Critical Illness Plan - Policy Conditions

Introduction

These policy conditions are written confirmation of your contract with Aviva Life & Pensions UK Limited. It’s important that you read them carefully together with your policy schedule and then keep both documents in a safe place.

If you have any questions, you can call us on 0800 285 1104 (from outside of the UK, please call +44 1603 603 479).

The words shown in bold may be defined terms; we explain these in the “Definitions” section.

Your cover

In order for cover to be maintained, you need to pay your premiums throughout the policy term. If you make a successful claim, the cover amount will be paid as a cash lump sum.

There are two types of cover to choose from – decreasing cover or increasing cover. Your policy schedule will confirm which type of cover you have. Further details about each cover type are provided below.

Decreasing cover

How it works Your premiums What you need to know
The cover amount decreases every month, broadly in line with a repayment loan, for example a mortgage, using a fixed interest rate of 8%. Premiums are guaranteed, so they’ll stay the same throughout the policy term, unless you change your policy. Your policy schedule will provide details of what your cover amount will be at each policy anniversary date.

Increasing cover

How it works Your premiums What you need to know

The cover amount increases each year, in line with the percentage increase in the Consumer Prices Index (CPI).

It’s calculated over a 12 month period ending approximately 3 months prior to each policy anniversary.

If there’s no increase in the CPI during that period, your cover amount will stay the same.

The maximum annual increase applied will be 10%.

Premiums increase each year. To calculate the increase, we’ll multiply your current premium by 1.5 and the percentage increase in CPI.

If there’s no increase in the CPI, your premium will remain the same.

Your premium won’t increase by more than 15% each year (1.5 multiplied by the maximum increase in the CPI of 10%).

We will contact you at least eight weeks before each anniversary date to tell you how much the cover amount and premiums will increase by. If you’re happy to accept the increase you don’t need to do anything as it will be applied automatically.

If you don’t want to pay the higher premium, then, each year, you can choose not to increase your cover amount. If you do this, your cover amount, and your premiums, will stay the same. However, you must tell us as soon as possible before each anniversary date, if you want to cancel the increase.

We won’t increase your cover amount if doing so would mean that the total amount of cover a life covered has with us (on this policy and any others) exceeds the maximum we allow at the time.

Your benefits

Critical illness cover

We’ll pay the critical illness benefit if we accept a claim. Once we’ve accepted a claim, the policy will end and you won’t be able to make another claim. For joint policies, we’ll only pay out once. So when we’ve accepted a claim for one life covered, the policy will end.

Critical Illness benefit What we pay

We’ll pay this benefit if the life covered is diagnosed with, or undergoes surgery for, a critical illness during the policy term and survives for at least 10 days.

Once we’ve accepted a claim, the policy will end.

We’ll pay the cover amount shown in the policy schedule.

We’ll pay the following benefits if we accept a claim, as long as you haven’t already made, nor are you eligible to make, a claim for the critical illness benefit.

They are provided in addition to the other benefits on your policy. If we accept a claim for the additional critical illness benefit or the children’s benefit, your policy will continue. So it won’t stop you from making a claim for the critical illness benefit at a later date. Also, it won’t affect the payment we’ll make if we accept your claim.

Additional critical illness benefit What we pay

We’ll pay this benefit if the life covered is diagnosed with, or undergoes surgery for, an additional critical illness during the policy term and survives for at least 10 days.

We’ll accept one claim per additional critical illness for each life covered.

Once we’ve accepted a claim, the life covered will no longer be covered for that condition. However, cover will continue for the other additional critical illnesses, and for any other life covered.

For carcinoma in situ of the breast and low grade prostate cancer, we’ll pay the lower of:

  • £25,000; or
  • 25% of the cover amount shown in the policy schedule

For the other additional critical illnesses, we’ll pay the lower of:

  • £20,000; or
  • 20% of the cover amount shown in the policy schedule

Children’s benefit

Children’s critical illness benefit What we pay

We’ll pay this benefit if a child is diagnosed with, or undergoes surgery for, a children’s critical illness during the policy term and survives for at least 10 days.

