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Major Critical Illness

The following Critical Illness conditions are covered under the Major-Stage Critical Illness Benefit:

No.

Organs Part

Critical Illness List

Definition 

1

 

 

Cancer 

 

 

Major Cancer

 

 

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. Diagnosis must be made by a Specialist. 

 

Exclusion:

For the above definition, the following are not covered: 

  • All cancers which are histologically classified as any of the following:

  • pre-malignant 
  • non-invasive
  • carcinoma in situ 
  • having borderline malignancy
  • having malignant potential 

  • All tumours of the prostate histologically classified as T1N0M0 (TNM classification).

  • All tumours of the thyroid histologically classified as T1N0M0 (TNM classification). 

  • All tumours of the urinary bladder histologically classified as T1N0M0 (TNM classification).

  • Chronic Lymphocytic Leukemia less than RAI Stage 3. 

  • All cancers in the presence of HIV.

  • Any skin cancer other than malignant melanoma. 

  • Gastro-Intestinal Stromal tumours histologically classified as AJCC Stage I. 

  • Neuroendocrine tumours histologically classified as T1N0M0 (TNM Classification). 

2

 

 

Heart

 

 

Heart Attack

 

 

Death of heart muscle due to obstruction of blood flow, that is evident by at least three of the following criteria proving the occurrence of a new heart attack:  

  1. History of typical chest pain; 

  2. 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; 

  3. Elevation of the cardiac biomarkers, inclusive of CKMB above the generally accepted normal laboratory levels or Cardiac Troponin T or I at 0.5ng/ml and above;  

  4. Left ventricular ejection fraction less than 50% measured 3 months or more after the event.  

The evidence must show the occurrence of a definite acute myocardial infarction, which should be confirmed by a consultant Cardiologist. 

 

Exclusion:

For the above definition, the following are excluded: 

  • Angina or other acute coronary syndrome; 

  • Heart attack of indeterminate age; and  

  • A rise in cardiac biomarkers or Troponin T or I following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty. 

 

Explanatory note: 0.5ng/ml = 0.5ug/L = 500pg/ml

3

 

 

Heart

 

 

Coronary Artery By-Pass Surgery

 

 

The actual undergoing of open-chest surgery to correct the narrowing or blockage of one or more coronary arteries with bypass grafts. This diagnosis must be supported by angiographic evidence of more than fifty percent (50%) coronary artery obstruction and the procedure must be considered Medically Necessary by a consultant cardiologist.  

 

Exclusion:

Angioplasty stent insertion and all other intra-arterial catheter-based techniques, ‘keyhole’ or laser procedures are excluded.


 

 

Heart 

 

 

Open Surgery to Aorta 

 

 

Aortic surgery is defined as the undergoing of open-chest or open-abdomen surgery to repair or correct an aneurysm, narrowing, obstruction or dissection of the aorta requiring excision and surgical replacement of any part of the diseased aorta with a graft. For the purpose of this definition, aorta shall mean the thoracic and abdominal aorta but not its branches. The surgery must be determined to be Medically Necessary by a Specialist. 

 

Exclusion: 

For the definition, the following are not covered:  

  • Angioplasty  

  • Intra-arterial, laser or trans-catheter procedures 

  • Keyhole, minimally invasive or non-surgical procedures. 


 

 

Heart 

 

Heart Valve Surgery (replacement or repair) 

 

 

The undergoing of open-heart surgery to replace any heart valve with either a bioprosthetic or mechanical valve, or to repair heart valve defects or abnormalities. Evidence of the heart valve abnormality from cardiac catheterization or echocardiogram must be provided and the procedure must be considered Medically Necessary by a consultant cardiologist. 

 

Exclusion: 

For the above definition, the following are not covered: 

Repair or replacement via key-hole or percutaneous transcatheter procedures, or any other similar technique. 


 

 

Heart 

 

 

Heart Transplant  

 

 

The receipt of a transplant of the heart medically necessitated from its irreversible end failure diagnosed by a specialist. 

