Appendix 1 - Covered Critical Illness
Definitions
I. Irreversible means cannot be reasonably improved upon by medical treatment and/or surgical procedures
consistent with the current standard of the medical services available in Malaysia.
II. Permanent neurological deficit with persisting clinical symptoms means symptoms of dysfunction in the
nervous system that are present on clinical examination and expected to last throughout the lifetime of the
Life Assured. Symptoms that are covered include numbness, paralysis, localised weakness, dysarthria
(difficulty with speech), aphasia (inability to speak), dysphagia (difficulty swallowing), visual impairment,
difficulty in walking, lack of coordination, tremor, seizures, dementia, delirium and coma.
III. Activities of Daily Living (ADL) are as follows:
i. Transfer
Getting in and out of a chair without requiring physical assistance.
ii. Mobility
The ability to move from room to room without requiring any physical assistance.
iii. Continence
The ability to voluntarily control bowel and bladder functions such as to maintain personal hygiene.
iv. Dressing
Putting on and taking off all necessary items of clothing without requiring assistance of another person.
v. Bathing/Washing
The ability to wash in the bath or shower (including getting in or out of the bath or shower) or wash by
any other means.
vi. Eating
All tasks of getting food into the body once it has been prepared.
IV. Assessment Period means the period during which the insurer will assess a condition before deciding
whether or not the condition qualifies as being permanent. The assessment period will be for the minimum
period time frame stated in the relevant definition and will not be longer than twelve (12) months (provided all
required evidence has been submitted).
Cover Critical Illness
1. Stroke - Resulting in Permanent Neurological Deficit with Persisting Clinical Symptoms
Death of brain tissue due to inadequate blood supply, bleeding within the skull or embolization from an
extra cranial source resulting in permanent neurological deficit with persisting clinical symptoms. The
diagnosis must be based on changes seen in a CT scan or MRI and certified by a Neurologist. A
minimum Assessment Period of three (3) months applies.
For the above definition, the following are not covered:
Transient ischemic attacks
Cerebral symptoms due to migraine
Traumatic injury to brain tissue or blood vessels
Vascular disease affecting the eye or optic nerve or vestibular functions.
2. Heart Attack - of Specified Severity
Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence
of acute myocardial infarction:
A history of typical chest pain;
New characteristic electrocardiographic changes; with the development of any of the following: ST
elevation or depression, T wave inversion, pathological Q waves or left bundle branch block; and
Elevation of the cardiac biomarkers , inclusive of CPK-MB above the generally accepted normal
laboratory levels or Troponins recorded at the following levels or higher:- Cardiac Troponin T or
Cardiac Troponin I > / = 0.5 ng/ml.
The evidence must show the occurrence of a definite acute myocardial infarction which should be
confirmed by a cardiologist or physician.
For the above definition, the following are not covered:
occurrence of an acute coronary syndrome including but not limited to unstable angina
a rise in cardiac biomarkers resulting from a percutaneous procedure for coronary artery disease.
3. Kidney Failure - Requiring Dialysis or Kidney Transplant
End-stage kidney failure presenting as chronic Irreversible failure of both kidneys to function, as a result
of which regular dialysis is initiated or kidney transplantation is carried out.
4. Cancer - of Specified Severity and does not cover very early cancers
Any malignant tumour positively diagnosed with histological confirmation and characterized by the
uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes
leukemia, lymphoma and sarcoma.
For the above definition, the following are not covered:
All cancers which are histologically classified as any of the following:
pre-malignant
non-invasive
carcinoma in situ
having borderline malignancy
having malignant potential
All tumours of the prostate histologically classified as T1N0M0 (TNM classification)
All tumours of the thyroid histologically classified as T1N0M0 (TNM classification)
All tumours of the urinary bladder histologically classified as T1N0M0 (TNM classification)
Chronic Lymphocytic Leukemia less than RAI Stage 3
All cancers in the presence of HIV
Any skin cancer other than malignant melanoma
5. Coronary Artery By-Pass Surgery
Refers to the actual undergoing of open-chest surgery to correct or treat Coronary Artery Disease (CAD)
by way of coronary artery by-pass grafting.
For the above definition, the following are not covered:
angioplasty;
other intra-arterial or catheter based techniques;
keyhole procedures;
laser procedures.
6. Serious Coronary Artery Disease
The narrowing of the lumen of Right Coronary Artery (RCA), Left Anterior Descending Artery (LAD) and
Circumflex Artery (not inclusive of their branches) occurring at the same time by a minimum of sixty
percent (60%) in each artery as proven by coronary arteriography (non-invasive diagnostic procedures
are not covered). A narrowing of sixty percent (60%) or more of the Left Main Stem will be considered as
a narrowing of the Left Anterior Descending Artery (LAD) and Circumflex Artery. This covered event is
payable regardless of whether or not any form of coronary artery surgery has been performed.
