TriShield9 Health CI

Deterioration or loss of intellectual capacity as confirmed by clinical evaluation and imaging tests, arising from Alzheimer's disease or irreversible organic disorders, resulting in there being at least three (3) of the six (6) Activities of Daily Living which the Insured (with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) is unable to perform without the continuous assistance of another person.

The Diagnosis must be clinically confirmed by an appropriate neurologist acceptable to MaxiLife. For clarity, neurosis and psychiatric illnesses do not meet the above definition of Alzheimer’s Disease as they are non-organic diseases.

Universal necrosis of the brain cortex with the brainstem intact. The definite Diagnosis must be confirmed by a neurologist acceptable to MaxiLife and evidenced by specific findings in neuro-radiological tests. This Condition has to be medically documented for a continuous period of at least one (1) month.

Chronic persistent bone marrow failure which results in anemia, neutropenia and thrombocytopenia requiring treatment with at least one of the following:

blood product
marrow stimulating agents
immunosuppressive agents, or iv. bone marrow transplantation.

The Diagnosis must be confirmed by a hematologist acceptable to MaxiLife.

Bacterial infection resulting in severe inflammation of the membranes of the brain or spinal cord resulting in significant, irreversible and permanent neurological deficit as confirmed by a neurologist acceptable to MaxiLife. Confirmation of bacterial infection in cerebrospinal fluid by lumbar puncture is required and the neurological deficit must persist continuously for at least six (6) weeks.

A benign tumor in the brain as evidenced by all of the following:

the tumor is life threatening,
it has caused damage to the brain, and
it has undergone surgical removal or, if inoperable, has caused a permanent neurological deficit.

The presence of the underlying tumor must be confirmed by a neurologist or neurosurgeon acceptable to MaxiLife, supported by findings on Magnetic Resonance Imaging, Computerized Tomography scan, or other reliable imaging techniques.

For clarity, the following conditions do not meet the above definition of Benign Brain Tumor:

cysts,
granulomas,
vascular malformations,
haematomas, and
tumors of the pituitary gland or spine.

An impaired function of the heart muscle, unequivocally diagnosed as Cardiomyopathy by a cardiologist acceptable to MaxiLife, and which results in permanent physical impairment to the degree of New York Heart Association classification Class III or Class IV, or its equivalent, for at least six (6) months based on the following classification criteria:

Class III - Marked functional limitation. Affected patients are comfortable at rest but performing activities involving less than ordinary exertion will lead to symptoms of congestive cardiac failure.
Class IV - Inability to carry out any activity without discomfort. Symptoms of congestive cardiac failure are present even at rest. With any increase in physical activity, discomfort will be experienced.

The Diagnosis of Cardiomyopathy should be supported by echographic findings of compromised ventricular performance.

Invasive brain surgery to correct an abnormal dilation of cerebral arteries, involving all three (3) layers of the walls of the cerebral arteries. The aneurism must be at least 10 mm in size or increasing by at least 0.95 mm per year and the need for surgery must be confirmed by a neurosurgeon acceptable to MaxiLife, as evidenced by the results of cerebral angiography. For clarity, limited craniotomy and burr-hole procedures do not meet the above definition of Cerebral Aneurism Requiring Invasive Brain Surgery as neither are typically invasive and both usually have shorter recovery times. Similarly, infection and mycotic aneurisms do not meet the above definition of Cerebral Aneurism Requiring Invasive Brain Surgery.

End-stage liver failure as evidenced by all of the following:

permanent jaundice,
ascites, and
hepatic encephalopathy.

The Diagnosis must be confirmed by a Physician acceptable to MaxiLife.

End-stage lung disease, causing chronic respiratory failure, as evidenced by all of the following:

FEV1 test results consistently less than one (1) liter,
the requirement for permanent supplementary oxygen therapy for hypoxemia,
arterial blood gas analyses with partial oxygen
pressures of 55mmHg or less (PaO2 < 55mmHg), and dyspnoea at rest

The Diagnosis must be confirmed by a pulmonologist acceptable to MaxiLife.

