Bod systems areas of the bod) Clinical claims definitions ... · Disorders of cranial nerve VIII (the Vestibulocochlear nerve) Permanent Vestibulocochlear nerve palsy⁶ (paralysis)

Appendix

Permanent Standard Definition sets B(V7.0), Set C(V7.0), Set D(V6.0)

Body systems (areas of the body)

Cancer

Digestive system

3

5 Heart and blood vessels

HIV/AIDS

Hormones

Kidney and genital/urinary tract

Lungs and breathing

Muscles, bones and joints

Job Fitness Test

6

7

8

9

10

11

12

Activities of Daily Living16

Sensory system

Trauma

Skin and soft tissue disorders

13

15

14

Brain and nerves2

4

Personal Job Fitness Test

Blood production disorders1

Reference notes

Clinical claims definitions: Permanent Standard

BrightRock has worked in partnership with international clinical and risk experts to ensure our clinical claims criteria are objective, transparent and industry-leading.To give you and your clients peace of mind that our claims definitions are comprehensive and clinically objective, we provide a full list of our claims definitions and criteria, divided by body system.

This document applies to your permanent expenses cover for the following needs:

Cover for illness or injury with a financial impact

Additional expense needs

Death-related needs

Debt needs

Healthcare needs

Childcare needs

Household needs

BrightRock Life Ltd, an authorised financial services provider and registered insurer (FSP 11643, Registration number: 1996/014618/06).Sanlam Life Insurance Ltd, an authorised financial services provider and registered insurer (FSP 2759, Registration number: 1998/021121/06).Copyright ©November 2019 BrightRock. All rights reserved. Terms and conditions apply. Document number: 30000007622.

Please note:In this document, we’ve provided our clinical claims definitions accompanied with explanatory text for ease of understanding. The information provided in the columns labelled with the words “layman’s explanation” is provided purely for information purposes. If there is any uncertainty or ambiguity, then the wording provided under the column labelled “BrightRock clinical definitions” will prevail.

Appendix

With layman’s explanation

BrightRock clinical definition

Condition or medical procedure How serious it is

Total %pay-out


Cancer

Blood production disorders

Digestive system

3

5


Heart and blood vessels

HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12

Sensory system

Trauma


13

15

14

Brain and nerves2

4


1

Permanent Standard Definition sets B(V7.0), Set C(V7.0), Set D(V6.0)Reference notes

Refractory pancytopenia resulting from an irreversible treatment resistant disorder with any 2 of the following: • persistent haemoglobin levels of 8g/dl or less OR• neutropenia of less than 1x109 WBC/l OR• thrombocytopenia of less than 100x109/l

Refractory pancytopenia (a lack of blood cells) resulting from an irreversible treatment-resistant disorder with any two of the following:

• Persistent haemoglobin (the oxygen-carrying protein in the red blood cells) levels of 8g/dl or less OR• Neutropenia (a lack of white blood cells) of less than 1x109 WBC/l OR• Thrombocytopenia (a lack of platelets) of less than 100x109/l

100%

Appendix




Total %pay-out


Cancer

Digestive system

3

5



HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12

Sensory system

Trauma


13

15

14

4



Brain and nerves2


Medically certified⁷ institutionalisation for a mental and behavioural disorder for at least 6 months continuously

Medically certified⁷ institutionalisation for a mental and behavioural problem

Needs to be for a continuous period of at least six months

100%

Documented mental and behavioural disorders⁷ with evidence of all of the following criteria in the last 2 years:• Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND• Admission to a psychiatric in-patient facility of at

least four weeks or longer in total AND• Personal Job Fitness Test Failure demonstrated 2 years after the onset of the medical event.

Documented mental and behavioural disorders⁷

With evidence of all of the following in the last two years:• Consistent taking of psychotropic medication (which treats the condition), as prescribed by a psychiatrist AND• Admission to a psychiatric hospital or clinic for at least four weeks AND• Personal Job Fitness Test Failure two years after the condition began (meaning the person is still not able to perform certain tasks)

100%

Documented mental and behavioural disorders7 with evidence of all of the following criteria in the last 1 year:• Uninterrupted compliance with prescribed psychotropic medication (as prescribed by a psychiatrist) AND• Admission to a psychiatric in-patient facility of at least 12 weeks or longer in total AND• Personal Job Fitness Test Failure demonstrated 1 year after the onset of the medical event.

Documented mental and behavioural disorders7

With evidence of all of the following in the last year:• Consistent taking of psychotropic medication (which affects the mental state), as prescribed by a psychiatrist AND• Admission to a psychiatric hospital or clinic for at least 12 weeks AND• Personal Job Fitness Test Failure one year after the condition began (meaning the person is still not able to perform certain tasks)

100%

Documented treatment resistant generalized epilepsy¹ of at least 3 months’ duration (despite optimal treatment and patient compliance) of more than 2 seizures per week ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Epilepsy 1. Documented treatment-resistant generalised epilepsy¹ with more than two fits per week

for at least three months, despite taking the correct medicine exactly as prescribed by the treating doctor AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

Non-traumatic organic cognitive disorder (excluding psychological disorders) resulting in irreversible cognitive impairment² as evidenced by Mini Mental State Examinations (MMSE) ≤ 19/30

Cognitive disorders Any condition affecting cognitive function (the brain’s capacity to think, remember and judge clearly) where physical examination, lab tests or other diagnostic studies show measurable evidence of disease (in other words, not due to physical injury and excluding psychological disorders) that leads to permanent cognitive impairment² as evidenced by a Mini-Mental State Examination (MMSE) score of 19 or less out of a possible 30.

100%

1 2 3

*

*

*

*

*

*

*

*

*

*

Appendix




Total %pay-out


Cancer

Digestive system

3

5



HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12

Sensory system

Trauma


13

15

14

4



Brain and nerves2


Vestibular dysfunction3 presenting with attacks of nausea, vomiting, vertigo and dizziness with at least 10 episodes per month resulting from brainstem causes including:• Vascular lesions OR• Tumours of the cerebellum or fourth ventricle OR• Demyelination disorders

Neurological vestibular disorders Vestibular dysfunction (balance disorder)3 confirmed by a neurologist with supporting tests, such as brain scans, which results in attacks of nausea, vomiting, dizziness and vertigo (a sense of falling), with at least 10 episodes per month due to problems in the brainstem (base of the brain), including:• Vascular lesions (blood vessel abnormalities) OR• Tumours of the cerebellum or fourth ventricle (a region in the base of the brain) OR• Demyelination disorders (involving loss of the insulating myelin sheath around nerves)

100%

Confirmed irreversible central respiratory failure (on a life support system)

Central respiratory failure (a life-threatening problem with oxygen and/or carbon dioxide exchange)

Confirmed permanent central respiratory failure, with the need for a life support system

100%

Aphasia/dysphasia: The irreversible loss of language comprehension and production⁵ resulting from damage to the portions of the brain responsible for language

Aphasia/ dysphasia (communication disorders)

Permanent loss of the ability to understand, produce and/or use words⁵, caused by damage to the parts of the brain responsible for language

100%

Documented treatment resistant sleep disorder4 (excluding sleep apnoea) resulting in abnormal sleep cycles and sustained cognitive impairment as evidenced by MMSE of less than 24/30

Sleep disorders A documented treatment-resistant sleep disorder4 (excluding sleep apnoea) that causes abnormal sleep cycles and reduced mental functioning, as evidenced by a Mini-Mental State Examination MMSE of less than 24 of a possible 30

100%

Irreversible cerebellum dysfunction⁶ resulting in the inability to stand without assistive devices

Disorders of the cerebellum (part of the brain responsible for coordination and balance)

Permanent cerebellar dysfunction⁶ causing an inability to stand without a cane or other device

100%

1 2 3

*

*

*

*

Appendix




Total %pay-out


Cancer

Digestive system

3

5



HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12

Sensory system

Trauma


13

15

14

4



Brain and nerves2


Irreversible bulbar palsy⁶ as a result from bilateral impairment of function of cranial nerves V, IX, X and XII that presents with loss of facial sensation including dysarthria, dysphagia, dysphonia, regurgitation and/or aspiration

Bulbar palsy (paralysis of the lower cranial nerves)

Impaired function of cranial nerves V, IX, X and XII that leads to permanent bulbar palsy⁶ (paralysis) on both sides, including loss of facial sensation, dysarthria (inability to speak clearly), dysphagia (difficulty swallowing), dysphonia (impaired voice sound production), regurgitation and/or aspiration (inhaling stomach contents)

100%

Irreversible unilateral vestibulocochlear nerve palsy⁶ resulting in hearing loss and vestibular dysfunction manifested by attacks of nausea, vomiting, vertigo and dizziness

Disorders of cranial nerve VIII (the Vestibulocochlear nerve)

Permanent Vestibulocochlear nerve palsy⁶ (paralysis) on one side, causing hearing loss and vestibular dysfunction (balance disorder) such as attacks of nausea, vomiting, dizziness and vertigo (a sense of falling)

100%

Irreversible unilateral facial nerve palsy⁶ resulting in the total inability to control eyelid closure ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Disorders of cranial nerve VII (the facial nerve)

1. Permanent facial nerve palsy⁶ (paralysis) on one side, causing a complete inability to control eyelid closure AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

1 2 3

Appendix




Total %pay-out


Digestive system


HIV/AIDS

Hormones


Lungs and breathing



Job Fitness Test

6

7

8

9

10

11

12

Sensory system

Trauma


13

15

14

4



Brain and nerves2

Cancer3


Confirmed diagnosis of any stage 4 cancer, including any cancer classified by SCIDEP as level A. Includes:1. Acute myeloid leukaemia;2. Chronic lymphocytic leukaemia, stage 3 or 4 on the

Rai classification, or Binet C;3. Chronic myeloid leukaemia (requiring bone marrow

transplant);4. Acute lymphocytic leukaemia (adults);5. Hodgkin’s/non-Hodgkin’s lymphoma stage 4 on Ann

Arbor classification system;6. Multiple myeloma stage 3 on the Durie- Salmon

scale;7. WHO grade 3 or 4 brain tumour.

