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7-11-18 Critical Illness Benefits( First issued on: 2018-12-04 )
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Critical Illness (7, 11 & 18 Diseases)

On insured being diagnosed with onset of any of the listed Critical Illness during the term of the policy, an additional sum equal to Sum Assured under the basic policy or NPR 50 Lakhs, whichever is less, is payable subject to survival of insured and continuity of the said illness for 30 days from the date of diagnosis.

S.No.

List of Critical Illness

7 Diseases

11 Diseases

18 Diseases

1

Cancer of Specified Severity

Yes

Yes

Yes

2

Major Organ/Bone Marrow Transplant

Yes

Yes

Yes

3

Open Heart Replacement or Repair of Heart Valves

Yes

Yes

Yes

4

Open Chest Coronary Artery Bypass Graft (CABG)

Yes

Yes

Yes

5

Myocardial Infarction (First Heart Attack of Specific Severity)

Yes

Yes

Yes

6

Stroke Resulting in Permanent Symptom

Yes

Yes

Yes

7

Benign Brain Tumor

Yes

Yes

Yes

8

Kidney Failure Requiring Regular Dialysis

 

Yes

Yes

9

Multiple Sclerosis with Persisting Symptoms

 

Yes

Yes

10

End Stage Liver Failure

 

Yes

Yes

11

Aorta Graft Surgery

 

Yes

Yes

12

Paralysis or Permanent Paralysis of Limbs

 

 

Yes

13

Alzheimer’s Disease

 

 

Yes

14

Coma of Specified Severity

 

 

Yes

15

Parkinson’s Disease

 

 

Yes

16

Third Degree Burns

 

 

Yes

17

Deafness

 

 

Yes

18

Loss of Speech

 

 

Yes

 

Condition: The Company shall not be liable or make any payment for any Critical Illness discovered or discoverable within 90 days from the inception date of the policy. Other conditions apply.

Premium Paying Term: Up to the end of the premium paying term or diagnosis of onset of any of the Critical Illness, if earlier.

 

Exlusions apply to know more download the brochure from the link below. 

Exclusions:

 

 

 A. Definition of Critical Illness

For the purposes of this Policy and the determination of the Company’s liability under it, a Critical Illness shall mean one of the following suffered or undertaken by the Insured as long as it is shown in the Schedule to be an operative event:

 

1. Cancer of Specified Severity

A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.

The following are excluded:

  1. All tumors which are histologically described as carcinoma in situ, benign, pre- malignant, borderline malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN - 2 and CIN-3.
  2. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
  3. Malignant melanoma that has not caused invasion beyond the epidermis;
  4. All tumors of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0
  5. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
  6. Chronic lymphocytic leukaemia less than RAI stage 3
  7. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,
  8. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;
  9. All tumors in the presence of HIV infection.

 

2. Kidney Failure Requiring Regular Dialysis

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.

 

3. Multiple Sclerosis with Persisting Symptoms

The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following:

  1. investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple sclerosis and
  2. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months.

Other causes of neurological damage such as SLE and HIV are excluded.

 

4. Major Organ/Bone Marrow Transplant

The actual undergoing of a transplant of:

  1. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or
  2. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical practitioner.

 

The following are excluded:

  1. Other stem-cell transplants
  2. Where only islets of Langerhans are transplanted

 

5. Open Heart Replacement or Repair Of Heart Valves

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner. Catheter based techniques including but not limited to, balloon valvotomy / valvuloplasty are excluded.

 

6. Open Chest CAGB

The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass grafting done via a sternotomy (cutting through the breast bone) or minimally invasive keyhole coronary artery bypass procedures. The diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a cardiologist. The following are excluded: Angioplasty and/or any other intra-arterial procedures.

 

7. Myocardial Infarction (First Heart Attack of Specific Severity)

The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:

 

  1. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
  2. New characteristic electrocardiogram changes
  3. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

 

The following are excluded:

  1. Other acute Coronary Syndromes
  2. Any type of angina pectoris
  3. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.

 

8. Stroke Resulting in Permanent Symptoms

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.

 

The following are excluded:

  1. Transient ischemic attacks (TIA)
  2. Traumatic injury of the brain
  3. Vascular disease affecting only the eye or optic nerve or vestibular functions.

 

9. Benign Brain Tumor

Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain, cranial nerves or meninges within the skull. The presence of the underlying tumor must be confirmed by imaging studies such as CT scan or MRI. This brain tumor must result in at least one of the following and must be confirmed by the relevant medical specialist.

 

  1. Permanent Neurological deficit with persisting clinical symptoms for a continuous period of at least 90 consecutive days or
  2. Undergone surgical resection or radiation therapy to treat the brain tumor.

The following conditions are excluded:

Cysts, Granulomas, malformations in the arteries or veins of the brain, hematomas, abscesses, pituitary tumors, tumors of skull bones and tumors of the spinal cord.

