Serious Illness Definitions
The death of a portion of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction:
- typical chest pain
- new characteristic electrocardiographic changes
- the characteristic rise of cardiac enzymes, troponins or other biochemical markers
- where all of the above shows a definite acute myocardial infarction
Other acute coronary syndromes, including but not limited to angina, are not covered under this definition.
A heart attack (or Myocardial Infarction) may occur when the arteries which supply blood to the heart become blocked or constricted resulting in the death of part of the heart muscle.
Inevitably, at the time of a heart attack severe chest pains may be experienced. To diagnose that a heart attack has actually taken place a doctor will use an electrocardiograph (ECG). This machine produces a graph showing the electrical activity in the heart. Certain features on the graph will indicate whether a heart attack has occurred.
When the heart muscle dies certain chemicals known as cardiac enzymes are released into the blood stream. A blood test showing higher than normal levels of these enzymes will also indicate that a heart attack has recently taken place.
Angina is the name given to chest pains associated with a restriction in the blood supply to the heart but without death of the heart muscle. Angina is not covered under the policy.
Any malignant tumour characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. The term cancer includes leukaemia and Hodgkin's disease but the following are excluded:
- All tumours which are histologically described as pre-malignant, as non-invasive or as cancer in situ
- All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least TNM classification T2NOMO
- All forms of lymphoma in the presence of any Human Immunodeficiency Virus
- Kaposi's sarcoma in the presence of any Human Immunodeficiency Virus
- Any skin cancer other than invasive malignant melanoma
Cancer is the abnormal growth of cells which may spread throughout the body and destroy healthy tissue. Such a growth is described as malignant.
Cancers which are in the very early stages of development are not yet capable of spreading to other sites in the body and are not covered by the policy as they are generally easy to treat and are not life threatening at that time. These include most skin cancers and certain bladder tumours.
A cerebrovascular incident resulting in permanent neurological damage. Transient Ischaemic Attacks are specifically excluded.
A stroke involves the death of part of the brain as a result of a reduction in the blood supply. This may be caused by a blood clot blocking an artery or by the bursting of a blood vessel.
For a claim to be valid there must be permanent damage to the nervous system which can include paralysis - often of one side of the body, loss of memory and impaired speech.
Transient Ischaemic Attacks (TIA) which produce symptoms such as dizziness or loss of balance are similar to strokes but do not leave any permanent damage and generally resolve within 24 hours.
TIA's are specifically excluded from the cover.
End stage renal failure presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis or renal transplant is initiated.
The kidneys remove waste products from the blood. It is usually possible to survive with only one functioning kidney. However, if both kidneys fail the blood will not be cleaned and ultimately death will occur.
Treatment of kidney failure is usually by one of two methods:
- Dialysis - where, at regular intervals, the kidney function is replaced by a machine
- Transplantation - where an individual's diseased kidneys are removed and replaced by a healthy kidney from a donor.
For a claim to be valid both kidneys must have failed and dialysis implemented or transplantation carried out.
Major surgeries must be certified as being immediately necessary and being the most appropriate method of treating the condition which threatens you.
Aorta Graft Surgery
Undergoing surgery for disease of the aorta needing excision and surgical replacement of a portion of the diseased aorta with a graft. For this definition, aorta means the thoracic and abdominal aorta but not its branches.
The aorta is the main artery in the body which may be weakened by an aneurysm (bulging of the artery wall) or become restricted by the build up of fatty deposits. Surgery can repair this damage.
Pulmonary Artery Surgery
The actual undergoing of surgery on the advice of a Consultant Cardiothoracic Surgeon for a disease of the pulmonary artery to exercise and replace the diseased pulmonary artery with a graft.
The pulmonary artery is the major vessel that supplies blood to the lungs. A claim will be paid if you undergo surgery to repair this artery, on the advice of an appropriate specialist.
Coronary Artery Bypass Surgery
The undergoing of open heart surgery on the advice of a Consultant Cardiologist to correct narrowing or blockage of one or more coronary arteries with by-pass grafts but excluding balloon angioplasty, laser relief or any other procedures.
Where one or more of the coronary arteries which supply blood to the heart are narrowed or blocked coronary artery surgery may be necessary.
