Coverage

Definitions for Coverage

 

 

Accidental Fracture

Your Accidental Fracture protection provides an additional amount of insurance if you suffer a fracture due to an accident.

Accidental Fracture Protection
FRACTURE SUM INSURED
Of the skull (dome of the skull) $5,000
Of the spine (excluding the coccyx) $5,000
Of the pelvis $5,000
Of the femur $5,000
Of a rib $1,500
Of a sternum $1,500
Of the scapula $1,500
Of the humerus $1,500
Of the patella $1,500
Of the tibia $1,500
Of the fibula $1,500
Of a bone not listed above $750


A benefit is payable for each fracture or complete severance, provided each one is due to a different accident. If you sustain more than one fracture or complete severance as a result of the same accident, the Company pays for the fracture or complete severance with the highest amount. Your fracture must be diagnosed within 30 days following the date of the accident. The protection ends when the insured reaches the age of 65.

Autism

The diagnosis of an organic defect in brain development characterized by failure to develop communicative language or other forms of social communication. The diagnosis must be confirmed before age three.

Rett Syndrome

The diagnosis of a genetic disorder of the central nervous system which is characterized by a retardation of cephalic growth after age of six months, the loss of use of the hands and a communication disorder associated with severe psychomotor retardation. The diagnosis must be confirmed before age three.

Cystic Fibrosis

The definitive diagnosis of Cystic Fibrosis with evidence of chronic lung disease and pancreatic insufficiency. The diagnosis must be confirmed before age 18.

Type 1 (Juvenile) Diabetes Mellitus

The diagnosis of type 1 diabetes mellitus, characterized by absolute insulin deficiency and continuous dependence on exogenous insulin for survival. There must be evidence of dependence on insulin for a minimum of three months. The diagnosis must be confirmed before age 18.

Cerebral Palsy

The definitive diagnosis of Cerebral Palsy, a non-progressive neurological defect characterized by spasticity and incoordination of movements. The diagnosis must be confirmed before age 18.

Muscular Dystrophy

The definitive diagnosis of Muscular Dystrophy characterized by well defined neurological abnormalities, confirmed by electromyography and muscle biopsy. The diagnosis must be confirmed before age 18.

Cancer

Carcinoma in situ; or Stage 1A malignant melanoma (melanoma less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion); or any non-melanoma skin cancer that has not metastasized: or Stage A (T1 a or T1 b) prostate cancer.
A definite diagnosis of a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The diagnosis of Cancer must be made by a specialist.

Exclusion: No benefit will be payable under this condition for the following cancers: Moratorium Period Exclusion No benefit will be payable under this condition if: Within the first 90 days following the later of: the effective date of this coverage; or the effective date of last reinstatement of this coverage; the Insured Person has any of the following: signs, symptoms or investigations, that lead to a diagnosis of cancer (covered or excluded under this coverage), regardless of when the diagnosis is made; a diagnosis of cancer (covered or excluded under this coverage). The Insured Person must report this medical information to the Company within 6 months of the date of the diagnosis.

Heart Attack

A definite diagnosis of the death of heart muscle due to obstruction of blood flow, that results in :
Rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:
heart attack symptoms; new electrocardiogram (ECG) changes consistent with a heart attack; or development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.
The diagnosis of Heart Attack must be made by a specialist.

Exclusion: No benefit will be payable under this condition for: elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves; or ECG changes suggesting a prior myocardial infarction, which do not meet the heart attack definition as described above.

Coronary Artery Bypass Surgery

The undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s), excluding any non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of an obstruction. The surgery must be determined to be medically necessary by a specialist.

Heart Valve Replacement

The undergoing of surgery to replace any heart valve with either a natural or mechanical valve. The surgery must be determined to be medically necessary by a specialist.

Exclusion: No benefit will be payable under this condition for heart valve repair.

Aortic Surgery

The undergoing of surgery for disease of the aorta requiring excision and surgical replacement of the diseased aorta with a graft. Aorta refers to the thoracic and abdominal aorta but not its branches. The surgery must be determined to be medically necessary by a specialist.

Stroke (Cerebrovascular Accident)

A definite diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with: acute onset of new neurological symptoms, and new objective neurological deficits on clinical examination,
persisting for more than 30 days following the date of diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing. The diagnosis of Stroke must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for: Transient Ischaemic Attacks; or Intracerebral vascular events due to trauma; or
Lacunar infarcts which do not meet the definition of stroke as described above.

