NFU MUTUAL GUIDE TO THE CRITICAL ILLNESS DEFINITIONS PROTECTION

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1 NFU MUTUAL GUIDE TO THE CRITICAL ILLNESS DEFINITIONS PROTECTION

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3 NFU MUTUAL GUIDE TO THE CRITICAL ILLNESS DEFINITIONS Critical Illness Definitions We will use the definitions shown in this column to assess claims. Some of the words within the definitions are shown in semibold, these are generic terms that we will use to assess whether a claim meets the definition for that illness. We explain the generic terms underneath the illness definition. ALZHEIMER S DISEASE BEFORE AGE 65 A definite diagnosis of Alzheimer s disease before age 65 by a Consultant Neurologist, Psychiatrist or Geriatrician. There must be permanent clinical loss of the ability to do all of the following: Remember Reason; and Perceive, understand, express and give effect to ideas. For the above definition, the following is not covered: Other types of dementia. Generic Terms Clinical Relating to the observed symptoms and course of a disease. Diagnosis based on a study of the signs and symptoms of a disease. Permanent Expected to last throughout life with no prospect of improvement, irrespective of when the cover ends or the insured person expects to retires. Explanatory notes The notes in this column are intended to provide a less technical explanation of the illness definitions shown in the left-hand column, and some of the medical terms used within those definitions. They are not intended as an alternative definition of the illness and we will not use them to assess claims. We will consider a claim if a Consultant Neurologist, Psychiatrist or Geriatrician has confirmed Alzheimer s disease. The illness must have reached the point where there are permanent clinical symptoms of dementia. Dementia Impairment of intellectual faculties. For example, loss of memory, concentration and judgement because of disease or disorder of the brain. Guide to the Critical Illness Definitions 03

4 AORTA GRAFT SURGERY The undergoing of surgery for disease or trauma to the aorta with excision and surgical replacement of a portion of the diseased aorta with a graft. The term aorta includes the thoracic and abdominal aorta but not its branches. For the above definition, the following is not covered: Any other surgical procedure, for example, the insertion of stents or endovascular repair. Surgery carried out to repair the aorta with a graft after it has been damaged by disease or trauma. Aorta The main artery of the body, starting at the heart and which supplies oxygenated blood to the body. Endovascular repair A minimal invasive method of repairing the diseased part of the aorta by going through other arteries. Graft Any organ or tissue implanted to repair or replace a diseased or damaged organ or body tissue. Stent A tubular structure inserted into a blood vessel or organ; used to provide support during or after surgical procedures. BENIGN BRAIN TUMOUR A non-malignant tumour or cyst originating from the brain, cranial nerves or meninges within the skull, resulting in permanent neurological deficit with persisting clinical symptoms. Benign Brain tumours that are causing ongoing clinical symptoms because of permanent brain damage. For the above definition, the following are not covered: Tumours in the pituitary gland Tumours originating from bone tissue Angiomas and cholesteatoma. 04

5 Generic Terms Permanent neurological deficit with persisting clinical symptoms Dysfunction in the nervous system that is present on clinical examination and expected to last throughout the insured person s life. To include numbness, hyperaesthesia (increased sensitivity), paralysis, localised weakness, dysarthria (difficulty with speech), aphasia (inability to speak), dysphagia (difficulty in swallowing), visual impairment, difficulty in walking, lack of coordination, tremor, seizures, dementia, delirium and coma. The following are not covered: An abnormality seen on brain scan or other scans without definite related clinical symptoms. Neurological signs occurring without symptomatic abnormality, e.g. brisk reflexes without other symptoms. Angioma A benign tumour of blood vessels. Benign Not malignant. Cranial Nerves Nerves that start at the base of the brain. Cyst A cavity or sac enclosed by a membrane, often containing liquid or semi-solid material. Meninges Membranes that cover and protect the brain and spinal cord. Pituitary gland A small pea sized organ connected by a stalk to the middle of the underside of the brain behind the nasal cavity. Symptoms of psychological or psychiatric origin. BLINDNESS Permanent and irreversible loss of sight to the extent that even when tested with the use of visual aids, vision is measured at 3/60 or worse in the better eye using a Snellen eye chart. Generic Terms Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of the claim. Permanent Expected to last throughout the insured person s life with no prospect of improvement, irrespective of when the cover ends or the insured person retires. Blindness means completely losing sight in both eyes where the condition cannot be cured and is expected to be permanent. Snellen eye chart A Snellen test uses a chart to measure central vision. It usually consists of a number of rows of letters which get smaller as you read down the chart. A measure of 3/60 or worse would mean that you qualify as severely sight impaired. Guide to the Critical Illness Definitions 05