This involves by-passing the diseased or blocked artery by grafting an artery from the chest or vein from the leg around it. Angiographical evidence that disease of the arteries exists must be provided for a claim to be valid.
Heart Valve Replacement or Repair
Undergoing open heart surgery from medical necessity to replace or repair one or more heart valves.
There are four valves which regulate the flow of blood through the heart. It is essential that these work properly in order that the heart can function efficiently.
Occasionally the valves may become diseased and the efficiency of the heart will be affected with disabling or life threatening consequences.
A claim will be valid if the insured undergoes open heart surgery to treat a diseased valve by repair or replacement.
Major Organ Transplant
The actual undergoing as a recipient of, or inclusion on an official waiting list in Ireland or the UK for, a transplant of a heart, liver, lung, pancreas or bone marrow.
In certain cases a doctor may decide that one or more of the major internal organs are so seriously diseased that the only effective treatment is the transplantation of a healthy organ to replace the diseased one.
For a claim to be valid you must have undergone surgery to receive a heart, a lung, a liver, a kidney, a pancreas or bone marrow.
In addition a claim will also be valid if you receive a combination of the above organs such as a heart and a lung.
Total and Permanent Disability
The benefit as specified will be payable, after the lapse of a qualifying period, if you are diagnosed and certified to the satisfaction of our Chief Medical Officer as being permanently disabled during the term of the policy but before age 65, due to:
- Permanent inability to perform three of the following activities without the help of a third party, but with
the use of aids and appliances:
- Cannot walk more than 200 metres without stopping
- Cannot pick up from table height and carry for 5 metres a 1 kg weight with either hand (i.e. neither left or right)
- Lack physical ability to use a pen, pencil or keyboard with either hand (i.e., neither left or right) or any artificial aids
- Cannot hear well enough (with the use of a hearing aid), to understand someone speaking a common language in a normal voice in a quiet room.
- Cannot be understood in a common language in a quiet room by people you work with
- Cannot see well enough to read large print book (16 point)
- The suffering of a mental disorder causing severe dysfunctioning which has failed to respond to a minimum of 2 years optimal treatment by a Consultant Psychiatrist and continues to require continuous Psychotropic medication, continuous supervision and care from a Consultant Psychiatrist. Severe dysfunction is defined as a recording score of between 50 - 41 on the Global Assessment of Functioning (GAF) Scale, a recognised medical scale which considers psychological, social and occupational functioning. The prognosis must be that the score recorded is not capable of improvement in the future.
The benefit after age 65 will be payable if you have suffered loss of Independence Existence due to:
- Permanent disability causing either:
- Permanent confinement to a wheelchair
- Permanent hospitalisation or residency in a nursing home in the Republic of Ireland or the United Kingdom
- Permanent inability to perform three of the following activities without the help of a third party, but with the use of aids and appliances:
- Walk 10 metres on the flat without stopping.
- Get into and out of a standard family saloon type car
- Put on, take off, secure and unfasten all necessary items of clothing
- Eat food, which has been prepared
- Wash in a bath or shower
- Climb a flight of 12 stairs in a conventional residential dwelling
- The suffering of a mental disorder causing severe dysfunctioning which has failed to respond to a minimum of 2 years optimal treatment by a Consultant Psychiatrist and continues to require continuous Psychotropic medication, continuous supervision and care from a Consultant Psychiatrist. Severe dysfunction is defined as a recording score of between 50 - 41 on the Global Assessment of Functioning (GAF) Scale, a recognised medical scale which considers psychological, social and occupational functioning. The prognosis must be that the score recorded is not capable of improvement in the future
For this benefit to be payable you must be permanently and totally disabled. The criteria we use will vary by your age when you make a claim.
If the claim is made before you are 65 we will require that you are unable to perform three out of six work related activities.
Alternatively we will require that you have suffered a mental disorder.
The Global Assessment of Functioning Scale is a recognised medical scale, which considers how you function psychologically, socially and occupationally.
If the claim is made after you are 65 we will require evidence that you are unable to perform three out of six activities related to everyday living. Alternatively we will allow a claim if you suffer a mental disorder or are confined to a wheelchair or nursing home.
