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Clinical claims definitions: Additional expense needs

BrightRock has worked in partnership with international clinical and risk expertsto ensure our clinical claims criteria are objective, transparent and industry-leading.To give you peace of mind that our claims definitions are comprehensive and clinically objective, we provide a full list of our

claims definitions and criteria, divided by body system.

Cover for illness or injury with a financial impact

Additional expense needs

Death-related needs

Debt needs

Healthcare needs

Childcare needs

Household needs

BrightRock Life Ltd, an authorised financial services provider (FSP 11643, Registration number: 1996/014618/06) is an underwriting management agency ofSanlam Life Insurance Ltd, an authorised financial services provider and registered insurer (FSP 2759, Registration number: 1998/021121/06).Copyright © May 2018 BrightRock. All rights reserved. Terms and conditions apply.

Important to note• This clinical definition 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 pay-out, no matter the option you chose.

• The pay-outs in the last three columns under the heading If you choose the lump-sum plus recurring pay-out 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 lump-sum pay-out for the condition, or taking an initial lump-sum plus a series of regular monthly pay-outs for the number of months shown. Each regular monthly pay-out will be equal to 3.25% of the specified initial lump-sum. We provide the total value of the initial lump-sum plus the regular monthly pay-outs in the final column.

• For conditions where we don’t offer the option of both a lump-sum and regular pay-out, we have left the last three columns blank.

• In this document, we’ve provided our clinical claims definitions 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 “BrightRock clinical definitions” will prevail.

Definition sets D(v5), E(v1)Additional expense needs

Appendix

Reference notes:

Activities of Daily Living:

13 Sensory system

Trauma

Muscles, bones and joints12

Lungs and breathing11

Kidney and genital/urinary tract10

Hormones9

HIV/AIDS8

7 Heart and blood vessels

Digestive system6

5 Child illnesses and injuries

Connective tissue conditions4

Cancer3

Brain and nerves2

Body systems (areas of the body)

Trauma impact quotient

14

15

Introduction1

Appendix


Connective tissue conditions

Digestive system

4

5

6

7

HIV/AIDS

Hormones

Kidney and genital/urinary tract

Lungs and breathing

Muscles, bones and joints

9

10

11

12

13 Sensory system

Trauma


14

15

Cancer3

Heart and blood vessels

8

Brain and nerves2

Introduction1

Child illnesses and injuries


If you chose the Premier Max option: If you chose the Premier option: If you chose the Primary option:

Maximum pay-out You can receive a potential maximum pay-out of:• Up to 200% for related claims for illnesses

and injuries you can recover from• Up to 200% for related claims for illnesses

and injuries that are permanent.

The total maximum pay-out you can receive for all claims is 200% for related claims.

The total maximum pay-out you can receive for all claims is 200% for related claims.

Increased pay-outs for certain conditions For conditions where we’ve included a number of months and a total pay-out percentage (last three columns), you can choose the standard pay-out or an initial pay-out plus a series of recurring pay-outs for the specified period.

For conditions where we’ve included a number of months and a total pay-out percentage (last three columns), you can choose the standard pay-out or an initial pay-out plus a series of recurring pay-outs for the specified period.

Only the lump-sum shown in the ‘Standard pay-out’ column applies tothis 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 months have passed since qualifying for your claim) or within a year of your last recurring pay-out (where chosen), you can access extended cover. You can receive a monthly cover pay-out to a maximum of 200% 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 months have passed since qualifying for your claim) or within a year of your last recurring pay-out (where chosen), you can access extended cover. You can receive a monthly cover pay-out to a maximum of 200% 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 months have passed since qualifying for your claim), you can access extended cover. You can receive a monthly cover pay-out to a maximum of 200% 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.

Introduction: Your cover for additional expense needs

An illness or injury 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 you can recover from 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 BrightRock clinical definition 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 advanced pay-out option, you can receive an additional pay-out for conditions marked with the symbol.

If you chose to add the advanced pay-out option, you’ll receive an automatic, condition-specific increase for the conditions marked with the symbol. We will automatically increase your standard pay-out to the percentage shown next to the symbol, up to a maximum of 100%. Where we offer clients the choice to receive a lump-sum and recurring pay-out, these pay-outs will also increase by the same proportion.

Automatic cover for child additional expense needs, so parents can enjoy peace of mind

We automatically offer parents the ability to receive a pay-out 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 36 clinical conditions that apply specifically to the child cover, which you’ll find in the section marked “Child illnesses and injuries”. Check your Owner’s Manual to see if you qualify for this cover.

Reference notes:


Appendix

With layman’s explanation

BrightRock clinical definition

Condition or medical procedure

How serious it isTotal % pay-out

For which insurable event

does the pay-out apply?

Standard pay-out

Number of months

Initiallump-sum

If you choose the lump-sum plus recurring pay-out at claim-stage:


Trauma impact quotient15


Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Cancer3


8

Brain and nerves2

Introduction1



• Radiologically documented cerebral infarction with corresponding permanent neurological deficit, established 30 days after the event with any two of the following: motor deficit (power <3/5), speech deficit, new onset epilepsy and/or visual or hearing deficit, or cerebellar dysfunction confirmed by a neurologist OR

• Equivalent SCIDEP stroke definition - Level A

Where the advanced option is selected, no waiting period applies

Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and established 30 days after any two of the following events: loss of mobility (less than 3/5 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

An illness or injury that’s permanent

100% 80% 18 126,8%

• Radiologically documented cerebral infarction with resultant permanent cognitive deficit (MMSE of less than 19) as established 30 days after the events OR

• Equivalent SCIDEP stroke definition - Level A


Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and scored less than 19 on the Mini-Mental State Examination (MMSE) when tested 30 days after the event, as confirmed by a neurologist


100% 80% 18 126,8%

Total and permanent aphasia Aphasia (a language disorder that makes it difficult to remember words or even impossible to speak, read and write)

Total and permanent An illness or injury that’s permanent

100% 80% 18 126,8%

Motor neuron disease confirmed by a neurologist

Motor neuron disease (a degenerative disease that affects the motor neurons, nerve cells that control muscle movement)

Confirmed by a neurologist An illness or injury that’s permanent

100% 80% 18 126,8%

Alzheimer’s disease confirmed by neurologist/psychiatrist

Alzheimer's disease (a condition that causes the gradual loss of brain function)

Confirmed by a neurologist or a psychiatrist


100% 80% 18 126,8%

Parkinson’s disease confirmed by neurologist

Parkinson’s disease (a condition that causes tremors or shaking, and difficulty with movement and coordination)


100% 80% 18 126,8%

1 2 3 4 5

* *

* *

Reference notes:


6

Appendix







Standard pay-out

Number of months

Initiallump-sum





Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Cancer3


8

Brain and nerves2

Introduction1



Multiple sclerosis confirmed by a neurologist with two or more admissions of more than 72 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 disease-modifying drugs (beta interferon, glatiramer). It must also have resulted in at least two hospital admissions of three days or longer in the past year

An illness or injury that's permanent

100% 80% 18 126,8%

Muscular dystrophy confirmed by neurologist

Muscular dystrophy (a group of disorders that involve the gradual weakening and loss of muscle tissue)


100% 80% 18 126,8%

Glasgow Coma Scale score of less than 8/15 for longer than 96 hours confirmed by a neurologist or neurosurgeon. (Medically-induced coma is excluded)

Coma (being unconscious) Confirmed score of less than 8 out of 15 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)


100% 80% 18 126,8%

Documented diagnosis of a recognised neurological condition resulting in 3 or more of the following permanent (of more than 3 months’ duration) findings: motor deficit (power <3/5), cognitive deficit (MMSE <19/30), speech deficit, epilepsy and/or visual or hearing deficit, all confirmed by a neurologist

Any recognised neurological condition

Documented diagnosis that has caused three or more of the following for more than three months: loss of mobility (less than 3/5 power), reduced brain function (with a Mini-Mental State Examination or MMSE score of less than 19 out of 30), speech problems, epilepsy or the loss of hearing and/or sight. The condition and its complications must be confirmed by a neurologist


100% 80% 18 126,8%

Documented cerebral malaria with a parasitaemia count of >5% or > 250 000 parasites / μl , with one of the following permanent (of more than 3 months duration) findings: motor deficit (power <3/5), cognitive deficit (MMSE <19/30), speech deficit, epilepsy and / or visual or hearing deficit confirmed by a neurologist

Cerebral malaria (a parasitic disease)

Confirmed, documented diagnosis with a parasitaemia count of more than 5% or more than 250 000 parasites per microliter that has caused one of the following for more than three months: loss of mobility (less than 3/5 power), reduced brain function (with a Mini-Mental State Examination or MMSE score of less than 19 out of 30), 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


100% 80% 18 126,8%

1 2 3 4 5

* *

* *

Reference notes:


6

Appendix







Standard pay-out

Number of months

Initiallump-sum





Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Cancer3


8

Brain and nerves2

Introduction1



• Radiologically documented cerebral infarction with corresponding permanent neurological deficit, established 30 days after the event of any of the following: motor deficit (power <3/5), speech deficit, new onset epilepsy and/or visual or hearing deficit, or cerebellar dysfunction confirmed by a neurologist OR

• Equivalent SCIDEP stroke definition - Level B or C

Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and established 30 days after any of the following events: loss of mobility (less than 3/5 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


75% 60% 18 95.1%


100% 80% 18 126.8%

• Radiologically documented cerebral infarction with resultant permanent cognitive deficit (MMSE of 19 to 21) as established 30 days after the event OR

• Equivalent SCIDEP stroke definition - Level A, B or C

Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with permanent neurological deficit (damage to the nervous system) and scored 19 to 21 on the Mini-Mental State Examination (MMSE) when tested 30 days after the event, as confirmed by a neurologist


75% 60% 18 95,1%


100% 80% 18 126.8%

Confirmed Guillain-Barre syndrome resulting in permanent neurological deficit that requires the use of ambulatory aids

Guillain-Barre Syndrome (a disorder that attacks the peripheral nervous system)

Confirmed diagnosis that has resulted in permanent neurological deficit (damage to the nervous system) with the need to use ambulatory devices (walking aids)


75% 60% 18 95,1%

Non-endovascular procedures performed by a neurosurgeon (excluding drainage of brain abscess) e.g. craniotomy

Brain surgery 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)


50% 40% 18 63,4%

Cavernous sinus thrombosis Cavernous sinus thrombosis (a blood clot in a cavity at the base of the brain)

Confirmed diagnosis An illness or injury that’s permanent

50% 40% 18 63,4%

Confirmed diagnosis of a subarachnoid haemorrhage

Subarachnoid haemorrhage (bleeding into the subarachnoid space surrounding the brain)


25% 20% 24 35,6%

1 2 3 4 5

* *

Reference notes:


6

Appendix







Standard pay-out

Number of months

Initiallump-sum





Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Cancer3


8

Brain and nerves2

Introduction1



Multiple sclerosis confirmed by a neurologist

Multiple sclerosis (an autoimmune disease that attacks the central nervous system)

Confirmed by a neurologist An illness or injury that's permanent

25% 20% 18 31,7%

Status epilepticus resulting in permanent neurological deficit as confirmed by a neurologist

Status epilepticus (a life-threatening, prolonged epileptic attack)

Documented diagnosis with permanent neurological deficit (damage to the nervous system) that has been confirmed by a neurologist


25% 20% 18 31,7%

Confirmed Guillain-Barre syndrome resulting in permanent neurological deficit but requires no use of ambulatory aids

Guillain-Barre Syndrome (a disorder that attacks the peripheral nervous system)

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)


25% 20% 18 31,7%

• Radiologically documented cerebral infarction with no permanent neurological deficit, OR

• Equivalent SCIDEP stroke definition - Level D

Cerebral infarction (stroke) Confirmed by radiological evidence (scan) with no permanent damage

An illness or injury you can recover from

25%


Endovascular procedures performed by a neurosurgeon

Brain surgery Endovascular procedures (minimally invasive surgery via major blood vessels) that have been performed by a neurosurgeon


25%

One payment for the treatment of hydrocephalus by insertion of a shunt

Hydrocephalus (the build-up of fluid inside the skull). NB: Limited to one payment.

