Private Healthcare Facilities and Services Act (PHFSA) 1998 and Regulations 2006

Private hospital bills

By Dr MILTON LUM  (complied from The Star - Sunday May 30, 2010)

Dr Milton Lum is Chairperson of the Commonwealth Medical Trust. This article provides general information only and is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.

When looking at a hospital bill, be aware of the differences between doctors’ professional fees and private hospital charges, amongst other things.

THERE are many patients who seek healthcare in a private hospital. The patients, relatives, and their employers or insurers often have to make sense of the various items in a private hospital bill. This article provides information to assist in the interpretation of the intricacies of a private hospital bill.


It is vital to always remember that a private hospital bill has two components, i.e. the doctors’ professional fees and the hospital charges. A distinction has to be made between the doctors’ professional fees and the private hospital charges. This is important as the doctor is, not uncommonly, held responsible for the whole hospital bill because the doctor is symbolic of the healthcare system.


Doctors’ professional fees
The doctors’ professional fees include consultation fees, fees for ward visits, and procedure or operation fees. The professional fees are regulated by the Private Healthcare Facilities and Services Act (PHFSA) and its regulations. The fees in the 13th Schedule of the PHFSA Regulations are the maximum permitted.


The same Schedule stipulates that “When two procedures are performed through the same incision, the fee chargeable for the lesser procedure should not exceed 50% of the fee charged for the first procedure. When a repeat procedure is required, consequent to the first procedure, the fee chargeable for the second procedure should not exceed 50% of the first and when a third repeat procedure is required, the fee chargeable for the third procedure should not exceed 25% of the fee charged for the first procedure.”


The provisions in the 13th Schedule are of particular relevance in the event a patient has to have another procedure or operation should there be complications consequent to the initial procedure or operation.

Patients have a right to an itemised bill for the whole course of the treatment at the private hospital at no extra cost.

Complications are always a possibility whenever a procedure or operation is undertaken. No doctor who performs a procedure or operation can guarantee that no complications will arise, however simple the procedure or operation may appear to be.


Doctors’ professional fees may vary in different private hospitals and clinics and even within the same hospital and clinic. This is because the individual circumstances of each patient are different.


There are no fees prescribed for some of the newer procedures or operations in the PHFSA Regulations. In such situations, the patient will be informed of the professional fees involved.


Patients should not feel uncomfortable about asking the attending doctor(s), what the professional fees are, particularly if a procedure or operation has been recommended. The question should also include the professional fees that would be charged in the event a complication arises.


Any reduction of a doctor’s professional fees is a matter between the individual doctor and patient. Many doctors have waived part or all of their professional fees for patients who are financially not well off or who have incurred a bigger than anticipated hospital bill. Doctors do not publicise this fact because it may be construed as advertising, which is not permitted by the Malaysian Medical Council.


Hospital charges
Unlike doctors’ professional fees, the charges of private hospitals are unregulated, for reasons best known to those involved in the formulation of the PHFSA Regulations.


The private hospital charges include accommodation, laboratory, imaging, medication, labour ward, operating theatre, nursing, physiotherapy and other charges.


Accommodation charges vary in different private hospitals depending on whether it is room with more than two beds, double beds, single bed, or a suite. The choice of accommodation lies with the patient. It would be prudent to consider the duration of stay when deciding on accommodation as this may be factored in the charges for other services provided by the private hospital.


Laboratory charges vary in different private hospitals. Some hospitals do all laboratory tests within their premises while others out-source all or some laboratory tests. Some more complex tests are outsourced to laboratories within the country or even abroad.


Imaging investigations refer to x-rays, computerised tomography (CTs), ultrasound scans, magnetic resonance imaging (MRI). The majority of medical conditions require basic imaging investigations. Complex medical conditions, however, require more sophisticated imaging investigations. In short, not every patient requires a CT or MRI.


If complex laboratory tests and imaging are recommended, it would be prudent to ask the attending doctor(s) about its relevance to the patient’s management and the cost. There are some laboratory tests and imaging that may provide useful information but which do not impact on patient management decisions.


The medicines prescribed are either original compounds or generic ones. The former usually costs more than the latter. However, the price differential between them may not be substantial for many medicines. Doctors prefer original medicines in critical situations as its pharmacokinetics and pharmacodynamics are known, unlike many generics.


Pharmacokinetics refers to what the body does to the medicine administered, i.e. the mechanisms of absorption and distribution of the medicine, the rate at which its action begins, and the duration of its effect, the chemical changes to the medicine in the body, as well as the effects and routes of excretion of its metabolites. Pharmacodynamics refers to what the medicine does to the body.


The attending doctor(s) will advise on whether to continue taking medicines already prescribed for the long term. In general, they should continue to be taken, particularly medicines for high blood pressure, diabetes, high cholesterol, thromboembolism etc. One should be able to bring such medicines to the private hospital.


The charges for the labour ward and/or operating theatre include charges for monitoring, equipment, surgical or disposable items, and medical gases used. There is also a charge for the duration of usage of the labour ward and/or operating theatre.


Patients’ rights
The PHFSA stipulates that a private hospital has a legal obligation to make available, upon registration or admission, its policy statement stating its obligations to patients.


The PHFSA Regulations go on to state that patients have a right to be informed of the estimated charges that may be incurred prior to the initiation of care or treatment. The estimate would be based on an average patient with the same provisional diagnosis of the patient would incur. The patient also has a right to be informed of other unanticipated charges for services that are routine, usual and customary.


Patients have the right to be informed of the private hospital’s billing procedures prior to the initiation of care or treatment.


In addition, patients have a right to an itemised bill for the whole course of the treatment at the private hospital at no extra cost.


These legal provisions will enable patients to know what he or she has been charged for. 


Anyone who does not comply with these legal provisions will, upon conviction, can be fined an amount not exceeding RM10,000 or imprisoned for not more than three months or both.


The PHSFA Regulations also prescribe a patient grievance mechanism. If there is dissatisfaction with any matter in the private hospital, and this includes private hospital bills, a complaint can be submitted orally or in writing to the private hospital’s patient relations officer, doctor(s), nurse(s) or any healthcare professional of the private hospital.


The patient relations officer has to document all complaints and resolve the complaint within three working days. If she or he is unable to do so, the matter has to be referred to the licensee or person in charge of the private hospital, who shall investigate and provide a reply to the complainant within 10 working days.


The report shall include information to the complainant that if she or he considers the reply unsatisfactory, the matter can be referred, in writing, to the Director General of Health.


Exercising one’s rights
It would be prudent for a patient not to abdicate his or her rights but to exercise it from the time of entry to the time of exit from a private hospital.


Whenever admission, a procedure or operation is advised, one should ask the doctor the rationale for the recommendation. Any caring doctor would welcome such inquiries, as it is well documented that well informed patients have higher patient satisfaction rates than those less informed.