Any stage 4 cancer (includes any cancer classified by SCIDEP as level A)

Includes:1. Acute myeloid leukaemia (a type of cancer

characterised by an overproduction of immature white blood cells, called myeloblasts);

2. Chronic lymphocytic leukaemia (a type of slow growing leukaemia that affects developing white blood cells called B-lymphocytes), stage 3 or 4 on the Rai classification, or Binet C;

3. Chronic myeloid leukaemia (a cancer where the bone marrow produces too many white cells called granulocytes) requiring bone marrow transplant;

4. Acute lymphocytic leukaemia in adults (a type of cancer characterised by an overproduction of immature white blood cells called lymphoblasts);

5. Hodgkin’s/non-Hodgkin’s lymphoma (cancerous tumour of the lymph nodes) stage 4 on Ann Arbor classification system;

6. Multiple myeloma (a cancer that forms in a type of white blood cell called a plasma cell) stage 3 on the Durie-Salmon scale;

7. Brain tumour that is considered WHO (World Health Organisation) grade 3 or 4

100%

Confirmed diagnosis of any stage 3 cancer or WHO grade 2 brain tumour (including any cancer that is classified by SCIDEP as level B such as Hodgkin’s or non-Hodgkin’s lymphoma stage 3 on the Ann Arbor classification system) for which the insured life has undergone continuous cancer treatment for a period of six months or longer ANDPersonal Job Fitness Test failure, even after Optimal Recovery has been achieved

Any stage 3 cancer or WHO grade 2 brain tumour (includes any cancer classified by SCIDEP as level B such as Hodgkin’s or non-Hodgkin’s lymphoma stage 3 on the Ann Arbor classification system) that:

1. Has undergone continuous cancer treatment for at least six months AND2. Causes Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

**




Total %pay-out

Appendix



HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4


Chronic gastro-intestinal tract and/or liver and/or biliary disorders1 that has resulted in:• Unintentional treatment resistant weight loss of at least 25% over a 5-month period OR• Unintentional treatment resistant weight loss resulting in a BMI of less than 16

Digestive disorders, defined as: Chronic gastrointestinal tract and/or liver and/or biliary (relating to bile, the bile ducts or the gallbladder) disorders1 that have caused:• Unintentional treatment-resistant weight loss of at least 25% over five months OR• Unintentional treatment-resistant weight loss resulting in a BMI of less than 16

100%

Chronic irreversible liver disease1 with at least 2 of the following:• Serum bilirubin more than 51 µmol/l• Serum albumin less than 30g/dl• Prolonged Prothrombin time of more than 6 seconds or INR more than 2.3• Ascites requiring on-going surgical drainage• Hepatic encephalopathy

Digestive disorders, defined as: Chronic, permanent liver disease1 with at least two of the following:• Serum bilirubin levels of more than 51 µmol/l• Serum albumin levels of less than 30g/dl• Prolonged prothrombin time (PPT) of more than six seconds, or an international normalised ratio (INR) of more than 2.3 seconds. PPT and INR are tests to check for blood clotting. • Ascites (free fluid in the abdominal cavity) that require on-going surgical drainage• Hepatic encephalopathy (a state of mental confusion caused by liver failure)

100%

Confirmed diagnosis of chronic irreversible liver failure¹ confirmed by a gastroenterologist (PLUS inclusion on a recognised transplant list) with one of the following:1. Serum bilirubin more than 51 μmol/l2. Serum albumin lower than 30g/dl3. Prolonged prothrombin time of more than six

seconds or INR more than 2.34. Ascites requiring ongoing surgical drainage5. Hepatic encephalopathy

Digestive disorders, defined as: Chronic, permanent liver failure¹ (PLUS inclusion on a recognised transplant list) with one of the following:1. Serum bilirubin levels of more than 51μmol/l

(bilirubin is a bile pigment formed in the liver)2. Serum albumin levels lower than 30g/dl

(albumin is a protein that’s produced by the liver and circulates in the blood)

3. Prolonged prothrombin time (how long it takes for blood to clot) of more than six seconds, or an international normalised ratio (INR) of more than 2.3 seconds (INR is a standardised version of the prothrombin time)

4. Ascites (free fluid in the abdominal cavity) that needs ongoing draining through surgery

5. Hepatic encephalopathy (a state of mental confusion caused by liver failure)

100%

Primary sclerosing cholangitis1 Digestive disorders, defined as: Primary sclerosing cholangitis1 (inflammation and scarring of the biliary tract. The biliary tract transports bile from the liver to the small intestine.)

100%

1 2

* *

* *

* *




Total %pay-out

Appendix



HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4


Irreversible biliary tract obstruction1 with clinical evidence of cholestasis i.e. ascending cholangitis, jaundice and deranged liver enzymes (more than 2x raised liver enzymes)

Digestive disorders, defined as: Permanent blockage in the biliary tract1 (transports bile from the liver to the small intestine) with clinical evidence of cholestasis (blocked bile ducts) in the form of ascending cholangitis (inflammation of the biliary tract), jaundice and at least a two-fold increase in liver enzymes

100%

Irreversible total dysphagia1 resulting from organic disease which has undergone more than one surgical intervention and/or radiotherapeutic intervention

Digestive disorders, defined as: Permanent dysphagia1 (difficulty swallowing) caused by an organic disease (any health condition where physical examination, lab tests or other diagnostic studies show measurable evidence of disease) that has undergone more than one surgical procedure and/or radiation treatment

100%

Irreversible faecal incontinence1 treated by permanent colostomy

Digestive disorders, defined as: Irreversible faecal incontinence1 (loss of bowel control), which is treated by permanent colostomy (surgery where end of the large intestine is brought out through an opening in the abdominal wall)

100%

Irreparable abdominal or inguinal hernia (where surgery is now contraindicated1) with documented persistent malabsorption syndrome resulting from previous bowel loss

Digestive disorders, defined as: • Irreparable abdominal or inguinal (groin) hernia, where surgery is not advised1 AND • Documented persistent malabsorption syndrome caused by previous bowel loss

100%

Irreparable abdominal or inguinal hernia (where surgery is now contraindicated1) with documented evidence of previous bowel obstruction ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Digestive disorders, defined as: • Irreparable abdominal or inguinal (groin) hernia, where surgery is now contraindicated1 AND • There is documented evidence of a previous bowel blockage AND• Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Permanent colostomy ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Digestive disorders, defined as: Permanent colostomy (surgery where end of the large intestine is brought out through an opening in the abdominal wall) ANDPersonal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

1 2

* *




Total %pay-out

Appendix

Trauma


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4

Heart and blood vessels5


Any recognised cardiovascular or cardio-pulmonary disorder1 that results in the following cardiovascular assessments: New York Heart Association Functional Classification (NYHA) III /IV ANDPermanent Ejection Fraction (EF) < 35% ORMetabolic Equivalents (METS) < 2

Any recognised heart, circulation and/or lung disorder1 with the following scores:

1. A New York Heart Association Functional Classification (NYHA) of III or IV; AND2. A Permanent Ejection Fraction (EF) of less than 35%. (Permanent Ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction); OR3. Metabolic Equivalents (METS) of 2 or less. (METS is a measure of the energy you burn and oxygen you use during exercise).

100%

Chronic peripheral arterial insufficiency (also known as ischaemia) presenting with: no palpable pulses ANDDoppler readings of Ankle: Brachial systolic pressure index (ABI) ≤ 0.5 ANDrest pain ORulceration ORgangrene with or without amputation

Chronic peripheral arterial insufficiency or ischaemia (due to blockages in blood vessels to the upper and lower limbs) that presents with:

1. No palpable pulses (no pulse felt on physical examination); AND2. Doppler readings of a low Ankle Brachial Pressure Index (ABPI) of 0.5 or less (a test that measures the difference in blood pressure between the arteries of your arm and ankle); AND3. Pain when at rest caused by restricted arterial blood flow; OR4. Vascular ulcers (loss of skin); OR5. Gangrene (tissue death) with or without complete surgical removal (amputation).

