The following key definitions apply to the policy/certificate and riders as approved in most states. Definitions may vary by state. For a list of all definitions, refer to the actual policy/certificate.
Actively Employed and Active Employment
The primary insured person (employee) must be working at least the number of hours required for benefit eligibility as shown on the policyholder’s application and performing the substantial and material duties of their regular occupation. Normal vacation or personal days are considered actively employed. However, if vacation or personal days are used to cover disability, sickness or injury, those days are not considered actively employed.
Activities of Daily Living (ADL)
Certain basic daily tasks necessary to maintain an insured person’s health and safety. ADLs refer to the activities described below.
•Bathing means washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower.
•Continence means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).
•Dressing means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.
•Eating means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) feeding tube or intravenously.
•Toileting means getting to and from the toilet, transferring on and off the toilet and performing associated personal hygiene.
•Transfer and mobility means the ability to move into or out of a bed, chair or wheelchair or to move from place to place, either via walking, wheelchair, cane, crutches, walker or other equipment.
Advanced Alzheimer’s Disease
Loss of intellectual capacity involving impairment of memory and judgment as measured by cognitive and neuroradiological tests (e.g. CT scan, MRI, PET of the brain). It must result in significant reduction in mental and social functioning such that the insured person requires substantial assistance in performing at least three of the six activities of daily living (as defined in the policy/certificate). The diagnosis must be made by a physician board certified in Psychiatry or Neurology. No other dementing organic brain disorders or psychiatric illnesses shall meet the definition of Advanced Alzheimer’s Disease, nor will they be considered a specified critical illness.
Advanced Amyotrophic Lateral Sclerosis (ALS) (as applies to Additional Critical Illness Rider only)
A progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord causing muscle weakness and impacting physical function. ALS, also known as Lou Gehrig’s disease, causes nerve cells to gradually break down and die. The diagnosis must be made by a physician board certified in Neurology according to criteria established by the World Federation of Neurology.
Advanced Parkinson’s Disease (as applies to Additional Critical Illness Rider only)
A brain disorder where the insured person:
•exhibits two or more of the following clinical manifestations: muscle rigidity, tremor, or bradykinesia (abnormal slowness of movement or sluggishness of physical and mental responses); and
•is certified by a physician as requiring substantial assistance.
The diagnosis must be made by a psychiatrist or physician board certified in Neurology.
AngioJet Clot Busting (as applies to Cardiopulmonary Rider only)
Clears blood clots from coronary arteries before angioplasty and stenting. The device delivers a
high-pressure saline solution through the artery to the clot, breaking it up and simultaneously drawing it out.
Angioplasty
Undergoing a percutaneous transluminal angioplasty procedure deemed medically necessary to correct a narrowing or blockage of one or more coronary arteries. The procedure must be performed by a physician board certified in Cardiology. Other surgical or non-surgical techniques such as other intra-arterial procedures are excluded.
Atherectomy (as applies to Cardiopulmonary Rider only)
Opens blocked coronary arteries or clears bypass grafts by using a device on the end of a catheter to cut or shave away atherosclerotic plaque.
Aortic Valve Replacement or Repair (as applies to Cardiopulmonary Rider only)
A surgical procedure in which a patient’s aortic valve is repaired or replaced by a different valve.
Automatic Implantable Cardioverter Defibrillator (AICD) (as applies to Cardiopulmonary Rider only)
The initial placement of the AICD. AICDs are used for treating irregular heartbeats. The defibrillator is surgically placed inside the patient's chest where it monitors the heart's rhythm. When it identifies a serious arrhythmia, it produces an electrical shock to disrupt the arrhythmia.
Benign Brain Tumor (as applies to Additional Critical Illness Rider only)
A non-malignant tumor within the substance of the brain or meninges resulting in permanent deficit to the neurological system. Permanent deficit is defined as a continuous residual neurological deficit resulting from the tumor, as evidenced by physical examination. The diagnosis must be made by a physician board certified in Neurology. A tumor of the skull, pituitary adenomas, germinomas, cysts, granulomas, meningiomas, malformations of the intracranial arteries or veins, or tumors of the cranial nerves, pituitary gland or spinal cord are excluded.
Bone Marrow Transplant (as applies to Additional Critical Illness Rider only)The irreversible failure of an insured person’s bone marrow for which a physician has determined that medical evidence supports the replacement of bone marrow with bone marrow from the insured person or another human donor.
Cardiac Catheterization (as applies to Cardiopulmonary Rider only)
A diagnostic and occasionally therapeutic procedure that allows a comprehensive examination of the heart and surrounding blood vessels.
