Recovery Insurance Cover types
You can choose which cover you’d like for Recovery Insurance:
- Cancer Cover
- Critical Injury Cover; and
- Critical Illness Cover.
|Recovery Insurance||What you're Covered for|
You will be Covered in the event of Cancer, subject to any Special Conditions specified in your Policy Schedule. For example Cover would be provided for Cancer (of a specified criteria) or Benign Brain Tumour (resulting in irreversible neurological deficit)
As Cover is based on the medically-tested severity, you should refer to the Glossary of Recovery Insurance Conditions for the full definition and conditions of Cancer Cover.
In the case of Cancer (of a specified criteria),, Carcinoma In Situ, Diagnosed Benign Brain Tumour, Early Stage Chronic Lymphocytic Leukaemia, Early Stage Melanoma or Early Stage Prostate Cancer, a three month waiting period applies from the Cover Commencement Date, the date of any increase but only in respect if the increase, or the date of any reinstatement before a claim can be made.
|Critical Injury Cover||
You will be Covered in the event of Critical Injury as the result of an Accident, subject to any Exclusions and Special Conditions outlined in your Policy Schedule. For example, Cover would be provided for Severe Burns (covering at least 20% of the body’s surface area), Blindness (permanent),or Loss of use of a Limb (permanent).
You should refer to the Glossary of Recovery Insurance Conditions for the full list of events Covered under Critical Injury.
|Critical Illness Cover||
You will be Covered in the event of a Critical Illness, subject to any Exclusions and Special Conditions outlined in your Policy Schedule. Critical Illness includes the diagnosis of a number of Heart and neurological conditions, permanent conditions and organ disorders. For example Cover would be provided for the diagnosis of major heart conditions such as Heart Attack (of specified severity), neurological conditions such as Dementia including Alzheimer's Disease (permanent) or Stroke (resulting in neurological deficit), permanent conditions such as Loss of Hearing (other than Loss of Hearing as a result of Accidents), and organ disorders such as Chronic Kidney Failure.
Below is a full list of all conditions that may be Covered depending on the severity of your diagnosis. You should refer to the Glossary of Recovery Insurance Conditions for the specific definition of each condition.
Please note that these conditions are Covered only as the result of Illness. If you wish to be covered for conditions as the result of an Accident, you will need to select Critical Injury Cover.
Please note that any claim for a Minor Heart Attack will be paid at 25% of the Benefit Amount to a maximum of $50,000 and can only be claimed once.
In the case of Angioplasty, Coronary Artery Bypass Surgery, Heart Attack, Heart Valve Surgery, Minor Heart Attack, Open Heart Surgery, Out of Hospital Cardiac Arrest, Stroke or Triple Vessel Angioplasty, a three month waiting period applies from the Cover Commencement Date, the date of any increase but only in respect if the increase, or the date of any reinstatement before a claim can be made.
|Recovery Insurance||What you're not Covered for|
|Cancer Cover||If you select only Cancer Cover, then no Cover is provided in the event of Critical Injury or Critical Illness. For example, no Cover would be provided for Severe Burns or a Heart Attack.|
|Critical Injury Cover||If you select only Critical Injury Cover, then no Cover is provided in the event of Cancer or Critical Illness. For example, no Cover would be provided for malignant tumours, Chronic Kidney Failure or Blindness as a result of Illness.|
|Critical Illness Cover||If you select only Critical Illness Cover, then no Cover is provided in the event of Cancer or Critical Injury. For example, no Cover would be provided for skin cancers showing evidence of metastases, Blindness or Severe Burns as the result of an Accident.|
Depending on what Recovery Insurance Cover you take out, we pay a lump sum for any of the listed conditions under that Cover where they meet the severity criteria specified. Please refer to the Glossary of Recovery Insurance Conditions for the full list of events Covered.
You can also choose whether you want your Cover to increase each year in line with the cost of living – this will mean that your premium will increase each year as the Cover is increased through a process called indexation. If you have a Stepped Premium Policy, it will mean that there are two reasons your Policy will increase each year.
The default setting for all TAL Lifetime Protection Policies is for those Policies to have indexation applied to them but can be turned off on request. If you are Bundling TPD or Recovery Insurance with your Life Insurance, you will need to have Inflation Protection switched on or off for all insurances.
Indexation can be declined on any number of occasions or switched off permanently at any time, otherwise indexation continues on Life Insurance, and on TPD or Recovery Insurance Bundled with Life Insurance until Policy expiry. For TPD which is Standalone, indexation ends at the Policy Anniversary prior to your 65th birthday. For Recovery Insurance which is Standalone, indexation ends at the Policy Anniversary prior to your 70th birthday.
Indexation applies to both Stepped and Level Premiums. For Level Premiums, the additional premium for the increased Cover is based on your age at the time of the increase – not at the time the Policy started. Indexation does not apply to Cover due to Life Insurance Buy Back Options, and Future Life Event increases.