100%

Non-healing venous ulcer of (> 3 months duration despite treatment by a vascular surgeon) with documented evidence of deep venous insufficiencyAND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

A non-healing venous ulcer (loss of skin), with the following features:

1. The ulcer persists for longer than three months, even after the patient has received treatment from a vascular surgeon, and there is clinical evidence of poor circulation in the deep veins AND 2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

1 2

* *




Total %pay-out

Appendix

Trauma


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



Documented treatment-resistant hypertension2 complicated by at least two of the following: Chronic Kidney Disease (CKD) stage 4 or 5 (Estimated glomerular filtration rate (eGFR) <30ml/min) ORRadiological evidence of a stroke (CVA) ORGrade III or IV hypertensive retinopathy ORDocumented left ventricular hypertrophy (septal wall thickness to posterior LV wall thickness of 1: 1.3 on ECHO) ORCongestive Cardiac Failure (CCF) defined as:- New York Heart Association Functional Classification (NYHA) II AND- Permanent Ejection Fraction (EF) < 45% OR- Metabolic Equivalents (METS) 2-5

High blood pressure that is documented as being resistant to treatment and complicated by at least two of the following:

1. Stage 4 or 5 Chronic Kidney Disease (CKD) with an estimated glomerular filtration rate (eGFR) of less than 30ml/min, indicating reduced

kidney function OR2. Signs of a stroke (CVA) on a scan OR3. Grade III or IV hypertensive retinopathy (damage to the retina in the eye caused by high blood pressure) OR4. Documented left ventricular hypertrophy (abnormal enlargement of the left lower chamber of the heart) with a ratio of the thickness of the septal wall (between heart chambers) to rear left ventricle wall of 1:1.3 found on heart sonogram (ECHO) OR5. Congestive Cardiac Failure (heart failure, or CCF) defined as:- A New York Heart Association Functional Classification (NYHA) of II, AND- A Permanent Ejection Fraction (EF) of less than 45% (Permanent Ejection fraction is a measure of the volume of blood that the heart pumps out with every contraction) OR- Metabolic Equivalents (METS) of 2 to 5,

(METS is a measure of the energy you burn and oxygen you use during exercise)

100%

1 2




Total %pay-out

Appendix

Trauma


Hormones


Lungs and breathing


Job Fitness Test

7

8

9

10

11

12

Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4


HIV/AIDS6



Advanced AIDS4, confirmed by: • A positive HIV antibody test AND• A current CD4 cell count of less than 200 in spite of optimal anti-retroviral combination therapy AND• The confirmed diagnosis of at least one of the following diseases: • Kaposi’s sarcoma • Pneumocystis carinii pneumonia • Progressive multifocal leukoencephalopathy • Extrapulmonary or MDRD/XDR pulmonary tuberculosis • Pulmonary Cryptococcus

Advanced AIDS, confirmed by: 1. A positive HIV antibody test AND2. A current CD4 cell count of less than 200, in spite of optimal anti-retroviral combination therapy AND3. The confirmed diagnosis of at least one of the following conditions:• Kaposi’s sarcoma (a cancerous tumour of the connective tissue associated with HIV infection)• Pneumocystis carinii pneumonia (a fungal infection of the lungs caused by pneumocystis carinii)• Progressive multifocal leukoencephalopathy (a viral disorder that damages the insulating myelin layer around nerves)• Extrapulmonary tuberculosis (tuberculosis or organs other than the lungs), multidrug resistant pulmonary tuberculosis (MDR-TB) or extensively drug-resistant pulmonary tuberculosis (XDR-TB) • Pulmonary Cryptococcus (a fungal infection of the lungs)

100%

Diagnosis of any of the following HIV treatment-related disorders¹⁺⁴: • Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI) lactic acidosis defined as venous lactate level > 10 mmol/l with signs and symptoms including nausea, vomiting, abdominal pain, tachycardia, fatigue and weight loss where sepsis has been excluded

Diagnosis of any of the following HIV treatment-related disorders1:

1. Lactic acidosis (a build-up of lactic acid in the bloodstream) caused by the use of a Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI), with a venous lactate level of more than 10 mmol/l AND 2. Some or all of the following signs and symptoms: nausea, vomiting, abdominal pain, tachycardia (racing pulse), fatigue and weight loss, where sepsis has been excluded

100%

Diagnosis of any of the following HIV treatment-related disorders¹⁺⁴: • Lipodystrophy2 and new-onset diabetes mellitus requiring oral hypoglycaemic medication and/or insulin


Lipodystrophy2 and new-onset diabetes mellitus that requires oral medication and/or insulin

100%

1 2




Total %pay-out

Appendix

Trauma


Hormones


Lungs and breathing


Job Fitness Test

7

8

9

10

11

12

Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4


HIV/AIDS6



Diagnosis of any of the following HIV treatment-related disorders¹⁺⁴: • Chronic pancreatitis with: o documented malabsorption syndrome or o new-onset diabetes mellitus requiring oral hypoglycaemic medication and/or insulin, AND Personal Job Fitness Test failure demonstrated after Optimal Recovery has been achieved


Chronic pancreatitis with:• Documented malabsorption syndrome OR • New-onset diabetes mellitus that requires oral medication and/or insulin AND• Personal Job Fitness Test failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Diagnosis of any of the following HIV treatment-related disorders¹⁺⁴: • Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI) lactic acidosis defined as venous lactate level 5 - 10 mmol/l with signs and symptoms including nausea, vomiting, abdominal pain, tachycardia, fatigue and weight loss where sepsis has been excluded as well as one of the following: • Lipodystrophy2 or • Irreversible peripheral neuropathy3 (duration of more than 6 months)

Diagnosis of any of the following HIV treatment-related disorders⁹:

1. Lactic acidosis (a build-up of lactic acid in the bloodstream) caused by the use of a Nucleoside/Nucleotide Reverse Transcriptase Inhibitor (NRTI), with a venous lactate level of 5 to 10 mmol/l AND 2. Some or all of the following signs and symptoms: nausea, vomiting, abdominal pain, tachycardia (racing pulse), fatigue and weight loss, where sepsis has been excluded as well as one of the following:• Lipodystrophy2 OR• Permanent peripheral neuropathy3 (damage to the nerves outside the brain and spinal cord) for more than six months

100%

1 2




Total %pay-out

Appendix

Trauma


Lungs and breathing


Job Fitness Test

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS

Hormones

6

7


Documented diabetes mellitus type 1 or 2 complicated by at least two of the following:• Chronic Kidney Disease (CKD) stage 3B (Estimated glomerular filtration rate (eGFR) 30-44ml/min) OR• Radiological evidence of a stroke (CVA) OR• Grade III diabetic retinopathy OR• Coronary artery disease which has undergone coronary artery bypass

Signs of established endocrine disorders disorders of hormone-secreting glands)1

Documented diabetes mellitus (type 1 or 2), complicated by at least two of the following:• Chronic Kidney Disease (CKD) stage 3B, with an estimated glomerular filtration rate (eGFR) of 30 to 44ml/min OR• Radiological evidence of a stroke (cerebrovascular accident) OR• Grade III diabetic retinopathy (damage to the retina) OR• Coronary artery disease that has undergone a coronary artery bypass

100%

Documented diabetes mellitus type 1 or 2 complicated by:• Grade IV or V diabetic retinopathy

Signs of established endocrine disorders (disorders of hormone-secreting glands)¹:

Documented diabetes mellitus (type 1 or 2), complicated by Grade IV or V diabetic retinopathy (damage to the retina)

100%

Cushing’s syndrome as evidenced by at least 2 of the following:• Documented profound proximal myopathy resulting in the permanent use of assistive devices OR• A diagnosis of new- onset persistent diabetes mellitus made following the diagnosis of Cushing’s syndrome requiring on-going insulin OR• Refractory hypertension (BP > 140/90 as evidenced by 4 or more separate readings taken at least 2 months apart within the last 12 months) with newly diagnosed ischaemic heart disease (angina or MI or stent or CABG) OR• New-onset psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)

Cushing’s syndrome (a condition caused by high levels of cortisol), as evidenced by at least two of the following:

• Documented, serious proximal myopathy (muscle weakness in the shoulder and limb girdles), which has resulted in the permanent use of assistive devices OR• The diagnosis of new-onset, persistent diabetes mellitus that requires on-going insulin treatment, after the diagnosis of Cushing’s syndrome OR• Refractory hypertension (treatment-resistant high blood pressure), with blood pressure levels of more than 140/90 in four or more separate readings taken at least two months apart within the last 12 months AND• newly diagnosed ischaemic heart disease (reduced blood flow to the heart), including angina, a heart attack, a stent or Coronary Artery Bypass Grafting (CABG) OR• New-onset psychotic disorder, which requires continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist)

100%

1 2 3 4




Total %pay-out

Appendix

Trauma


Lungs and breathing


Job Fitness Test

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS

Hormones

6

7


Refractory syndrome of inappropriate antidiuretic hormone secretion or SIADH (with Na+ < 130 mmol/l and no evidence of hypovolaemia with normal BP, pulse and serum urea: creatinine ratio demonstrated by 2 or more readings taken at least 2 months apart within the last 6 months) as a result of any of the following:• Small cell lung cancer• Mesothelioma• GI tract malignancy• Pancreatic malignancy• Asbestosis • Progressive multiple sclerosis

Refractory (treatment-resistant) SIADH syndrome involving

1. Inappropriate secretion of antidiuretic hormones (which limit urine production) AND 2. Na+ <130 mmol /l AND 3. No evidence of hypovolaemia (reduced blood volume) AND 4. Normal blood pressure, pulse and serum urea:creatinine ratio demonstrated by two or more readings taken at least two months apart within the last six months AND 5. Caused by any of the following: • Small cell lung cancer OR • Mesothelioma (cancer of the tissue that lines the chest, abdomen or around the heart) OR • Cancer of the gastrointestinal tract • Cancer of the pancreas • Asbestosis (a lung condition caused by inhaling asbestos fibres) • Progressive multiple sclerosis

