(1) STROKE – resulting in permanent neurological deficit with persisting clinical symptoms
Death of brain tissue due to inadequate blood supply, bleeding within the skull or embolization from an extra cranial source resulting in permanent neurological deficit with persisting clinical symptoms. The diagnosis must be based on changes seen in a CT scan or MRI and certified by a neurologist. A minimum Assessment Period of three (3) months applies.
For the above definition, the following are not covered:
(i) Transient ischemic attacks
(ii) Cerebralsymptomsduetomigraine
(iii) Traumatic injury to brain tissue or blood vessels
(iv) Vascular disease affecting the eye or optic nerve or vestibular functions.
(2) HEART ATTACK – of specified severity
Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction:
(i) A history of typical chest pain;
(ii) New characteristic electrocardiographic changes; with the development of any of the following:
ST elevation or depression, T wave inversion, pathological Q waves or left bundle branch block
and
(iii) Elevation of the cardiac biomarkers, inclusive of CPK-MB above the generally accepted normal
laboratory levels or Troponins recorded at the following levels or higher: - Cardiac Troponin T or Cardiac Troponin I > / = 0.5 ng/ml
The evidence must show the occurrence of a definite acute myocardial infarction which should be confirmed by a cardiologist or physician.
For the above definition, the following are not covered:
• occurrence of an acute coronary syndrome including but not limited to unstable angina.
• a rise in cardiac biomarkers resulting from a percutaneous procedure for coronary artery disease.
(3) KIDNEY FAILURE – requiring dialysis or kidney transplant
End-stage kidney failure presenting as chronic irreversible failure of both kidneys to function, as a result of which regular dialysis is initiated or kidney transplantation is carried out.
(4) CANCER – of specified severity and does not cover very early cancers
Any malignant tumour positively diagnosed with histological confirmation and characterized by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukemia, lymphoma and sarcoma.
For the above definition, the following are not covered:
(i) All cancers which are histologically classified as any of the following:
- pre-malignant
- non-invasive
- carcinoma in situ
- having borderline malignancy - having malignant potential
(ii) All tumours of the prostate histologically classified as T1N0M0 (TNM classification)
(iii) All tumours of the thyroid histologically classified as T1N0M0 (TNM classification)
(iv) All tumours of the urinary bladder histologically classified as T1N0M0 (TNM classification)
(v) Chronic Lymphocytic Leukemia less than RAI Stage 3
(vi) All cancers in the presence of HIV
(vii)Any skin cancer other than malignant melanoma.
(5) CORONARY ARTERY BY-PASS SURGERY
Refers to the actual undergoing of open-chest surgery to correct or treat Coronary Artery Disease (CAD) by way of coronary artery by-pass grafting.
For the above definition, the following are not covered: (i) angioplasty;
(ii) otherintra-arterialorcatheterbasedtechniques; (iii) keyhole procedures;
(iv) laser procedures.
(6) SERIOUS CORONARY ARTERY DISEASE
The narrowing of the lumen of Right Coronary Artery (RCA), Left Anterior Descending Artery (LAD) and Circumflex Artery (not inclusive of their branches) occurring at the same time by a minimum of sixty percent (60%) in each artery as proven by coronary arteriography (non-invasive diagnostic procedures are not covered). A narrowing of sixty percent (60%) or more of the Left Main Stem will be considered as a narrowing of the Left Anterior Descending Artery (LAD) and Circumflex Artery. This covered event is payable regardless of whether or not any form of coronary artery surgery has been performed.
(7) 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 as shown by angiographic evidence.
Intra-arterial investigative procedures are not covered. Payment under this clause is limited to ten percent (10%) of the Critical Illness coverage under respective Annexure subject to a maximum of RM25,000. This covered event is payable once only and shall be deducted from the amount of respective Annexure, thereby reducing the amount of the Lump Sum Payment which may be payable.