Has undergone treatment by insertion of a shunt (a tube that drains fluid). Payment will be made for placement of one shunt only


25%

Documented cerebral malaria confirmed by a physician with a parasitaemia count of 5% or more, or more than 250 000 parasites /μl


Documented and must be confirmed by a physician, with a parasitaemia count of 5% or more, or more than 250 000 parasites per microliter


25%

Infective meningitis as confirmed by a physician with supporting medical evidence

Infective meningitis (a bacterial infection of the membranes covering the brain and spinal cord)

Confirmed by a physician with supporting medical evidence


25%

Amyloidosis involving a nerve Infiltrative conditions (caused by the accumulation of an abnormal substance in the cells or tissues)

Amyloidosis involving a nerve (a build-up of abnormal protein in organs or tissues)


15%

1 2 3 4 5

* *

100%

Reference notes:


6

Appendix







Standard pay-out

Number of months

Initiallump-sum





Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Cancer3


8

Brain and nerves2

Introduction1



Cerebral oedema with confirmed intracranial pressure of >30mmHg

Cerebral oedema (accumulation of fluid in the brain)

The pressure inside the skull is confirmed as more than 30mmHg


15%

Brain abscess treated with surgery or intravenous antibiotic therapy

Brain abscess (collection of pus in the brain)

Has undergone treatment with either surgery or intravenous antibiotics (delivered directly into the blood stream)


15%

Glasgow coma scale of 9 to 11/15 for more than 48 hours. (Medically-induced comas are excluded)

Coma (being unconscious) Confirmed score of 9 to 11 out of 15 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)


15%

Pituitary macroadenomas that have undergone a surgical procedure or received radiation therapy

Pituitary macroadenomas (tumours that occur in the pituitary gland)

Tumours are larger than 10mm and have undergone a surgical or clinical procedure or received radiation therapy intended to remove or reduce the tumour


15%

Surgery to a major nerve Surgery to a major nerve Has undergone surgery An illness or injury you can recover from

10%

Stereotactic brain surgery Brain surgery Stereotactic brain surgery (using a three-dimensional coordinate system to target a specific area)


10%

Surgical repair of a neurotmesis Brain surgery Surgery to repair a neurotmesis (severe damage to a nerve)


10%

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 An illness or injury you can recover from

10%

Suturing of a major nerve to restore function to a hand or limb

Stitches to a major nerve to restore function to a hand, arm or leg

Has undergone suturing (stitches) An illness or injury you can recover from

10%

Status epilepticus which has undergone intubation

Status epilepticus (life-threatening, prolonged epileptic attack)

Has undergone intubation (where a tube is inserted into the wind pipe to make sure you can breathe)


5%

1 2 3 4 5 6

* *

* *

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum





Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Cancer3


8

Brain and nerves2

Introduction1



Confirmed hydrocephalus Hydrocephalus (the build-up of fluid inside the skull)


5%

1 2 3 4 5 6Reference notes:


Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



Brain cancer (WHO grade III or IV) Cancer of an organ or tissue Diagnosis of any brain cancer at WHO (World Health Organisation) grade III or IV


100% 80% 24 142,4%

Inoperable (non-removable) benign brain tumours WITH permanent neurological deficit as confirmed by a specialist neurosurgeon

Cancer 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 that’s permanent

100% 80% 24 142,4%

• Any cancer stage IV (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR

• Equivalent SCIDEP cancer definition - Level A

Cancer of an organ or tissue Diagnosis of any type of advanced cancer as Stage IV. This excludes:• Cancer in situ• All pre-malignant conditions• All skin cancers• Prostate cancer


100% 80% 18 126,8%

• Any stage III cancer (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR

• Equivalent SCIDEP cancer definition - Level B

Cancer of an organ or tissue Diagnosis of any cancer as Stage III.This excludes:• Cancer in situ• All pre-malignant conditions• All skin cancers• Prostate cancer


100% 80% 18 126,8%

• Acute myeloid leukaemia (AML) OR• Equivalent SCIDEP cancer definition -

Level A

Cancers of the blood, bone marrow or lymphatic tissue

Diagnosis of acute myeloid leukaemia or AML (a cancer of immature myeloid white blood cells)


100% 80% 18 126,8%

• Chronic myeloid leukaemia (CML) OR• Equivalent SCIDEP cancer definition -

Level A or Level C


Diagnosis of chronic myeloid leukaemia or CML (a cancer involving an over-production of mature myeloid white blood cells) confirmed by histological evidence from a biopsy


100% 80% 18 126,8%

• Acute lymphoblastic leukaemia (ALL) OR• Equivalent SCIDEP cancer definition -

Level A


Diagnosis of acute lymphoblastic leukaemia or ALL (a cancer of immature lymphoid cells)


100% 80% 18 126,8%

• Chronic Lymphocytic Leukaemia (Rai classification stage III / IV) OR



Diagnosis of Chronic Lymphocytic Leukaemia (a cancer of mature lymphoid cells) where the cancer is advanced and diagnosed at Rai stage III or IV


100% 80% 18 126,8%

• Multiple Myeloma (Stage III on Durie-Salmon scale) OR



Diagnosis of multiple myeloma (cancer of the plasma cells) as Stage III on the Durie-Salmon scale


100% 80% 18 126,8%

1 2 3 4 5 6 7Reference notes:


Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



Any cancer treated with bone marrow transplantation


Any cancer of the blood or bone marrow that has undergone a bone marrow transplant


100% 80% 18 126,8%

Severe 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) where the condition is categorised as severe based on the definition of the International Aplastic Anaemia study group


100% 80% 18 126,8%

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


100% 80% 18 126,8%

• Stage 4 - T4, N0, M0 any G prostate cancer OR

• Equivalent SCIDEP cancer definition - Level B

Prostate cancer Diagnosed as Stage 4 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


100% 80% 18 126,8%

• Stage 4 - Any T, N1 – 3, M0 any G prostate cancer OR


Prostate cancer Diagnosed as Stage 4 according to TMN (Tumour, lymph Node, Metastasis) staging, with spread to the lymph nodes and any Gleason grade of abnormality


100% 80% 18 126,8%

• Hodgkin’s or Non Hodgkin’s Lymphoma Ann Arbor stage III or IV OR

• Equivalent SCIDEP cancer definition - Level A or B


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


100% 80% 12 111,2%

Brain cancer (WHO Grade II) Cancer or pre-cancer of an organ or tissue

Diagnosis of brain cancer at WHO (World Health Organisation) grade II


50% 40% 24 71,2%

100% 80% 24 142.4%

• Multiple Myeloma (Stage I / II on Durie-Salmon scale) OR

• Equivalent SCIDEP cancer definition - Level C


Diagnosis of multiple myeloma (cancer of the plasma cells) as Stage I or II on the Durie-Salmon (DS) scale


50% 40% 18 63,4%

100% 80% 18 126.8%



Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Definition sets D(v5), E(v1)Additional expense needs 1 2 3 4 5 6

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


50% 40% 18 63,4%

100% 80% 18 126.8%

• Any stage II cancer (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR


Cancer or pre-cancer of an organ or tissue

Diagnosis of any cancer as Stage II. This excludes:• Cancer in situ• All pre-malignant conditions• All skin cancers• Prostate cancer


50%

100%

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 from a biopsy. This excludes non-melanomas.


50%

75%

Ductal carcinoma-in-situ of the breast Cancer 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 from a biopsy.


50%

75%

• Hodgkin’s or Non Hodgkin’s Lymphoma Ann Arbor stage II OR



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


50%

100%

7Reference notes:


Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



• Chronic lymphocytic leukaemia (Rai classification stage II) OR



Diagnosis of chronic lymphocytic leukaemia (a cancer of certain white blood cells),where the cancer is more advanced and diagnosed at Rai stage II


50%

100%

• Stage 3 - T3, N0, M0 any G prostate cancer OR


Prostate cancer Diagnosed as Stage 3 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


50%

100%

Any brain cancer (WHO grade I) Cancer or pre-cancer of an organ or tissue

Diagnosis of brain cancer at WHO (World Health Organisation) grade I


25% 20% 24 35,6%

75% 60% 24 106.8%

Surgically removed benign brain tumours that cause no permanent neurological deficit as confirmed by a neurosurgeon


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


25% 20% 18 31,7%

75% 60% 18% 95.1%

• Any stage I cancer (excluding cancer in situ, all pre-malignant conditions, all skin cancers and prostate cancer) OR

• Equivalent SCIDEP cancer definition - Level D

Cancer of an organ or tissue Diagnosis of any cancer as Stage I, except for prostate cancer and skin cancers other than melanomas. This excludes:• Cancer in situ• All pre-malignant conditions• All skin cancers• Prostate cancer


25%

100%

Skin cancer stage I Cancer 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 from a biopsy. This excludes non-melanomas.


25%

50%

7Reference notes:


Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



Lobular carcinoma-in-situ of the breast which has necessitated a mastectomy


Pre-cancer of the lobular type (milk-producing cells of the breast) that has undergone a mastectomy (surgical removal of the breast) This must be confirmed by a genetic test


25%

75%

Prophylactic mastectomy (medically sanctioned) for a family history of breast cancer, confirmed by genetic testing


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


25%

50%

• Hodgkin’s or Non Hodgkin’s Lymphoma Ann Arbor stage I OR



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


25%

100%

• Chronic lymphocytic leukaemia (Rai classification stage 0 or I) OR



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


25%

100%

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 definition of the International Aplastic Anaemia study group


25%

50%

7Reference notes:


Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



• T2, N0, M0, any Gleason prostate cancerOR• Equivalent SCIDEP cancer definition -

Level D

Prostate cancer Diagnosed as Stage 2 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


25%

100%

• T1a-c, N0, M0, Gleason ≥ 7 prostate cancer

OR• Equivalent SCIDEP cancer definition -

Level D

Prostate cancer Diagnosed as Stage 2 according to TMN(Tumour, lymph Node, Metastasis)staging, with no spread beyond theprostate and Gleason grade 7 or higherabnormality


25%

100%

• Hairy cell leukaemia with histological confirmation, OR


There is no requirement to undergo treatment


Diagnosis of hairy cell leukaemia, as confirmed by histological evidence.There is no requirement to undergo treatment


25%

100%

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


15%

Carcinoid syndrome Cancer of an organ or tissue Diagnosis of carcinoid syndrome (caused by hormones secreted by one or more carcinoid tumours)


15%

Myelodysplastic syndrome Cancers 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)


15%

Myelofibrosis Cancers of the blood, bone marrow or lymphatic tissue

Myelofibrosis (a condition in which bone marrow is replaced by fibrous tissue)


15%

Myeloproliferative disorders: Polycythaemia Vera, Essential thrombocytosis


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)


10%

7Reference notes:


Appendix

Cancer3







Standard pay-out

Number of months

Initiallump-sum


Brain and nerves2




Digestive system

4

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



Basal cell carcinoma (greater than 1.75cm) Cancer 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 1.75cm


5%

Squamous cell carcinoma (greater than 1.75cm)


Diagnosis of a squamous cell carcinoma (cancer of the squamous cells at the surface of the skin) larger than 1.75cm


5%

T1a, N0, M0, Gleason ≤ 4 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 4 or lessabnormality


5%

T1a, N0, M0, Gleason 5-6 prostate cancer Prostate cancer Diagnosed as Stage 2 according to TMN(Tumour, lymph Node, Metastasis)staging, with no spread beyond the prostate and Gleason grade 5 to 6abnormality


5%

T1b-c, N0, M0, Gleason 2-6 prostate cancer Prostate cancer Diagnosed as Stage 2 according to TMN(Tumour, lymph Node, Metastasis)staging, with no spread beyond the prostate and Gleason grade 2 to 6abnormality


5%

7Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Cancer3


Brain and nerves2



Digestive system

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



Polyarteritis Nodosa 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).