100%

Refractory hypocalcaemia resulting from parathyroid disorders with evidence of any of the following:Chronic hypocalcaemia (serum calcium < 2.3 mmol/l as evidenced by 3 or more separate readings taken at least 2 months apart within the last 6 months) with any of the following:

• New-onset seizure disorder on permanent anti-convulsant medication (diagnosed and treated by a neurologist) OR

• Raised intracranial pressure necessitating surgical intervention OR

• Refractory new-onset prolonged QT interval on ECG OR

• Osteomalacia OR• New-onset psychotic disorder requiring continuous

antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist)

Refractory hypocalcaemia (treatment-resistant excess or lack of calcium) caused by parathyroid disorders with evidence of any of the following:

Chronic hypocalcaemia (too little calcium), with serum calcium readings of less than 2.3 mmol/l in three or more separate tests taken at least two months apart within the last six months. These results must be accompanied by any of the following:

• New-onset seizure disorder that requires permanent anti-convulsant medication (diagnosed and treated by a neurologist) OR• Raised intracranial pressure (pressure inside he skull) that requires surgery OR• Refractory (treatment-resistant) new-onset prolonged QT interval on an

electrocardiogram (measures the heart’s electrical activity) OR• Osteomalacia (softening of the bones) OR• New-onset psychotic disorder that requires

continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist)

100%

1 2 3 4




Total %pay-out

Appendix

Trauma


Lungs and breathing


Job Fitness Test

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS

Hormones

6

7


Refractory hypercalcaemia resulting from parathyroid disorders with evidence of any of the following:Chronic hypercalcaemia (serum calcium ≥ 3.0 mmol/l) as evidenced by 3 or more separate readings, following correction for serum albumin, taken at least 2 months apart within the last 6 months) with any of the following:• Chronic pancreatitis OR• New onset irreversible dementia (confirmed by

MMSE of less than 24/30 on 3 separate tests at least 3 months apart over the preceding 12 months diagnosed and treated by a psychiatrist) OR

• New-onset psychotic disorder requiring continuous antipsychotic medication for at least 12 months (as diagnosed and treated by a psychiatrist) OR

• Unintentional weight loss of at least 15% over a 3 month period or unintentional weight loss resulting in a BMI of less than 18 within the last year OR

• Cardiac arrhythmias necessitating a permanent pacemaker

Refractory hypercalcaemia (treatment-resistant excess or lack of calcium) caused by parathyroid disorders with evidence of any of the following:

Chronic hypercalcaemia (too much calcium), with serum calcium readings of at least 3.0 mmol/l in three or more separate tests after correction for serum albumin. The tests must have been taken at least two months apart within the last six months, and the results must be accompanied by any of the following:• Chronic pancreatitis (inflammation of the pancreas) OR• New-onset, permanent dementia (loss of brain function), confirmed by Mini-Mental

State Examination (MMSE) score of less than 24 out of 30 in three separate tests that were taken at least three months apart over the last 12 months (diagnosed and treated by a

psychiatrist) OR• New-onset psychotic disorder that requires continuous antipsychotic medication for at least 12 months (diagnosed and treated by a psychiatrist) OR• Unintentional weight loss of at least 15% over

three months or unintentional weight loss that’s resulted in a BMI of less than 18 within

the last year OR• Cardiac arrhythmias (disorder of heart rhythm) that requires a permanent pacemaker

100%

Polyglandular autoimmune syndrome II; Multiple Endocrine Neoplasia1 I or II

Any of the following endocrine conditions1 (affecting hormone-secreting glands)

1. Multiple Endocrine Neoplasia1 I or II (tumours of the endocrine, or internally secreting, glands) OR 2. Polyglandular autoimmune syndrome II (when the immune system attacks multiple glands in the body)

100%

Diabetes Insipidus1 as evidenced by: • Refractory polyuria and hypernatraemia

(Na > 150 mmol/l as evidenced by 3 or more separate readings taken at least 1 month apart within the last 6 months). The diagnosis must be confirmed by a water deprivation and desmopressin test AND

• Personal Job Fitness Test failure demonstrated after Optimal Recovery has been achieved

Diabetes Insipidus1 (a condition that affects the body’s ability to retain water), as evidenced by:

With the following supporting evidence: • Refractory polyuria (passing an abnormally

large quantity of urine) and hypernatraemia (a higher-than-normal concentration of sodium in the blood), with sodium levels of more than 150 mmol/l, as shown by three or more separate readings taken at least one month apart within the last six months. The diagnosis must be confirmed by a water deprivation and desmopressin test AND


100%

1 2 3 4




Total %pay-out

Appendix

Trauma


Lungs and breathing


Job Fitness Test

8

9

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS

Hormones

6

7


Chronic adrenal insufficiency as evidenced by: • Symptomatic, persistent postural hypotension

documented for longer than 6 months with a fall in blood pressure of ≥ 20 mm Hg AND

• Unintentional weight loss of at least 15% over a 3 month period or unintentional weight loss resulting in a BMI of less than 18 within the last year, AND


Chronic adrenal insufficiency (a disorder in which the adrenal glands don’t produce enough hormones), as evidenced by:

• Symptomatic, persistent postural hypotension (a drop in blood pressure) of at least 20mmHg on standing up that’s been documented over a period longer than six months AND• Unintentional weight loss of at least 15% over

three months, or unintentional weight loss that’s resulted in a BMI of less than 18 within the last year, AND

• Personal Job Fitness failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Chronic hyperaldosteronism as evidenced by: • Refractory hypokalaemia (K < 3.5 mmol/l as

evidenced by 3 or more separate readings taken at least 1 month within the last 6 months) AND

• Refractory hypertension (BP > 150/100 as evidenced by 4 or more separate readings taken at least 2 months within the last 12 months) AND


Chronic hyperaldosteronism (overproduction of aldosterone), as evidenced by:

• Refractory hypokalaemia (treatment-resistant potassium shortage) with potassium readings of less than 3.5 mmol/l in three or more separate tests taken at least one month apart within the last six months AND• Refractory hypertension (treatment-resistant high blood pressure), with blood pressure levels of more than 150/100 in four or more separate readings taken at least two months apart within the last 12 months) AND• Personal Job Fitness Test failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Panhypopituitarism defined as more than 80% loss of the anterior pituitary gland as evidenced by:• Growth hormone deficiency AND• Gonadotrophin deficiency AND• TSH (thyroid-stimulating hormone) deficiency AND• ACTH (adrenocorticotropic hormone) deficiency

Panhypopituitarism (reduced production of most pituitary hormones):

Defined as more than 80% loss of the anterior (front portion of the) pituitary gland as evidenced by:• Growth hormone deficiency AND• Gonadotrophin deficiency AND• TSH (thyroid-stimulating hormone) deficiency AND• ACTH (adrenocorticotropic hormone) deficiency

100%

1 2 3 4




Total %pay-out

Appendix

Trauma

Lungs and breathing


Job Fitness Test

9

10


11

12

Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones


7

8


Lifelong haemo- or peritoneal dialysis Lifelong dialysis Lifelong need of a dialysis machine to fulfil the kidneys’ function of filtering blood - either haemodialysis (via the bloodstream) or peritoneal dialysis (within the abdominal cavity)

100%

Irreversible chronic kidney disease (CKD): stage 4 or 5 of eGFR < 30ml/min

Irreversible chronic kidney disease (CKD) Stage 4 or 5 Chronic Kidney Disease with an estimated glomerular filtration rate (eGFR) of less than 30ml/min

100%

Urinary incontinence or urethral dysfunction which has resulted in a permanent indwelling catheter

Incontinence (loss of bladder control) Urinary incontinence (a loss of bladder control) or urethral dysfunction (abnormal flow of urine), leading to the insertion of a permanent catheter tube

100%

Treatment resistant nephrotic range proteinuria (> 3g/24 hours) of more than 1 year with evidence of irreversible impaired renal function eGFR < 50ml/min,ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Treatment-resistant nephrotic range proteinuria (large amounts of protein in the urine)

1. For more than a year, tests show the concentration of protein in the urine produced in a 24-hour period is more than 3g, with evidence of permanently impaired kidney function (an estimated glomerular filtration rate or eGFR below 50ml/min) AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%




Total %pay-out

Appendix

Trauma


Job Fitness Test

10

11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7


Lungs and breathing

8

9


Documented respiratory disorder1 resulting in irreversible respiratory impairment of: FEV ≤ 40% ORFVC ≤ 40% ORDCO ≤ 40%

A documented respiratory problem1 that leads to irreversible impairment and the following measurements:

1. A Forced Expiration Volume or FEV1 (the volume of air that can be blown out in the first second) of 40% or less, indicating reduced lung function OR2. A Forced Vital Capacity or FVC (the volume of air that can be blown out after inhaling fully) of 40% or less, indicating reduced lung function OR3. A Diffusion Capacity or DCO of 40% or less, indicating the lungs’ reduced ability to transfer oxygen

100%




Total %pay-out

Appendix

Trauma

Job Fitness Test11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7

Kidney and genital/urinary tract8

Lungs and breathing


9

10


The total and irreversible loss of functioning of both lower limbs

Paraplegia (paralysis from the waist down) The loss of function of both lower limbs is permanent and complete

100%

The total and irreversible loss of functioning of upper limbs and lower limbs

Quadriplegia (paralysis from the neck down)

The loss of function of both the upper and the lower limbs is permanent and complete

100%

The total and irreversible loss of functioning of one side of the body (including upper and lower limb, and trunk)

Hemiplegia (paralysis of the left or right side of the body)

The loss of function of one side of the body (including upper limb, lower limb and trunk) is permanent and complete

100%

The total and irreversible loss of functioning of corresponding limbs on each side of the body

Diplegia (paralysis of the same limbs on both sides of the body)

The loss of function of both of the affected limbs is permanent and complete

100%

Loss of both lower limbs where lower limb is defined as limb above the ankle

Loss of both lower limbs The loss is from above the ankles 100%

Loss of or irreversible complete loss of use of one or both lower limb(s) above the knee.

