Do u read the HIDDEN CLAUSES in your Policy Documents?

I just found out that under Annexure for IL Health Protector, Sec 6, Policy Conditions, Sub Sec 6.7. Renewability Privilege & Sub Sec 6.10. Portfolio Withdrawal Condition, GE reserves the right to cancel the portfolio as a whole if it decides to discontinue underwriting this insurance product.

In short, it means that whatever funky terms u purchase today might be withdrawn in the future. That's the fine prints u need to beware.

Isn't it that when we buy medical plan, we want the plan to be around and cover us until age 70, 80 or 100, and the terms and conditions to stay the same no matter what is the status of our health conditions by then?

We will definitely be more healthier today than 30 years down the road. But when our medical plan that we assumed will cover us until age 80, changed midway, or worst still, been withdrawn altogether, who will pay for our medical bills during our golden years?

A check at Prudential Policy Document revealed that, Prudential don't have such clauses that take advantages of it's clients.

Under Part 6: General Conditions for Annexure PRUhealth, Sub Sec A, Non-Cancellable. The Annexure is non-Cancellable by the Company except where there is fraud or any circumstance that renders the policy null and void, provided always that all premiums are duly paid AND that the Policy remains in force.

In summary, Prudential cannot withdraw the plan sold to us, nor can they change the terms or clauses in the Annexure as they like.

The purpose of bringing this up is so that u guys aware what u are getting yourself into when u got yourself a medical plan. Most never read the fine prints; while some don't really understand them after reading. Your Professional agents should be able to highlight to u above points and go through the policy document with u after the purchase.

Know your rights. U have 15 days cooling off period to read the policy document, and if u are unhappy with the terms and clauses, go back to the branch office to cancel your policy, u will get full refunds of your premiums.

READ the fine prints, so that one day, no one will scream, "Insurance is cheating me...!"

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

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.