Cerebral Palsy (as applies to Childhood Critical Illness Rider only)
A group of non-progressive disorders of movement and posture attributed to abnormal development of,
or damage to motor control centers of the brain while a child’s brain is still developing before, during and immediately after birth. Autism as a primary diagnosis or motor deficits due to an underlying medical condition (syndrome, genetic or hereditary conditions) are excluded.
Cleft Lip or Cleft Palate (as applies to Childhood Critical Illness Rider only)
Cleft Lip is a congenital failure of the upper lip to close, resulting in a narrow gap in the upper lip that extends to the nostril on one side or both sides of the mouth. Cleft Palate is a congenital failure to close an opening in the roof of the mouth that extends to the nasal cavity.
Clinical Diagnosis
A clinical identification by a physician of a critical illness based on history, laboratory study and symptoms.
Coma (as applies to Additional Critical Illness Rider only)
A state of unconsciousness from which the insured person cannot be aroused, in which external stimulation will produce no more than primitive avoidance reflexes, and has persisted continuously for at least 96 hours. The diagnosis much be made by a physician board certified in Neurology. A medically induced coma is excluded.
Complex Congenital Heart Disease (as applies to Childhood Critical Illness Rider only)
Heart defects or problems with the heart's structure that are present at birth and that require surgery to be repaired.
Diagnosis with at least one of the following covered heart conditions:
•coarctation of the aorta;
•Ebstein’s anomaly;
•Eisenmenger syndrome
•Tetralogy of Fallot;
•transposition of the great vessels; or
•any other congenital cardiac condition that requires open heart surgery.
Coronary Artery Bypass Surgery
Undergoing coronary artery bypass surgery using either a saphenous vein or internal mammary artery graft for the treatment of coronary heart disease deemed medically necessary to correct a narrowing or blockage of one or more coronary arteries. The procedure must be performed by a physician board certified as a cardiothoracic surgeon. Other surgical or non-surgical techniques such as laser relief or any other intra-arterial procedures are excluded.
Cystic Fibrosis (as applies to Childhood Critical Illness Rider only)
A hereditary chronic disease affecting the exocrine glands, causing the production of abnormally thick
mucus, leading to the blockage of the pancreatic ducts, intestines, and bronchi and often resulting in respiratory infection. Asymptomatic, clinical features limited to CABVD (congenital absence of vas deferens) or gastrointestinal issues are excluded.
Date of Diagnosis
The date the diagnosis is established by a physician, who is a board certified specialist where required under this policy/certificate, through the use of clinical and/or laboratory findings as supported by an insured person’s medical records. For a procedure, it is the date an insured person undergoes the procedure.
Dependent Grandchild(ren)
The primary insured person’s grandchild under 26 years of age, who is legally dependent on the primary insured person.
Diagnosis
The definitive establishment of the specified critical illness through the use of clinical and/or laboratory findings. The diagnosis must be made by a physician who is a board certified specialist where required under this policy/certificate.
Down Syndrome (as applies to Childhood Critical Illness Rider only)
A congenital disorder arising from a chromosome defect involving chromosome 21, causing intellectual impairment, physical abnormalities and developmental delays.
Elimination Period
The 180 consecutive days an insured person must be unable to perform two or more activities of daily living. The elimination period begins after the waiting period.
Grace Period
The 31-day period after a due date in which premiums can still be paid and are considered to have been paid on the due date.
Heart Attack (Myocardial Infarction)
Death of a portion of the heart muscle due to inadequate blood supply. All of the following criteria for acute myocardial infarction must be satisfied:
•clinical symptoms, for example, central chest pain;
•diagnostic increase of specific cardiac markers; and
•new electrocardiographic changes of infarction.
Established (old) myocardial infarction prior to the issue date and sudden cardiac arrest are excluded.
Idiopathic Pulmonary Fibrosis (as applies to Cardiopulmonary Rider only)
A lung disease in which tissue deep in the lungs becomes thick and stiff, or scarred over time causing the formation of scar tissue called fibrosis.
Insured Child(ren)
The primary insured person’s or their spouse’s natural children, stepchildren, foster children, adopted children or children placed as foster children or for adoption, who are younger than age 26.
Invasive Cancer
A malignant neoplasm, which is characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue, and which is not specifically hereafter excluded. Leukemia and lymphoma are included. The diagnosis of invasive cancer must be pursuant to a pathological or clinical diagnosis.
While not an exhaustive list, the following conditions are not considered to be invasive cancer: (a) pre-malignant lesions (such as intraepithelial neoplasia), (b) benign tumors or polyps, (c) early prostate cancer as T1N0M0 or equivalent staging, (d) carcinoma in situ or (e) any skin cancer (other than invasive malignant melanoma in the dermis or deeper or skin malignancies that have become metastatic).