100% 80% 18 126,8%

Systemic Sclerosis Systemic sclerosis (an autoimmune disorder characterised by the fibrosis of the skin and internal organs)


100% 80% 18 126,8%

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

Systemic lupus erythematosis, (an autoimmune disorder where the body attacks its own tissues)

• 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)


100% 80% 18 126,8%

Sarcoidosis with documented involvement of any three of the following organ systems:Eyes, and/or, Infiltrative lung diseaseand/or, Nervous system (CNS), and/orCardiovascular involvement, and/orLiver involvement

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:• Confirmed infiltrative lung disease• Eyes• Central nervous system (CNS)• Heart and blood vessels• Liver


100% 80% 18 126,8%

1 2 3 4 5Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Cancer3


Brain and nerves2



Digestive system

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



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)


100% 80% 18 126,8%

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

Giant cell arteritis (disease characterised by inflammation in the walls of medium- and large-sized arteries)

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• Heart and blood vessels: angina, heart

attack, aortic arch syndrome, thoracic aortic aneurysm or aortic dissection


100% 80% 18 126,8%

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

Any recognised connective tissue condition (not explicitly listed elsewhere)

Confirmed by a rheumatologist, along with the documented systemic involvement of three or more organs (excluding the skin and joints)


100% 80% 18 126,8%

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


100% 80% 9 103,4%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Cancer3


Brain and nerves2



Digestive system

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



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:



Systemic lupus erythematosis (an autoimmune disorder where the body attacks its own tissues)

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)


75% 60% 18 95,1%

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


Documented involvement of any two of the following:• Confirmed Sarcoidosis of the lungs • Eyes• Central nervous system (CNS)• Heart and blood vessels• Liver


75% 60% 18 95,1%

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



Documented involvement of any two of the following:• Eyes: Ischaemic optic neuropathy or





75% 60% 18 95,1%

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.

Any recognised connective tissue condition (not explicitly listed elsewhere)

Confirmed by a rheumatologist, along with the documented systemic involvement of two or more organs (excluding the skin and joints)


75% 60% 18 95,1%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Cancer3


Brain and nerves2



Digestive system

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



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



Systemic lupus erythematosis (auto-immune disease, meaning the body attacks its own tissues)

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)


50% 40% 9 51,7%

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


Documented involvement of any one of the following:• Confirmed infiltrative lung disease • Eyes• Central nervous system• Heart and blood vessels• Liver


50% 40% 9 51,7%

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



Documented involvement of any one of the following:• Eyes: Ischaemic optic neuropathy or





50% 40% 9 51,7%

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 An illness or injury you can recover from

50%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Cancer3


Brain and nerves2



Digestive system

5

6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1



Rheumatoid arthritis treated with: Combination therapy of any of the following disease modifying anti-rheumatic drugs (DMARDs): Sulphasalazine, Methotrexate, Gold, Penicillamine, Hydroxychloroquine


Has undergone treatment with a combination of any of the following disease modifying anti-rheumatic drugs (DMARDs): Sulphasalazine, Methotrexate, Gold, Penicillamine or Hydroxychloroquine


25% 20% 9 25,8%

Rheumatoid arthritis treated with any tumour necrosis factor TNF alpha inhibitor or other biological therapies


Treatment using a tumour necrosis factor (TNF) alpha inhibitor, or any other biological therapy


25% 20% 9 25,8%

Rheumatoid arthritis treated with any one of the following chemotherapy agents: Azathioprine, Cyclophosphamide, Cyclosporin


Treatment using any of the following chemotherapy medications: Azathioprine, Cyclophosphamide or Cyclosporine


25% 20% 9 25,8%

Hypermobility syndrome Hypermobility syndrome (a condition in which the joints move easily beyond their normal range)


15%

Ehlers-Danlos syndrome Ehlers-Danlos syndrome (a group of inherited disorders caused by a lack of collagen or faulty collagen production)


15%

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)


10%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Bacteriologically confirmed meningococcal meningitis, as evidenced by a lumbar puncture, in a child younger than 18 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

Bacterial meningitis 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 18


100%

A benign brain tumour in a child younger than 18 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 18

Benign brain tumour 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 18


100%

The total and permanent loss of use, in a child younger than 18 years, of 2 or more limbs for a continuous period of at least 3 months

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 months. Cover applies only to children under the age of 18


100%

Any disorder that results in the irreversible failure of the heart, liver, bone marrow, lungs, pancreas or kidneys in a child younger than 18 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 18


100%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Any disease or disorder that results in end-stage liver failure in a child younger than 18 years. There must be objective evidence of jaundice, oesophageal varices and ascites

Chronic liver failure 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 18


100%

Confirmed diagnosis of cardiomyopathy in a child younger than 18 years, as evidenced by objective investigations. There must be functional impairment resulting in symptoms of heart failure at rest, confirmed by a cardiologist

Cardiomyopathy 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 18


100%

Any open-heart surgery in a child younger than 18 years to replace or repair a diseased heart valve or heart septum defect, or to reposition any of the major heart vessels

Open heart surgery 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 18


100%

Cerebral malaria in a child younger than 18 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


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 18


100%

A gunshot wound or any penetrating traumatic injury to the skull, chest or abdomen of a child younger than 18 years, resulting in surgical exploration of the skull, chest or abdomen, under general anaesthetic

Penetrating gunshot wound or stab wound to the skull, chest or abdomen

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 18


75%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


The permanent and total loss of hearing in both ears, without any possibility of correction, in a child younger than 18 years. The auditory threshold must be more than 90 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 90 decibels. Cover applies only to children under the age of 18


75%

A confirmed history of rheumatic fever in a child younger than 18 years, with the complications of heart disease, characterised by fibrosis of the heart valves. This must be confirmed by a cardiologist

Rheumatic fever with cardiac complications

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 18


75%

Any surgery in a child younger than 18 years to replace or repair a diseased heart valve by endoscopic procedures or minimally invasive procedures

Keyhole heart valve surgery 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 18


75%

Any disease in a child younger than 18 years that causes the permanent and irreversible failure of both kidneys resulting in the requirement of treatment by dialysis

Kidney failure (renal failure) 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.


75%

Hydrocephalus in a child younger than 18 years resulting in raised intracranial pressure as a result of which surgical shunt procedure is required

Hydrocephalus 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 from the brain). Cover applies only to children under the age of 18


75%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


A traumatic head injury in a child younger than 18 years that results in surgery in the form of a craniotomy, decompression holes to drain a brain bleeding, or open reduction of a depressed skull fracture

Traumatic head injury Injury to the head caused by force (trauma). The injury requires one of the following surgeries:• craniotomy (surgery to remove part of

the skull)• decompression holes (holes drilled in

the skull) to drain bleeding on the brain• open reduction of a depressed skull

fracture (surgery to expose bone fragments where the skull has been broken and the bone fragments are dented in, toward the brain). Cover applies only to children under the age of 18


75%

Admission of a child younger than 18 years into a registered intensive care unit with mechanical ventilation continuously for at least 48 hours

ICU admission with ventilation for at least 48 hours

An admission to ICU where the child is put on a ventilation machine for at least 48 hours because the child is unable to breathe on its own. Cover applies only to children under the age of 18


75%

The permanent, irreversible and total loss of the ability to speak in a child younger than 18 years, due to disease or injury, as established over a continuous period of 3 months. An appropriate medical consultant must confirm the diagnosis. Psychiatric causes are specifically excluded for this benefit

Loss of speech The complete and permanent loss of the ability to speak, because of an illness or injury, for a period of at least three months. An appropriate medical consultant must confirm the diagnosis. This excludes loss of speech because of any psychiatric cause. Cover applies only to children under the age of 18


75%

Any disease, or injury that results in the complete physical severance of one hand at the level of the wrist, in a child younger than 18 years

Amputation of one hand The complete amputation of one hand, at the wrist joint, because of any disease or injury. Cover applies only to children under the age of 18


75%

Any disease or injury that results in the complete physical severance of one foot at the level of the ankle joint. This condition applies only to children under the age of 18

Amputation of one foot The complete amputation of one foot, at the ankle joint, because of any disease or injury. Cover applies only to children under the age of 18


75%

Any disease or disorder that results in the complete physical severance of a thumb at the level of the metacarpo-phalangeal (MCP) joint, in a child younger than 18 years

Amputation of thumb The complete amputation of one thumb, at the knuckle (MCP joint), because of any disease or injury. Cover applies only to children under the age of 18


75%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Any fractures in a child younger than 18 years that affect the frontal bones, orbital bones, zygoma, and/or maxilla resulting in maxillofacial reconstructive surgery

Fracture of the facial bones requiring reconstructive surgery

A fracture of the bones of the face — the frontal bone (the front part of the skull and upper part of the eye sockets), the orbital bones (bones of the eye cavity), zygoma (cheek bone) and/or maxilla (upper jaw bone) — that requires maxillofacial reconstructive surgery. Cover applies only to children under the age of 18


75%

Any injury in a child younger than 18 years that results in more than one fracture of the pelvic framework, resulting in instability, and requiring surgical intervention

Unstable pelvis fracture Any injury that causes the child to fracture more than one of its pelvic bones. The fractures must cause instability and require surgery. Cover applies only to children under the age of 18


75%

Any injury in a child younger than 18 years that results in multiple rib fractures, requiring artificial ventilation in an intensive care unit

Multiple rib fractures with unstable ribcage

An injury that results in an ICU admission for multiple broken ribs, and where the child requires artificial ventilation (machines that help you breathe). Cover applies only to children under the age of 18


75%

Any injury in a child younger than 18 years that results in objective radiological evidence of a fracture-dislocation of the spine, or involving dislocation of the facet joints, with or without neurological deficit

Fracture-dislocation of the spine

Any injury that causes the discs of the spine to fracture and dislocate, or involves dislocation of the spine's facet joints. This may or may not cause nerve damage. Cover applies only to children under the age of 18


75%

Perthes disease of the hips requiring traction, splinting or surgery to correct defect, in a child younger than 18 years

Perthes disease (a disease of the hip joint in children)

Diagnosis of Perthes disease where the child requires traction, splinting or surgery to the hip. Cover applies only to children under the age of 18


75%

Rupture of the liver or spleen, or injury to the kidney, as a result of any blunt injury to the abdomen, necessitating emergency laparotomy and surgical repair, splenectomy or nephrectomy, in a child younger than 18 years

Abdominal injury with liver rupture, spleen rupture or kidney damage

An injury of the abdomen that results in a ruptured liver or spleen or damaged kidney. The injury must require abdominal surgery to repair the damage, or to remove the spleen or the damaged kidney. Cover applies only to children under the age of 18


75%

Surgical correction of congenital heart disease or defect

Congenital heart disease The child has undergone an operation to repair the heart condition they were born with

An injury or illness that's permanent

50%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Acute lymphoblastic leukaemia (ALL) Cancers of the blood, bone marrow or lymphatic tissue

The child has been diagnosed with acute lymphoblastic leukaemia or ALL (a cancer of immature lymphoid cells)

An injury or illness that's permanent

50%

Congenital anomaly repair Congenital anomaly The child has undergone an operation or other medical procedure to repair a birth defect

An injury or illness you can recover from

15%

Rheumatic fever with cardiac complications Rheumatic fever (a serious inflammatory disease caused by a bacterial infection) that:

Has led to cardiac complications (heart problems)


15%

Type I diabetes mellitus Type I diabetes mellitus (pancreatic dysfunction or failure)

Confirmed diagnosis of diabetes that requires ongoing insulin treatment


15%

Juvenile rheumatoid arthritis, septic arthritis, osteomyelitis

Childhood bone disorders Confirmed diagnosis of one of the following:• juvenile rheumatoid arthritis

(an inflammatory disease of the joints that affects children)

• septic arthritis (arthritis caused by an infection of the joints)

• osteomyelitis (long-term bone infection)


5%

Hirschsprung’s disease Hirschsprung’s disease (a congenital condition where the large intestine becomes blocked because of poor muscle function, leading to severe constipation)

Confirmed diagnosis An injury or illness you can recover from

5%

Surfactant therapy Surfactant therapy (a treatment for respiratory distress in babies where a fatty liquid is fed into the lungs through a tube inserted into the child’s windpipe)

The child has undergone life-saving surfactant therapy to suppport their breathing


5%



Appendix







Standard pay-out

Number of months

Initiallump-sum




Cancer3

Brain and nerves2



Digestive system6

7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Disorders of amino acid metabolism Metabolic disorders The child has been diagnosed with a disorder of their amino acid metabolism, which affects their ability to convert food to energy because of a problem with the enzymes that help to digest food.