(8) END-STAGE LIVER FAILURE
End-stage liver failure as evidenced by all of the following: - Permanent jaundice;
- Ascites (excessive fluid in peritoneal cavity); and,
- Hepatic encephalopathy.
Liver failure secondary to alcohol or drug abuse is not covered.
(9) FULMINANT VIRAL HEPATITIS
A sub-massive to massive necrosis (death of liver tissue) caused by any virus as evidenced by all of the following diagnostic criteria:
(i) A rapidly decreasing liver size as confirmed by abdominal ultrasound;
(ii) Necrosisinvolvingentirelobules,leavingonlyacollapsedreticularframework; (iii) Rapidly deteriorating liver functions tests; and
(iv) Deepening jaundice.
Viral hepatitis infection or carrier status alone (inclusive but not limited to Hepatitis B and Hepatitis C) without the above diagnostic criteria is not covered.
(10) COMA – resulting in permanent neurological deficit with persisting clinical symptoms
A state of unconsciousness with no reaction to external stimuli or internal needs, persisting continuously for at least ninety six (96) hours, requiring the use of life support systems and resulting in a permanent neurological deficit with persisting clinical symptoms. A minimum Assessment Period of thirty (30) days applies. Confirmation by a neurologist must be present.
The following is not covered:
(i) Coma resulting directly from alcohol or drug abuse.
(11) BENIGN BRAIN TUMOR – of specified severity
A benign tumour in the brain or meninges within the skull, where all of the following conditions are met:
(i) It is life threatening.
(ii) It has caused damage to the brain.
(iii) It has undergone surgical removal or has caused permanent neurological deficit with persisting clinical symptoms; and
(iv) Its presence must be confirmed by a neurologist or neurosurgeon and supported by findings on MRI, CT or other reliable imaging techniques.
The following are not covered:
(i) Cysts
(ii) Granulomas
(iii) Malformations in or of the arteries or veins of the brain
(iv) Hematomas
(v) Tumours in the pituitary gland
(vi) Tumours in the spine
(vii)Tumours of the acoustic nerve.
(12) PARALYSIS OF LIMBS
Total, permanent and irreversible loss of use of both arms or both legs, or of one arm and one leg, through paralysis caused by illness or injury. A minimum Assessment Period of six (6) months applies.
(13) BLINDNESS – Permanent and Irreversible
Permanent and irreversible loss of sight as a result of Accident or illness to the extent that even when tested with the use of visual aids, vision is measured at 3/60 or worse in both eyes using a Snellen eye chart or equivalent test and the result must be certified by an ophthalmologist.
(14) DEAFNESS – Permanent and Irreversible
Permanent and irreversible loss of hearing as a result of Accident or illness to the extent that the loss is greater than 80 decibels across all frequencies of hearing in both ears. Medical evidence in the form of an audiometry and sound-threshold tests result must be provided and certified by an Ear, Nose, and Throat (ENT) specialist.
(15) THIRD DEGREE BURNS – of specified severity
Third degree (i.e. full thickness) skin burns covering at least twenty percent (20%) of the total body surface area.
(16) HIV INFECTION DUE TO BLOOD TRANSFUSION
Infection with the Human Immunodeficiency Virus (HIV) through a blood transfusion, provided that all of the following conditions are met:
(i) The blood transfusion was medically necessary or given as part of a medical treatment;
(ii) The blood transfusion was received in Malaysia or Singapore after the commencement of this
Policy;
(iii) The source of the infection is established to be from the institution that provided the blood
transfusion and the institution is able to trace the origin of the HIV tainted blood;
(iv) The Insured Life does not suffer from hemophilia; and
(v) The Insured Life is not a member of any high risk groups including but not limited to intravenous
drug users.