7. Angioplasty and Other Invasive Treatments for Coronary Artery Disease
The actual undergoing for the first time of Coronary Artery Balloon Angioplasty, atherectomy, laser
treatment or the insertion of a stent to correct a narrowing or blockage of one or more coronary arteries
as shown by angiographic evidence.
Intra-arterial investigative procedures are not covered. Payment under this clause is limited to ten
percent (10%) of the Critical Illness coverage under this certificate subject to a maximum of RM25,000.
This covered event is payable once only and shall be deducted from the amount of this certificate,
thereby reducing the amount of the lump sum payment which may be payable.
8. End-Stage Liver Failure
End-stage liver failure as evidenced by all of the following:
Permanent jaundice;
Ascites (excessive fluid in peritoneal cavity); and
Hepatic encephalopathy.
Liver failure secondary to alcohol or drug abuse is not covered.
9. Fulminant Viral Hepatitis
A sub-massive to massive necrosis (death of liver tissue) caused by any virus as evidenced by all of the
following diagnostic criteria:
A rapidly decreasing liver size as confirmed by abdominal ultrasound;
Necrosis involving entire lobules, leaving only a collapsed reticular framework;
Rapidly deteriorating liver functions tests; and
Deepening jaundice.
Viral hepatitis infection or carrier status alone (inclusive but not limited to Hepatitis B and Hepatitis C)
without the above diagnostic criteria is not covered.
10. Coma - Resulting in Permanent Neurological Deficit with Persisting Clinical Symptoms
A state of unconsciousness with no reaction to external stimuli or internal needs, persisting continuously
for at least ninety six (96) hours, requiring the use of life support systems and resulting in a permanent
neurological deficit with persisting clinical symptoms. A minimum Assessment Period of thirty (30) days
applies. Confirmation by a Neurologist must be present.
The following is not covered:
Coma resulting directly from alcohol or drug abuse.
11. Benign Brain Tumor - of Specified Severity
A benign tumour in the brain or meninges within the skull, where all of the following conditions are met:
It is life threatening;
It has caused damage to the brain;
It has undergone surgical removal or has caused permanent neurological deficit with persisting
clinical symptoms; and
Its presence must be confirmed by a Neurologist or neurosurgeon and supported by findings on
MRI, CT or other reliable imaging techniques.
The following are not covered:
Cysts
Granulomas
Malformations in or of the arteris or veins of the brain
Hematomas
Tumours in the pituitary gland
Tumours in the spine
Tumours of the acoustic nerve.
12. Paralysis of Limbs
Total, permanent and Irreversible loss of use of both arms or both legs, or of one arm and one leg,
through paralysis caused by illness or injury. A minimum Assessment Period of six (6) months applies.
13. Blindness - Permanent and Irreversible
Permanent and Irreversible loss of sight as a result of accident or illness to the extent that even when
tested with the use of visual aids, vision is measured at 3/60 or worse in both eyes using a Snellen eye
chart or equivalent test and the result must be certified by an ophthalmologist.
14. Deafness - Permanent and Irreversible
Permanent and Irreversible loss of hearing as a result of accident or illness to the extent that the loss is
greater than 80 decibels across all frequencies of hearing in both ears. Medical evidence in the form of
an audiometry and sound-threshold tests result must be provided and certified by an Ear, Nose, and
Throat (ENT) specialist.
15. Third Degree Burns - of Specified Severity
Third degree (i.e. full thickness) skin burns covering at least twenty percent (20%) of the total body
surface area.
16. HIV Infection due to Blood Transfusion
Infection with the Human Immunodeficiency Virus (HIV) through a blood transfusion, provided that all of
the following conditions are met:
The blood transfusion was medically necessary or given as part of a medical treatment
The blood transfusion was received in Malaysia or Singapore after the commencement of this
Annexure;
The source of the infection is established to be from the institution that provided the blood
transfusion and the institution is able to trace the origin of the HIV tainted blood;
The Insured Person does not suffer from hemophilia;and
The Insured Person is not a member of any high risk groups including but not limited to intravenous
drug users.
17. Occupationally Acquired Human Immunodeficiency Virus (HIV) Infection
Infection with the Human Immunodeficiency Virus (only if the Insured Person is a Medical Staff as
defined below), where it was acquired as a result of an accident occurring during the course of carrying
out normal occupational duties with seroconversion to HIV infection occurring within six (6) months of the
accident. Any accident giving rise to a potential claim must be reported to Us within thirty (30) days of
the accident taking place supported by a negative HIV test taken within seven (7) days of the accident.