Continuing chronic inflammatory process of the pancreas, characterized by irreversible morphological changes and progression of the disease and evidenced by all of the following:

uniform accumulation of calcium in the pancreas as evidenced from the results of imaging tests, and
chronic failure of pancreatic function, causing continuous disruption of intestinal absorption (excess fat in the faeces) or diabetes.

The Diagnosis must be confirmed by a specialist in Internal Medicine acceptable to MaxiLife.

A coma that persists for a continuous period of at least ninety-six (96) hours and evidenced by all of the following:

there is no response to external stimuli for at least ninety-six (96) hours,
life support measures are necessary to sustain life, and
there is brain damage that results in a permanent neurological deficit.

The permanence of the neurological deficit must be assessed by a neurologist acceptable to MaxiLife at least thirty (30) days after the onset of the coma.

The actual undergoing of open-heart surgery to correct the narrowing or blockage of one or more of the coronary arteries with bypass grafts. Angiographic evidence of significant coronary artery obstruction must be provided and the procedure must be considered medically necessary by a cardiologist acceptable to MaxiLife. For clarity, as the following procedures do not involve open-heart surgery, they do not meet the above definition of Coronary Artery Bypass Grafting: angioplasty and all other intra-arterial, catheter-based techniques, keyhole or laser procedures.

A chronic, transmural inflammatory disorder of the bowel, as evidenced with continued inflammation in spite of optimal therapy, with all of the following having occurred:

Stricture formation causing intestinal obstruction requiring admission to hospital
Fistula formation between loops of bowel, and
At least one (1) bowel segment resection.

The Diagnosis must be proven histologically in a pathology report and/or the results of sigmoidoscopy or colonoscopy.

Severe inflammation of brain substance, resulting in permanent neurological deficit which is documented for a minimum of thirty (30) days. The Diagnosis must be confirmed by a neurologist acceptable to MaxiLife.

A submassive to massive necrosis of the liver by the hepatitis virus, leading precipitously to liver failure. The Diagnosis in respect of this illness must be evidenced by all of the following:

a rapidly decreasing liver size,
necrosis involving entire lobules, leaving only a collapsed reticular framework,
rapid deterioration of liver function tests,
deepening jaundice, and
hepatic encephalopathy.

and confirmed by a Physician acceptable to MaxiLife.

The actual undergoing of open-heart surgery to replace or repair heart valve abnormalities. The Diagnosis of heart valve abnormality must be supported by cardiac catheterization or echocardiogram and the procedure must be considered medically necessary by a cardiologist acceptable to MaxiLife.

Infection with the Human Immunodeficiency Virus (HIV) through a blood transfusion, as evidenced by all of the following:

the infection was due to a blood transfusion that was medically necessary or given as part of a medical treatment,
the blood transfusion was received in Philippines after the Effective Date, or date of reinstatement of this Supplementary Benefit (whichever is the latest),
the source of the infection is established to be from the institution that provided the transfusion and the institution is able to trace the origin of the HIV tainted blood; and
the insured does not suffer from thalassaemia major or hemophilia.
No payment will be made under this condition where a cure has become available prior to the infection. “Cure” means any treatment that renders the HIV inactive or non-infectious.

Total and irreversible loss of hearing in both ears as a result of illness or Accident. The inability to hear must be established for a continuous period of six (6) months and must (at the end of that period) be deemed permanent on the basis of audiometric and sound-threshold test results furnished by an Ear, Nose and Throat (ENT) specialist acceptable to MaxiLife. Total means “the loss of at least 80 decibels in all frequencies of hearing”.

Inability to perform without the continuous assistance of another person at least three (3) of the Activities of Daily Living for a continuous period of at least six (6) months and leading to a permanent inability to perform the same. The benefit for Loss of Independent Existence will automatically cease after the Insured attains age 69. Furthermore, all psychiatric related causes are excluded. The loss of Independent Existence must be confirmed by a Physician acceptable to MaxiLife.