Kidney (Renal) Failure
The chronic and irreversible failure of both kidneys, which requires periodic and ongoing peritoneal dialysis or hemodialysis. The diagnosis must be made by a physician board certified in Nephrology.
Loss of Independent Living
An insured person both incurring and receiving a diagnosis, by a physician, of the permanent inability to perform two or more activities of daily living.
Loss of Sight (as applies to Additional Critical Illness Rider only)
The total and irreversible loss of vision in both eyes, as 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.
Loss of Speech (as applies to Additional Critical Illness Rider only)
The total and irreversible loss of the ability to speak or communicate verbally without the assistance of a medical device.
Loss of Hearing (as applies to Additional Critical Illness Rider only)
The total and irreversible loss of hearing in both ears. Loss of hearing does not include loss of hearing that can be corrected by the use of any hearing aid or device resulting in an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz.
Major Organ Transplant
The clinical evidence of major organ(s) failure which requires the malfunctioning organ(s) or tissue of an insured person to be replaced with an organ(s) or tissue from a suitable human donor under generally accepted medical procedures. The organs and tissues covered by this definition are limited to: liver, kidney, lung, entire heart or pancreas. In order for the major organ transplant to be covered under this policy, the insured person must be registered by the United Network of Organ Sharing (UNOS).
Mitral Valve Replacement or Repair (as applies to Cardiopulmonary Rider only)
A surgical procedure in which a patient’s mitral valve is repaired or replaced by a different valve.
Multiple Sclerosis (MS) (as applies to Additional Critical Illness Rider only)
A chronic disease involving damage to the protective sheaths of nerve cells in the brain and spinal cord. Symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue. Eventually, the disease can cause the nerves themselves to deteriorate or become permanently damaged. The diagnosis must be made by a physician board certified in Neurology.
Non-Invasive Cancer (Carcinoma In Situ)
A diagnosis of cancer wherein the tumor cells still lie within the tissue of origin without having invaded neighboring tissue. Carcinoma in situ includes, but is not limited to (a) the diagnosis of early prostate cancer as T1N0M0 or equivalent staging; (b) early cancers, Stage Ta, Tis, 0a, and 0is and (c) melanoma not invading the dermis. The diagnosis of carcinoma in situ must be pursuant to a pathological or clinical diagnosis.
Skin cancer (as defined below), skin malignancies other than melanoma, pre-malignant lesions (such as intraepithelial neoplasia) or benign tumors or polyps are not considered to be carcinoma in situ.
Occupational HIV (as applies to Additional Critical Illness Rider only)
The infection with the Human Immunodeficiency Virus (HIV), which exposed an insured person to HIV-contaminated blood or bodily fluids during the course of the duties of the insured person’s normal occupation.
Payment under this critical illness requires all of the following criteria are met:
•the injury must be reported to Us within 14 days of the accidental injury;
•an HIV test must be taken within 14 days of the accidental injury, and the result must be negative;
•an HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;
•the injury must have been reported, investigated and documented in accordance with workplace legislation and regulations; and
•the accidental injury must have occurred in the United States.
The following are excluded:
•HIV infection acquired via sexual transmission;
•HIV infection acquired via IV drug use; or
•HIV infection determined not to be the result of an accidental injury.
Open Heart Surgery as applies to Cardiopulmonary Rider only)
An open chest surgery, where the heart is exposed and/or manipulated for open cardiothoracic situations.
Pacemaker Placement (as applies to Cardiopulmonary Rider only)
The initial placement and implantation of a pacemaker, which sends electrical signals to make the heart beat when a person’s natural pacemaker is not working properly. This electrical device is placed under the skin. A lead extends from the device to the right side of the heart.
Paralysis (as applies to Additional Critical Illness Rider only)
The complete and permanent loss of use of two or more limbs through neurological injury for a continuous period of at least 180 days. Limb is defined as a complete arm or leg. The diagnosis must be made by a physician board certified in Neurology.
Pathological Diagnosis
Identification of a critical illness based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. This diagnosis must be made by a physician who is a board-certified pathologist where required under this certificate.
Phenylalanine Hydroxylase Deficiency (PAH)/Phenylketonuria (PKU) (as applies to Childhood Critical Illness Rider only)
The inherited inability to process the amino acid phenylalanine normally, due to deficiency of the enzyme PAH. This deficiency is caused by mutation in the gene for the hepatic enzyme phenylalanine hydroxylase PAH, rendering it nonfunctional.
