless curative intent therapy has been administered in connection with such cancer All AIDS-related malignancies Tumours treated by endoscopic procedures alone Chronic Lymphocytic Leukaemia (as defined on page 16) Removal of Carcinoma in situ of the Breast (as defined on page 16) Melanoma (as defined on this page) Hydatidiform Mole (as defined on page 17) Carcinoma in situ of the Cervix Uteri (as defined on page 16) Carcinoma in situ of the Vagina (as defined on page 17) Carcinoma in situ of the Vulva or Perineum of limited extent (as defined on page 17). The last seven exclusions do not apply to Income Care Plus. Cancer starts when a cell or group of cells changes from being normal and begins to grow in an uncontrolled fashion. The uncontrolled growth expands in the first site, damaging normal tissue, and cells can spread via the blood stream or the lymphatic system to other parts of the body, where they can multiply. Many cancers can be cured if detected early. Cancer is a leading cause of morbidity and mortality in Australia. Excluding skin cancers other than melanoma, there were 85,231 new cancer cases and 35,466 deaths due to cancer in Australia in Even allowing for the fact that a person may have more than one cancer, at the incidence rates prevailing in 2000, it would be expected that one in three men and one in four women will be diagnosed with a malignant cancer in the first 75 years of life. Source: Australian Institute of Health and Welfare, Melanoma A melanoma which has a depth of invasion of: Clark level 2, or more than 1.25mm, but less than 1.5mm, in Breslow thickness as determined by histological examination. The malignancy must be characterised by the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue. Melanoma is cancer of melanocyte cells and the vast majority occur in the skin. Melanomas are the most lethal form of skin cancer and, as with most forms of cancer, earlier detection of melanoma gives patients a better chance of survival. Melanoma is a major Australian health problem. Every year over 8,000 Australians are diagnosed with melanoma and more than 1,000 Australians die from melanoma. Australia has the highest incidence of melanoma in the world. Melanoma is the most common cancer in males aged and in females aged years. It is the second most common cancer in women years of age and in the overall population of Australia, melanoma now ranks as the third most common cancer. Source: NSW statistics and figures are from the Cancer Institute NSW. 15
18 Body Organ Disorders Chronic Lymphocytic Leukaemia The presence of chronic lymphocytic leukaemia diagnosed as Rai stage 0 or 1, which is defined to be in the blood and bone marrow and/or lymph nodes only. Leukaemia is a cancer of the white blood cells. Chronic lymphocytic leukaemia is a slow growing cancer that produces too many white cells that are called lymphocytes. These cancerous lymphocytes multiply too quickly and live too long so that there are too many of them circulating in the blood stream. These malignant lymphocytes may just be found in the blood stream. This is known as Stage Rai 0. When they are found not only in the blood stream but also cause swelling of the glands that filter out infections (called lymph glands), this is called Stage Rai 1. When other organs are affected by the leukaemia or when there are problems with other cells formed in the bone marrow, then we have higher Rai stagings. Cancer of the Vulva or Perineum Any lesion described by a histopathologist as carcinoma of the vulva or perineum that meets the criteria of either Stage 3 or 4 (tumour of any size with contiguous invasion of local organs) of the 1998 International Federation of Gynecology and Obstetrics (FIGO) surgical staging system. Cancer of the vulva may involve any of the external female sex organs. The most common areas for it to develop are the inner edges of the labia majora (two outer larger lips) and the labia minora (two inner smaller and thinner lips). Less often, vulva cancer may also involve the clitoris or the Bartholon s glands (small glands, one on each side of the vagina). It can also affect the perineum (area of the skin between the vulva and the anus). Cancer of the vulva usually occurs in postmenopausal women in peak incidence between the ages of 65 and 75. However, 15% of the cases occur in women aged 40 or younger. Five-year survival rates in women who are diagnosed and treated in the early stages of vulva cancer can be excellent (more than 90%). Source: Removal of Carcinoma in Situ of the Breast Surgical removal of a carcinoma in situ of the breast, where the carcinoma in