Critical Illness Cover - Insurance Definitions
This directory provides information on critical illness conditions. This list is not exhaustive and you should check the keyfacts information on individual products for the conditions covered under your policy and the exact definitions.
Alzheimer’s disease – resulting in permanent symptoms
Aorta graft surgery – for disease or traumatic injury
Aplastic anaemia – with permanent bone marrow failure
Bacterial meningitis – resulting in permanent symptoms
Benign brain tumour – resulting in permanent symptoms or surgical removal
Blindness – permanent and irreversible
Cancer – excluding less advanced cases
Cardiomyopathy – of specified severity
Coma – resulting in permanent symptoms
Coronary artery by-pass grafts – with surgery to divide the breastbone
Creutzfeldt-Jakob disease – resulting in permanent symptoms
Deafness – permanent and irreversible
Emphysema – end stage
Encephalitis – resulting in permanent symptoms
Heart attack – of specified severity
Heart valve replacement or repair – with surgery to divide the breastbone
HIV infection
Kidney failure – requiring dialysis
Liver failure – end stage
Loss of hands or feet – permanent physical severance
Loss of speech – permanent and irreversible
Major organ transplant
Motor neurone disease – resulting in permanent symptoms
Multiple sclerosis – with persisting symptoms
Open heart surgery – with surgery to divide the breastbone
Paralysis of limbs – total and irreversible
Parkinson’s disease – resulting in permanent symptoms
Pre-senile dementia – resulting in permanent symptoms
Primary pulmonary hypertension – of specified severity
Progressive supranuclear palsy – resulting in permanent symptoms
Pulmonary artery surgery – with surgery to divide the breastbone
Rheumatoid arthritis – chronic and severe
Severe lung disease – end stage
Stroke – resulting in permanent symptoms
Systemic lupus erythematosus – with severe complications
Terminal Illness
Third degree burns – covering 20% of the body’s surface area
Total and Permanent Disability (TPD) – before age 60
Traumatic head injury – resulting in permanent symptoms
Alzheimer’s disease – resulting in permanent symptoms
This is a progressive and degenerative form of dementia occurring in middle age or later life. It is likely to cause a severe loss of memory and general decline in mental abilities. If the Consultant hasn’t made a definite diagnosis of Alzheimer’s disease, the claim will not be valid.
Aorta graft surgery – for disease or traumatic injury
The aorta is the main artery in the body, carrying blood from the heart to supply the tissues. The thoracic and abdominal sections are the widest parts, found in the chest area and stomach area. The aorta might be damaged by disease (fatty deposits causing narrowing) or weakening of the artery wall from an aneurysm (a thinned section which might bulge out and burst). Claims will not be paid where surgery was on a part of the aorta other than the thoracic or abdominal sections.
Aplastic anaemia – with permanent bone marrow failure
This is a severe form of anaemia where the bone marrow fails to produce new blood cells. It can be a reaction to drugs or due to underlying disease. Claims will not be paid where the condition is temporary or doesn’t require at least one of the defined treatments.
Bacterial meningitis – resulting in permanent symptoms
Bacterial meningitis is caused by bacterial infection of the protective layer around the brain (meninges). Without adequate treatment this can result in permanent and severe neurological damage.
Benign brain tumour – resulting in permanent symptoms or surgical removal
A benign tumour is an abnormal growth of tissue that is not cancerous. Benign brain tumours can be dangerous because of the pressure they might put on the brain resulting in bleeding, ulceration and permanent damage. Symptoms might include muscle weakness or sensory loss. Surgery to remove and cure the condition is not always possible.
Blindness – permanent and irreversible
The loss of vision is permanent and without the possibility of improvement. If registered blind as a result of loss of vision, the measurement criteria must still be met in order to validate a claim. Claims will not be paid where the loss of sight is temporary or partial.
Cancer – excluding less advanced cases
Cancer causes uncontrolled growth of cells which might spread through the body. Malignant cancers are called invasive because of this potential to spread to other tissues and organs. The impact of these cancers is likely to be significant. Abnormal cell growth that is non cancerous or borderline can be treated relatively quickly and successfully, for instance a skin cancer confined to the top level of your skin. These won’t qualify as a claim. The histology of the tumour is particularly relevant as this shows whether the cell growth was cancerous and the extent to which this growth has taken place. These might have been analysed from a biopsy or from tissue removed at an operation.
