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Serious Condition

Definition

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.

For the above definition, the following are not covered:

(i)  Transient ischemic attacks

(ii) Cerebral symptoms due to migraine

(iii) Traumatic injury to brain tissue or blood vessels

(iv) Vascular disease affecting the eye or optic nerve or vestibular functions.

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.

Heart Attack

Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction:

(i) A history of typical chest pain;

(ii) 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

(iii) 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 Doctor or Physician.

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:

(i) angioplasty;

(ii) other intra-arterial or catheter based techniques;

(iii) keyhole procedures;

(iv) laser procedures.

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.

Angioplasty and Other Invasive Treatments for Coronary Artery Disease

The actual undergoing of Coronary Artery Balloon Angioplasty, artherectomy, 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.

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:

(i) Repair via intra-arterial procedure

(ii) Repair via key-hole surgery or any other similar techniques.

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:

(i) All cancers which are histologically classified as any of the following:

• pre-malignant

• non-invasive

• carcinoma in situ

• having borderline malignancy

• having malignant potential
  
  

(ii) All tumours of the prostate histologically classified as T1N0M0 (TNM classification)

(iii) All tumours of the thyroid histologically classified as T1N0M0 (TNM classification)

(iv) All tumours of the urinary bladder histologically classified as T1N0M0 (TNM classification)

(v) Chronic Lymphocytic Leukemia less than RAI Stage 3

(vi) All cancers in the presence of HIV

(vii) Any skin cancer other than malignant melanoma.

Brain Surgery 

The actual undergoing of surgery to the brain under general anesthesia during which a craniotomy (surgical opening of skull) is performed.For the above definition, the following are not covered:

(i) Burr hole procedures

(ii) Transphenoidal procedures

(iii) Endoscopic assisted procedures or any other minimally invasive procedures

(iv) Brain surgery as a result of an Accident.

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. The covered event must be certified by a neurologist.

Encephalitis in the presence of HIV infection is not covered.

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:

(i) Cannot be controlled with medication;

(ii) Shows signs of progressive impairment; and

(iii) Confirmation of the Permanent inability of the Insured Life 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.

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 Life. The diagnosis must be clinically confirmed by a neurologist.

From the above definition, the following are not covered:

(i) Non organic brain disorders such as neurosis

(ii) Psychiatric illnesses

(iii) Drug or alcohol related brain damage

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

Crohn’s Disease with Intestinal Fistula, Obstruction or Perforation

Crohn’s Disease is a chronic granulomatous inflammatory bowel disease. Crohn’s Disease must have resulted in fistula formation, or intestinal obstruction or intestinal perforation that has required surgery and continuous immunosuppressive treatment or continuous treatment with immunomodulating drugs. Crohn’s Disease must be proven on biopsy and there must be continuous treatment under the care of a gastroenterologist.

Serious Accident - including Major Head Trauma with Permanent inability to perform Activities of Daily Living

Inability to perform at least three (3) of the Activities of Daily Living resulting from serious accident.

Advanced Treatment

Coverable Conditions

Cryoablation

Primary therapy alternative to surgery for individuals with localized disease or as a salvage therapy for recurrent cancer following failure of radiation therapy.

• Prostate Cancer with localized disease (T1 or T2 - Organ confined) as a primary therapy alternative to surgery or irradiation

• Prostate Cancer with (locally advanced) or as salvage therapy for recurrent cancer following failure of radiation therapy

• Malignant Endobronchial Obstruction

• High risk individual for surgical intervention with Renal Cell Carcinoma, up to 4-cm in size

• Drug resistant or intolerance Atrial fibrillation, with evidence of a localized site(s) of origin

• Low-risk superficial Basal Cell Carcinoma or Squamous Cell Carcinoma in situ (Bowen disease), where surgery or radiation is contraindicated or impractical

• Soft Tissue Sarcoma of the extremities or the trunk in symptomatic persons with disseminated metastases

Combined and Personalized Immunotherapy (CIC)

Nivolumab (Opdiva) are man-made monoclonal antibodies versions of immune system proteins designed to bind to specific targets in the body and causes immune response that destroys cancer cells.

• Bladder cancer

• Recurrence post cystectomy, or for metastatic disease

• Classical Hodgkin lymphoma

• Colorectal cancer, small bowel adenocarcinoma, appendicle carcinoma, and anal adenocarcinoma

• Head and neck cancer

• Hepatocellular carcinoma

• Kidney cancer

• Malignant pleural mesothelioma

• Melanoma

• Metastatic squamous cell anal carcinoma

• Non-small cell lung cancer (adenocarcinoma with mixed type)

• Primary carcinoma of the urethra

• Small cell lung cancer

• Upper gastrointestinal tract tumors

• Urothelial carcinoma of the prostate

Combined and Personalized Immunotherapy (CIC)

Pembrolizumab (Keytruda) are Immune checkpoint inhibitors drugs that remove obstacles from the immune system.

• Urothelial carcinoma (Transitional cell carcinoma)

• Bladder cancer

• Primary carcinoma of the urethra

• Upper gastrointestinal tract tumors

• Urothelial carcinoma of the prostate

• Colorectal cancer

• Small bowel adenocarcinoma

• Appendiceal carcinoma

Combined and Personalized Immunotherapy (CIC)

Cancer Vaccine Therapy known as Tumor-associated antigenic peptide-based vaccines for treatment of cancers.

• Adult metastatic castrate-resistant Prostate cancer

Proton Beam Radiotherapy (PBRT)

Proton beam radiation therapy (PBRT) is a type of external beam radiation therapy (EBRT) that utilizes protons (positively charged subatomic particles) that are precisely targeted to a specific tissue mass.