If there is any doubt, additional medical opinions can be sought, either at the same private hospital, another private hospital, or a public hospital. Medical opinions may differ as doctors have different approaches to management, depending on their experience, the facilities available at the private hospital, and their understanding of the patients’ preferences.


It is also important to remember that despite the technological advances, there are still uncertainties in the practice of medicine. It is advisable to ask the attending doctor for the reasons when a referral to another doctor is recommended.


Should a patient require hospitalisation, it would be advisable to ask at admission what the estimated hospital bill will be. One should also ask what the charges are for various services, particularly nursing services. The private hospital has a legal obligation to inform patient what is provided for each item that is to be charged and what is not.


One should always be wary of scam-like practices. For example, patients in one private hospital in the Klang Valley are persuaded by the hospital staff to part with their own medicines upon admission. The nurses subsequently serve patients’ their own medicines back to them. The patients are then charged for the so-called service!


The same private hospital has also set the amount that a ward or department charges its patients as a key performance indicator for its nursing sisters. This has led to unhealthy practices, e.g. patients being charged for nursing assistance when they go the toilet or when they press the call bell etc.


It is a patient’s right not to accede to scam-like or unhealthy practices. For example, one does not have to surrender to the staff of a private hospital the existing medicines that one already has, upon admission.


A useful tip is to request the private hospital to provide a daily update of the charges incurred. This will avoid any surprises when the final bill is presented. It will also serve notice that one is a discerning patient. If the amount has increased beyond one’s expectations, it would be prudent to request for an explanation, without delay. This is particularly so when the hospital stay is beyond that which is anticipated. The request can be made by the patient or his or her next of kin.


A word with the attending doctor(s) would be advisable if one is unable or unwilling to meet the rising hospital bill, which may occur because of complications or unanticipated events. In such situations, the attending doctor(s) has an obligation to make all efforts to arrange the transfer the patient to a public or less expensive private hospital.


When a private hospital bill is presented, it would be prudent to scrutinise it and ask for an itemised bill if the amount is more than that expected from the discussions prior to admission.


A discussion with the attending doctor(s) will clarify what investigations, imaging, procedure, or operation were carried out and whether particular items were used or prescribed.


All medicines have recommended retail prices. Whenever there is any doubt or dispute, a check with the local pharmacy will provide useful information on the reasonableness of the hospital’s pricing.


If the hospital charges for medicines are considered excessive, it is a patient’s right to request the attending doctor(s) to write a prescription for purchase of their medicines from a pharmacy.
Similarly, a check with other private laboratories will provide information on the usual charges for the various laboratory tests. Assistance may also be sought from the attending doctor(s) or one’s regular doctor to check on the reasonableness of charges for laboratory tests and imaging investigations.


Allegations about overcharging by private hospitals and their doctor(s) are not uncommon. The reasons for this include miscommunication, misperception, and overcharging.


If there is any indication that there is overcharging or the explanation provided by the private hospital or the attending doctor(s) is unsatisfactory, a report can be made. In the case of the private hospital, the report can be made to the Health Ministry; and in the case of the attending doctor(s), to the Malaysian Medical Council (MMC).


Both the Health Ministry and MMC have statutory authority to take action against the private hospital and doctor(s) respectively.


There have been occasional reports of private hospital staff refusing to release the body of a deceased patient from the mortuary until the hospital bill has been settled in full. Such conduct is considered unethical and any doctor involved in such activity may be the subject of disciplinary action.


Discounts
The question of discounts given by private hospitals to managed care organisations (MCOs), insurance companies, and corporate organisations crops up from time to time. The argument given is that since healthcare is considered a consumer service by some people, discounts could be given for volume, in the same way that discounts are given when bulk purchases of goods are made.


The press statement by the Director General of Health dated April 2, 2010, is of particular relevance. It states: “The Ministry would like to reaffirm that the practice of fee-splitting is a breach of the Private Healthcare Facilities and Services Act 1998 (Act 586) and its regulations. It is also unethical and is considered as a form of serious professional misconduct by the Malaysian Medical Council.


“Fee-splitting is defined under the Regulations of Act 586 as any form of kickbacks or arrangements made between practitioners, healthcare facilities, organisations, or individuals as an inducement to refer or receive a patient to or from another practitioner, healthcare facility, organisation, or individual. The term ‘organisation’ here includes any insurance company or corporate body.”


In short, patients’ interests cannot be traded like common goods sold in the supermarket. The fundamental question is: how much value should be placed on patients’ interests, i.e. how and to what extent discounts will benefit patients? Would the range of healthcare benefits of patients be increased? Would their premiums be adjusted downwards in subsequent year(s)? Is it acceptable for non-healthcare providers, whether they are MCOs, insurance companies or employers, to take a slice of the healthcare ringgit for its human resource and marketing expenditures, and provide dividends for their shareholders?


Be aware
There are two components of a private hospital bill, i.e. doctors’ professional fees and hospital charges. The former is regulated by law; the latter is unregulated.


Patients’ rights are already enshrined in the PHFSA and its regulations. There are specific sections in the PHFSA Regulations regarding private hospital bills and grievance mechanisms. It would be prudent for patients who seek treatment in private hospitals to be cognisant of their rights and to exercise it at all times.


A patient has a right to an itemised bill. There are various techniques that can be used to check on the reasonableness of a private hospital bill. If there is any indication of overcharging or the explanation provided by the private hospital or the attending doctor(s) is unsatisfactory, reports can be made to the Health Ministry and/or Malaysian Medical Council.
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In case you realized the fees stated in your itemized billing are not tally with the below stated maximum rates, pls contact Consumers Association of Penang (CAP) to help you escalate the issue.

Organisation Name: Consumers Association of Penang (CAP)
Address: 10 Jalan Masjid Negeri, 11600 Pulau Pinang
Telephone: +604 829 9511
Fax: +604 829 8109
Email: cap1@streamyx.com
Website: http://www.consumer.org.my
Main contact: Tuan Haji S.M. Mohd Idris

13th schedule
Private Healthcare Facilities & Services 1998 and Regulations 2006
PROFESSIONAL FEES

Procedure Fee
Adoption of 90% from maximum charges of 13th schedule of Private Healthcare Facilities & Services Regulation 2006 (PHFSA) rate.

Consultation Fees
The consultation within the range of 13th Schedule of PHFSA, charged at fixed rate. 

