What's Covered
Critical illness benefits
Health screenings
Certain critical illnesses apply to eligible children only as noted.
Abdominal Aortic Aneurysm
The diagnosis of an enlargement of the abdominal aorta of 5 cm or more, or of 4 cm or greater and rapidly expanding, for which a surgical repair has been advised.
Addison's Disease
The diagnosis of a long-term endocrine disorder that occurs when your body produces insufficient amounts of steroid hormones produced by your adrenal glands, confirmed via blood tests, urine tests, or medical imaging.
Advanced Dementia
A clinically established diagnosis of Alzheimer’s Disease, or other type of permanent and progressive advanced dementia, with severe cognitive decline and with findings consistent with a Global Deterioration Scale (GDS) or Functional Assessment Staging (FAST) Stage 3 or more, or a Clinical Dementia Rating Scale (CDR) of 1.
Amyotrophic Lateral Sclerosis (ALS)
The diagnosis of a motor neuron disease, marked by progressive muscular weakness and atrophy with spasticity and hyperreflexia due to a loss of motor neurons of the spinal cord, medulla and cortex.
Benign Brain Tumor
The diagnosis of a non-cancerous brain tumor confirmed by the examination of tissue (biopsy or surgical excision) or specific neurological examination. The tumor must result in persistent neurological deficits including but not limited to:
- Loss of vision
- Loss of hearing
- Balance disruption
Exclusions: For the purposes of this policy, the following are not considered benign brain tumors:
- Tumors of the skull
- Pituitary adenomas
- Germinomas
Voya 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
Bone Marrow Transplant
The clinical diagnosis of the need for a surgical transplant when you have been added to the Be The Match registry for a bone marrow transplant.
Bone marrow transplant includes a clinical diagnosis and actual transplant that occurs before you are able to be added to the Be The Match registry.
Cancer (Invasive)
The diagnosis of a group of diseases characterized by the uncontrolled growth and/or spread of abnormal cells. Cancer is limited to malignancies of solid tissue, blood or lymph tissue and includes leukemia, lymphoma and Hodgkin’s disease. The diagnosis must be established according to the criteria of the American Board of Pathology or the American Joint Committee on Cancer. This includes a clinical diagnosis whenever such diagnosis is consistent with professional medical standards.
For purposes of this policy, the following are not considered as cancer (invasive):
- Cancer (invasive)
- Skin cancer
- Pre-malignant conditions or polyps
- Any other histologically benign or nonmalignant condition
Cancer (Non-Invasive)
The diagnosis of tumor cells tending toward malignancy but that do not invade the underlying tissue or have the ability to spread beyond the site from which they originate (e.g. malignant cells confined to the epithelium without penetration of the basement membrane). The diagnosis of Cancer (Non-Invasive) must be established according to the criteria of the American Board of Pathology or the American Joint Committee on Cancer. This includes a clinical diagnosis whenever such diagnosis is consistent with professional medical standards. This cancer is also known as carcinoma in situ.
For the purposes of this policy, the following are not considered as cancer (non-invasive):
- Cancer (invasive)
- Skin cancer
- Pre-malignant conditions or polyps
- Any other histologically benign or nonmalignant condition
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.
Coma
A diagnosis of a continuous state of profound unconsciousness, characterized by having a Glasgow scale of 3; defined as the absence of:
- Eye opening
- Verbal response
- Motor response
The condition must require intubation for respiratory assistance and must not be medically induced.
“Continuous state of profound unconsciousness” means 14 consecutive days or longer.
Congenital Birth Defects (Children Only)
The malformation of an organ or organ system that results in the recommendation of surgery.
Examples include but are not limited to the following:
- Heart defects
- Lung defects
- Spina Bifida
- Cleft lip or palate
- Limb malformations
Congenital birth defects includes developmental disorders of the brain or being born blind without the recommendation of surgery.
Congenital birth defects does not include prematurity.
Coronary Angioplasty
A diagnosis of significant coronary artery disease which is causing symptoms and for which a cardiologist advises a procedure, done through the blood vessels, to open a blocked coronary artery and/or remove a blood clot. This includes coronary balloon angioplasty, angiojet clot removal, and rotational and orbital atherectomy procedures.
Coronary Artery Bypass
A diagnosis of severe left main or multi-vessel coronary artery disease (such as a SYNTAX score >23) for which is advised an open heart coronary artery bypass surgery—a surgical procedure that requires an incision through the chest and an incision in the heart and/or attached blood vessels.
Cystic Fibrosis (Children Only)
A definite diagnosis of cystic fibrosis by a licensed family practitioner, pediatrician or pulmonologist where the Child has chronic lung disease and pancreatic insufficiency. The diagnosis made via a sweat test should be based upon sweat chloride concentrations greater than 60 mmol/L on two independent tests.