5%

Cleft palate or cleft lip repair Cleft palate or cleft lip The child has undergone an operation to repair a cleft palate or cleft lip.


5%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system

5

6



Cancer3

Brain and nerves2



7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Complete hepatectomy/liver transplant Surgery to the digestive system

Complete hepatectomy (surgical removal of the liver), followed by a liver transplant


100% 80% 18 126,8%

Complete pancreatectomy/pancreas transplant

Surgery to the digestive system

Complete pancreatectomy (surgical removal of the pancreas)


100% 80% 18 126,8%

Primary biliary cirrhosis confirmed on a liver biopsy by a gastroenterologist

Primary biliary cirrhosis (a chronic progressive auto-immune disease that destroys the bile ducts)

Confirmed by a gastroenterologist through a liver biopsy


100% 80% 18 126,8%

Cirrhosis of the liver confirmed on liver biopsy by a gastroenterologist

Cirrhosis (permanent scarring) of the liver



100% 80% 18 126,8%

Fulminant hepatic necrosis confirmed on liver biopsy by a gastroenterologist

Fulminant hepatic necrosis (widespread or severe sudden death of liver tissue cells)



100% 80% 18 126,8%

End-stage liver failure confirmed on liver biopsy by a gastroenterologist

Organ dysfunction End-stage liver failure that’s been confirmed by a gastroenterologist through a liver biopsy


100% 80% 18 126,8%

Permanent ileostomy or colonostomy Organ dysfunction Permanent ileostomy or colonostomy (surgeries where end of the small intestine or large intestine is brought out through an opening in the abdominal wall)


100%

Sclerosing cholangitis confirmed on liver biopsy by a gastroenterologist

Sclerosing cholangitis (inflammation of the biliary tract)



75% 60% 18 95,1%

Chronic persistent hepatitis (Knodell score of at least 13/22) confirmed by a gastroenterologist

Chronic persistent hepatitis Confirmed by a gastroenterologist with a Knodell score of at least 13/22. (Knodell score is a classification system used to define the extent of liver inflammation and damage)


50% 40% 18 63,4%

Chronic pancreatitis with documented malabsorption and diabetes confirmed by a gastroenterologist

Chronic pancreatitis (inflammation of the pancreas)

Has resulted in documented malabsorption and diabetes, as confirmed by a gastroenterologist


50% 40% 18 63,4%

1 2 3

* *

* *

* *

* *

* *

* *

* *

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system

5

6



Cancer3

Brain and nerves2



7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Documented portal hypertension of more than 15mmHg pressure in the portal vein and the presence of oesophageal varices, ascites or splenomegaly confirmed by a gastroenterologist

Portal hypertension (high blood pressure in the portal venous system)

Documented high blood pressure of more than 15mmHg in the hepatic portal vein (which carries blood to the liver). This must be documented and confirmed by a gastroenterologist and accompanied by oesophageal varices (dilated veins in the lower part of the food-pipe or in the upper section of the stomach), ascites (free fluid in the abdominal cavity) or splenomegaly (enlarged spleen)


50% 40% 18 63,4%

Confirmed diagnosis ulcerative colitis Ulcerative colitis (a chronic inflammatory bowel disease that usually affects the lining of the colon and rectum, and is characterised by abdominal pain diarrhoea, fatigue and weight loss)


25% 20% 18 31,7%

Confirmed diagnosis of Crohn’s disease Crohn’s disease (a chronic inflammatory bowel disease that affects the entire digestive tract characterised by abdominal pains, diarrhoea, fatigue and weight loss)


25% 20% 18 31,7%

Partial hepatectomy Surgery to the digestive system

Partial hepatectomy (surgical removal of part of the liver)


25%

Partial pancreatectomy Surgery to the digestive system

Partial pancreatectomy (surgical removal of part of the pancreas)


25%

Confirmed amyloidosis of the liver, spleen or tongue

Infiltrative conditions of the digestive system (caused by the accumulation of an abnormal substance in the cells or tissues)

Confirmed diagnosis of amyloidosis in the liver, spleen or tongue (a build-up of abnormal protein in organs or tissues)


15%

1 2 3

* *

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system

5

6



Cancer3

Brain and nerves2



7

HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14


8

Introduction1


Colectomy, ileocolectomy or total colectomy due to any cause

Surgery to the digestive system

Colectomy or ileocolectomy (surgical removal of part of the large or small intestine)


15%

Loss of more than 1/3 of the tongue Disorders of the digestive system

Loss of more than a third of the tongue An illness or injury you can recover from

15%

Surgical repair of a tracheal oesophageal fistula

Tracheal-oesophageal fistula (an abnormal connection between the wind-pipe and the food-pipe)

Has undergone surgical repair An illness or injury you can recover from

10%

Chronic rectal fistula Chronic rectal fistula (an abnormal connection between the anal canal and the surface of the skin)


10%

Surgical drainage of a pancreatic cyst Pancreatic cyst (an abnormal pocket of fluid in the pancreas)

Has undergone surgical drainage An illness or injury you can recover from

10%

Surgical intervention for generalised peritonitis (excluding appendectomy)

Generalised peritonitis (inflammation of the peritoneum, the lining of the abdomen that covers most abdominal organs)

Has undergone surgical treatment, but excluding removal of the appendix


5%

1 2 3

* *

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


Lung and/or heart disorder(s) which has resulted in a heart/heart and lung transplantation

Disorder of the lungs or heart, or of both

Has undergone a lung transplant, heart transplant or a lung-and-heart transplant


100% 80% 24 142,4%

Cardiomyopathy confirmed by cardiologist with a permanent ejection fraction of less than 40%

Cardiomyopathy (disease of the heart muscle)

Confirmed by a cardiologist with a finding of a permanent ejection fraction (EF) of less than 40%. (Ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction)


100% 80% 18 126,8%

Cor pulmonale confirmed by a cardiologist Cor pulmonale (abnormal enlargement or failure of the right lower chamber of the heart, caused by disease of the lungs or of the lung’s blood vessels)

Confirmed by a cardiologist An illness or injury that’s permanent

100% 80% 18 126,8%

Open surgical repair of aneurysm or dissection of the aorta

Vascular surgery (blood vessel surgery)

Open surgery that has been done to repair an aneurysm in the aorta (an abnormal ballooning or widening in the wall of the body’s largest artery) or dissection of the aorta (tear in the wall of the aorta)


100% 80% 18 126,8%

Gangrene resulting from peripheral arterial disease

Peripheral arterial disease (a problem with the blood vessels supplying the upper and lower limbs)

Blockage of blood flow has resulted in gangrene (tissue death)


100% 80% 18 126,8%

Loss of limb resulting from peripheral arterial disease


Complete blockage of blood flow to an upper or lower limb has resulted in the complete surgical removal (amputation) of the limb


100% 80% 18 126,8%

• Heart attack confirmed by specialist cardiologist with a post event finding of EF ≤ 40% measured not less than 7 days post admission OR

• Equivalent SCIDEP heart attack definition - Level A


Heart attack Confirmed by a specialist cardiologist with a finding of an ejection fraction of less than 40% at least seven days after admission. (Ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction)


100%

* *

Reference notes:


1 2 3 4 5 6 7

Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


The definitive diagnosis of a right ventricle myocardial infarction, confirmed by angiogram or echocardiogram findings. The insured must have undergone any two of the following:

• Intravenous anti-arrhythmic therapy or inotropic support treated in ICU for at least 48 hours

• Arrhythmia that has undergone cardioversion

• External defibrillation

As per equivalent SCIDEP heart attackdefinition - Level C

Heart attack involving the right ventricle (heart chamber responsible for pumping oxygen-poor blood to the lungs)

Confirmed by a cardiologist based on an angiogram or echocardiogram and treated using at least two of the following:

• 48 hours of treatment in an intensive care unit using medication to correct an abnormal heart rhythm or medication to support the contraction of the heart

• abnormal heart rhythm corrected using an electronic device (cardioverter)

• external defibrillation (emergency treatment to restore a normal heartbeat using an electronic device called an external defibrillator)

Classified as moderate according to the SCIDEP definition (standardised definitions adopted by the Association for Savings and Investments South Africa – ASISA – an industry body for life insurance companies)


100%

• Coronary artery bypass graft (CABG) of 3 or more coronary vessels OR

• Equivalent SCIDEP CABG definition - Level A

Disorder of an artery supplying blood to the heart muscle

Treated with a coronary artery bypass graft or CABG of three or more coronary arteries (CABG is a surgical procedure in which a graft made from another blood vessel is inserted to bypass a problem in one of the arteries to the heart)


100%

Heart valve replacement performed through open heart surgery

Disorder of a heart valve Has undergone surgical heart valve replacement, through open-heart surgery (by division of the breast bone)


100%

Simultaneous bypass grafts/endarterectomies for bilateral carotid artery stenosis (narrowing)

Bilateral carotid artery stenosis

Has undergone bypass graft (surgery where a graft made from another blood vessel is inserted to bypass a problem in both neck arteries) or endarterectomy (surgery to remove or bypass the blockage in both neck arteries)


100%

Cardiomyopathy confirmed by cardiologist with a permanent ejection fraction of less than 50%

Cardiomyopathy (disease of the heart muscle)

Confirmed by a cardiologist with a finding of a permanent ejection fraction (EF) of less than 50%. (Ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction)


75% 60% 18 95,1%

* *

Reference notes:


1 2 3 4 5 6 7

Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


Ulceration or rest pain resulting from confirmed peripheral arterial disease with no palpable pulses and Doppler readings of ABI ≤ 0.5


Has resulted in ulceration (loss of skin) or rest pain (pain when sitting or lying down) in a limb, confirmed on examination by no palpable pulses (no pulse felt) and a Doppler reading with an Ankle Brachial Pressure Index (ABPI) reading of 0.5 or less. (APBI is a test that measures the difference in blood pressure between the arteries of your arm and ankle)


75% 60% 18 95,1%

• Heart attack confirmed by a specialist cardiologist with a post event finding of EF < 50% measured not less than 7 days post admission

OR • Equivalent SCIDEP heart attack

definition - Level A or B

Heart attack Confirmed by a specialist cardiologist with a finding of an ejection fraction (EF) of less than 50% measured at least seven days after admission. (Ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction)


75%


100%

The definitive diagnosis of a right ventricle myocardial infarction, confirmed by angiogram or echocardiogram findings. The insured must have undergone any one of the following:

• Intravenous anti-arrhythmic therapy or inotropic support treated in ICU for at least 48 hours

• Arrhythmia that has undergone cardioversion

• External defibrillation

As per equivalent SCIDEP heart attackdefinition - Level C

Heart attack involving the right ventricle (heart chamber responsible for pumping oxygen-poor blood to the lungs)

Confirmed by a cardiologist based on an angiogram or echocardiogram and treated using at least one of the following:

• 48 hours of treatment in an intensive care unit using medication to correct an abnormal heart rhythm or medication to support the contraction of the heart

• abnormal heart rhythm corrected using an electronic device (cardioverter)

• external defibrillation (emergency treatment to restore a normal heartbeat using an electronic device called an external defibrillator)

Confirmed by a cardiologist and classified as moderate according to the SCIDEP definition (standardised definitions adopted by the Association for Savings and Investments South Africa – ASISA – an industry body for life insurance companies)


75%

100%

Reference notes:


1 2 3 4 5 6 7

Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


• Coronary artery bypass graft (CABG) of 2 coronary vessels

OR• Equivalent SCIDEP CABG definition -

Level B


Treated with a coronary artery bypass graft or CABG of two coronary arteries. (CABG is a surgical procedure in which a graft made from another blood vessel is inserted to bypass a problem in one of the arteries to the heart)


75%

100%

Bypass graft or endarterectomy for unilateral carotid artery stenosis (narrowing)

Unilateral carotid stenosis (narrowing of one carotid artery, located in the neck)

Has undergone bypass graft (surgery where a graft made from another blood vessel is inserted to bypass a problem in a neck artery) or endarterectomy (surgery to remove or bypass a blockage in a neck artery)


75%

Any pericardial disease treated with pericardiectomy

Pericardial disease (disease of the pericardial sac that surrounds the heart)