The indexation rate is the CPI or 5%, whichever is the greater for Life Insurance, TPD and Recovery Insurance. For Income Protection Insurance, the indexation rate is 3% or CPI, whichever is the greater. The CPI rate is published each October and applies from the beginning of the following calendar year. Indexation applies to the Anniversary Statement issued for the next Policy Anniversary (i.e. after 1 January.) Indexation will cease on the anniversary prior to the Policy Expiry Date. Indexation continues through the maximum Cover allowable at the time of taking out the Policy.
While you have an active Income Protection Insurance claim, and you are receiving payments from TAL, the Benefits are not indexed unless the Policy has the “increasing claims” optional extra. Indexation of these Benefit Amounts is the lower of CPI and 3%.
Indexation increases can be reversed on request. In this case only the most recently increased portion of the Cover is cancelled. The rest of the Cover (pre indexation) remains the same, and the premium relating to this Cover is the premium based on the recently calculated anniversary.
Inflation Protection will not apply if Premiums are being waived under the Premium Relief Option.
Future Life Events
Future Life Events means you can increase your Life Insurance, TPD or Recovery Insurance Benefit Amount(s) without evidence of your health or pastimes when specific life events occur, for example, getting married or divorced, obtaining or increasing a mortgage or increasing your financial interest in a business.
|Future Life Event||Maximum allowable increase|
|You or your spouse becoming a new parent through birth or adoption||25% of the Benefit Amount at Policy commencement, or $200,000, whichever is the lesser.|
|Your marriage or divorce|
|Your dependent child starting secondary school|
|Your completion of a post-graduate degree|
|You becoming a full-time carer|
|An increase in your financial interest in a business to which the Policy is related via a buy-sell, share purchase or succession agreement|
|An increase in the loan liability of the business for which you are the primary guarantor|
|An increase in your value to a business in which you are a key person|
|Taking out or increasing a mortgage on your home||The amount of the mortgage being taken out, or the increased portion of an existing mortgage, to a maximum of $200,000.|
|Your annual income increasing by $10,000 or more||Five times the annual salary increase, or $200,000, whichever is the lesser|
The following terms and conditions apply to Future Life Events:
- You must be under the age of 55 at the time of the Future Life Event.
- Applications for increasing Cover must be made within 30 days of a specified Future Life Event, or within 30 days of the Policy Anniversary following the Future Life Event. Increases are at our discretion based on evidence acceptable to us.
- The amount of an increase cannot exceed the maximum Cover amounts and combined Cover limits specified for the relevant product. Find out limits for
- Future Life Events may be exercised only once in a 12 month period (designated by the last time the option was exercised).
- Cumulative increases from Future Life Events may not exceed $1,000,000 or the original Benefit Amount, whichever is the lesser.
Future Life Events cannot be exercised where:
- you have lodged or are eligible to lodge a claim under any policy with TAL or any other insurer; or
- a medical loading or medical Exclusion applies to you; or
- Premiums are being waived under the Premium Relief Option; or
- the Cover has resulted from applying for the Life Buy Back Option
In the first 6 months following the date of increase, the increased portion of the Benefit will only be paid in the event you suffer from a claimable event as a result of:
- an Accident or an Accident as a result of Adventure Sports, depending on the Life Insurance Cover you have selected. If your Cover is for Illness only, then you are unable to claim the increased portion for any Illness occurring in the first 6 months;
- an Accident or an Accidental Injury as a result of Sports, depending on the TPD Insurance Cover you have selected. If your Cover is for Illness only, then you are unable to claim the increased portion for any Illness occurring in the first 6 months; or
- a Critical Injury as the result of an Accident under Recovery Insurance. If your Cover is for Critical Illness or Cancer, then you are unable to claim the increased portion for any diagnosed Event occurring within the first 6 months.
At TAL we understand that not everything always goes as planned, that’s why we allow you to request to pause your Cover for up to three months in the event of financial hardship. During Cover Pause you will not have to pay premiums.
You need to be aware that no Cover will be provided under any TAL Lifetime Protection Insurance Cover while the Cover Pause is in effect – so if you request a Cover Pause, you will not be able to claim should your death or the Illness or Injury leading to your death occur or become apparent during the time your Cover is paused and you are not paying premiums.
At the end of the Cover Pause period, you can re-start Cover without needing to go through health and lifestyle assessment again.
Once your Cover is restarted by paying your premium, a qualifying period of three months will apply, so you’ll be eligible to claim three months after you re-start your Cover. You will not be eligible to claim should your death, or Illness or Injury leading to your death occur or become apparent during the qualifying period.
Cancer Advancement Benefit (for Cancer Cover only)
We will make an advance payment to you if you suffer one of the listed conditions:
|Advancement Benefit Event||Amount to be Paid|
||25% of the Benefit Amount up to $50,000|
You should refer to the Glossary of Recovery Insurance Conditions for a full list of definitions for these conditions. The same Exclusions apply as for Cancer Cover.
