Critical Illness

List of 36 Critical Illness

1                     AIDS

(a)                 AIDS due to a blood transfusion

If the Covered Person is infected by the HIV virus or AIDS as long as:

i.       the infection is due to a blood transfusion received in Malaysia or Singapore after the commencement date of the certificate;
ii.                   the Covered Person is not a haemophiliac; and

iii.          the Covered Person is not a member of any high-risk group such as but not limited to homosexuals, intravenous drug users, or sex workers.

We will need proof of the transfusion, such as a statement from health authorities, that the Covered Person was infected through a medical procedure.

(b)                 Full blown AIDS

The Covered Person must have a positive HIV (human immunodeficiency virus) antibody test and a confirmatory Western Blot test.

The Covered Person must also have a CD4 cell count of less than two hundred (200) and meet one (1) or more of the following criteria:

i.                lost more than 10% of the Covered Person’s body weight over six (6) months or less (wasting syndrome).
ii.                   suffering from Kaposi’s sarcoma.
iii.                  having pneumocystic carinii pneumonia.
iv.                  having progressive multifocal leukoencephalopathy.
v.                    having active tuberculosis.

vi.                  having less than one thousand (1,000) lymphocytes.
vii.                 having malignant lymphoma.

If you make a claim (except for Contributor, Spouse Contributor and Parent Contributor), we will pay 50% of all benefits which apply (up to Ringgit Malaysia Five Hundred Thousand (RM500,000) on any one (1) life under this and all other contributions) for this illness. We will pay the rest of the payment on the Covered Person’s death, total and permanent disability, or the Diagnosis of another critical illness whichever happens first.

2                     Aplastic anaemia

Chronic persistent bone-marrow failure, which results in bone marrow no longer being produced and which needs treatment with at least one (1) of the following:
(a)                 Regular blood product transfusion;

(b)                 Marrow-stimulating agents;

(c)                 Immunosuppressive agents; or
(d)                 A bone marrow transplant.

3                     Apallic syndrome

Universal necrosis of the brain cortex, with the brain stem staying intact. The Diagnosis must be confirmed by a consultant neurologist and the Covered Person’s condition must be documented for at least thirty (30) days.

4                     Alzheimer’s disease

Deterioration or loss of intellectual ability or abnormal behavior, which is proven using the clinical state and accepted standardised questionnaires or tests, arising from Alzheimer’s disease or irreversible organic

degenerative brain disorders. This does not include neurosis, psychiatric illness, and any drug or alcohol-related organic disorder. The condition results in significant reduction in mental and social functioning where the Covered Person needs to be continuously supervised. The Diagnosis must be clinically confirmed by an appropriate medical consultant.

5                     Benign brain tumour

A life-threatening, non-cancerous tumour in the brain, which shows signs of increased pressure within the skull such as papilloedema, mental symptoms, seizures, and sensory impairment. The presence of this tumour must be confirmed by imaging studies such as a CT scan or MRI scan.

We will not cover:

(a)                 cysts;

(b)                 granulomas;

(c)                 malformations in or of the arteries or veins of the brain;

(d)                 haematomas;

(e)                 tumours in the pituitary gland, or spine; or

(f)                   tumours of the acoustic nerve.

6                     Blindness
The total, permanent and irrecoverable loss of the sight of both eyes as confirmed by an ophthalmologist.

7                     Brain surgery

Having surgery to the brain under general anesthesia, during which a craniotomy is performed. We do not cover Bur Hole and brain surgery due to an Accident.

8                     Cancer

The uncontrollable growth and spread of malignant cells into surrounding tissue and destruction of normal tissue for which the Covered Person need major treatment or surgery (but not just endoscopic procedures). The cancer must be confirmed by histological evidence of malignancy.

The following conditions are not covered:
(a)                 Carcinoma in situ, of the cervix.
(b)                 Ductal carcinoma in situ, of the breast.
(c)                 Papillary carcinoma of the bladder and stage-1 prostate cancer.

