Clinical claims definitions: Additional expense needs

Transcription

1 1 Introduction Clinical claims s: Additional expense needs BrightRock has worked in partnership with international clinical and risk experts to ensure our clinical claims criteria are objective, transparent and industry-leading. Cover for illness or injury with a financial impact To give you and your clients peace of mind that our claims s are comprehensive and clinically objective, we provide a full list of our claims s and criteria, divided by body system. Cover for illness or injury with a financial impact Household needs Childcare needs Healthcare needs Debt needs Death-related needs Additional expense needs 1 1 Sensory system Important to note This clinical set applies to all three of the options we offer, namely the Premier Max, Premier and Primary option (please see Introduction for details). You must meet the same criteria to receive a, no matter the option you chose. The s in the last three columns under the heading recurring at claim-stage apply only to specific conditions, and only to the Premier and Premier Max options. These are conditions where BrightRock gives you the option of taking the standard for the condition, or taking an initial plus a series of regular monthly s for the number of shown. Each regular monthly will be equal to.% of the specified initial. We provide the total value of the initial plus the regular monthly s in the final column. For conditions where we don t offer the option of both a and regular, we have left the last three columns blank. 1 In this document, we ve provided our clinical claims s accompanied with explanatory text for ease of understanding. The information provided in the columns labelled with the words layman s explanation is provided purely for information purposes. If there is any uncertainty or ambiguity, then the wording provided under the column labelled s will prevail. BrightRock Life Ltd, an authorised financial services provider and registered insurer (FSP Registration number: 1/0/0) Sanlam Life Insurance Ltd, an authorised financial services provider and registered insurer (FSP, Registration number: 1/01/0) Copyright June 01 BrightRock. All rights reserved. Terms and conditions apply. Document number: Illness Additional and expense injury additional needs expenses Definition Definition set C: set Effective B: Effective 1 August 1 June V.0 v1

2 1 Introduction Introduction: Your cover for additional expense needs can give rise to new and unpredictable costs like out-of-pocket medical costs not covered by your medical aid, rehabilitation and recovery costs, and lifestyle adjustment costs. BrightRock offers you protection for these extra expenses through your cover for illness and injury additional expenses. You ve got cover both for illnesses or injuries and illnesses or injury that are permanent. How your cover pays out depends on the choices you made when you signed up with us. When looking up different conditions in this set, please bear these choices in mind. We ve provided a summary below, but please see your BrightRock Owner s Manual for a detailed explanation of how your cover works. If you chose the Premier Max option: If you chose the Premier option: If you chose the Primary option: Maximum You can receive a potential maximum of: Up to 00% for related claims for illnesses and injuries Up to 00% for related claims for illnesses and injuries that are permanent. The total maximum you can receive for all claims is 00% for related claims. The total maximum you can receive for all claims is 00% for related claims. Increased s for certain conditions For conditions where we ve included a number of and a total percentage (last three columns), you can choose the standard or an initial plus a series of recurring s for the specified period. For conditions where we ve included a number of and a total percentage (last three columns), you can choose the standard or an initial plus a series of recurring s for the specified period. Only the shown in the column applies to this option. Extended cover if you don t recover after your initial claim If you ve not recovered within a year of your initial claim (we ll start counting this period once six have passed since qualifying for your claim) or within a year of your last recurring (where chosen), you can access extended cover. You can receive a monthly cover to a maximum of 00% of the cover amount. This extended cover is available for all conditions. To assess whether or not you ve recovered, we will use the BrightRock Activities of Daily Living. If you ve not recovered within a year of your initial claim (we ll start counting this period once six have passed since qualifying for your claim) or within a year of your last recurring (where chosen), you can access extended cover. You can receive a monthly cover payout to a maximum of 00% of the cover amount. This extended cover is available for all conditions. To assess whether or not you ve recovered, we will use the BrightRock Activities of Daily Living. If you ve not recovered within a year of your initial claim (we ll start counting this period once six have passed since qualifying for your claim), you can access extended cover. You can receive a monthly cover to a maximum of 00% of the cover amount. This extended cover is available for all conditions. To assess whether or not you ve recovered, we will use the BrightRock Activities of Daily Living. 1 1 Sensory system If you chose the advanced option, you can receive an additional for conditions marked with the If you chose to add the advanced option, you ll receive an automatic, condition-specific increase for the conditions marked with the symbol. We will automatically increase your standard to the percentage shown next to the symbol, up to a maximum of 0%. Where we offer clients the choice to receive a and recurring, these s will also increase by the same proportion. symbol. 1 Automatic cover for child additional expense needs, so parents can enjoy peace of mind We automatically offer parents the ability to receive a under your cover for additional expense needs should your child become seriously ill or injured. Note that the child additional expense needs cover applies to all the conditions listed here. However, we ve also added a specific set of clinical conditions that apply specifically to the child cover, which you ll find in the section marked. Check your Owner s Manual to see if you qualify for this cover. Additional expense needs Definition set C: Effective 1 August 01 V.0

