What does critical illness insurance cover?

Selecting a level of coverage

With policies ranging from one illness to 26 or more you might be wondering how many illnesses you should get covered for?

If you want the best protection, you should obviously opt for a policy that covers the entirety of the CLHIA’s standard definitions. While it can be tempting to write off less common diseases as “unlikely to happen to you,” if you do contract one of them, you’ll undoubtedly regret the decision to leave them out of your coverage plan.

However, if premium cost is an issue, or you have a higher risk tolerance, there are some stats worth contemplating.

Most claimed critical illnesses in Canada

While these numbers may change with time, historically the vast majority of critical illness claims in Canada are for some form of cancer, to the tune of 60 percent or more. Heart attack and stroke represent the second and third most likely claims, contributing another 20 percent. It’s known in the industry that these “big three” conditions are the most commonly diagnosed and that’s why you’ll see them offered together in most basic policies.

Definitions of critical illnesses in Canada

In 2013, the Canadian Life and Health Insurance Association published a standardized list of critical illness definitions (referred to as Critical Illness Benchmark Definitions) in order to help standardize the language around common conditions and afflictions across the industry.

In 2018, the language of these definitions have been updated. Below are the definitions for the following 26 conditions that are widely used in the Canadian insurance industry for critical illness insurance policies, though by no means should this list be considered exhaustive or definitive.

Cancers and Tumours

Benign Brain Tumour

Benign Brain Tumour means a 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).

These deficits must be corroborated by diagnostic imaging showing changes that are consistent in character, location and timing with the neurological deficits.

The Diagnosis of Benign Brain Tumour must be made by a Specialist.

For purposes of the policy, neurological deficits must be detectable by the Specialist and may include, but are not restricted to, measurable loss of hearing, measurable loss of vision, measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia (difficulty with speech), dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination, or new-onset seizures undergoing treatment. Headache or fatigue will not be considered a neurological deficit.

Exclusions: No benefit will be payable under this condition for:

• Pituitary adenomas less than 10 mm;
• Vascular malformations;
• Cholesteatomas; or
• Infectious or inflammatory tumours.

90-Day Exclusion: No benefit will be payable under this Covered Condition if, within the first 90 days following the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

• Signs, symptoms or investigations that lead to a Diagnosis of Benign Brain Tumour (covered or excluded under the Policy), regardless of when the Diagnosis is made; or
• A Diagnosis of Benign Brain Tumour (covered or not covered under the Policy).

Medical Information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Benign Brain Tumour or any Critical Illness caused by any Benign Brain Tumour or its treatment.

Cancer (Life-Threatening)

Cancer (Life-Threatening) means the definite Diagnosis of a malignant tumour. This tumour must be characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Types of cancer include carcinoma, melanoma, leukemia, lymphoma, and sarcoma.

The Diagnosis of Cancer must be made by a Specialist and must be confirmed by a pathology report.

For purposes of the Policy:

• T1a or T1b prostate cancer means a clinically inapparent tumour that was not palpable on digital rectal examination and was incidentally found in resected prostatic tissue.
• The term gastrointestinal stromal tumours (GIST) classified as AJCC Stage 1 means:
• Gastric and omental GISTs that are less than or equal to 10 cm in greatest dimension with five or fewer mitoses per 5 mm2, or 50 per HPF; or
• Small intestinal, esophageal, colorectal, mesenteric and peritoneal GISTs that are less than or equal to 5 cm in greatest dimension with 5 or fewer mitoses per 5 mm2, or 50 per HPF;
• The terms Tis, Ta, T1a, T1b, T1 and AJCC Stage 1 are as defined in the American Joint Committee on Cancer (AJCC) cancer staging manual, 8th Edition, 2018.
• The term Rai stage 0 is as defined in KR Rai, A Sawitsky, EP Cronkite, AD Chanana, RN Levy and BS Pasternack: Clinical staging of chronic lymphocytic leukemia. Blood 46:219,1975.