Severance of two limbs at or above wrist or ankle as a result of illness or injury

Total and irreversible loss of sight in both eyes as a result of illness or Accident. The blindness must be confirmed by an ophthalmologist acceptable to MaxiLife.

Total and irrecoverable loss of the ability to speak due solely to the Insured’s vocal cords being permanently damaged from an injury or disease. The inability to speak must be established for a continuous period of twelve (12) months and must (at the end of that period) be deemed permanent on the basis of medical evidence furnished by an Ear, Nose and Throat (ENT) specialist acceptable to MaxiLife.

Third degree (full thickness of the skin) burns covering at least twenty percent (20%) of the surface of the Insured’s body. Diagnosis must be confirmed by a specialist acceptable to MaxiLife and must be evidenced by specific results using the Lund Browder Chart or equivalent burn area calculators.

A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissue. The cancer must be confirmed by histological evidence of malignancy and an oncologist acceptable to MaxiLife.
The following are not classified as Major Cancer:

Early Bladder Cancer: Papillary micro-carcinoma of bladder
Early Chronic Lymphocytic Leukemia: Chronic Lymphoctic Leukemia (CLL) RAI Stage 1 or 2
Early Prostate Cancer: Prostate Cancer histologically described using the TNM Classification as T1a or T1b or Prostate cancers described using another equivalent classification
Early Thyroid Cancer: Thyroid Cancer histologically described using the TNM Classification as T1N0M0 including Papillary micro-carcinoma of thyroid where the tumor is less than 1 cm in diameter
Early Invasive Melanomas: Invasive melanomas of less than 1.5 mm Breslow thickness or less than Clark Level 3
Tumors of the Ovary: Tumors of the ovary classified as T1aN0M0, T1bN0M0 or FIGO 1A, FIGO 1B, or
Carcinoma in situ: as defined below.
‘‘Carcinoma in situ’ or (CIS) means the focal autonomous new growth of carcinomatous cells confined to the cells in which it originated and has not yet resulted in the invasion and/or destruction of surrounding tissues. 'Invasion' means an infiltration and/or active destruction of normal tissue beyond the basement membrane. The CIS diagnosis must be supported by both a histopathological report and microscopic examination of the fixed tissue and supported by a biopsy result. Non-melanoma skin cancer and all carcinoma in-situ of skin or earlier stages do not meet the definition of Major Cancer

A head injury due solely to an Accident that results in there being at least three (3) of the six (6) Activities of Daily Living which the Insured (with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) is unable to perform without the continuous assistance of another person.

The neurological deficit must have persisted continuously for at least six (6) weeks and must (at the end of that period) be deemed permanent by a neurologist acceptable to MaxiLife, supported by unequivocal findings on Magnetic Resonance Imaging, Computerized Tomography scan, or other reliable imaging techniques.

For clarity, major head injuries due to non-Accidental causes and spinal cord injuries do not meet the above definition of Major Head Trauma with Severe Brain Damage.

The actual undergoing (as a recipient) of a transplant of:

one of the following human organs:
- heart,
- lung,
- liver,
- kidney,
- pancreas or,
human bone marrow using haematopoietic stem cells preceded by total bone marrow ablation, as a result of irreversible end-stage failure of the relevant organ.

For clarity, transplants of other human organs and other stem cell transplants do not meet the above definition of Major Organ Transplant.

A cerebro-vascular incident including infarction of brain tissue, cerebral and subarachnoid haemorrhage, cerebral embolism and cerebral thrombosis, as evidenced by all of the following:

there is evidence of permanent neurological damage confirmed by a neurologist acceptable to MaxiLife for a continuous period of at least six (6) weeks after the event,
there are findings on Magnetic Resonance Imaging, Computerized Tomography scan, or other reliable imaging techniques consistent with the diagnosis of a new stroke.