“Medical Staff” is defined as doctors (general physicians and specialists), traditional practitioners,
nurses, paramedics, laboratory technicians, dentists, dental nurses, ambulance workers who are working
in a medical centre or hospital or dental clinic/polyclinic in Malaysia. Doctors, traditional practitioners,
nurses and dentists must be registered with the Ministry of Health of Malaysia.
18. Full-Blown AIDS
The clinical manifestation of AIDS (Acquired Immuno-deficiency Syndrome) must be supported by the
results of a positive HIV (Human Immuno-deficiency Virus) antibody test and a confirmatory test. In
addition, the Insured Person must have a CD4 cell count of less than two hundred (200)/ μL and one or
more of the following criteria are met:
Weight loss of more than 10% of body weight over a period of six (6) months or less (wasting
syndrome)
Kaposi Sarcoma
Pneumocystis Carinii Pneumonia
Progressive multifocal leukoencephalopathy
Active Tuberculosis
Less than one-thousand (1000) Lymphocytes/μL
Malignant Lymphoma
19. End-Stage Lung Disease
End-stage lung disease causing chronic respiratory failure.
All of the following criteria must be met:
The need for regular oxygen treatment on a permanent basis;
Permanent impairment of lung function with a consistent Forced Expiratory Volume (FEV) of less
than 1 liter during the first second;
Shortness of breath at rest;and
Baseline Arterial Blood Gas analysis with partial oxygen pressures of 55mmHg or less.
20. Encephalitis - Resulting in Permanent Inability to Perform Activities of Daily Living
Severe inflammation of brain substance, resulting in permanent functional impairment. The permanent
functional impairment must result in an inability to perform at least three (3) of the Activities of Daily
Living.
A minimum Assessment Period of thirty (30) days applies. The covered event must be certified by a
Neurologist.
Encephalitis in the presence of HIV infection is not covered.
21. Major Organ / Bone Marrow Transplant
The receipt of a transplant of:
Human bone marrow using hematopoietic stem cells preceded by total bone marrow ablation; or
One of the following human organs: heart, lung, liver, kidney, pancreas that resulted from
Irreversible end-stage failure of the relevant organ
Other stem cell transplants are not covered.
22. Loss of Speech
Total, permanent and Irreversible loss of the ability to speak as a result of injury or illness. A minimum
Assessment Period of six (6) months applies. Medical evidence to confirm injury or illness to the vocal
cords to support this disability must be supplied by an Ear, Nose, and Throat specialist.
All psychiatric related causes are not covered.
23. Brain Surgery
The actual undergoing of surgery to the brain under general anaesthesia during which a craniotomy
(surgical opening of skull) is performed.
The following are not covered:
Burr hole procedures
Transphenoidal procedures
Endoscopic assisted procedures or any other minimally invasive procedures
Brain surgery as a result of an accident.
24. Heart Valve Surgery
The actual undergoing of open-heart surgery to replace or repair cardiac valves as a consequence of
heart valve defects or abnormalities.
For the above definition, the following are not covered:
Repair via intra-arterial procedure
Repair via key-hole surgery or any other similar techniques.
25. Terminal Illness
The conclusive diagnosis of a condition that is expected to result in death of the Insured Person within
twelve (12) months. The Insured Person must no longer be receiving active treatment other than that for
pain relief. The diagnosis must be supported by written confirmation from an appropriate specialist and
confirmed by the Our appointed doctor.
26. Loss of Independent Existence
Confirmation by an appropriate specialist of the loss of independent existence and resulting in a
permanent inability to perform at least three (3) of the Activities of Daily Living. A minimum Assessment
Period of six (6) months applies.
27. Bacterial Meningitis - Resulting in Permanent Inability to Perform Activities of Daily Living
Bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in
permanent functional impairment. The permanent functional impairment must result in an inability to
perform at least three (3) of the Activities of Daily Living. A minimum Assessment Period of thirty (30)
days applies.
The diagnosis must be confirmed by:
an appropriate specialist; and
the presence of bacterial infection in the cerebrospinal fluid by lumbar puncture.
For the above definition, other forms of meningitis, including viral meningitis are not covered.
28. Major Head Trauma - Resulting in Permanent Inability to Perform Activities of Daily Living
Physical head injury resulting in permanent functional impairment verified by a Neurologist. The
permanent functional impairment must result in an inability to perform at least three (3) of the Activities of
Daily Living. A minimum Assessment Period of three (3) months applies.
29. Chronic Aplastic Anemia - Resulting in Permanent Bone Marrow Failure
Irreversible permanent bone marrow failure which results in anaemia, neutropenia and thrombocytopenia
requiring at least two (2) of the following treatments:
Regular blood product transfusion;
Marrow stimulating agents;
Immunosuppressive agents;or
Bone marrow transplantation.