(d)                 All skin cancer except malignant melanoma.
(e)                 Stage-1 Hodgkin’s disease.
(f)                   Tumours, which are complications of AIDS.

9                     Cardiomyopathy

The unequivocal diagnosis by a consultant cardiologist of cardiomyopathy causing impaired ventricular function, suspected by ECG abnormalities and confirmed by cardiac echo of variable aetiology and resulting in permanent physical impairments to the degree of at least class III of the New York Association Classification of cardiac impairment.

Class III - Marked limitation - Such patients are comfortable at rest but performing less than ordinary activity will lead to symptoms of Congestive Cardiac Failure.

Class IV - Inability to carry out any activity without discomfort. Symptoms of Congestive Cardiac Failure are present even at rest. With any increase in physical activity, discomfort will be experienced.

We will not cover any cardiomyopathy secondary to alcohol or drug misuse.

10        Chronic liver Disease
             End-stage liver failure, which is shown by:

(a)                 permanent jaundice,

(b)                 ascites (excess fluid),

(c)                 encephalopathy (a brain disorder), and

(d)                 portal hypertension (increased blood pressure).

We do not cover Wernicke’s encephalopathy and liver failure secondary to alcohol or drug misuse.

11                 Chronic lung disease

End-stage respiratory failure including chronic interstitial lung disease. The Covered Person must meet all of the following criteria:

(a)                 The Covered Person needs permanent oxygen therapy because of a consistent Forced Expiratory Volume (FEV1) test value of less than one (1) liter.
(b)                 Arterial blood gas analysis with partial oxygen pressures of 55mmHg or less.

(c)                 Feeling short of breath when resting.

12                 Coma

A state of unconsciousness where the Covered Person cannot react or respond to any stimulation from outside the body or to his/her own body’s needs, which must continue for at least ninety six (96) hours, requiring the use of life-support systems and resulting in neurological deficit that last for more than thirty (30) days. We will need confirmation by a consultant neurologist.

We will not cover a coma resulting directly from self-inflicted injury, alcohol or drug misuse.

13                 Coronary artery disease
(a)                 Coronary artery disease which needs surgery

When the Covered Person have coronary artery bypass surgery using thoracotomy to correct or treat coronary artery disease. This does not include angioplasty, other intra-arterial, bypass keyhole or laser procedures.

(b)                 Other serious coronary artery disease

The lumen of at least three (3) major coronary arteries (circumflex, right coronary artery (RCA), left anterior descending artery (LAD)), when narrows by at least 60% or more as proven by coronary arteriography, we will pay this benefit whether or not any form of coronary artery surgery has been performed.

(c)                 Angioplasty and other invasive treatments for coronary artery disease

The actual undergoing for the first time of Coronary Artery Balloon Angioplasty, artherectomy, laser treatment or the insertion of a stent to correct a narrowing or blockage of one or more coronary arteries. This does not include intra-arterial investigative procedures.

The following medical evidence must be provided:

i.                     Evidence of significant and relevant ECG changes (ST segment depression of two (2) millimetres or more), and
ii.                   Angiographic evidence to confirm the location of stenosis.

14                 Deafness

Total and permanent loss of hearing in both ears as a result of disease or Accident. We must receive medical evidence in the form of an audiometry and sound-threshold tests.

15                 Encephalitis

Severe inflammation of the brain, resulting in permanent neurological deficit lasting for at least thirty (30) days and confirmed by a consultant neurologist. The permanent deficit must result in the Covered Person’s inability to carry out at least three (3) of the Activities of Daily Living either with or without mechanical equipment, special devices or other aids and adaptations for disabled people. For the purpose of this benefit, the word “permanent” means beyond the hope of recovery with current medical knowledge and technology.

We do not cover encephalitis because of HIV infection.