 

10. End Stage Liver Failure

Permanent and irreversible failure of liver function that has resulted in all three of the following:

  1. Permanent jaundice; and
  2. Ascites; and
  3. Hepatic encephalopathy.

Liver failure secondary to drug or alcohol abuse is excluded

 

11. Aorta Graft Surgery

The actual undergoing of major Surgery to repair or correct aneurysm, narrowing, obstruction or dissection of the Aorta through surgical opening of the chest or abdomen. For the purpose of this cover the definition of “Aorta” shall mean the thoracic and abdominal aorta but not its branches.

You understand and agree that we will not cover:

  1. Surgery performed using only minimally invasive or intra-arterial techniques.
  2. Angioplasty and all other intra-arterial, catheter based techniques, "keyhole" or laser procedures.

 

12. Permanent Paralysis of Limbs

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist medical practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

 

 

13. Alzheimer’s Disease

Alzheimer’s (presenile dementia) disease is a progressive degenerative disease of the brain, characterised by diffuse atrophy throughout the cerebral cortex with distinctive histopathological changes. Deterioration or loss of intellectual capacity, as confirmed by clinical evaluation and imaging tests, arising from Alzheimer’s disease, resulting in progressive significant reduction in mental and social functioning, requiring the continuous supervision of the Insured Person. The diagnosis must be supported by the clinical confirmation of a Neurologist and supported by our appointed Medical Practitioner.

 

The following conditions are however not covered:

  1. non-organic diseases such as neurosis and psychiatric Illnesses;
  2. alcohol related brain damage; and
  3. any other type of irreversible organic disorder/dementia

 

14. Coma of Specified Severity

A state of unconsciousness with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by evidence of all of the following:

  1. no response to external stimuli continuously for at least 96 hours;
  2. life support measures are necessary to sustain life; and
  3. Permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
  4. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from alcohol or drug abuse is excluded.

 

15. Parkinson’s Disease

The unequivocal diagnosis of progressive, degenerative idiopathic Parkinson’s disease by a Neurologist acceptable to us.

The diagnosis must be supported by all of the following conditions:

  1. the disease cannot be controlled with medication;
  2. signs of progressive impairment; and
  3. inability of the Insured Person to perform at least 3 of the 6 activities of daily living as listed below (either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) for a continuous period of at least 6 months.

 

Activities of daily living:

  1. Washing: the ability to wash in the bath or shower (including getting into and out of the shower) or wash satisfactorily by other means and maintain an adequate level of cleanliness and personal hygiene.
  2. Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or other surgical appliances;
  3. Transferring: The ability to move from a lying position in a bed to a sitting position in an upright chair or wheel chair and vice versa;
  4. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory level of personal hygiene;
  5. Feeding: the ability to feed oneself, food from a plate or bowl to the mouth once food has been prepared and made available.
  6. Mobility: The ability to move indoors from room to room on level surfaces at the normal place of residence

Parkinson’s disease secondary to drug and/or alcohol abuse is excluded.

 

16. Third Degree Burns

There must be third-degree burns with scarring that cover at least 20% of the body’s surface area. The diagnosis must confirm the total area involved using standardized, clinically accepted, body surface area charts covering 20% of the body surface area.

 

17. Deafness

Total and irreversible loss of hearing in both ears as a result of illness or accident. This diagnosis must be supported by pure tone audiogram test and certified by an Ear, Nose and Throat (ENT) specialist. Total means “the loss of hearing to the extent that the loss is greater than 90decibels across all frequencies of hearing” in both ears.

 

18. Loss of Speech

Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords. The inability to speak must be established for a continuous period of 12 months. This diagnosis must be supported by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist. All psychiatric related causes are excluded.

 

B. Exclusions

The Company shall not be liable or make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:

  1.  Any Critical Illness existing or for which the Insured sought or received treatment prior to:
  1. The inception date of the first Policy of a series of Critical Illness Policies taken by the Insured from the Company without any break, where this insurance is shown in the Schedule to be an annual contract or a longer-term contract.
  2. The inception date of this Policy where this insurance is shown in the Schedule to be an annual contract and either:
  1. This is the Insured’s first Critical Illness Policy taken from the Company, or
  2. There has been a break between this Critical Illness Policy being taken and an earlier Critical Illness Policy having expired.

 

  1. Any Critical Illness discovered or discoverable within 90 days of the inception date of this Policy, but this exclusion shall not apply to the second or subsequent Critical Illness Policy taken by the Insured from the Company without any break.
  2. Any Critical Illness discovered or discoverable when the premium due for this Policy has not been received by the Company.
  3. Congenital external illness or defects or anomalies, intentional self-injury and the use or misuse of intoxication liquor or drugs.
  4. Any sexually transmitted diseases or any condition directly or indirectly caused by or associated with Human T-Cell Lymphotropic Virus type III (III LB III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
  5. Pregnancy and childbirth.
  6. Consequential losses of any kind.
  7. War (declared or not), invasion, act of foreign enemy, hostilities, civil war, insurrection, rebellion, revolution, mutiny, military or usurped power, riot, strike, lockout, military or popular uprising, civil commotion, martial law, loot, sack, pillage, terrorism or terrorist acts, or any epidemic.
  8. Nuclear weapons, materials, ionizing radiation, contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel.
  9. In case any dispute arises regarding version of policy, the Nepali version should be treated as official.

 

 

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