The diagnosis must be confirmed by a bone marrow biopsy.
30. Motor Neuron Disease - Permanent Neurological Deficit with Persisting Clinical Symptoms
A definite diagnosis of motor neuron disease by a Neurologist with reference to either spinal muscular
atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must
be permanent neurological deficit with persisting clinical symptoms
31. Parkinson’s Disease - Resulting in Permanent Inability to Perform Activities of Daily Living
A definite diagnosis of Parkinson’s Disease by a Neurologist where all the following conditions are met:
Cannot be controlled with medication;
Shows signs of progressive impairment; and
Confirmation of the permanent inability of the Insured Person to perform without assistance three (3)
or more of the Activities of Daily Living.
Only idiopathic Parkinson’s Disease is covered. Drug-induced or toxic causes of Parkinsonism are not
covered.
32. Alzheimer’s Disease/Severe Dementia
Deterioration or loss of intellectual capacity confirmed by clinical evaluation and imaging tests arising
from Alzheimer’s Disease or Severe Dementia as a result of Irreversible organic brain disorders.
The covered event must result in significant reduction in mental and social functioning requiring
continuous supervision of the Insured Person. The diagnosis must be clinically confirmed by a
Neurologist.
From the above definition, the following are not covered:
Non organic brain disorders such as neurosis;
Psychiatric illnesses.
Drug or alcohol related brain damage.
33. Muscular Dystrophy
The definite diagnosis of a Muscular Dystrophy by a Neurologist which must be supported by all of the
following:
Clinical presentation of progressive muscle weakness;
No central / peripheral nerve involvement as evidenced by absence of sensory disturbance; and
characteristic electromyogram and muscle biopsy findings.
No benefit will be payable under this covered event before the Insured Person has reached the age of
twelve (12) years next birthday.
34. Surgery to Aorta
The actual undergoing of surgery via a thoracotomy or laparotomy (surgical opening of thorax or
abdomen) to repair or correct an aortic aneurysm, an obstruction of the aorta or a dissection of the aorta.
For this definition, aorta shall mean the thoracic and abdominal aorta but not its branches.
For the above definition, the following are not covered:
angioplasty;
other intra-arterial or catheter based techniques;
other keyhole procedures;
laser procedure
35. Multiple Sclerosis
A definite diagnosis of multiple sclerosis by a Neurologist. The diagnosis must be supported by all of the
following:
Investigations which confirm the diagnosis to be Multiple Sclerosis;
Multiple neurological deficits resulting in impairment of motor and sensory functions occurring over a
continuous period of at least six (6) months; and
Well documented history of exacerbations and remissions of said symptoms or neurological deficits.
36. Primary Pulmonary Arterial Hypertension - of Specified Severity
A definite diagnosis of primary pulmonary arterial hypertension with substantial right ventricular
enlargement established by investigations including cardiac catheterization, resulting in permanent
physical impairment to the degree of at least Class III of the New York Heart Association (NYHA)
classification of cardiac impairment.
Pulmonary arterial hypertension resulting from other causes shall be excluded from this benefit.
The NYHA Classification of Cardiac Impairment for Class III and Class IV means the following:
Class III: Marked limitation of physical activity. Comfortable at rest but less than ordinary activity
causes symptoms
Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present
even at rest.
37. Medullary Cystic Disease
A progressive hereditary disease of the kidney characterized by the presence of cysts in the medulla,
tubular atrophy and interstitial fibrosis with the clinical manifestations of anemia, polyuria and renal loss
of sodium, progressing to chronic kidney failure. Diagnosis must be supported by a renal biopsy.
38. Cardiomyopathy - of Specified Severity
A definite diagnosis of cardiomyopathy by a cardiologist which results in permanently impaired
ventricular function and resulting in permanent physical impairment of at least Class III of the New York
Heart Association’s classification of cardiac impairment. The diagnosis has to be supported by
echocardiographic findings of compromised ventricular performance.
The New York Heart Association Classification of Cardiac Impairment for Class III and Class IV means
the following:
Class III: Marked limitation of physical activity. Comfortable at rest but less than ordinary activity
causes symptoms.
Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present
even at rest.
Cardiomyopathy directly related to alcohol or drug abuse is not covered.
39. Systemic Lupus Erythematosus with Severe Kidney Complications
A definite diagnosis of Systemic Lupus Erythematosus confirmed by a rheumatologist. For this definition
, the covered event is payable only if it has resulted in Type III to Type V Lupus Nephritis as established
by renal biopsy. Other forms such as discoid lupus or those forms with only hematological or joint
involvement are not covered.
WHO Lupus Classification:
Type III - Focal Segmental glomerulonephritis
Type IV - Diffuse glomerulonephritis
Type V - Membranous glomerulonephritis