Any Cancer Cover Benefit paid under the Cancer Advancement will reduce the overall Recovery Insurance Benefit Amount by a corresponding amount. If the Cancer Advancement is paid and the Recovery Insurance is Bundled the payment will reduce the Benefit Amount(s) for the other Bundled Covers. If this occurs, the corresponding premium will also reduce.
Stepped vs. Level Premiums
TAL Lifetime Protection offers the choice of Stepped or Level Premiums for all Insurances.
Stepped Premiums means that the amount you pay in premiums increases each year as you get older.
Stepped Premiums are re-calculated based on your age at each Policy Anniversary. This generally means your premium rate will start lower than the Level Premium structure, but will increase each year corresponding with increasing risks.
Level Premiums means that the base cost of your Cover stays the same year on year, however as your Cover increases with Inflation Protection, the cost of that new Cover will be added to your premium.
Level Premiums can give you more certainty on cost when planning ahead for the future and if you’re planning to keep your Cover for many years. If keeping your costs stable is important to you, you also have the option of removing Inflation Protection.
When you select our Level Premium option, you should note that Level Premiums end at age 65 and will revert to the corresponding Stepped Premium for your age after age 65 until your Policy expiry.
The options you can add
Life Buy Back Option
Only available where you have Bundled Recovery Insurance with Life Insurance. This needs to be set up over the phone with one of our Insurance Specialists.
If you have chosen to Bundle your Recovery Insurance with your Life Insurance, if a claim is paid for Recovery Insurance, your Life Insurance amount will reduce by the same amount.
However, for an additional premium, you can have the option to Buy Back any Life Insurance that has been reduced after payment of a full claim on your Bundled Recovery Insurance – up to the equivalent of the claim amount paid. This increase in Cover is not subject to health and lifestyle assessment. The ability to purchase back this Cover is available for 30 days from the first anniversary (12 months) of you notifying us of a claim for which a full claim payment was subsequently made. If you have not notified us in writing during this 30 day period, the Buy Back Option will expire. If you are eligible to Buy Back Cover, we will remind you about this option 12 months after the Recovery Insurance claim is paid.
If payment of your Recovery Insurance claim occurs more than 12 months after the formal claim notification was made to us, the 30 day period will begin on the date of payment.
The Life Buy Back Option will expire at your Policy Anniversary prior to age 70.
The premium for the bought back Life Insurance will be calculated using our standard premium rates for your age at the time the option is exercised and will take into account any extra premiums charged (Loadings) and any Exclusions that apply to your Life Insurance.
You may not buy back any Life Insurance, or Cover which has already been bought back under the TPD Insurance Life Buy Back option.
Any Life Insurance Cover bought back under the Buy Back Option will not be eligible for increases under:
- Inflation Protection; or
- Future Life Events.
Premium Relief Option
This needs to be set up over the phone with one of our Insurance Specialists.
If you are between 18 and 61 when applying, you can add Premium Relief to your Life Insurance, TPD and/or Recovery Insurance for an additional premium. If you are covered under this option, we will waive your Life Insurance, TPD and/or Recovery Insurance (as applicable) premiums if you are unable to work for at least three consecutive months due to Illness or Accident.
This option expires on the Policy Anniversary prior to you turning 65.
To qualify for the Premium Relief Option you will need to be:
- Totally unable to work in any occupation that you could be considered suitable for by training, education or experience;
- Not earning an income; and
- Following the advice of a Medical Practitioner
The amount waived will be the daily proportion of premiums due.
While premiums are being waived, Future Life Events are unable to be activated and your premiums and Cover will not increase with Inflation Protection.
Premium waivers under this option will cease on the earlier of:
- Returning to work;
- Generating Monthly Income; or
- The Policy Anniversary prior to your 65th Birthday.
How claims work
How to make a claim
If you wish to make a claim under the Policy, you must contact us at the earliest possible opportunity. Once a claim has been lodged, we will begin the assessment process and identify any opportunities where further assistance can be provided.
Who receives the Benefits?
Your Recovery Insurance Benefit will be paid to you, as the Policy Owner.
The event for which you are claiming must occur at a time while your Cover is current. Benefit payments will commence once we are satisfied you have met the terms and conditions of your Policy.
To ensure we are able to assist you in an efficient manner, you must notify us in writing or by telephone, of any event that gives rise to a claim. This should be done as soon as reasonably possible otherwise claim payments may be reduced to the extent the ability to assess the claim has been prejudiced by the delay in being able to adequately assess the claim.
Claim requirements at your expense
You must provide us with any requirements we reasonably consider necessary to assess your claim. Upon notification, TAL will provide specific details of these claim requirements.
