The Critical Illness Benefit provides financial assistance in the event you are diagnosed with one of the covered illnesses.  The benefit is designed to alleviate some of the financial street resulting from a critical illness at a time when the focus should be on recovery.  There is no restriction on the use of the benefit; you can use it in any way that will meet your particular needs.

This benefit is available only to Active Members under the age of 70.   This benefit does not apply to retirees or Dependents.

Benefit Amount

You are covered for a flat amount of $20,000 which is referred to as the Principal Sum.  The amount payable for a critical illness will be reduced by 50% if an insured member is age 65 or older on the date the benefit becomes payable.

A Second Event Benefit may be payable equal to the Principal Sum, subject to certain conditions as described under the Second Event Benefit.

Benefit Payment Conditions

Payment of benefits upon the first diagnosis of the critical illnesses listed below is subject to the following:

1. the insured member survives for at least 30 days after diagnosis of a covered Critical Illness;
2. the diagnosis is made within Canada;
3. the diagnosis is made while the insured member’s coverage is in force under the policy;
4. payment is not precluded by any general or specific exclusion or limitation set forth in the policy or any failure to meet any condition precedent set out below; and
5. once 100% of the Maximum Benefit Amount has been paid, coverage terminates and no further benefits are payable, except as described under Second Event Benefit.

Covered Critical Illnesses:

Alzheimer's Disease - a progressive degeneration of the brain as diagnosed by a certified neurologist or psychiatrist.   The diagnosis must be supported by medical evidence of progressive deterioration of memory and the ability to reason and perceive, to understand, and to express and give effect to ideas.  The deterioration must be severe enough to render the insured member incapable of independent living to the extent that he/she requires a minimum of 8 hours of daily supervision.  No other dementing organic brain disorders or psychiatric illnesses are included.

Benign Brain Tumour - means a benign neoplasm within the substance of the brain or the meninges.  The following conditions are deemed not to be Benign Brain Tumour:

1. Cysts, granulomas, malformations of the intracranial arteries and veins; or
2. Tumours or lesions of the pituitary.

A diagnosis of Benign Brain Tumour must be made by a physician. Interpretation: Benign Brain Tumours are typically more harmful than benign tumours in other parts of the body.  This is because any abnormal growth in the brain can place pressure on sensitive tissue causing impaired functions and neurological deficits. Benign tumours within the substance of the brain or the meninges (the membrane enclosing the brain) are covered.  Other problems within or near the brain, such as cysts, granulomas, malformations of the intracranial arteries and veins, and tumours or lesions of the pituitary are not covered.

Coma - The diagnosis of a coma must indicate that permanent neurological deficit is present.

Coronary Artery Bypass Graft - The diagnosis of the condition that necessitates a coronary artery bypass graft must be made by a cardiologist and based on angiographic evidence of the underlying disease.

Heart Attack - The diagnosis of heart attack must be based on an event which contains all of the following criteria:

1. associated new electrocardiographic (EKG) changes which support the diagnosis;
2. concurrent diagnostic elevation of cardiac enzymes above normal levels; and
3. confirmatory imaging studies such as thallium scans, MUGA scans, or stress echocardiograms.

Heart Valve Replacement - means replacing any heart valve with either a natural or mechanical valve.  The surgery must be recommended and performed by a physician in Canada.  The insured member must survive for 30 days following the date of the surgery.

Kidney (Renal) Failure - The diagnosis of end stage renal disease must be based on chronic irreversible failure of the function of both kidneys requiring regular hemodialysis or necessitating kidney transplant.

Life Threatening Cancer - first manifested while the insured member’s insurance under this contract is in effect, which is characterized by the presence of a malignant tumour and by the uncontrolled growth and spread of malignant cells and the invasion of tissue.  Life threatening Cancer includes leukemia, Hodgkin’s disease, lymphoma and invasive malignant melanoma as well as cancers for which chemotherapy or radiation treatments have been recommended.

Life Threatening Cancer does not include the following forms of cancer:

1. malignant melanoma to a depth of .75 mm or less;
2. carcinoma in situ;
3. basal cell carcinoma and squamous cell carcinoma of the skin that have not metastasized;
4. early prostate cancer diagnosed as T1a or T1b; and any tumour in the presence of any Human Immunodeficiency Virus (HIV);
5. pre-malignant lesions, benign tumours or polyps;
6. stage A colon cancer;
7. stage 1 Hodgkin’s disease (unless requiring chemotherapy and/or radiation treatments).

Definitions

1. Basal cell carcinoma - a skin cancer that arises in the basal cells, which are at the bottom of the epidermis (outer layer of skin).
2. Carcinoma in situ - the cancer is superficial and has not penetrated into the organ involved.
3. Malignant melanoma to a depth of .75 mm or less - a cancerous mole which is .75 mm or less when measured under a microscope.
4. Metastasized - spread of the cancer from one part of the body to another.
5. Squamous cell carcinoma - a skin cancer that arises from the upper part of the epidermis (outer layer of skin).

Partial Payment for Non Life Threatening Cancer - Non Life Threatening Cancer must be positively diagnosed by a physician and supported with pathological report.  The benefit will provide 25% of the Principal Sum for the following conditions:

1. Malignant melanoma to a depth of 0.75 mm or less, excluding malignant melanoma in situ;
2. Basal or squamous cell carcinoma that has spread beyond the deepest layer of skin and has not metastasized;
3. Ductal carcinoma in situ of the breast;
4. Early prostate cancer diagnosed as T1a or T1b; or
5. Any tumour in the presence of any Human Immunodeficiency (HIV).