6 CANCER Any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, sarcoma and lymphoma except cutaneous lymphoma (lymphoma confined to the skin). For the above definition, the following are not covered: All cancers which are histologically classified as any of the following: pre-malignant; non-invasive; cancer in situ; having either borderline malignancy; or having low malignant potential. All tumours of the prostate unless histologically classified as having a Gleason score of 7 or above or having progressed to at least TNM classification T2bN0M0. Chronic lymphocytic leukaemia unless histologically classified as having progressed to at least Binet Stage A. Any skin cancer (including cutaneous lymphoma) other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin). Not all cancers are covered under the cancer definition. A cancer will only be potentially covered if it meets both of the following two main conditions: It must be malignant; and It must have progressed to the point where it has invaded the cells in nearby surrounding tissue. Cancers that have not yet progressed to the point where they have invaded the surrounding tissue might sometimes be referred to as pre-malignant or as cancer in situ cancers like these are not covered. For example early forms of breast cancer are not covered where the tumour has not caused invasion, even if it is treated by a mastectomy. Prostate cancers are relatively common in men. A low Gleason score indicates a more easily treated and less aggressive tumour. Most skin cancers are not covered, as they are easy to treat. Malignant melanoma is a very serious form of skin cancer which can spread quickly throughout the body. 06

7 Generic Terms Cancer in-situ The presence of malignant/cancerous cells at a stage of development such that they have not spread into surrounding healthy cells or tissue. In medical terminology, this means that the cancer cells are confined to the epithelium (the tissue that lines the internal and external surfaces of the body). For malignant melanomas of the skin, this means that cancer cells are confined to the epidermis and may be categorised as Clark s level 1. Histological/Histologically The appearance of the cancer under the microscope which leads to its diagnosis and, additionally, gives information on its differentiations or grading (how aggressive it may be). Invasion The occurrence of malignant/cancerous cells that have spread into surrounding healthy cells and tissue (that is, more extensive than cancer in-situ). Pre malignant Cells which may develop into a malignant tumour but have not yet done so. COMA A state of unconsciousness with no reaction to external stimuli or internal needs which: Requires the use of life support systems for a continuous period of at least 96 hours; and With associated permanent neurological deficit with persisting clinical symptoms. Chronic lymphocytic leukaemia A cancer in which too many white blood cells are produced. The Binet classification can help to determine when and how to treat the condition. Gleason Score A grading system for determining the grading of prostate cancer. Lymphoma A broad term which covers a variety of cancers of the lymphatic system. The lymphatic system is a major part of the immune system. Malignant Tumour A tumour that invades the tissue in which it starts and can spread to other parts of the body. Sarcoma A cancer of connective tissue bone, muscle, nerves, fatty tissue cartilage. TNM classification An internationally recognised method of staging cancers. Being in a coma which has lasted continuously for at least 96 hours. During this time the person must have been on life support and it must have caused permanent neurological deficit. For the above definition, the following are not covered: Medically induced coma Coma secondary to alcohol or drug abuse. Guide to the Critical Illness Definitions 07

8 Generic Terms Permanent neurological deficit with persisting clinical symptoms Dysfunction in the nervous system that is present on clinical examination and expected to last throughout the insured person s life. To include numbness, hyperaesthesia (increased sensitivity), paralysis, localised weakness, dysarthria (difficulty with speech), aphasia (inability to speak), dysphagia (difficulty in swallowing), visual impairment, difficulty in walking, lack of coordination, tremor, seizures, dementia, delirium and coma. The following are not covered: An abnormality seen on brain scan or other scans without definite related clinical symptoms Neurological signs occurring without symptomatic abnormality, e.g. brisk reflexes without other symptoms Symptoms of psychological or psychiatric origin. Alcohol or drug abuse Inappropriate use of alcohol or drugs, including but not limited to the following: Consuming too much alcohol Taking an overdose of drugs, whether lawfully prescribed or otherwise Taking Controlled Drugs (as defined by the Misuse of Drugs Act 1971) otherwise than in accordance with a lawful prescription. External stimuli Things that would normally produce a reaction/response. For example, sight, hearing, touch, taste or smell. Internal needs Basic survival needs. For example, food, drink, using the toilet. CORONARY ARTERY BY-PASS GRAFTS The undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a Consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts. Coronary artery by-pass surgery; involves opening the ribcage and attaching a short length of vein to the artery, or using arteries in the area of the breast, to by-pass a blockage in one or more of the coronary arteries that supply blood to the heart. Coronary Artery An artery that supplies blood to the heart. Median Sternotomy Surgery to divide the breastbone (open the ribcage). 08