We’ll accept one claim per child. Once we’ve accepted a claim, the cover will continue for any other child.

We’ll pay the lower of:

  • £25,000; or
  • 50% of the cover amount shown in the policy schedule
Children’s death benefit What we pay

We’ll pay this benefit if a child dies during the policy term.

We’ll pay it in addition to any benefit we may have already paid for children’s critical illness.

We’ll pay £5,000.

Additional benefits

Your policy schedule will show whether the separation benefit is included on your policy.

Separation benefit

Available with all types of cover.

Can be used six months from the start date.

What this means for your policy

If you separate, you can split your joint policy and each take out a new single policy without answering any further medical questions.

This additional benefit will only be included if:

  • we accepted your policy on standard terms; and
  • you are the policyholder as well as the life covered.
Separation Evidence needed
Divorce, dissolution of civil partnership or separation Decree absolute or dissolution order.
Mortgage transferred into one name only Evidence of mortgage transfer.
Moving into a different house Evidence of new mortgage or new address.

You can use the separation benefit as long as:

  • you and the other policyholder agree to cancel the original policy; and
  • you take out the new policy before you turn 55; and
  • you take out the new policy within 90 days of the separation happening; and
  • you send us the evidence we need; and
  • neither of you have made, nor are you eligible to make a claim for any benefit except children’s benefit; and
  • the premium of the new policy meets the minimum premium limit that applies at the time.

The new policy:

  • can only start when your original policy has been cancelled, and
  • has to end before you turn 70, and
  • has to have a cover amount which is less than, or equal to, the current cover amount.

You can only use the separation benefit once, and the new policy won’t include the separation benefit.

The new policy can have either decreasing cover or increasing cover.

The premium you’ll pay for any new policy will be based on the rates available at the time of the request and the personal circumstances of the life covered. The policy conditions in force at the time will apply to the new policy.

Making changes to your policy

You can make certain changes to your policy six months from the start date. If you ask to make any changes, they will apply from the date your next premium is due.

Amending your policy

If you make any of the following changes, we’ll amend your policy:

Reducing:

  • the cover amount
  • the policy term.

Increasing:

  • the policy term

With the exception of increasing the policy term, you can make the above changes without any further medical questions being asked.

If you want to increase the policy term, we may need to ask some further medical questions. Depending on the answers, we may not be able to carry out the increase.

For increasing the policy term, we’ll use the premium rates available when we make the change, based on the personal circumstances of the life covered.

For all other changes, we’ll use the original premium rates based on the personal circumstances of the life covered.

After you’ve made any of the above changes, your premium can’t be lower than the minimum premium limit which applies at the time we agree to your request.

These policy conditions will continue to apply to your amended policy.

Issuing a new policy

If you increase the cover amount, we’ll issue a new policy to go with your original policy, which will remain in force.

We may need to ask some further medical questions. Depending on the answers, we may not be able to carry out the change.

If we can carry out the change, the policy conditions in force at the time of the change will apply to the new policy.

Making a claim

If you need to make claim, please contact us on 0800 285 1104 (from outside of the UK, please call +44 1603 603 479). Our claims line is open Monday to Friday 8:30am to 5:30pm.

Before we can pay a claim we need to assess it. To do this, we’ll ask for some important information. If we ask for information from third parties, we’ll pay for it. If you want to, you can provide dditional evidence at your own expense.

The kind of information we need may include, but isn’t limited to, the following:

  • Proof that the life covered has become critically ill, or incapacitated.
  • Proof that a child has died or become critically ill.
  • Proof of who legally owns the policy.
  • Written consent that lets us:
    • access the medical records or reports of the life covered (or child for a children’s benefit claim)
    • receive the results of any medical examinations or tests of the life covered.
  • Conversations with, and reports from, third parties such as coroners, attending Consultants, employers and the police.