(17) FULL-BLOWN AIDS
The clinical manifestation of AIDS (Acquired Immuno-deficiency Syndrome) must be supported by the results of a positive HIV (Human Immuno-deficiency Virus) antibody test and a confirmatory test. In addition, the Insured Life must have a CD4 cell count of less than two hundred (200)/μL and one or more of the following criteria are met:
(i) Weight loss of more than 10% of body weight over a period of six (6) months or less (wasting syndrome)
(ii) Kaposi Sarcoma
(iii) Pneumocystis Carinii Pneumonia
(iv) Progressive multifocal leukoencephalopathy
(v) Active Tuberculosis
(vi) Less than one-thousand (1000) Lymphocytes/μL
(vii)Malignant Lymphoma.
(18) END-STAGE LUNG DISEASE
End-stage lung disease causing chronic respiratory failure.
All of the following criteria must be met:
(i) The need for regular oxygen treatment on a permanent basis;
(ii) Permanent impairment of lung function with a consistent Forced Expiratory Volume (FEV) of less
than one (1) liter during the first second;
(iii) Shortness of breath at rest; and
(iv) Baseline Arterial Blood Gas analysis with partial oxygen pressures of 55mmHg or less.
(19) ENCEPHALITIS – resulting in permanent inability to perform Activities of Daily Living
Severe inflammation of brain substance, resulting in permanent functional impairment. The permanent functional impairment must result in an inability to perform at least three (3) of the Activities of Daily Living. A minimum Assessment Period of thirty (30) days applies. The covered event must be certified by a neurologist.
Encephalitis in the presence of HIV infection is not covered.
(20) MAJOR ORGAN / BONE MARROW TRANSPLANT
The receipt of a transplant of:
- Human bone marrow using hematopoietic stem cells preceded by total bone marrow ablation; or
- One of the following human organs: heart, lung, liver, kidney, pancreas that resulted from irreversible
end-stage failure of the relevant organ. Other stem cell transplants are not covered.
(21) LOSS OF SPEECH
Total, permanent and irreversible loss of the ability to speak as a result of injury or illness. A minimum Assessment Period of six (6) months applies. Medical evidence to confirm injury or illness to the vocal cords to support this disability must be supplied by an Ear, Nose, and Throat specialist.
All psychiatric related causes are not covered.
(22) BRAIN SURGERY
The actual undergoing of surgery to the brain under general anesthesia during which a craniotomy (surgical opening of skull) is performed.
For the above definition, the following are not covered:
(i) Burr hole procedures
(ii) Transphenoidalprocedures
(iii) Endoscopic assisted procedures or any other minimally invasive procedures (iv) Brain surgery as a result of an Accident.
(23) HEART VALVE SURGERY
The actual undergoing of open-heart surgery to replace or repair cardiac valves as a consequence of heart valve defects or abnormalities.
For the above definition, the following are not covered:
(i) Repair via intra-arterial procedure
(ii) Repairviakey-holesurgeryoranyothersimilartechniques.
(24) LOSS OF INDEPENDENT EXISTENCE
Confirmation by an appropriate specialist of the loss of independent existence and resulting in a permanent inability to perform at least three (3) of the Activities of Daily Living. A minimum Assessment Period of six (6) months applies.
(25) BACTERIAL MENINGITIS - resulting in permanent inability to perform Activities of Daily Living
Bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in permanent functional impairment. The permanent functional impairment must result in an inability to perform at least three (3) of the Activities of Daily Living. A minimum Assessment Period of thirty (30) days applies.
The diagnosis must be confirmed by:
(i) an appropriate specialist; and
(ii) thepresenceofbacterialinfectioninthecerebrospinalfluidbylumbarpuncture.
For the above definition, other forms of meningitis, including viral meningitis are not covered.
(26) MAJOR HEAD TRAUMA - resulting in permanent inability to perform Activities of Daily Living
Physical head injury resulting in permanent functional impairment verified by a neurologist. The permanent functional impairment must result in an inability to perform at least three (3) of the Activities of Daily Living. A minimum Assessment Period of three (3) months applies.