16                 Fulminant viral hepatitis

We define this as a sub-massive to massive necrosis of the liver caused by any virus leading to liver failure. The diagnostic criteria to be met are:
(a)                 a rapidly reducing liver size as confirmed by abdominal ultrasound;

(b)                 failure of entire lobules, leaving only a collapsed reticular framework;

(c)                 rapidly deteriorating liver function tests; and

(d)                 deepening jaundice.

Having hepatitis B infection or being a carrier alone does not meet the diagnostic criteria.

17                 Heart Attack

When part of the heart muscle (myocardium) fails as a result of inadequate blood supply and being evidenced by:

(a)                 a history of typical prolonged chest pain;
(b)                 new electrocardiographic changes resulting from this event; and
(c)                 elevation in the cardiac enzyme (CPK-MB) above normally accepted laboratory level.

Diagnosis based on the elevation Troponin T test alone will not be accepted as a Diagnosis of a heart attack.

We will not cover angina (chest pain).

18                 Heart-valve replacement

Having an open-chest surgery to replace or repair the cardiac valves as a result of heart-valve defects or abnormalities that have happened after the date of issue or revival of the related Annex.

We do not cover repairs using valvotomy, intra-arterial procedure, keyhole surgery, or similar techniques.

19                 Kidney failure

End-stage kidney failure presenting as chronic irreversible failure of both kidneys to function, as a result of which the Covered Person need regular dialysis or a transplant.

20                 Loss of independent existence

Confirmation by a Consultant Physician of the loss of independent existence lasting for a minimum period of six (6) months and resulting in a permanent inability to perform at least three (3) of the Activities of Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For the purpose of this benefit, the word "permanent" means beyond the hope of recovery with current medical knowledge and technology.

21                 Loss of speech

Total and permanent loss of the ability to speak continuously for twelve (12) months. We must receive medical evidence to confirm the injury or illness to the vocal cords from an appropriate (ear, nose, throat) specialist.

We will not cover any psychiatric-related causes.

22                 Major burns

Third-degree burns covering at least 20% of the Covered Person’s body surface area as measured by ‘The Rule of 9’ of the Lund and Browder Body Surface Chart.

23                 Major head trauma

Physical head injury causing significant permanent functional impairment lasting for at least ninety (90) days from the date of the trauma or injury. The resulting impairment must be verified by a consultant neurologist and/or a neurosurgeon which must be agreed by our medical officer. The Covered Person must also be unable to carry out at least three (3) of the Activities of Daily Living either with or without mechanical equipment, special devices or other aids and adaptations for disabled people. For the purpose of this benefit, the word “permanent” means beyond the hope of recovery with current medical knowledge and technology.

24                 Major organ transplant

When the Covered Person receive one of the following human organs:

(a)                 Kidney

(b)                 Lung(s)

(c)                 Liver

(d)                 Heart
(e)                 Bone marrow

25                 Medullary cystic disease

A progressive hereditary disease of the kidneys characterized by the presence of cysts in the medulla, tubular atrophy and intestitial fibrosis with the clinical manifestations of anaemia, polyuria and renal loss of sodium, progressing to chronic renal failure. Diagnosis should be supported by renal biopsy.

26                 Meningitis

Bacterial meningitis causes inflammation of the membranes of the brain and/or spinal cord. This results in a permanent neurological problem lasting for at least thirty (30) days and results in a permanent inability to carry out at least three (3) of the Activities of Daily Living either with or without mechanical equipment, special devices or other aids and adaptations for disabled people. For the purpose of this benefit, the word “permanent” means beyond the hope of recovery with current medical knowledge and technology.

The Diagnosis is to be confirmed by a consultant neurologist.

27                 Motor neurone disease

Motor neurone disease of unknown cause is characterised by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. These include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis, and primary lateral sclerosis.

The Diagnosis must be confirmed by a consultant neurologist.