situ of the breast: is characterised by a focal autonomous new growth of carcinomatous cells which has not yet resulted in the invasion of normal tissues does not result in the removal of the entire breast, and is classified as Tumour Nodes Metastasis (TNM) stage Tis or International Federation of Gynecology and Obstetrics (FIGO) stage 0. The procedure must be performed specifically to arrest the spread of malignancy and be considered the appropriate and necessary treatment. Carcinoma in situ of the breast is a disease that involves changes in the cells in the lining of the ducts or lobules of the breast. Although the changes are like those seen in breast cancer, carcinoma in situ stays confined to the ducts or lobules and does not invade surrounding fatty tissues in the breast or spread to other organs in the body. There are two types of breast carcinoma in situ: Ductal carcinoma in situ (DCIS): The most common type of non-invasive breast cancer. Cancer cells inside the ducts do not spread through the walls of the ducts into the fatty tissue of the breast. Lobular carcinoma in situ (LCIS): Also called lobular neoplasia. It begins in the lobules, but does not penetrate through the lobule walls. If left untreated, it may increase the chances that a woman will develop an invasive breast cancer. Carcinoma in situ can be found in women at any age; however, most women are between 50 and 59 years old. It can also develop in men, although this is very rare. About 1,200 women are diagnosed with DCIS each year in Australia. Source: National Breast Cancer Centre, Carcinoma in Situ of the Cervix Uteri Confirmation by biopsy of localised pre-invasive cancer in the cervix uteri at severe dysplasia of the level of CIN 3 grading where cancer cells do not penetrate the basement membrane nor invade the surrounding tissues or stroma. For the purposes of this definition, invade means to infiltrate and/or destroy the tissue of origin or surrounding tissue. The cervix is the lower part of the uterus and sits in the upper part of the vagina. Cancer of the cervix is a disease in which the cells of the cervix become abnormal and start to grow uncontrollably, forming tumours. 16
19 Cancer of the cervix is the fifth most common cancer in women. The development of cancer of the cervix is slow. First there are pre-cancer changes in the cells. Eventually they turn into cancer, but initially this cancer remains localised (carcinoma in situ). If this localised cancer isn t treated, it will start invading surrounding tissues (invasive carcinoma). A sexually transmitted virus (known as the human papilloma virus) is the cause of many cases of cancer of the cervix. Carcinoma in Situ of the Vulva or Perineum of limited extent Any lesion described by a histopathologist as carcinoma or intraepithelial neoplasia of the vulva or perineum that meets the criteria of either of the following stages of the 1988 International Federation of Gynecology and Obstetrics (FIGO) surgical staging system: Stage 0. Carcinoma in situ; intraepithelial neoplasia Stage 1A, 1B or 2 where the cancer is confined to the vulva or perineum. Carcinoma in Situ of the Vagina Any lesion described by a histopathologist as carcinoma or intraepithelial neoplasia of the vagina that meets the criteria of Stage 0, (carcinoma in situ; vaginal intraepithelial neoplasia) of the 1988 International Federation of Gynecology and Obstetrics (FIGO) surgical staging system. Hydatidiform Mole The surgical removal of a Hydatidiform mole as confirmed by a histopathologist. A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta. Most often, a hydatidiform mole is an abnormal fertilized egg. The abnormal egg develops into a hydatidiform mole rather than a foetus (a condition called molar pregnancy). Possible complications include haemorrhage, ovarian cysts, pre-eclampisa (toxaemia of pregnancy), and recurrence of the mole. Most often a woman has a miscarriage and passes the mole from her body, or it may need to be removed by D&C (dilatation and curettage). In some rare cases the mole can become cancerous and spread to other parts of the body. Benign Brain Tumour A non-cancerous tumour in the brain giving rise to characteristic symptoms of increased intracranial pressure such as papilloedema, mental symptoms, seizures and sensory impairment as confirmed by a medical practitioner who is a consultant neurologist. The tumour must result in permanent neurological deficit: causing at least a permanent 25% impairment of whole person function (as defined in the edition of the American Medical Association s publication Guides to the Evaluation of