9 DEAFNESS Permanent and irreversible loss of hearing to the extent that the loss is greater than 95 decibels across all frequencies in the better ear using a pure tone audiogram. Generic Terms Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of the claim. Permanent Expected to last throughout the insured person s life with no prospect of improvement, irrespective of when the cover ends or the insured person retires. HEART ATTACK Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction: Typical clinical symptoms (for example, characteristic chest pain) New characteristic electrocardiographic changes The characteristic rise of cardiac enzymes or Troponins recorded at the following levels or higher: Troponin T > 200 ng/l (0.2 ng/ml or 0.2 ug/l) Troponin I > 500 ng/l (0.5 ng/ml or 0.5 ug/l) The evidence must show a definite acute myocardial infarction. Deafness means completely losing hearing in both ears where the condition cannot be cured and is expected to be permanent. Being registered deaf may not always mean you have a valid claim. Decibels A measure of the loudness of sound. Pure tone audiogram A device for measuring a person s hearing ability. If the blood supply to the heart is interrupted, this can cause a portion of the heart muscle to die. Doctors call this sudden death of heart muscle an acute myocardial infarction, but the condition is widely known as a heart attack. A heart attack causes permanent damage to the heart muscle, which can be detected using an ECG machine that traces the heartbeat. A heart attack releases chemicals such as cardiac enzymes and troponins into the blood stream these are usually present for several days after the event and can be detected by a blood test. The presence of these chemicals provides important diagnostic information, but they can also be present for reasons other than a heart attack. Troponin tests which indicate recorded levels below those mentioned in the definition will not be considered as evidence of acute myocardial infarction. Guide to the Critical Illness Definitions 09

10 For the above definition, the following are not covered: Other acute coronary syndromes. Angina without myocardial infarction. Generic Terms Clinical Relating to the observed symptoms and course of a disease. Diagnosis based on a study of the signs and symptoms of a disease. The term heart attack may sometimes be used loosely to describe a range of other heart conditions, but none of these, for example angina, are covered under our definition. Acute Intense and/or sudden in onset. Angina The often severe chest pain or discomfort that is a symptom of coronary artery disease. Cardiac enzymes or troponins Chemicals found in the blood that when raised above normal levels may indicate damage to heart muscle. Electrocardiographic (ECG) A tracing on graph paper representing the electrical events associated with the beating of the heart. Changes to the shape of the heartbeat trace can help diagnose a number of heart abnormalities, including acute myocardial infarction. Other acute coronary syndromes The collective name given to the various conditions associated with coronary artery disease, which do not meet with our definition of heart attack, for example stable and unstable angina. HEART VALVE REPLACEMENT OR REPAIR The undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a Consultant Cardiologist to replace or repair one or more heart valves. Having a defective heart valve replaced or repaired is covered if the procedure is done using open heart surgery involving opening the ribcage. This shows the serious nature of this procedure and the consequent recovery times for patients. 10

11 Median sternotomy Surgery to divide the breastbone (open the ribcage). HIV INFECTION Caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation. Infection by Human Immunodeficiency Virus resulting from: A blood transfusion given as part of medical treatment; A physical assault; or An incident occurring during the course of performing normal duties of employment (from the eligible occupations listed below). After the start of the policy and satisfying all of the following: The incident must have been reported to appropriate authorities and have been investigated in accordance with the established procedures. Where HIV infection is caught through a physical assault or as a result of an incident occurring during the course of performing normal duties of employment, the incident must be supported by a negative HIV antibody test taken within 5 days of the incident. There must be a further HIV test within 12 months confirming the presence of HIV or antibodies to the virus. The incident causing infection must have occurred in the UK. HIV is covered if it is caught: from a blood transfusion in the UK as part of medical treatment as a result of a physical assault at work in an eligible occupation. HIV resulting from any other cause, for example, sexual activity or drug abuse is not covered. Where the incident relates to a physical assault, this should be reported to the police. If the incident occurred at work, it should be reported in line with the employer s procedures. A test for HIV should be taken within 5 days of the incident. For the above definition, the following is not covered: HIV infection resulting from any other means, including sexual activity or drug abuse. Guide to the Critical Illness Definitions 11