Exclusions: No benefit will be payable under this Covered Condition for the following:

No benefit will be payable for the following:

• Lesions described as benign, non-invasive, pre-malignant, of low and/or uncertain malignant potential, borderline, carcinoma in situ, or tumors classified as Tis or Ta;
• Malignant melanoma of skin that is less than or equal to 1.0mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;
• Any non-melanoma skin cancer, without lymph node or distant metastasis. This includes but is not limited to, cutaneous T cell lymphoma, basal cell carcinoma, squamous cell carcinoma or Merkel cell carcinoma;
• Prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;
• Papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0cm in greatest dimension and classified as T1, without lymph node or distant metastasis;
• Chronic lymphocytic leukemia classified as Rai stage 0 without enlargement of lymph nodes, spleen or liver and with normal red blood cell and platelet counts;
• Gastro-intestinal stromal tumours classified as AJCC Stage 1;
• Grade 1 neuroendocrine tumours (carcinoid) confined to the affected organ, treated with surgery alone and requiring no additional treatment, other than perioperative medication to oppose effects from hormonal oversecretion by the tumour; or
• Thymomas (stage 1) confined to the thymus, without evidence of invasion into the capsule or spread beyond the thymus.

90-Day Exclusion: No benefit will be payable under this Covered Condition if, within the first 90 days following the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage, the Insured Person has any of the following:

• Signs, symptoms or investigations leading directly or indirectly to a Diagnosis of any cancer (covered or not covered under the Policy), regardless of when the Diagnosis is made; or
• A diagnosis of any cancer (covered or not covered under the Policy).

Medical Information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Cancer or any critical illness caused by any cancer or its treatment.

Cardiovascular

Aortic Surgery

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

Exclusions: No benefit will be payable under this condition for:

• Angioplasty;
• intra-arterial procedures;
• percutaneous trans-catheter procedures; or
• non-surgical procedures.

Coronary Artery Bypass Surgery definition

Coronary Artery Bypass Surgery means the undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s). The Surgery must be determined to be medically necessary by a Specialist.

Exclusions: No benefit will be payable under this Covered Condition for:

• Angioplasty;
• Intra-arterial procedures;
• Percutaneous trans-catheter procedures; or
• Non-surgical procedures.

Heart Attack definition

Heart Attack means a definite diagnosis of the death of heart muscle due to obstruction of blood flow, that results in a 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
• 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 (acute myocardial infarction) must be made by a specialist.

Exclusions: No benefit will be payable under this covered condition for:

• ECG changes suggestive of a prior myocardial infarction;
• Other acute coronary syndromes, including angina pectoris and unstable angina; or
• Elevated cardiac biomarkers and/or symptoms that are due to medical procedures or diagnoses other than heart attack.

Heart Valve Replacement or Repair definition

Heart Valve Replacement or Repair means the undergoing of Surgery to replace any heart valve with either a natural or mechanical valve or to repair heart valve defects or abnormalities. The Surgery must be determined to be medically necessary by a Specialist.

Exclusions: No benefit will be payable under this condition for:

• Angioplasty;
• Intra-arterial procedures;
• Percutaneous trans-catheter procedures; or
• Non-surgical procedures.

Stroke definition

Stroke (Cerebrovascular Accident) means 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 covered 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.

Neurological

Bacterial Meningitis

Bacterial Meningitis means a definite Diagnosis of meningitis, confirmed by cerebrospinal fluid showing the presence of pathogenic bacteria.  The presence of pathogenic bacteria must be confirmed by culture or other generally medically accepted microbiological testing.  The Bacterial Meningitis must result in neurological deficits persisting for at least 90 days from the Date of Diagnosis.

The Diagnosis of Bacterial Meningitis must be made by a Specialist.

For purposes of the policy, neurological deficits must be detectable by the Specialist and may include, but are not restricted to, measurable loss of hearing, measurable loss of vision, measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia (difficulty with speech), dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination, or new-onset seizures undergoing treatment. Headache or fatigue will not be considered a neurological deficit.