The unequivocal diagnosis by a Consultant Cardiologist of Cardiomyopathy demonstrating Impaired Ventricular Function so that the ejection fraction is 40% or less. This must be accompanied by a marked limitation of physical activity with you being unable to progress beyond stage two of a treadmill exercise test using the standard Bruce Protocol.
Cardiomyopathy is a serious heart condition, often of unknown cause, in which a heart muscle can no longer effectively receive or pump blood through the body. While it can be a temporary condition, in some cases it goes on to be a permanent condition. When the condition is permanent it cannot be cured and usually deteriorates over time. The symptoms of Cardiomyopathy include shortness of breath on moderate exercise, chest pain and fainting.
A claim may be made if there is a definite diagnosis by a consultant cardiologist of a major hospital that you have suffered Cardiomyopathy which is permanent and causing symptoms which significantly hinder normal everyday activities. This will be measured by a treadmill exercise test. This involves recording electrical impulses while exercising and your ability to exercise must be limited to a specific degree as measured by Stage 2 of the standard Bruce Protocol.
Cardiomyopathy directly related to alcohol or drug misuse is excluded.
A definite diagnosis by a Consultant Neurologist of Multiple Sclerosis which satisfies all of the following criteria:
- There must be current impairment of motor or sensory function, which must have persisted for a continuous period of at least six months
- The diagnosis must be confirmed by diagnostic techniques current at the time of the claim.
Multiple Sclerosis (MS) is a disease of the body's central nervous system for which there is no known cure. The disease is very difficult to diagnose. A consultant neurologist will perform various tests to help confirm the disease. The symptoms of MS include weakness or heaviness in the limbs, numbness and lack of co-ordination. For a claim to be valid confirmation must be provided by a consultant neurologist that symptoms have persisted for a continuous period of 6 months.
Total permanent and irreversible loss of all sight in both eyes.
A claim will be valid if there is a total and irreversible loss of sight in both eyes. Being registered blind will, in itself, not necessarily constitute a valid claim. It is possible to be registered blind and still have partial or limited vision.
Benign Brain Tumour
A non-malignant tumour in the brain resulting in permanent deficit to the neurological system. Tumours or lesions in the pituitary gland are not covered.
A benign tumour is a non-cancerous abnormal growth of tissue. A benign tumour in the brain, although not cancerous, is very serious because the growth may be pressing on areas of the brain. Such growth may be potentially life threatening and it may be necessary to remove the growth by surgery.
Motor Neurone Disease
Confirmation by a Consultant Neurologist of a definite diagnosis of Motor Neurone Disease.
Motor Neurone Disease is a progressive degenerative disease of the nervous system. There is no known cure for this disease. For a claim to be paid the consultant neurologist must confirm a definite diagnosis of Motor Neurone Disease.
Total irreversible loss of muscle function or sensation to the whole of any two limbs as a result of injury or disease. The disability must be permanent and supported by appropriate neurological evidence.
Paralysis is the loss of the power of movement and sensation in the body due to accident or disease. For a claim to be valid the paralysis must involve two or more limbs which is termed Paraplegia.
Loss of Limbs
The permanent physical severance of two or more limbs from above the wrist or ankle joint.
A claim will be valid if you lose two limbs, severed above the ankle or wrist.
Loss of Speech
Total permanent and irreversible loss of the ability to speak as a result of physical injury or disease.
A claim will be valid if the vocal chords are physically damaged to such an extent that the ability to speak is completely lost without hope of recovery. Where speech is lost without any detectable physical damage it is extremely unlikely that it would be possible to prove that the loss was permanent. Such situations are not covered by the policy.
Total permanent and irreversible loss of all hearing in both ears.
A claim will be valid if you suffer total and permanent loss of hearing in both ears.
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. Coma secondary to alcohol or drug misuse is not covered.
A coma is a state of complete unconsciousness in which all reflexes are absent. In severe cases the body may no longer be able to function properly and treatment with a life support system may be needed. For a claim to be valid you must have been in a coma continuously for 96 hours requiring the use of a life support system.
Third Degree Burns
Third degree burns covering at least 20% of the body surface area.
Three levels of burns exist, the extent of damage to the skin is indicated by the 'degree' of burning:
First degree burns damage the upper layer of skin (e.g. sunburn).