12 Generic Terms Eligible occupation The emergency services police, fire, ambulance. The medical profession including: administrators, cleaners, dentists, doctors, nurses and porters. The armed forces. UK Great Britain and Northern Ireland, the Isle of Man and the Channel Islands. KIDNEY FAILURE Chronic and end stage failure of both kidneys to function, as a result of which regular dialysis is permanently required. Kidneys clean the blood of waste products produced by the body. A claim for kidney failure will be valid if both kidneys have stopped functioning and the person is having regular dialysis (a process using a machine to perform the function of the kidneys). End stage The final phase of a disease process. LOSS OF HANDS OR FEET Permanent physical severance of any combination of 2 or more hands or feet at or above the wrist or ankle joints. Loss of a combination of limbs could mean 1 hand plus 1 foot, or 2 hands or feet. Loss of limbs could be caused by an accident or because of an illness. LOSS OF SPEECH Total permanent and irreversible loss of the ability to speak as a result of physical injury or disease. Loss of speech means completely losing the ability to speak because of physical injury or disease, which cannot be cured and is expected to be permanent. Cases caused by surgery or medical treatment for an illness are also covered. 12

13 Generic Terms Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of claim. Permanent Expected to last throughout the insured person s life with no prospect of improvement, irrespective of when the cover ends or the insured person retires. MAJOR ORGAN TRANSPLANT The undergoing as a recipient of a transplant from another person, of bone marrow or of a complete heart, kidney, liver, lung, or pancreas, or inclusion on an official UK waiting list for such a procedure. For the above definition, the following is not covered: Transplant of any other organs, parts of organs, tissues or cells. MOTOR NEURONE DISEASE A definite diagnosis of one of the following motor neurone diseases by a Consultant Neurologist. There must also be permanent clinical impairment of motor function: Amyotrophic lateral sclerosis (ALS) Primary lateral sclerosis (PLS) Progressive bulbar palsy (PBP) Progressive muscular atrophy (PMA). Generic Terms Clinical Relating to the observed symptoms and course of a disease. Diagnosis based on a study of the signs and symptoms of a disease. A claim will be valid from the point at which the earliest of the following occurs: You are added to a UK waiting list for a suitable organ to become available; or The organ transplant takes place. Motor Neurone disease is a degenerative condition that causes weakness and the wasting of muscles. The condition is covered: If there is a definite diagnosis made by a Consultant Neurologist; and The disease has reached the point where it has caused permanent impairment of the ability to move. Motor Relating to movement. Permanent Expected to last throughout the insured person s life with no prospect of improvement, irrespective of when the cover ends or the insured person retires. Guide to the Critical Illness Definitions 13

14 MULTIPLE SCLEROSIS A definite diagnosis of Multiple Sclerosis by a Consultant Neurologist. There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months. Generic Terms Clinical Relating to the observed symptoms and course of a disease. Diagnosis based on a study of the signs and symptoms of a disease. PARALYSIS OF LIMBS Total and irreversible loss of muscle function to the whole of any 2 limbs. Generic Terms Irreversible Cannot be reasonably improved upon by medical treatment and/or surgical procedures used by the National Health Service in the UK at the time of the claim. Multiple Sclerosis, often abbreviated to MS, is an incurable disease which attacks the central nervous system. It can result in worsening of the senses and/or the ability to control movement. A claim for Multiple Sclerosis will be valid from the point where, for a continuous period of at least 6 months, the disease has physically affected your ability to move or your senses (sight, hearing, touch, taste or smell). The diagnosis must be confirmed by a Consultant Neurologist using up-to-date diagnostic equipment and methods at the time of the claim. Motor Relating to movement. Sensory Relating to the senses (sight, hearing, touch, taste or smell). Paralysis and paraplegia are covered if the person totally and irreversibly loses the ability to move, or use, any 2 or more limbs. The disability must be considered irreversible. Paralysis of the right or left half of the body is called hemiplegia. If all 4 limbs are paralysed this is called quadriplegia. Paralysis of the lower part of the body is called paraplegia. 14

15 PARKINSON S DISEASE A definite diagnosis of Parkinson s disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function with associated tremor and muscle rigidity. For the above definition, the following is not covered: Parkinsonian syndromes/parkinsonism. Parkinson s disease is a degenerative brain disease that causes involuntary tremor, muscle rigidity and the slowing of body movements. The condition is covered: If there is a definite diagnosis made by a Consultant Neurologist; and The disease has reached the point where there is a permanent clinical impairment of motor function, along with tremor, inflexibility of movement and unstable posture. Generic Terms Clinical Relating to the observed symptoms and course of a disease. Diagnosis based on a study of the signs and symptoms of a disease. Permanent Expected to last throughout the insured person s life with no prospect of improvement, irrespective of when the cover ends or the insured person retires. Tremor Involuntary, rhythmic movement of part of the body. For example, most commonly the hands and arms. Guide to the Critical Illness Definitions 15

