Group Critical Illness. Member Guide

Transcription

1 Group Critical Illness Member Guide

2 Aviva By choosing Aviva, part of the UK s largest insurance group, you benefit from our financial strength. Together with millions of customers worldwide you can feel certain of your choice whether you invest for the future, provide against the unexpected, or protect the things that are important to you. Our size and efficiency give us the strength to deliver an extensive range of value for money, quality products investments, retirement, protection and healthcare designed and changing to meet your needs, both now and in the future. 2

3 Contents Page 4 Group Critical Illness Cover Risk factors 5 Your questions answered: What benefit levels are available? What are the eligibility conditions? When will cover stop? What type of cover is available? When is the lump sum paid? What happens if someone is temporarily absent? 12 Does any evidence of health have to be provided before I am covered? 12 Claiming benefit How are claims made? How do we assess claims? Can another claim be made in the future? 13 What is not covered? 17 Can cover be provided for an employee who is not in the UK? Taxation Continuation option 18 Further information aviva.co.uk/health 3

4 Group Critical Illness Cover Group Critical Illness cover is designed to pay a lump sum if a member of the scheme, or an employee s child: l is diagnosed with one of the illnesses, or l undergoes one of the operations covered. A member can be an employee and, if you choose to cover them as well, your husband, wife, civil partner or unmarried partner. An employee s children will be automatically covered by the scheme. We will pay the lump sum only to the employee. This guide will tell you which illnesses and operations can be covered. It will also tell you the circumstances when members will not be eligible to receive a lump sum, even if they have suffered an illness or undergone an operation normally covered. Risk factors l l You may not have adequate cover if you do not adjust your choices at the anniversary date or a lifestyle event. Each scheme year, members can increase their benefit at the anniversary date and on a qualifying lifestyle event. l Aviva can review the cover it provides. 4

5 Your questions answered What benefit levels are available? l You can elect cover in multiples (units) of 25,000. We allow a maximum lump sum of the employee s salary x 5 (although this is capped we will pay no more than 250,000 per claim for an employee or their husband, wife, civil partner or unmarried partner) l Cover for your husband, wife, civil partner or unmarried partner cannot exceed the cover for an employee. (Children can receive up to 25% of the employee s benefit with a cap of 20,000) l members can increase their benefit by any number of units of 25,000 at each anniversary date or lifestyle event. The pre-existing conditions exclusion will apply to the increased benefit from that anniversary date or lifestyle event l members can decrease their benefit by any number of units of 25,000 at each anniversary date or lifestyle event. What are the eligibility conditions? l We allow membership for people who are 69 and younger (we will automatically cancel membership when a member reaches 70 years old). Children aged 30 days to the day before their 18th birthday will be automatically covered (we will no longer cover children when they reach 18 years old, or when the employee reaches 70 years old if this happens earlier) When will cover stop? Under normal circumstances l Employees will stop being covered when: they are no longer eligible for the scheme they are no longer employed they reach the membership cancellation age they die l If an employee is not at work due to a statutory absence (for example maternity leave), the longest that they can be covered is three years. For employees on unpaid leave (for example a sabbatical), the longest that they can be covered is three years. l We will no longer cover your husband, wife, civil partner, unmarried partner or child: if we pay a claim for them (only employees can remain covered after making a claim), or when they are no longer eligible for the scheme when they reach the membership cancellation age (for children, when they reach 18) when they die if you leave the scheme, for whatever reason. What type of cover is available? We use the Association of British Insurers (ABI) definitions for all critical illnesses that have been defined by them. These definitions are marked with an asterisk. Within the critical illness definitions there are three words or phrases that have very specific meanings. These are also defined by the ABI and are: 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 member s life, irrespective of when the cover ends or the member retires. Permanent neurological deficit with persisting clinical symptoms Symptoms of dysfunction in the nervous system that are present on clinical examination and expected to last throughout the member s life. Symptoms that are covered 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, lethargy, dementia, delirium and coma. The following are not covered: l an abnormality seen on brain or other scans without definite related clinical symptoms l neurological signs occurring without symptomatic abnormality, eg brisk reflexes without other symptoms l symptoms of psychological or psychiatric origin. aviva.co.uk/health 5