3 1 Introduction Radiologically documented cerebral infarction with corresponding permanent neurological deficit, established 0 days after the event with any two of the following: motor deficit (power </), speech deficit, new onset epilepsy and/ or visual or hearing deficit, or cerebellar dysfunction confirmed by a neurologist OR Equivalent SCIDEP stroke - Level A Where the advanced option is selected, no waiting period applies Radiologically documented cerebral infarction with resultant permanent cognitive deficit (MMSE of less than 1) as established 0 days after the events OR Equivalent SCIDEP stroke - Level A Where the advanced option is selected, no waiting period applies Cerebral infarction (stroke) Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and established 0 days after any two of the following events: loss of mobility (less than / power), loss of speech, new onset epilepsy, loss of sight or hearing, or cerebellar dysfunction (affecting balance and coordination) that s been confirmed by a neurologist Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and scored less than 1 on the Mini-Mental State Examination (MMSE) when tested 0 days after the event, as confirmed by a neurologist recurring at claim-stage: 0% 0% 1 1,% 0% 0% 1 1,% 1 Total and permanent aphasia Motor neuron disease confirmed by a neurologist Aphasia (a language disorder that makes it difficult to remember words or even impossible to speak, read and write) Total and permanent * * Motor neuron disease (a degenerative disease that affects the motor neurons, nerve cells that control muscle movement) Confirmed by a neurologist 0% 0% 1 1,% 0% 0% 1 1,% 1 Sensory system 1 Alzheimer s disease confirmed by neurologist/psychiatrist Parkinson s disease confirmed by neurologist Alzheimer's disease (a condition that causes the gradual loss of brain function) Parkinson s disease (a condition that causes tremors or shaking, and difficulty with movement and coordination) Confirmed by a neurologist or a psychiatrist Confirmed by a neurologist * * 0% 0% 1 1,% 0% 0% 1 1,% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

4 1 Introduction Multiple sclerosis confirmed by a neurologist with two or more admissions of more than hours each in the preceding year, and treated with disease modifying drugs (beta interferon, glatiramer) Multiple sclerosis (an autoimmune disease that attacks the central nervous system) Confirmed by a neurologist and has undergone treatment with diseasemodifying drugs (beta interferon, glatiramer). It must also have resulted in at least two hospital admissions of three days or longer in the past year recurring at claim-stage: 0% 0% 1 1,% Muscular dystrophy confirmed by neurologist Muscular dystrophy (a group of disorders that involve the gradual weakening and loss of muscle tissue) Confirmed by a neurologist 0% 0% 1 1,% 1 1 Sensory system 1 Glasgow Coma Scale score of less than /1 for longer than hours confirmed by a neurologist or neurosurgeon. (Medically-induced coma is excluded) Documented diagnosis of a recognised neurological condition resulting in or more of the following permanent (of more than duration) findings: motor deficit (power </), cognitive deficit (MMSE <1/0), speech deficit, epilepsy and/or visual or hearing deficit, all confirmed by a neurologist Documented cerebral malaria with a parasitaemia count of >% or > parasites / μl, with one of the following permanent (of more than duration) findings: motor deficit (power </), cognitive deficit (MMSE <1/0), speech deficit, epilepsy and / or visual or hearing deficit confirmed by a neurologist Coma (being unconscious) Confirmed score of less than out of 1 on the Glasgow Coma Scale (a scale for measuring the level of unconsciousness or severity of a brain injury). This must apply for longer than four days, and it must be confirmed by a neurologist or neurosurgeon. (Medically-induced coma is excluded) * * Any recognised neurological condition Documented diagnosis that has caused three or more of the following for more than three : loss of mobility (less than / power), reduced brain function (with a Mini-Mental State Examination or MMSE score of less than 1 out of 0), speech problems, epilepsy or the loss of hearing and/or sight. The condition and its complications must be confirmed by a neurologist * * Cerebral malaria (a parasitic disease) Confirmed, documented diagnosis with a parasitaemia count of more than % or more than parasites per microliter that has caused one of the following for more than three : loss of mobility (less than / power), reduced brain function (with a Mini- Mental State Examination or MMSE score of less than 1 out of 0), speech problems, epilepsy or the loss of hearing, or sight, or both hearing and sight. The condition and its complications must be confirmed by a neurologist 0% 0% 1 1,% 0% 0% 1 1,% 0% 0% 1 1,% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

5 recurring at claim-stage: 1 Introduction Radiologically documented cerebral infarction with corresponding permanent neurological deficit, established 0 days after the event of any of the following: motor deficit (power </), speech deficit, new onset epilepsy and/or visual or hearing deficit, or cerebellar dysfunction confirmed by a neurologist OR Equivalent SCIDEP stroke - Level B or C Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and established 0 days after any of the following events: loss of mobility (less than / power), loss of speech, new onset epilepsy, loss of sight or hearing, or cerebellar dysfunction (affecting balance and coordination) that s been confirmed by a neurologist % 0% 1.1% Where the advanced option is selected, no waiting period applies 0% 0% 1 1.% Radiologically documented cerebral infarction with resultant permanent cognitive deficit (MMSE of 1 to 1) as established 0 days after the event OR Equivalent SCIDEP stroke - Level A, B or C Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and scored 1 to 1 on the Mini-Mental State Examination (MMSE) when tested 0 days after the event, as confirmed by a neurologist % 0% 1,1% Where the advanced option is selected, no waiting period applies 0% 0% 1 1.% 1 Confirmed Guillain-Barre syndrome resulting in permanent neurological deficit that requires the use of ambulatory aids Non-endovascular procedures performed by a neurosurgeon (excluding drainage of brain abscess) e.g. craniotomy Guillain-Barre Syndrome (a disorder that attacks the peripheral nervous system) Brain surgery Confirmed diagnosis that has resulted in permanent neurological deficit (damage to the nervous system) with the need to use ambulatory devices (walking aids) Non-endovascular procedures (surgery that isn t performed via the blood vessels), for example a craniotomy, that have been performed by a neurosurgeon. This excludes the drainage of a brain abscess (collection of pus in the brain) % 0% 1,1% 0% 0% 1,% 1 Sensory system Cavernous sinus thrombosis Cavernous sinus thrombosis (a blood clot in a cavity at the base of the brain) Confirmed diagnosis 0% 0% 1,% 1 Confirmed diagnosis of a subarachnoid haemorrhage Subarachnoid haemorrhage (bleeding into the subarachnoid space surrounding the brain) Confirmed diagnosis * * % 0%,% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