Loss, or the permanent and complete loss of use, of one or both lower limbs

The loss or loss of use is from above the knee 100%

Loss of or irreversible loss of use of 1 or both upper limbs above the elbow

Loss of, or the permanent and complete loss of use of one or both upper limbs

The loss of use is from above the elbow 100%

The permanent partial loss of use of a lower limb defined as to include the foot/ankle or knee or hipANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Permanent loss of use of part of a lower limb (part of a leg)

1. The loss includes the foot/ankle or knee or hip AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

Loss of or irreversible complete loss of use of the entire hand

Loss of a hand, or the permanent and complete loss of its use

The loss of, or permanent loss of the use of entire hand

100%

Loss of or irreversible loss of use of thumb and two fingers of the non-dominant hand ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Loss of the thumb and two fingers on the non-dominant hand, or the permanent and complete loss of their use

1. The loss is permanent and complete AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

Loss of or irreversible loss of use of thumb and index finger of the dominant hand ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Loss of the thumb and index finger on the dominant hand, or the permanent and complete loss of their use

1. The loss is permanent and complete AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

1 2 3

**

**

**

**




Total %pay-out

Appendix

Trauma

Job Fitness Test11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7


Lungs and breathing


9

10


The permanent partial loss of use of an upper limb defined as to include the wrist/carpal bones or elbow or shoulder ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Permanent partial loss of use of an upper limb (arm)

1. The loss includes the wrist (carpal bones) or elbow or shoulder AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

The loss of manual dexterity ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Loss of manual dexterity (ability to use the hands for complex or detailed tasks)

Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

The loss of eye-hand coordination ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Loss of hand-eye coordination Personal Job Fitness Test Failure, even afterOptimal Recovery (meaning the person is still not able to perform certain tasks)

100%

Persistent documented neurological impairment1 despite two or more spinal operations including laminectomy and/or discectomy and/or fusion and/or surgical motion preserving technologies such as discarthroplasty and dynamic stabilization techniques on separate occasions, as a result of the same disease process, within a 5 year periodAND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Spinal problems The neurological impairment1 (nerve damage) persists, despite two or more separate spinal operations for the same condition within five years, including: • Laminectomy (removal of the back of a vertebral bone to relieve pressure on the spinal cord) AND/OR• Discectomy (removal of part or all of one of the cartilage discs between vertebrae) AND/OR • Fusion (surgical joining of two or more vertebrae to reduce pain and abnormal movement) AND/OR • Non-fusion (motion preserving) techniques - such as discarthroplasty (replacement of a damaged disc with an artificial one) and dynamic stabilisation (insertion of a device that stabilises the spine without eliminating its ability to move) AND • Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

100%

A disorder of the spine resulting in a diagnosis of bladder incontinence with a permanent indwelling catheter or bowel incontinence with a permanent colostomy

Loss of control of the bladder or bowel A spinal problem that causes incontinence (loss of control) of the bladder or bowel, with a permanent catheter inserted in the case of the bladder, and a colostomy (surgery where end of the large intestine is brought out through an opening in the abdominal wall) in the case of the bowel

100%

Cauda equina syndrome: diagnosis of this disorder Cauda equina syndrome (a severe condition in which the bundle of nerves at the bottom of the spine is compressed and damaged)

The disorder is diagnosed by a neurosurgeon 100%

1 2 3

*

*

*

*




Total %pay-out

Appendix

Trauma

Job Fitness Test11

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7


Lungs and breathing


9

10


50% or more compression of a vertebral body or multiple level compression fractures with documented corresponding neurological impairment1

AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Spinal problems At least 50% compression of a vertebral body (the largest part of a vertebral bone) or several compression fractures (collapsed vertebrae), with documented neurological impairment1 (nervous system damage) AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

100%

Corresponding clinical and radiological evidence of a radiculopathy defined as motor and sensory deficit, muscle atrophy and clinical signs of nerve tension where surgical treatment is contra-indicated AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Spinal problems Evidence of a radiculopathy (damage to one or more nerves at their root in the spine) on examination and on a scan, with impaired movement and sensation, muscle wasting and nerve tension where surgery is contraindicated AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

100%

Spinal disorder resulting in loss of spine motion segment integrity (with radiographic evidence) and documented corresponding neurological impairment1 where surgical treatment is contra-indicated AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Spinal problems A spinal disorder that impairs spine motion segment integrity (movement in a section of the spine), which is seen on an x-ray or scan and accompanied by neurological impairment1 (nervous system damage) where surgery is contraindicated AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

100%

1 2 3

Appendix

Muscles, bones and joints10

Trauma

Job Fitness Test

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7


Lungs and breathing9

11


The Job Fitness Test assesses your ability to work in your current occupation


1 2 3 4 5 6

The Job Fitness Test is an objective test that uses a points-based system to assess whether you can do the activities you need to do to work in your current occupation.

The Job Fitness Test is clear and objective, and looks at the type of work you doWe use an objective test, the Job Fitness Test to evaluate your ability to do the work that someone in your current occupation would typically do. This points-based test is made up of a series of different physical and cognitive assessments.(Cognitive assessments are a set of tests done by a doctor or occupational therapist to check how well you are able to do certain thinking, remembering and problem-solving tasks.) An independent occupational therapist does the assessment. It is essential that an underlying disease diagnosis or injury, supported by an ICD-10 code, causes you to fail the Job Fitness Test.

Important features of the Job Fitness Test• Clear and transparent, because you know about it upfront. The full criteria are detailed below, as well as the points-based scoring system; • Relevant, because it’s based on your current occupation, and looks at the manual component of your work;• Objective, because it’s based on global best practice and done by a third party, not by us.

If you use assistive devices because of your disability, you will do the test using these devices except if the test specifically requires you not to use an assistive device. Assistive devices are tools or equipment, like wheelchairs or crutches that you use to help you do everyday tasks.

Details of the Job Fitness Test1. Categorising your occupationThe Job Fitness test assesses your ability to work in your current occupation. The first step for this assessment is to categorise your current occupation in an occupational group, based on how much manual work it involves. We categorise your occupation based on the following bands:

Occupational Group: Duties:

Non-manual 20% or less of your duties are manual

Non-manual with essential manual component 20% or less of your duties are manual, with manual duties considered an essential job function*

Manual More than 20% of your duties are manual

* Definition of an essential job function: An essential job function is:• a part of your work that is inherent to your occupation, that cannot be performed by other colleagues in the normal course of their work and that requires special

expertise; or• the manual duties inherent to the scope of practice of a specific profession; or • manual duties essential to the operation of a small business (excluding office tasks) that no other person in a small business is able to perform.

Appendix


Trauma

Job Fitness Test

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7



11




2. Assessing your ability using the points-based scoring system The occupational therapist will assess you using the list of definitions and assessments shown in the table below. Depending on how severe your condition is, the occupational therapist will award you points for each of the criteria where you permanently meet the definition. You can only earn points at one severity level for any criteria. Your points will depend on the occupational category (as set out above).

The test only has two outcomes – the independent occupational therapist can either find you have failed the Job Fitness Test or that you have passed the test, since you have not scored enough points. If you fail the Job Fitness Test and we deemed you to be permanently disabled, you will meet the criteria for a pay-out. To fail the test and qualify for a claims pay-out of 100%, you must score 10 or more points in total across all the criteria when added together.

The test is a very powerful tool, as the unique scoring mechanism also allows for interactions between the different criteria, making it possible for us to take the impact of a number of different criteria into account at once.

The points-based score sheet

Criteria Sub-criteria Definitions (you must meet these definitions permanently) Non-manual Non-manual with essential manual component

Manual

Capacity to handle weight

Lifting and carrying

You are unable to lift a 20kg weight from the floor to waist, and are unable to pick up and move a 20kg weight from waist level to another surface at waist level.

0 0 2

You are unable to lift a weight of up to 10kg from the floor to waist, and are unable to pick up and move a 15kg weight from waist level to another surface at waist level.

1 2 5

You are unable to lift a 5kg weight or more from the floor to waist level, and are unable to move a 5kg weight from waist level to another surface at waist level.

2 5 10

Dynamic posturing (alignment of your body while moving)

Mobility and transfers (walking, stair climbing and dynamic balance)

You can move between a standing, seated, squatting and supine (lying on your back) posture, and can repeatedly alternate between postures while maintaining dynamic balance. You can ascend (climb up) and descend (climb down) 20 stairs. May use railing for light balance.

0 0 0

You can move between a standing, seated, squatting and supine (lying on your back) posture, and can repeatedly alternate between postures while maintaining dynamic balance. However, you require external support from another person, furniture, built environment or assistive device. You are unable to climb up or climb down 20 stairs without use of the handrail.