Cardiomyopathy – of specified severity
Cardiomyopathy is a chronic disease of the heart muscle wall which can result in severe heart disease and in some cases sudden death.
Coma – resulting in permanent symptoms
A coma might be caused by a serious accident, a tumour or by bleeding in the brain. A coma is a state of unconsciousness from which there is no response to any kind of stimulation or control over bodily functions. A permanent neurological deficit means a loss of functions that won’t be recovered.
Coronary artery by-pass grafts – with surgery to divide the breastbone
‘Open heart’ surgery, is performed to gain access to the arteries surrounding the heart. The diseased artery will be replaced by a new section of artery or vein (often grafted from the leg) which is inserted around the diseased section resulting in restoration of supply of blood to the heart. Procedures that don’t involve surgery to open your chest are excluded from cover.
Creutzfeldt-Jakob disease – resulting in permanent symptoms
A relatively rare degenerative brain disease which may be inherited or acquired and is thought to be associated with BSE or ‘mad cow’ disease. There is no cure. Progressive degeneration of the central nervous system causes severe mental and physical deterioration.Claims will not be paid where the diagnosis is uncertain or if permanent supervision is not needed.
Deafness – permanent and irreversible
The decibel level stipulated in the definition means being significantly deaf from which the hearing loss will be irreversible. Claims will not be paid where the loss of hearing is temporary and likely to recover, or partial.
A chronic lung disease associated with persistent breathlessness with minimal exertion requiring frequent oxygen therapy.
Encephalitis – resulting in permanent symptoms
Inflammatory disease of the membranes that surround the brain and spinal cord. Some cases are short and relatively benign but other cases are severe and result in permanent neurological impairment and sometimes sudden death.
Heart attack – of specified severity
Symptoms of a heart attack usually include crushing central chest pain, possibly with radiation of the pain into the jaw or left arm. Typically the heart attack also results in large amounts of cardiac enzymes and troponins being released into the blood stream with changes to the normal electrical impulses passing through the heart muscle. These abnormalities can be detected through blood tests and electrocardiography. The tests have to show that there was damage being sustained to the heart muscle at that time. Episodes of severe chest pain only won’t qualify for a claim.
Heart valve replacement or repair – with surgery to divide the breastbone
Infection or disease can damage the delicate leaflets that form the heart valves meaning the effective functioning of the heart is impaired. This can be corrected by ‘open heart’ surgery in the more severe cases, repairing or replacing the diseased valves with mechanical, animal or human valves.
HIV infection caught in the UK and other specified countries from a blood transfusion, a physical assault or at work in an eligible occupation. HIV can be transmitted by contact with infected blood or other body fluids. The definition covers accidental infection.
Kidney failure – requiring dialysis
The kidneys filter out waste products from the blood and pass them out of the body in the urine. If they don’t work properly dangerous levels of waste products can build up in the blood. If the kidneys are damaged chronically and irreversibly then treatment with dialysis is undertaken to temporarily replace kidney function. Surgery (transplanting of a new kidney) can be performed to provide a long term solution. Claims will not be paid where only one kidney wasn’t working properly, or both had a reduced function but didn’t need dialysis.
Cirrhosis is due to longstanding damage to the liver caused by chronic disease or alcohol or drugs. Chronic failure can lead to severe abdominal disorders and brain damage.
Loss of hands or feet – permanent physical severance
This means more than one limb must be permanently severed. Loss of fingers or toes alone, or one limb would not be covered.
Loss of speech – permanent and irreversible
This means the loss of being able to talk on a permanent non curable basis. It may be caused by damage to the vocal chords in an accident or due to disease. Claims will not be paid if the loss of speech is psychological (e.g. after a traumatic incident due to shock), and there is no physical injury or disease to the vocal chords.
When an organ undergoes serious failure it may be necessary to replace it via a transplant. Clients who are on a waiting list or have received the new organ this will be covered. Claims will not be paid where an organ or bone marrow has been donated to someone else, you are not yet on the transplant waiting list, or the transplant is for any other organs, or parts of organs, tissues or cells.
Motor neurone disease – resulting in permanent symptoms
This is a progressive disease of the nervous system leading to permanent severe disability and early death. There is no known cure.