Second degree burns go deeper into the layers of skin, but can heal without scarring.
Third degree burns are the most serious, as they destroy the full thickness of the skin.
For a valid claim the insured must have suffered third degree burns covering 20% or more of the surface area of their body.
The diagnosis and certification of Rheumatoid Arthritis as evidenced by widespread joint destruction with major clinical deformity of three or more of the following joint areas - hands, wrists, elbows, cervical spine, knees, ankles and metatacarpophalangeal joints in the foot.
For admission of a claim the severity of the disease shall be such that the Insured will have been disabled for a continuous period of at least six months (the Qualifying Period) from performing his/her usual occupation and any other to which suited by education, training or experience.
Rheumatoid Arthritis is a disease characterised by swelling, pain and restriction of movement of the joints, particularly the hands, wrists and feet. The disease causes the destruction of the joint and can be very disabling. In some cases more generalised illness arise.
The symptoms of Rheumatoid Arthritis include restriction of the joints in the morning lasting for over an hour, often with the same joints being affected on both sides of the body.
For a claim to be valid Rheumatoid Arthritis must be diagnosed by a Consultant Rheumatologist. The disease will have involved the wrists and hands or toes on both sides of the body, diagnosis being confirmed by blood tests and x-rays showing erosion of the joints.
Confirmation by a Consultant Neurologist of a definite diagnosis of Parkinson's Disease. Parkinson's Disease secondary to alcohol or drug misuse is not covered.
Parkinson's Disease is characterised by tremor of the limbs and head together with rigidity of muscles giving rise to a mask-like facial expression. The disease is associated with a lack of dopamine in the nerve cells. This substance transmits messages between nerve endings. Where the cause of disease is not know it is termed idiopathic and often arises in later life. For a claim to be valid you must have developed idiopathic Parkinson's Disease which has been treated by drugs which replace the natural dopamine in the body. Such treatment is only administered when the disease is well developed.
Deterioration or loss of intellectual capacity or abnormal behaviour, as diagnosed and Certified by a Consultant Neurologist and evidenced by the clinical state and accepted questionnaires and tests relating to Alzheimer's Disease or irreversible organic degenerative disorders (excluding neurosis or psychiatric illness) resulting in a significant reduction in mental and social functioning requiring continuous supervision of the Insured.
Alzheimer's Disease is a form of presenile dementia. It is an organic brain disease characterised by impairment of memory. A claim will be paid if a diagnosis of Alzheimer's Disease is clinically established.
Chronic Lung Disease including Severe Emphysema
The diagnosis and certification of Chronic Lung Disease by a Consultant Physician. Chronic Lung Disease is defined as severe restrictive lung disease where there is dyspnoea at rest with markedly abnormal pulmonary function tests, the diagnosis being evidenced by all of the following:
- Vital lung capacity being less than 50% of normal
- FEV1 (Forced Expiratory Volume at 1 second) being less than 50% of normal
- The need to use oxygen at home
Chronic Lung Disease or Emphysema is characterised by enlargement of the air spaces in the lungs with destruction of their walls. It can occur without any other disease but in most cases is preceded by chronic bronchitis. It tends to be progressive disorder, in which chronic cough, increased sputum production and shortness of breath (dyspnoea) are all present. The severity of the condition can be measured by specific pulmonary function tests such as vital capacity and FEV1.
For a claim to be valid you must suffer from severe irreversible lung disease as evidence by the need to use oxygen at home and pulmonary function tests showing vital capacity and FEV1 less than 50% of normal.
Major Head Trauma
Accidental injury to the head resulting in residual brain damage. There must be permanent neurological deficit causing significant functional impairment as defined by a Consultant Neurologist to the satisfaction of our Chief Medical Officer, using standard measures of head injury (for example, the insured must score 5 or less on the Eight Point Glasgow Outcome Scale for head injuries).
Accidental injury to the head can cause damage to the brain.
A claim may be made if you suffer a major head trauma which leaves evidence of permanent damage to the nervous system.
The Glasgow Outcome Scale of Head Injuries is a numerical system used to estimate in an objective way the conscious state of an individual following head injury.