Has undergone the surgical removal of the pericardial sac surrounding the heart


75%

• Heart attack of moderate severity confirmed by cardiologist

• As per equivalent SCIDEP heart attack definition - Level C

Moderate heart attack Confirmed by a cardiologist and classified as moderate according to the SCIDEP definition (standardised definitions adopted by the Association for Savings and Investments South Africa - ASISA - an industry body for life insurance companies)


50%


100%

• Coronary artery bypass graft (CABG) of 1 coronary vessel OR

• Equivalent SCIDEP CABG definition - Level C or D


Has undergone a coronary artery bypass graft or CABG of one coronary artery. (CABG is a surgical procedure in which a graft made from another blood vessel is inserted to bypass a problem in one of the arteries to the heart)


50%

100%

Structural abnormality in the heart which has undergone open heart surgical repair

Structural abnormality of the heart

Has undergone repair with open-heart surgery (through division of the breast bone)


50%

Aorto-iliac aneurysm surgical repair Aorta-iliac aneurysm (abnormal ballooning or widening of the aorta-iliac artery, which is located in the pelvic area)


50%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


Insertion of Implantable Cardioverter Defibrillator (ICD) for abnormal heart rhythm

Arrhythmia (disorder of heart rhythm)

Has undergone insertion of an Implantable Cardioverter Defibrillator or ICD (a surgically implanted device that regulates heartbeat)


50%

• Heart attack of mild severity confirmed by a specialist cardiologist

• As per equivalent SCIDEP heart attack definition - Level D

A mild heart attack Confirmed by a cardiologist and classified as mild according to the SCIDEP definition (standardised definitions adopted by the Association for Savings and Investments South Africa - ASISA - an industry body for life insurance companies)


25%


100%

Percutaneous Transluminal Coronary Angioplasty (PTCA) with or without stenting of 2 or more coronary vessels


Treated with a procedure to open up a blocked artery to the heart (called Percutaneous Transluminal Coronary Angioplasty, or PTCA), with or without a stent or tube placed in two or more heart vessel


25%

Valvuloplasty or valve repair including valvotomy performed through endoscopic or keyhole surgery

Disorder of a heart valve Has undergone heart valve repair surgery, including valvuloplasty or valvotomy performed with endovascular surgery (surgery via a blood vessel) or with scopes through a tiny keyhole incision


25%

Ileofemoral aneurysm requiring surgical repair

Ileofemoral artery aneurysm (abnormal ballooning or widening of the wall of the ileofemoral artery, which is located in the hip area)

Has undergone surgery An illness or injury you can recover from

25%

Bypass graft to correct a damaged or diseased peripheral artery

Vascular surgery (blood vessel surgery)

Has undergone a peripheral artery bypass graft (surgery where a graft made from synthetic material or from another blood vessel is inserted to bypass a problem in a peripheral artery)


25%

Reference notes:


1 2 3 4 5 6 7

Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


Unilateral carotid artery stenosis which has undergone stent insertion

Unilateral carotid stenosis (narrowing of one carotid artery, located in the neck

Has undergone insertion of a stent or tube


25%

Insertion of a pacemaker (one event only) Arrhythmia (disorder of heart rhythm)

Has undergone insertion of a pacemaker to restore a normal heart rhythm. NB: You can claim for one event only.


25%

Pathway ablation for the treatment of an arrhythmia


Has undergone a pathway ablation (a procedure that corrects an abnormal heart rhythm by cauterising an abnormal heart conduction pathway)


25%

Pulmonary thromboendarterectomy Open heart surgery to remove blood clots from the artery that carries blood to the lungs

Has undergone open-heart surgery (through division of the breast bone)


25%

Diagnosis of acute rheumatic fever with a confirmed major Jones criteria carditis

Acute rheumatic fever (a disease that causes inflammation of the heart)

Has been clinically confirmed with a carditis (inflammation of the heart) which meets the Major Jones clinical criteria


15%

Confirmed endocarditis and/or pericarditis with at least 5 days ICU stay

Endocarditis (inflammation of the lining of the heart chambers and valves), or pericarditis (inflammation of the pericardial sac that surrounds the heart)

Has undergone at least five days’ treatment in an intensive care unit (ICU)


15%

Confirmed amyloidosis of the heart Amyloidosis of the heart (a build-up of abnormal protein in organs or tissues)

Confirmed by a cardiologist An illness or injury you can recover from

15%

Intravenous anti-arrhythmic therapy or inotropic support for at least 5 days ICU stay


Has undergone at least five days of treatment in an intensive care unit using medication to correct an abnormal heart rhythm or medication to support the contraction of the heart


15%

Percutaneous Transluminal Coronary Angioplasty (PTCA) with or without stenting of 1 coronary vessel


Has undergone a procedure to open up the blocked artery (called Percutaneous Transluminal Coronary Angioplasty, or PTCA), with or without a tube placed in one of the heart vessels


10%

Confirmed arteritis which has necessitated a hospital stay of at least 7 days

Arteritis (inflammation of the walls of arteries)

Has resulted in at least seven consecutive days’ admission to hospital


10%

* *

Reference notes:


1 2 3 4 5 6 7

Appendix







Standard pay-out

Number of months

Initiallump-sum


Digestive system6




Cancer3

Brain and nerves2



HIV/AIDS

Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

8

Introduction1


Structural abnormality in the heart which has undergone endovascular or keyhole surgical repair

Structural abnormality of the heart

Has been repaired with endovascular surgery (surgery via a blood vessel) or keyhole surgery (using scopes through a tiny keyhole incision or cut)


10%

Pericarditis confirmed by a cardiologist Pericarditis (inflammation of the pericardial sac that surrounds the heart)

Confirmed by a cardiologist An illness or injury you can recover from

5%

External defibrillation Arrhythmia (disorder of heart rhythm)

Has undergone external defibrillation (emergency treatment to restore a normal heartbeat using an electronic device called an external defibrillator)


5%

Arrhythmia that has undergone cardioversion


Corrected using an electronic device (cardioverter)


5%

Malignant hypertension confirmed by a specialist which has necessitated hospital admission for >24 hours

Malignant hypertension (severe and damaging high blood pressure)

Confirmed by a specialist and has resulted in a hospital admission of more than one full day


5%

Radiologically confirmed occlusion of any direct branch of the aorta

Vascular occlusion (blockage) of any direct branch of the aorta (the largest artery in the body)

Confirmed by a CAT scan An illness or injury you can recover from

5%

Intravenous anti-arrhythmic therapy or inotropic support treated in ICU for at least 48 hours


Has undergone two days of treatment in an intensive care unit (ICU) using anti-arrhythmic therapy (medication to correct an abnormal heart rhythm) or inotropic support (medication to support the contraction of the heart)


5%

* *

* *

* *

Reference notes:


1 2 3 4 5 6 7

Appendix







Standard pay-out

Number of months

Initiallump-sum


7

HIV/AIDS


8

Digestive system6



Cancer3

Brain and nerves2



Hormones


Lungs and breathing


9

10

11

12

13 Sensory system

Trauma14

Introduction1


Diagnosis of advanced AIDS¹ Advanced AIDS¹ Clinically confirmed diagnosis An illness or injury that’s permanent

100% 80% 18 126,8%

Accidental contraction of HIV infection2 Accidental HIV infection2 Clinically confirmed diagnosis An illness or injury that’s permanent

100%

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


HIV/AIDS

Hormones9

8


Digestive system6



Cancer3

Brain and nerves2




Lungs and breathing


10

11

12

13 Sensory system

Trauma14

Introduction1


Acute adrenal crisis Acute adrenal crisis (a life-threatening condition caused by the lack of corticosteroid hormones)

Diagnosis has been clinically confirmed An illness or injury you can recover from

15%

Diabetes insipidus Diabetes insipidus (a condition that affects the body’s ability to retain water)


15%

Sheehan’s syndrome Sheehan’s syndrome (tissue death with the resultant loss of pituitary gland function, caused by blood loss during childbirth)


15%

Thyrotoxic crisis Thyrotoxic crisis (a medical emergency caused by excessive thyroid hormones in the bloodstream)


15%

Type I or II diabetes requiring insulin treatment - insulin therapy must have been for minimum period of 6 months

Type I or II diabetes (pancreatic dysfunction or failure)

Has undergone insulin treatment for at least six months


10%

Addison’s disease Addison’s disease (failure of the adrenal glands to produce enough cortisol and aldosterone)


10%

Conn’s syndrome Conn’s syndrome (a condition in which the adrenal glands release too much aldosterone, causing high blood pressure, low blood potassium levels and salt retention)


10%

Cushing’s syndrome Cushing’s syndrome (a condition caused by high levels of cortisol)


10%

Diabetic coma (one event only) A diabetic coma (a state of deep unconsciousness caused by extremely high or low blood sugar levels)

Diagnosis has been clinically confirmed. Can claim for one event only.


10%

1 2Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


HIV/AIDS

Hormones9

8


Digestive system6



Cancer3

Brain and nerves2




Lungs and breathing


10

11

12

13 Sensory system

Trauma14

Introduction1


Endocrine tumours that have undergone surgical excision

An endocrine tumour (tumour of a hormone-secreting gland)

Has undergone surgical removal An illness or injury you can recover from

10%

Glycogen storage disease Glycogen storage disease (an inherited disorder that affects the body’s ability to use and store glycogen)


10%

Hypophysectomy Hypophysectomy (surgical removal of the pituitary gland)


10%

Phaeochromocytoma Phaeochromocytoma (a catecholamine-secreting tumour that most often arises in the adrenal glands, but can also be found elsewhere)


10%

Acromegaly Acromegaly (a condition caused by too much growth hormone production)


5%

Adrenalectomy Adrenalectomy (the surgical removal of an adrenal gland)


5%

Insulinoma Insulinoma (a tumour in the pancreas that produces too much insulin)


5%

Parathyroid tetany Parathyroid tetany (muscular spasms and tremors, caused by low levels of parathyroid hormone)


5%

Simmond’s disease Simmond’s disease (decreased functioning of the pituitary gland, not related to pregnancy)


5%

1 2Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Hormones


9

10

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Lungs and breathing


11

12

13 Sensory system

Trauma14

Introduction1


End stage renal failure with on-going haemodialysis and a GFR of < 15ml/min/1.73m2 as confirmed by a nephrologist

End-stage kidney failure Confirmed end-stage kidney failure with on-going haemodialysis (procedure using a special machine to remove the body’s waste products from the blood stream), and a glomerular filtration rate (GFR) of less than 15ml/min/1.73m2. This must be confirmed by a nephrologist.


100% 80% 24 142,4%

On-going peritoneal dialysis as confirmed by a nephrologist

Kidney failure Is receiving on-going peritoneal dialysis (procedure that uses a machine or a tube within the abdominal cavity to remove the body’s waste products). This must be confirmed by a nephrologist.