When we assess a claim, we rely on the information we’re given. If any of the information is untrue or incomplete, it could affect whether we pay a claim or not, and may mean we won’t pay a claim. Or, if we’ve already paid a claim, it may mean we can reclaim the money.If this happens, we won’t make any further payments. We may also cancel the policy without refunding any premiums.

This doesn’t affect any other legal rights we have.

If we accept a claim, we’ll make any relevant payment to you.

Paying your premiums

Premiums are payable monthly by Direct Debit. All Direct Debits need to come from a bank or building society in the UK, the Channel Islands, the Isle of Man or Gibraltar, in the currency of the UK.

We show the initial premium you’ll pay, and the date it and subsequent premiums are due, in the policy schedule. You have 60 days from each due date to pay your premium. If you have to make a claim during this period, we’ll deduct the unpaid premium from the benefit we pay.

If you don’t pay your premiums within the 60 day period, we’ll cancel your policy. If this happens, you won’t be able to make a claim.

Policy term

The minimum policy term is 5 years. The maximum is 50 years. This is subject to the oldest life covered being 75 years of age or less at the policy end date.

We show your policy term in the policy schedule.

Changing your details

You need to let us know if your contact details, or those of any life covered, change.

Acceptance of instructions

We can’t accept any instruction, request or notice from you until we receive all the information we need. We’ll tell you what kind of information or documentation we need.

Cancelling your policy

You have a 30 day cooling off period to change your mind. If you cancel within this period, we’ll refund any premiums you’ve paid.

The cooling off period begins on the later of:

  • the day we tell you when your policy will start
  • the day you receive your policy documents.

You can still cancel the policy after the cooling off period ends, but we won’t refund your premiums.

If you cancel your policy, you won’t be able to make a claim.

Eligibility

You must be at least 18 to apply for this policy.

You must also be a resident of the UK. This does not include the Channel Islands, the Isle of Man or Gibraltar.

General conditions

Policy amendments

We may alter these policy conditions for any of the following reasons:

  • To respond, in a proportionate manner, to changes in:
    • the way we administer these type of policies
    • technology or general practice in the life and pensions industry
    • taxation, law or the interpretation of the law, decisions or recommendations of an ombudsman, regulator or similar body, or any code of practice with which we intend to comply.
  • To correct errors if it is fair and reasonable to do so.

If we think any alteration to these policy conditions is to your advantage, we’ll make it immediately and tell you at a later date.

We’ll also do this if the alteration is due to regulatory requirements.

If any alteration is to your disadvantage, we’ll aim to tell you in writing at least 60 days before we make it. However, external factors beyond our control may mean we have to give you less notice.

If you’re not happy with any alteration we make to your policy, you can cancel it.

Incorrect Information

If the date of birth of any life covered is wrong we’ll base the payment we make for any successful claim on the correct date of birth. We’ll tell you if this happens.

If, using the correct date of birth, the age of any life covered when you took out your policy would have been outside of our limits,we’ll cancel your policy. If this happens, we’ll tell you. You won’t be able to make a claim after we’ve cancelled your policy. However, we’ll refund all your premiums (without interest). We rely on the information you give us. If any of it is untrue or incomplete and would have affected our decision to provide your policy, we may:

  • change the terms of your policy
  • change the premiums you have to pay
  • cancel your policy and refund the premiums you’ve paid (without interest).

If we cancel your policy, you won’t be able to make a claim.

Third party rights

This policy does not give any rights to anyone except you and us.

We may, with your agreement, amend or cancel this policy without reference to, or consent from, any other person.

General

If you want to transfer (‘assign’) the policy to someone else, you must tell us in writing before we can pay a claim.

Where appropriate, words in the singular include the plural and vice versa.

Law

This policy is issued in England, under English law.