6 1 1 Sensory system 1 Multiple sclerosis confirmed by a neurologist Status epilepticus resulting in permanent neurological deficit as confirmed by a neurologist Confirmed Guillain-Barre syndrome resulting in permanent neurological deficit but requires no use of ambulatory aids Radiologically documented cerebral infarction with no permanent neurological deficit, OR Equivalent SCIDEP stroke - Level D Where the advanced option is selected, no waiting period applies Endovascular procedures performed by a neurosurgeon One payment for the treatment of hydrocephalus by insertion of a shunt Documented cerebral malaria confirmed by a physician with a parasitaemia count of % or more, or more than parasites /μl Infective meningitis as confirmed by a physician with supporting medical evidence Amyloidosis involving a nerve Multiple sclerosis (an autoimmune disease that attacks the central nervous system) Status epilepticus (a lifethreatening, prolonged epileptic attack) Confirmed by a neurologist Documented diagnosis with permanent neurological deficit (damage to the nervous system) that has been confirmed by a neurologist * * Guillain-Barre Syndrome (a disorder that attacks the peripheral nervous system) Cerebral infarction (stroke) Brain surgery Hydrocephalus (the build-up of fluid inside the skull). NB: Limited to one payment. Cerebral malaria (a parasitic disease) Infective meningitis (a bacterial infection of the membranes covering the brain and spinal cord) Infiltrative conditions (caused by the accumulation of an abnormal substance in the cells or tissues) Confirmed diagnosis that has resulted in permanent neurological deficit (damage to the nervous system) but without the need for any kind of ambulatory device (walking aid) Confirmed by radiological evidence (scan) with no permanent damage Endovascular procedures (minimally invasive surgery via major blood vessels) that have been performed by a neurosurgeon Has undergone treatment by insertion of a shunt (a tube that drains fluid). Payment will be made for placement of one shunt only Documented and must be confirmed by a physician, with a parasitaemia count of % or more, or more than parasites per microliter Confirmed by a physician with supporting medical evidence Amyloidosis involving a nerve (a build-up of abnormal protein in organs or tissues) recurring at claim-stage: % 0% 1 1,% % 0% 1 1,% % 0% 1 1,% % % % % % % 1% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

7 1 Introduction Cerebral oedema with confirmed intracranial pressure of >0mmHg Brain abscess treated with surgery or intravenous antibiotic therapy Cerebral oedema (accumulation of fluid in the brain) Brain abscess (collection of pus in the brain) The pressure inside the skull is confirmed as more than 0mmHg Has undergone treatment with either surgery or intravenous antibiotics (delivered directly into the blood stream) 1% 1% recurring at claim-stage: Glasgow coma scale of to /1 for more than hours. (Medically-induced comas are excluded) Pituitary macroadenomas that have undergone a surgical procedure or received radiation therapy Coma (being unconscious) Confirmed score of to out of 1 on the Glasgow Coma Scale (a scale for measuring the level of unconsciousness or severity of a brain injury) for more than two days. (Medically-induced comas are excluded) * * Pituitary macroadenomas (tumours that occur in the pituitary gland) Tumours are larger than mm and have undergone a surgical or clinical procedure or received radiation therapy intended to remove or reduce the tumour 1% 1% Surgery to a major nerve Surgery to a major nerve Has undergone surgery Stereotactic brain surgery Brain surgery Stereotactic brain surgery (using a threedimensional coordinate system to target a specific area) Surgical repair of a neurotmesis Brain surgery Surgery to repair a neurotmesis (severe damage to a nerve) % % % 1 The definitive diagnosis of infective encephalitis, as confirmed by a neurologist with the following supportive evidence: neuro-imaging, blood tests, cerebrospinal fluid findings (excluding myalgic encephalitis) Infective encephalitis (inflammation of the brain due to infection). Excludes myalgic encephalitis (ME or yuppie flu ) Confirmed diagnosis % 1 Sensory system 1 Suturing of a major nerve to restore function to a hand or limb Status epilepticus which has undergone intubation Confirmed hydrocephalus Stitches to a major nerve to restore function to a hand, arm or leg Status epilepticus (life-threatening, prolonged epileptic attack) Has undergone suturing (stitches) Has undergone intubation (where a tube is inserted into the wind pipe to make sure you can breathe) * * Hydrocephalus (the build-up of fluid inside the skull) Confirmed diagnosis % % % Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