Our obligation to pay a Benefit under the Policy is subject to the following information being provided to us:
- notice of any claim or potential claim being provided to us as soon as reasonably possible;
- the initial Medical Practitioner’s report;
- a certified copy of your identification and proof of age;
- the Policy Schedule;
- all standard claim forms and other documentation or reports required by us to continue the initial and ongoing assessment, including but not limited to progress medical reports, records of your income and other personal financial documentation; and
- such other information relating to the claim that we may reasonably request.
Claim requirements at TAL’s expense
If we arrange for you to be medically examined in connection with your claim:
- the person who examines you will be an appropriate registered Medical Practitioner or other health practitioner chosen by us at our discretion;
- you must use your best endeavours to attend the examination; and
- we will pay the Medical Practitioner’s fees.
If we arrange for you to be medically examined and you fail to attend the examination and we incur a non-attendance fee, this fee must be paid by you.
We may also require you to:
- attend interviews with a member of our staff or someone appointed by us as often as is reasonably required to fully consider your claim; and
- attend and engage with occupational rehabilitation services by an appropriately qualified person selected by us.
If you are outside Australia and become Disabled, the entitlement to your claim may be suspended where we are unable to appraise the medical opinion or data relied upon by you. Consequently, you may have to return to Australia for the claim to be assessed, at no expense to us, before we are able to determine our liability for the claim.
We may cancel a Policy for a fraudulent claim
If you make a fraudulent claim under your Policy or another policy you have with us, we may cancel your Policy.
Both the eligibility and extent of any claim payments relating to your Illness, Injury or Disablement will be based solely on the medical factors contributing to the Illness, Injury or Disablement. Under the terms of this Policy, we will exclude any claims made on the basis of additional impact due to economic, seasonal or any other non-medical factors.
Payment of claim
If you are judged not to be legally competent, we will pay any Benefits to whomever we are legally permitted to make payments.
Claims contact details
GPO Box 5380 Sydney NSW 2001
Customer Service 1800 101 016
The cost of your Policy depends on a range of factors, including your age and gender, the type and amount of Cover, the number of Cover types you hold, the length of time you’ve held Cover with us and whether or not you smoke.
We also take your occupation, health, income and personal pastimes into account. Once we know a little bit about you and the Cover you require, we can then determine the basic costs involved.
When you take out a Policy you will receive welcome documentation and a Policy Schedule, you should read it carefully. The welcome documentation will show you the first premium payable and due date. The premium amount will also include any extra amounts charged to you when we accepted your application or re-issued you a Policy.
Australian citizens, permanent Australian residents, or New Zealand citizens residing permanently in Australia aged 18 to 59 are eligible to apply. .
Minimum and Maximum Cover
|Minimum Cover Amount||Maximum Cover Amount|
|Bundled with Life Insurance||$10,000||Must not exceed Life Insurance Cover amount|
If you have some Recovery Insurance as Standalone, and some Bundled with your Life Insurance, the total of these covers must not exceed $500,000.
Cover Start and End Dates
Once your application is accepted by us, your Cover continues until the Policy Anniversary prior to you turning 70 or 100 when you Bundle with Life Insurance as long as you have complied with the Duty of Disclosure and paid the premiums when due.
Your Cover will end when the full Benefit Amount is paid, Cover is removed from your Policy, Cover is cancelled through non-payment of premiums or when Cover expires at age 69. There may be other reasons Cover may end .
What you’re not covered for
Specific Exclusions will apply to your Recovery Insurance depending on the Cover that you have selected. Refer to your Policy Schedule for details of any additional Special Conditions that apply to your Policy.
Some Exclusions apply to your Recovery Insurance regardless of the Cover options you have selected, these are:
- where Cover is Standalone, no payment will be made under Recovery Insurance unless you survive a Covered Event for at least 14 days;
- no payment will be made under Recovery Insurance if the event giving rise to the claim is caused directly or indirectly by suicide within the first 13 months of the Cover Commencement Date and any increases in Cover, but only in respect of the increase; and
- in the case of Angioplasty, Coronary Artery Bypass Surgery, Cancer, Heart Attack, Heart Valve Surgery, Minor Heart Attack, Open Heart Surgery, Out of Hospital Cardiac Arrest, Triple Vessel Angioplasty, Stroke, Carcinoma In Situ, Diagnosed Benign Brain Tumour, Early Stage Chronic Lymphocytic Leukaemia, Early Stage Melanoma or Early Stage Prostate Cancer, no payment will be made under Recovery Insurance if the condition occurred or was diagnosed, or the signs or symptoms leading to diagnosis became apparent or would have become apparent to a reasonable person in your position:
- within three months after the Cover Commencement Date; or
- within three months after the date of an increase but only in respect of the increase
We will waive this three-month period if, immediately prior to the commencement of cover, we or another insurer Covered you for the same specified events and you have transferred your Cover to Recovery Insurance (and the transfer was not within our or the other insurer’s three-month period). The waiver will only apply up to the level of similar Cover that you had with us or the other insurer. Should you reinstate your Cover, the three-month period will recommence from the date of reinstatement.