The following are excluded:

transient ischaemic attacks,
brain damage due to an Accident or injury, infection, vasculitis, and inflammatory disease,
vascular disease affecting the eye or optic nerve, and
ischaemic disorders of the vestibular system.

The actual undergoing of major surgery to repair or correct an aneurysm, narrowing, obstruction or dissection of the aorta through surgical opening of the chest or abdomen. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches.

For clarity, surgery performed using only minimally invasive or intra-arterial techniques do not meet the above definition of Major Surgery to Aorta.

A progressive hereditary disease of the kidneys characterized by the presence of cysts in the medulla in both kidneys, tubular atrophy and intestitial fibrosis with the clinical manifestations of anemia, polyuria and renal loss of sodium. The condition must present as the chronic irreversible failure of both kidneys to function, requiring regular renal dialysis. Diagnosis must be supported by renal biopsy.

Motor neurone disease of unknown etiology, as characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. These include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary lateral sclerosis.

The condition must result in there being at least three (3) of the six (6) Activities of Daily Living which the Insured (with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) is unable to perform without the continuous assistance of another person.

For a benefit to be payable, such disability must have persisted for a continuous period of at least three (3) months and must (at the end of that period) be confirmed by a neurologist acceptable to MaxiLife as progressive and resulting in permanent disability and neurological deficit.

The definite occurrence of multiple sclerosis, as diagnosed by a neurologist acceptable to MaxiLife, and as evidenced by all of the following:

investigations unequivocally confirm the diagnosis to be multiple sclerosis,
multiple neurological deficits have occurred over a continuous period of at least six (6) months, and
there is a well-documented history of exacerbations and remissions of said symptoms or neurological deficits.

For clarity, other causes of neurological damage such as SLE do not meet the above definition of Multiple Sclerosis.

A group of hereditary degenerative diseases of muscle, characterized by weakness and atrophy of muscle. The Diagnosis of muscular dystrophy must be unequivocal and made by a neurologist acceptable to MaxiLife. The condition must result in there being at least three (3) of the six (6) Activities of Daily Living which the Insured (with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) is unable to perform without the continuous assistance of another person.

For a Benefit to be payable, such disability must have persisted for a continuous period of at least six (6) months and must (at the end of that period) be deemed permanent by a Physician acceptable to MaxiLife.

Death of a portion of the heart muscle arising from inadequate blood supply to the relevant area. The Diagnosis must be met by three (3) or more of the following five (5) criteria, which are consistent with a new heart attack:

a history of typical chest pain,
new electrocardiogram (ECG) changes proving infarction,
diagnostic elevation of cardiac enzyme CK-MB,
cardiac troponin T or I at 0.5ng/ml and above, or
left ventricular ejection fraction less than fifty percent (50%), measured three (3) months or more after the event.

Infection with the Human Immunodeficiency Virus (HIV) which resulted from an Accident occurring after the Policy Effective Date or date of reinstatement of this Policy (whichever is the latest) and whilst the Insured was carrying out the normal professional duties of his or her occupation in Philippines. No payment will be made unless all of the following are proved to MaxiLife’s satisfaction:

proof of the Accident giving rise to the infection must be reported to MaxiLife within thirty (30) days of the Accident taking place,
proof that the Accident involved a definite source of the HIV infected fluids and
proof of sero-conversion from HIV negative to HIV positive occurring during the one hundred eighty (180) days following the documented Accident. This proof must include a negative HIV antibody test conducted within five (5) days of the Accident.

For clarity, HIV infection resulting from any other means (including sexual activity and the use of intravenous drugs) does not meet the above definition of Occupationally Acquired HIV/AIDS.