8 1 Introduction Brain cancer (WHO grade III or IV) of an organ or tissue Diagnosis of any brain cancer at WHO (World Health Organisation) grade III or IV recurring at claim-stage: 0% 0% 1,% Inoperable (non-removable) benign brain tumours WITH permanent neurological deficit as confirmed by a specialist neurosurgeon of an organ or tissue Diagnosis of a benign or non-cancerous brain tumour that cannot be surgically removed and has caused permanent nervous system damage according to a neurosurgeon An injury or illness 0% 0% 1,% Any cancer stage IV (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR Equivalent SCIDEP cancer - Level A of an organ or tissue Diagnosis of any type of advanced cancer as Stage IV. This excludes: in situ All pre-malignant conditions All skin cancers Prostate cancer An injury or illness 0% 0% 1 1,% Any stage III cancer (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR Equivalent SCIDEP cancer - Level B Acute myeloid leukaemia (AML) OR Equivalent SCIDEP cancer - Level A of an organ or tissue s of the blood, bone marrow or lymphatic tissue Diagnosis of any cancer as Stage III. This excludes: in situ All pre-malignant conditions All skin cancers Prostate cancer Diagnosis of acute myeloid leukaemia or AML (a cancer of immature myeloid white blood cells) An injury or illness An injury or illness 0% 0% 1 1,% 0% 0% 1 1,% Chronic myeloid leukaemia (CML) OR Equivalent SCIDEP cancer - Level A or Level C s of the blood, bone marrow or lymphatic tissue Diagnosis of chronic myeloid leukaemia or CML (a cancer involving an overproduction of mature myeloid white blood cells) confirmed by histological evidence a biopsy An injury or illness 0% 0% 1 1,% 1 Acute lymphoblastic leukaemia (ALL) OR Equivalent SCIDEP cancer - Level A s of the blood, bone marrow or lymphatic tissue Diagnosis of acute lymphoblastic leukaemia or ALL (a cancer of immature lymphoid cells) An injury or illness 0% 0% 1 1,% 1 Sensory system 1 Chronic Lymphocytic Leukaemia (Rai classification stage III / IV) OR Equivalent SCIDEP cancer - Level A s of the blood, bone marrow or lymphatic tissue Diagnosis of Chronic Lymphocytic Leukaemia (a cancer of mature lymphoid cells) where the cancer is advanced and diagnosed at Rai stage III or IV An injury or illness 0% 0% 1 1,% Multiple Myeloma (Stage III on Durie-Salmon scale) OR Equivalent SCIDEP cancer - Level A s of the blood, bone marrow or lymphatic tissue Diagnosis of multiple myeloma (cancer of the plasma cells) as Stage III on the Durie-Salmon scale An injury or illness 0% 0% 1 1,% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

9 1 Introduction Any cancer treated with bone marrow transplantation s of the blood, bone marrow or lymphatic tissue Any cancer of the blood or bone marrow that has undergone a bone marrow transplant recurring at claim-stage: 0% 0% 1 1,% Severe aplastic anaemia as defined by the International Aplastic Anaemia Study group Other severe blood cancerrelated disorders Diagnosis of chronic aplastic anaemia (a condition where the bone marrow does not produce enough new blood cells) where the condition is categorised as severe based on the of the International Aplastic Anaemia study group Stage IV skin cancer Skin cancers Diagnosis of Stage IV malignant melanoma skin cancer, including any Stage IV non-melanoma skin cancer, such as: squamous cell carcinoma or basal cell carcinoma. The cancer diagnosis must be confirmed by histological evidence An injury or illness 0% 0% 1 1,% 0% 0% 1 1,% Stage - T, N0, M0 any G prostate cancer OR Equivalent SCIDEP cancer - Level B Prostate cancer Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with a more advanced tumour but no spread beyond the prostate and any Gleason grade of abnormality 0% 0% 1 1,% 1 1 Sensory system Stage - Any T, N1, M0 any G prostate cancer OR Equivalent SCIDEP cancer - Level A Hodgkin s or Non Hodgkin s Lymphoma Ann Arbor stage III or IV OR Equivalent SCIDEP cancer - Level A or B Brain cancer (WHO Grade II) Prostate cancer s of the blood, bone marrow or lymphatic tissue or pre-cancer of an organ or tissue Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with spread to the lymph nodes and any Gleason grade of abnormality Diagnosis of Hodgkin s or Non Hodgkin s lymphoma (cancer of the lymphatic system) where the cancer has spread extensively and is diagnosed at Ann Arbor stage III or IV Diagnosis of brain cancer at WHO (World Health Organisation) grade II 0% 0% 1 1,% 0% 0% 1 1,% 0% 0% 1,% 0% 0% 1.% 1 Multiple Myeloma (Stage I / II on Durie-Salmon scale) OR Equivalent SCIDEP cancer - Level C s of the blood, bone marrow or lymphatic tissue Diagnosis of multiple myeloma (cancer of the plasma cells) as Stage I or II on the Durie-Salmon (DS) scale 0% 0% 1,% 0% 0% 1 1.% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

10 1 Introduction Stage III skin cancer Skin cancers Diagnosis of Stage III malignant melanoma skin cancer, including any Stage III non-melanoma skin cancer, such as squamous cell carcinoma or basal cell carcinoma. The cancer diagnosis must be confirmed by histological evidence recurring at claim-stage: 0% 0% 1,% Any stage II cancer (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR Equivalent SCIDEP cancer - Level C or pre-cancer of an organ or tissue Diagnosis of any cancer as Stage II. This excludes: in situ All pre-malignant conditions All skin cancers Prostate cancer 0% 0% 1 1.% 0% Skin cancer stage II Skin cancers Diagnosis of stage II malignant melanoma (cancer of the cells in the skin that produce pigments), as confirmed by histological evidence a biopsy. This excludes non-melanomas. Ductal carcinoma-in-situ of the breast or pre-cancer of an organ or tissue Diagnosis of pre-cancer of the ductal type (cells lining the small ducts of the breast, which carry the milk) that has not yet spread to other cells. The diagnosis must be confirmed by histological evidence a biopsy. 0% 0% % 0% 1 1 Sensory system 1 Hodgkin s or Non Hodgkin s Lymphoma Ann Arbor stage II OR Equivalent SCIDEP cancer - Level C s of the blood, bone marrow or lymphatic tissue Diagnosis of Hodgkin s or Non Hodgkin s lymphoma (cancer of the lymphatic system), where the cancer has started to spread and is diagnosed at Ann Arbor stage II % 0% 0% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