Definitions

Throughout these policy conditions we have highlighted defined terms in bold type (except for personal terms like “we” and “you”) so you know when they apply. The meanings of these words are set out below.

You or your refers to the policyholder(s) named in the policy schedule, or anyone else who becomes the legal owner of the policy.

We, us or our means Aviva Life & Pensions UK Limited.

Additional critical illness

An illness or condition suffered by the life covered, as detailed in Appendix 2.

Anniversary date

The anniversary of the start date shown in the policy schedule.

Attending Consultant

The appropriately qualified medical specialist supervising care of the life covered.

The attending Consultant must be resident and practicing in Andorra, Australia, Canada, the Channel Islands, the European Union, the Faroe Islands, Gibraltar, the Isle of Man, Liechtenstein, Monaco, New Zealand, Norway, San Marino, Switzerland, USA or the Vatican City. We may add further countries in the future.

Child

The natural, step, legally adopted and/or future children of the life covered, and in the event of their diagnosis of (or undergoing surgery for) a children’s critical illness, or in the event of their death, a claim could be made under the children’s benefit.

The child must be aged between 30 days and their 18th birthday (or their 21st birthday if in full time education) at the time of their death or at the time they are diagnosed with (or undergo surgery for) the children’s critical illness.

Children’s critical illness

An illness or condition suffered by the child, as detailed in Appendix 1 (but excluding terminal illness) and Appendix 2, which the child survives for at least 10 days after meeting the relevant critical illness or additional critical illness definition.

The illness or condition must not have been present at birth (whether diagnosed or not), and the symptoms must not have started before the start of the policy or before the child was covered by the policy.

Consumer Prices Index (CPI)

The monthly index calculated by the government that demonstrates the movement of consumer prices in the UK, or an equivalent replacement of that index.

Cover amount

The amount we pay for a successful claim under this policy. The cover amount is shown in your policy schedule.

Critical illness

An illness or condition suffered by the life covered, as detailed in Appendix 1.

End date

The date that cover under this policy will end. This is shown in your policy schedule.

Joint policy

The policy can cover up to two people – usually you and your partner, spouse or civil partner. A joint policy will only pay out once following a successful claim for critical illness benefit.

So when we’ve accepted a claim for one person, the policy will end.

Life covered

The person covered under this policy, and in the event of their diagnosis of a critical illness or additional critical illness, a claim could be made.

Personal circumstances

These can include the age, smoker status (both previous and current), health and lifestyle of the life covered.

Policy conditions

This document which forms our contract of insurance with you providing the cover under the policy as agreed. The application (that you made and which we have accepted) and the policy schedule also form part of the contract and must be read together with these policy conditions.

Policy schedule

This will show the specific detail of your policy, such as who it covers, the cover amount, how much it will cost and any additional benefits included. The definition also includes any subsequent amendments to your policy, which we confirm to you in writing.

Policy term

This is the period your policy is in force, from the start date until the end date.

Resident

At the time you complete the application you must be physically living in the UK and:

  • a citizen of the UK; or
  • have been granted permission to settle permanently in the UK.

Single policy

A policy which covers the life of just one person.

Standard terms

The premium and benefits we quote before the underwriting process is completed.

Following an application being underwritten, we may only be able to offer cover with a higher premium than first quoted, with certain benefits excluded, or both. This would not be classed as standard terms.We will have told you whether you were accepted on standard terms when confirming our decision on your application.

Start date

The date on which cover under this policy starts. It’s shown in the policy schedule.

Appendix 1

Details of critical illnesses & children’s critical illnesses covered

For each critical illness or condition listed in alphabetical order below, we have set out the definition we’ll use when we’re assessing a claim.

Alzheimer’s disease or pre-senile dementia - resulting in permanent symptoms

A definite diagnosis of Alzheimer’s disease or pre-senile dementia, by a consultant neurologist, psychiatrist or geriatrician.There must be permanent clinical loss of the ability to do all of the following:

  • remember;
  • reason; and
  • perceive, understand, express and give effect to ideas.