• Chordomas or chondrosarcomas arising at the base of the skull or cervical spine without distant metastases; or

• Malignancies in children (21 years of age and younger); or

• Uveal melanomas confined to the globe (i.e. not distant metastases) (the uvea is comprised of the iris, ciliary body, and choroid [the vascular middle coat of the eye])

Neutron Beam Radiation Therapy (NBRT)

Neutron beam radiation therapy (NBRT) is a specialized type of EBRT that uses high energy neutrons (neutral charged subatomic particles) targeted toward tissue masses that are characterized by lower tumor oxygen levels and a slower cell cycle as neutrons require less oxygen and are less dependent on the cell’s position in the cell division cycle.

• Inoperable tumor; or

• Locally advanced tumor especially in persons with gross residual disease; or unresectable tumor.

Stem Cells for Hematopoietic Cell Transplant

Bone marrow harvested from compatible donors to obtain the stem cells or bone marrow name as allogeneic bone marrow or peripheral stem cell transplant.

• Hodgkin's disease

• Non-Hodgkin's lymphoma (NHL)

• High risk stage II to stage III neuroblastoma & stage IV neuroblastoma primary recurrent or refractory disease (Primary refractory is defined as a tumor that does not achieve a complete remission after initial standard-dose chemotherapy. Relapse is defined as a tumor recurrence after a prior complete remission)

• People with chemosensitive neuroblastoma who have relapsed after an autologous hematopoietic cell transplant.

• People who have relapsed or progressive chemotherapy sensitive Ewing's sarcoma family of tumors that is not widely metastatic.

• People with primitive neuroectodermal tumors (PNET) including medulloblastoma and pineoblastoma.

• People with ependymoma who are ineligible for radiotherapy.

• People with extraocular retinoblastoma

• People with progressive or relapsed chemosensitive Wilms’ tumor.

Deep-Brain Stimulation (DBS)

Unilateral or bilateral deep brain stimulators (e.g. stimulation of the ventral intermediate thalamic nucleus, globus pallidus, and subthalamic nucleus) criteria with Durable Medical Equipment (DME)

• For treatment of intractable tremors as a consequence of Parkinson's disease with appropriate assessment of the independence in his/her daily life to meet the medical necessity.

Nerve Block

A nerve block is a form of regional anesthesia. Peripheral nerve blocks (PNBs) entail the injection of corticosteroids, local anesthetics, neurolytic agents and/or sclerosing agents into or near peripheral nerves or nerve ganglion resulting in the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks (somatic and sympathetic nerves). Peripheral nerve blocks attempt to block pain signals and in theory provide prolonged relief from pain.

• Femoral nerve blocks for acute postoperative pain after knee replacement surgery.

• Intercostal nerve blocks for acute intercostal pain, and for chronic intercostal neuritis as part of a comprehensive pain management programme.

• Peripheral nerve blocks (continuous or single-injection) for the treatment of (i) acute pain, and (ii) For chronic pain only as part of an active component of a comprehensive pain management programme.

• Peripheral nerve blocks for the treatment of chronic pain post-herniorrhaphy to avoid more aggressive treatments (e.g. surgery).

Back Pain (Invasive procedures)

Procedures that used to treat chronic pain that an individual especially at neck and back bone that limit daily activities and has lasted more than 3 months despite appropriate conservative treatment (including, but not limited to rest, systemic medications, and/or physical therapy).

• Facet joint injections (intra-articular and medial branch blocks) in persons with severe chronic neck and back pain. A set of facet joint injections (intra-articular or medial branch blocks) means up to 6 such injections per sitting, and this can be repeated once at the same levels and side, no sooner than one week after the initial set of injections.

• Trigger point injections of corticosteroids and/or local anesthetics for treating members with chronic neck or back pain or myofascial pain syndrome.

• Sacroiliac joint injections are considered medically necessary to relieve pain associated with lower lumbosacral disturbances. Interlaminar epidural injections of corticosteroid preparations (e.g. Depo-Medrol), with or without added anesthetic agents.

• Chymopapain chemonucleolysis is considered medically necessary for the treatment of sciatica due to a herniated disc with the following criteria met:

1. Person has leg pain worse than low back pain; and

2. Person has radicular symptoms reproduced by sciatic stretch tests; and

3. Person has only a single-level herniated disc with nerve root impingement at clinically suspected level demonstrated by MRI, CT, or myelography; and

4. Person has objective neurologic deficit (e.g. diminished deep tendon reflex, motor weakness, or hyperalgesia in dermatomal distribution); and

5. Person with pain not relieved by at least 6 weeks of conservative treatments

• Percutaneous lumbar discectomy , manual or automated.

• Non-pulsed radiofrequency facet denervation with intractable cervical or back pain with or without sciatica.

Brachytherapy

Also known as interstitial radiation, intracavitary radiation, internal radiation therapy)

• Breast cancer

• Esophageal cancer

• Eye tumors

• Genitourinary cancers other than bladder cancer (including penile cancer, prostate cancer, urethral cancer)

• Gynecologic cancer (cervical, endometrial, vaginal or vulvar)

• Head and neck cancers (including buccal mucosa cancer, lip cancer, mouth cancer, nasopharyngeal cancer, salivary gland cancer, soft palate cancer, tonsillar fossa/pillar cancer)

• Respiratory and digestive tract cancers (including lung cancer for palliation of obstructive symptoms due to intraluminal tumor), pelvic recurrence of colorectal cancer, pleural mesotheliomas, rectal (anal cancer)

• Skin cancer, where surgical resection and photon or electron beam techniques are contraindicated.

• Soft tissue sarcomas

• Stenotic obstruction post lung transplantation refractory to other treatments such as balloon dilation, laser debridement, or stent placement.