(27) CHRONIC APLASTIC ANEMIA - resulting in permanent Bone Marrow Failure
Irreversible permanent bone marrow failure which results in anemia, neutropenia and thrombocytopenia requiring at least two (2) of the following treatments:
(i) Regular blood product transfusion;
(ii) Marrowstimulatingagents;
(iii) Immunosuppressive agents; or
(iv) Bone marrow transplantation.
The diagnosis must be confirmed by a bone marrow biopsy.
(28) MOTOR NEURON DISEASES – permanent neurological deficit with persisting clinical symptoms
A definite diagnosis of motor neuron disease by a neurologist with reference to either spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be a permanent neurological deficit with persisting clinical symptoms.
(29) PARKINSON’S DISEASE – resulting in permanent inability to perform Activities of Daily Living
A definite diagnosis of Parkinson's Disease by a neurologist where all the following conditions are met:
(i) Cannot be controlled with medication;
(ii) Shows signs of progressive impairment; and
(iii) Confirmation of the permanent inability of the Insured Life to perform without assistance three (3)
or more of the Activities of Daily Living.
Only idiopathic Parkinson's Disease is covered. Drug-induced or toxic causes of Parkinsonism are not covered.
(30) ALZHEIMER’S DISEASE/SEVERE DEMENTIA
Deterioration or loss of intellectual capacity confirmed by clinical evaluation and imaging tests arising from Alzheimer's Disease or Severe Dementia as a result of irreversible organic brain disorders. The covered event must result in significant reduction in mental and social functioning requiring continuous supervision of the Insured Life. The diagnosis must be clinically confirmed by a neurologist.
From the above definition, the following are not covered: (i) Non organic brain disorders such as neurosis
(ii) Psychiatricillnesses
(iii) Drug or alcohol related brain damage
(31) SURGERY TO AORTA
The actual undergoing of surgery via a thoracotomy or laparotomy (surgical opening of thorax or abdomen) to repair or correct an aortic aneurysm, an obstruction of the aorta or a dissection of the aorta. For this definition, aorta shall mean the thoracic and abdominal aorta but not its branches.
For the above definition, the following are not covered: (i) angioplasty;
(ii) otherintra-arterialorcatheterbasedtechniques; (iii) other keyhole procedures;
(iv) laser procedures
(32) MULTIPLE SCLEROSIS
A definite diagnosis of multiple sclerosis by a neurologist. The diagnosis must be supported by all of the following:
- Investigations which confirm the diagnosis to be Multiple Sclerosis;
- Multiple neurological deficits resulting in impairment of motor and sensory functions occurring over
a continuous period of at least six (6) months; and
- Well documented history of exacerbations and remissions of said symptoms or neurological deficits.
(33) PRIMARY PULMONARY ARTERIAL HYPERTENSION – of specified severity
A definite diagnosis of primary pulmonary arterial hypertension with substantial right ventricular enlargement established by investigations including cardiac catheterization, resulting in permanent physical impairment to the degree of at least Class III of the New York Heart Association (NYHA) classification of cardiac impairment.
Pulmonary arterial hypertension resulting from other causes shall be excluded from this benefit.
The NYHA Classification of Cardiac Impairment for Class III and Class IV means the following:
Class III: Marked limitation of physical activity. Comfortable at rest but less than ordinary activity
causes symptoms.
Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present
even at rest.
(34) MEDULLARY CYSTIC DISEASE
A progressive hereditary disease of the kidney characterized by the presence of cysts in the medulla, tubular atrophy and interstitial fibrosis with the clinical manifestations of anemia, polyuria and renal loss of sodium, progressing to chronic kidney failure. Diagnosis must be supported by a renal biopsy.
(35) CARDIOMYOPATHY – of specified severity
A definite diagnosis of cardiomyopathy by a cardiologist which results in permanently impaired ventricular function and resulting in permanent physical impairment of at least Class III of the New York Heart Association's classification of cardiac impairment. The diagnosis has to be supported by echocardiographic findings of compromised ventricular performance.