1 4 6

You are unable to move between a standing, seated, squatting and supine (lying on your back) posture, without support from a human, furniture, built environment or assistive device. You are unable to perform these postural changes at all or are unable to perform the postural changes safely without external support.

5 7 10

1 2 3 4 5 6

Appendix


Trauma

Job Fitness Test

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7



11





Manual

Static posturing (alignment of your body while staying still)

Includes elevated work, forward bending, standing, sitting, crouching, kneeling, static balance

You are able to assume and sustain various basic static postures independently. You make minimal use of external supports (such as another person, furniture, the built environment or an assistive device) and you are able to accept minor postural changes as normal.

0 0 0

You have some limitations in your ability to assume and/or sustain basic static posture. You make moderate use of external supports (such as another person, furniture, the built environment or an assistive device) and without these supports, you would not be able to maintain posture. For example, you can stand but without a crutch it is difficult for you to safely maintain the standing posture (crutch reliant)

1 5 5

You are unable to assume and/or sustain basic static posture. You are completely reliant on an assistive device to assume and sustain these postures. For example, you are wheelchair or crutch-reliant.

5 7 10

Effort tolerance

The impact of physical effort on your heart (cardiac effort)

You have some cardiac symptoms, as shown by one of these objective measurements: METS of 6 or EF of 51-54% or FVC of 61-79% (pred), FEV1 of 61-79% or Dco of 61-79% (pred) NYHA 1. However, there are no symptoms and you don’t show any limitations in your ability to do ordinary physical activity. For example, you show no sign of shortness of breath when walking.

0 0 0

You have clear cardiac symptoms, as shown by one of these objective measures (as assessed by a medical practitioner or specialist): METS of 4-7 or EF of 41-49% or FVC of 50-60% (pred), FEV1 of 50-60% or Dco of 50-60% (pred). In the absence of objective clinical measures, your symptoms are line with an NYHA 2 rating - Mild symptoms. You show mild shortness of breath and/or angina (chest pain) and show slight limitations in your ability to do ordinary activity. Ordinary physical activity results in fatigue, palpitation (racing pulse), dyspnoea (laboured breathing), or anginal pain (chest pain).

1 1 3

You have clear cardiac symptoms, as shown by one of these objective measures (as assessed by a medical practitioner or specialist): METS of less than 3 or EF of less 40% OR FVC 40-49% (pred) or FEV1 of 40-49% (pred) or Dco 40-49% (pred). In the absence of an objective measure, your symptoms are line with an NYHA 3 rating - Marked limitation in activity because of heart symptoms. These symptoms are visible even during less-than-ordinary activity – for example, when walking short distances (20–100 m). Less than ordinary activity causes fatigue, palpitation (racing pulse), dyspnoea (laboured breathing), or anginal pain (chest pain). You are comfortable only at rest.

2 3 6

1 2 3 4 5 6

Appendix


Trauma

Job Fitness Test

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7



11





Manual

Effort tolerance

The impact of physical effort on your heart (cardiac effort)

You have serious cardiac symptoms, as shown by one of these objective measures (as assessed by a medical practitioner or specialist): METS less than 2 or EF less than 35% OR FVC less than 40% (pred) or FEV1 of less than 40% (pred) or Dco of less than 40% (pred). In the absence of the availability of an objective measure, your symptoms are in line with an NYHA 4 rating - Severe limitations. You experience symptoms even while at rest and are mostly bed-bound.

5 7 10

Hand functioning

Grip strength The strength of your hand grip falls within 2 standard deviations of the norm for age and gender.

0 0 0

The strength of your hand grip falls between 3 and 4 standard deviations of the norm for age and gender.

1 2 3

The strength of your hand grip falls below 4 standard deviations of the normal ranges for age and gender. You are unable to sufficiently close your hand or are lacking in sufficient muscle strength in our hand to hold the dynamometer (an instrument measuring your muscle contraction) in the required testing position.

5 5 5

Dexterity and coordination

Your performance outcomes on the standardised assessment fall within the average range. In other words, you fall within the expected norm, characterised by an efficient and dextrous manner and the speed of your performance is not affected.

0 0 0

Your performance outcomes on the standardised assessment fall within the average to low range. In other words, you fall below the expected norm, characterised by low rate of performance and decreased quality of movement. Given additional time and adaptations, including posture or tools, you may be able to achieve improvement in your overall performance.

3 4 4

Your performance outcomes on the standardised assessment are poor. In other words, you fall far below the expected norm, or you are unable to participate or complete the task as per standard assessment protocols. Even with additional time and/or adaptions, you are unable to achieve an improved outcome. The rate of your performance and quality of execution remains far below expected norms.

5 5 5

1 2 3 4 5 6

Appendix


Trauma

Job Fitness Test

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7



11





Manual

Senses Vision Your visual acuity, when best corrected, is 20/40 or worse, or you have a visual field of 70 degrees or less, in your best eye (as assessed by an optometrist).

2 2 2

Your visual acuity is 20/70 or less, or you have a visual field of 40 degrees or less, in your best eye (as assessed by an optometrist)

4 4 4

Your visual acuity is 20/200 or less, or you have a visual field of 20 degrees or less, in your best eye (as assessed by an optometrist).

10 10 10

Hearing You have irreversible binaural loss of hearing of 30% to 59% as measured by audiometry at hearing thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz (as assessed by an audiologist).

2 2 2

You have irreversible binaural loss of hearing of 60% to 85% as measured by audiometry at hearing thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and your speech discrimination threshold is less than 60% (as assessed by an audiologist).

5 5 5

You have irreversible binaural loss of hearing of greater than 85% as measured by audiometry at hearing thresholds of 500Hz, 1000Hz, 2000Hz and 3000Hz and your speech discrimination threshold is less than 60% (as assessed by an audiologist).

10 10 10

Speech You have little or no speech impairment, as characterised by your ability to maintain normal verbal communication (both receptive and expressive) that is intelligible and audible in your primary language or mother tongue.

0 0 0

You show a moderate inability to comprehend or produce language symbols as evidenced by testing, and an impaired ability to sustain effective verbal communication that is intelligible and audible in your primary language or mother tongue. You have this speech impairment in the absence of severe hearing loss. This includes an impairment of both receptive and expressive language.

5 5 4

You show a severe inability to comprehend or produce language symbols, as evidenced by testing, with limited to no functional verbal communication that is intelligible and audible in your primary language or mother tongue. You have this speech impairment in the absence of severe hearing loss. This includes an impairment of both receptive and expressive language.

10 10 8

1 2 3 4 5 6

Appendix


Trauma

Job Fitness Test

12


Sensory system

Trauma


13

15

14



Brain and nerves2

Cancer3

Digestive system4



HIV/AIDS6

Hormones7



11





Manual

Cognition Thinking, remembering and problem-solving

Your cognitive abilities are within normal limits 0 0 0

You suffer cognitive impairment as found on standardised testing or screening. In the absence of formal testing by a neuropsychologist, you have an MMSE of less than 21/30, as measured a minimum of three months apart, and there is evidence that your condition is permanent.

5 5 3

You suffer moderate to severe cognitive impairment, as found on standardised testing. In the absence of formal testing by a neuropsychologist, you have an MMSE of less than 19/30, as measured a minimum of three months apart, and there is evidence that your condition is permanent.

10 10 8

Mental illness

Serious and pervasive illness requiring daily care or supervision, or extended periods of continuous care

You have been institutionalised (and medically certified) for a mental and behavioural disorder for at least 1.5 months continuously OR rapid cycling that has not stabilised on medication after 12 months. If you are readmitted within 7 days of discharge, this will be considered continuous institutionalisation.

2 2 2

You have been institutionalised (and medically certified) for a mental and behavioural disorder for at least three months continuously, or continue to suffer prominent symptoms after two years of ongoing treatment by a psychiatrist and admission to a psychiatric facility for at least four weeks during the two-year period. If you are readmitted within 7 days of discharge, this will be considered continuous institutionalisation.

5 5 5

You have been institutionalised (and medically certified) for a mental and behavioural disorder for at least six months continuously or continue to suffer prominent symptoms after one year of uninterrupted compliance with prescribed medication by a psychiatrist and admission to a psychiatric facility for at least 12 weeks. If you are readmitted within 7 days of discharge, this will be considered continuous institutionalisation.

10 10 10

1 2 3 4 5 6

Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11


Sensory system

Trauma


13

15

14

Brain and nerves2

4

Personal Job Fitness Test12

The Personal Job Fitness Test assesses your ability to work in your own, specific job


1 2

We’ll pay your claims for illnesses or injuries if you meet our clinical claims criteria. However, you may not meet our clinical criteria but may still qualify for a claim if you’re unable to work because of your condition. In these cases, we’ll assess your claim using the Personal Job Fitness Test or the Job Fitness Test, depending on how your illness or injury affects your ability to work. In this section of our claims criteria, we look at the Personal Job Fitness Test.

