Critical illness cover – A guide to the Basic definitions

Before taking out critical illness cover, applicants should always

check exactly what they are covered for; this is detailed in the key

features documents of your policy.

Almost all insurance providers will adhere to the 21 definitions of the main critical illnesses set out by the Association of British Insurers (ABI) As with any insurance policy customers should always check the small print before

proceeding to make sure any claim you do make in the future will be successful.

Detailed below are the guideline criteria set out by the ABI for the

critical illnesses all insurance providers are expected to cover.

Critical illness: Alzheimer’s disease (before age x) – resulting in

permanent symptoms

Criteria: There must be a loss of the ability to:

• Remember

• Reason

• Understand, express, perceive and give in put on

ideas.

Other types of dementia are not covered by this definition.

Customers should also note that PruProtect do not impose an age

limit on being able to claim for Alzheimer’s, unlike other insurance

providers.

Critical illness: Benign brain tumor – permanent and irreversible

Criteria: A non-malignant tumor/cyst in the brain, cranial

nerves or meninges within the skull, resulting in permanent neurological deficit that has persisting symptoms.

Using the above definitions Tumors in the pituitary gland and Angimas

are not covered.

Critical illness: Blindness – permanent and irreversible

Criteria: Loss of sight that is permanent and irreversible to the

extent that vision is measured 3/60, even with the use of visual aids.

Vision is measured using a Snellen eye chart.

Critical illness: Deafness – Resulting in permanent and irreversible

symptoms.

Criteria: Using an audiogram loss of hearing must be permanent and

irreversible to the extent that the loss is greater than 95 decibels

across all frequencies in the better ear.

Critical illness: Loss of speech – Resulting in permanent and

irreversible symptoms

Criteria: Permanent and irreversible loss of the ability of speech due to a

physical injury or disease.

Critical illness: Aorta graft surgery

Criteria: The term “aorta” includes the abdominal and thoracic aorta but does not include its branches.

Claimants must be undergoing surgery for disease to the aorta with excision and surgical replacement of

the diseased aorta with a graft.

The above definition does not cover any other surgical procedure, for

example insertion of stents or endovascular repair.

Surgery due to traumatic injury to the aorta is also not included.

Critical illness: Coronary artery by-pass grafts – surgery to divide the

breastbone

Criteria: Having to undergo surgery that involves dividing the breast

bone, after following advice from a consultant cardiologist, in order to correct blockage or narrowing of

one or more coronary arteries using by-pass graft.

Critical illness: Cancer – excluding less advanced cases

Criteria: Any malignant tumour that has been diagnosed with histological

conformation and is characterized by uncontrollable growth of

malignant cells and invasion of tissue.

The definition of malignant tumor includes : leukaemia, lymphoma and

sarcoma

The above criteria will not cover the following: all cancers that are

histologically classified as:

• Pre-malignant

• Non-invasive

• Cancer in situ

• Borderline malignancy / having low malignant potential

• Any tumor of the prostate unless classified as having a Gleason

score of greater the 6 or having progressed to at least “TNM

classification T2N0M0”

• Chronic leukaemia unless classified as having progressed to

the stated criteria.

• Any skin cancer, other than a malignant melanoma that has been

proven to having caused invasion beyond the outer layer of skin.

Customers should note that companies such as PruProtect do offer far more extensive coverage

for cancer including mastectomy of the breast.

Critical illness: Coma – Resulting in permanent and irreversible

symptoms

Criteria – A state of complete unconsciousness with no reaction to

external symptoms and internal needs which require the use of a life

support system for more than 96 hours.

Resulting in persisting symptoms and a permanent neurological

deficit

A coma induced by alcohol or drug abuse is not covered.

Critical illness: Heart attack – specified severity

Criteria: The death of a heart muscle due to inadequate blood supply,

resulting in acute myocardial infraction, all of the following

evidence must be met:

• Applicant must show typical symptoms, for example characteristic chest pain

• Electrocardiographic changes

• The rise of cardiac enzymes Troponins recorded and specified

levels.