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

Dementia definition, including Alzheimer’s Disease

Dementia, including Alzheimer’s Disease means a definite Diagnosis of dementia, which must be characterized by a progressive deterioration of memory and at least one of the following areas of cognitive function:

• Aphasia (a disorder of speech)
• Apraxia (difficulty performing familiar tasks);
• Agnosia (difficulty recognizing objects); or
• Disturbance in executive functioning (e.g. inability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior), which is affecting daily life.

The Insured Person must exhibit:

• Dementia of at least moderate severity, which must be evidenced by a Mini Mental State Exam of 20/30 or less, or equivalent score on another generally medically accepted test or tests of cognitive function; and
• Evidence of progressive worsening in cognitive and daily functioning either by serial cognitive tests or by history over at least a 6 month period.

The Diagnosis of Dementia, including Alzheimer’s Disease must be made by a Specialist.

Exclusion: No benefit will be payable under this Covered Condition for affective or schizophrenic disorders, or delirium.

For purposes of the Policy, reference to the Mini Mental State Exam is to Folstein MF, Folstein SE, McHugh PR, J Psychiatr Res. 1975;12(3):189.

Motor Neuron Disease definition

Motor Neuron Disease means a definite Diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral 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.

Multiple Sclerosis definition

Multiple Sclerosis means a definite Diagnosis of one of the following occurring after the later of the Issue Date of an Insured Person’s coverage, or the last Reinstatement Date of an Insured Person’s coverage:

Two or more separate clinical attacks, confirmed by a magnetic resonance imaging (MRI) of the nervous system, showing multiple lesions of demyelination;

A single attack, with objective neurological deficits lasting more than 6 months, confirmed by MRI of the nervous system, showing multiple lesions of demyelination; or,

A single attack, confirmed by repeated MRI 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.

For purposes of the Policy, neurological deficits must be detectable by a Specialist and may include, but are not restricted to, measurable loss of hearing, measurable loss of vision, measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia (difficulty with speech), dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination, or new-onset seizures undergoing treatment. Headache or fatigue will not be considered a neurological deficit.

Exclusion: No benefit will be payable for the following:

• Solitary sclerosis;
• Clinically isolated syndrome;
• Radiologically isolated syndrome;
• Neuromyelitis optica spectrum disorders; or
• Suspected multiple sclerosis or probable multiple sclerosis.

1-Year Exclusion – No benefit will be payable under this Covered Condition if, within the first year following the later of the Issue Date of an Insured Person’s coverage or the last Reinstatement Date of an Insured Person’s coverage, the Insured Person has any of the following:

• Signs, symptoms or investigations leading directly or indirectly to a Diagnosis of multiple sclerosis (covered or not covered under the policy) regardless of when the Diagnosis is made; or
• A Diagnosis of multiple sclerosis (covered or not covered under the Policy).

Medical information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Multiple Sclerosis or, any critical illness caused by multiple sclerosis or its treatment.

Parkinson’s Disease and Specified Atypical Parkinsonian Disorders definitions

Parkinson’s Disease and Specified Atypical Parkinsonian Disorders means a definite Diagnosis of either A) Parkinson’s Disease or B) Specified Atypical Parkinsonian Disorders, as defined below.

1. Parkinson’s Disease means a definite Diagnosis of primary Parkinson’s disease, a permanent neurological condition which must be characterized by bradykinesia (slowness of movement) and at least one of the following: muscular rigidity or rest tremor. The Insured Person must exhibit objective signs of progressive deterioration in function for at least one year, for which the treating neurologist has recommended dopaminergic medication or other generally medically accepted equivalent treatment for Parkinson’s Disease.
2. Specified Atypical Parkinson’s Disorders means a definite Diagnosis of progressive supranuclear palsy, corticobasal degeneration, or multiple system atrophy.

The Diagnosis of Parkinson’s Disease or a Specified Atypical Parkinsonian Disorder must be made by a Specialist.