The Personal Job Fitness Test is a fair, objective and transparent assessmentThere are illnesses and injuries that could leave a specific person unable to work but that have no impact on another person’s ability to work and earn a living. These are usually conditions that are not clinically severe enough to meet our clinical definitions, but still have a financial impact because they leave you unable to do the activities required by your specific job. In these cases, we will use the Personal Job Fitness Test to assess whether you are able to work in your own, specific occupation. We’ll pay your claim if you are permanently disabled and fail the Personal Job Fitness Test. There are also some conditions where the Personal Job Fitness Test is part of the claims definition. In those cases, you will need to meet our clinical criteria and fail the Personal Job Fitness Test to qualify for a claim. It is essential that an underlying disease diagnosis or injury, supported by an ICD-10 code, causes you to fail the Personal Job Fitness Test.

The Personal Job Fitness Test is a fair, objective and transparent test. We base the criteria we use to measure your ability to work in the specific job that you’re doing at the time of the claim event.

The test is administered by an independent occupational therapistBrightRock will appoint an independent occupational therapist to do the Personal Job Fitness Test with you. The test assesses your ability to do your own specific work by comparing your performance to the demands of your specific job function. The test has only two possible outcomes. The occupational therapist can find that you are able to do your job (pass) or that you are permanently unable to do the activities required for you to do your own specific job (fail).

If you fail the test and we consider you permanently disabled, you will meet the claims criteria and receive a pay-outIf you fail the Personal Job Fitness Test and we pay you out, we will deem your condition to be permanent. We will never reassess your claim once approved, which means that even if you are later able to work in your own or a similar occupation, we won’t reduce your pay-out.

Important features of the Personal Job Fitness Test• The test is designed to be objective and consistent. This means that it will always deliver a consistent result, regardless of the occupational therapist doing the

assessment;• The test is clear and transparent, because you know about it upfront;• The test is absolutely relevant, because it is based on the your specific job;• The test is objective, because it’s based on global best practice and done by an independent third party, not by BrightRock.

If you use assistive devices because of your disability, you will do the test using these devices except if the test specifically requires you not to use an assistive device. Assistive devices are tools or equipment, like wheelchairs or crutches that you use to help you do everyday tasks.

Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11


Sensory system

Trauma


13

15

14

Brain and nerves2

4


The Personal Job Fitness Test assesses your ability to work in your own, specific job


Details of the Personal Job Fitness TestHow we establish which activities and abilities to assess

The activities and abilities assessed are based on your own specific job, and differ for each person. To ensure that the activities and abilities assessed in the test are the most relevant, frequent and essential to your job, the occupational therapist will first build a detailed understanding of your job roles and responsibilities before performing the assessment. This ensures that you are assessed fairly, and that the assessment is relevant to your own specific job. At BrightRock, we believe in understanding your specific circumstances and needs – so your cover matches your needs not only at the outset, but when we pay your claim.

The occupational therapist could base their understanding of your job roles and responsibilities on the following information.

Typical steps Detail

1. The occupational information we gathered at underwriting stage

When you applied for cover with BrightRock, we asked for your occupation. Your occupation category tells us what proportion of time you spend sitting, walking or standing, whether you travel for work and whether you manually handle or carry heavy weights. For some occupations, we ask for more information about your job and your work activities before we approve your cover.

If the occupation that you’re doing at the time of your claim is different to the occupation that you were doing when you took out the cover, we’ll ask for full information on your current work duties.

The information we gathered about your occupation at underwriting stage helps the occupational therapist doing the Personal Job Fitness Test to categorise the kind of work you are likely to do, before collecting more specific information about the exact tasks and duties specific to your own job (steps 2 to 4);

2. An in-depth interview at assessment stage When you claim, the occupational therapist will interview you to gain an understanding of how you spend your working day, what activities you do, how essential each activity is and how often you do each activity;

3. Additional employer interviews If the occupational therapist needs more information, they may also interview your employer to achieve a better understanding of what tasks are required to fulfil the requirements of your job;

4. Site visits The occupational therapist is also likely to conduct a site visit of your work premises and “walk through” a typical working day to further understand what exactly it is that you do to earn a living and what physical and mental activities this requires of you.

Based on the information that the independent occupational therapist has gathered from the above interviews, the independent occupational therapist will generate a list of the activities and tasks you do in your job – for example, sitting, standing and using your hands. The occupational therapist then also classifies each of these activities according to frequency and demand.The occupational therapist then uses internationally standardised tests and assessments to measure your ability to do the identified activities. These tests may vary from person to person, depending on the activities that are essential to your job, the level of endurance required and the length of time you are required to spend on this activity every day. The occupational therapist will factor this into your assessment.

If a particular activity is deemed essential – in other words, without this ability you cannot continue working in the same job on the same basis as before you became sick or injured – and you fail the assessment for that specific activity, you will fail the Personal Job Fitness Test altogether. This will apply regardless of the percentage of time you spend doing the activity.

1 2




Total %pay-out

Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11


Trauma


15

14

Brain and nerves2

4


Sensory system13


Irreversible binaural loss of hearing of greater than 85% as measured by audiometry at hearing thresholds of 500 Hz, 1000 Hz, 2000Hz and 3000 Hz and with a speech discrimination threshold of less than 60%

Permanent hearing loss of more than 85% in both ears (binaural)

Measured at hearing thresholds (sound levels) of 500 Hz, 1000 Hz, 2000 Hz and 3000 Hz, with a speech discrimination threshold (ability to hear and understand speech) of less than 60%

100%

Irreversible and complete loss of hearing¹ in both ears (total loss of hearing bilaterally)

Total and permanent hearing loss in both ears

The hearing loss is total and bilateral (on both sides)

100%

Bilateral loss of visual acuity as evidenced by a Snellen chart reading of 20/200 or worse in the best eye after full correction

Loss of visual acuity (clear vision) in both eyes

With a Snellen chart (eye-chart) reading of as low as 20/200 or worse in the better functioning eye, even after full correction

100%

Dysarthria defined as the inability to produce coherent speech due to the dysfunction of anatomical structures responsible for the mechanical production of sound e.g. mouth cavity, larynx, vocal cords ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Dysarthria (the inability to speak clearly) 1. The loss of speech is caused by a problem with the mouth, larynx, vocal cords or other anatomical structures that helps produce sound AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

Vestibular dysfunction¹ presenting with medically documented attacks of nausea, vomiting, vertigo, dizziness and tinnitus with at least 2 episodes per week resulting from:• Meniere’s disease OR• Involvement of the vestibular labyrinth by documented auto-immune disease AND Personal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Vestibular dysfunction¹ (balance disorder) that causes medically documented attacks of nausea, vomiting, dizziness, vertigo (a sense of falling) and tinnitus (ringing in the ears)

At least two attacks per week are due to:• Meniere’s disease (an inner ear condition that impairs hearing and balance) OR• A known autoimmune condition that affects the vestibular labyrinth (a part of the inner ear) • AND Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%




Total %pay-out

Appendix



Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

Trauma15

Brain and nerves2

4


Sensory system


13

14


Full thickness burns of more than 18% of body surface Burns Full thickness burns (burns to all the layers of the skin) over more than 18% of the body surface

100%

Full thickness burns of 9-18% body surface involving both palms of the hands or both soles of the feet

Burns Full thickness burns (burns to all the layers of the skin) over 9 to 18% of the body surface, involving both palms of the hands or both soles of the feet

100%

Full thickness burns of 9-18% of body surfaceANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Burns “• Full thickness burns (burns to all the layers of the skin) over 9 to 18% of the body surface AND• Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)”

100%

Full thickness burns of 8% of body surface involving at least the palm of one hand or the sole of one footANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Burns • Full thickness burns (burns to all the layers of the skin) over 8% of the body surface, involved at least the palm of one hand or the sole of one foot AND• Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Full thickness burn of greater than 25% of the face Burns Full thickness burns (burns to all the layers of the skin) over more than 25% of the face

100%

Full thickness burn of 10-25% of the faceANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Burns • Full thickness burns (burns to all the layers of the skin) over 10 to 25% of the face AND• Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Irreversible disfigurement of more than 36% of the body surface resulting from a chronic treatment resistant skin disorder ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Skin disorders, defined as • Permanent disfigurement of more than 36% of the body surface, caused by a chronic treatment-resistant skin disorder AND• Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still unable to perform certain tasks)

100%

Irreversible disfigurement of more than 36% of the body surface resulting from a chronic treatment resistant skin disorder with systemic organ involvement of the central nervous system or the heart or lungs or liver or kidneys resulting from a chronic treatment resistant skin disorder

Skin disorders, defined as • Permanent disfigurement of more than 36% of the body surface, caused by a chronic treatment-resistant skin disorder AND• systemic organ involvement of the central nervous system, heart, lungs, liver or kidneys resulting from a chronic treatment resistant skin disorder

100%

**

**

**




Total %pay-out

Appendix


Body systems (areas of the body)Body systems (areas of the body)

Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

13

Brain and nerves2

4


Sensory system

Trauma


15

14


A state of unresponsiveness, as evidenced by a Glasgow Coma Scale of 8 and less, which persists for more than 96 hours. (medically-induced comas are excluded)

Coma (being unconscious) A coma that lasts longer than four days andscores 8 and less on the Glasgow Coma Scale(a scale for measuring the level ofunconsciousness or severity of a brain injury)(medically-induced comas are excluded)

100%

A traumatic injury to the brain, with resultant documented Glasgow Coma Scale of less than 12/15, caused by an external physical force with:• irreversible cognitive impairment of MMSE < 21/30 or• permanent neurological deficit (motor and or sensory impairment) resulting in continuous professional care and supervision of more than 4 hours a day