First A&E visit/initial consultation
During clinic hours
RM100
After clinic hours
- Before midnight
RM180
- After midnight
RM245

Outpatient visit /consultation
First visit/consultation
RM60-RM100

Follow up visit/consultation
RM35-RM60

Ward Visit
First Ward/initial visit (referred from MO)
During clinic hours
RM100
After clinic hours:
- Before midnight
RM180
- After midnight
RM245

First Consultation in ward (referred from other consultant)
During clinic hours
RM100
After clinic hours:
- Before midnight
RM150
- After midnight
RM245

Follow up ward visit
Week Days (2 visits per day)
RM 120 (RM60 per visit)
Rest day & Public Holidays
RM120
Night visit (called to see patient)
RM135

ICU/SCN Visit
Week Days
RM90
Rest day and Public Holidays
RM135
Night visit (called to see patient)
RM135


source: http://www.kpjselangor.kpjhealth.com.my 
Generated: 31 May, 2010, 08:00

Why buy Insurance for unborn child as early as 18 weeks into your pregnancy?

先天脑积水... Infantile Hydrocephalus...

Pediatric hydrocephalus affects one in every 500 live births, making it one of the most common developmental disabilities, more common than Down syndrome or deafness.

^Source: http://en.wikipedia.org/wiki/Hydrocephalus

PRUmy Child 婴儿保单里的 PRUbest start 有特别保障这种先天疾病，在肚子里18个星期的婴儿就可以买。。

FYI, this Congenital condition is specially covered under PRUmy Child plan, with attaching PRUbest start rider, specially created by PRUDENTIAL for your unborn child as early as 18 weeks up until 35 weeks into your pregnancy and if you are between 18 – 45 years of age next birthday.. 

详情，参考：
For more info, refer:

http://www2.prudential.com.my/corp/prudential_en_my/solutions/child/PMCPESPBS.html

or contact MARVYN CHOONG 012-5601227

Insurance Returns are LOW

Common Belief:

Insurance Companies like to quote us high NON-GUARANTEED returns on their quotations and entices us to buy their plans... But in actual fact, the returns are very LOW...

First of all, Insurance Products are normally used as a Protection Tool.

In case you are planning to get yourself an endowment savings plan, then you must be very clear of the rationale of doing this. The main reason we would want an endowment savings plan is because of the certainty, capital protected nature, for retirement savings purposes, and finally, in the event that we are critically ill, insurance companies will continue to save on behalf of us.

If you are going after higher returns, then you should look at Unit Trust Funds, or Investment-linked Insurance Plan.

Hey, but my Unit Trust Consultant told me that PROTECTIONS and INVESTMENTS should not mixed together. So, should I just leave investment-linked plans behind if I solely want to invest?

For your kind information, PRUDENTIAL ASSURANCE (M) BERHAD are able to offer affordable insurance plans for the Malaysian market made possible by the introduction of Investment-linked plans in 1997. Premiums paid under Investment-linked plans are not burned. A pool of cash value was created through the investments for our insurance plans without us even noticing it. For those who have their Investment-linked Insurance Plans purchased in the 90s, their cash value would have ballooned and they are laughing all the way to the bank without understanding why. That is only for a mere span of roughly 10 years plus. They asked me, how come got so much even though they have made several hospitalization claims in the past 10 years.

My own plan was bought in Year 2000 April, monthly premium RM150, total cash value up to date is already more than 5 figures. Wow, it is as if, I get almost 70% of my premiums back. I was covered by PRUDENTIAL for nothing? I love you, PRUDENTIAL.

Now, of course we need to understand how the whole things work, and whether this stellar performance of the Investments is sustainable. In short, everyone would like to know how it works, and whether it will work for those of you who plan to join now. Will it be too late and missed the boat already?

First of all, for all Investment-linked Plans, the premiums paid by us are converted to UNITS. It operates similarly to Unit Trusts Fund (a.k.a. Mutual Funds), where it charges a one time sales charges of 5%-6%, and yearly management fees of 0.8%-1.5% regardless of whether the fund make or loss money. But, the returns for Investment-linked Funds are much more consistent and stable than Unit Trust Funds.

REASON?

Simple, let’s say, in the year 2005, you decided to invest into a Unit Trust Fund of your choice (FUND A). Then your Unit Trust Consultant will most probably advise you to invest monthly, instead of lump sum investment. He would have told you everything about the power of Dollar-Cost Averaging (DCA), which is rephrased to RCA (Ringgit-Cost Averaging) in Malaysia. Your investment value is closely related to how much units you have accumulates at the end of the day, as all money invested are converted to units, by referring to the unit price on the day that you invest. [To those of you who are not so well-verse with the term RCA, it simply means that since the market fluctuates monthly, it is better to invest monthly to take advantage of the low price in exchange for more units.]

So, heeding his advice, you decided to invest RM200 monthly into the fund. But so happen that there is a newly launch fund which offer free units, and lower sales charges of less than 5%, you decided to invest in the new fund (FUND B) instead. Then in the year 2007, market have reach its peak, will you withdraw your cash from the fund to take profits? Maybe yes, maybe no for some. Doesn’t matter. Will you continue to invest at the peak? Probably not. Suddenly, in the year 2008, market crash, will you still continue to invest the RM200 monthly? For majority, people will freak out and stop investing in 2008 although that is the best time to invest as the unit price have gone down and it is very very cheap. But most stop investing more money. What is making things worst, is when a lot of people not only stop plugging more money into the fund, they withdraw it. Let’s assume that the Fund Manager for FUND B is a fundamental long-term investor, and he had invested heavily to take advantage of the cheap market. But can he invest more when many of its Unit Holders are withdrawing? He might even be force to sell the shares at loss just to meet the withdrawing requirements of the Unit Trust Fund. Even if you have decided to continue invest the RM200 throughout the market low, you might face the uncertainty of losing more money because your Fund Manager are forced to sell at loss.

NOW, how is Investment-linked Fund different?

Everyone who bought an Investment-linked policy from PRUDENTIAL, will only have 3 non-shariah funds and 3 shariah-compliance funds to choose.

The funds are:

PRUlink Equity

PRUlink Managed

PRUlink Bond

PRUlink Dana Unggul

PRUlink Dana Urus

PRUlink Dana Aman

In fact, for PRUlink Managed, 70% are invested in PRUlink Equity and 30% goes back to PRUlink Bond. Same case for PRUlink Dana Urus which invest 70% back to PRUlink Dana Unggul and 30% into PRUlink Dana Aman. So, there are actually only 4 funds altogether, right?

When do we normally withdraw from our Investment-linked Insurance Plans?

We normally only withdraw our plans, either when we die, totally and permanently disabled, and when we are diagnosis with critical illnesses. Regardless of market directions, you still pay the premiums for your Insurance Plans, right? Will you cancel your Medical Insurance because the market has reached new height?

These are why Investment-linked funds are much more stable than Unit Trust funds in general. The demands are always consistent and keep growing because every now and then, people are buying PRUDENTIAL insurance and they are indirectly participating in above 4 funds. What about the supply then? Supply is already fixed and will only increase if there are demands. So, in short, with increasing steady demands, the units prices of the funds are definitely have only one direction, which is UP NORTH.