11 1 Introduction Chronic lymphocytic leukaemia (Rai classification stage II) OR Equivalent SCIDEP cancer - Level C s of the blood, bone marrow or lymphatic tissue Diagnosis of chronic lymphocytic leukaemia (a cancer of certain white blood cells),where the cancer is more advanced and diagnosed at Rai stage II 0% recurring at claim-stage: 0% Stage - T, N0, M0 any G prostate cancer OR Equivalent SCIDEP cancer - Level C Prostate cancer Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with a more advanced tumour but no spread beyond the prostate and any Gleason grade of abnormality 0% Any brain cancer (WHO grade I) or pre-cancer of an organ or tissue Diagnosis of brain cancer at WHO (World Health Organisation) grade I 0% % 0%,% % 0%.% Surgically removed benign brain tumours that cause no permanent neurological deficit as confirmed by a neurosurgeon or pre-cancer of an organ or tissue Benign or non-cancerous brain tumours that have undergone surgical removal and where a neurosurgeon has confirmed there is no residual permanent brain or nerve dysfunction % 0% 1 1,% % 0% 1%.1% 1 Any stage I cancer (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR Equivalent SCIDEP cancer - Level D of an organ or tissue Diagnosis of any cancer as Stage I, except for prostate cancer and skin cancers other than melanomas. This excludes: in situ All pre-malignant conditions All skin cancers Prostate cancer % 1 Sensory system 1 Skin cancer stage I or pre-cancer of an organ or tissue Diagnosis of stage I malignant melanoma (cancer of the cells in the skin that produce pigments), as confirmed by histological evidence a biopsy. This excludes non-melanomas. % % 0% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

12 1 Introduction Lobular carcinoma-in-situ of the breast which has necessitated a mastectomy or pre-cancer of an organ or tissue Pre-cancer of the lobular type (milkproducing cells of the breast) that has undergone a mastectomy (surgical removal of the breast) % recurring at claim-stage: % Prophylactic mastectomy (medically sanctioned) for a family history of breast cancer, confirmed by genetic testing or pre-cancer of an organ or tissue That has undergone prophylactic mastectomy (preventative surgical removal of one or both breasts) on recommendation by a specialist as a result of the person s high genetic risk of developing breast cancer. This must be confirmed by a genetic test % 0% Hodgkin s or Non Hodgkin s Lymphoma Ann Arbor stage I OR Equivalent SCIDEP cancer - Level D s of the blood, bone marrow or lymphatic tissue Diagnosis of Hodgkin s or Non Hodgkin s lymphoma (cancer of the lymphatic system) where the cancer has not spread and is diagnosed at Ann Arbor stage I % Chronic lymphocytic leukaemia (Rai classification stage 0 or I) OR Equivalent SCIDEP cancer - Level D s of the blood, bone marrow or lymphatic tissue Diagnosis of chronic lymphocytic leukaemia (a cancer of certain white blood cells) that is in the early stages and considered Rai stage 0 or I % % % 1 1 Sensory system Moderate chronic aplastic anaemia as defined by the International Aplastic Anaemia study group Other severe blood cancer-related disorders Diagnosis of chronic aplastic anaemia (a condition where the bone marrow does not produce enough new blood cells), diagnosed as moderate based on the of the International Aplastic Anaemia study group % 0% 1 Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

13 1 Introduction T, N0, M0, any Gleason prostate cancer OR Equivalent SCIDEP cancer - Level D Prostate cancer Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with a more advanced tumour, but no spread beyond the prostate and any Gleason grade of abnormality % % recurring at claim-stage: T1a-c, N0, M0, Gleason prostate cancer OR Equivalent SCIDEP cancer - Level D Prostate cancer Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with no spread beyond the prostate and Gleason grade or higher abnormality % % Hairy cell leukaemia with histological confirmation, OR Equivalent SCIDEP cancer - Level D There is no requirement to undergo treatment s of the blood, bone marrow or lymphatic tissue Diagnosis of hairy cell leukaemia, as confirmed by histological evidence. There is no requirement to undergo treatment % % Amyloidosis of the bone marrow Infiltrative conditions (caused by the accumulation of an abnormal substance in the cells or tissues) Diagnosis of amyloidosis (build up of abnormal protein in the tissues or organs) of the bone marrow 1% 1 1 Sensory system Carcinoid syndrome of an organ or tissue Diagnosis of carcinoid syndrome (caused by hormones secreted by one or more carcinoid tumours) Myelodysplastic syndrome s of the blood, bone marrow or lymphatic tissue Diagnosis of Myelodysplastic syndrome (a collection of conditions in which the bone marrow doesn t produce enough mature blood cells) 1% 1% 1 Myelofibrosis s of the blood, bone marrow or lymphatic tissue Myelofibrosis (a condition in which bone marrow is replaced by fibrous tissue) 1% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

14 1 Introduction Myeloproliferative disorders: Polycythaemia Vera, Essential thrombocytosis s of the blood, bone marrow or lymphatic tissue Diagnosis of myeloproliferative disorders (a group of conditions that cause blood cells to grow abnormally in the bone marrow), including polycythaemia vera (involving red blood cells) and essential thrombocytosis (involving platelets) % recurring at claim-stage: Basal cell carcinoma (greater than 1.cm) Squamous cell carcinoma (greater than 1.cm) or pre-cancer of an organ or tissue or pre-cancer of an organ or tissue Diagnosis of a basal cell carcinoma (cancer of the basal cells, found in the deeper layers of the skin) larger than 1.cm Diagnosis of a squamous cell carcinoma (cancer of the squamous cells at the surface of the skin) larger than 1.cm % % T1a, N0, M0, Gleason prostate cancer Prostate cancer Diagnosed as Stage 1 according to TMN (Tumour, lymph Node, Metastasis) staging, with no spread beyond the prostate and Gleason grade or less abnormality % T1a, N0, M0, Gleason - prostate cancer Prostate cancer Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with no spread beyond the prostate and Gleason grade to abnormality % T1b-c, N0, M0, Gleason - prostate cancer Prostate cancer Diagnosed as Stage according to TMN (Tumour, lymph Node, Metastasis) staging, with no spread beyond the prostate and Gleason grade to abnormality % 1 1 Sensory system 1 Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