Upon payment of the partial payment for Non Life Threatening Cancer, the insurance of the insured member remains in effect with the Principal Sum reduced by the amount of the partial payment.  Only one claim per condition is permitted for partial payment for Non Life Threatening Cancer.

Loss of Sight, Speech, or Hearing in Both Ears - The diagnosis of loss of sight, speech or hearing must be made by a licensed specialist in that field of medicine.  The diagnosis of loss of sight must indicate that corrected visual acuity must be worse than 20/200 in both eyes or the field of vision must be less than 200 degrees in both eyes.  
The diagnosis of loss of speech must be established for a continuous period of 12 months.  Psychiatric related causes are not covered.  The diagnosis of loss of hearing must include audiometric and sound threshold tests.  The auditory threshold cannot be more than 90 decibels.

Major Organ Transplant - The diagnosis is a result of a condition that necessitates a major organ transplant.

Motor Neuron Disease - is defined as a definitive 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 entities. A diagnosis of Motor Neuron Disease must be made by a Physician who is a certified neurologist.

Multiple Sclerosis - The unequivocal written diagnosis by a physician who is certified as a neurologist confirming at least moderate persisting neurological abnormalities, with impairment of function, but not necessarily confining to a wheelchair or bed.

Paralysis - Quadriplegia, Paraplegia, Hemiplegia - The diagnosis of paralysis must include documented evidence of the illness or injury that caused the paralysis.

Parkinson’s Disease - is defined as primary idiopathic Parkinson’s Disease which is characterized by a minimum of two or more of the following clinical manifestations:

1. tremors
2. muscle rigidity
3. bradykinesis, (abnormal slowness of movement, sluggishness of physical and mental responses)

All other types of Parkinsonism are specifically excluded.

In addition, the insured member must require substantial physical assistance from another adult to perform two or more of the activities of daily living.

Severe Burn - The diagnosis of severe burn must be a result of suffering a full thickness or third degree burn covering 20% or more or the body.

Stroke - The diagnosis of stroke must be made by a licensed neurologist and based on documented neurological deficits and confirmatory neuroimaging studies.

Second Event Benefit

If the insured member is diagnosed with Cancer for which the Principal Sum has been paid and the insured member has thereafter been considered actively at work for at least 90 days and is then diagnosed with a Heart Attack, Stroke or Coronary Artery Bypass, Alzheimer’s Disease, Coma, Loss of Sight, Speech or Hearing, Motor Neuron Disease, Multiple Sclerosis, Parkinson’s Disease, Quadriplegia, Paraplegia, Hemiplegia, Severe Burn, then a Second Event Benefit equal to the Principal Sum will be payable.  The Second Event Benefit is subject to the insured member surviving 30 days after the diagnosis of the second event.

If the insured member is diagnosed with Heart Attack, Stroke, Coronary Artery Bypass for which the Principal Sum has been paid and the insured member has thereafter been actively at work for at least 90 days and is then diagnosed with Cancer, Alzheimer’s Disease, Coma, Loss of Sight, Speech or Hearing, Motor Neuron Disease, Multiple Sclerosis, Parkinson’s Disease, Quadriplegia, Paraplegia, Hemiplegia, Severe Burn or Stroke, then a Second Event Benefit equal to the Principal Sum will be payable.  The Second Event Benefit is subject to the insured member surviving 30 days after the diagnosis of the second event.

The Second Event Benefit is payable only once. Payment of the Second Event Benefit will represent full and final discharge of all claims under the Critical Illness Benefit.

Diagnostic Requirements

The insurer reserves the right to have any Critical Illness diagnosis reviewed by a physician of its choosing.  In the event of any dispute or disagreement regarding the appropriateness or correctness of the diagnosis, the insurer shall have the right to request an examination of either the insured member or the evidence used in the arriving at such diagnosis by an independent acknowledged expert selected by the insurer in the applicable field of medicine. The opinion of such expert as to such diagnosis shall be binding on both the insured member and the insurer.

Exclusions and Limitations

The policy does not provide benefits caused in whole or in part by, or resulting in whole or in part from, the following: 

1. the insured member’s suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt at intentionally self-inflicted injury;
2. declared or undeclared war, or any act of declared or undeclared war;
3. the insured member’s commission of or attempt to commit a felony;
4. the insured member’s voluntary participation in any riot or civil insurrection;
5. any illness specifically excluded from the definition of any critical illness.

How To Claim

Claim forms can be obtained at:

Benefit Plan Administrators Limited
2-1793 Dundas Street East
London, ON N5W 3E7
Phone No: 519-453-3340
Toll Free: 1-877-513-3340

Written notice of claim must be filled within 20 days after the diagnosis, or as soon thereafter as is reasonably possible.

Proof of Loss

Written proof of loss must be furnished within 90 days after the date of the diagnosis.  Failure to furnish proof within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required.

Payment of Claims

Upon receipt of due written proof of loss, benefit payments will be made to (or on behalf of, if applicable) the insured member suffering the loss.  If an insured member dies before all payments due have been made, the amount still payable will be paid to his or her beneficiary.

If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee’s property.  If the payee has no legal guardian for his or her property, a payment not exceeding $1,000 may be made, to any relative by blood or connection by marriage of the payee, who in the Insurer’s opinion, has assumed the custody and support of the minor or responsibility for the incompetent person’s affairs.