Critical Illness and Waiver of Payment Definitions Guide for the Loan Assurance Plan, Level Term Assurance Plan and Flexible Protection Plan

Transcription

1 Critical Illness and Waiver of Payment Definitions Guide for the Loan Assurance Plan, Level Term Assurance Plan and Flexible Protection Plan Provided by St Andrew's Life Assurance plc (St Andrew's Life) 1/16

2 2/16 Contents 1. Introduction 1 2. Critical illness conditions covered Alzheimer s disease before age 65 2 Aorta graft surgery 2 Aplastic anaemia 2 Bacterial meningitis 3 Benign brain tumour 3 Blindness 3 Cancer 3 Coma 4 Coronary artery by-pass surgery 4 Creutzfeldt-Jakob disease 5 Deafness 5 Heart attack 5 Heart valve replacement or repair 6 HIV/AIDS as a result of physical assault or accident 6 HIV/AIDS from blood transfusion 7 Kidney failure 7 Loss of limbs 8 Loss of speech 8 Major organ transplant 8 Motor neurone disease 8 Multiple sclerosis 8 Parkinson s disease before age 65 9 Stroke 9 Third degree burns 9 Total permanent disability Waiver of payment cover 11

3 3/16 1. Introduction This guide contains details of the protection that is available if you have chosen critical illness or waiver of payment cover under the Loan Assurance Plan or Level Term Assurance Plan. It also contains details of the protection that is available if you have chosen waiver of payment cover or critical illness cover under a Flexible Protection Plan sold after 26 May Please note that all three of the above plans are now closed to new business. You should read it with your plan documents and key features. In this guide you will find a plan definition (shown in bold) and, where helpful, further explanation for the conditions covered. We use these definitions when we assess a claim. Please note that you may not be covered under your plan for some of the critical illness conditions listed. You should refer to your plan documents to check the conditions for which you are covered before making a claim. 1

4 4/16 2. Critical Illness conditions covered Alzheimer s disease before age 65 Deterioration or loss of intellectual capacity or abnormal behaviour as evidenced by the clinical state and accepted standardised questionnaires or tests, arising from Alzheimer s disease (and excluding neurosis and psychiatric illness) resulting in significant reduction in mental and social functioning requiring the continuous supervision of the life covered. The diagnosis must be made before the age of 65 and must be clinically confirmed by a suitably qualified Consultant and must be supported by our Chief Medical Officer. Alzheimer s disease, sometimes called presenile dementia, is a progressive form of dementia associated with degeneration of the brain cells. The cause is as yet unknown. Aorta graft surgery Undergoing surgery for disease of the aorta needing excision and surgical replacement of a portion of the diseased aorta with a graft. For this definition, aorta means the thoracic and abdominal aorta but not its branches. The aorta is the main artery taking blood from the heart to the rest of the body. It can become weakened by an aneurysm (thinning and bulging of the artery wall) or by narrowing because of fatty deposits lining the inside of the artery wall. If this results in the damaged portion of the aorta being removed and replaced by artificial material then a valid claim will be payable under this benefit. If the surgery is undergone following an injury to the aorta then this too will result in a valid claim. Aplastic anaemia Permanent bone marrow failure which results in anaemia, neutropaenia and thrombocytopaenia requiring treatment with at least one of the following: Blood transfusion Marrow stimulating agents Immunosuppressive agents Bone marrow transplant Aplastic anaemia is a blood disorder characterised by a decrease in blood forming cells due to bone marrow failure. 2

5 5/16 Bacterial meningitis Bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in permanent neurological deficit. The diagnosis must be confirmed by a Consultant Neurologist. Bacterial meningitis in the presence of HIV infection is excluded. All other forms of meningitis including viral meningitis are not covered. The meninges are the membranes that line the brain and spinal cord (central nervous system). They act as a barrier between the central nervous system and the rest of the body, preventing the transference of infection. Meningitis is infection of the meninges. Viral meningitis is more common and normally less serious. Bacterial meningitis is less common but always a serious and severe illness. Benign brain tumour A non-malignant tumour in the brain resulting in permanent deficit to the neurological system. Tumours or lesions in the pituitary gland are not covered. A benign tumour, whilst not normally dangerous, can if occurring in the brain, cause neurological damage due to increased pressure. Such growths may be potentially life-threatening and require surgical removal. Blindness Total, permanent and irreversible loss of all sight in both eyes. Loss of sight must be total and permanent. It should be pointed out that it is possible to be registered blind whilst being only partially sighted. Partial loss of sight is not covered. Cancer Any malignant tumour characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. The term cancer includes leukaemia and Hodgkin s disease but the following are excluded: All tumours which are histologically described as pre-malignant, as noninvasive or as cancer in situ. All tumours of the prostate unless histologically classified as having a Gleason score greater than six or having progressed to at least TNM classification T2N0M0. 3