 

Exclusion: 

Stem cell transplants and/or transplants of part of the heart are excluded.  


 

 

Heart 

 

 

Idiopathic Pulmonary Hypertension 

 

 

Idiopathic Pulmonary Hypertension is defined as pulmonary arterial hypertension due to an unknown cause. The definite diagnosis of idiopathic pulmonary arterial hypertension must be made by a Specialist and should include the following:  

  1. Symptoms of right ventricular heart failure including shortness of breath, exertional chest pain, exertional syncope, or weight gain from fluid retention, resulting in permanent physical impairment to the degree of at least Class III of the New York Heart Association (NYHA) classification of cardiac impairment.  

  2. Echocardiographic findings of right ventricular heart failure including increased right ventricular wall thickness and size with decreased right ventricular function.   

  3. Right Heart Catheterization with a mean pulmonary artery pressure ≥ 20mmHg and a mean pulmonary capillary wedge pressure (PCWP) ≤15mmHg. 

     

Exclusion: 

Secondary causes of pulmonary arterial hypertension, such as left heart disease, congenital heart disease, lung disease, pulmonary artery obstruction, hematologic, infectious, systemic, or metabolic disorders are excluded. 


 

 

Brain 

 

 

Major Stroke 

 

 

An acute cerebrovascular event including infarction of brain tissue, cerebral, subarachnoid hemorrhage, cerebral embolism, or cerebral thrombosis resulting in permanent neurological deficit with persisting clinical symptoms. 

 

This diagnosis must be supported by clinical evidence of a new permanent neurological and functional impairment from results of a brain CT scan or MRI and confirmed by a neurologist at least three (3) months after the initial event.  

 

Exclusion: 

The following neurological events are excluded:  

  • Transient ischemic attacks or reversible ischemic neurological events  

  • Brain damage or vascular event due to an accidental or external injury or infection, vasculitis, inflammatory disease and migraine   

  • Disorders of the optic nerve or the blood vessels affecting the eye  

  • Reversible ischemic disorders of the vestibular system  

  • Microvascular ischemia. 


 

 

Brain 

 

 

Alzheimer's Disease/Dementia  

 

 

Progressive and permanent deterioration of memory and intellectual capacity as evidenced by accepted standardized questionnaires and cerebral imaging. The diagnosis of Alzheimer’s disease must be confirmed by a Medical Practitioner who is an appropriate consultant and supported by the Company’s appointed Medical Practitioner. There must be significant reduction in mental and social functioning requiring the continuous supervision of the Insured. There must also be a permanent inability of the Insured to perform, without any form of assistance, at least three (3) of the six (6) Activities of Daily Living for a continuous period of at least one-hundred-eighty (180) days. 

 

Exclusion: 

Psychiatric illnesses and drug or alcohol related brain damage. 

10 

 

 

Brain 

 

 

Idiopathic Parkinson's Disease 

 

 

A definite diagnosis by a neurologist of primary idiopathic Parkinson’s disease, or a specified atypical Parkinsonian syndrome* as a permanent and progressive neurologic condition characterized by bradykinesia (slowness of movement) and both the following criteria:     

  1. At least one symptom of: muscle rigidity or rest tremor    

  2. Inability to perform three or more Activities of Daily Living (ADLs) without assistance for a continuous period of at least one-hundred-eighty (180) days despite optimal antiparkinsonian therapy.    

     

*Specified Atypical Parkinsonian Syndromes are defined as a definite diagnosis of progressive supranuclear palsy, corticobasal degeneration, or multiple system atrophy.   

 

Exclusion: 

  • Drug induced or toxic causes of Parkinsonism.   

  • Secondary Parkinson Disease. 

11 

 

 

Brain 

 

 

Brain Surgery  

 

 

Confirmation from a neurologist or neurosurgeon of surgery to the brain under general anesthesia of which a craniotomy is performed.  