15 1 Introduction Polyarteritis Nodosa Systemic Sclerosis Polyarteritis nodosa (an inflammatory disease affecting the walls of blood vessels, characterised by multiple aneurysms. An aneurysm is the abnormal widening or ballooning of the blood vessel walls). Systemic sclerosis (an autoimmune disorder characterised by the fibrosis of the skin and internal organs) Confirmed diagnosis Confirmed diagnosis recurring at claim-stage: 0% 0% 1 1,% 0% 0% 1 1,% 1 1 Sensory system 1 Systemic lupus erythematosis with documented involvement of any three of the following organ systems: Kidneys, and/or Eyes, and/or Brain, and/or The following GIT involvement: Hepatomegaly AND splenomegaly, and/or Pulmonary, and/or Nervous system (CNS), and/or The following cardiovascular involvement: Endocarditis, cardiomyopathy or recurrent arterial thrombosis Sarcoidosis with documented involvement of any three of the following organ systems: Eyes, and/or, Infiltrative lung disease and/or, Nervous system (CNS), and/or Cardiovascular involvement, and/or Liver involvement Systemic lupus erythematosis, (an autoimmune disorder where the body attacks its own tissues) Sarcoidosis (disease of unknown cause characterised by granulomas or lumps of inflammation that affect almost any organ of the body) Documented involvement of any three of the following organ systems: Kidneys Eyes Brain The following gastrointestinal tract (digestive system involvement): Hepatomegaly (enlargement of the liver) AND splenomegaly (enlargement of the spleen) Lungs Central nervous system The following cardiovascular (heart and blood vessel) involvement: Endocarditis (inflammation of the lining of the heart chambers and valves), cardiomyopathy (disease of the heart muscle) or recurrent arterial thrombosis (formation of a blood clot inside an artery) Documented involvement of any three of the following: Confirmed infiltrative lung disease Eyes Central nervous system (CNS) Liver 0% 0% 1 1,% 0% 0% 1 1,% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

16 1 Introduction Polymyositis with documented evidence of both: Dysphonia and dysphagia Polymyositis (a systemic connective tissue disease characterised by inflammation of the muscles) Documented evidence of dysphonia (voice disorders) and dysphagia (difficulty swallowing) recurring at claim-stage: 0% 0% 1 1,% Giant cell arteritis with documented involvement of any three of the following organ systems: Eyes: Ischaemic optic neuropathy or central retinal occlusion, and/or Nervous system: cranial nerve palsy or hemiplegia or epilepsy, and/or Cardiovascular: angina and/or myocardial infarct or aortic arch syndrome or thoracic aortic aneurysm or aortic dissection Any recognised connective tissue disease, not explicitly defined elsewhere in this document, confirmed by a rheumatologist with documented systemic involvement of three or more organs excluding the skin and any joints Giant cell arteritis (disease characterised by inflammation in the walls of medium- and large-sized arteries) Any recognised connective tissue condition (not explicitly listed elsewhere) Features the documented involvement of any three of the following: Eyes: Ischaemic optic neuropathy or central retinal occlusion Nervous system: cranial nerve palsy, hemiplegia or epilepsy : angina, heart attack, aortic arch syndrome, thoracic aortic aneurysm or aortic dissection Confirmed by a rheumatologist, along with the documented systemic involvement of three or more organs (excluding the skin and joints) 0% 0% 1 1,% 0% 0% 1 1,% Rheumatoid arthritis with any of the following extra-articular manifestations: Lung disease, or Heart disease, or Involvement of the spleen Rheumatoid arthritis (a disease that causes inflammation of the joints and surrounding tissues, and may also affect other organs) Has manifested in any of the following diseases outside the joints: Lung disease Heart disease Involvement of the spleen 0% 0%,% 1 1 Sensory system 1 Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

17 1 1 Sensory system 1 Systemic lupus erythematosis with documented involvement of any two of the following organ systems: Kidneys, and/or Eyes, and/or Brain, and/or The following GIT involvement: Hepatomegaly AND splenomegaly, and/or Pulmonary, and/or Nervous system (CNS), and/or The following cardiovascular involvement: Endocarditis, cardiomyopathy or recurrent arterial thrombosis Sarcoidosis with documented involvement of any two of the following organ systems: Confirmed Sarcoidosis of the lungs and/or, Eyes, and/or Nervous system (CNS), and/or Cardiovascular involvement, and/or Liver involvement Giant cell arteritis with documented involvement of any two of the following organ systems: Eyes: Ischaemic optic neuropathy/central retinal occlusion, and/or Nervous system: cranial nerve palsy/ hemiplegia/epilepsy, and/or Cardiovascular: angina and/or myocardial infarct or aortic arch syndrome or thoracic aortic aneurysm or aortic dissection Any recognised connective tissue disease, not explicitly defined elsewhere in this document, confirmed by a rheumatologist with documented systemic involvement of two or more organs excluding the skin and any joints. Systemic lupus erythematosis (an autoimmune disorder where the body attacks its own tissues) Sarcoidosis (disease of unknown cause characterised by granulomas or lumps of inflammation that affect almost any organ of the body) Giant cell arteritis (disease characterised by inflammation in the walls of medium- and large-sized arteries) Any recognised connective tissue condition (not explicitly listed elsewhere) Documented involvement of any two of the following: Kidneys Eyes Brain The following gastrointestinal tract (digestive system): Hepatomegaly (enlargement of the liver) AND splenomegaly (enlargement of the spleen) Lungs Central nervous system The following cardiovascular (heart and blood vessel) involvement: Endocarditis (inflammation of the lining of the heart chambers and valves), cardiomyopathy (disease of the heart muscle) or recurrent arterial thrombosis (formation of a blood clot inside an artery) Documented involvement of any two of the following: Confirmed Sarcoidosis of the lungs Eyes Central nervous system (CNS) Liver Documented involvement of any two of the following: Eyes: Ischaemic optic neuropathy or central retinal occlusion Nervous system: cranial nerve palsy, hemiplegia or epilepsy : angina, heart attack, aortic arch syndrome, thoracic aortic aneurysm or aortic dissection Confirmed by a rheumatologist, along with the documented systemic involvement of two or more organs (excluding the skin and joints) recurring at claim-stage: % 0% 1,1% % 0% 1,1% % 0% 1,1% % 0% 1,1% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