This benefit is only payable when the occupation of the Insured at the time of infection is a medical practitioner, medical student, registered nurse, medical laboratory technician, dentist (surgeon or nurse) or paramedical worker, registered with the appropriate body and working in a medical center or clinic (in Philippines). No payment will be made under this condition where a cure has become available prior to the infection. “Cure” means any treatment that renders the HIV inactive or non-infectious.

Total and irreversible loss of use of at least two (2) entire limbs due to illness or Accident. This condition must have persisted for a continuous period of at least six (6) months and must (at the end of that period) be deemed permanent by a neurologist acceptable to MaxiLife.

The unequivocal Diagnosis of Parkinson’s Disease by a neurologist acceptable to MaxiLife, as evidenced by all of the following:

it cannot be controlled with medication,
it shows signs of progressive impairment and
it results in there being at least three (3) of the six (6) Activities of Daily Living which the Insured (with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) is unable to perform without the continuous assistance of another person.

For a benefit to be payable, such disability must have persisted for a continuous period of at least six (6) months and must (at the end of that period) be deemed permanent by a neurologist acceptable to MaxiLife.

Primary pulmonary hypertension with substantial right ventricular enlargement, established by investigations including cardiac catheterisation and resulting in permanent physical impairment to the degree of at least Class IV of the New York Heart Association (NYHA) Functional Classification of cardiac impairment. Class IV is defined as the inability to carry out any activity without discomfort. Symptoms of Congestive Cardiac Failure are present even at rest. With any increase in physical activity, discomfort will be experienced. The Diagnosis must be confirmed by a Physician acceptable to MaxiLife.

A systemic collagen-vascular disease causing progressive diffuse fibrosis in the skin, blood vessels and visceral organs. An unequivocal Diagnosis of this disease must be supported by biopsy and serological evidence and the disorder must have reached systemic proportions to involve the heart, lungs or kidneys such that two (2) of the following criteria are met:

pulmonary involvement showing carbon monoxide diffusing capacity (DLCO) < seventy percent (70%) of the predicted value, or forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC) or total lung capacity (TLC) < seventy five percent (75%) of the predicted value;
renal involvement showing glomerular filtration rate (GFR) < 60 ml/min;
cardiac involvement showing evidence of either congestive heart failure, cardiac arrhythmia requiring medication, or pericarditis with moderate to large pericardial effusion.

For clarity, whilst Localised scleroderma (linear scleroderma or morphea), eosinophilic fasciitis and CREST may exhibit some or all of the above signs and/or symptoms, they are medically different conditions and therefore do not meet the above definition of Progressive Scleroderma.

Chronic irreversible failure of both kidneys, requiring either permanent renal dialysis or kidney transplantation. The Diagnosis must be confirmed by a Physician acceptable to MaxiLife.

Severe rheumatoid arthritis, with the diagnosis confirmed by a rheumatologist acceptable to Maxilife and as evidenced by all of the following:

x-ray reveals typical rheumatoid change,
the joint deformity change persists continuously for at least six (6) months, and
at least three of the following groups of joints are involved and deformed:
-finger joints
-wrist joints
-elbow joints
-knee joints
-hip joints
-ankle joints
-spine

The condition must result in there being at least three (3) of the six (6) Activities of Daily Living which the Insured (with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons) is unable to perform without the continuous assistance of another person.

For a benefit to be payable, such disability must have persisted for a continuous period of at least six (6) months and must (at the end of that period) be deemed permanent by a Physician acceptable to MaxiLife.

Means the conclusive Diagnosis by a specialist of an illness that is expected to result in death of the Insured within twelve (12) months. The Insured must no longer be receiving active treatment other than that for pain relief and the diagnosis must be confirmed by a specialist acceptable to MaxiLife.

In recognition of medical advances, MaxiLife does not consider HIV/AIDS to be a Terminal Illness.

Acute fulminant ulcerative colitis with life threatening electrolyte disturbances meeting the following criteria:

The entire colon is affected with severe bloody diarrhea, and
The necessary treatment is total colectomy.

as diagnosed based on histopathological features.

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