 

Exclusion: 

The following are excluded:  

  • Burr hole procedures 

  • Transsphenoidal or Endoscopic assisted procedures   

  • Stereotactic or aspiration biopsy of the brain. 

  • Brain surgery as a result of an accident. 

12 

 

 

Brain 

 

 

Multiple Sclerosis (MS) 

 

 

A definite Diagnosis of multiple sclerosis by a neurologist. The diagnosis must be supported by all of the following:  

  1. Investigations of MRI or CT which confirm the diagnosis to be Multiple Sclerosis; 

  2. Multiple neurological deficits resulting in impairment of motor and sensory functions occurring over a continuous period of at least six (6) months; and 

  3. Well documented history of exacerbations and remissions of said symptoms or neurological deficits. 

 

In any event, medically appropriate treatment must have been recommended and pursued.   

 

Exclusion: 

Other causes of neurological damage such as Systemic Lupus Erythematosus and HIV are excluded. 

Assessment Period:  

Until the date the criteria outlined in multiple sclerosis above have been met.   

13 

 

 

Brain 

 

 

Creutzfeldt-Jacob Disease (CJD) 

 

 

The occurrence of Creutzfeldt-Jacob Disease or Variant Creutzfeldt-Jacob Disease where there is an associated neurological deficit, which is solely responsible for the Life Insured's permanent inability to perform at least three (3) of the listed Activities of Daily Living. These conditions have to be medically documented for at least six (6) months and confirmed by a consultant neurologist with appropriate testing such as conclusive Electroencephalography (EEG) and Cerebrospinal Fluid (CSF) findings as well as Computerized Tomography (CT) scan and Magnetic Resonance Imaging (MRI). 

 

Exclusion: 

Disease caused by human growth hormone treatment is excluded. 

14 

 

 

Brain 

 

 

Coma (at least 96 hours) 

 

 

A coma that persists for at least ninety-six (96) hours. This diagnosis must be supported by evidence of all of the following: 

  1. no response to external stimuli for at least 96 hours; 

  2. life support measures are necessary to sustain life for at least 96 hours; and 

  3. brain damage resulting in permanent neurological deficit which leads to the permanent inability to perform 3 out of 6 “activities of daily living” without the assistance of another person at least 30 days after the onset of the coma.  

     

Exclusion: 

  • Coma resulting directly from alcohol or drug abuse. 

  • Medically induced coma or sedation. 

 15 

 

 

Brain 

 

 

Encephalitis 

 

 

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. 

 

Exclusion: 

  • Encephalitis due to bacterial infection is excluded. 

  • Encephalitis in the presence of HIV infection is not covered. 

16 

 

 

Brain 

 

 

Bacterial Meningitis 

 

 

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 ninety (90) days applies.  

 

The diagnosis must be certified by a consultant neurologist and confirmed by isolation and growth of bacterial pathogen in the cerebrospinal fluid in culture. 

 

Exclusion: 

  • All other forms of Meningitis, including but not limited to viral meningitis, are excluded.  

     

Bacterial Meningitis in the presence of HIV infection is excluded. 

17 

 

 

Liver 

 

 

End-Stage Liver Failure 

 

 

End stage liver failure as evidenced by all of the following:   

  1. Permanent jaundice;  

  2. Ascites; and  

  3. Hepatic encephalopathy.  

 

Exclusion: 

Liver disease secondary to alcohol or drug abuse is excluded. 

18 

 

 

Liver 

 

 

Surgical Liver transplant  

 

 

The receipt of a transplant of the liver medically necessitated from its irreversible end failure diagnosed by a Specialist. 

 

Exclusion: 

  • Stem cell transplants, islet cell transplants are excluded. 

  • Irreversible end failure of the liver secondary to proven alcohol or drug abuse is excluded. 

19 

 

 

Kidney 

 

 

Kidney Failure 

 

 

A definite diagnosis of end-stage irreversible failure of both kidneys to function, as a result of which regular hemodialysis, peritoneal dialysis or renal transplantation is recommended and Medically Necessary. The dialysis must be on a continuing and permanent basis.  