Are you sure that Life Insurance gives HIGH returns?

People always say that:

Insurance Companies like to quote us high NON-GUARANTEED returns on their quotations and entices us to buy their plans... But in actual fact, the returns are very LOW...

Well, you do not need to believe me. Go pick up a copy of July 2011 issued of PERSONAL MONEY magazine and look under the column of PRUDENTIAL PRUlink Equity Fund, you will be shock to find out that the 5 years average returns per annum is 12.57%. Now, who is misleading you with the statement that Life Insurance gives low returns?

Is 12.57% per annum for 5 years average consider as high?

Did I just explain that why the returns of Investment-linked are so stable and so…. HIGH?

Since PRUlink Equity launched in 1997 at unit price of RM1, it has never dip below that value even in the year 2008 when global market crash. I have no shares in company that sell or distribute PERSONAL MONEY, so for those of you who want to save a buck, you may view it for free at MPH, or borrow it from friends who bought the magazine, or alternatively, you may refer to www.bloomberg.com/apps/quote?ticker=PRLEQTY:MK for the latest price. Today it is hovering at the range of RM3.30 a unit.

Of course, past performance of the funds is not a guide to the future or likely performance of the funds, and it all depends on the investing experiences of the Fund Manager, and the market conditions.

Want to know how you may participate in this HIGH returns plan, contact me at 012-5601227 or email me at marvyncjj@gmail.com.

What if your Policies are Purchased 5 to 10 years ago?

After flipping through various policy documents, and researching the different versions of Annexures for Critical Illnesses under PRUDENTIAL ASSURANCE (M) BERHAD, I came to a conclusion. There are altogether 3 versions of Annexure namely Annexure DFH, DFL, and the latest being DFN.

Annexure DFH was introduced much earlier than year 2000, but I have no record when the Annexure was finally replaced by Annexure DFL and DFN. Well, let's talk about the latest versions of Annexure DFL and DFN first. Many must be curious is there any differences? YES, I found out that the only difference between Annexure DFL & DFN is the numbering for item (20) Loss of Independent Existence and item (21) Loss of Speech. Everything else are exactly the same for arrangements, numbering and wordings.

I have attached a copy of the initial Annexure DFH for policies prior to year 2000 below. If you have gone through all the items below like myself and comparing it to the latest Annexure DFN (published in previous post), you would have noticed that there are significant differences in the wordings, descriptions, and items. For certain illnesses, it seems the wordings are more lenient and not so many details or qualifications listed. There are these so called gray area where you stand a chance to "fight" if you wish. I also noticed that the phrase "as is appropriate if applicable" was totally removed in the latest Annexure DFL & DFN altogether, unlike Annexure DFH which uses quite a number of them.

Now, many would have wonder why I wasted so much time finding the differences? Just for fun? 

The rational of finding the differences is to answer the question, should we increase the coverage in older policies, or should we purchase new policy with the newer Annexure DFN which comes with clearer but stricter definitions?

But wait a minute, isn't it if you add on the Critical Illness cover today, your coverage will follow the latest Annexure DFN? 

Yes, at first we also thought that if we add on the coverage for critical illness, be it in older policies or getting new policy, we will get the latest Annexure DFN, but NO. Upon confirming with company, it is confirmed that, if the extra coverage will follow old Annexure. 

So, should we add on to older policies (if you have one), or should we just get a new one? Or should we cancel off the old policy and consolidates all into new one?

To the first question, preferably to get new policy with latest Annexure DFN because the 36 types included did not overlap itself unlike the old one. 

To the 2nd question, like I mentioned in previous posting, never cancel an older policy just to get a new one. Agents who influenced you to do so can be sued. It was because older policies are generally cheaper than newer policies, as the age of entry are different. Furthermore, it is clearly stated that Critical Illnesses shall means any one of the following illnesses as defined separately hereunder occuring more than 30 days (60 days for Heart Attack, Coronary Artery Heart Disease or Cancer) after the Commencement Date of the Policy as specified in the Schedule or the date of any Revival of Benefit(s) or the date of any Endorsement of Benefit(s) secured under the Policy or the date issue of this Annexure whichever is latest. Anything less than the waiting period is considered PRE-EXISTING ILLNESS, and is not covered. So, you are advisable to get additional coverage under new policy.

(1) Heart Attack

The death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis in respect of this illness must be based on the meeting of all of the following criteria:
(i) a history of typical chest pain;
(ii) new electrocardiographic changes; and
(iii) elevation of the cardiac enzyme.

(2) Coronary Artery Disease Requiring Surgery

The undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts in persons with limiting anginal symptoms, but excluding non-surgical techniques such as balloon angioplasty or laser relief of an obstruction.

(3) Stroke

Any cerebrovascular incident producing neurological sequelae lasting more than twenty four hours and including infarction of brain tissue, haemorrhage and embolisation from an extra-cranial source. There must be evidence of permanent neurological deficit.

(4) Cancer

A malignant tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. This includes leukaemia but excludes non-invasive cancers in situ, tumours in the presence of any Human Immunodeficiency Virus and any skin cancer other than malignant melanoma.

(5) Kidney Failure

End stage renel disease, due to whatever cause or causes, with the insured undergoing regular peritoneal dialysis or haemodialysis or having had renel transplantation.

(6) Paralysis

The complete and permanent loss of use of two or more limbs through paralysis.

(7) Major Organ Transplantation

The actual undergoing as a recipient of a transplant of a heart, heart and lung, liver, pancreas, kidney or bone marrow.

(8) Multiple Sclerosis

The unequivocal diagnosis by a consultant neurologist registered in Malaysia or Singapore confirming more than one episode of well-defined neurological deficit, with persisting signs of involvement of the optic nerves, brain stem and spinal cord together with impairment of co-ordination and motor and sensory function, with the Assured or the Life Assured (as is appropriate if applicable) not necessarily confined to a wheelchair.

(9) Fulminant Viral Hepatitis

A submassive to massive necrosis of the liver caused by the Hepatitis virus, leading precipitously to liver failure. The diagnostic in respect of this illness must be based on the meeting of all of the following criteria:
(i) a rapidly decreasing liver size;
(ii) necrosis involving entire lobules, leaving only a collapsed reticular framework;
(iii) rapidly degenerating liver functions tests; and
(iv) deepening jaundice.

Excluding however the diagnosis of this illness if such diagnosis is directly or indirectly caused by attempted suicide, poisoning, drug overdose and excessive alcohol ingestion.

(10) Pulmonary Arterial Hypertension

Primary pulmonary hypertension as established by clinical and laboratary investigations including cardiac catheterization.

(11) Coma

A state of unconsciousness with no reaction to external stimuli or internal needs, persisting continuously with the use of life support systems for a period of at least 96 hours and resulting in permanent neurological deficit.