Down Syndrome (Children Only)
A diagnosis of down syndrome through a study of the 21st chromosome. Down Syndrome includes:
- Trisomy 21—an individual has three instead of two #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.
Gaucher Disease, Type II or III (Children Only)
A definitive diagnosis of Gaucher Disease, Type II or III through a blood test reviewing beta-glucosidase leukocyte (BGL).
Heart Attack
The diagnosis of a clinical picture of myocardial infarction that was caused by a blockage of one or more coronary arteries. The medical evidence must be consistent with the diagnosis of heart muscle death. Significant electrocardiogram (EKG) changes must be seen, and one or both of the following must confirm the acute myocardial infarction (heart attack):
Cardiac enzyme changes as typically seen with myocardial damage found in the blood (elevated CK-MB isoenzyme fraction or elevated troponins).
Confirmatory imaging test, such as a nuclear imaging test or echocardiogram that is consistent with a myocardial infarction.
A sudden cardiac arrest is not in itself considered a heart attack.
Huntington's Disease (Huntington's Chorea)
The diagnosis of an inherited disease that causes the progressive degeneration of nerve cells in the brain. The Huntington’s Disease (Huntington’s Chorea) diagnosis must be based on symptoms and laboratory testing.
Implantable (or Internal) Cardioverter Defibrillator (ICD) Placement
The diagnosis of ventricular tachycardia or fibrillation, or deemed at high risk for cardiac arrest, for which the initial placement of an implantable cardioverter-defibrillator (ICD) has been advised.
Infantile Tay Sachs (Children Only)
A definitive diagnosis of Infantile Tay Sachs through a blood test reviewing Hexosaminidase A levels.
Infectious Disease Requiring Hospitalization
The diagnosis of an infectious disease that results in you being confined to a hospital for five (5) or more consecutive days or confined to a transitional care facility for five (5) or more consecutive days. In the event you die while confined as the result of being diagnosed with an infectious disease, we will consider this time period to have been met regardless of the actual number of days confined.
Infectious diseases include, but are not limited to:
- Polio;
- Rabies;
- Meningitis;
- Lyme’s Disease;
- Bovine spongiform encephalopathy (Mad Cow Disease);
- Flesh eating bacteria;
- Methicillin-resistant Staphylococcus aureus (MRSA);
- Sepsis;
- Tuberculosis;
- Bacterial pneumonia;
- Diphtheria;
- Encephalitis.
- Legionnaire’s Disease;
- Malaria;
- Necrotizing Fasciitis;
- Osteomyelitis;
- Tetanus;
- Ebola Virus Disease; and
- COVID-19.
“Confined/confinement” means that on the advice of a doctor, your assignment to a bed as a resident inpatient in a hospital or transitional care facility. There must be a charge for room and board, other than in any government, military or veterans’ facility for which there is no charge for room and board. “Transitional care facility” means a facility which provides a bridge between the hospital and home for restorative and rehabilitation care. It must provide skilled nursing care and must be either located in a community nursing home or a hospital. Confined/confinement also includes assignment to an observation unit in a hospital, if you stay for at least 20 consecutive hours.
Loss of Hearing
The diagnosis of profound deafness in both ears that is not correctable.
Loss of Sight
The diagnosis of clinically proven irreversible reduction of sight in both eyes 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); or
Visual field restriction to 20 degrees or less in both eyes.
Loss of Speech
The clinical diagnosis of total and permanent loss of the ability to speak.
Major Organ Transplant
The irreversible failure of your heart, lung, pancreas, entire kidney or liver, or any combination thereof, determined by a physician specialized in care of the involved organ. Acceptance to the UNOS (United Network for Organ Sharing) list is required for this determination. If you receive the transplant prior to placement on the network, the network requirement will be waived.
Multiple Sclerosis
The unequivocal diagnosis of multiple sclerosis following more than one episode of well- defined neurological symptoms and signs and confirmed by a neurological exam and MRI scan of the brain or spinal fluid analysis. Symptoms must persist for 6 months to ensure that the condition is permanent.
Muscular Dystrophy
The diagnosis of a group of muscle diseases that weaken the musculoskeletal system and are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.
Myasthenia Gravis
The diagnosis of a neuromuscular disease characterized by weakness and rapid fatigue of any of the muscles under your voluntary control.
Niemann-Pick Disease (Children Only)
A definitive diagnosis of Niemann-Pick, Type A, B, or C, through blood test or genetic test.
Open Heart Surgery for Valve Replacement or Repair
The diagnosis of severe valvular heart disease for which is advised open heart surgery - a surgical procedure that requires an incision through the chest and an incision in the heart and/or attached blood vessels.
Pacemaker Placement
The diagnosis of symptomatic sinus node dysfunction, high-grade atrioventricular (AV) block, or other serious cardiac arrhythmia for which the initial placement of a permanent pacemaker has been advised.
