Critical Illness - Coverage Details
This is a guide designed to provide information about the Critical Illness benefit, and the covered conditions definitions. This is not a contract, and coverage will be subject to the terms and conditions of the Blue Cross Life policy.
25 covered conditions
Eligible for up to 2 full payments, when the conditions fall under different categories
4 covered conditions eligible for partial payment
Critical Illness - Coverage Details
This is a guide designed to provide information about the Critical Illness benefit, and the covered conditions definitions. This is not a contract, and coverage will be subject to the terms and conditions of the Blue Cross Life policy.
25 covered conditions
Eligible for up to 2 full payments, when the conditions fall under different categories
4 covered conditions eligible for partial payment
Eligible for up to 2 full payments, when the conditions fall under different categories
Category 1
Category 2
Category 3
Category 4
A partial benefit payment will be paid for any of the following non-life threatening critical conditions:
Plan members may be eligible for one partial payment per lifetime for each covered condition eligible. A partial benefit payment does not reduce the amount of coverage available for covered conditions eligible for full payment.
A child's benefit amount will be paid for up to 1 childhood condition per lifetime. Coverage includes the following childhood illnesses/conditions:
No benefit is payable if a Child is born within 10 months of the effective date of Child optional critical illness coverage, and that Child is diagnosed with a childhood condition within those 10 months.
A child’s coverage terminates after payment of 1 covered childhood condition.
Blue Cross will not pay benefits for any condition that results, directly or indirectly, from any of the following causes:
a Pre-Existing Condition, unless the covered condition occurs after 24 consecutive months of coverage;
an Accident, unless the covered condition is a Severe Burn;
attempted suicide or voluntary injury or Illness;
use of any poison, intoxicant or drug, unless prescribed by a Physician and used as directed;
participation in a criminal act or an attempt to commit a criminal act, regardless of whether charges are laid or a conviction is obtained;
any Accident or injury occurring while operating a vehicle under the influence of drugs (including marijuana) or with a blood alcohol level in excess of the legal limit in the jurisdiction in which the Accident occurs; or
insurrection, war (declared or not), the hostile action of the armed forces of any country or participation in any riot or civil commotion.
Any condition for which, during the 24 months immediately before the effective date of this benefit, the participant has:
This definition does not apply to a Child born while Child optional critical illness coverage is in force.
The continuous period of time between the date the definition of a covered condition is met and the date the benefit is payable. The survival period is 30 consecutive days unless otherwise specified in the details of the covered condition.
Definitions
Covered Conditions eligible for Full Payment
Definition - 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 - This coverage excludes angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non- surgical procedures.
Definition - 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:
The diagnosis of Aplastic Anemia must be made by a Specialist.
Definition - 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 objective neurological deficits persisting for at least 90 days from the date of diagnosis.
The diagnosis of Bacterial Meningitis must be made by a Specialist.
Neurological deficits must be detectable by the Specialist and may include, but are not restricted to, measurable loss of hearing or 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 is not considered a neurological deficit.
Exclusions - This coverage excludes viral meningitis.
Definition - Definite diagnosis of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The Participant must have undergone surgery or radiation treatment or the tumour must have caused irreversible objective neurological deficits.
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.
Neurological deficits must be detectable by the Specialist and may include, but are not restricted to, measurable loss of hearing or 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 is payable under this condition for pituitary adenomas less than 10 mm, vascular malformations; cholesteatomas or infectious or inflammatory tumours.
90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Benign Brain Tumour or, any critical illness caused by any benign brain tumour or its treatment.
Definition - Definite diagnosis of the total and irreversible loss of vision in both eyes, evidenced by:
The diagnosis of Blindness must be made by a Specialist.
Definition - 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 this condition:
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.
Exclusions - No benefit is payable under this condition for the following:
90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Cancer, or any critical illness caused by any cancer or its treatment.
Definition - 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.
Exclusions - This coverage excludes:
Definition - Heart surgery to correct narrowing or blockage of 1 or more coronary arteries with bypass graft(s). The surgery must be determined to be Medically Necessary by a Specialist.
Exclusions - This coverage excludes angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
Definition - 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.
Definition - Definite diagnosis, made by a Specialist, of dementia which must be characterized by a progressive deterioration of memory and at least one of the following areas of cognitive function:
The Participant must exhibit:
Exclusions - This coverage excludes affective or schizophrenic disorders or delirium.
Reference to the Mini Mental State Exam is to Folstein MF, Folstein SE, McHugh PR, J Psychiatry Res. 1975; 12(3):189.
Definite diagnosis of death of heart muscle due to obstruction of blood flow that results in a rise and fall of cardiac biomarkers to levels considered diagnostic of acute myocardial infarction, with at least one of the following:
The diagnosis of Heart Attack must be made by a Specialist.
Exclusions - No benefit is payable under this condition for:
Definition - 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 - This coverage excludes angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
Definition - 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.
Definition - Definite diagnosis of the total inability, due to disease or injury, to independently perform at least 3 of 6 Activities of Daily Living:
The diagnosis of Loss of Independent Existence must be made by a Physician and supported by an independent home care assessment made by an occupational therapist or equivalent.
No additional Survival Period is required once the conditions described above are satisfied.
Activities of Daily Living: The following 6 activities:
Definition - 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.