(12) Blindness

A total, permanent and irrecoverable loss of all vision in both eyes.

(13) Heart Valve Surgery

The undergoing of open heart surgery to correct valvular abnormalities.

(14) Surgery To The Aorta

The undergoing of surgery to correct any narrowing, dissection or aneurysm of the thoracic and abdominal aorta.

(15) Alzheimer’s Disease

Deterioration or loss of intellectual capacity or abnormal behavior as evidenced by the clinical state and accepted standardized questionnaires or tests arising from Alzheimer’s Disease or irreversible organic degenerative disorders, excluding neurosis and psychiatric illness, resulting in significant reduction in mental and social functioning requiring the continuous supervision of the Assured or the Life Assured (as is appropriate where applicable).

(16) Deafness

Total and irreversible loss of hearing in both ears.

(17) Loss of Speech

Total and irrecoverable loss of the ability to speak due to physical damage to the vocal cord.

(18) Major Burns

Third degree burns covering at least 20% of the surface area of the Assured’s or the Life Assured’s body (as is appropriate where applicable).

(19) Terminal Illness

In the opinion of the medical specialist involved and subject to the acceptance of the Company’s appointed medical officer the advent of death is highly likely within 12 months.

(20) AIDS Due To Blood Transfusion

The Assured or the Life Assured (as is appropriate where applicable) being infected by Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome provided that:
(i) the infection is due to blood transfusion received in Malaysia after the commencement of the Policy;
(ii) the infected Assured or Life Assured (as is appropriate where applicable) is not a haemophiliac;
(iii) there is no known cure.

(21) Motor Neurone Disease

Motor neurone disease of unknown aetiology is characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. These include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary lateral sclerosis.

Claims shall only be admitted if the condition is confirmed by a consultant neurologist registered in Malaysia or Singapore as progressive and resulting in irreversible damage to the nervous system.

(22) Parkinson’s Disease

Slowly progressive degenerative disease of the central nervous system as a result of loss of pigment containing neurons of the brain.

Unequivocal diagnosis of Parkinson’s Disease must include the following conditions:

(i) cannot be controlled with medication;
(ii) shows signs of progressive impairment;

(iii) inability of the Assured or the Life Assured (as is appropriate where applicable) to  perform three or more of the following – bathing, dressing, using the lavatory, eating, ability to move in or out of bed or chair.

and must be made by a consultant neurologist registered in Malaysia or Singapore. Only idiopathic Parkinson’s Disease is covered. All other forms of Parkinsonism are excluded. 

(23) Chronic Liver Disease

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

(i) permanent jaundice;

(ii) ascites;

(iii) encephalopathy.

Liver disease secondary to excessive alcohol ingestion, drug misuse or attempted suicide is excluded.

(24) Chronic Lung Disease

End stage lung disease including interstital lung disease requiring extensive and permanent oxygen therapy as well as a FEV1 test result of consistently less than one liter.

(25) Aplastic Anaemia

Bone marrow failure which results in anaemia, neutropenia and thrombocytopenia requiring treatment with at least one of the following:
(i) blood product transfusion;
(ii) marrow stimulating agents;
(iii) immunosuppressive agents;
(iv) bone marrow transplantation.

(26) Muscular Dystrophy

A hereditary muscular dystrophy confirmed by a consultant neurologist registered in Malaysia or Singapore resulting in the inability to perform without assistance three or more of the following – bathing, dressing, using the lavatory, eating, ability to move in or out of bed or chair.

(27) Poliomyelitis

Unequivocal diagnosis by a consultant neurologist registered in Malaysia or Singapore of infection by the polio virus leading to paralytic disease as evidenced by impaired motor function or respiratory weakness. Cases not involving paralysis will not be eligible for this benefit. Other causes of paralysis are specifically excluded.

(28) Bacterial Meningitis

Bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in permanent neurological deficit, the diagnosis to be confirmed by a consultant neurologist registered in Malaysia or Singapore.

(29) Benign Brain Tumor

A non-cancerous tumour in the brain. Cysts, granulomas, malformations in, or of, the arteries or veins of the brain, haematomas and tumours in the pituitary gland or spine are excluded.

(30) Encephalitis

Severe inflammation of brain substance which results in significant and permanent neurological sequelae as certified by a consultant neurologist registered in Malaysia or Singapore. Encephalitis as a result of HIV infection is excluded.

(31) Full Blown AIDS

Clinical manifestation of AIDS (Acquired Immune-deficiency Syndrome), which must be supported by the results of a positive HIV (Human Immuno-deficiency Virus) antibody test and a confirmatory Western Blot test. In addition, the diagnosis in respect of this illness must be based on the meeting of all of the following criteria at the time of the diagnosis:

(i) the Assured or the Life Assured (as is appropriate where applicable) must have a CD4 cell count of less than 200 and have evidence of opportunistic infection and/or AIDS related tumours; and

(ii) there is no known cure.

In the event of a claim except for PRUpayor, PRUspouse payor and PRUparent payor, 50% of all applicable Benefits (up to a maximum of RM500,000 on any one life under this and all other policies) payable in respect of this illness will be paid. The balance amount shall be payable on death, total permanent disability or the diagnosis of another Critical Illness whichever shall first occur.

(32) Other Serious Coronary Artery Disease

The narrowing of the lumen of at least three coronary arteries by a minimum of 75%, as proven by coronary arteriography carried out in Malaysia or Singapore, regardless of whether any form of coronary artery surgery has been performed.

(33) Brain Surgery

The actual undergoing of surgery to the brain under general anesthesia during which a craniotomy is performed. Brain surgery following an accident is excluded.

(34) Appalic Syndrome

Universal necrosis of the brain cortex, with the brainstem remaining intact. The definite diagnosis must be confirmed by a consultant neurologist registered in Malaysia or Singapore. The condition has to be medically documented for at least one month.

(35) Major Head Trauma

Accidental head injury resulting in cerebral damage (as demonstrated by modern scanning or imaging techniques and certified by a consultant neurologist registered in Malaysia or Singapore) leading to permanent functional impairment and the inability to perform without assistance of at least 3 of the following activities of daily living: - bathing, dressing, using the lavatory, eating, ability to move in or out of bed or chair.

(36) Loss of Limbs

A complete and permanent loss of use of two or more limbs. Loss of use must be established for a continuous period of at least six months and be supported by appropriate medical evidence confirmed by a consultant neurologist registered in Malaysia or Singapore.

The Brief History and Developments of the Definitions for 36 Critical Illnesses or Dread Diseases in Malaysia Insurance Industry

Before we buy an Insurance plan, how many of us will normally ask an Insurance Agent to show them the detail definitions of the 36 Critical Illness of the respective Insurance company? Do you go through the definitions one by one? Do you know that every Insurance Company will have their own sets of 36 types of Critical Illnesses?