Permanent Paralysis
The diagnosis of total and permanent loss of the use of two or more limbs (arms or legs or combination) due to accident or sickness for a continuous period of at least 60 days.
Permanent paralysis does not include paralysis as the result of a stroke.
Pompe Disease (Children Only)
A definitive diagnosis of Pompe Disease (Type II Glycogen Storage Disease) through enzyme testing or genetic testing.
Ruptured or Dissecting Aneurysm
The diagnosis of a balloon-like bulge in an artery that ruptures or dissects as confirmed by an ultrasound, CT scan, angiogram or MRI.
For purposes of the policy, aneurysms of the arm or leg are not considered a ruptured or dissecting aneurysm.
Severe Burns
The diagnosis of cosmetic disfigurement of the surface of a body area not less than 35 square inches, that is a full-thickness or third-degree burn. A full-thickness or third-degree burn is the destruction of the skin through the entire thickness or depth of the dermis and possibly into underlying tissues, with loss of fluid and sometimes shock, by means of exposure to fire, heat, caustics, electricity or radiation.
Sickle Cell Anemia
The diagnosis of a blood disorder that results in an abnormality in the oxygen-carrying protein hemoglobin found in red blood cells, which is confirmed via blood testing.
Skin Cancer
The diagnosis of tumor cells tending toward malignancy and which invade the underlying tissue or are present in situ. The diagnosis of skin cancer must be established according to the criteria of the American
Board of Pathology or the American Joint Committee on Cancer. This includes a clinical diagnosis whenever such diagnosis is consistent with professional medical standards.
Skin cancer includes:
- Basal cell carcinoma and squamous cell carcinoma of the skin including squamous cell carcinoma in situ; and
- Melanoma that is diagnosed as Breslow’s classification less than 0.75mm or which is considered melanoma in situ. Melanoma that is deeper than 0.75mm is considered to be cancer (invasive) instead of skin cancer.
Stem Cell Transplant
The clinical diagnosis of a blood or bone marrow malignancy for which the need for a surgical stem cell transplant has been advised.
Stroke
The diagnosis of an acute cerebral event including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism and cerebral thrombosis. The diagnosis of stroke must be based on confirmatory neuroimaging studies and evidence of persistent neurological impairment confirmed at the time of discharge from a hospital.
Stroke does not include:
- Transient ischemic attacks (TIA)
- Temporary neurological deficits lasting less than 24 hours that result from a variety of causes; can be a precursor
- to stroke; but, does not result in infarction/death of brain tissue.
- Ischemic disorders of the vestibular system;
- Brain injury related to trauma or infection; or
- Brain injury associated with hypoxia/anoxia or hypotension.
Systemic Lupus Erythematosus (SLE)
The diagnosis of an autoimmune disease that occurs when your body's immune system attacks your own tissues and organs.
Systemic Sclerosis (Scleroderma)
The diagnosis of an autoimmune disease that involves the hardening and tightening of the skin and connective tissues.
Thoracic Aortic Aneurysm
The diagnosis of an enlargement of the thoracic aorta of 5.5 cm or more, or causing symptoms, or of 4.5 cm or greater and rapidly expanding, for which surgical repair has been advised.
Transcatheter Heart Valve Replacement or Repair
The diagnosis of significant valvular heart disease for which is advised a procedure, performed through the blood vessels, to repair or replacement of one or more of the heart valves.
Transient Ischemic Attacks (TIA)
The diagnosis of a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction, that is confirmed via documented neurological deficit and neuroimaging studies.
Type 1 Diabetes
An auto-immune destruction of insulin-producing cells in the pancreas that results in total loss of insulin production.
Type IV Glycogen Storage Disease
A definitive diagnosis or Type IV Glycogen Storage Disease through testing of glycogen branching enzyme deficiency in the liver, muscle, or skin, or through genetic testing.
Zellweger Syndrome
A definitive diagnosis of Zellweger Syndrome through genetic testing.
- Blood test for triglycerides
- Pap smear or thin prep pap test
- Flexible sigmoidoscopy
- CEA (blood test for colon cancer)
- Bone marrow testing
- Serum cholesterol test for HDL and LDL levels
- Hemoccult stool analysis
- Serum Protein Electrophoresis (myeloma)
- Breast ultrasound, sonogram, MRI
- Molecular or antigen test (Coronavirus)
- Chest x-ray
- Mammography
- Colonoscopy
- CA 15-3 (breast cancer)
- Stress test on a bicycle or treadmill
- Fasting blood glucose test
- Thermography
- PSA (prostate cancer)
- Endoscopy
- Carotid Doppler
- Any cervical cancer screening test approved by the FDA
- Generally medically accepted cancer screening tests
- Routine eye exam
- Routine dental exam
- Well child/preventive exams age 1 through 18
- Biometric screenings
- Electrocardiogram (EKG)