6 6/16 All forms of lymphoma in the presence of any Human Immunodeficiency Virus. Kaposi s sarcoma in the presence of any Human Immunodeficiency Virus. Any skin cancer other than invasive malignant melanoma. Cancer, also known as malignant tumour or malignancy, causes abnormal and uncontrolled growth of the cells which spread and destroy tissue. The cells may then spread through your bloodstream or lymphatic system to other parts of the body. You can claim if the life covered is suffering from a malignant tumour which has invaded surrounding tissue. The claim must be supported by histological evidence. This is a microscopic examination of a sample of the diseased cells. Coma A state of unconsciousness with no reaction to external stimuli or internal needs, persisting continuously with the use of life support systems for a period of at least 96 hours and resulting in permanent neurological deficit. Coma secondary to alcohol or drug misuse is not covered. Coma can occur when the brain has been damaged or disturbed due to trauma or disease. Whilst in a coma an individual cannot be roused from a state of unconsciousness, has no control over their body and is unresponsive to physical stimulation. Level of recovery is variable and claims will only be considered for those individuals proven to have residual permanent neurological deficit. Coronary artery by-pass surgery The undergoing of open heart surgery on the advice of a Consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts but excluding balloon angioplasty, laser relief or any other procedures. Coronary artery by-pass surgery, also known as coronary by-pass grafting, may be needed when one or more of the coronary arteries are narrowed or blocked and cannot supply enough blood to the heart muscle. The surgery is done by inserting short lengths of vein, usually taken from the leg or chest into the artery. This increases the blood flow to 4

7 7/16 the heart muscle by providing an alternative route for blood to reach the heart. We do not cover, under this definition, open-heart surgery to correct any fault of the heart or aorta (the main artery of the body) where the heart is temporarily by-passed during the operation but is then reconnected as normal once the surgery has been completed. Creutzfeld-Jakob disease Unequivocal diagnosis by a Consultant Neurologist of Creutzfeld-Jakob disease. Diagnosis must be based on conclusive EEG and CSF findings as well as CT scan and MRI. Creutzfeldt-Jakob disease (CJD) is a rapidly progressive disease of the brain. There is currently no known cure. From the first onset of symptoms deterioration in intellectual ability is usually rapid, leading to dementia and neurological problems requiring nursing care in up to 18 months. Deafness Total permanent and irreversible loss of all hearing in both ears. In order to qualify, hearing loss must be total and permanent in both ears. Partial or temporary deafness is not covered. Heart attack The death of a portion of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction: typical chest pain; new characteristic electrocardiographic changes; the characteristic rise of cardiac enzymes, troponins or other biochemical markers; where all of the above shows a definite acute myocardial infarction. Other acute coronary syndromes, including but not limited to angina, are not covered under this definition. A heart attack, also known as a myocardial infarction, occurs when an area of the heart muscle dies. This usually happens because a coronary artery becomes blocked by atheroma (fatty deposits) or a blood clot, which is known as coronary occlusion or coronary thrombosis. This results in the heart receiving insufficient oxygen causing permanent damage to the heart muscle. A claim under heart attack will need to 5

8 8/16 be supported by evidence of severe chest pains, new electrocardiographic (ECG) changes and an increase in cardiac enzymes or markers. These enzymes or markers are released into the blood stream from the damaged heart muscle. An electrocardiograph is a machine that monitors how the heart muscles work. Electrocardiographic changes happen when the heart is not working in the normal way. Angina symptoms may be similar to those suffered during a heart attack, but angina is not a condition covered under this definition. The reason is that heart muscle does not die as a result of an angina attack, but is only temporarily impaired due to lack of oxygen. Heart valve replacement or repair Undergoing open-heart surgery from medical necessity to replace or repair one or more heart valves. The flow of blood through the heart is regulated by four valves. These must work properly for the heart to function efficiently. Any deterioration in their function, for example because of disease, can have potentially serious effects. This can lead to a need to repair a damaged valve or, if this is not possible its replacement by an artificial or tissue valve. If this is done by undergoing openheart surgery, that is opening the chest wall to reach the heart, then a valid claim will be payable under this benefit. HIV/AIDS as a result of physical assault or accident A definite diagnosis of infection with Human Immunodeficiency Virus (HIV) which was caused by: physical assault (including sexual assault) on the life covered or accidental exposure in the United Kingdom to a hypodermic needle or another sharp instrument which is infected with HIV. The assault or accident must have occurred during the 12 months preceding diagnosis and after the date on which the critical illness cover starts. There must be evidence that the infection occurred as a result of the assault or accident, and any assault must have been reported to the Police within 24 hours of its occurrence. 6