18 1 1 Sensory system Systemic lupus erythematosis with documented involvement of any one of the following organ systems: Kidneys, and/or Eyes, and/or Brain, and/or The following GIT involvement Hepatomegaly AND splenomegaly, and/or Pulmonary, and/or Nervous system (CNS), and/or The following cardiovascular involvement: Endocarditis, cardiomyopathy or recurrent arterial thrombosis Sarcoidosis with documented involvement of any one of the following organ systems: Confirmed infiltrative lung disease, and/or Eyes, and/or Nervous system (CNS), and/or Cardiovascular involvement, and/or Liver involvement Giant cell arteritis with documented involvement of any one of the following organ systems: Eyes: Ischaemic optic neuropathy/central retinal occlusion, and/or Nervous system: cranial nerve palsy/ hemiplegia/epilepsy, and/or Cardiovascular: Angina and/or myocardial infarct or aortic arch syndrome or thoracic aortic aneurysm or aortic dissection Systemic lupus erythematosis (auto-immune disease, meaning the body attacks its own tissues) Sarcoidosis (disease of unknown cause characterised by granulomas or lumps of inflammation that affect almost any organ of the body) Giant cell arteritis (disease characterised by inflammation in the walls of medium- and large-sized arteries) Documented involvement of any one of the following: Kidneys Eyes Brain The following gastrointestinal tract (digestive system) involvement: Hepatomegaly (enlargement of the liver) AND splenomegaly (enlargement of the spleen) Lungs Central nervous system The following cardiovascular (heart and blood vessel) involvement: Endocarditis (inflammation of the lining of the heart chambers and valves), cardiomyopathy (disease of the heart muscle) or recurrent arterial thrombosis (blood clot inside an artery) Documented involvement of any one of the following: Confirmed infiltrative lung disease Eyes Central nervous system Liver Documented involvement of any one of the following: Eyes: Ischaemic optic neuropathy or central retinal occlusion Nervous system: cranial nerve palsy, hemiplegia or epilepsy : angina, heart attack, aortic arch syndrome, thoracic aortic aneurysm or aortic dissection recurring at claim-stage: 0% 0% 1,% 0% 0% 1,% 0% 0% 1,% 1 Joint replacement as a result of joint destruction by a sero-positive connective tissue disease Joint destruction caused by a sero-positive connective tissue disease Has undergone joint replacement 0% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

19 1 Introduction Rheumatoid arthritis treated with: Combination therapy of any of the following disease modifying anti-rheumatic drugs (DMARDs): Sulphasalazine, Methotrexate, Gold, Penicillamine, Hydroxychloroquine Rheumatoid arthritis (a disease that causes inflammation of the joints and surrounding tissues, and may also affect other organs) Has undergone treatment with a combination of any of the following disease modifying anti-rheumatic drugs (DMARDs): Sulphasalazine, Methotrexate, Gold, Penicillamine or Hydroxychloroquine recurring at claim-stage: % 0%,% Rheumatoid arthritis treated with any tumour necrosis factor TNF alpha inhibitor or other biological therapies Rheumatoid arthritis (a disease that causes inflammation of the joints and surrounding tissues, and may also affect other organs) Treatment using a tumour necrosis factor (TNF) alpha inhibitor, or any other biological therapy % 0%,% Rheumatoid arthritis treated with any one of the following chemotherapy agents: Azathioprine, Cyclophosphamide, Cyclosporin Rheumatoid arthritis (a disease that causes inflammation of the joints and surrounding tissues, and may also affect other organs) Treatment using any of the following chemotherapy medications: Azathioprine, Cyclophosphamide or Cyclosporine % 0%,% Hypermobility syndrome Hypermobility syndrome (a condition in which the joints move easily beyond their normal range) Confirmed diagnosis 1% 1 1 Sensory system Ehlers-Danlos syndrome Ehlers-Danlos syndrome (a group of inherited disorders caused by a lack of collagen or faulty collagen production) Confirmed diagnosis 1% 1 Pseudoxanthoma elasticum with documented involvement of two or more organs, excluding the skin Pseudoxanthoma elasticum (a genetic disorder causing tiny fibres in the tissue of the eyes, skin and blood vessels to degenerate) Clinically confirmed, with medical evidence proving that the condition affects at least two organs (other than the skin) % Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