Multiple Sclerosis

A definite diagnosis of at least one of the following:
two or more separate clinical attacks, confirmed by magnetic resonance ImagIng (MRI) of the nervous system, showing multiple lesions of demyelination; or well-defined neurological abnormalities lasting more than 6 months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination; or a single attack, confirmed by repeated MRI imaging of the nervous system, which shows multiple lesions of demyelination which have developed at intervals at least one month apart. The diagnosis of multiple sclerosis must be made by a specialist.

Alzheimer's Disease

A definite diagnosis of a progressive degenerative disease of the brain. The Insured Person must exhibit the loss of intellectual capacity involving impairment of memory and judgement, which results in a significant reduction in mental and social functioning, and requires a minimum of 8 hours of daily supervision. The diagnosis of Alzheimer's Disease must be made by a specialist.

Exclusion: No benefit will be payable under this condition for all other dementing organic brain disorders and psychiatric illnesses.

Parkinson's Disease

A definite diagnosis of primary idiopathic Parkinson's Disease, which is characterized by a minimum of two or more of the following clinical manifestations: muscle rigidity, tremor, or bradykinesis (abnormal slowness of movement, sluggishness of physical and mental responses). The Insured Person must require substantial physical assistance from another adult to perform at least 2 of the following 6 Activities of Daily Living. The diagnosis of Parkinson's Disease must be made by a specialist.

Activities of Daily Living are:
Bathing: the ability to wash oneself in a bath tub, shower or by sponge bath. with or without the aid of equipment.
Dressing: the ability to put on and remove necessary clothing including braces, artificial limbs or other surgical appliances.
Toileting : the ability to get on and off the toilet and maintain personal hygiene.
Bladder and Bowel Continence : the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained.
Transferring: the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment.
Feeding: the ability to consume food or drink that already has been prepared and made available,with or without the use of adaptive utensils

Exclusion: No benefit will be payable under this condition for all other types of Parkinsonism.

Paralysis

A definite diagnosis of the total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event. The diagnosis of Paralysis must be made by a specialist.

Loss of Limbs

A definite diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation. The diagnosis of loss of limbs must be made by a specialist.

Blindness

A definite diagnosis of the total and irreversible loss of vision in both eyes, evidenced by: the corrected visual acuity being 20/200 or less in both eyes; or the field of vision being less than 20 degrees in both eyes. The diagnosis of blindness must be made by a specialist.

Deafness

A definite diagnosis of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The diagnosis of deafness must be made by a specialist.

Loss of Speech

A definite diagnosis of the total and irreversible loss of the ability to speak as the result of physical injury or disease, for a period of at least 180 days. The diagnosis of loss of speech must be made by a specialist.

Exclusion: No benefit will be payable under this condition for all psychiatric related causes.

Major Organ Failure on Waiting List

A definite diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessory. To qualify under major organ failure on waiting list, the insured person must become enrolled as the recipient in a recognized transplant centre in Canada or the United States of America that performs the required form of transplant surgery. For the purposes of the survival period, the date of diagnosis is the date of the insured person's enrollment in the transplant centre. The diagnosis of the major organ failure must be made by a specialist.

Major Organ Transplant

A definite diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under major organ transplant, the insured person must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The diagnosis of the major organ failure must be made by a specialist.

Kidney Failure

A definite diagnosis of chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated. The diagnosis of kidney failure must be made by a specialist.

Bacterial Meningitis

A definite diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of diagnosis. The diagnosis of bacterial meningitis must be made by a specialist.

Exclusion: No benefit will be payable under this condition for viral meningitis.

Coma

A definite diagnosis of a state of unconsciousness with no reaction to external stimuli or response to internal needs for: 3 continuous period of of least 96 hours, and for which period the Glasgow coma score must be 4 or less. The diagnosis of coma must be made by a specialist.

Exclusion: No benefit will be payable under this condition for: a medically induced coma; or a coma which results directly from alcohol or drug use; or a diagnosis of brain death.

Motor Neuron Disease

A definite diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), primary laleral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy, or pseudo bulbar palsy, and limited to these conditions. The diagnosis of motor neuron disease must be made by a specialist.

Benign Brain Tumour

The definite diagnosis of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgical or radiation treatment or cause irreversible objective neurological deficit(s). The diagnosis of benign brain tumour must be made by a specialist.