9 9/16 The life covered must have a blood test within five days of the assault or accident and this test must indicate the absence of HIV or antibodies to HIV. The life covered must have a further blood test within 12 months of the assault or accident which indicates the presence of HIV or antibodies to HIV. All blood tests must be carried out by a recognised hospital laboratory in the United Kingdom. Human Immunodeficiency Virus (HIV) is the virus which can lead to Acquired Immune Deficiency Syndrome (AIDS). Once infected the body s defence system breaks down leaving an individual open to infection and certain forms of cancer. HIV from blood transfusion The life covered being infected by Human Immunodeficiency Virus or suffering from Acquired Immune Deficiency Syndrome or other related virus or syndrome as a result of infection due to a blood transfusion received in the UK after the date on which critical illness cover starts. Confirmation will be required by a suitable qualified Consultant. Liability must be admitted by the medical facility. Human Immunodeficiency Virus (HIV) is the virus which can lead to Acquired Immune Deficiency Syndrome (AIDS). Once infected the body s defence system breaks down leaving an individual open to infection and certain forms of cancer. Kidney failure End stage renal failure presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis or renal transplant is initiated. Kidney failure is also known as renal failure. The kidneys remove waste materials from the blood supply. When they fail to function properly there is a dangerous, and possibly life-threatening, build up of waste material. The body can work with one kidney, but if both fail, long-term dialysis or a kidney transplant will be required. A claim can be made if this occurs. 7

10 10/16 Loss of limbs The permanent physical severance of two or more limbs from above the wrist or ankle joint. We will pay a valid claim if at least two limbs are cut off above the ankle or wrist. We will not pay if the limbs are sewn back on during surgery. Loss of speech Total, permanent and irreversible loss of the ability to speak as a result of physical injury or disease. Loss of speech must be due to physical damage to the vocal cords due to injury or disease. Cover does not extend to claims where there is no physical damage as may be the case in loss of speech due to mental trauma. Major organ transplant The actual undergoing as a recipient of, or inclusion on an official UK waiting list for, a transplant of a heart, liver, lung, pancreas or bone marrow. If an organ is seriously damaged or diseased due to injury or illness, it may become necessary for it to be replaced with a healthy one. (Kidney transplants are covered under Kidney Failure.) Motor neurone disease Confirmation by a Consultant Neurologist of a definite diagnosis of Motor Neurone Disease. Motor Neurone disease is a progressive degeneration of the nerve cells in the brain that controls muscular activity. Nerve degeneration results in increasing muscle weakness. The cause of Motor Neurone Disease is as yet unknown. Multiple sclerosis A definite diagnosis by a Consultant Neurologist of Multiple sclerosis, which satisfies all of the following criteria: There must be current impairment of motor or sensory function, which must have persisted for a continuous period of at least six months. The diagnosis must be confirmed by diagnostic techniques current at the time of the claim. Multiple sclerosis is an incurable disease of the body s central nervous system. The disease is difficult to diagnose but a neurologist can carry out several tests to help confirm the diagnosis. For your claim to be valid, there must be persistent symptoms for six months and 8

11 11/16 the disease confirmed by a consultant neurologist. Parkinson s disease before age 65 Confirmation by a Consultant Neurologist of a definite diagnosis of Parkinson s disease before age 65. Parkinson s disease secondary to alcohol or drug misuse is not covered. Parkinson s disease is a progressive, degenerative disorder of the central nervous system, characterised by disturbance of voluntary movement and muscle rigidity, leading to severe physical disability. Stroke A cerebrovascular incident resulting in permanent neurological damage. Transient Ischaemic Attacks are specifically excluded. A stroke involves permanent damage to the brain. This may be caused by cerebral thrombosis (a blood clot formed in a furred-up artery of the brain). Or, it can be caused by cerebral embolism (the movement of a blood clot from some other part of the body), or cerebral haemorrhage (when one of the brain s blood vessels bursts). The reduction in blood supply to the brain causes brain cells to die (infarction). To claim, there must be evidence of permanent damage to the nervous system which can include paralysis to the right or left-hand sides of the body, problems with speech or sight or loss of strength. This will depend on the area of the brain affected. Mini-strokes or minor incidents known as Transient Ischaemic Attacks are excluded as they leave no long-term problems. Third degree burns Third degree burns covering at least 20% of the body surface area. The severity of a burn is described in terms of degree. First degree burns affect only the top layer of skin. Second degree burns damage several skin layers whilst third degree burns penetrate the entire depth of skin, causing damage to underlying fat, muscle and even bone. Claims will only be considered for individuals who have suffered third degree burns covering at least 20% of their body surface area. 9