6 Critical illness or operation *Alzheimer s disease resulting in *Aorta graft surgery for disease Aplastic anaemia with permanent bone marrow failure Bacterial meningitis resulting in *Benign brain tumour resulting in *Blindness permanent and irreversible *Cancer excluding less advanced cases Definition A definite diagnosis of Alzheimer s disease 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 are not covered: other types of dementia. The undergoing of surgery for disease 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 are not covered: any other surgical procedure, for example the insertion of stents or endovascular repair surgery following traumatic injury to the aorta. A definite diagnosis of aplastic anaemia by a Consultant Haematologist. There must be permanent bone marrow failure with anaemia, neutropenia and thrombocytopenia. A definite diagnosis of bacterial meningitis resulting in permanent neurological deficit with persisting clinical symptoms. We do not cover any other form of meningitis, only meningitis caused by bacterial infection. A non-malignant tumour or cyst in the brain, cranial nerves or meninges within the skull, resulting in permanent neurological deficit with persisting clinical symptoms. For the above definition, the following are not covered: tumours in the pituitary gland angiomas. 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. 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, lymphoma and sarcoma, except cutaneous lymphoma (lymphoma confined to the skin). For the above definition, the following are not covered: all cancers which are histologically classiled as any of the following: pre-malignant; non-invasive; cancer in situ; having borderline malignancy; or having low malignant potential. all tumours of the prostate unless histologically classiled as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0 chronic lymphocytic leukaemia unless histologically classiled 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). 6

7 Critical illness or operation Cardiomyopathy of specified severity *Coma resulting in permanent symptoms Coronary angioplasty to 2 or more coronary arteries *Coronary artery by-pass grafts with surgery to divide the breastbone Creutzfeldt-Jakob disease (CJD) resulting in *Deafness permanent and irreversible Dementia resulting in permanent symptoms Encephalitis resulting in permanent symptoms Definition A definite diagnosis of cardiomyopathy by a Consultant Cardiologist. There must be clinical impairment of heart function resulting in the permanent loss of ability to perform physical activities to at least Class 3 of the New York Heart Association (NYHA) classification s of functional capacity*. For the cardiomyopathy definition, we do not cover: cardiomyopathy secondary to alcohol or drug abuse any other form of heart disease, heart enlargement and myocarditis. * NYHA Class 3. Heart disease resulting in marked limitation of physical activities where less than ordinary activity causes fatigue, palpitation, breathlessness or chest pain. 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 results in permanent neurological delcit with persisting clinical symptoms. For the above definition, the following is not covered: Coma secondary to alcohol or drug abuse. The undergoing of balloon angioplasty, atherectomy, laser treatment or stent insertion on the advice of a Consultant Cardiologist to correct at least 70% narrowing or blockage of two or more coronary arteries as a single procedure. 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. A definite diagnosis of CJD by a Consultant Neurologist. There must be permanent clinical impairment of motor function and loss of the ability to: remember reason, and perceive, understand, express and give effect to ideas. For the CJD definition, we do not cover other types of dementia. 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. A definite diagnosis of dementia by a Consultant Neurologist, Psychiatrist or Geriatrician. There must be permanent clinical loss of the ability to: remember reason and perceive, understand, express and give effect to ideas We do not cover dementia secondary to alcohol or drug abuse. A definite diagnosis of encephalitis by a Consultant Neurologist. There must be permanent neurological deficit with persisting clinical symptoms. aviva.co.uk/health 7

8 Critical illness or operation *Heart attack of specified severity *Heart valve replacement or repair with surgery to divide the breastbone *HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation *Kidney failure requiring dialysis Liver failure of advanced stage *Loss of hands or feet permanent physical severance Definition 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 > 1.0 ng/ml AccuTnI > 0.5 ng/ml or equivalent threshold with other Troponin I methods. The evidence must show a definite acute myocardial infarction. For the above definition, the following are not covered: other acute coronary syndromes including but not limited to angina. 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. 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; the emergency services police, lre and ambulance the medical profession including administrators, cleaners, dentists, doctors, nurses and porters the armed forces after the start of the cover 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 conlrming the presence of HIV or antibodies to the virus the incident causing infection must have occurred in the UK For the above definition, the following is not covered: HIV infection resulting from any other means, including sexual activity or drug abuse. Chronic and end stage failure of both kidneys to function, as a result of which regular dialysis is necessary. Liver failure due to cirrhosis and resulting in: permanent jaundice ascites, and encephalopathy We do not cover liver disease secondary to alcohol or drug abuse. Permanent physical severance of any combination of 2 or more hands or feet at or above the wrist or ankle joints. 8