 

The diagnosis of kidney failure must be made by a Specialist. 

20 

 

 

Kidney 

 

 

Surgical Kidney Transplant  

 

 

The receipt of a transplant of both kidneys medically necessitated from the irreversible end failure diagnosed by a Specialist. 

 

Exclusion: 

Stem cell transplants, islet cell transplants and/or transplants of part of the kidney are excluded.  

21 

 

 

Lung 

 

 

End-Stage Lung Disease 

 

 

End-stage lung disease, causing chronic respiratory failure which is permanent and irreversible as all evidenced by:  

 

  1. Consistent test results of FEV1 (post bronchodilator) of less than or equal to thirty percent (30%) of predicted value;  

  2. Permanent supplementary oxygen therapy; and 

  3. Arterial blood gas analysis with partial oxygen pressures of 55mmHg or less (PaO2 ≤ 55mmHg) at room air. 

 

The diagnosis must be confirmed by a respiratory Specialist. 

22 

 

 

Lung 

 

 

Surgical Lung Transplant  

 

 

The receipt of a transplant of both lungs medically necessitated from the irreversible end failure diagnosed by a Specialist. 

 

Exclusion: 

Stem cell transplants and/or transplants of part of the lung are excluded.  

23 

 

 

Organ Transplantation 

 

 

Surgical Pancreas Transplant 

 

 

The receipt of a transplant of the pancreas medically necessitated from its irreversible end failure diagnosed by a Specialist. 

 

Exclusion: 

  • Stem cell transplants, islet cell transplants and/or transplants of part of the pancreas are excluded. 

  • Irreversible end failure of the pancreas secondary to proven alcohol abuse, cystic fibrosis and congenital anomalies of the pancreas are excluded. 

24 

 

 

Organ Transplantation 

 

 

Bone Marrow Transplant 

 

 

A definite diagnosis of end-stage irreversible failure of the bone marrow from a Specialist and transplantation must be Medically Necessary.  To qualify under Major Organ Transplant, the Insured person must undergo a transplantation procedure as the recipient of human bone marrow using haematopoietic stem cells preceded by total bone marrow ablation. 

 

Exclusion: 

Other stem cell transplants are excluded. 

25 

 

 

Dismemberment 

 

 

Blindness (Loss of Sight) 

 

 

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. 

26 

 

 

Other 

 

 

Severe Rheumatoid Arthritis 

 

 

Chronic Rheumatoid arthritis as a result of autoimmune disturbance which is diagnosed by a rheumatologist and immunologist. The characteristic of this disease should meet all of following criteria: 

  1. Diagnosis based on American College of Rheumatology guidelines, and 

  2. Chronic progressive joint destruction with deformity, affecting at least three following joints (e.g. interphalangeal hand joints, wrists, elbows, knees, hips, ankles, cervical bones, or interphalangeal foot joints). The diagnosis must be supported by clinical examination and imaging study evidenced the involvement. 

  3. There is the permanent inability to perform, without any form of assistance, three (3) of the six (6) Activities of Daily Living for a continuous period of at least one-hundred-eighty (180) days. 

27 

 

 

Other 

 

 

Crohn's Disease 

 

 

Crohn’s Disease is a chronic, transmural inflammatory disorder of the bowel. To be considered as severe, there must be evidence of continued inflammation in spite of optimal therapy, with all of the following having occurred: 

  1. Stricture formation causing intestinal obstruction requiring admission to hospital, and 

  2. Fistula formation between loops of bowel, and 

  3. At least one bowel segment resection. 

     

The diagnosis must be made by a Specialist Gastroenterologist and be proven histologically on a pathology report and/or the results of sigmoidoscopy or colonoscopy. 

 

Exclusion: 

The inflammation bowel disease other than Crohn’s disease is excluded. 