Aorta graft surgery - for disease or trauma

The undergoing of surgery for disease or trauma to the aorta with excision and surgical replacement of a portion of the diseased aorta with a graft. The term aorta includes the thoracic and abdominal aorta but not its branches. For the above definition, the following is not covered:

  • Any other surgical procedure, for example the insertion of stents or endovascular repair.

Aplastic anaemia

A definite diagnosis of aplastic anaemia by a consultant haematologist. There must be permanent bone marrow failure with anaemia, neutropenia and thrombocytopenia.

Bacterial meningitis

A definite diagnosis of bacterial meningitis resulting in permanent neurological deficit with persisting clinical symptoms.

Benign brain tumour - resulting in permanent symptoms or requiring invasive surgery

A non-malignant tumour or cyst originating from the brain, cranial nerves or meninges within the skull, resulting in permanent neurological deficit with persisting clinical symptoms or requiring invasive surgery.

For the above definition, the following are not covered:

  • Tumours in the pituitary gland.
  • Tumours originating from bone tissue.
  • Angioma and cholesteatoma.

Benign spinal cord tumour

A non-malignant tumour in the spinal canal involving the meninges or spinal cord. This tumour must be interfering with the function of the spinal cord which results in permanent neurological deficit with persisting clinical symptoms. This diagnosis must be made by a medical specialist and must be supported by appropriate evidence. Excluded under this definition are cysts, granulomas, malformations in the arteries or veins of the spinal cord, haematomas, abscesses, disc protrusions and osteophytes.

Blindness - permanent and irreversible

Permanent and irreversible loss of sight to the extent that, even when tested with the use of visual aids, vision is measured at 6/60 or worse in the better eye using a Snellen eye chart or visual field is reduced to 20 degrees or less of an arc, as certified by an ophthalmologist.

Cancer - excluding less advanced cases

Any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, sarcoma and lymphoma except cutaneous lymphoma (lymphoma confined to the skin). For the above definition, the following are not covered:

  • All cancers which are histologically classified as any of the following:
    • pre-malignant;
    • non-invasive;
    • cancer in situ;
    • having either borderline malignancy; or
    • having low malignant potential.
  • All tumours of the prostate unless histologically classified as having a Gleason score of 7 or above, or having progressed to at least TNM classification T2bN0M0.
  • Any skin cancer (including cutaneous lymphoma) other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin) unless the skin cancer has been confirmed as malignant and has spread to the lymph nodes or distant organs.

Cardiac arrest - with insertion of a cardiac defibrillator

Sudden loss of heart function with interruption of blood circulation around the body resulting in unconsciousness and resulting in either of the following devices being surgically implanted:

  • Implantable cardioverter-defibrillator (ICD) or;
  • Cardiac resynchronisation therapy with defibrillator (CRT-D).

For the above definition the following are not covered:

  • Insertion of a pacemaker.
  • Insertion of a defibrillator without cardiac arrest.
  • Cardiac arrest secondary to alcohol or drug abuse.

Cardiomyopathy - of specified severity.

A definite diagnosis of cardiomyopathy by a consultant cardiologist. There must be clinical impairment of heart function resulting in the permanent loss of ability to perform physical activities to at least Class 3 of the New York Heart Association classifications of functional capacity (i.e. heart disease resulting in marked limitation of physical activities where less than ordinary activity causes fatigue, palpitation, breathlessness or chest pain). The following are not covered:

  • Cardiomyopathy secondary to alcohol or drug abuse.
  • All other forms of heart disease, heart enlargement and myocarditis.

Coma - with associated permanent symptoms

A state of unconsciousness with no reaction to external stimuli or internal needs which:

  • requires the use of life support systems; and
  • results in associated permanent neurological deficit with persisting clinical symptoms.