The NYHA Classification of Cardiac Impairment for Class III and Class IV means the following:
Class III: Marked limitation of physical activity. Comfortable at rest but less than ordinary activity
causes symptoms.
Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present
even at rest.
Cardiomyopathy directly related to alcohol or drug abuse is not covered.
(36) SYSTEMIC LUPUS ERYTHEMATOSUS WITH SEVERE KIDNEY COMPLICATIONS
A definite diagnosis of Systemic Lupus Erythematosus confirmed by a rheumatologist.
For this definition , the covered event is payable only if it has resulted in Type III to Type V Lupus Nephritis as established by renal biopsy. Other forms such as discoid lupus or those forms with only hematological or joint involvement are not covered.
WHO Lupus Classification:
Type III - Focal Segmental glomerulonephritis Type IV - Diffuse glomerulonephritis
Type V - Membranous glomerulonephritis
(37) OCCUPATIONALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION
Infection with the Human Immunodeficiency Virus (HIV) (only if the Insured Life is a Medical Staff as defined below), where it was acquired as a result of an accident occurring during the course of carrying out normal occupational duties as a Medical Staff with seroconversion to HIV infection occurring within six (6) months from the date of the accident. Any accident giving rise to a potential claim must be reported to us within thirty (30) days from the date of that accident, supported by a negative HIV test taken within seven (7) days from the date of that accident.
“Medical Staff” is defined as a doctor (general physician or specialist), traditional and complementary medicine practitioner, nurse, paramedic, laboratory technician, dentist, dental nurse, or ambulance worker, who is working in a medical centre, Hospital, dental clinic, or polyclinic (“Workplace”). When the law requires, the Medical Staff and his/her Workplace must be registered with the Ministry of Health in Malaysia.
(38) MUSCULAR DYSTROPHY
The definite diagnosis of a Muscular Dystrophy by a neurologist which must be supported by all of the following:
(i) Clinical presentation of progressive muscle weakness;
(ii) No central / peripheral nerve involvement as evidenced by absence of sensory disturbance; and
(iii) Characteristic electromyogram and muscle biopsy findings.
No benefit will be payable under this Critical Illness before the Insured Life has reached the age of twelve (12) years next birthday.
(39) TERMINAL ILLNESS
The conclusive diagnosis of a condition that is expected to result in death of the Insured Life within twelve (12) months. The Insured Life must no longer be receiving active treatment other than that for pain relief. The diagnosis must be supported by written confirmation from an appropriate specialist and confirmed by a Doctor we have appointed.
(40) POLIOMYELITIS
Unequivocal diagnosis by a consultant neurologist of infection with the Poliovirus leading to paralytic disease as evidenced by impaired motor function or respiratory weakness. Cases not involving paralysis will not be eligible for this benefit. Other causes of paralysis (such as Guillain-Barre syndrome) are specifically excluded.
(41) APALLIC SYNDROME
Universal necrosis of the brain cortex, with the brainstem remaining intact. Diagnosis must be confirmed by a neurologist and the condition must be documented for at least one (1) month.
(42) CHRONIC RELAPSING PANCREATITIS
Multiple attacks of pancreatitis resulting in pancreatic dysfunction causing malabsorption needing enzyme replacement therapy. The diagnosis must be made by a gastroenterologist and supported by appropriate investigation results.
Chronic Relapsing Pancreatitis caused by alcohol use is excluded.
(43) PROGRESSIVE SCLERODERMA
A systemic collagen-vascular disease causing progressive diffuse fibrosis in the skin, blood vessels and visceral organs. This diagnosis must be unequivocally supported by biopsy and serological evidence and the disorder must have reached systemic proportions to involve the heart, lungs or kidneys.
The following are excluded:
(i) Localised scleroderma (linear scleroderma or morphea);
(ii) Eosinophilic fasciitis; and
(iii) CREST syndrome.
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