12 12/16 Total permanent disability Total permanent disability of a life covered means one or other of the definitions detailed below, depending on the age of the life covered at the start of the disability. The total permanent disability of the life covered under the plan before age 60 which prevents the life covered from performing at least three of the following five activities for a continuous period of 12 months and which will continue to do so in the future. Dressing and undressing, putting on and taking off all necessary items of clothing. Using the toilet, getting to and from the toilet, getting on and off the toilet and associated personal hygiene. Getting up and down a flight of stairs. Getting in and out of a bed or chair. General household duties including cleaning, ironing, childminding and shopping. The total permanent disability of the life covered under the plan after age 60 which prevents the life covered from performing at least four of the following six activities for a continuous period of 12 months and which will continue to do so in the future. Taking a bath or shower, or maintaining personal cleanliness. Dressing and undressing, including putting on and taking off surgical appliances usually worn. Getting to and from the toilet, getting on and off the toilet and maintaining an adequate level of personal hygiene. Voluntarily controlling bowel and bladder function, with or without catheters, incontinence pads or other artificial aids. Moving in and out of a chair or bed. Eating and drinking once food or drink has been prepared and made available. We will consider the life covered unable to perform an activity when the following applies. The life covered is unable to perform the activity even with the use of equipment. and The life covered always needs the help of another person to perform the activity. 10

13 13/16 3. Waiver of payment cover Waiver of payment benefit starts after the first 26 weeks of total disability (as long as, when total disability starts, the life covered is less than 60 years old on the next anniversary of the start date). Under a Level Term Assurance Plan or Loan Assurance Plan, waiver of payment benefit will be payable when the following condition is met: At the start of the disablement the life covered is in paid employment for 16 or more hours a week, and due to an accident or sickness as certified by a registered medical practitioner to the reasonable satisfaction of our Chief Medical Officer, is unable to perform the life covered's own or any other occupation for which the life covered is reasonably suited by experience or training and is not following another occupation. or At the start of the disablement the life covered is not in paid employment, or is in paid employment for less than 16 hours a week and due to an accident or sickness as certified by a registered medical practitioner to the reasonable satisfaction of our Chief Medical Officer, is unable to perform unaided three or more of the activities described below. Dressing and undressing, putting on and taking off all necessary items of clothing Using the toilet, getting to and from the toilet, getting on and off the toilet and associated personal hygiene Getting up and down one flight of stairs Getting in and out of a bed or chair General household duties including: cleaning, ironing, childminding and shopping. We will consider a life covered unable to perform an activity when the following applies. The life covered is unable to perform the activity even with the use of equipment. and The life covered always needs the help of another person to perform that activity. 11

14 14/16 Under a Flexible Protection Plan sold after 26 May 2006, waiver of payment benefit will be payable when the following condition is met: Due to an accident or sickness as certified by a registered medical practitioner to the reasonable satisfaction of our Chief Medical Officer the life covered is unable to perform unaided three or more of the six activities described below and the life covered will not recover. Mobility The ability to move indoors from room to room on level surfaces. Washing The ability to wash in the bath or shower (including getting into or out of the bath or shower) or wash satisfactorily by other means. Dressing The ability to put on, take off, secure and unfasten all garments and any braces, artificial limbs or other surgical devices. Transferring The ability to move from a bed to an upright chair or wheel chair or vice versa. Toileting The ability to use the lavatory or otherwise manage bowel and bladder function so as to maintain a satisfactory level of personal hygiene. Feeding The ability to feed oneself once food has been prepared and made. We will consider a life covered unable to perform an activity when the following applies. The life covered is unable to perform the activity even with the use of equipment. and The life covered always needs the help of another person to perform the activity. 12

15 Notes 15/16 13

16 16/16 St Andrew s Life Assurance plc. Registered Office: 33 Old Broad Street, London EC2N 1HZ. Registered in England No Authorised and regulated by the Financial Services Authority. 1/ (0209)