9 Critical illness or operation Loss of independent existence permanent and irreversible *Loss of speech permanent and irreversible *Major organ transplant *Motor neurone disease resulting in *Multiple sclerosis with persisting symptoms *Paralysis of limbs total and irreversible *Parkinson s disease resulting in Pulmonary artery graft surgery Respiratory failure of advanced stage Definition The permanent loss of the ability to perform routinely at least three of the following six tasks without the assistance of another person, even with the use of special devices or equipment. The tasks are: 1. 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. 2. 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. 3. Feeding yourself the ability to feed yourself when food has been prepared and made available. 4. Maintaining personal hygiene the ability to maintain a satisfactory level of personal hygiene by using the toilet or otherwise managing bowel and bladder function. 5. Getting between rooms the ability to get from room to room on a level floor. 6. Getting in and out of bed the ability to get out of bed into an upright chair or wheelchair and back again. Total permanent and irreversible loss of the ability to speak as a result of physical injury or disease. The undergoing as a recipient of a transplant 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. A definite diagnosis of motor neurone disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function. 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. Total and irreversible loss of muscle function to the whole of any 2 limbs. A definite diagnosis of Parkinson s disease by a Consultant Neurologist. There must be permanent clinical impairment of motor function with associated tremor, muscle rigidity and postural instability. For the above definition, the following is not covered: Parkinson s disease secondary to drug abuse other Parkinsonian syndromes. The undergoing of surgery on the advice of a Consultant Cardiothoracic Surgeon for a disease of the pulmonary artery to excise and replace the diseased pulmonary artery with a graft. For the pulmonary artery graft surgery definition we do not cover any other surgical procedure, for example endovascular repairs or the insertion of stents. Advanced stage emphysema or other chronic lung disease, resulting in: the need for regular oxygen treatment on a permanent basis, and the permanent impairment of lung function tests where Forced Vital Capacity (FVC) and Forced Expiratory Volume at 1 second (FEV1) are less than 50% of normal. aviva.co.uk/health 9

10 Critical illness or operation Rheumatoid arthritis chronic and severe *Stroke resulting in permanent symptoms *Terminal illness *Third degree burns covering 20% of the body s surface area *Traumatic head injury resulting in *Total permanent disability of specified severity *Total permanent disability unable to do a suited occupation ever again Definition A definite diagnosis of rheumatoid arthritis by a Consultant Rheumatologist: there must be morning stiffness in the affected joints lasting for at least one-hour there must be arthritis of at least three joint groups, with soft tissue swelling or muid observed by a physician the arthritis must involve at least the: wrists or ankles hands and fingers, or feet and toes there must be symmetrical arthritis there must be subcutaneous nodules there must be radiographic changes typical of rheumatoid arthritis. 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. 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 the earlier of 12 months and the member s cancellation age. 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. Death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms. There are three variations of the total permanent disability benefit. For your employees only, they are automatically covered for disability meaning that they cannot perform a job which they are suited to. You have the option, for an extra premium, of choosing to cover your employees who are unable to perform their own occupation. Your employees husbands, wives, civil partners and unmarried partners who are covered by the scheme must satisfy the criteria around being able to look after themselves in order to claim for total permanent disability. Loss of the physical or mental ability through an illness or injury to the extent that the member is unable to do the material and substantial duties of a suited occupation ever again. The material and substantial duties are those that are normally required for, and/or form a significant and integral part of, the performance of a suited occupation that cannot reasonably be omitted or modified. A suited occupation means any work the member could do for profit or pay taking into account their employment history, knowledge, transferable skills, training, education and experience, and is irrespective of location and availability. 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 member expects to retire. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered. 10

11 Critical illness or operation *Total permanent disability unable to do your own occupation ever again *Total permanent disability unable to look after yourself ever again Definition Loss of the physical or mental ability through an illness or injury to the extent that the insured person is unable to do the essential duties of their own occupation ever again. The essential duties are those that are normally required for, and/or form a significant and integral part of, the performance of the person s own occupation that cannot reasonably be omitted or modified. Own occupation means your trade, profession or type of work you do for profit or pay. It is not a specific job with any particular employer and is irrespective of location and availability. 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. For the above definition, disabilities for which the relevant specialists cannot give a clear prognosis are not covered. 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 member expects to retire. The member 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: 1. 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. 2. 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. 3. Feeding yourself the ability to feed yourself when food has been prepared and made available. 4. Maintaining personal hygiene the ability to maintain a satisfactory level of personal hygiene by using the toilet or otherwise managing bowel and bladder function. 5. Getting between rooms the ability to get from room to room on a level floor. 6. 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. aviva.co.uk/health 11

