Definitions and exclusions

General exclusions

Benefits are not paid for claims resulting directly or indirectly from:

  • self-inflicted injury or attempted suicide, regardless of whether you have the ability to form the requisite intent or regardless of whether you have a mental illness such that you do not know or understand the consequences of your action(s).
  • the hostile action of any armed forces, insurrection or participation in a riot or civil commotion;
  • participation in a criminal offence;
  • the use of illegal or illicit drugs or substances, misuse of drugs or alcohol;
  • the death of the insured during the required survival period.

Additional provisions, exclusions and limitations may apply, including a 12 month pre-existing condition clause and 90-day cancer waiting period

General definitions

Spouse means your spouse by marriage or under any other formal union recognized by law; or a person of the opposite sex or of the same sex who is publicly represented as your spouse for a period of at least 12 months. You can only cover one spouse at a time. Discontinuance of cohabitation terminates the eligibility of a common-law spouse.

Critical illness means only an illness, disorder or surgery that is defined under the covered conditions. Any illness, disorder or surgery not specifically defined under covered conditions will not be insured under these critical illness provisions and no benefit will be payable.

Diagnosis or Diagnosed means a written diagnosis by a physician or specialist physician, licensed and practising in Canada or the United States, of the covered condition. Any diagnosis must be made while coverage is in force and will be effective as of the date it is established by the physician or specialist physician, as supported by your (or your spouse's/or your dependent's) medical records. Any diagnosis of a covered condition that was made prior to the effective date of coverage will not be covered.

Life support means you (or your spouse/or your dependent) are under the regular care of a licensed physician or specialist physician for nutritional, respiratory and/or cardiovascular support when irreversible cessation of all functions of the brain has occurred.

Physician means a legally and professionally qualified medical practitioner practising in Canada or the United States. The physician providing the diagnosis or treating you (or your spouse/or your dependent) must not be you (or your spouse/or your dependent), a relative, or a person who normally resides in your household.

Specialist physician means a legally and professionally qualified medical practitioner who has been trained in the specific area of medicine relevant to the covered critical illness condition for which a benefit is being claimed, and who has been certified by a speciality examining board. In the absence or unavailability of a specialist physician, and as approved by the company, a condition may be diagnosed by a legally and professionally qualified medical practitioner practising in Canada or the United States. The specialist physician providing the diagnosis or treating you (or your spouse/or your dependent) must not be you (or your spouse/or your dependent), a relative, or a person who normally resides in your household.

Surgery means a medical operation performed on you (or your spouse/or your dependent) and recommended by a physician or specialist physician, licensed and practising in Canada or the United States.

Survival Period means the period starting on the date of diagnosis of the covered critical illness condition and ending 30 days following the date of diagnosis of the covered critical illness condition, unless a covered condition described below expressly modifies this definition. The survival period does not include the number of days on life support. You (or your spouse/or your dependent) must be alive at the end of the survival period and must not have experienced irreversible cessation of all functions of the brain.

Definitions and exclusions of covered conditions

1. Blindness is defined as 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.

2.  Cancer (Life-Threatening) is defined as a definite diagnosis of a tumour, which 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 physician. You must survive for 30 days following the date of diagnosis.

Exclusions:

No benefit will be payable for a recurrence or metastasis of an original cancer which was diagnosed prior to the effective date of coverage.

No benefit will be payable for the following:

  • lesions described as benign, pre-malignant, uncertain, borderline, non-invasive, carcinoma in-situ (Tis), or tumors classified as Ta;
  • malignant melanoma skin cancer that is less than or equal to 1.0 mm 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;
  • 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 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis;
  • chronic lymphocytic leukemia classified less than Rai stage 1; or
  • malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than AJCC Stage 2.

Moratorium Period Exclusion:

No benefit will be payable for cancer and your coverage for cancer will terminate if within 90 days following the later of:

  • the date the enrolment for this coverage was signed; or,
  • the effective date of coverage,

you have any of the following:

  • signs, symptoms or investigations, that lead to diagnosis of cancer (covered or excluded under the Group policy), regardless of when the diagnosis is made; or,
  • a diagnosis of cancer (covered or excluded under the Group policy).

While your insurance for cancer terminates, insurance for all other covered conditions remains in force.

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 the 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.

For purposes of the policy, the terms Tis, Ta, T1a, T1b, T1 and AJCC Stage 2 are to be applied as defined in the American Joint Committee on Cancer (AJCC) cancer staging manual, 7th Edition, 2010.

For purposes of the policy, the term Rai staging is to be applied as set out in KR Rai, A Sawitsky, EP Cronkite, AD Chanana, RN Levy and BS Pasternack: Clinical staging of chronic lymphocytic leukemia. Blood 46:219, 1975.

3. Coronary artery bypass surgery is defined as 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 physician. You must survive for 30 days following the date of surgery.

Exclusion:

No benefit will be payable under this condition for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

4.  Deafness is defined as 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 physician. You must survive for 30 days following the date of diagnosis.

5.  Heart attack is defined as 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; or,
  • 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 physician. You must survive for 30 days following the date of diagnosis.

Exclusions:

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.

6.  Kidney failure is defined as 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 physician. You must survive for 30 days following the date of diagnosis.

7.  Loss of independent existence

Loss of independent existence means a definite diagnosis of either:

  1. a total inability to perform, by oneself, at least 2 of the following 6 activities of daily living, or,
  2. cognitive impairment, as defined below,

for a continuous period of at least 90 days with no reasonable chance of recovery.

Activities of daily living are:

  1. Bathing:  the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of equipment.
  2. Dressing:  the ability to put on and remove necessary clothing including braces, artificial limbs or other surgical appliances.
  3. Toileting:  the ability to get on and off the toilet and maintain personal hygiene.
  4. 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.
  5. Transferring:  the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment.
  6. Feeding:  the ability to consume food or drink that already have been prepared and made available, with or without the use of adaptive utensils.

Cognitive impairment means 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 Physician. The degree of cognitive impairment must be sufficiently severe 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.

The Diagnosis of loss of independent existence must be made by a Specialist Physician. No additional survival period is required once the conditions described above are satisfied.

Exclusion:

No benefit will be payable under this condition for any mental or nervous disorder without a demonstrable organic cause.

8.  Major organ transplant is defined as 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, you 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 physician. You must survive for 30 days following the date of the transplant. 

9.  Multiple sclerosis is defined as 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 physician. You must survive for 30 days following the date of diagnosis.

10.  Paralysis is defined as 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 physician. You must survive for 90 days following the precipitating event. 

11.  Stroke (cerebrovascular accident) is defined as 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 physician. You must survive for 30 days following the date of the diagnosis.

Exclusions:

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

This website is intended only as an outline of the insurance policy. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policy issued by Sun Life Assurance Company of Canada.