Well, let me share a brief introduction of the history and development of the definitions for 36 Critical Illnesses in Malaysia. Prior to Year 2000, every company has their own definition, and Insurance Companies are free to define themselves each and every illnesses as they feel appropriate. Smaller companies will tend to follow suit and include the illnesses in their plans and modify a little here and there. Big leading companies will try to include as many illnesses as possible to capture the market shares, starting from one company coming out with 3 Illnesses, then another introduced 8 Illnesses, and then the next one topping up till 12 Illnesses, all trying to steal the market by introducing more and more each and every year. Finally, it has reach to a level where we have seen today, a total of 36 Illnesses.

Then problem arise, so happen that there is a person who have 3 policies from 3 different Insurance companies diagnosis with a critical illness, but only able to claim from 2 policies. Reason given is that, although his critical illness matched with the definitions of 2 companies, resulting in 2 claims, the third one was not. The third company denied honoring the claim despite the policy holder file to the tribunal. And it happen that, the third company is not liable to pay, because the definition in the policy document do not matched the conditions experienced by the policy holder.

This issue of course did not end there. BNM (Bank Negara Malaysia) being the parent of all banking and insurance industry, steps in and required that all insurance companies should form an association for self-regulation and there should be a standardization across the board. So, LIAM (Life Insurance Association Malaysia) was tasked to regulate and standardize all the definitions for Critical Illnesses. 

Today, Insurance Companies are free to choose from a total of 42 Critical Illnesses and formulate their own 36 Illnesses, but definitions will be the same across all companies. Out of the 42 definitions, AIDS are separated into 3 definitions, but luckily PRUDENTIAL chose to combine into 1.
(1) Full Blown AIDS
(2) AIDS due to Blood Transfusion
(3) AIDS Cover of Medical Staff

Another example, Coronary Artery Disease are also separated into 3 illnesses, but PRUDENTIAL also combine into 1.
(1) Coronary Artery Disease Requiring Surgery
(2) Other Serious Coronary Artery Disease
(3) Angioplasty and Other Invasive Treatments for Coronary Artery Disease

I do not include other companies’ definitions here as I am not representations of other companies other than PRUDENTIAL. Here is the definition taken from latest PRUDENTIAL Life insurance policy, as at the time of writing. (ANNEXURE DFN)

In case you find that your current coverage are not complete, please consider getting additional coverage instead of cancelling old policies because older policies’ definitions are generally more lenient, and definitely cheaper than if you are purchasing new today because of your age.

DISCLAIMERS:

Please do not take this note as final, as upon claims, your policy documents will be served as final supporting documents for filing of claim. In case there is any part that I unintentionally missed, or mislead, I should not be liable as this is just for reference and do not construes as any law-abiding document. Please ignore this in case you find that I am misleading. I do this out of my interests to educate my friends and clients, and represent my sole views and opinions and have nothing to do with PRUDENTIAL ASSURANCE (M) BHD.

(1) AIDS

(a) AIDS Due To Blood Transfusion

Shall mean the Insured Life being infected by HIV virus or AIDS provided that:

(i) the infection is due to blood transfusion received in Malaysia or Singapore after the commencement of the Policy;
(ii) the Insured Life is not a haemophiliac; and
(iii) the Insured Life is not a member of any high risk groups such as but not limited to homosexuals, intravenous drug users or sex workers.

Notification & proof of incident will be required via a statement from a statutory Health Authority that the infection is medically acquired.

(b) Full Blown AIDS

Shall mean the clinical manifestation of AIDS (Acquired Immune-deficiency Syndrome) must be supported by the results of a positive HIV (Human Immuno-deficiency Virus) antibody test and a confirmatory Western Blot test. In addition, the Insured Life must have a CD4 cell count of less than two hundred (200) and one or more of the following criteria are met:
(i) Weight loss of more than 10% of body weight over a period of six (6) months or less (wasting syndrome); or
(ii) Kaposi Sarcoma; or
(iii) Pneumocystic Carinii Pneumonia; or
(iv) Progressive multifocal leukoencephalopathy; or
(v) Active Tuberculosis; or
(vi) Less than one-thousand (1000) lymphocytes; or
(vii) Malignant Lymphoma.

(2) Aplastic Anaemia

Shall mean chronic persistent bone marrow failure which results in total aplasia of the bone marrow & requires treatment with at least one of the following:

(a) Regular blood product transfusion; or
(b) Marrow stimulating agents; or
(c) Immunosuppressive agents; or
(d) Bone marrow transplantation.

(3) Apallic Syndrome

Shall mean universal necrosis of the brain cortex, with the brainstem remaining intact. Diagnosis must be confirmed by a neurologist & condition must be documented for at least one month.

(4) Alzheimer’s Disease

Shall mean deterioration or loss of intellectual capacity or abnormal behavior as evidenced by the clinical state and accepted standardized questionnaires or tests arising from Alzheimer’s Disease or irreversible organic degenerative brain disorders excluding neurosis, psychiatric illness, and any drug or alcohol related organic disorder, resulting in significant reduction in mental and social functioning requiring the continuous supervision of the life insured. The diagnosis must be clinically confirmed by an appropriate consultant.

(5) Benign Brain Tumor

Shall mean a life-threatening, non-cancerous tumour in the brain giving rise to characteristic signs of increased intra-cranial pressure such as papilloedema, mental symptoms, seizures and sensory impairment. The presence of the underlying tumour must be confirmed by imaging studies such as CT Scan or MRI. The following are excluded:
(a) Cysts;

(b) Granulomas;

(c) Malformations in or of the arteries or veins of the brain;

(d) Haematomas;

(e) Tumours in the pituitary gland, or spine; and

(f) Tumours of the acoustic nerve.

(6) Blindness

Shall mean the total, permanent and irrecoverable loss of the sight of both eyes. Certification by an ophthalmologist is necessary.

(7) Brain Surgery

Shall mean the actual undergoing of surgery to the brain under general anesthesia during which a craniotomy is performed. Bur Hole & brain surgery as a result of an accident is excluded.

(8) Cancer

Shall mean uncontrollable growth & spread of malignant cells and the invasion & destruction of normal tissue for which major interventionist treatment or surgery (excluding endoscopic procedures alone) is considered necessary. The cancer must be confirmed by histological evidence of malignancy.
The following conditions are excluded:-
(a) Carcinoma in situ including of the cervix;
(b) Ductal Carcinoma in situ of the breast;
(c) Papillary Carcinoma of the bladder & Stage 1 Prostate Cancer;
(d) All skin cancers except malignant melanoma;
(e) Stage I Hodgkin’s disease; and
(f) Tumors manifesting as complications of AIDS.

(9) Cardiomyopathy

Shall mean the unequivocal diagnosis by a consultant cardiologist of cardiomyopathy causing impaired ventricular function, suspected by ECG abnormalities and confirmed by cardiac echo of variable aetiology and resulting in permanent physical impairments to the degree of at least class III of the New York Association Classification of cardiac impairment.