Multiple sclerosis – with persisting symptoms
MS is a demyelinating disease where the breakdown of the sheaths surrounding the spinal cord that transmit nerve impulses disrupts the normal functioning of the nervous system. Symptoms can be intermittent or permanent. There can be years between episodes of symptoms but this should not affect your claim. A number of tests will be needed to confirm the diagnosis but once the diagnosis and the definition are met then permanent ongoing symptoms aren’t necessary in order to have a valid claim.
Open heart surgery – with surgery to divide the breastbone
‘Open heart’ surgery is performed to gain access to repair or replace the heart defect.
Paralysis of limbs – total and irreversible
This can be two legs, two arms, or one arm and a leg. It can be due to accident or disease.
Parkinson’s disease – resulting in permanent symptoms
This is a progressive disease of the nervous system, often associated with shaking, muscle stiffness and weakness. Treatment is available to slow down the progression of the disease but this becomes less effective over time.
Pre-senile dementia – resulting in permanent symptoms
Deterioration of the mental capabilities resulting in loss of memory, recognition and impairment of behaviour. The diagnosis must be supported by standard assessment tests.
Primary pulmonary hypertension – of specified severity
A rare disease characterised by elevated pulmonary artery pressure often with no apparent cause.Symptoms are typically chronic shortness of breath, weakness, and fainting. Untreated the disease results in right-sided heart failure and death.
Progressive supranuclear palsy – resulting in permanent symptoms
The disease causes tremors and rigidity in the head and limb muscles.Treatment is available to slow down the progression of the disease but this becomes less effective over time.
Pulmonary artery surgery – with surgery to divide the breastbone
‘Open heart’ surgery is performed to gain access to repair the diseased section of the pulmonary artery with a graft.
Rheumatoid arthritis – chronic and severe
Rheumatoid arthritis (RA) is a chronic disease that causes the immune system to attack the joints and sometimes the major organs. The disease can be very disabling and painful leading to substantial loss of function and mobility. Various treatments are available to suppress symptoms and the course of the disease varies greatly but in most cases the disease is progressive throughout life.
Severe lung disease – end stage
Chronic lung disease associated with persistent breathlessness with minimal exertion requiring daily oxygen therapy.
Stroke – resulting in permanent symptoms
Also known as a Cerebrovascular Accident (CVA) caused by narrowing of the vessels in the brain due to disease, or haemorrhage (due to disease or trauma). The disease can cause severe neurological weakness affecting movement and sensory loss which in many cases is permanent.
Systemic lupus erythematosus – with severe complications
A chronic auto-immune disease that attacks cells and tissue most commonly in the nervous system, kidneys, blood vessels, liver, heart and skin.
The medical Consultant and the Chief Medical Officer must agree that the diagnosis is terminal and that the person covered is expected to die within 12 months.
Third degree burns – covering 20% of the body’s surface area
Third degree burns involve the full thickness of the skin and are the most serious of the 3 levels of burn.
Total and Permanent Disability (TPD) – before age 60
If the relevant Life Assured is employed at the onset of the disability, then the definition depends on whether "Own", "Own or suited", or "Activities of Daily Working" is applied at the outset of the Cover. If the relevant Life Assured is not employed at the onset of disability, then the “Activities of Daily Working” is applied.
"Activities of Daily Working" definition:
A permanent and irreversible inability before age 60, as a result of illness or injury to carry out (if necessary with the use of artificial aids or appliances, but without help from another person) three or more of the following ‘Activities of Daily Working’:
- Walking – Walk 200 metres on a level surface without stopping.
- Mobility – Walk up and down a flight of 12 stairs
- Dressing – Put on and take off items of clothing which are normally worn.
- Communication – Answer a telephone and relay a message
- Reading – The eyesight, if necessary as adjusted by the use of spectacles, contact lenses or other visual aid to read a daily newspaper.
- Dexterity – The manual dexterity necessary to write using a pen or pencil.
- Eating – Use normal cutlery to eat a meal that has already been prepared.
- Hygiene – Wash oneself all over.
- Continence – Manage bowel and bladder function, including through the use of protective undergarments or surgical appliances.
Traumatic head injury – resulting in permanent symptoms
A severe head injury resulting in permanent neurological deficit where a loss of normal function won’t be recovered.