If you have selected Cancer Cover only, no claim will be payable in the event of:
- your diagnosis with an Illness that results in a Critical Illness event; or
- a Critical Injury as the result of an Accident.
If you have selected Critical Illness Cover only, no claim will be payable in the event of:
- your being diagnosed with Cancer; or
- a Critical Injury as the result of an Accident.
If you have selected Critical Injury Cover only, no claim will be payable in the event of your diagnosis with:
- any Critical Injury which occurred while undertaking sports, pastimes or activities which carry an inherently higher risk of death or Injury to the participant, including but not limited to recreational aviation, hang-gliding, scuba diving, rock fishing, rock climbing, surfing, skydiving, jet skiing, and motor racing; or
- a Critical Illness.
If you have selected Cancer Cover and Critical Injury Cover only, no claim will be payable in the event of your diagnosis with:
- a Critical Illness; or
- any Critical Injury which occurred while undertaking sports, pastimes or activities which carry an inherently higher risk of death or Injury to the participant, including but not limited to recreational aviation, hang-gliding, scuba diving, rock fishing, rock climbing, surfing, skydiving, jet skiing, and motor racing.
If you have selected Cancer Cover and Critical Illness Cover only, no claim will be payable in the event of a Critical Injury as the result of an Accident.
If you have selected Critical Injury and Critical Illness Cover only, no claim will be payable in the event of your diagnosis with Cancer.
Loadings and Exclusions
When you apply for TAL Lifetime Protection, you will be asked a number of questions. These questions relate to your Duty of Disclosure.
Your answers to the questions may mean that you have increased risk factors under the Policy. In some cases we will be unable to provide you with all or some parts of the Cover for which you have applied. In other cases, Cover may be subject to conditions such as a premium loading, or an Exclusion. A premium loading will mean that you pay a higher premium for the Cover, an Exclusion will mean that you will not be Covered if you suffer a specified excluded medical condition, or you are injured or die as a result of participating in an excluded pastime or activity.
We can change the premium rates applying to all TAL Lifetime Protection Policies. If we do change them you will be advised of the change 30 days prior to it taking effect.
No one individual Policy can be singled out for an increase in premium rates because of an adverse change in your health or circumstances, once your Cover is in place.
Structuring the right Policy for you
With TAL Lifetime Protection you can have as much or as little flexibility as you want. If you’re tailoring your own Cover, there are a number of choices you’ll need to make.
Standalone and Bundled Cover
You can keep your Insurances independent - purchase just one, two, three or all four Insurances independently and receive the full Benefit Amount on acceptance of your claim. (This is subject to any adjustments and meeting eligibility criteria).
You will pay more for Standalone, but the advantage is if you make a claim your Life Insurance Cover Benefit Amount will not be drawn down unlike Bundled Covers.
This can only be set up over the phone.
To keep the cost down, you can Bundle TPD and Recovery Insurance with your Life Insurance.
If you make a claim on a Bundled Cover, your Life Insurance Cover Benefit Amount and the Benefit Amount of any other Cover in the Bundle will be drawn down by the amount of the claim payment. Structuring your Policy in this way means that generally the cost of Cover will be reduced. Once you have claimed and your Benefit Amount is reduced, your premiums will also reduce accordingly.
Your Bundled Insurance needs to have a lower Benefit Amount than your Life Insurance and any Inflation Protection must be consistently applied across all Covers. For example if you wish to turn Inflation Protection off for your Life Insurance, it must also be turned off for the Bundled Covers.
If your Life Insurance has been reduced due to a TPD or Recovery Insurance claim, you can buy back the Life Cover to its original level if you have selected the Life Buy Back Option.
How Bundled Cover works at Claim
If you Bundle TPD or Recovery Insurance with Life Insurance Cover, the payout of one Cover will reduce the Benefit Amount of the Covers within the Bundle by a corresponding amount.
You take out $1,000,000 of Life Insurance and Bundle this with $500,000 TPD and $250,000 Recovery Insurance.
Two years later, you are diagnosed with a Brain Tumour and make a claim on Recovery Insurance under Cancer Cover.
Policy before claim on Recovery Insurance Cancer Cover
When your claim is approved and $250,000 has been paid to you, you are no longer Covered by Recovery Insurance and the Benefit Amount for the other Covers within the same Bundle reduces in line with the Benefit Amount paid. In this case:
- your Life Insurance Cover amount reduces to $750,000, and
- your TPD Cover amount reduces to $250,000
Policy after payout of claim on Recovery Insurance Cancer Cover
Your premium will also reduce in line with the reduced Benefit Amounts.