12 When is the lump sum paid? We will pay a lump sum to an employee covered if they (or their husband, wife, civil partner, unmarried partner or child covered): l are diagnosed with one of the illnesses, or l undergo one of the operations which is covered, and they survive for 14 days after the date of the diagnosis or operation. For a claim for total permanent disability, the member must have been continuously and permanently disabled for six months in order that we can assess the extent of the disablement. What happens if someone is temporarily absent? l Employees who are not at work because they are ill can still be covered as long as they remain employed and their premiums are paid. l Employees who are not at work because the law allows them to be away, for example those on maternity / paternity leave, and those on compassionate leave or taking a sabbatical can be covered for up to three years. Does any evidence of health have to be provided before I am covered? We do not need any medical information about the members before the cover begins. If you need to make a claim, we will investigate whether or not: l the illness, or l an associated illness existed before cover started, and then assess the claim. Claiming benefit In order to make a claim, the employee (or their husband, wife civil partner, unmarried partner or child) covered must have: l been diagnosed with a critical illness, or How are claims made? The employer must make the claim on behalf of the member within 3 months of the date that the critical illness is diagnosed or the member undergoes the operation. In order to assess a claim we will need: l a claim form completed by the employer. l a completed member s claim form. This form gives us: medical information about the illness or operation contact details for the doctors who are treating the member the opportunity to ask for the member s consent to contact their GP and the doctors involved in their treatment and ask for medical information relevant to the claim If you need help in completing any of the paperwork please telephone the my Aviva flex helpline on Depending on who the claim is for, and what the claim is for, we may need to see birth or adoption certificates, marriage certificates or civil partnership agreements. If we need any more information, we will contact the people that we need to in order to get it (provided that we have the appropriate consent to do this). We cannot pay a claim if we are not able to get the information that we need to assess the claim. How do we assess claims? Once we have received the completed claim forms: l we will assess the claim to see if the medical evidence confirms that the member has suffered an illness or undergone one of the operations covered l if we need more medical information we will ask for it. If we ask for any other medical information that comes from the UK (for example a medical report), we will pay for it. In some circumstances we may ask for an independent medical examination l if we accept a claim we will pay the lump sum to the employee. l undergone one of the operations which is covered, and have survived for 14 days after the date of the diagnosis or operation. For a claim for total permanent disability, the member must have been continuously and permanently disabled for six months in order that we can assess the extent of the disablement. 12

13 Can another claim be made in the future? l We will not pay a second claim for husbands, wives, civil partners, unmarried partners or an individual child of an employee. We will cancel their cover when we pay a claim for them. l If an employee has been paid a lump sum by this scheme and then suffers another critical illness or undergoes a further operation covered, we may pay a lump sum. However, we will not make a payment if that member has already been paid a lump sum for: that critical illness or operation, or any related illness or operation. We would treat it as a pre-existing condition. For example, a member suffers an unexpected heart attack, we pay the claim. However, if the member suffers a further heart attack six months later, we will not pay the second claim as the initial heart attack is now a pre-existing condition. If the member then went on to undergo a coronary angioplasty, that would not be covered either as angioplasty is related to heart attack. l We will not pay a lump sum for any illness or operation covered if the member has previously claimed for total permanent disability paralysis of limbs, or terminal illness and that claim was paid. l We will not pay a lump sum for total permanent disability or terminal illness if the member has previously claimed for any other illness or undergone an operation covered. What is not covered? Pre-existing conditions Pre-existing conditions are not covered. This means if a member: l has suffered from any critical illness, or l undergone any operation covered at any time before they join the scheme, we will not pay a lump sum if they suffer the same critical illness or undergo the same operation whilst they are covered. If a member: l is suffering from a critical illness, or l waiting for an operation when they join the scheme, we will not pay a lump sum: l for that critical illness or operation, or l if they suffer the same critical illness or undergo that operation again whilst they are covered. Related pre-existing critical illnesses and operations Cover does not extend to illnesses or operations which are directly or indirectly related to pre-existing conditions. The following are related: l heart attack l coronary artery bypass surgery l heart transplant l aorta graft surgery l heart valve replacement or repair l balloon (coronary) angioplasty, and l stroke For example, if a member had a heart attack before joining the scheme, we would not pay a lump sum if they later needed coronary artery bypass surgery. Cover does not extend to l total permanent disability l loss of independent existence l coma l paralysis / paraplegia l loss of speech l blindness, or l deafness that is directly or indirectly related to a critical illness or operation that a member had before joining the scheme. Critical illnesses and operations are related if, in our reasonable medical opinion, one is a result of the other or if each is a result of the same disease, illness or injury. aviva.co.uk/health 13