100% 80% 24 142,4%

Kidney transplant Surgery to the urogenital tract (the urinary tract and reproductive organs)

Has undergone a kidney transplant An illness or injury that’s permanent

100% 80% 18 126,8%

Polycystic kidney disease confirmed by a nephrologist with the confirmatory investigations and imaging

Polycystic kidney disease (an inherited disorder that causes cysts to form in the kidneys)

Confirmed by a nephrologist, along with the supporting investigations and scans


50% 40% 18 63,4%

More than 5 haemodialysis treatments for acute kidney disease

Acute kidney disease Has undergone more than five haemodialysis treatments (procedure that uses a special machine to remove the body’s waste products from the blood stream)


50% 40% 9 51,7%

Renal cortical necrosis confirmed by a nephrologist or urologist with the confirmatory investigations and imaging

Renal cortical necrosis (tissue death in the outer part of the kidney)

Confirmed by a nephrologist or a urologist, along with the supporting investigations and scans


50% 40% 9 51,7%

Total nephrectomy (kidney donation and analgesic abuse nephropathy excluded)

Surgery to the urogenital tract (the urinary tract and reproductive organs)

Total nephrectomy (surgical removal of a kidney), excluding voluntary kidney donation or kidney damage caused by the abuse of analgesics (painkillers)


50%

Total amputation of the penis (excluding gender reassignment surgery)


Surgical removal (amputation) of the entire penis, excluding gender reassignment (sex change) surgery


50%

Bilateral orchidectomy (excluding gender reassignment surgery)


Bilateral orchidectomy (surgical removal of both testicles), excluding gender reassignment (sex change) surgery


50%

1 2 3Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Hormones


9

10

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Lungs and breathing


11

12

13 Sensory system

Trauma14

Introduction1


Complete cystectomy Surgery to the urogenital tract (the urinary tract and reproductive organs)

Complete cystectomy (surgical removal of the bladder)


50%

Partial nephrectomy Surgery to the urogenital tract (the urinary tract and reproductive organs)

Partial nephrectomy (surgical removal of part of a kidney)


25%

Partial amputation of the penis (excluding circumcision)


Surgical removal (amputation) of part of the penis, excluding circumcision


25%

Partial cystectomy Surgery to the urogenital tract (the urinary tract and reproductive organs)

Partial cystectomy (surgical removal of part of the bladder)


25%

Chronic bilateral pyelonephritis confirmed by a nephrologist or urologist with the confirmatory investigations and imaging

Chronic bilateral pyelonephritis (recurrent kidney infections)



25%

Documented renal vein thrombosis confirmed by a nephrologist or urologist with the confirmatory investigations and imaging

Renal vein thrombosis (a blood clot in the vein that drains blood from the kidney)



25%

Amyloidosis of kidney Infiltrative disease of the kidney

Confirmed diagnosis of amyloidosis of the kidney (a build-up of abnormal protein in organs or tissues)


15%

Unilateral orchidectomy Surgery to the urogenital tract (the urinary tract and reproductive organs)

Unilateral orchidectomy (surgical removal of one testicle)


15%

Confirmed diagnosis of chronic tubulointerstitial disease

Chronic tubulointerstitial disease (swelling of the area surrounding the kidney tubules)


10%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Hormones


9

10

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Lungs and breathing


11

12

13 Sensory system

Trauma14

Introduction1


Confirmed diagnosis of urethral fistula Urethral fistula (an abnormal connection between the urinary canal and the rectum or vagina)


10%

Confirmed diagnosis of nephrotic syndrome Nephrotic syndrome (a group of symptoms that include protein in the urine, low blood protein levels, high cholesterol levels, high triglyceride levels and swelling)


10%

Confirmed diagnosis of vesico or recto-vaginal fistula

Vesico- or recto-vaginal fistula (an abnormal connection between the bladder and vagina or vagina and rectum)


10%

Renal abscess which has undergone surgical drainage or intravenous antibiotic treatment

Renal abscess (a collection of pus in the kidney tissue)

Has undergone surgical drainage or treatment with intravenous antibiotics (delivered directly into the blood stream)


5%



Appendix







Standard pay-out

Number of months

Initiallump-sum



Lungs and breathing

10

11

Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2




13 Sensory system

Trauma14

Introduction1


Lung transplant Disorders of the lung Has undergone lung transplant An illness or injury that’s permanent

100% 80% 24 142,4%

Irreversible pulmonary hypertension confirmed by a cardiologist or pulmonologist

Permanent pulmonary hypertension (high blood pressure in the arteries of the lungs)

Confirmed by a cardiologist or a pulmonologist


100% 80% 18 126.8%

Irreversible end stage lung disease with FEV1 of less than 40% (obstructive) and FVC of less than 40% predicted (restrictive) confirmed by a pulmonologist

End-stage lung disease Permanent end-stage lung disease, with an FEV1 (Forced Expiratory Volume) score of less than 40% – implying obstructive lung disease – and an FVC (Forced Vital Capacity) score of less than 40% of the predicted result, implying restrictive lung disease. These results must be confirmed by a pulmonologist


100% 80% 18 126,8%

Pulmonary venous occlusive disease Pulmonary venous occlusive disease (blockage or narrowing of the pulmonary veins caused by fibrous tissue, leading to clinical signs of high blood pressure in the lungs)


75% 60% 18 95,1%

Removal of two or more lobes of the lung Lobectomy Removal of two or more lobes of the lung An illness or injury that’s permanent

75% 60% 18 95,1%

Irreversible end stage lung disease with FEV1 of less than 50% (obstructive lung disease) and FVC of less than 50% predicted (restrictive lung disease) confirmed by a pulmonologist

End-stage lung disease Permanent end stage lung disease has resulted in an FEV1 (Forced Expiratory Volume) score of less than 50% (implying obstructive lung disease) and an FVC (Forced Vital Capacity) score of less than 50% of the predicted result, implying restrictive lung disease. These results must be confirmed by a pulmonologist


50% 40% 18 63,4%

Veno-caval filter insertion due to recurrent pulmonary emboli

Pulmonary emboli (blood clots)

Has undergone insertion of a veno-caval filter into the chest to prevent recurrent emboli (blood clots) from reaching the lungs


50%

Removal of one lobe of a lung (lobectomy) Lobectomy Removal of one lobe of a lung An illness or injury you can recover from

25%



Appendix







Standard pay-out

Number of months

Initiallump-sum



Lungs and breathing

10

11

Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2




13 Sensory system

Trauma14

Introduction1


Drainage of an empyema Empyema (a collection of pus between the lung and the chest wall)

Has undergone surgical drainage An illness or injury you can recover from

25%

Bronchopleural fistula confirmed by a pulmonologist with the confirmatory investigations and imaging

Bronchopleural fistula (an abnormal connection between the space around the lungs and the inner airways)

Confirmed by a pulmonologist, along with the supporting investigations and scans


25%

Pulmonary embolus confirmed by a pulmonologist with the confirmatory investigations and imaging

Pulmonary embolus (blockage of the main artery of the lung or one of its branches)



25%

Lung abscess confirmed by a pulmonologist with the confirmatory investigations and imaging

Lung abscess (a collection of pus in the lung)



25%

Pneumoconiosis Pneumoconiosis (a lung disease caused by the accumulation of dust in the lungs)


15%

Bronchiectasis Bronchiectasis (abnormal thickening of the airway walls and stretching of the central and medium-sized airways caused by repeated cycles of airway infection and inflammation)


15%

Any chronic lung disease which has undergone decortication

Any chronic lung disease Has undergone decortication (the surgical removal of the surface layer) of the lung


15%

Pleural effusion surgically treated with an intercostal drain

Pleural effusion (a build-up of fluid between the layers that line the lungs and chest cavity)

Has undergone surgical treatment with an intercostal drain (a tube inserted to drain the fluid)


10%

Near drowning requiring post resuscitation ventilation in an ICU for a minimum of 24 hours

Near-drowning Has resulted in at least one day’s admission to an intensive care unit ICU to restore breathing


10%

Confirmed diagnosis of fibrosing alveolitis Fibrosing alveolitis (inflammation and thickening of the air sacs in the lungs)


5%

1 2 3

* *

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum



Lungs and breathing

10

11

Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2




13 Sensory system

Trauma14

Introduction1


Status asthmaticus which has necessitated hospital admission and intravenous therapy for a minimum of 36 hours

Status asthmaticus (a potentially life-threatening asthma attack)

Has resulted in hospital admission and intravenous therapy (medication delivered directly into the bloodstream) for at least 36 hours


5%

Hyperbaric therapy for decompression sickness

Decompression sickness Has undergone hyperbaric therapy, where the body is treated to remove gas bubbles that form in the blood after a sudden change of atmospheric pressure


5%



Appendix







Standard pay-out

Number of months

Initiallump-sum


Lungs and breathing


11

12


Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



13 Sensory system

Trauma14

Introduction1


Amputation or irreversible functional loss of: two or more limbs, where the lower limb is defined as loss of leg above the ankle joint and upper limb is defined as loss of arm above the wrist (with loss of the radius and ulna)

Surgical removal (amputation) or permanent loss of function

Two or more limbs (arms above the wrist, including the forearm bones; legs above the ankle joint)


100% 80% 24 142,4%

Quadriplegia Quadriplegia (paralysis from the neck down)

Diagnosis has been clinically confirmed An illness or injury that’s permanent

100% 80% 24 142,4%

Hemiplegia Hemiplegia (paralysis of the left or right side of the body)

Diagnosis has been clinically confirmed An illness or injury that's permanent

100% 80% 24 142,4%

Paraplegia Paraplegia (paralysis from the waist down)


100% 80% 24 142,4%

Diplegia Diplegia (paralysis of the same limbs on both sides of the body)


100% 80% 24 142,4%

Amputation or irreversible functional loss of: one leg above the knee OR one arm above the elbow


One leg (above the knee) or one arm (above the elbow)


75% 60% 9 77,55%

Amputation or irreversible functional loss of: the arm below the elbow OR the hand below the wrist


One arm (below the elbow) or one hand (below the wrist)


50% 40% 9 51,7%

Amputation or irreversible functional loss of the leg below the knee


One leg (below the knee) An illness or injury you can recover from

25%

Amputation of 2 or more digits at the MCP or MTP joint (finger or toe)

Surgical removal (amputation)

Surgival removal (amputation) of two or more fingers or toes at the knuckle (MCP joint) or at the joint where the bones of the toes join the bones of the foot (MTP joint)


10%

One or more surgical joint replacements Injuries or diseases of the joints

Has undergone one or more surgical joint replacements


10%

Confirmed diagnosis of chronic osteomyelitis Chronic osteomyelitis (long-term bone infection)


10%

Petrositis Infection of the temporal bone, the part of the skull that surrounds the ear


5%

1 2

* *

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


Lungs and breathing


11

12


Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



13 Sensory system

Trauma14

Introduction1


Amputation of a single digit at the MCP or MTP joint (finger or toe)

Surgical removal (amputation).

Surgical removal (amputation) of one finger at the knuckle (MCP joint) or at the joint where the bones of the toe join the bones of the foot (MTP joint)


5%

Confirmed diagnosis of Paget’s disease of the bone

Paget’s disease (abnormal bone tissue formation)


5%

Radiologically demonstrated cervical spine injury which has undergone traction therapy for at least 48 hours

Injury to the cervical spine (neck area of the spine)

Confirmed by an x-ray or scan and having undergone at least two days of traction therapy (to realign the spine)


5%

More than one radiologically confirmed vertebral collapse resulting from disease

Vertebral collapse At least two collapsed vertebrae confirmed by an x-ray or scan and as a result of disease (not because of a physical injury or trauma event)


5%

1 2Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum



13 Sensory system



Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Trauma14

Introduction1

Definition sets D(v5), E(v1)Additional expense needs 1 2 3

Total and permanent loss of hearing in both ears, of an average of >90dB, as measured by audiometry at hearing threshold of 500 Hz, 1 000 Hz, 2 000 Hz and 3 000 Hz and with a speech discrimination threshold of less than 60%

Total and permanent hearing loss in both ears

You can’t hear anything below 90dB when you have a hearing test at thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and with a speech discrimination threshold of less than 60%


100% 80% 18 126,8%

Total and permanent loss of hearing in both ears. This is hearing loss at an average of 76 to 89dB, as measured by audiometry at hearing threshold of 500 Hz, 1 000 Hz, 2 000 Hz and 3 000 Hz and with a speech discrimination threshold of less than 60%. This is equivalent to a calculated binaural loss of hearing of greater than 75%.

Permanent hearing loss in both ears

You can’t hear anything below 76 to 89dB when you have a hearing test at thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and with a speech discrimination threshold of less than 60%. This is equivalent to a calculated hearing loss of greater than 75% in both ears


75% 60% 12 83,4%

Irreversable loss of hearing in both ears, of an average of 61 to 75dB, as measured by audiometry at hearing threshold of 500 Hz, 1 000 Hz, 2 000 Hz and 3 000 Hz and with a speech discrimination threshold of less than 60%. This is equivalent to a calculated binaural loss of hearing of approximately 50% to 75%.