For the above definition, the following is not covered:

  • Coma secondary to alcohol or drug abuse.
  • Medically induced coma.

Coronary artery by-pass grafts

The undergoing of surgery on the advice of a consultant cardiologist to correct narrowing or blockage of one or more coronary arteries with by- pass grafts.

Creutzfeldt – Jakob disease

An unequivocal diagnosis of Creutzfeldt-Jakob disease made by a consultant neurologist.

Deafness - permanent and irreversible

Permanent and irreversible loss of hearing to the extent that the loss is greater than 70 decibels across all frequencies in the better ear using a pure tone audiogram.

Devic’s disease - with persisting clinical symptoms

A definite diagnosis of Devic’s disease by a consultant neurologist. There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 3 months.

Encephalitis

A definite diagnosis of encephalitis by a consultant neurologist resulting in permanent neurological deficit with persisting clinical symptoms.

Heart attack

Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction:

  • New characteristic electrocardiographic changes.
  • The characteristic rise of cardiac enzymes or Troponins.

The evidence must show a definite acute myocardial infarction.

For the above definition, the following are not covered:

  • Other acute coronary syndromes.
  • Angina without myocardial infarction.

Heart valve replacement or repair

The undergoing of surgery on the advice of a consultant cardiologist to replace or repair one or more heart valves.

HIV infection - caught in the European Union, Andorra, the Channel Islands, the Faroe Islands, Gibraltar, the Isle of Man, Liechtenstein, Norway, Monaco, San Marino, Switzerland, Vatican City, USA, Canada, Australia or New Zealand from a blood transfusion, a physical assault or at work.

Infection by human immunodeficiency virus resulting from:

  • a blood transfusion given as part of medical treatment;
  • a physical assault; or
  • an incident occurring during the course of performing normal duties of employment

after the start of the policy and satisfying all of the following:

  • The incident must have been reported to appropriate authorities and have been investigated in accordance with the established procedures.
  • Where HIV infection is caught through a physical assault or as a result of an incident occurring during the course of performing normal duties of employment, the incident must be supported by a negative HIV antibody test taken within five days of the incident.
  • There must be a further HIV test within 12 months confirming the presence of HIV or antibodies to the virus.
  • The incident causing infection must have occurred in the European Union, Andorra, the Channel Islands, the Faroe Islands, Gibraltar, the Isle of Man, Liechtenstein, Norway, Monaco, San Marino, Switzerland, Vatican City, USA, Canada, Australia or New Zealand.

For the above definition, the following is not covered:

  • HIV infection resulting from any other means, including sexual activity or drug abuse.

Intensive care - requiring mechanical ventilation for 10 consecutive days

Any sickness or injury resulting in the insured requiring continuous mechanical ventilation by means of tracheal intubation for 10 consecutive days (24 hours per day) or more in an intensive care unit in a UK hospital.

For the above definition the following is not covered: sickness or injury as a result of drug or alcohol intake or other self inflicted means.

Kidney failure - requiring permanent dialysis

Chronic and end stage failure of both kidneys to function, as a result of which regular dialysis is permanently required.

Liver failure

A definite diagnosis, by a consultant physician, of irreversible end stage liver failure due to cirrhosis resulting in all of the following:

  • Permanent jaundice; and
  • Ascites; and
  • Encephalopathy.

The following is not covered:

  • Liver failure secondary to alcohol or drug abuse.

Loss of hand or foot - permanent physical severance

Permanent physical severance of either a hand or a foot at or above the wrist or ankle joint.

Loss of speech - total, permanent and irreversible

Total permanent and irreversible loss of the ability to speak as a result of physical injury or disease.

Major organ transplant - from another donor

The undergoing as a recipient of a transplant from another donor of bone marrow or of a complete heart, kidney, liver, lung or pancreas, or a whole lobe of the lung or liver, or inclusion on an official UK waiting list for such a procedure.

For the above definition, the following is not covered:

  • Transplant of any other organs, parts of organs, tissues or cells.