If you hold a Life Buy Back Option , you have the opportunity to buy back the $250,000 sum insured of Life Insurance Cover after 12 months from date of claim.
Glossary of Recovery Insurance Conditions
Alzheimer’s Disease means the unequivocal diagnosis of Alzheimer’s Disease by a consultant neurologist or geriatrician. The diagnosis must confirm dementia due to failure of brain function with cognitive impairment for which no other recognisable cause has been identified. A Mini-Mental State Examination score of 24 or less is required.
Angioplasty means the actual undergoing of Coronary Artery Angioplasty to correct a narrowing or blockage of one or more coronary arteries.
Aortic Surgery means surgery to repair or correct an aortic aneurysm, an obstruction of the aorta, a coarctation of the aorta or traumatic Injury to the aorta. For the purpose of this definition, aorta means the thoracic and abdominal aorta but not its branches.
Aplastic Anaemia means bone marrow failure, which results in anaemia, neutropenia and thrombocytopenia requiring treatment, with at least one of the following:
- blood product transfusions;
- marrow stimulating agents;
- immunosuppressive agents; or
- bone marrow transplantation.
Benign Brain Tumour
Benign Brain Tumour means a non-cancerous tumour in the brain, resulting in an irreversible neurological deficit which has caused:
- a permanent impairment of at least 25% of the Whole Person Function; or
- you to be totally and permanently unable to perform any one of the Activities of Daily Living.
The presence of the underlying tumour must be confirmed by CT Scan, MRI or other imaging studies.
Blindness means the permanent Loss of Sight of both eyes.
Cancer means the presence of one or more malignant tumours. The malignant tumour is to be characterised by the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue.
The following tumours are excluded:
- tumours showing the malignant changes of carcinoma in situ (including cervical dysplasia CIN-1, CIN-2 and CIN-3#) or which are histologically described as premalignant*;
- all skin cancers, unless
- there is evidence of metastases; or
- the tumour is a melanoma of at least Clark level 3; or
- the tumour is a melanoma showing signs of ulceration; or
- the tumour is a melanoma of greater than 1.0mm maximum thickness as determined by examination using the Breslow method.
- prostatic cancers which:
- are histologically described as TNM Classification T1a or T1b; and
- are characterised by Gleason Score of 5 or less; unless major intervention therapy including radiotherapy, chemotherapy, biological response modifiers or any other major treatment has been required to arrest the spread of malignancy.
- Lymphocytic Leukaemia less than Rai Stage 1.
# CIN-1, CIN-2, and CIN-3 may also be referred to or known as mild dysplasia, moderate dysplasia, and severe dysplasia; or low grade squamous intraepithelial lesion (CIN-1) and high grade squamous intraepithelial lesion (CIN-2 and CIN-3).
* Carcinoma in situ of the breast is covered if a procedure is required for:
- the removal of the entire breast; or
- breast conserving surgery together with radiotherapy or chemotherapy. Carcinoma in situ of the testicle is covered if a procedure is required for the removal of the entire testicle.
The procedure must be performed specifically to arrest the spread of malignancy, and be considered the appropriate and necessary treatment.
Carcinoma in Situ
Carcinoma In Situ means you have a carcinoma in situ, characterised by a focal autonomous new growth of carcinomatous cells, which has not yet resulted in the invasion of normal tissues.
‘Invasion’ means an infiltration and/or active destruction of normal tissue beyond the basement membrane. The tumour must be classified as Tis according to the TNM staging method or FIGO Stage 0.
Only Carcinoma In Situ of the following sites is covered:
- Cervix Uteri (Excluded are Cervical Intraepithelial Neoplasia (CIN) classifications including CIN-1 and CIN-2).
- Corpus Uteri
- Fallopian Tube (the tumour must be limited to the tubal mucosa)
Note: FIGO refers to the staging method of the Fédération Internationale de Gynécologie et d’Obstétrique.
Cardiomyopathy means impaired ventricular function of variable aetiology resulting in permanent and irreversible physical impairment to the degree of at least Class 3 of the New York Heart Association classification of cardiac impairment.
Chronic Kidney Failure
Chronic Kidney Failure means end-stage renal failure presenting as chronic irreversible failure of both kidneys to function, resulting in renal transplantation or the permanent requirement for renal dialysis.
Chronic Liver Failure
Chronic Liver Failure means end-stage liver failure resulting in permanent jaundice, ascites and/or encephalopathy.
Chronic Lung Failure
Chronic Lung Failure means end-stage lung disease with a consistent pulmonary function test result of FEV1 less than 40% predicted and requiring permanent oxygen therapy.
Coma means a state of unconsciousness with no reaction to external stimuli or internal needs, resulting in a documented Glasgow Coma Scale of 6 or less, for a continuous period of at least 72 hours.
Coronary Artery Bypass Surgery
Coronary Artery Bypass Surgery means bypass grafting performed to correct or treat coronary artery disease.
