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What's Covered

SPDs  /  Critical Illness Insurance  /  UNUM Voluntary Critical Illness Benefit  /  What's Covered

What's Covered

Certain critical illnesses apply to eligible children only as noted.

  

Benign Brain Tumor

A non-cancerous brain tumor confirmed by the examination of tissue (biopsy or surgical excision) or specific neuroradiological examination. The tumor must result in persistent neurological deficits including but not limited to:

  • Loss of vision
  • Loss of hearing
  • Balance disruption

The date of diagnosis for a benign brain tumor is determined by examination of tissue (biopsy or surgical excision) or specific neuroradiological examination.

Exclusions: For the purposes of this policy, the following are not considered benign brain tumors:

  • Tumors of the skull
  • Pituitary adenomas
  • Germanomas

Unum will not pay for benign brain tumors for individuals diagnosed with any of the following conditions prior to your coverage effective date:

  • Neurofibromatosis I
  • Neurofibromatosis II
  • Von Hippel Lindau
  • Tuberous Sclerosis
  • Li Fraumani Syndrome
  • Cowden Disease
  • Turcot Syndrome

  

Blindness

Clinically proven irreversible reduction of sight in both eyes certified by an ophthalmologist with:

  • Sight in the better eye reduced to a best corrected visual acuity of less than 6/60 (Metric Acuity) or 20/200 (Snellen or E-Chart Acuity)
  • Visual field restriction to 20° or less in both eyes

The date of diagnosis for blindness is the date the ophthalmologist makes an accurate certification of blindness.

  

Cancer

Malignant cells or a malignant tumor characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells.

The date of diagnosis for cancer or carcinoma in situ is the date the tissue specimen, blood samples and/or titer(s) are taken on which the diagnosis is based.

For purposes of this policy, the following are not considered as cancer:

  • Pre-malignant conditions or conditions with malignant potential
  • Carcinoma in situ
  • Basal cell carcinoma and squamous cell carcinoma of the skin, unless metastatic disease develops
  • Melanoma that is diagnosed as Clark's Level I or II or Breslow less than .75 mm or melanoma in situ

  

Carcinoma in Situ

A malignant tumor that has not yet become invasive but is confined only to the superficial layer of cells from which it arose (i.e. malignant cells confined to the epithelium without penetration of the basement membrane).

The date of diagnosis for cancer or carcinoma in situ is the date the tissue specimen, blood samples and/or titer(s) are taken on which the diagnosis is based.

For the purposes of this policy, the following are not considered as carcinoma in situ:

  • Pre-malignant conditions or conditions with malignant potential
  • Basal cell carcinoma and squamous cell carcinoma of the skin
  • Melanoma or melanoma in situ

Note: The pathological diagnosis of cancer or carcinoma in situ is based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. A clinical diagnosis of cancer or carcinoma in situ is based on the study of symptoms. Unum pays benefits for a clinical diagnosis only if there is medical evidence to support a positive diagnosis of cancer or carcinoma in situ. Either diagnosis must be done by a qualified physician whose positive diagnosis of malignancy is in keeping with the professional medical standards of care for cancer or carcinoma in situ.

  

Cerebral Palsy (Children Only)

A group of disorders of the development of movement and posture causing activity limitation, that are attributed to progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behavior and/or by a seizure disorder.

The date of diagnosis of cerebral palsy is the date a licensed pediatrician or neurologist diagnoses cerebral palsy after live birth.

  

Cleft Lip or Palate (Children Only)

A cleft lip appears as a narrow opening or gap in the skin of the upper lip that extends all the way to the base of the nose. A cleft palate is an opening between the roof of the mouth and the nasal cavity. This policy covers clefts occurring on one side of the mouth (unilateral clefting) or on both sides of the mouth (bilateral clefting).

The date of diagnosis of cleft lip or palate (unilateral or bilateral clefting) is the date given by a physician after a live birth.

  

Coma as the Result of Severe Traumatic Brain Injury

A coma resulting from a severe traumatic brain Injury that results in a continuous state of profound unconsciousness lasting for a period of 14 or more consecutive days, characterized by the absence of:

  • Eye opening
  • Verbal response
  • Motor response

The condition must require intubation for respiratory assistance.

The date of diagnosis is the date a physician confirms the coma as lasting 14 or more consecutive days.

  

Coronary Artery Bypass Surgery

Heart disease or angina that has been clinically diagnosed and requires the insured to undergo coronary artery bypass surgery, which is a surgical procedure to bypass a narrowing or blockage of one or more coronary arteries utilizing venous or arterial grafts.

The date of diagnosis is the date the coronary artery bypass surgery occurs.

For purposes of this policy, the following are not considered as coronary artery bypass surgery:

  • Percutaneous coronary intervention (balloon angioplasty),
  • Stent implantation, or
  • Related procedures to increase the flow of blood through the coronary arteries).