14 Pre-existing cancer If anyone has suffered with cancer: l before joining the scheme, or l whilst covered we will not pay a lump sum if they are diagnosed with any subsequent cancer. This exclusion applies regardless of whether or not the subsequent cancer is related to the previous diagnosis of cancer. Terminal illness We will not pay a claim for terminal illness if the member has already died. Exclusions for children We will not pay claims for l total permanent disability or l loss of independent existence for a child. Conditions that are pre-existing and associated with critical illnesses and operations Cover does not extend to critical illnesses or operations if a member: l has suffered from, or l is suffering from an associated condition before they are covered. This exclusion applies even if the associated condition has not been diagnosed or treated. The table shows the critical illnesses and includes, but is not limited to, these associated conditions (if there are any). 14

15 Critical illness or operation Alzheimer s disease resulting in Aorta graft surgery for disease Aplastic anaemia with permanent bone marrow failure Bacterial meningitis resulting in Benign brain tumour resulting in Blindness permanent and irreversible Cancer excluding less advanced cases Cardiomyopathy of specified severity Coma resulting in Coronary angioplasty to two or more coronary arteries Coronary artery by-pass grafts with surgery to divide the breastbone Creutzfeldt-Jakob disease (CJD) resulting in Deafness permanent and irreversible Dementia resulting in permanent symptoms Heart attack of specified severity Heart valve replacement or repair with surgery to divide the breastbone HIV infection caught in the UK from a blood transfusion, a physical assault or at work in an eligible occupation Kidney failure requiring dialysis Liver failure of advanced stage Loss of hands or feet permanent physical severance Loss of independent existence permanent and irreversible Associated condition Head injury, pure amnesia, depression, psychosis, dementia Any disease or disorder of the heart, diabetes mellitus or any obstructive/occlusive arterial disease Fanconi s anaemia, cancer Chronic ear disease or hydrocephalus Neurofibromatosis (von Recklinghausen s disease), haemangioma (von Hippel-Lindau disease) Stroke or transient ischaemic attack, diabetes, optic neuritis, macular degeneration, retinitis pigmentosa. No benefit will be payable under the blindness critical illness in respect of an insured member who at any time prior to the date of entry into the scheme has been registered blind Malignant, early malignant or pre-malignant tumour or condition, leukaemia or Hodgkin s disease, plus polyposis coli, carcinoma in situ, papilloma of the bladder, Crohn s disease, ulcerative colitis or abnormal smear test Any disease or disorder of the heart, diabetes mellitus or any obstructive/occlusive arterial disease Self inflicted injury or misuse of drugs or alcohol Any disease or disorder of the heart, diabetes mellitus or any obstructive/occlusive arterial disease Any disease or disorder of the heart, diabetes mellitus or any obstructive/occlusive arterial disease Organic brain disease, disease of the central nervous system, CJD, Parkinson s disease, depression, epilepsy, pure amnesia, aphasia, psychosis Acoustic nerve tumour, neurofibromatosis (von Recklinghausen s disease). Stroke, cerebrovascular disease, organic brain disease, brain tumours, disease of the central nervous system, hydrocephalus, CJD, Parkinson s disease, depression, pure amnesia, aphasia, psychosis, head injury Any disease or disorder of the heart, diabetes mellitus or any obstructive/occlusive arterial disease Any disease or disorder of the heart, or any obstructive/occlusive arterial disease. We will not pay a lump sum for HIV infection to a member who, at any time before joining the scheme, has been infected with any Human Immunodeficiency Virus (HIV) or has demonstrated any antibodies to such virus. Familial polycystic kidney disease, diabetes mellitus or any chronic renal disease or disorder Chronic liver disease, including but not limited to hepatitis B & C, primary sclerosing cholangitis, and portal hypertension Diabetes mellitus, peripheral vascular disease, bone and soft tissue cancer. Multiple sclerosis, muscular dystrophy, motor neurone disease, Parkinson s disease, progressive supranuclear palsy or any disease or disorder of or any disease or disorder of the brain, spinal cord or column aviva.co.uk/health 15