Traumatic (physical) brain injury Injury to the brain caused by an external physical force and leading to a Glasgow Coma Scale (a scale for measuring the level of unconsciousness or severity of a brain injury) score of less than 12, as well as:• Irreversible cognitive impairment (reduced mental function) with a Mini–Mental State Examination (MMSE) score of less than 21 of a possible 30 OR• Permanent neurological deficit (damage to the nervous system) that impairs movement and sensation and causes a need for professional care and supervision for more than four hours a day

100%

Irreversible anatomical distortion of the face of 25-50% resulting from an external physical force ANDPersonal Job Fitness Test Failure demonstrated after Optimal Recovery has been achieved

Facial injury 1. Permanent disfigurement (anatomical distortion) of 25 to 50% of the face caused by an external physical force AND2. Personal Job Fitness Test Failure, even after Optimal Recovery (meaning the person is still not able to perform certain tasks)

100%

Irreversible anatomical distortion of the face of 25-50% resulting from an external physical force which has undergone multi-stage facial reconstructive surgery

Facial injury Permanent disfigurement (anatomical distortion) of 25 to 50% of the face, which was caused by an external physical force and has had several stages of reconstructive surgery

100%

Irreversible anatomical distortion of the face of more than 50% resulting from an external physical force

Facial injury Permanent disfigurement (anatomical distortion) of more than 50% of the face caused by an external physical force

100%

**


Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6

7

8

9

10

11

13

Brain and nerves2

4


Sensory system

Skin and soft tissue disorders14

Trauma15

Permanent Standard




Total %pay-out

Permanent failure of 4 out of 5 BrightRock Activities of Daily Living (excluding cognitive failure)

ADL failure Has resulted in permanent inability to perform four out of five BrightRock Activities of Daily Living (excluding cognitive impairment. Cognitive impairment is where the brain’s capacityto think, remember and judge clearly is reduced)

100%

Permanent failure of cognitive BrightRock Activities of Daily Living (see definition) with an irreversible MMSE of ≤ 18

ADL failure Has resulted in permanent inability to perform the cognitive BrightRock Activities of Daily Living (this refers to the brain’s capacity to think, remember and judge clearly) and a permanent score of 18 or less when a neurologist tests the person’s cognitive (thinking) skills with the Mini Mental State Examination (MMSE)

100%

BrightRock Activities of Daily Living (ADLs)

1. Washing: You rely entirely on someone else to help you wash, bath or shower.

2. Dressing Skills: You need the help of another person to help you fasten clothes (open/close zips, fasten/unfasten buttons, close belts, tie laces) and, if applicable,

attach and fasten any braces, prosthetics or other surgical appliances that you usually wear.

3. Eating and feeding: You’re physically unable to feed yourself and need someone’s help.

4. Mobility: You need physical help when moving between rooms on a level surface, despite the use of an assistive device such as a walking cane or wheelchair.

5. Transferring: You need someone’s help when moving between a bed and a chair.

6. Cognitive Impairment: You have suffered irreversible brain damage, and can no longer perform the Activities of Daily Living without medical help or supervision.

This must be confirmed by a neurologist or psychiatrist and formally tested by a neuropsychologist.

Permanence will be established not less than three months after the event

Definition sets B(V7.0), Set C(V7.0), Set D(V6.0)Reference notes

Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6


7

8

9

10

11

13

Brain and nerves2

4


Sensory system


Trauma15


Appendix

Reference notes

Brain and nerves 1. The diagnosis of treatment-resistant generalised epilepsy is defined as the failure to control seizure activity by surgery or an adequate trial (despite full patient compliance) of at least three antiepileptic medications. At least two must have been used in combination (confirmed by therapeutic blood levels where possible). This diagnosis must be confirmed by a neurologist, with supporting investigations i.e. EEG and brain imaging studies. Non-Epileptic Attack Disorder (NEAD) and psychogenic non-epileptic seizure (PNES) are excluded from this benefit category.

2. Irreversible cognitive impairment must be confirmed by a neuropsychologist assessment.

3. The diagnosis of vestibular dysfunction must be confirmed by a neurologist with supporting investigations (i.e. brain imaging studies). Neurological vestibular conditions excluded from this benefit include vasospastic conditions, such as migraines.

4. The diagnosis of treatment-resistant sleep disorder must be confirmed by formal neurophysiological testing as performed in an accredited sleep laboratory.`

5. Loss of language comprehension and production must be confirmed by a neurologist with radiographic evidence in keeping with the clinical findings.

6. Must be confirmed by a neurologist with supporting investigations.

7. Examples of mental and behavioural disorders that result in the severity criteria as specified here include but are not limited to:

• Dementia

• Depression and other mood disorders

• Schizophrenia and other psychotic disorders

• Anxiety disorders

The following mental and behavioural disorders are specifically excludedfrom this benefit category:

• Factitious disorders.

• Malingering

• Substance-use disorders

Digestive system

1. Eating and functional disorders are excluded from this benefit category.

2. Accepted desirable weight is that implied by a BMI between 20 and 25, given the person’s height. Heart and blood vessels

1. Examples of cardiovascular or cardio-pulmonary disorders that result in the severity criteria we’ve specified include, but are not limited to:

• Myocardial infarction

• Ischaemic heart disease

• Valvular heart disease

• Cardiomyopathy

• Coronary artery disease

• Hypertension

• Congenital heart disease

• Pericardial heart disease

• Arrhythmia

• Pulmonary arterial hypertension

• Pulmonary venous hypertension

• Cor pulmonale

• Aortic disease, e.g. aneurysm

2. Treatment-resistant hypertension is high blood pressure that is treated with more than four different medicines.

HIV/AIDS 1. To be confirmed by an HIV specialist with supporting laboratory and/or radiological investigations.

2. HIV-associated lipodystrophy refers to abnormal central fat accumulation (lipohypertrophy) and localised loss of fat tissue (lipoatrophy) in individuals with HIV infection on treatment with anti-retroviral medications.

3. Confirmed by neurophysiological tests.

4. For these conditions, claims for insured lives who have already been diagnosed as HIV-positive prior to taking out their cover with BrightRock are excluded.

1 2 3

Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6


7

8

9

10

11

13

Brain and nerves2

4


Sensory system


Trauma15


Appendix

Reference notes

Hormones 1. The endocrine disorders (as confirmed by an endocrinologist) must be supported by the relevant laboratory and radiological investigations and shown to be persistent despite full compliance with optimal medical and surgical treatment. Psychogenic polydipsia is excluded.

Lungs and breathing

1. Examples of respiratory disorders that result in the severity criteria as specified here include but are not limited to:

• Chronic obstructive airways disease

• Restrictive lung disease.


1. Neurological impairment must include evidence of a lower motor neuron lesion with evidence of:

• Motor weakness of the muscles corresponding to the nerve level involved AND

• Prominent muscle wasting.

Sensory system

1. The hearing loss must be permanent and completely uncorrectable by surgery or a fitted hearing aid/device.

2. Vestibular conditions excluded from this benefit include:

• Viral labyrinthitis

• Vestibular neuronitis

• Benign positional vertigo.

** Our optimal treatment requirement doesn’t apply to these conditions

We won’t apply the requirement for optimal treatment to a claim on clinical definitions marked with the ** symbol.

** Our optimal treatment requirement doesn’t apply to these conditions

We won’t apply the requirement for optimal treatment to a claim on clinical definitions marked with the ** symbol, but only where the limb(s) or finger(s) have been amputated.

1 2 3

* Condition-specific alcohol exclusion:

For the conditions marked with the * symbol, claims for injuries or illnesses related to long-term alcohol or drug abuse are excluded.

Appendix


Cancer


Digestive system

3

1


HIV/AIDS

Hormones


Lungs and breathing


Job Fitness Test

6


7

8

9

10

11

13

Brain and nerves2

4


Sensory system


Trauma15


Appendix

Reference notes

BrightRock has the right to ask for a second opinion if the medical information we initially receive is not sufficient to prove conclusively that the client has met the claims criteria. For example, if the information provided is not sufficient to confirm the client’s diagnosis. Depending on the case, BrightRock may recommend a medical professional for the second opinion or the client may consult a medical professional of their own choosing.

“Confirmed” means that the diagnosis has been made with appropriate and supporting medical evidence in the form of reports, blood tests, histological findings, imaging, scans or any other relevant investigations.

BrightRock has no explicit general survival or general waiting periods on our permanent expenses cover (condition-specific waiting periods, however, do apply for certain conditions. Please refer to the clinical definitions contained in this document to see which ones have this type of waiting period). This gives you greater certainty of claim. If the insured life has a valid permanent expenses claim that meets our clinical criteria but dies before we have made the pay-out, BrightRock will still pay the claim out. This applies as long as the insured life was alive at the time of the diagnosis that led to the permanent expenses claim.

Unless otherwise specified, if you become ill or injured, you must get medical treatment as soon as possible to qualify for a claim against your permanent expenses cover on your BrightRock policy. You must fully comply with your doctor’s advice and finish your full treatment regime. If you don’t seek and receive optimal treatment and fail to comply with your treatment, the claim will be invalid.

1 2 3

Documents

Bod systems areas of the bod) Clinical claims definitions ... · Disorders of cranial nerve VIII (the Vestibulocochlear nerve) Permanent Vestibulocochlear nerve palsy⁶ (paralysis)