Motor neurone disease - resulting in permanent symptoms

A definite diagnosis of motor neurone disease by a consultant neurologist. There must be permanent clinical impairment of motor function. All forms of motor neurone disease are covered including spinal muscular atrophy.

Multiple sclerosis - where there have been symptoms

A definite diagnosis of multiple sclerosis by a consultant neurologist. There must have been clinical impairment of motor or sensory function caused by multiple sclerosis.

Multiple system atrophy

A definite diagnosis of multiple system atrophy confirmed by a consultant neurologist. There must be evidence of permanent clinical impairment of either:

Motor function with associated rigidity of movement or the ability to coordinate muscle movement or bladder control and postural hypotension.

Paralysis of a limb - total and irreversible

Total and irreversible loss of muscle function to the whole of a limb.

Parkinson’s disease - resulting in permanent symptoms

A definite diagnosis of Parkinson’s disease or other named Parkinsonian syndrome of specified severity by a consultant neurologist. The additional Parkinsonian syndromes covered are corticobasal degeneration and diffuse lewy body disease.

There must be permanent clinical impairment of motor function with associated tremor and muscle rigidity.

For the above definition the following are not covered:

  • Other Parkinsonian syndromes/Parkinsonism.

Pneumonectomy - removal of a complete lung

The undergoing of surgery on the advice of a consultant medical specialist to remove an entire lung due to disease or traumatic injury. Other forms of surgery to the lungs including removal of a lobe of the lungs (lobectomy) or lung resection are not covered under this definition.

Primary pulmonary hypertension - of specified severity

Primary pulmonary hypertension with permanent clinical impairment of heart function resulting in marked limitation of physical activities to at least Class 3 of the New York Heart Association’s classification of functional capacity.

Progressive supranuclear palsy

A definite diagnosis by a consultant neurologist of progressive supranuclear palsy. There must be permanent clinical impairment of eye movement and motor function with associated tremor, rigidity of movement and postural instability.

Pulmonary artery surgery

The undergoing of surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a consultant cardiologist for disease of the pulmonary artery to excise and replace the diseased pulmonary artery with a graft.

Rheumatoid arthritis - of specified severity

Severe chronic rheumatoid arthritis evidenced by joint destruction and deformity of at least three major joint groups, resulting in the inability to do three of the following; bend or kneel to pick up an object from the floor; use hands or fingers to pick up or manipulate small objects such as cutlery or a pen; lift or carry an everyday object such as a kettle; walk a distance of 200m on flat ground with or without use of a walking stick and without experiencing severe discomfort.

Severe lung disease - of specified severity

Severe lung disease where there is permanent impairment of lung function with lung function tests: Forced Vital Capacity (FVC) and Forced Expiratory Volume at 1 second (FEV1) below 50% of normal and a need for daily oxygen therapy for a minimum of 15 hours per day for at least six months.

Spinal stroke - resulting in permanent symptoms

Death of spinal cord tissue due to inadequate blood supply or haemorrhage within the spinal column resulting in permanent neurological deficit with persisting clinical symptoms.

Stroke

Death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in either:

  • permanent neurological deficit with persisting clinical symptoms; or
  • definite evidence of death of brain tissue or haemorrhage on a brain scan; and
  • neurological deficit with persistent clinical symptoms lasting at least 24 hours.

For the above definition, the following is not covered:

  • Transient ischaemic attack.
  • Death of tissue of the optic nerve or retina/eye stroke.

Structural heart surgery

The undergoing of heart surgery requiring median sternotomy (surgery to divide the breastbone) on the advice of a consultant cardiologist to correct any structural abnormality of the heart.

Systemic lupus erythematosus - of specified severity

A definite diagnosis with either, permanent impaired kidney function with glomerular filtration rate below 30ml/min or permanent neurological deficit resulting in persistent symptoms of paralysis, localised weakness, dysarthria, dysphagia or difficulty in walking.