16 STROKE Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in permanent neurological deficit with persisting clinical symptoms. For the above definition, the following are not covered: Transient ischaemic attack; Traumatic injury to brain tissue or blood vessels; Death of tissue of the optic nerve or retina/ eye stroke. Generic Terms Permanent neurological deficit with persisting clinical symptoms Dysfunction in the nervous system that is present on clinical examination and expected to last throughout the insured person s life. To include numbness, hyperaesthesia (increased sensitivity), paralysis, localised weakness, dysarthria (difficulty with speech), aphasia (inability to speak), dysphagia (difficulty in swallowing), visual impairment, difficulty in walking, lack of coordination, tremor, seizures, dementia, delirium and coma. A stroke is caused either by a blocked artery preventing blood reaching the brain, or by a blood vessel in the brain bursting. In either case, a claim will be valid if it causes permanent neurological deficit with persisting clinical symptoms. Transient ischaemic attacks are not covered because there are no permanent effects typically patients recover in 24 hours. Doctors sometimes refer to these as mini-strokes to aid patients understanding. Transient ischaemic attack Temporary disruption of the blood circulation to part of the brain. The symptoms may be similar to those of a stroke but patients recover within 24 hours. The following are not covered: An abnormality seen on brain scan or other scans without definite related clinical symptoms Neurological signs occurring without symptomatic abnormality, e.g. brisk reflexes without other symptoms Symptoms of psychological or psychiatric origin. 16

17 TERMINAL ILLNESS A definite diagnosis by the attending Consultant of an illness that satisfies both of the following: The illness either has no known cure or has progressed to the point where it cannot be cured, and In the opinion of the attending Consultant, the illness is expected to lead to death within 12 months. THIRD DEGREE BURNS Burns that involve damage or destruction of the skin to its full depth through to the underlying tissue and covering at least 20% of the body s surface area. Benefits payable on the death of the person whose life is covered by the policy may be paid early if that person is diagnosed as having a terminal illness. After receiving satisfactory proof that the person whose life is covered by the policy is diagnosed as suffering from a terminal illness, NFU Mutual will bring forward the payment of the lump sum. Third degree burns that damage or destroy the skin to its full depth and cause damage to the tissue underneath, with at least 20% of the body surface area being affected. TOTAL PERMANENT DISABILITY Loss of the physical ability through an illness or injury to do at least 3 of the 6 tasks listed below ever again. The relevant specialists must reasonably expect that the disability will last throughout life with no prospect of improvement, irrespective of when the cover ends or the insured person expects to retire. The insured person must need the help or supervision of another person and be unable to perform the task on their own, even with the use of special equipment routinely available to help and having taken any appropriate prescribed medication. The tasks are: Washing the ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily by other means. Getting dressed and undressed the ability to put on, take off, secure and unfasten all garments and, if needed, any braces, artificial limbs or other surgical appliances. Guide to the Critical Illness Definitions 17

18 Feeding yourself the ability to feed yourself when food has been prepared and made available. Maintaining personal hygiene the ability to maintain a satisfactory level of personal hygiene by using the toilet or otherwise managing bowel and bladder function. Getting between rooms the ability to get from room to room on a level floor. Getting in and out of bed the ability to get out of bed into an upright chair or wheelchair and back again. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered. TRAUMATIC BRAIN INJURY Death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms. Traumatic brain injury is covered if it results in ongoing clinical symptoms resulting from permanent brain damage. Generic Terms Permanent neurological deficit with persisting clinical symptoms Dysfunction in the nervous system that is present on clinical examination and expected to last throughout the insured person s life. To include numbness, hyperaesthesia (increased sensitivity), paralysis, localised weakness, dysarthria (difficulty with speech), aphasia (inability to speak), dysphagia (difficulty in swallowing), visual impairment, difficulty in walking, lack of coordination, tremor, seizures, dementia, delirium and coma. The following are not covered: An abnormality seen on brain scan or other scans without definite related clinical symptoms Neurological signs occurring without symptomatic abnormality, e.g. brisk reflexes without other symptoms Symptoms of psychological or psychiatric origin. 18

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20 nfumutual.co.uk NFU Mutual is The National Farmers Union Mutual Insurance Society Limited (No ). Registered in England. Registered Office: Tiddington Road, Stratford upon Avon, Warwickshire CV37 7BJ. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. A member of the Association of British Insurers. For security and training purposes, telephone calls may be recorded and monitored. CI/SUPP/011215