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.