A hereditary muscular dystrophy confirmed by a Consultant Neurologist resulting in the inability to perform, without the continual assistance of another person, three or more of the following activities:
- Walk 10 metres on the flat without stopping
- Get into and out of a standard family saloon type car
- Put on, take off, secure and unfasten all necessary items of clothing
- Eat food, which has been prepared
- Wash in a bath or shower
- Climb a flight of 12 stairs in a conventional residential dwelling
This is a hereditary condition which involves the degeneration of muscle tissue.
Diagnosis and certification of infection by any Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome (AIDS) in the following circumstances:
- The infection is due to a blood transfusion received in Ireland or the United Kingdom after the start date of the policy provided that:
- The institution which provided the transfusion admits liability
- The insured is not a Haemophiliac
- Coverage is provided for certain occupations where infection is caused by an accidental injury by a sharp instrument
or by exposure to blood or bloodstained body fluid
The following conditions apply prior to claim admittance:
- The injury must be caused during a period when the insured was carrying out the normal duties of his/her occupation
- The accident was reported in accordance with established occupational procedures for such accidents
- Blood tests are carried out in the following order:
- Within 7 days of the accident a blood test indicates the absence of any HIV or antibodies to such a virus
- Within 12 months of the accident a blood test indicates the presence of HIV or of antibodies to such a virus
- Within 14 days of the accident you have reported the accident in writing to us with confirmation that blood tests have been carried out
- The infection is caused by a physical assault on the Insured in Ireland, provided that:
- The assault must have occurred at least 26 weeks after the effective date of the policy
- There must be evidence that the infection occurred as a result of the assault on the Insured
- The assault must have been reported to the Garda Siochana within 24 hours of its occurrence
- The Insured must have undergone a blood test within 5 days of the assault which caused the infection
- indicating the absence of HIV or antibodies of such a virus and a further blood test within 12 months of the assault
- indicating the presence of HIV antibodies to such a virus. All blood tests must be processed by a recognised hospital laboratory in Ireland.
Note: The occupations which are covered are:
Ambulance Workers, Dental Nurses, Dental Surgeons, District Nurses, Brigade & Fire Fighters, Gardai, General Practitioners, Hospital Caterers, Hospital Cleaners, Hospital Doctors, Hospital Surgeons, Consultants, Hospital Laboratory Technicians, Hospital Laundry Workers, Hospital Nurses, Hospital Porters, Midwives, Paramedics, Prison Officers.
Human Immunodeficiency Virus (HIV) is a virus spread through infected blood products, contaminated needles or exchange of body fluids directly through sexual activity In addition it may be passed on to children born to infected mothers. The virus acts by attacking the body's natural defence system. The majority of people who contract HIV will go on to develop Acquired Immune Deficiency Syndrome (AIDS), a disease which suppresses the body's immune system, and which leaves the individual increasingly vulnerable to opportunistic infections, such as pneumonia and meningitis, amongst others. HIV/AIDS is covered when the infection is a result of blood transfusion or a physical assault. For certain occupations we will also cover HIV/AIDS which results from accidental infection in the course of your job.
Chronic Liver Disease
End stage failure due to cirrhosis and resulting in all of the following:
- Permanent Jaundice
- Liver disease secondary to alcohol or drug misuse is excluded.
The liver is the largest single organ in the body and is essential to life. In cirrhosis normal liver tissue is replaced by bands of fibrous tissue resulting in liver failure.
Jaundice, a yellowing of the skin or whites of the eyes can be caused by the disease of the liver cells.
Ascites is the accumulation of fluid in the abdominal cavity, causing abdominal swelling and is often a complication of cirrhosis.
Encephalopathy is any of the various diseases that affect the functioning of the brain. In liver failure, brain function may be impaired by the presence of toxic substances which are normally removed or detoxified by the liver.
A claim may be made if you suffer chronic liver failure due to cirrhosis which results in permanent jaundice, ascites and encephalopathy
Systemic Lupus Erythematosus
The unequivocal diagnosis by a Consultant Rheumatologist of Systemic Lupus Erythenatosus with cardiac, central nervous system or renal impairment. Discoid Lupus is specifically excluded.