Dementia means the unequivocal diagnosis of Alzheimer’s Disease or other dementia by a consultant neurologist or geriatrician. The diagnosis must confirm permanent irreversible failure of brain function with cognitive impairment for which no other recognizable cause has been identified. A Mini-Mental State Examination score of 24 or less is required.
Diagnosed Benign Brain Tumour
Diagnosed Benign Brain Tumour means a non-cancerous tumour in the brain, giving rise to symptoms of increased intracranial pressure such as papilloedoma, mental symptoms, seizures, sensory impairment and motor impairment.
The presence of the underlying tumour must be confirmed by CT Scan, MRI or other imaging studies.
Early Stage Chronic Lymphocytic Leukaemia
Early Stage Chronic Lymphocytic Leukaemia means the presence of chronic lymphocytic leukaemia diagnosed as Rai Stage 0, which is defined to be in the blood and bone marrow only.
Early Stage Melanoma
Early Stage Melanoma means the presence of one or more malignant melanomas of 1.0mm or less maximum thickness as determined by histological examination using the Breslow method, or less than Clark Level 3 depth of invasion as determined by histological examination. The malignancy must be characterised by the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue.
Early Stage Prostate Cancer
Early Stage Prostate Cancer means the presence of a tumour confined within the prostate, which is histologically described as TNM Classification T1 or a Gleason Score of either 2, 3, 4 or 5 where major medical intervention therapy is not required.
Encephalitis and Meningitis
Encephalitis and Meningitis means the unequivocal diagnosis of encephalitis or meningitis where the condition is characterised by severe inflammation of the brain or the meninges of the brain resulting in permanent neurological deficit causing:
- at least a permanent 25% Impairment of Whole Person Function; or
- you to be totally and permanently unable to perform any one of the Activities of Daily Living.
Heart Attack - myocardial infarction
Heart Attack (myocardial infarction) means the death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The basis of diagnosis will be:
- a confirmatory new electrocardiogram (ECG) changes; and
- a diagnostic rise and fall (other than as a result of cardiac or coronary intervention) in either Troponin I in excess of 2.0g/L or Troponin T in excess of 0.6g /L or cardiac enzyme CK-MB.
If the above criteria are not met, we will pay a claim based on satisfactory evidence that you have unequivocally been diagnosed as having suffered a myocardial infarction resulting in:
- a permanent reduction in the Left Ventricular Ejection Fraction to less than 50%, measured three months or more after the event; or
- new pathological Q waves.
At our discretion, we will also consider any other medical test result provided by a cardiologist that unequivocally diagnoses myocardial infarction of the degree of severity or greater as documented above.
Heart Valve Surgery
Heart Valve Surgery means surgery to replace or repair a cardiac valve as a consequence of a cardiac valve abnormality or a cardiac aneurysm or other cardiac defects.
Intensive Care means an Illness or Injury has resulted in you requiring continuous mechanical ventilation by means of tracheal intubation for ten consecutive days (24 hours per day) in an authorised intensive care unit of an acute care hospital.
No amount will be paid where your Intensive Care results from the consumption of alcohol or the use of non- prescribed drugs.
Limb means an arm, leg, hand or foot. In respect of this definition, the hand or foot starts from the wrist or ankle joint, respectively.
Loss of a Single Limb
Loss of a Single Limb means the total and irrecoverable loss of use of one Limb.
Loss of Hearing
Loss of Hearing means the total and irrecoverable loss of hearing, both natural and assisted, in both ears as a result of Illness or Injury.
Loss of Hearing in one ear
Loss of Hearing in one ear means the total and irrecoverable loss of hearing in one ear, both natural and assisted, as a result of Illness or Injury.
Loss of Independent Existence
Loss of Independent Existence means Significant Cognitive Impairment, or the total and irrecoverable loss of ability, due to Illness or Injury, to perform at least two of the Activities of Daily Living without the physical assistance of another person.
Loss of Limbs
Loss of Limbs means the total and irrecoverable loss of use of two or more Limbs.
Loss of Limbs and Sight
Loss of Limbs and Sight means the total and irrecoverable loss of use of one Limb and the permanent Loss of Sight in one eye.
Loss of Sight
Loss of Sight means the total and irrecoverable loss of sight (whether aided or unaided) in an eye, as a result of Illness or Injury to the extent that visual acuity in the eye, on a Snellen Scale after correction by a suitable lens is less than 6/60, or to the extent that the visual field is reduced to 10 degrees or less of arc.
Loss of Speech
Loss of Speech means the total and irrecoverable loss of the ability to produce intelligible speech, as a result of permanent damage to the larynx or its nerve supply or to the speech centres of the brain, due to Illness or Injury.
Major Head Trauma
Major Head Trauma means Accidental head Injury resulting in neurological deficit causing:
- at least a permanent 25% impairment of Whole Person Function; or
- you being totally and permanently unable to perform any one of the Activities of Daily Living.