Physician
A doctor of medicine or osteopathy who is duly licensed by the state medical board and practicing in the United States. Such Physician cannot be a member of an insured person’s immediate family or business associate and must be providing services within the scope of his or her license/specialty. Physician will also include nurse practitioners and physician assistants. Practitioners other than those named above are not physicians. For the purposes of the certificate, chiropractors are not considered physicians.
Pre-existing Condition
A sickness or physical condition for which, during the 12 months before the issue date, an insured person received medical consultation, diagnosis, advice or treatment from a physician or had taken prescribed medication.
Pulmonary Embolism (as applies to Cardiopulmonary Rider only)
The sudden blockage of a major blood vessel in the lung, usually caused by a blood clot that traveled to the lungs from the legs, or rarely, other parts of the body.
Schizophrenia (as applies to Additional Critical Illness Rider only)
A long-term mental disorder that affects a person’s ability to think, feel and behave clearly. Symptoms may include distorted thoughts, hallucinations and feelings of fright and paranoia. Diagnosis much be based on criteria established in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV-TR). The diagnosis must be made by a physician board certified in Psychiatry or Ph.D.-level Psychologist.
Severe Burns (as applies to Additional Critical Illness Rider only)
Third degree burns covering at least 20% of the surface area of the body. The diagnosis must be made by a physician board certified as a General Surgeon or Plastic Surgeon.
Skin Cancer
Cancer on the surface of the body or skin which includes basal cell carcinoma and squamous cell carcinoma of the skin. The diagnosis of skin cancer must be pursuant to a pathological diagnosis by a licensed physician certified by the American Board of Pathology to practice Pathological Anatomy, or an Osteopathic Pathologist. Malignant melanoma in the dermis or deeper, skin malignancies that have become metastatic, and any conditions which may be considered precancerous, such as leukoplakia, actinic keratosis, carcinoid, hyperplasia, non-malignant melanoma, moles, or similar diseases or lesions are excluded.
Spina Bifida (as applies to Childhood Critical Illness Rider only)
A congenital defect of the spine in which part of the spinal cord and its meninges are exposed through a gap in the backbone. Spina bifida includes Meningocele or Myelomeningocele. A diagnosis of spina Bifida occulta is excluded.
Stent Implementation (as applies to Cardiopulmonary Rider only)
The implantation of a stainless steel mesh coil in a narrowed part of an artery to keep it open.
Stroke
Any acute cerebrovascular accident producing neurological impairment and resulting in paralysis or other measurable objective neurological deficit persisting for at least 24 hours. The diagnosis must be made by a physician board certified in Neurology. Transient Ischemic Attack (TIA), brain injury associated with hypoxia, anoxia, or hypotension, brain injury related to trauma or infection, ischemic disorders of the vestibular system, vascular disease affecting the eye or optic nerve, chronic cerebrovascular insufficiency and reversible ischemic neurological deficits are excluded.
Sudden Cardiac Arrest
The sudden, unexpected loss of heart function in which the heart, abruptly and without warning, stops working as a result of an internal electrical system heart malfunction due to coronary artery disease, cardiomyopathy or hypertension. Heart attack (myocardial infarction) is excluded.
Surgical Treatment of Abdominal Aortic Aneurysm (as applies to Cardiopulmonary Rider only)
A surgical procedure opening the abdomen and repairing or removing an abdominal aortic aneurysm.
Symptom(s)
The subjective evidence of disease or physical disturbance observed by a medical professional or the insured person.
Symptom- and Treatment-Free
Free of any symptoms and free of any treatment.
Total Disability and Totally Disabled
A disability due to a sickness or injury which:
•starts while the certificate is in force;
•requires a physician’s care for the treatment of a critical illness for which a benefit is paid;
•for the first year after the start of disability, keeps the primary insured person (employee) from doing the primary insured person from doing the substantial and material duties of their own occupation; and
•after premiums have been waived for one year, keeps the primary insured person from doing the substantial and material duties of any occupation for which they are reasonably suited by education, training or experience.
Transient Ischemic Attack (TIA) (as applies to Additional Critical Illness Rider only)
A brief stroke-like attack, producing similar symptoms to a stroke, but usually lasting only a few minutes and causing no permanent damage.
Treatment
Medical care, prevention or management of any critical illness listed in the certificate including services of a radiologist, pathologist or other physician. Maintenance drugs and routine follow-up office visits are not considered treatment.
Type 1 Diabetes (as applies to Childhood Critical Illness Rider only)
A chronic autoimmune, genetic or infectious destruction of the insulin producing cells in the pancreas
and that requires continuous, lifelong insulin therapy.
Valvuloplasty (as applies to Cardiopulmonary Rider only)
A procedure to repair a heart valve that has a narrowed opening.
Waiting Period
The 30 days following the certificate issue date or ten days following the certificate last reinstatement date.