Terminal illness - where death is expected within 12 months

This does not apply to children’s critical illness benefit

A definite diagnosis by the attending Consultant of an illness that satisfies both of the following:

  • The illness either has no known cure or has progressed to the point where it cannot be cured: and
  • In the opinion of the attending Consultant, the illness is expected to lead to death within 12 months.

Third degree burns - covering at least 20% of the body’s surface area or covering at least 20% of the surface area of the face or head

Burns that involve damage or destruction of the skin to its full depth through to the underlying tissue and covering at least 20% of the body’s surface area or covering at least 20% of the surface area of the face or head.

Traumatic brain injury - resulting in permanent symptoms

Death of brain tissue due to traumatic injury resulting in permanent neurological deficit with persisting clinical symptoms.

Appendix 2

Details of additional critical illnesses & children’s critical illnesses covered

For each additional critical illness or condition, we have set out the definition we’ll use when we’re assessing a claim.

Arteriovenous malformation (AVM) of the brain - with specified treatment

The undergoing of craniotomy, endovascular repair or radiosurgery to treat an arteriovenous malformation (AVM) of the brain.

Bladder removal

Complete surgical removal of the urinary bladder (total cystectomy).

For the above definition the following are not covered:

  • Urinary bladder biopsy.
  • Removal of a portion of the urinary bladder.

Carcinoma in situ of the breast- requiring surgery to remove the tumour

Carcinoma in situ of the breast positively diagnosed with histological confirmation by biopsy together with the undergoing of surgery to remove the tumour.

Carcinoma in situ of the cervix- requiring treatment with hysterectomy

Carcinoma in situ of the cervix positively diagnosed with histological confirmation together with the undergoing of a hysterectomy on the advice of a specialist, to treat the carcinoma in situ of the cervix.

The following are excluded:

  • All grades of dysplasia.
  • Cervical squamous intra-epithelial lesion (SIL) and Cervical intra- epithelial neoplasia (CIN), unless carcinoma in-situ is present.
  • Carcinoma in-situ of any other gynaecological organ (for example the ovary, or the fallopian tube).
  • Any other disease or disorder of the cervix or other gynaecological organs that is treated with hysterectomy.

Carcinoma in situ of the testicle- requiring surgical removal of one or both testicles

Carcinoma in situ of the testicle (also known as intratubular germ cell neoplasia unclassified or ITGCNU) positively diagnosed with histological confirmation and treated with an orchidectomy (complete surgical removal of the testicle).

Cerebral aneurysm- with specified treatment

The undergoing of craniotomy, endovascular repair or radiosurgery to treat a cerebral aneurysm.

Crohn’s disease- treated with intestinal resection

A definite diagnosis by a consultant gastroenterologist of Crohn’s disease which has been treated with surgical intestinal resection.

Low grade prostate cancer- with specified treatment

Tumours of the prostate histologically classified as having a Gleason score between 2 and 6 inclusive provided the tumour has progressed to a clinical TNM classification between T1N0M0 and T2aN0M0; and the tumour has been treated by one of the following:

  • Complete removal of the prostate.
  • External beam or interstitial implant radiotherapy.
  • Cryotherapy.
  • Hormone therapy.
  • High intensity focused ultrasound.

For the above definition, the following is not covered:

  • Prostate cancers where the treatment is not one of the specified treatments above, or requires observation only.

Non-malignant pituitary tumour- with specified treatment

A non-malignant pituitary tumour requiring radiotherapy or surgical removal.

For the above definition the following are not covered

  • Non-malignant tumours of the pituitary gland treated by any other method.

Removal of an eyeball

Surgical removal of an eyeball due to disease or injury. Self-inflicted injuries are excluded.

Ulcerative colitis - treated with total colectomy

A definite diagnosis of ulcerative colitis which is treated with total colectomy (removal of entire large bowel).

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