Permanent Impairment current as at the preparation date of the Personal Insurance Portfolio PDS), or requiring cranial surgery for its removal. The presence of the underlying tumours must be confirmed by imaging studies such as CT Scan or MRI. Cysts, granulomas, malformations in or of the arteries or veins of the brain, haematomas, and tumours in the pituitary gland or spine are excluded. Brain tumours are usually known for the cell type from which they arise. Brain tumours are either benign or malignant. A benign tumour is not cancerous and unlikely to spread. Some benign brain tumours can cause problems by pressing on and damaging the tissue around the brain. These, however, can often be successfully removed. There are almost 1,400 new cases of malignant brain tumours each year in Australia and many more benign brain tumours that can be just as deadly if the tumour is in a vital area of the brain. More than 1,200 people die each year from malignant and benign brain tumours. Source: Statistics on Incidence, Survival Rates and Mortality Associated with Brain Tumours in Australia, Information Paper for the Australian Brain Tumour Advocacy Group, Denise Chang, June Hydatidiform mole occurs in approximately one in 1,500 pregnancies. Source: Sydney Gynaecological Oncology Group Sydney Cancer Centre,
20 Body Organ Disorders Blindness The permanent loss of sight in both eyes, whether aided or unaided, due to sickness or injury to the extent that visual acuity is 6/60 or less in both eyes, or to the extent that the visual field is reduced to 20 degrees or less of arc, as certified by an ophthalmologist. Partial Blindness The permanent loss of sight in one eye, whether aided or unaided, due to sickness or injury to the extent that visual acuity is 6/60 or less in one eye, or to the extent that the visual field is reduced to 20 degrees or less of arc, as certified by an ophthalmologist. 95% of blindness is caused by diseases such as: glaucoma macular degeneration diabetes cancer. Injury to the eye or the brain may result in blindness. Occasionally, blindness is caused by a genetic disorder, e.g. retinitis pigmentosa. Sight loss is one of the most common causes of disability in Australia, affecting one in 60 Australians. It is estimated that almost 300,000 people across Australia are blind or vision impaired. Source: Royal Blind Society Australia, Chronic Kidney Failure End stage renal failure presenting as chronic irreversible failure of both kidneys to function as a result of which regular renal dialysis is instituted or renal transplantation is performed. When kidneys fail, there is a build-up of poisonous substances in the blood and the blood can become very acidic. The level of some salts, such as potassium, can be high enough to cause sudden cardiac arrest. The only way these imbalances can be corrected is by dialysis. 75% of adult renal failure is caused by: diabetic kidney disease high blood pressure glomerulonephritis. Major Organ or Bone Marrow Transplant The human to human transplant from a donor to the life insured of: one or more of the following organs kidney lung pancreas heart liver bone marrow. The transplantation of all other organs or parts of organs or any other tissue transplant is excluded. Kidney transplantation is considered the most successful treatment for most patients with end stage renal failure. Liver transplant is the treatment for end stage liver failure. Heart/lung transplants are performed less often, but still have remarkable survival rates. Pancreas transplants are performed in patients with insulin-dependent diabetes mellitus. There were 540 kidney transplant operations performed in Australia and New Zealand in Of patients on the active kidney transplant list, 41% are under the age of 65. Source: The Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), Annual Report, Placement on a Waiting List for Major Organ Transplant The life insured must: be diagnosed with a sickness or injury which necessitates a Major Organ or Bone Marrow Transplant (as defined above) and meet the Recipient Suitability Criteria of an Organ Allocation Protocol of the Transplantation Society of Australia and New Zealand and be on a waiting list for the transplant of the relevant organ for at least six months where waiting list means the waiting list of a Transplantation Society of Australia and New Zealand recognised transplant unit. The diagnosis, suitability and placement on a waiting list must be certified by an appropriate medical specialist. You can lose up to 90% of kidney function before even feeling sick. Source: The Australian Kidney Foundation, June