Class III – Marked limitation – Such patients are comfortable at rest but performing less than ordinary activity will lead to symptoms of Congestive Cardiac Failure.

Class IV – Inability to carry out any activity without discomfort. Symptoms of Congestive Cardiac Failure are present even at rest. With any increase in physical activity, discomfort will be experienced.

Cardiomyopathy directly related to alcohol misuse is excluded.

(10) Chronic Liver Disease

Shall mean end stage liver failure evidenced by all of the following:

(a) Permanent jaundice;

(b) Ascites;

(c) Encephalopathy; and

(d) Portal hypertension

Wernicke’s encephalopathy & liver failure secondary to alcohol or drug misuse is excluded.

(11) Chronic Lung Disease

Shall mean end stage respiratory failure including chronic interstitial lung disease.
The following criteria must be met:

(a) Requiring permanent oxygen therapy as a result of a consistent FEV1 test value of less than one liter. (Forced Expiratory Volume during the first second of a forced exhalation);
(b) Arterial Blood Gas analysis with partial oxygen pressures of 55mmHg or less;
(c) Dyspnoea at rest.

(12) Coma

Shall mean a state of unconsciousness with no reaction or response to external stimuli or internal needs, persisting continuously for at least 96 hours, requiring the use of life support systems and resulting in a neurological deficit, lasting more than 30 days. Confirmation by a neurologist must be present.

Coma resulting directly from self-inflicted injury, alcohol or drug misuse is excluded.

(13) Coronary Artery Disease

(a) Coronary Artery Disease Requiring Surgery

Shall mean the actual undergoing of Coronary artery by-pass surgery by way of thoracotomy to correct or treat coronary artery disease but not including angioplasty, other intra-arterial, keyhole or laser procedures.

(b) Other Serious Coronary Artery Disease

Shall mean the narrowing of the lumen of at least three major arteries i.e. Circumflex, Right Coronary Artery (RCA), Left Anterior Descending Artery (LAD), by a minimum of 60 percent or more as proven by coronary arteriography. This benefit is payable regardless of whether or not any form of coronary artery surgery has been performed.

(c) Angioplasty and Other Invasive Treatments for Coronary Artery Disease

Shall mean the actual undergoing for the first time of Coronary Artery Ballon Angioplasty, artherectomy, laser treatment or the insertion of a stent to correct a narrowing or blockage of one or more coronary arteries. Intra-arterial investigative procedures are not included.

Medical evidence shall include all of the following:
(i) Evidence of significant and relevant ECG changes (ST segment depression of 2 millimeters or more) and
(ii) Angiographic evidence to confirm the location of stenosis.

(14) Deafness

Shall mean total, permanent and irreversible loss of hearing in both ears as a result of disease or accident. Medical evidence in the form of an audiometry and sound-threshold test must be provided.

(15) Encephalitis

Shall mean severe inflammation of brain substance, resulting in permanent neurological deficit lasting for a minimum period of 30 days and certified by a consultant neurologist. The permanent deficit must result in an inability to perform at least three (3) of the following Activities of Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For the purpose of this benefit, the word “permanent”, shall mean beyond the hope of recovery with current medical knowledge and technology.

The Activities of Daily Living are:

(a)        Transfer

Getting in & out of a chair without requiring any physical assistance.

(b)        Mobility

The ability to move from room to room without requiring any physical assistance.

(c)        Continence

The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.

(d)       Dressing

Putting on and taking off all necessary items of clothing without requiring assistance of another person.

(e)        Bathing / Washing

The ability to wash in the bath and shower (including getting in or out of the bath or shower) or wash by any other means.

(f)        Eating

All tasks of getting food into the body once it have been prepared.

Encephalitis as a result of HIV infection is excluded.

(16) Fulminant Viral Hepatitis

Shall mean a sub massive to massive necrosis of the liver caused by any virus leading precipitously to liver failure.

The diagnostic criteria to be met are:
(a) A rapidly decreasing liver size as confirmed by abdominal ultrasound;
(b) Necrosis involving entire lobules, leaving only a collapsed reticular framework;
(c) Rapidly deteriorating liver functions tests; and
(d) Deepening jaundice.

Hepatitis B infection or carrier status alone does not meet the diagnostic criteria.

(17) Heart Attack

Shall mean death of a portion of the heart muscle (myocardium) as a result of inadequate blood supply and being evidenced by:-

(a) A history of typical prolonged chest pain;
(b) New electrocardiographic changes resulting from this occurrence; and
(c) Elevation of the cardiac enzyme (CPK-MB) above the generally accepted laboratory levels of normal.

Diagnosis based on the elevation of Troponin T test alone shall not be considered diagnostic of a heart attack.Angina is specifically excluded.

(18) Heart Valve Replacement

Shall mean the actual undergoing of open-chest surgery to replace or repair cardiac valves as a consequence of heart valve defects or abnormalities that have occurred after the date of issue or date of reinstatement of this contract.

Repair, via valvotomy, intra-arterial procedure, key-hole surgery or similar techniques are specifically excluded.

(19) Kidney Failure

Shall mean end stage kidney failure presenting as chronic irreversible failure of both kidneys to function, as a result of which regular renal dialysis is initiated or renal transplantation carried out.

(20) Loss of Independent Existence

Shall mean confirmation by a Consultant Physician of the loss of independent existence lasting for a minimum period of 6 months and resulting in a permanent inability to perform at least three (3) of the following Activities of Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For the purpose of this benefit, the word “permanent”, shall mean beyond the hope of recovery with current medical knowledge and technology.

The Activities of Daily Living are:

(a)        Transfer

Getting in & out of a chair without requiring any physical assistance.

(b)        Mobility

The ability to move from room to room without requiring any physical assistance.

(c)        Continence

The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.

(d)       Dressing

Putting on and taking off all necessary items of clothing without requiring assistance of another person.

(e)        Bathing / Washing

The ability to wash in the bath and shower (including getting in or out of the bath or shower) or wash by any other means.

(f)        Eating

All tasks of getting food into the body once it have been prepared.

(21) Loss of Speech

Shall mean total and irrecoverable loss of the ability to speak for a continuous period of 12 months. Medical evidence to confirm injury or illness to the vocal cords to support this disability must be supplied by an appropriate (Ear, Nose, Throat) specialist.
All psychiatric related causes are excluded.

(22) Major Burns

Shall mean third degree burns covering at least twenty percent (20%) of the Insured Life’s body surface area as measured by “The Rule of 9” of the Lund & Browder Body Surface Chart.