Permanent hearing loss in both ears

You can’t hear anything below 61 to 75dB when you have a hearing test at thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and with a speech discrimination threshold of less than 60%. This is equivalent to a calculated hearing loss of 50 to 75% in both ears


25% 20% 12 27,8%

Complete mastoidectomy Complete mastoidectomy (surgery to remove infected parts of the mastoid bone behind the ear)

Clinically confirmed An illness or injury you can recover from

25%

Acoustic neuroma Acoustic neuroma (a non-cancerous tumour on the nerve that connects the ear to the brain)


25%

Chronic petrositis Chronic petrositis (a long-term infection of the temporal bone surrounding the ear)


15%

Total and irreversible loss of hearing in one ear (This is a pure tone average loss of 90 decibels or more, measured by audiometry at hearing thresholds of 500Hz, 2000Hz and 3000Hz)

Total and permanent hearing loss in one ear.

You can’t hear any pure tone below 90dB when you have a hearing test at thresholds of 500Hz, 2000Hz and 3000Hz.


10%

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum



13 Sensory system



Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Trauma14

Introduction1


Recipient of cochlear or middle ear implant Replacement of the cochlea (hearing component of the inner ear) or replacement of the middle ear


10%

Confirmed tympanosclerosis Tympanosclerosis (calcification of tissues in the eardrum and middle ear)


10%

Total and permanent loss of sight in both eyes defined as visual acuity of a Snellen chart reading of 20/200 or worse in the best eye after full correction

Total and permanent blindness in both eyes

With a Snellen chart reading (eye-chart) of 20/200 or worse in your best eye with the strongest corrective lens


100% 80% 18 126,8%

Total and permanent loss of sight in both eyes defined as visual acuity of a Snellen chart reading of 20/125 or worse in the best eye after full correction

Total and permanent blindness in both eyes

With a Snellen chart reading (eye-chart) of 20/125 or worse in your best eye with the strongest corrective lens


75% 60% 18 95,1%

Enucleation of one eye Traumatic loss or surgical removal of one eye


75%

Permanent hemianopia for more than three months

Loss of half the visual field (left or right) of one or both eyes

Clinically confirmed condition that lasts for more than three months


50% 40% 9 51,7%

Optic nerve atrophy confirmed by an ophthalmologist

Optic nerve atrophy (damage to the nerve from the eye to the brain)

Confirmed by an ophthalmologist An illness or injury you can recover from

50% 40% 9 51,7%

Total and permanent loss of sight in one eye defined as visual acuity of a Snellen chart reading of 20/200 or worse in the affected eye after full correction

Total and permanent blindness in one eye

With a Snellen chart (eye-chart) reading of 20/200 or worse in the affected eye with the strongest corrective lens


50%

Retinitis pigmentosa confirmed by an ophthalmologist

Retinitis pigmentosa (a genetic eye disease that causes damage to the retina)

Confirmed by an ophthalmologist An illness or injury you can recover from

25% 20% 9 25.8%

Confirmed eye disease resulting in permanent visual field defect resulting in any of the following: bilateral tunnel vision, bilateral enlarged blind spots due to papilloedema, bilateral central scotomata for more than three months confirmed by an ophthalmologist

Confirmed eye disease Must be clinically confirmed and result in any of the following: tunnel vision in both eyes, enlarged blind spots in both eyes due to papilloedema (swelling of the optic disc), bilateral scotomata (blind spot areas) in both eyes for more than three months and confirmed by an ophthalmologist


25% 20% 9 25.8%

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum



13 Sensory system



Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Trauma14

Introduction1


Corneal transplant Corneal transplant Replacement of the cornea (the transparent front part of the eye)


15%

Optic neuritis (only 1 payment) Optic neuritis (inflammation of the optic nerve)

Clinically confirmed diagnosis. NB: we will approve only one payment


15%

Confirmed diagnosis of retinal detachment Detachment (loosening) of the retina (the light-sensitive layer at the back of the eye)

Clinically confirmed diagnosis An illness or injury you can recover from

10%

Confirmed macular degeneration Confirmed macular degeneration (a degenerative condition of the central part of the retina)

Clinically confirmed diagnosis An illness or injury you can recover from

10%

Chronic corneal ulcer of at least 3 months duration

A chronic corneal ulcer (a painful area on the transparent layer in front of the eye, caused by loss of outer cell lining)

Condition lasts at least three months An illness or injury you can recover from

10%

Orbital abscess that has undergone surgical drainage or intravenous antibiotic treatment

An orbital abscess (a collection of pus in the eye socket)

Has been surgically drained or treated with an intravenous antibiotic (delivered directly into the bloodstream)


5%

Dysarthria (defined as the inability to produce coherent speech due to the dysfunction of anatomical structures responsible for the mechanical production of sound e.g. mouth cavity, larynx, vocal cords)

Dysarthria (the inability to speak clearly, caused by problems with the body’s sound-producing structures, such as the mouth cavity, the voice box and the vocal cords)

Clinically confirmed An illness or injury that’s permanent

50% 40% 18 63,4%

Chronic osteomyelitis of the sinuses Chronic osteomyelitis (a long- term bone infection) in the sinuses


15%

Nasal destruction as a result of a disease process (trauma and substance abuse are specifically excluded)


10%

Reference notes:


Appendix







Standard pay-out

Number of months

Initiallump-sum


13 Sensory system

Trauma14




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Introduction1


Traumatic injury resulting in permanent failure of 4 out of 5 BrightRock Activities of Daily Living (excluding cognitive failure)

Traumatic injury Has resulted in permanent inability to perform four out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is where the brain’s capacity to think, remember and judge clearly is reduced)


100% 80% 24 142,4%

Permanent failure of the cognitive BrightRock Activity of Daily Living (see definition) as the result of a traumatic event, with an irreversible MMSE of ≤ 18

Traumatic injury Has resulted in permanent inability to perform the cognitive BrightRock Activities of Daily Living (this refers to the brain’s capacity to think, remember and judge clearly) and a permanent score of 18 or less when a neurologist tests the person’s cognitive (thinking) skills with the Mini Mental State Examination (MMSE)


100% 80% 24 142,4%

Full thickness burns of at least 18% of the body surface

Traumatic event - burns Full-thickness burns (burns to all layers of the skin) where at least 18% of the body surface is covered with burns


100% 80% 18 126,8%

Traumatic event resulting in ICU admission of more than 5 weeks with assisted mechanical ventilation for more than 3 of those weeks

Traumatic injuries Has resulted in an admission of more than five weeks in an intensive care unit (ICU), with at least three of those weeks on mechanical ventilation (machines to help you breathe)


100% 80% 18 126.8%

Traumatic injury resulting in permanent failure of the following BrightRock Activities of Daily Living: 3 out of 5 BrightRock Activities of Daily Living (excluding cognitive failure)

Traumatic injury Has resulted in permanent inability to perform three out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is where the brain’s capacity to think, remember and judge clearly is reduced)


75% 60% 24 106,8%

Permanent failure of the cognitive BrightRock Activity of Daily Living (see definition) as the result of a traumatic event, with an irreversible MMSE of 19 to 21

Traumatic injury Has resulted in permanent inability to perform the cognitive BrightRock Activities of Daily Living (this refers to the brain’s capacity to think, remember and judge clearly) and a permanent score of between 19 and 21 when a neurologist tests the person’s cognitive skills (ability to think, remember and judge clearly) with the Mini Mental State Examination (MMSE)


75% 60% 24 106,8%



Appendix







Standard pay-out

Number of months

Initiallump-sum


13 Sensory system

Trauma14




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Introduction1





75% 60% 18 95,1%

Depressed skull fracture having undergone removal of bone/reconstruction of the skull confirmed by a neurosurgeon

Traumatic event Has resulted in depressed (indented) fracture of the skull confirmed by a neurosurgeon and has undergone removal of bone or reconstruction of the skull


75% 60% 18 95,1%

Traumatic event resulting in ICU admission for more than 4 weeks with assisted mechanical ventilation for more than 2 of those weeks

Traumatic event Traumatic injuries have resulted in admission of more than four weeks to an intensive care unit (ICU), with at least two of those weeks on mechanical ventilation (machines to help you breathe)


75%

100%


Traumatic injury Has resulted in permanent inability to perform two out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is when the brain’s capacity to think, remember and judge clearly is reduced.)


50% 40% 24 71,2%




50% 40% 18 63,4%

Traumatic event resulting in ICU admission for more than 2 weeks with assisted mechanical ventilation for more than 1 of the weeks

Traumatic injuries Has resulted in admission of more than two weeks to an intensive care unit (ICU), with more than one of those weeks on mechanical ventilation (machines) to help you breathe


50%

100%


Traumatic injury Has resulted in permanent inability to perform one out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is when the brain’s capacity to think, remember and judge clearly is reduced.)


25% 20% 24 35,6%



Appendix







Standard pay-out

Number of months

Initiallump-sum


13 Sensory system

Trauma14




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Introduction1


Full thickness burns to the face, both hands or airways

Traumatic event - burns Full-thickness burns (burns to all the layers of the skin) on the face, both hands or airways


25% 20% 18 31,7%

Depressed skull fracture with associated brain laceration

Traumatic event Has resulted in a depressed (indented) fracture of the skull and laceration (tearing) of the brain tissue


25% 20% 18 31,7%

Partial thickness burns (excluding superficial burns) involving 9% of the body surface

Traumatic event - burns Partial-thickness burns, where over 9% of the body surface is burned


25%

Traumatic event resulting in ICU admission of more than 1 week with assisted mechanical ventilation for more than 4 days in the week

Traumatic injuries Has resulted in admission of more than one week to an intensive care unit (ICU), with more than four days on mechanical ventilation (machines to help you breathe)


25%

75%

External defibrillation Traumatic event Has undergone external defibrillation (emergency treatment to restore a normal heartbeat using an electronic device called an external defibrillator)


15%

Emergency cardiac pacing Traumatic event Has undergone emergency cardiac pacing (treatment using a pacemaker to restore a normal heartbeat)


15%

Depressed skull fracture Traumatic event Has resulted in a depressed (indented) fracture of the skull


15%

Reconstructive surgery for multiple facial fractures (excluding elective cosmetic surgery)

Multiple facial fractures (broken bones of the face)

Has undergone reconstructive surgery. This excludes elective cosmetic surgery


15%

Occupational toxin exposure which necessitated supportive therapy in ICU for at least 48 hours (Acts of deliberate poison ingestion are excluded)

Occupational toxin exposure (exposure to chemicals in the workplace). Excludes deliberate ingestion of poison

Has resulted in admission to an intensive care unit (ICU) of at least two days


10%

Unintentional exposure related hypothermia (core body temperature less than 35˚C)

Traumatic event - unintentional exposure to extreme cold

Hypothermia (when the body’s core temperature drops below 35˚C


10%



Appendix







Standard pay-out

Number of months

Initiallump-sum


13 Sensory system

Trauma14




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Introduction1


Anaphylactic reaction necessitating ICU admission for at least 48 hours

Anaphylactic reaction (life-threatening allergic reaction)



10%

Full thickness burns involving one hand Traumatic event - burns Full-thickness burns (burns to all the layers of the skin) on one hand


10%

Spinal fusion as a result of a traumatic event that occurred after policy inception

Traumatic event Has undergone spinal fusion (surgery to join two or more vertebrae of the spine). The traumatic event must have taken place after your policy start date


10%

Decompression laminectomy as a result of a traumatic event

Traumatic event Has undergone decompression laminectomy (surgery to relieve pressure on the spinal cord or nerve roots)


10%

Orbital floor fracture Traumatic event Has resulted in a fracture of the orbital floor (bottom of the eye socket)


10%

Drainage of intracranial haemorrhage via burr hole as a result of a traumatic event

Intracranial haemorrhage (bleeding within the skull) after a traumatic event

Has undergone burr-hole drainage of intracranial haemorrhage


10%

Emergency tracheostomy or cricothyrodotomy as a result of a traumatic event

Traumatic event Has undergone an emergency tracheostomy or cricothyrodotomy (where an opening is made through the neck and into the windpipe) is performed to enable breathing after a traumatic event


10%

Snakebite requiring ICU admission for at least 48 hours

Snake bite Has resulted in admission to an intensive care unit (ICU) of at least two days


5%

Anaphylactic reaction as a result of any blood product transfusion

Anaphylactic reaction (life-threatening allergic reaction) caused by any blood product transfusion


5%



Appendix







Standard pay-out

Number of months

Initiallump-sum


13 Sensory system

Trauma14




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



Introduction1


Septic, cardiogenic or hypovolaemic shock which necessitated ICU admission for at least 48hours

Septic shock (a potentially life-threatening drop in blood pressure resulting from severe infection), cardiogenic shock (potentially life-threatening drop in blood pressure caused by heart failure) or hypovolaemic shock (potentially life-threatening drop in blood pressure caused by severe blood or fluid loss)



5%

Inotropic support for at least 48 hours Traumatic event Has resulted in hospital admission for inotropic support (medication to support the contraction of the heart) of at least two days


5%

1 2 3 4Reference notes:


5

Appendix

The Trauma Impact Quotient – Trauma IQ assessment – for accidents and trauma-related injuries

13 Sensory system

Trauma

15




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



14

Introduction1

Definition sets D(v5), E(v1)Additional expense needsReference notes:


1 2

We’ll pay your additional expense needs claims for trauma-related injuries or illnesses if you meet our clinical claims criteria (see the definitions listed under the “Trauma body system”). Our clinical claims criteria look at the diagnosis and treatment to establish the severity of your condition and determine your pay-out. However, we understand that you may suffer a trauma-related injury that doesn’t meet these clinical criteria, but still has a substantial impact on your health and your pocket. With the Trauma IQ assessment, you can still qualify for a claim for injuries sustained as the result of trauma or accidents, even if you don’t meet the clinical criteria. The Trauma IQ assessment takes into account a variety of factors to assess the impact of an injury as a result of trauma.