28                 Multiple sclerosis

A final Diagnosis by a consultant neurologist confirming the following combination, which has continued for at least one hundred eighty (180) days:

(a)                 Symptoms related to tracts (white matter) involving the optic nerves, brain stem and spinal cord, producing well-defined neurological deficits.
(b)                 Many or separate lesions.

(c)                 A well-documented history of worsening and remissions of the above symptoms and neurological deficits.

29                Muscular dystrophy
            The Diagnosis of muscular dystrophy must be confirmed by a consultant neurologist. The    Covered Person must have a combination of three (3) out of four (4) of the following conditions:

(a)                 Family history of other affected individuals.

(b)                 Clinical presentation including absence of sensory disturbance, normal cerebro-spinal fluid and mild tendon reflex reduction.

(c)                 Characteristic electromyogram.

(d)                 Clinical suspicion confirmed by muscle biopsy.

We do not cover children age twelve (12) years or below.

30                 Paralysis

The complete and permanent loss of use of both arms or both legs, or one arm and one leg, through paralysis caused by illness or injury, which lasts for at least one hundred eighty (180) days from the date of trauma or illness.

31                 Parkinson’s disease

A definite Diagnosis of Parkinson’s disease by a consultant neurologist where the condition:

(a)                 cannot be controlled with medication; and

(b)                 shows signs of progressive impairment.

It must be confirm that the Covered Person is unable to perform at least three (3) of Activities of Daily Living.

We will cover only idiopathic Parkinson’s disease. We will not cover drug-induced or toxic causes of Parkinson’s disease.

32                 Poliomyelitis

A definite Diagnosis by a consultant neurologist of infection with the poliovirus leading to paralytic disease. This can be seen by impaired motor function or respiratory weakness. Cases not involving paralysis will not be eligible for this benefit. We do not cover other causes of paralysis (such as Guillain-Barre syndrome).

33                 Primary pulmonary arterial hypertension

Primary pulmonary hypertension with substantial enlargement of the right ventricle, which is confirmed using investigations including cardiac catheterisation; which results in permanent irreversible physical impairment to the degree of at least class-3 of the New York Heart Association Classification of cardiac impairment. It also means the Covered Person cannot perform his/her usual occupation.

34                 Stroke

An accident or incident to the brain, which produces permanent neurological complications, which have lasted not less than one hundred eighty (180) days. This includes infarction of brain tissue, haemorrhage and embolism from an extra-cranial source. The Diagnosis must be based on changes seen in a CT scan or MRI scan and certified by a neurologist or neurosurgeon.

We will not cover cerebral symptoms due to transient ischemic attacks (temporary strokes), any reversible ischemic neurological deficit, vertebrobasilar ischemia, cerebral symptoms due to migraine, cerebral injury resulting from trauma or hypoxia and vascular disease affecting the eye or optic nerve or vestibular functions of the brain.

35                 Surgery to the aorta

Surgery to repair or correct an aortic aneurysm, an obstruction of the aorta or a narrowing of the aorta by thoracotomy or laparotomy. For this purpose, the definition of aorta means the thoracic and abdominal aorta but not its branches.

36                 Systemic lupus erythematosus lupus nephritis

A multisystem, multifactorial, autoimmune disorder which affects mostly females in their childbearing years and is characterized by the development of auto-antibodies, directed against various self-antigens.

In respect of this contract, SLE will be restricted to those forms of systemic lupus erythematosus which involve the kidneys (Type III to Type IV Lupus Nephritis, established by renal biopsy). Other forms, discoid lupus, and those forms with only haematological and joint involvement will be specifically excluded.

World Health Organisation Lupus Classification:

Class I (Minimal Change)            - Negative, normal urine
Class II (Mesangial)                   - Moderate proteinuria, active sediment

Class III (Focal Segmental)         - Proteinuria, active sediment

Class IV (Diffuse)                       - Acute neprritis with active sediment and/or nephritic Syndrome

Class V (Membranous)               - Nephrotic Syndrome or severe proteinuria.