The Critical Condition Benefit

(Underwritten by Blue Cross Life Insurance Company of Canada)

Qualifying Critical Conditions

A benefit will be paid if, as a result of sickness or disease (or accident if it is a severe burn) a Plan Member suffers from one of the following critical conditions that are severe and meet the degrees of severity in the contract:

  • Alzheimer’s Disease
  • Blindness
  • Burns
  • Coma
  • Deafness
  • Life Threatening Cancer
  • Loss of speech
  • Major Organ Failure
  • Major Organ Failure Requiring Transplant
  • Motor Neuron Disease
  • Multiple Sclerosis
  • Paralysis
  • Parkinson’s Disease
  • Senile Dementia
  • Severe Heart Attack
  • Severe Stroke

For example, only the most severe level of heart attack is covered (a Class 4 heart attack as classified by the Canadian Cardiovascular Society) i.e. unable to carry on any physical activity without discomfort.

The Benefits

The benefit amount for a critical condition is a lump sum non-taxable benefit payment of $50,000.

Benefit restrictions include:

  1. Coverage is provided prior to the earlier of the Member’s 65th birthday or retirement.
  2. A 30 day waiting period. The Member must survive the critical condition for 30 days and still meet the definition of critical condition.
  3. One payment of $50,000 can be paid for each type of critical condition.
  4. Up to two payments or $100,000 can be paid during a Member’s lifetime. The two occurrences must be unrelated.

Pre-Existing Conditions Restriction

If a Member is disabled when this benefit was introduced on April 1, 1997, the critical condition benefit coverage does not begin until the disability stops and the Member is available to return to work.

Any medical conditions for which the Member has received medical treatment, consultation, care or services (including diagnostic measures) and/or for which he or she has been prescribed medication during the 24 months immediately before coverage begins is not covered unless the critical condition begins after 24 consecutive months or more of coverage.

Waiting Period

The critical condition benefit is a living benefit, which means the Member must survive the onset of the critical condition for a period of 30 days before the benefit will be paid. At the end of this 30 day period, the Member must still meet the definition of critical condition and provide satisfactory medical proof within 365 days.

Overview of Critical Conditions

  • All conditions, with the exception of burns, must be the result of illness or disease.
  • Conditions resulting from an accident (except in the case of burns) will not be covered.

Covered Conditions

  1. Alzheimer’s Disease: Definite diagnosis of a progressive degenerative disease of the brain made by a certified neurologist or gerontologist acceptable by the Company, where there is a significant reduction in mental and social functioning as demonstrated by:
    1. a loss of intellectual capacity and cognitive impairment,
    2. impaired memory and sense of judgement, and
    3. required continuous adult supervision for health and safety, whether medicated or not.
  2. Blindness: Definite diagnosis made by a certified ophthalmologist acceptable by the Company, of the permanent loss of sight in both eyes. The loss of sight must be such that:
    1. visual acuity cannot be corrected beyond 20/200 in both eyes, or
    2. the field of vision must be less than 20 degrees in both eyes.
  3. Burns: Third degree burns, as a result of a single event, covering at least 20% of the body surface
  4. Coma: State of unconsciousness with no reaction to external stimuli or response to internal needs, for a continuous period of 30 days.
  5. Deafness: Definite diagnosis made by a certified otolaryngologist acceptable by the Company, of the permanent loss of hearing in both ears. The loss of hearing in each ear must be such that sounds of 90 decibels or less cannot be distinguished.
  6. Life Threatening Cancer: Incontrovertible evidence of a malignant tumor, as evidenced on a pathology report, characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue with distant metastasis and which is not listed in the exclusions, or any malignant tumors (with or without metastasis) listed as follows:
    1. oral cavity
    2. pharynx (including larynx)
    3. oesophagus
    4. stomach
    5. level IV Melanoma
    6. liver
    7. pancreas
    8. gallbladder and bile ducts
    9. lungs and respiratory tracts

The following forms of cancer or conditions are excluded from coverage:

  1. benign tumors or polyps;
  2. pre-malignant lesions;
  3. stage T1 prostate cancer;
  4. cancer-in-situ cancers (cancer has not spread outside the tissue in which it developed;
  5. Melanoma less than or equal to 1.0 mm in thickness, not ulcerated and without level IV or V invasion;
  6. basal cell and squamous cell carcinoma of the skin.
  1. Loss of Speech: Total and irreversible loss of speech as a result of physical disease as diagnosed by a medically appropriate specialist acceptable by the Company.
  2. Major Organ Failure: Advanced or rapidly progressing incurable terminal kidney, liver, lung or heart failure where the insured is not a candidate for organ transplant, as determined by a medically acceptable specialist approved by the Company.
  3. Major Organ Failure Requiring Transplant: The irreversible failure of the kidneys, liver, lungs or heart requiring receipt of a transplant of that organ. To qualify, the insured must be accepted in a transplant program satisfactory to the Company.
  4. Motor Neuron Disease: Definite diagnosis of motor neuron disease made by a certified neurologist acceptable by the Company, resulting in the inability to perform at least two of the five Activities of Daily Living without assistance, as determined by an occupational therapist acceptable by the Company.
  5. Multiple Sclerosis: Definite diagnosis, made by a certified neurologist acceptable by the Company, of having at least two episodes of well-defined neurological deficit with persisting neurological abnormalities to a degree that results in the inability to perform at least two of the five Activities of Daily Living without assistance, as determined by an occupational therapist acceptable by the Company.
  6. Paralysis: The complete and permanent loss of use of two or more limbs resulting from a neurological deficit with measurable objective impairment that cannot be corrected by surgery or any other means, as diagnosed by a medically appropriate specialist acceptable by the Company.
  7. Parkinson’s Disease: Definite diagnosis of Primary Idiopathic Parkinson’s disease made by a certified neurologist acceptable by the Company, resulting in:
    1. neurological impairment to a degree that requires continuous adult supervision for health and safety, whether medicated or not, or
    2. an inability to perform at least two of the five Activities of Daily Living without assistance, as determined by an occupational therapist acceptable by the Company.
  8. Senile Dementia: Definite clinical diagnosis, made by a certified neurologist or gerontologist acceptable by the Company, of a progressive degenerative disease of the brain resulting in a significant reduction in mental and social functioning as demonstrated by:
    1. a loss of intellectual capacity and cognitive impairment,
    2. impaired memory and sense of judgement, and
    3. required continuous adult supervision for health and safety whether medicated or not.
  9. Severe Heart Attack: A heart attack, based on symptoms and diagnostic investigations, resulting in a permanent functional classification of at least a CCSC Class IV as evidenced by:
    1. a reduced ejection fraction (<40%) on echocardiogram or nuclear study with a large or multiple wall motion defects and reduced function as evidenced by stress testing as indicated above, or
    2. severe left ventricular dysfunction and/or left ventricular aneurysm, reduced ejection fraction (<40%) and left main or 3 vessel disease (>70% narrowing) as seen on the coronary angiogram.
  10. Severe Stroke: Cerebrovascular event producing objective evidence of neurological sequelae lasting more than 30 days caused by intracranial thrombosis, hemorrhage or embolism from an extra-cranial source to a degree that requires continuous adult supervision for health and safety, whether medicated or not, or an inability to perform at least two of the five Activities of Daily Living without assistance, as determined by an occupational therapist acceptable by the Company.