“SAMPLE ONLY” WomensCare BENEFIT SHEET

“SAMPLE ONLY”
WomensCare
BENEFIT SHEET
Details of the WomensCare benefit and the names of the people insured for the benefit (called the life
or lives assured) are shown in the schedule.
Your WomensCare benefit currently provides coverage for the following conditions:
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•
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1.
Cancer
Early invasive cancer
Carcinoma-in-situ
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Specific women's conditions
Pregnancy complications
Children's congenital conditions
Reviewability of event definitions
Sovereign cannot cancel your WomensCare policy due to deterioration in health, or changes in
your occupation or pastimes.
Your WomensCare policy provides financial assistance in the event you suffer one of the
current specified major conditions defined in your policy document. Due to the continuing
medical advances in medical treatment and diagnostic techniques, we may need to review the
definitions used in your policy document to ensure that in the future they:
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Remain appropriate in regard to medical terminology and classification;
Take into account effective cures and vaccines and modern diagnostic procedures;
Include some diseases considered appropriate in the future;
Exclude diseases that are found to become minor.
Sovereign reserves the right to adjust your WomensCare definitions. The changes apply to all
WomensCare policies.
2.
When will Sovereign pay a WomensCare cancer benefit?
Sovereign will pay you (subject to the provisions of the policy) a WomensCare cancer benefit
if the life assured suffers cancer for the first time and, after the risk commencement date shown
in the schedule, survives for at least 14 days thereafter.
Sovereign will not pay the WomensCare cancer benefit if the life assured for the benefit suffers
cancer for the first time within three months after the risk commencement date shown in the
schedule (or in respect of an increase in benefit within three months after the effective date of
the increase).
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You can only make one claim under the WomensCare cancer benefit, after which the
entire WomensCare benefit for that relevant life assured will cease.
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The full description of the cancer benefit and any specific provisions relating to them are
set out in Section Ten.
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3.
When will Sovereign pay a WomensCare early invasive cancer benefit?
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Sovereign will pay you (subject to the provisions of the policy) a WomensCare early
invasive cancer benefit if the life assured suffers any of the following conditions for the
first time, after the risk commencement date shown in the schedule, and survives for at
least 14 days thereafter:
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Early invasive cancer of the
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Early invasive cancer of the Ovary
Endometrium
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Early invasive cancer of the
Early invasive cancer of the Vulva
Fallopian Tube
Early invasive cancer of the Vagina
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Early invasive cancer of the Bowel
Papillary micro-carcinoma of the
•
Papillary micro-carcinoma of the
thyroid
bladder
Chronic lymphocytic leukaemia less than Rai Stage 3
(The full description of these conditions and any specific provisions relating to them are
set out in Section Ten.)
4.
•
Sovereign will not pay the WomensCare early invasive cancer benefit if the life assured
for the benefit suffers any of the conditions for the first time within six months after the
risk commencement date shown in the schedule (or in respect of an increase in benefit
within six months after the effective date of the increase).
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You can only make one claim under the WomensCare early invasive cancer benefit,
after which the benefit will cease.
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The amount payable for the WomensCare early invasive cancer benefit is 25% of the
current sum assured of the cancer benefit. After you have made a claim for the early
invasive cancer benefit, cover will continue for other specified benefits; however, the
sum assured for the cancer benefit will reduce by the amount of any claim paid.
When will Sovereign pay a WomensCare carcinoma-in-situ benefit?
•
Sovereign will pay you (subject to the provisions of the policy) a WomensCare
carcinoma-in-situ benefit if the life assured suffers any of the following conditions for
the first time after the risk commencement date shown in the schedule, and survives for
at least 14 days thereafter:
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Carcinoma-in-situ of the Cervix
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•
Carcinoma-in-situ of the Vagina
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Ductal carcinoma-in-situ of the
Breast
Carcinoma-in-situ of the Vulva
(The full description of these conditions and any specific provisions relating to them are
set out in Section Ten.)
•
Sovereign will not pay the WomensCare carcinoma-in-situ benefit if the life assured for
the benefit suffers carcinoma-in-situ for the first time within six months after the risk
commencement date shown in the schedule (or in respect of an increase in benefit within
six months after the effective date of the increase).
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You can only make one claim under the WomensCare carcinoma-in-situ benefit, after
which the benefit will cease.
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5.
The amount payable for the WomensCare carcinoma-in-situ is 10% of the current sum
assured of the WomensCare cancer benefit. After you have made a claim for the
WomensCare carcinoma-in-situ benefit, cover will continue for other specified
WomensCare benefits; however, the sum assured for the cancer benefit will reduce by
the amount of any claim paid.
WomensCare specific conditions benefit.
•
Sovereign will pay you (subject to the provisions of the policy) a WomensCare specific
conditions benefit, if the life assured suffers for the first time, and after the risk
commencement date shown in the schedule, any of the following conditions and
survives for at least 14 days thereafter:
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•
•
•
Osteoporosis fracture
Chronic auto-immune hepatitis
Severe endometriosis
SLE with nephritis
(The full description of these conditions and any specific provisions relating to them are
set out in Section Ten.)
6.
•
You can only make one claim under the WomensCare specific conditions benefit, after
which the benefit will cease.
•
The amount payable for WomensCare specific conditions is 10% of the current sum
assured of the cancer benefit. After you have made a claim for the specific conditions
benefit, cover will continue for other specified WomensCare benefits; however, the sum
assured for the cancer benefit will reduce by the amount of any claim paid.
When will Sovereign pay a WomensCare pregnancy complication benefit?
•
Sovereign will pay you (subject to the provisions of the policy) a WomensCare
pregnancy complication benefit if the life assured suffers any of the following
conditions for the first time and, after the risk commencement date shown in the
schedule, survives for at least 14 days thereafter:
•
•
Ectopic pregnancy
Eclampsia
•
•
HELLP syndrome
Disseminated intravascular
coagulation
(The full description of these conditions and any specific provisions relating to them are
set out in Section Ten.)