Major Organ Transplant
Major Organ Transplant means either the undergoing of, or upon the advice of a specialist Medical Practitioner the placement on a waiting list of a Transplantation Society of Australia and New Zealand recognised transplant unit for, the human to human transplant from a donor to you of;
- bone marrow;
or one of the following organs or a permanent mechanical replacement of one of the following organs:
- pancreas; or
- small bowel.
The transplant of all other organs, parts of organs or any other tissue transplant is excluded.
Meningococcal Disease means the unequivocal diagnosis of meningococcal septicaemia resulting:
- in at least a permanent 25% impairment of Whole Person Function; or
- you being totally and permanently unable to perform any one of the Activities of Daily Living.
Minor Heart Attack
Minor Heart Attack means the death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The basis of the diagnosis will be:
- a confirmatory new electrocardiogram (ECG) changes; or
- a diagnostic rise and/or fall of cardiac biomarkers with at least one reading above the 99th percentile of the upper reference limit.
At our discretion, we will also consider any other medical test result provided by a cardiologist that unequivocally diagnoses myocardial infarction of the degree of severity documented above.
If the clinical diagnosis and disease management on hospital discharge for any medical event or investigation is not consistent with an acute myocardial infarction as confirmed by a consultant cardiologist, then a claim is not payable under this Policy.
Myocardial infarctions arising from percutaneous procedures are excluded.
Motor Neurone Disease
Motor Neurone Disease means the unequivocal diagnosis of a progressive form of debilitating Motor Neurone Disease.
Multiple Sclerosis means a disease characterised by demyelination in the brain and/or spinal cord. Multiple Sclerosis must be unequivocally diagnosed. There must be more than one episode of well-defined neurological deficit with persisting neurological abnormalities.
Neurological investigations such as lumbar puncture, MRI (Magnetic Resonance Imaging) evidence of lesions in the central nervous system, evoked visual responses, and evoked auditory responses are required to confirm diagnosis.
Muscular Dystrophy means the unequivocal diagnosis of muscular dystrophy.
Open Heart Surgery
Open Heart Surgery means the undergoing of open chest surgery for the surgical treatment of a cardiac defect, cardiac aneurysm or benign cardiac tumour.
Paralysis means the total and permanent loss of function of two or more limbs through Illness or Injury causing permanent damage to the nervous system. This includes, but is not limited to, quadriplegia, paraplegia, diplegia and hemiplegia.
Parkinson’s disease means the unequivocal diagnosis of degenerative idiopathic Parkinson’s disease as characterised by the clinical manifestation of one or more of the following:
- tremor; and
resulting in the degeneration of the nigrostriatal system.
All other types of Parkinsonism are excluded (e.g. secondary to medication).
Pneumonectomy means the undergoing of surgery to remove an entire lung. This treatment must be deemed the most appropriate treatment and medically necessary.
Primary Pulmonary Hypertension
Primary Pulmonary Hypertension means the unequivocal diagnosis of Primary Pulmonary Hypertension with right ventricular enlargement established by investigations including cardiac catheterisation.
Severe Burns means tissue Injury caused by thermal, electrical or chemical agents causing third degree or full thickness burns to at least:
- 20% of the body surface area as measured by the Lund and Browder Body Surface Chart;
- 50% of both hands, requiring surgical debridement and/or grafting; or
- 50% of the face, requiring surgical debridement and/or grafting.
Severe Diabetes means that a certified consultant endocrinologist has confirmed that at least two of the following complications have occurred as a direct result of diabetes:
- severe diabetic retinopathy resulting in visual acuity (whether aided or unaided) and corrected of 6/36 or worse in both eyes;
- severe diabetic neuropathy causing motor and/or autonomic impairment;
- diabetic gangrene leading to surgical intervention; or
- severe diabetic nephropathy causing chronic irreversible renal impairment as measured by a corrected creatinine clearance less than 28ml/min (CKD stage 4, International Chronic Kidney Disease classification).
Stroke means a cerebrovascular event producing neurological deficit. This requires clear evidence on a CT, MRI or similar, appropriate scan or investigation that a stroke has occurred and of infarction of brain tissue, intracranial and/or subarachnoid haemorrhage. Transient ischaemic attacks, reversible neurological deficit, cerebral symptoms due to migraine, cerebral Injury resulting from trauma or hypoxia and vascular disease affecting the eye, optic nerve or vestibular functions are excluded.
Triple Vessel Angioplasty
Triple Vessel Angioplasty means the actual undergoing for the first time of coronary artery Angioplasty to correct a narrowing or blockage of three or more coronary arteries within the same procedure.
In the event that not all coronary arteries can be corrected in a single procedure and a second procedure is required, a benefit will be payable provided the second procedure occurs no more than one month after the first.