28 

 

 

Other 

 

 

Systemic Lupus Erythematosus (SLE) 

 

 

Systemic Lupus Erythematosus (SLE) involving the kidneys or Central Nervous System (CNS) as defined below:  

  1. Lupus nephritis must be severe as established by renal biopsy to be of a degree of Class III to VI in accordance with the Abbreviated International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification of lupus nephritis (2003) / World Health Organization classification.   

  2. CNS Lupus means seizures or permanent neurological deficit as evidenced by the inability to perform 3 of the 6 activities of daily living without assistance.  

     

The final diagnosis must be confirmed by an appropriate Specialist.   

 

Exclusion: 

All other forms of SLE such as drug induced lupus, discoid lupus or those forms with only hematological or joint involvement. 

29 

 

 

Other 

 

 

Severe burn (Major Burn) 

 

 

Third degree (full thickness of the skin) burns covering at least twenty percent (20%) of the surface of the Life Insured’s body measured by the Lund & Browder Body Surface Chart and skin grafting treatment must be required in a recognized burns unit in a hospital. 

 

Third degree burns refer to burns in which all layers of the skin are destroyed, and damage extends into the subcutaneous tissues. 

30 

 

 

Other 

 

 

Primary Chronic Adrenal insufficiency 

 

 

An autoimmune disorder causing a gradual destruction of the adrenal gland resulting in the need for lifelong glucocorticoid and mineral corticoid replacement therapy. The disorder must be confirmed by a Medical Practitioner who is a qualified Specialist, through: 

  1. ACTH simulation tests; 

  2. Insulin-induced hypoglycemia test; 

  3. Plasma ACTH level measurement; and 

  4. Plasma Renin Activity (PRA) level measurement. 

 

Exclusion: 

Only autoimmune cause of primary adrenal insufficiency is included. All other causes of adrenal insufficiency. 

31 

 

 

Other 

 

 

HIV due to Blood Transfusion  

 

 

HIV infection as result of blood transfusion that occurred after the effective date of the coverage or reinstatement of the policy whichever is later. Benefit will be payable provided that:  

  1. The blood transfusion was Medically Necessary as part of treatment plan; and    

  2. The institution which provided the treatment admits liability, or malpractice insurance judged by court's final adjudication; and    

  3. The institution where treatment was provided must have legal operating license issued; and    

  4. Source of the infection is established to be from the institution that provided medical care and the facility is able to trace the origin of HIV contaminated blood;  

  5. The Life Insured does not suffer from hemophilia; and 

  6. The Life Insured is not a member of any high-risk groups including but not limited to intravenous drug users. 

 

Exclusion: 

  • HIV acquired through other means including but not limited to sexually transmitted and intravenous drug use.  

  • This benefit will not be payable if a cure has become available prior to the infection.  

     

“Cure” means any treatment that renders the HIV permanently inactive or non-infectious.  

 

Insurance company must have the right to obtain the Life Insured’s blood sample and process independent examination on the blood sample. 

32 

 

 

Other 

 

 

Occupationally Acquired Human Immunodeficiency Virus (HIV) Infection 

 

 

Infection with the Human Immunodeficiency Virus (only if the Life Insured is a Medical Staff as defined below) which occurred after the effective date of the coverage or reinstatement of the policy whichever is later. 

 

Only HIV infection acquired as a result of an accident occurring during the course of carrying out normal occupational duties with seroconversion to HIV infection occurring within six (6) months of the accident is covered. Any accident giving rise to a potential claim must be reported to the Company within thirty (30) days of the accident taking place supported by a negative HIV test taken within seven (7) days of the accident.  

 

"Medical Staff" is defined as Doctors (General Physicians and Specialists), traditional practitioners, nurses, paramedics, laboratory technicians, dentists, dental nurses, ambulance workers who are working in a medical centre or hospital or dental clinic/polyclinic in Kingdom of Cambodia. Doctors, traditional practitioners, nurses and dentists must be registered with the Ministry of Health (or other equivalent governmental authority) of Kingdom of Cambodia.