All evidence must show acute myocardial infraction

The above criteria does not cover other acute coronary syndromes, for

example angina.

Critical illness: Heart valve replacement or repair – with surgery

to divide the breastbone

Criteria: Acting on advice from a consultant cardiologist, the

applicant must be undergoing surgery which requires dividing the

breast bone to replace or repair one or more heart valves.

Critical illness: Stroke

Criteria: Due to inadequate blood supply or hemorrhaging within the skull, applicants must experience

death of brain tissue that results in permanent neurological impairment

with persisting symptoms.

Transient ischaemic attack and traumatic injury to brain tissue or

blood vessels is not covered by the above criteria.

Critical illness: HIV infection – caught from a blood transfusion, a

physical assault or at work in an eligible occupation (all must be

within the UK)

Criteria: Applicant must have caught the Infection HIV from one of the

following:

• a blood transfusion given as part of medical treatment;

• a physical assault; or

• an incident occurring during the course of normal duties of

employment (eligible employment only)

The virus has to have been contracted after the start of the

policy and must meet the following criteria:

• The incident must have been reported immediately to all

authorities an a full investigation has been carried out that complies with

set procedures.

• If the HIV virus was caught through physical assault or through

normal employment duties then this must be supported by a negative HIV antibody test taken within 5

days of the incident.

• A furhter HIV test must be taken within 12 months confirming

the presence of the HIV virus or antibodies.

• The incident must have occurred within the UK

The above criteria does not cover the applicant contracting the virus

by any other means including sexual activity or drugs.

Critical illness: Kidney failure- Requiring dialysis

Criteria: End stage failure of both kidneys, resulting in loss of function

and the need for regular dialysis

Critical illness: Loss of hands or feet

Criteria: Loss of any combination of 2 or more hands or feet at or above the wrist of ankle joints resulting in

permanent physical severance.

Critical illness: Paralysis of limbs

Criteria: Loss of muscle functions to the whole of any two limbs resulting

in permanent and irreversible symptoms.

Critical illness: Major organ transplant

Criteria: Procedures covered: transplant of bone marrow, or being

a recipient of a complete heart, kidney, liver, lung or pancreas.

Or inclusion on an official UK waiting list for one of the specified

criteria

The above criteria does not cover transplant of any other organs, parts

of organs, tissues or cells

Critical illness: Motor neurone disease.

(before the age x)

Criteria: A Consultant Neurologist must offer a diagnosis of motor

neurone disease (before the specified age) that will result in

permanent irreversible symptoms of clinical impairment.

Critical illness: Multiple sclerosis

Criteria: A Consultant Neurologist must offer a diagnosis of Multiple Sclerosis that has resulted in the clinical impairment of motor or

sensory function.

This impairment must have lasted over a continuous period of at least

6 months.

Critical illness: Parkinson’s disease (Before age x)

Criteria: A Consultant Neurologist must offer a diagnosis of Parkinson’s

disease (before the required age) that has resulted in permanent impairment of motor function.

This motor function must be associated with tremors, postural

instability and rigidity of movement.

The above criteria does not cover Parkinson’s disease as a result of

drug abuse.

Critical illness: Terminal illness

Criteria: Applicant must have an incurable illness that is advanced or

rapidly progressing.

This must have been diagnosed by a Consultant and the applicants life

expectancy must be no greater than 12 months.

Critical illness: Third degree burns

Criteria: Applicant must have burns that have caused damage or

deconstruction of the skin at its full depth to the underlying tissue that

covers at least 20% of the body surface area.

Critical illness – Traumatic head injury

Criteria: Applicant must have permanent neurological impairment with persistent symptoms caused by traumatic injury that has resulted in

the death of brain cells.

The 21 critical illnesses detailed by the ABI are those that should be

covered by all critical illness insurance policies.

However some providers may chose to cover more or less than others,

for example PruProtect cover up to 154 illnesses under their serious

illness insurance.

So if you are looking for more comprehensive cover there are

further options.

In addition to this applicants should be aware that the wording of these

polices can vary.

Before taking out policy customers should always check exactly what

they are covered for.