Definition - 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.
Exclusions - This coverage excludes all psychiatric related causes.
Definition - 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 Participant 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 Participant’s enrolment in the transplant centre. The diagnosis of the major organ failure must be made by a Specialist.
Definition - Definite diagnosis of irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, such that an organ transplant is Medically Necessary.
To qualify under Major Organ Transplant, the Participant 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.
Definition - 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.
Definition - Definite diagnosis of at least one of the following occurring after the effective date of coverage:
The diagnosis of Multiple Sclerosis must be made by a Specialist.
Neurological deficits must be detectable by a Specialist and may include, but are not restricted to, measurable loss of hearing or 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 is payable for the following:
1-Year Exclusion: No benefit will be payable under this condition if, within the first year following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Multiple Sclerosis or, any critical illness caused by multiple sclerosis or its treatment.
Definition - Definite diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis, haemorrhage or embolism with:
The diagnosis of Stroke must be made by a Specialist.
Neurological deficits must be detectable by a Specialist and may include, but are not restricted to, measurable loss of hearing or 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 is payable under this condition for:
Definition - Definite diagnosis of infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the Participant’s normal occupation, which exposed the person to HIV contaminated body fluids.
The accidental injury leading to the infection must have occurred after the effective date of the coverage.
Payment under this condition requires satisfaction of all of the following:
a) The accidental injury must be reported to Blue Cross within 14 days of the accidental injury;
b) A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative;
c) A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;
d) All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America; and
The diagnosis of Occupational HIV Infection must be made by a Specialist.
Exclusions - No benefit is payable under this condition if:
Definition - 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.
Definition - Definite diagnosis of primary Parkinson’s Disease, a permanent neurologic condition which must be characterized by bradykinesia (slowness of movement) and at least one of: muscular rigidity or rest tremor. The Participant 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.
Definition - 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 neurologist.
1-Year Exclusion: No benefit is payable for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders if, within the first year following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or, any critical illness caused by Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or its treatment.
Exclusions - No benefit is payable under Parkinson’s Disease and Specified Atypical Parkinsonian Disorders for any other type of parkinsonism.
Definition - 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.
Covered Conditions eligible for Partial Payment
Definition - 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.
Definition - A non-invasive cancer that must be confirmed by biopsy. The diagnosis of ductal carcinoma in situ of the breast must be made by a Specialist.
90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for cancer, or any critical illness caused by any cancer or its treatment.
Definition - The diagnosis of stage A (T1a or T1b) prostate cancer must be made by a Specialist and confirmed by pathological examination of prostate tissue.
90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for cancer, or any critical illness caused by any cancer or its treatment.
Definition - A melanoma confirmed by biopsy to be less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion. The diagnosis of state 1A malignant melanoma must be made by a Specialist.
90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:
Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for cancer, or any critical illness caused by any cancer or its treatment.
Covered Childhood Conditions (if applicable)
Definition - an organic defect in brain development characterized by failure to develop communicative language or other forms of social communication, with the diagnosis confirmed either by a pediatric psychiatrist or a pediatrician before the Child’s third birthday.
Definition - a definitive diagnosis of Cerebral Palsy, a non-progressive neurological defect characterized by spasticity and in coordination of movements.
Definition - any one or more diagnosis(es) from the following lists of heart conditions:
List A
a) Total Anomalous Pulmonary Venous Connection;
b) Transposition of The Great Vessels;
c) Atresia of any heart valve;
d) Coarctation of the Aorta;
e) Single Ventricle;
f) Hypoplastic Left Heart Syndrome;
g) Double Outlet Left Ventricle;
h) Truncus Arteriosus;
i) Tetralogy of Fallot;
j) Eisenmenger Syndrome;
k) Double Inlet Ventricle;
l) Hypoplastic Right Ventricle; or
The above conditions are covered after a 30-day Survival Period, beginning from the later of the date of diagnosis or birth. The diagnosis of any of the conditions in List A must be made by a qualified pediatric cardiologist and supported by appropriate cardiac imaging.
List B
a) Pulmonary Stenosis;
b) Aortic Stenosis;
c) Discrete Subvalvular Aortic Stenosis;
d) Ventricular Septal Defect; or
e) Atrial Septal Defect.
The above conditions are covered only when open heart surgery is performed for correction of the condition after a 30-day Survival Period from the later of the date of diagnosis or birth. The diagnosis of any of the conditions in this List B must be made by a qualified pediatric cardiologist and supported by appropriate cardiac imaging. The surgery must be recommended by a qualified pediatric cardiologist and performed by a cardiac surgeon in Canada.
Definition - a definitive diagnosis of Cystic Fibrosis with evidence of chronic lung disease and pancreatic insufficiency.
Definition - a definitive diagnosis of Down Syndrome by a qualified Specialist.
Definition - a definitive diagnosis of Muscular Dystrophy, characterized by well-defined neurological abnormalities, confirmed by electromyography and muscle biopsy.
Definition - a diagnosis of Type 1 Diabetes Mellitus, characterized by absolute insulin deficiency and continuous dependence on exogenous insulin for survival. The diagnosis must be made by a qualified pediatrician or endocrinologist licensed and practicing in Canada, and there must be evidence of dependence on insulin for a minimum of 3 months.
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1-844-949-3809