20 1 Introduction Bacteriologically confirmed meningococcal meningitis, as evidenced by a lumbar puncture, in a child younger than 1 years. This must cause inflammation of the membranes of the brain or spinal cord, resulting in permanent neurological deficit. All other types of meningitis, such as bacteriological, viral or fungal, are specifically excluded A benign brain tumour in a child younger than 1 years that is either inoperable or recurrent, or that causes permanent neurological impairment. Benign brain tumour that causes only cognitive impairment or that is only partially removable, or that is treated with chemotherapy or radiotherapy is not covered. This condition applies only to children under the age of 1 Bacterial meningitis Benign brain tumour Meningitis (inflammation of the membranes of the brain and the spinal cord) caused by the meningococcal bacteria. The bacterial infection must be confirmed by a lumbar puncture and must result in permanent damage to the nerves, brain or spine (neurological deficit). This excludes all other types of meningitis, such as bacteriological, viral or fungal meningitis. Cover applies only to children under the age of 1 A benign (non-cancerous) brain tumour that either cannot be operated on or that keeps recurring, or which causes permanent damage to the brain or nerves. This excludes benign brain tumours that cause cognitive impairment (impaired ability to think, remember or judge clearly), or that are treated with chemotherapy or radiotherapy. Cover applies only to children under the age of 1 0% 0% recurring at claim-stage: The total and permanent loss of use, in a child younger than 1 years, of or more limbs for a continuous period of at least Paralysis (including poliomyelitis) The complete and permanent loss of two or more limbs, or the complete and permanent loss of their use. The loss of use must last for a period of at least three. Cover applies only to children under the age of 1 0% 1 1 Sensory system 1 Any disorder that results in the irreversible failure of the heart, liver, bone marrow, lungs, pancreas or kidneys in a child younger than 1 years. This must result in the complete transplant of a whole organ to replace the affected organ, or proof of acceptance into a recognised transplant programme Major organ transplant Any disorder that causes the heart, liver, bone marrow, lungs, pancreas or kidneys to fail permanently. Because of this organ failure, the child has received an organ transplant or is awaiting an organ transplant. We require proof of acceptance into a recognised organ transplant programme. Cover applies only to children under the age of 1 0% Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

21 1 Introduction Any disease or disorder that results in endstage liver failure in a child younger than 1 years. There must be objective evidence of jaundice, oesophageal varices and ascites Confirmed diagnosis of cardiomyopathy in a child younger than 1 years, as evidenced by objective investigations. There must be functional impairment resulting in symptoms of heart failure at rest, confirmed by a cardiologist Any open-heart surgery in a child younger than 1 years to replace or repair a diseased heart valve or heart septum defect, or to reposition any of the major heart vessels Chronic liver failure Cardiomyopathy Open heart surgery Any illness or disorder that causes end-stage liver failure. Medical tests must show jaundice, enlarged veins in the lower part of the oesophagus (oesophageal varices) and fluid accumulated in the abdomen (ascites). Cover applies only to children under the age of 1 Confirmed diagnosis of chronic disease of the heart muscle, based on objective medical evidence. The condition must have caused damage to the heart's function, with the child showing symptoms of heart failure even when at rest. This damage must be confirmed by a heart specialist (cardiologist). Cover applies only to children under the age of 1 Heart surgery where the chest is opened (through division of the breast bone) to repair a heart valve, a defect of the wall between the chambers of the heart, or to switch the position of any of the major heart vessels. Cover applies only to children under the age of 1 0% 0% 0% recurring at claim-stage: 1 1 Sensory system 1 Cerebral malaria in a child younger than 1 years, resulting in a coma and permanent neurological deficit. This must be confirmed by the presence of plasmodium falciparum parasites on peripheral blood smear, and all other causes of coma must be excluded. The coma must result in mechanical ventilation and should not be medically induced A gunshot wound or any penetrating traumatic injury to the skull, chest or abdomen of a child younger than 1 years, resulting in surgical exploration of the skull, chest or abdomen, under general anaesthetic Cerebral malaria (a parasitic disease) Penetrating gunshot wound or stab wound to the skull, chest or abdomen Confirmed diagnosis of cerebral malaria that has put the child in a coma and caused permanent damage to the nerves, brain or spine (neurological deficit). A blood film test must show that the parasite that causes malaria is present in the blood. The child must require artificial ventilation (machines that help you breathe) and It must also be proven that the malaria is the only possible cause for the child's coma. Cover applies only to children under the age of 1 A gunshot wound or stab wound that has penetrated the child's skull, chest or abdomen, and has required surgery under general anaesthetic. Cover applies only to children under the age of 1 0% % Additional expense needs 1 Definition set C: Effective 1 August 01 V.0

22 1 Introduction The permanent and total loss of hearing in both ears, without any possibility of correction, in a child younger than 1 years. The auditory threshold must be more than 0 decibels, as confirmed by an ENT Loss of hearing in both ears Complete and permanent loss of hearing in both ears that cannot be corrected. An ear, nose and throat specialist must confirm that the child can't hear sounds at a frequency of lower than 0 decibels. Cover applies only to children under the age of 1 % recurring at claim-stage: 1 A confirmed history of rheumatic fever in a child younger than 1 years, with the complications of heart disease, characterised by fibrosis of the heart valves. This must be confirmed by a cardiologist Any surgery in a child younger than 1 years to replace or repair a diseased heart valve by endoscopic procedures or minimally invasive procedures Any disease in a child younger than 1 years that causes the permanent and irreversible failure of both kidneys resulting in the requirement of treatment by dialysis Hydrocephalus in a child younger than 1 years resulting in raised intracranial pressure as a result of which surgical shunt procedure is required Rheumatic fever with cardiac complications Keyhole heart valve surgery Kidney failure (renal failure) Hydrocephalus Confirmed rheumatic fever which has caused heart disease, specifically the thickening of the heart valves. A cardiologist must confirm this diagnosis. Cover applies only to children under the age of 1 Surgery through a small incision to replace or repair a damaged heart valve, which may include the use of an endoscope (a long tube-shaped instrument used to look inside the body). Cover applies only to children under the age of 1 Any disease that causes both kidneys to fail permanently, without the possibility of recovery. The child requires dialysis (removal of waste and excess fluid) because of the kidney failure. Excess build-up of fluid in the brain that causes raised pressure inside the skull and brain tissue. The condition must require an operation to insert a shunt (a narrow tube that drains the fluid away the brain). Cover applies only to children under the age of 1 % % % % 1 Sensory system 1 Additional expense needs 1 Definition set C: Effective 1 August 01 V.0