Definition of traumaFor purposes of this assessment, trauma is defined as:

• an injury suffered solely as the direct result of external, unforeseeable and visible means, and• occurring independently of other causes within four weeks of the acute accidental event.

Before the claim can be assessed to see if there is a pay-out at all under our Trauma IQ assessment, the event must meet the definition of a trauma as set out above. If it does, the nature of the claim event, and the severity of a number of factors (as described below) will be taken into account to determine if there is a pay-out and what percentage pay-out is due. The Trauma IQ assessment considers complications that arise from an acute trauma event, as long as these complications took place within four weeks of the trauma event. The complications must be the direct result of the trauma event. While meeting the criteria above is required for us to consider the event as a “trauma”, simply meeting the definition of a trauma doesn’t guarantee a pay-out under the Trauma IQ assessment. For example, while tripping and spraining your ankle may meet the above trauma criteria and qualify to be assessed, the outcome of the assessment and resulting impact will not be severe enough to generate a successful Trauma IQ claim or pay-out.

Cover for claims under the Trauma IQ assessmentThe maximum cover amount for claims paid under the Trauma IQ assessment is the lower of:

• Your cover for additional expense needs• A maximum amount of R500 000.

The Trauma IQ assessment is a proprietary, intelligent and objective tool that we have designed to calculate the lifestyle and financial impact of traumatic injuries.

We evaluate the impact of a trauma event using consistent guidelinesOur Trauma IQ assessment looks at nine different factors that affect the impact and severity of a traumatic injury. Each element is assigned a number of points, which are combined to provide an overall Trauma IQ score. The maximum number of points that can be assigned to each factor varies, because the impact the factor has on a client’s health and financial needs will vary. We use a calculator (pending patent), signed off by our reinsurers, so that clients can be assured that we apply consistent outcomes.

3

Appendix


13 Sensory system

Trauma

15




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



14

Introduction1


Impact element

1 Emergency Treatment (An unscheduled consultation that takes place at a registered hospital in the Accident and Emergency Unit (also known as the Casualty or Trauma Unit) within 12 hours of an acute traumatic injury or event. The hospital must be registered with the Hospital Association of South African (HASA) or Department of Health)

N/A

2 Surgery 20 minutes

3 Hospital – ICU Half a day

4 Hospital – High Care Half a day

5 Hospital – General ward One full day

6 Rehab – Past sessions (Rehabilitation sessions only include treatment from a medical professional such as a doctor, physiotherapist or occupational therapist, registered with the Health Professional Council of South Africa (HPCSA), or wound care performed at specialised wound clinics by nurses registered with the South African Nursing Council. This applies to both past and future rehab sessions.)

Three sessions

7 Rehab – Future sessions (BrightRock will need to receive written confirmation from the rehabilitation therapist of expected future therapy.) Three sessions

8 Home nursing (We define home nursing as a full 12 hour shift of home care by a nursing professional that is registered with the South African Nursing Council (SANC). A SANC-registered nurse must provide the home nursing care for it to count towards a Trauma IQ pay-out. This means that we won’t count care received at home from a family member as home nursing for the Trauma IQ assessment.

One full day

9 Temporary failure of the BrightRock Activities of Daily Living (ADLs) (The claimant’s primary physician or an occupational therapist must confirm that the claimant cannot perform the BrightRock ADLs. The physician or occupational therapist must be registered with the Health Professions Council of South Africa (HCPSA).)

Failure of two ADLs for a minimum of three days

Reference notes:


1 2 3

It’s important to note that these elements are designed to work together to generate a pay-out for you. Just on their own, some of them don’t trigger a Trauma IQ payment – for example rehabilitation (past or present) and home nursing. But when considered together with the other elements, these factors will result in a score accurately based on what happened to you and may result in a calculated score warranting a Trauma IQ payment.

Appendix


13 Sensory system

Trauma

15




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



14

Introduction1


Your pay-out will be calculated as the Trauma IQ pay-out percentage multiplied by the maximum cover amount set out above – that is, the lower of your additional expense needs cover amount or R500 000. The maximum of R500 00 applies per life insured, not per policy, and will not increase with any future increases in cover.

If you qualify for a pay-out under the Trauma IQ assessment and any other clinical definitionsIf you qualify for a pay-out for complications of a trauma event under the Trauma IQ assessment score and under any of the other clinical definitions for additional expense needs, you will receive the higher of the two pay-outs. This refers to the highest rand amount we could pay you out, and not the pay-out percentage. Note that the extender benefit does not apply to claims paid on the Trauma IQ assessment.

If you chose the Premier Max option and have two different cover amounts for additional expense needsIf you chose the Premier Max option and chose different cover amounts for an illness or injury with a financial impact you can recover from and for an illness or injury with a financial impact that’s permanent, we’ll use the lower of the two amounts to calculate your cover under the Trauma IQ assessment.

Child additional expense needs claims under the Trauma IQ assessmentIf your child qualifies for child additional expense needs cover, then the cover the child will have under the Trauma IQ assessment will be either 10% or 20% of their parents’ cover for Trauma IQ claims. To qualify for this cover, it’s not necessary for the child to be listed on the policy or for the parents to have bought childcare cover. However, where a parent has bought childcare cover for that specific child, the Trauma IQ cover will be increased from 10% to 20%. Children do not qualify for pay-outs below 5% as calculated under the Trauma IQ assess-ment – we will only pay their claim if they qualify for a Trauma IQ pay-out of 5% or more.

Additional notes:To qualify for a claim under the Trauma IQ assessment, the client’s claim must fall within the set time frame. Fewer than four weeks must have elapsed between the date the policyholder suffered the acute trauma-related injury or event and the date when the client first received medical treatment for it.

Medical treatment – any recognised medical intervention, surgery, medication, investigation or rehabilitation, undertaken by a physician registered with the Health Professional Council of South Africa (HPCSA). This may include any further referral by a registered physician to supporting medical professionals registered with the HPCSA including nurses registered with the South African Nursing Council.

We don’t include emergency treatment en route to the hospital in our definition of medical treatment. We will exclude all medical treatment undertaken by emergency practitioners working in ambulances, including paramedics.

BrightRock reserves the right to ask for evidence of all medical treatment the claimant received for purposes of the Trauma IQ assessment. We will ask for this evidence to verify the validity of claims submitted.

We calculate your pay-out based on your Trauma IQ scoreOnce the score for each element has been determined, the Trauma IQ assessment adds together these scores, taking into account any cross-factors. This scores maps to a pay-out percentage based on the overall severity and impact, as determined by the Trauma IQ assessment:

Trauma IQ pay-out percentage - life insured

1% 2.5% 5% 7.5% 10% 12.5% 25% 50% 75% 100%

Trauma IQ pay-out percentage - child

5% 7.5% 10% 12.5% 25% 50% 75% 100%

Reference notes:


Appendix

Appendix

13 Sensory system

Trauma




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



14

15

Introduction1


BrightRock Activities of Daily Living (ADLs)

1. Washing: You rely and entirely on someone else to help you wash, bath or shower.

2. Dressing Skills: You need the help of another person to help you fasten clothes (open/close zips, fasten/unfasten buttons, close belts, tie laces) and, if applicable, attach and fasten

any braces, prosthetics or other surgical appliances that you usually wear.

3. Eating and feeding: You’re physically unable to feed yourself and need someone’s help.

4. Mobility: You need physical help when moving between rooms on a level surface, despite the use of an assistive device such as a walking cane or wheelchair.

5. Transferring: You need someone’s help when moving between a bed and a chair.

6. Cognitive Impairment: You have suffered irreversible brain damage, and can no longer perform the Activities of Daily Living without medical help or supervision. This must be

confirmed by a neurologist or psychiatrist and formally tested by a neuropsychologist.

Permanence will be established not less than three months after the event

Reference notes:


Meeting the Activities of Daily Living criteria:

To meet the criteria for BrightRock’s extender benefit, you must fail:

• At least three out of five BrightRock Activities of Daily Living (excluding cognitive failure) OR

• Fail the cognitive impairment Activities of Daily Living (number 6 above)

BrightRock Activities of Daily Living for children aged five to seven years:

To meet the criteria for BrightRock’s extender benefit for children, the child must fail at least three of the following activities:

1. Washing: The child is unable to wash, bath or shower independently, even with an adult’s supervision

2. Eating and feeding: The child is unable to eat food independently (once an adult has prepared and served the food to the child)

3. Dressing: The child is unable to dress or undress independently (once an adult has helped the child choose and place the clothes), even with an adult’s supervision

4. Toileting: The child is unable to use the toilet independently, and is unable to identify independently when to go

5. Mobility: the child is unable to walk independently on a straight line for three metres with reasonably good coordination and balance

6. Communication: The child is unable to verbally make his or her needs known, and cannot understand basic instructions with two commands.

If the child is aged younger than five years, we will defer the assessment of the BrightRock Activities of Daily Living and the relevant claims pay-out until the child reaches the age of five. Once the child turns five, we will apply the test above. If the child is older than seven, the normal adult definitions will apply.

Appendix

Appendix

13 Sensory system

Trauma




Hormones9

HIV/AIDS8


Digestive system6



Cancer3

Brain and nerves2



14

15

Introduction1


* Condition-specific alcohol exclusion:

For the conditions marked with the * symbol, claims for injuries or illnesses related to long-term alcohol or drug abuse are excluded.

Cancer: All cancer-related diagnoses must be supported by histological evidence from a biopsy.

Reference notes:

HIV and AIDS

1. Diagnosis of advanced AIDS is based on a positive HIV antibody test and a current CD4 count of less than 200, even though you have complied fully with optimal retroviral combination therapy. You must also have been diagnosed with at least one of the following diseases:

• Kaposi’s sarcoma

• Pneumocysistits carinii pneumonia

• Progressive multifocal leukoencephalopathy

• Extra-pulmonary or MDRD/XDR pulmonary tuberculosis

• Pulmonary cryptococcus.

Reference notes:


2. Accidental contraction of HIV infection as a result of:

• Accidental needle stick injury suffered while rendering professional duties as a doctor, dentist, paramedic or nurse. To qualify, you must have had a negative HIV test within 24 hours of the needle stick injury;

• The transfusion of infected blood from a transfusion service recognised by BrightRock

• Receiving an organ transplant where the organ was previously infected with HIV

• Rape or criminal assault or any other violent crime that has been reported to the police and resulted in the opening of a criminal case. To qualify, you must have had anegative HIV test within 24 hours of the assault and undergone a medical examination directly after the assault.

BrightRock has the right to ask for a second opinion if the medical information we initially receive is not sufficient to prove conclusively that the client has met the claims criteria. For example, if the information provided is not sufficient to confirm the client’s diagnosis. Depending on the case, BrightRock may recommend a medical professional for the second opinion or the client may consult a medical professional of their own choosing.

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