Exclusions: No benefit will be payable for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders if, within the first year following the later of the Issue Date or the latest Reinstatement Date of an Insured Person’s coverage, such Insured Person has any of the following:

• signs, symptoms or investigations that lead to a Diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of parkinsonism, regardless of when the Diagnosis is made; or
• a Diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of Parkinsonism.

Medical information about the Diagnosis and any signs, symptoms or investigations leading to the Diagnosis must be reported to the Company within 6 months of the Date of Diagnosis. If this information is not provided within this period, the Company has the right to deny any claim for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or its treatment.

No benefit will be payable under Parkinson’s Disease and Specified Atypical Parkinsonian Disorders for any other type of Parkinsonism.

Vital Organs

Kidney Failure definition

Kidney Failure means 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.

Major Organ Failure on Waiting List definition

Major Organ Failure on Waiting List means 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 Failure on Waiting List, the Insured Employee must become enrolled as the recipient in a recognized transplant center in Canada or the United States of America that performs the required form of transplant Surgery. For the purpose of the Survival Period, the Date of Diagnosis is the date of the Insured Employee’s enrolment in the transplant centre. The Diagnosis of the major organ failure must be made by a Specialist.

Major Organ Transplant definition

Major Organ Transplant means 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.

Accident and Functional Loss

Acquired Brain Injury

Acquired brain injury means a definite diagnosis of new damage to brain tissue caused by traumatic injury, anoxia or encephalitis, resulting in signs and symptoms of neurological impairment that:

• are present and verifiable on clinical examination or neuropsychological testing,
• are corroborated by imaging studies of the brain such as Magnetic Resonance Imaging (MRI) or Computerized Tomography (CT) showing changes that are consistent in character, location, and timing with the new damage, and
• persist for more than 180 days following the date of diagnosis

The diagnosis of acquired brain injury must be made by a specialist.

Exclusions

No benefit will be payable under this condition for:

• an abnormality seen on brain or other scans without definite related clinical impairment, or
• neurological signs occurring without symptoms of abnormality.

Blindness

Blindness means 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.

Coma

Coma means a definite Diagnosis of a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at 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 covered condition for:

• a medically induced coma; or.
• a coma which results directly from alcohol or drug use; or.
• a diagnosis of brain death.

Deafness definition

Deafness means 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 Independent Existence definition

Loss of Independent Existence means a definite Diagnosis of the total inability, due to disease or injury, to perform independently, with or without the aid of assistive devices, at least 2 of 6 Activities of Daily Living listed below for a continuous period of at least 90 days with no reasonable chance of recovery. The Diagnosis must be made by a physician and supported by an independent home care assessment made by an occupational therapist or equivalent.

Activities of Daily Living are as follows:

• Bathing: washing oneself in a bathtub, shower or by sponge bath;
• Dressing: putting on and removing necessary clothing, braces, artificial limbs or other surgical appliances;
• Toileting: getting on and off the toilet and maintaining personal hygiene;
• Bladder and bowel continence: managing one’s bladder and bowel function with or without protective undergarments or surgical appliances so that hygiene is maintained;
• Transferring: moving in and out of a bed, chair or wheelchair;
• Feeding: consuming food or drink that already have been prepared and made available.

No additional survival period is required once the conditions described above are satisfied.

Loss of Limbs definition

Loss of Limbs means 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.

Loss of Speech definition

Loss of Speech means a definite Diagnosis of the total and Irreversible loss of the ability to speak as a 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 Covered Condition for all psychiatric related causes.

Paralysis definition

Paralysis means 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.

Severe Burns definition

Severe Burns means 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.

Other

Aplastic Anemia 

Aplastic Anemia means 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; or
• Bone marrow transplantation.

The Diagnosis of Aplastic Anemia must be made by a Specialist.

Occupational HIV Infection definition

Occupational HIV Infection means 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 Issue Date or latest Reinstatement Date of such Insured Person’s coverage.

Payment under this condition requires satisfaction of all of the following:

• The accidental injury must be reported to the Company 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 covered 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.