Exclusion: No benefit will be payable under this condition for pituitary adenomas less than 10 mm.

Moratorium Period Exclusion: No benefit will be payable under this condition if: within the first 90 days following the later of: the effective date of this coverage; or the effective date of last reinstatement of this coverage; the insured person has any of the following: signs, symptoms or investigations that lead to a diagnosis of benign brain tumour, regardless of when the diagnosis is made, a diagnosis of benign brain tumour. The insured person must report this medical information to the company within 6 months of the date of the diagnosis.

Severe Burns

A definite diagnosis of third-degree burns over at least 20% of the body surface. The diagnosis of severe burns must be made by a specialist.

Occupational HIV Infection

A definite diagnosis of infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the insured person's normal occupation. which exposed the person to HIV contaminated body fluids. The accidental injury leading to the infection must have occurred after the later of the effective date of this coverage, or the effective date of last reinstatement of this coverage.

Payment under this condition requires satisfaction of all of the following:
The accidental injury must be reported to the insurer within 14 days of the accidental injury;
A serum HIV test must be taken within 14 days of the accidental Injury and the result must be negative;
A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;
All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America; The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines
The diagnosis of occupational HIV Infection must be made by a specialist.

Exclusion: No benefit will be payable under this condition if: The insured person has elected not to take any available licensed vaccine offering protection against HIV; or A licensed cure for HIV infection has become available prior to the accidental injury; or
HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

Aplastic Anemia

A definite diagnosis of a chronic persistent bone marrow failure, confirmed by biopsy, which results in anemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following: marrow stimulating agents; immunosuppressive agents; bone marrow transplantation. The diagnosis of aplastic anemia must be made by a specialist.

Loss of Independent Existence

A definite diagnosis of: a total inability lo perform by oneself at least 2 of the following 6 activities of daily living; or, cognitive impairment as defined below; for a continuous period of at least 90 days with no reasonable chance of recovery. The diagnosis of loss of independent existence must be made by a specialist.

Activities of Daily Living are:
Bathing: the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of equipment;
Dressing: the ability to put on and remove necessary clothing including braces, artificial limbs or other surgical appliances;
Toileting: the ability to get on and off the toilet and maintain personal hygiene;
Bladder and Bowel Continence: the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained;
Transferring: the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment;
Feeding· the ability to consume food or drink that already has been prepared and made available, with or without the use of adaptive utensils.

Cognitive Impairment is defined as "mental deterioration and loss of intellectual ability, evidenced by deterioration in memory, orientation and reasoning, which are measurable and result from demonstrable organic cause as diagnosed by a specialist. The degree of cognitive impairment must be sufficiently severe as to require a minimum of 8 hours of daily supervision. Determination of a cognitive impairment will be made on the basis of clinical data and valid standardized measures of such impairments".

Exclusion: No benefit will be payable for a loss of independent existence caused by any mental or nervous disorder without a demonstrable organic cause.

Recovery Cash Advance Diagnosis and Treatment

Conditions or treatment covered:
Early prostate cancer - Stage T1a or T1b (stage A) prostate cancer
Ductal carcinoma of the breast - Ductal carcinoma in situ of the breast (DCIS) confirmed by a biopsy.
Stage 1A malignant melanoma - Stage 1A malignant melanoma (melanoma less than or equal to 1.0 mm in thickness)
HIV related cancer - Malignant tumour in the presence of any human immunodeficiency virus (H1V)
Coronary Angioplasty - The undergoing of an interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood. The procedure must be determined to be medically necessary by a specialist.

Serious Complications Caused by Infectious Diseases

West Nile Virus - The diagnosis of West Nile Virus causing serious health problems, such as meningitis, encephalitis and acute flaccid paralysis, and confirmed by blood tests.
Lyme Disease - The diagnosis of Lyme disease, caused by the Borrelia burgdoferi bacterium and transmitted by tics, in phase two or three, and confirmed by clinical tests. The insured person must present clinical signs, including neurological signs, and have had no episodes prior to the initial date of this coverage.
E.Coli Infection - The diagnosis of escherichia coli 0157H7 infection confirmed by a stool culture and causing one of the following complications: Hemolytic uremic syndrome; Hemolytic anaemia; Thrombocytopenia; or Renal failure.
Necrotizing Fasciitis (flesh-eating disease) - The diagnosis of a sudden bacterial infection characterized by involvement of the muscle sheath (fascia) requiring antibiotic therapy and surgery.