(23) Major Head Trauma

Shall mean physical head injury causing significant permanent functional impairment lasting for a minimum period of three (3) months from the date of the trauma or injury. The resultant permanent functional impairment is to be verified by a consultant neurologist and duly concurred by the Company’s Medical Officer and must result in an inability to perform at least three (3) of the following Activities of Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For the purpose of this benefit, the word “permanent”, shall mean beyond the hope of recovery with current medical knowledge and technology.

The Activities of Daily Living are:

(a)        Transfer

Getting in & out of a chair without requiring any physical assistance.

(b)        Mobility

The ability to move from room to room without requiring any physical assistance.

(c)        Continence

The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.

(d)       Dressing

Putting on and taking off all necessary items of clothing without requiring assistance of another person.

(e)        Bathing / Washing

The ability to wash in the bath and shower (including getting in or out of the bath or shower) or wash by any other means.

(f)        Eating

All tasks of getting food into the body once it have been prepared.

(24) Major Organ Transplant

Shall mean the actual undergoing of a transplant as a recipient of one of the following human organs:

(a) Kidney(s)
(b) Lung(s)
(c) Liver
(d) Heart
(e) Bone marrow

(25) Medullary Cystic Disease

Shall mean a progressive hereditary disease of the kidneys characterized by the presence of cysts in the medulla, tubular atrophy and intestitial fibrosis with the clinical manifestations of anaemia, polyuria and renel loss of sodium, progressing to chronic renal failure. Diagnosis should be supported by renel biopsy.

(26) Meningitis

Shall mean bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in permanent neurological deficit lasting for a minimum period of 30 days & resulting in a permanent inability to perform at least three (3) of the following Activities of Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For the purpose of this benefit, the word “permanent”, shall mean beyond the hope of recovery with current medical knowledge and technology.

The Activities of Daily Living are:

(a)        Transfer

Getting in & out of a chair without requiring any physical assistance.

(b)        Mobility

The ability to move from room to room without requiring any physical assistance.

(c)        Continence

The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.

(d)       Dressing

Putting on and taking off all necessary items of clothing without requiring assistance of another person.

(e)        Bathing / Washing

The ability to wash in the bath and shower (including getting in or out of the bath or shower) or wash by any other means.

(f)        Eating

All tasks of getting food into the body once it have been prepared.

(27) Motor Neurone Disease

Shall mean motor neurone disease of unknown aetiology is characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. These include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary lateral sclerosis.

Diagnosis must be confirmed by a consultant neurologist.

(28) Multiple Sclerosis

Shall mean unequivocal diagnosis by a consulting neurologist confirming the following combination, which has persisted for at least a continuous period of six (6) months:

(a) Symptoms referable to tracts (white matter) involving the optic nerves, brain stem and spinal cord, producing well-defined neurological deficits;
(b) A multiplicity or discrete lesions; and
(c) A well-documented history of exacerbation and remissions of said symptoms / neurological deficits.

(29) Muscular Dystrophy

Shall mean the diagnosis of muscular dystrophy shall require a confirmation by a consultant neurologist of the combination of 3 out of 4 of the following conditions:

(a) Family history of other affected individuals; or
(b) Clinical presentation including absence of sensory disturbance, normal cerebro-spinal fluid and mild tendon reflex reduction; or
(c) Characteristic electromyogram; or
(d) Clinical suspicion confirmed by muscle biopsy.

Children are excluded from the definition.

(30) Paralysis

Shall mean the complete and permanent loss of use of both arms or both legs, or one arm and one leg, through paralysis caused by illness or injury persisting for at least six (6) months from the date of trauma or illness.

(31) Parkinson’s Disease

Shall mean unequivocal diagnosis of Parkinson’s Disease by a consulting neurologist where the condition:

(a) Cannot be controlled with medication
(b) Shows signs of progressive impairment

Activities of daily living assessment confirm the inability of the life insured to perform without assistance three (3) or more of the following:

(a)        Transfer

Getting in & out of a chair without requiring any physical assistance.

(b)        Mobility

The ability to move from room to room without requiring any physical assistance.

(c)        Continence

The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.

(d)       Dressing

Putting on and taking off all necessary items of clothing without requiring assistance of another person.

(e)        Bathing / Washing

The ability to wash in the bath and shower (including getting in or out of the bath or shower) or wash by any other means.

(f)        Eating

All tasks of getting food into the body once it have been prepared.

Only idiopathic Parkinson’s Disease is covered. Drug-induced or toxic causes of Parkinsonism are excluded.

(32) Poliomyelitis

Shall mean unequivocal diagnosis by a consultant neurologist of infection with the Poliovirus leading to paralytic disease as evidenced by impaired motor function or respiratory weakness. Cases not involving paralysis will not be eligible for this benefit. Other causes of paralysis (such as Guillain-Barre syndrome) are specifically excluded.

(33) Primary Pulmonary Arterial Hypertension

Shall mean primary pulmonary hypertension with substantial right ventricular enlargement established by investigations including cardiac catheterization, resulting in permanent irreversible physical impairment to the degree of at least Class 3 of the New York Heart Association Classification of cardiac impairment, & resulting in the Life Assured being unable to perform his/her usual occupation.

(34) Stroke

Shall mean a cerebrovascular accident or incident producing neurological sequelae of a permanent nature, having lasted not less than six months. Infarction of brain tissue, haemorrhage and embolisation from an extra-cranial source are included. The diagnosis must be based on changes seen in a CT scan or MRI and certified by a neurologist.

Specifically excluded are cerebral symptoms due to transient ischaemic attacks, any reversible ischaemic neurological deficit, vertebrobasilar ischaemia, cerebral symptoms due to migraine, cerebral injury resulting from trauma or hypoxia & vascular disease affecting the eye or optic nerve or vestibular functions.

(35) Surgery To Aorta

Shall mean the actual undergoing of surgery via a thoracotomy or laprotomy to repair or correct an aortic aneurysm, an obstruction of the aorta or a coarctation of the aorta. For the purpose of this definition, aorta shall mean the thoracic and abdominal aorta but not its branches.

(36) Systemic Lupus Erythematosus Lupus Nephritis

Shall mean a multisystem, multifactorial, autoimmune disorder which affects mostly females in their childbearing years & is characterized by the development of auto-antibodies, directed against various self-antigens.

In respect f this contract, SLE will be restricted to those forms of systemic lupus erythematosus which involve the kidneys (Type III to Type IV Lupus Nephritis, established by renel biopsy). Other forms, discoid lupus, and those forms with only haematological and joint involvement will be specifically excluded.

WHO Lupus Classification:

Class I (minimal change)                     - Negative, normal urine

Class II (Mesangial)                            - Moderate proteinuria, active sediment

Class III (Focal Segmental)                - Proteinuria, active sediment

Class IV (Diffuse)                              - Acute nephritis with active sediment and/or nephritis Syndrome

Class V (Membranous)                       - Nephrotic Syndrome or severe proteinuria.