Systemic Lupus Erythenatosus (SLE) is an inflammatory disease in which the skin and various internal organs are affected. Typically, there is a red scaly rash on the face, arthritis, and damage to the kidneys. Often the heart and brain are also affected.
In Discoid Lupus Erythenatosus, which is not covered, only the skin is affected.
A claim may be made if you suffer from Systemic Lupus Erythenatosus which has impaired the function of the heart, the central nervous system or the kidneys.
An unequivocal diagnosis of Creutzfeldt-Jakob Disease made by a Consultant Neurologist.
Creutzfeldt-Jakob Disease (CJD) is a disease in which progressive degeneration of nerve cells of the central nervous system causes defective muscular control and dementia. CJD is the human equivalent of bovine spongiform encephalopathy (BSE) otherwise known as Mad Cow Disease.
Bacterial Meningitis causing inflammation of the membranes of the brain or the spinal cord resulting in significant permanent neurological deficit. The diagnosis must be confirmed by a Consultant Neurologist or by an appropriate consultant. Bacterial Meningitis in the presence of HIV is excluded. All other forms of meningitis including viral are not covered.
Bacterial Meningitis is an inflammation of the membranes of the brain or the spinal cord due to bacterial infection. Meningitis may, in severe cases, result in convulsions, vomiting, shock and delirium leading to death. Only Bacterial Meningitis is covered and other forms of meningitis such as viral meningitis are not covered.
Permanent bone marrow failure which results in anaemia, neutropenia and thrombocytopenia requiring treatment with at least one of the following:
- Blood Transfusion
- Marrow stimulating agents
- Immunosuppressive agents
- Bone marrow transplant
Anaemia, nueutropenia and thrombocytopenia are all conditions where there is a deficiency in some part of the blood. For example, anaemia is a lack of red blood cells. These conditions commonly occur when the body's bone marrow stops working properly. A claim may be made only if the condition is so severe that at leastone of the listed procedures is required.
Severe inflammation of the brain substance which results in significant and permanent neurological sequelae, causing at least 25% impairment of function, as defined by the Guide to the Evaluation of Permanent Impairment, 3rd Edition of the American Medical Association or its equivalent. The diagnosis must be made by a Consultant Neurologist of a major hospital.
Encephalitis in the presence of HIV infection is excluded.
Encephalitis results from an infection of the brain tissue usually caused by a virus. In some cases this may lead to a degree of permanent brain damage. We will consider a claim where the condition results in permanent damage to the brain.
- A Serious Illness Benefit will only be paid provided you are still living 14 days after the serious illness event date
- No benefit will be payable if a serious illness or disability results directly or indirectly from:
- self inflicted injury or illness or the taking of alcohol or drugs
- failure to follow reasonable medical advice
- In the case of serious illness or disability, no benefit will be payable if a condition arises as a result of:
- war (declared or not)
- participation in a riot, insurrection or civil commotion
- a self inflicted injury or illness whether you are sane or insane
- any Human Immunodeficiency Virus or Acquired Immunodeficiency Syndrome
- breach of any law by you
- No benefit will be payable if in the opinion of our Chief Medical officer a claim is made for a serious illness or a disability condition which was known to exist prior to the start date of the plan
- Any claim in respect of serious illness or disability shall be invalid if you (or your child, if relevant) are resident outside Western Europe (Andorra, Austria, Belgium, Channel Islands, Denmark, Finland, France, Germany Gibraltar, Greece, Iceland, Ireland, Isle of Man, Italy, Liechtenstein, Luxembourg, Monaco, Netherlands, Norway, Portugal, San Marino, Spain, Sweden, Switzerland and the United Kingdom), the USA or Canada, Australia or South Africa for more than 13 weeks in any 12 consecutive calendar months.
- No benefit will be payable in respect of disability arising directly or indirectly as a consequence of participation in any of the following activities: Abseiling, bob sleighing, boxing, hang gliding, scuba diving, equestrian events, motor or motor cycle sports, mountaineering, rock climbing, potholing, caving, parachuting, paragliding, boat racing, professional sports and aviation other than as a fare paying passenger.
- The payment of a claim will be governed by the policy conditions. These Serious Illness Definitions are for information only and does not form part of the policy conditions.