16 Loss of speech permanent and irreversible Major organ transplant Motor neurone disease resulting in Multiple sclerosis with persisting symptoms Paralysis of limbs total and irreversible Parkinson s disease resulting in Pulmonary artery graft surgery Respiratory failure of advanced stage Rheumatoid arthritis chronic and severe Stroke resulting in permanent symptoms Terminal illness For all total permanent disability (TPD) Stroke, transient ischaemic attack, motor neurone disease, or any disease or disorder of the brain, spinal cord or column Cardiomyopathy, coronary artery disease, cardiac failure, chronic liver disease, chronic pancreatitis, pulmonary hypertension, cystic fibrosis, chronic lung disease or chronic kidney disease Progressive muscular atrophy, primary lateral sclerosis, progressive bulbar palsy Any form of neuropathy, encephalopathy or myelopathy (disorders or functions of the nerves) including but not restricted to the following: abnormal sensation (numbness) of the extremities, trunk or face/ weakness or clumsiness of a limb/double vision/partial blindness/ocular palsy/vertigo (dizziness)/difficulty of bladder control/optic neuritis/spinal cord lesion/abnormal MRI scan Multiple sclerosis, muscular dystrophy, motor neurone disease or any disease or disorder of the brain, spinal cord or column Treatment with dopamine antagonist, tremor, extra pyramidal disease Pulmonary valve stenosis, pulmonary atresia, truncus arteriosus, Fallot s tetralogy, patent ductus arteriosus Any disease or disorder of the respiratory system including the lungs, bronchi and trachea Inflammatory polyarthropathy Atrial fibrillation, transient ischaemic attack, diabetes mellitus, intracranial aneurysm or occlusive arterial disease Any critical illness or operation covered Multiple sclerosis, muscular dystrophy, motor neurone disease, or any disease or disorder of the brain, spinal cord or column. Arthritis. Chronic or recurrent mental illness. Chronic or recurrent back, neck, joint or muscle pain. Chronic or recurrent fatigue 16

17 For all critical illnesses and operations except for: l total permanent disability l loss of independent existence permanent and irreversible, and l paralysis of limbs total and irreversible if a member does not suffer a critical illness or undergo an operation covered during the first two years that they are covered by the scheme, we will not apply the associated conditions exclusion. We will not pay a critical illness claim if it is caused directly or indirectly from: Self-inflicted injury Intentional self-inflicted injury. Unreasonable failure to follow medical advice Unreasonable failure to seek or follow medical advice. Can cover be provided for an employee who is not in the UK? Cover can only be provided for UK permanent employees and their spouse/partner. Taxation Under current tax rules lump sum benefits to a member are not taxable. Continuation option There is no continuation option available. aviva.co.uk/health 17

18 Further information Financial Services Compensation Scheme The FSCS covers the policy under which this scheme operates. It ll cover the employer if Aviva becomes insolvent and is unable to meet its obligations under the policy. For this type of policy, the FSCS will cover the employer for 90% of the total amount of an existing claim. The FSCS will also provide a refund to the employer of 90% of the premiums that have not been used to pay for cover whether a claim is made or not. For further information, see or telephone The Financial Ombudsman Service South Quay Plaza 183 Marsh Wall London E14 9SR Telephone: complaint.info@financialombudsman.org.uk Website: Please note that the Financial Ombudsman Service will only consider your complaint if you have given us the opportunity to resolve the matter first. Making a complaint to the Ombudsman will not affect your legal rights. If you have any cause for complaint Our aim is to provide a first class standard of service to our customers, and to do everything we can to ensure you are satisfied. However, if you ever feel we have fallen short of this standard and you have cause to make a complaint, please let us know. Our contact details are: Aviva Health UK Ltd Complaints Department PO Box 540 Eastleigh SO50 0ET Telephone: It is very rare that matters cannot be resolved amicably. However, if you are still unhappy with the outcome after we have investigated it for you and you feel that there is additional information that should be considered, you should let us have that information as soon as possible so that we can review it. If you disagree with our response or if we have not replied within eight weeks, you may be able to take your case to the Financial Ombudsman Service to investigate. Their contact details are: 18

19 Aviva Health UK Limited. Registered in England Number Registered Office 8 Surrey Street, Norwich NR1 3NG. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number This insurance is underwritten by Aviva Life & Pensions UK Limited. Registered in England No Rougier Street, York, YO90 1UU. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number Aviva Health UK Limited, Head Office: Chilworth House, Hampshire Corporate Park, Templars Way, Eastleigh, Hampshire SO53 3RY. GEN /2014 Aviva plc