  

Cystic Fibrosis (Children Only)

A diagnosis of cystic fibrosis by a licensed pediatrician or pulmonologist where the dependent child has chronic lung disease and pancreatic insufficiency. The diagnosis of cystic fibrosis made via a sweat test should be based upon sweat chloride concentrations greater than 60 mmol/L.

The date of diagnosis is the date a physician performs this sweat test.

  

Down Syndrome (Children Only)

Down Syndrome is diagnosed through study of the 21st chromosome.  Down Syndrome includes:

  • Trisomy 21—An individual has three instead of two number 21 chromosomes.
  • Translocation—An extra part of the 21st chromosome is attached to another chromosome.
  • Mosaicism—The individual has an extra 21st chromosome in only some of the cells but not all of them. The other cells have the usual pair of 21st chromosomes.

Diagnosis must be confirmed by a licensed pediatrician or another physician familiar with Down Syndrome diagnosis.

  

End Stage Renal (Kidney) Failure  

Chronic irreversible failure of the function of both kidneys such that regular hemodialysis or peritoneal dialysis is required to sustain life.

The date of diagnosis is the date the physician recommends the insured begin renal dialysis.

  

Heart Attack (Myocardial Infarction)

An identifiable clinical event consistent with a heart attack that results in some permanent functional loss of heart contraction detectable by a regional contraction abnormality study on an imaging study and which is defined as having two of the following:

  • Typical chest pain
  • Electrocardiographic (EKG) changes indicative of Myocardial Infarction; in the case of Myocardial Infarction associated with percutaneous coronary intervention (balloon angioplasty, stent implantation, and related procedures to increase the flow of blood through the coronary arteries), evolving ST elevations or new Q wave changes must be documented and included as one of the criteria on establishing a diagnosis
  • Elevation of biochemical markers of myocardial necrosis

The date of diagnosis is the date that the ischemic death of a portion of the heart muscle occurred, based on the criteria listed above.

In the event of death, an autopsy confirmation and/or death certificate identifying myocardial infarction as the cause of death will be accepted.

  

Major Organ Failure

Major organ failure of the liver, both lungs, pancreas, or heart resulting in being placed on the UNOS (United Network for Organ Sharing) list for a transplant. If an insured is on the UNOS list for a combined transplant (example: heart and lung); a single benefit will be paid.

The date of diagnosis is the date that the insured is placed on the UNOS list for transplantation.

Only one Major Organ Failure benefit will be paid per insured.

  

Occupational HIV

Occupational HIV is if an insured contracts HIV as a result of performing the duties of his or her job. The date of diagnosis for Occupational HIV must be after the insured's coverage effective date.

  

Permanent Paralysis as the Result of a Covered Accident

The complete and permanent loss of the use of two or more limbs through paralysis for a continuous period of 90 days as confirmed by a physician.

The date of diagnosis is the date a covered accident occurred which caused the permanent paralysis.

In the case of a transected spinal cord with supporting clinical and radiological evidence and no expectation of return of function, the continuous 90 days requirement specified above is waived.

  

Spina Bifida (Children Only)

A confirmed diagnosis of either of the following types of Spina Bifida:

  • Meningocele—The meninges (protective covering of the spinal cord) come through the open part of the spine like a sac that is pushed out. Cerebrospinal fluid is in the sac and there is usually no nerve damage. Individuals may suffer minor disabilities. New problems can develop later in life.
  • Myelomeningocele—The meninges (protective covering of the spinal cord) and spinal nerves come through the open part of the spine. This is the most serious type of Spina Bifida, which causes nerve damage and more severe disabilities.

Diagnosis must be made by a licensed physician familiar with Spina Bifida. The date of diagnosis of Meningocele or Myelomeningocele Spina Bifida is determined by a physician familiar with the diagnosis and/or treatment of Spina Bifida after live birth.

Exclusions: This policy excludes Spina Bifida Occulta.

  

Stroke 

A cerebrovascular incident including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism, and cerebral thrombosis. The diagnosis must be supported by:

  • Evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event
  • Confirmatory neuroimaging studies consistent with the diagnosis of a new stroke

The date of diagnosis is the date a stroke occurred based on neuroimaging consistent with an acute or subacute abnormality or other neurodiagnostic study and presence of neurological deficits persisting for a period of 30 days or greater.

For purposes of this policy, the following are not considered as stroke:

  • Transient ischemic attack
  • Brain injury related to trauma or infection
  • Brain injury associated with hypoxia, anoxia, or hypotension
  • Vascular disease affecting the eye or optic nerve
  • Ischemic disorders of the vestibular system

In the event of death, an autopsy confirmation and/or death certificate identifying stroke as the cause of death will be accepted.