•
Sovereign will not pay a WomensCare pregnancy complications benefit if the life
assured for the benefit suffers any of the pregnancy complications within 365 days after
the risk commencement date shown in the schedule (or in respect of an increase in
benefit within six months after the effective date of the increase).
•
You can only make one claim under the WomensCare pregnancy complications benefit,
after which the benefit will cease.
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The amount payable for the WomensCare pregnancy complication benefit is 5% of the
sum assured of the cancer benefit. After you have made a claim for the pregnancy
complication benefit, cover will continue for other specified WomensCare benefits:
however, the sum assured for the cancer benefit will reduce by the amount of any claim
paid.
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7.
When will Sovereign pay WomensCare children's congenital abnormality benefit?
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Sovereign will pay you (subject to the provisions of the policy) a WomensCare
children's benefit, if a biological child of the life assured suffers any of the following
conditions for the first time and after the risk commencement date shown in the
schedule, survives for at least 14 days thereafter:
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•
•
•
Down syndrome
Transposition of the Great Vessels
Tetralogy of Fallot
Cleft palate, cleft lip and palate
•
•
•
Spina bifida
Ventricular Septal Defect
Infantile Hydrocephalus
(The full description of these conditions and any specific provisions relating to them are
set out in Section Ten.)
•
8.
The benefit payment amount for the children's benefit is limited to $5,000 per child.
You can only make one claim under the children's benefit, per live birth prior to each
child's 3rd birthday, after which the benefit will cease.
How to make a claim
Proof of occurrence of any insured event must be supported by:
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•
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Diagnosis or examination by an appropriate Registered Medical Practitioner registered
in New Zealand; and,
Confirmatory investigations including, but not limited to, clinical, radiological,
histological and laboratory evidence; and,
If the insured event requires a surgical procedure to be performed, the procedure must
be the usual treatment for the condition and be medically necessary.
Sovereign reserves the right to require the life assured to undergo an examination or other
reasonable tests to confirm the occurrence of an insured event.
To make a claim, you must follow the relevant procedures in the section of your Sovereign
WomensCare policy entitled “How to claim a benefit”.
9.
Exclusions – When Sovereign will not pay a benefit
Sovereign will not pay any benefit described in this appendix where any of the following (and
in each case either directly or indirectly) causes or contributes to the claim:
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The life assured deliberately injuring herself or attempting to do so.
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The life assured participating in any criminal act.
Sovereign will not pay a benefit for in respect of a condition that existed before the risk
commencement date, unless Sovereign is satisfied that you could not have known of the
existence of the condition, or the condition was declared on your application and accepted by
Sovereign.
These exclusions apply to any subsequent benefit increase you make.
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10.
Definition of medical conditions
WomensCare Cancer benefit
For the purpose of this benefit cancer is defined as the presence of one or more malignant
tumours. The malignant tumour is to be characterised by the uncontrolled growth and spread of
malignant cells and the invasion and destruction of normal tissue for which major
interventionist treatment or surgery (excluding endoscopic procedures alone) is considered
medically necessary.
The following tumours are excluded except where specified in this policy schedule:
•
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. Ductal Carcinoma-in-situ of the breast is covered if it results directly in
the removal of the entire breast. The procedure must be performed specifically to arrest
the spread of malignancy, and be considered the appropriate and necessary treatment.
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All skin cancers, including hyperkeratoses, basal cell carcinomas, squamous cell
carcinomas, unless there is evidence of metastases. Malignant melanomas of greater than
1.5mm maximum thickness as determined by histological examination using the Breslow
method are covered.
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Early cancers as listed in Section Eleven. Early invasive cancers are excluded under this
benefit.
WomensCare Early Invasive Cancer benefit
For the purposes of this benefit, and notwithstanding any other criteria that may be found
elsewhere, the following criteria for the tumour of the covered organs must all be satisfied:
Endometrium:
The tumour invasion is limited to the endometrium, classified
as FIGO Stage 1A (International Federation of Gynaecology
and Obstetrics).
Ovary:
The tumour is limited to one ovary, where the capsule is
intact with no tumour on the ovarian surface and there are no
malignant cells in ascites or peritoneal washings. Classified
as T1aNOMO (TNM classification) or FIGO Stage1A .
Fallopian Tube:
The tumour should be limited to the tubal mucosa with no
ascites classified as T1 NOMO according to the TNM staging
method or FIGO Stage1A.
Vulva:
The tumour is confined to the vulva and/or perineum, is less
than 2 cm in its greatest diameter, and invades to a depth of
equal to or less than1 mm, classified FIGO Stage 1 or T1
NOMO.
Basal cell carcinoma of the Vulva is specifically excluded.
Vagina:
The tumour is limited to the vaginal wall, FIGO Stage 1.
Bowel:
Intramucosal carcinoma of the bowel is defined as an
extension of malignant cells through the basement membrane
into the surrounding lamina propria. It may occur through the
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entire mucosal thickness or it may represent a small focal
area within an adenoma. Intramucosal carcinoma invades
into but not through the muscularis mucosae.
Papillary micro-carcinoma
of the thyroid:
An incidental finding of a microscopic focus of papillary
thyroid tumour which is clinically occult. The tumour must
be intra-thyroidal and be less than one centimetre in size.
Papillary micro-carcinoma
of the bladder:
The papillary bladder tumour has invaded the lamina propria
but not the muscularis.
Chronic lymphocytic
leukaemia:
Non-life-threatening measuring less than Rai Stage 3.
WomensCare
Carcinoma-in-situ benefit:
For the purposes of this benefit, and not withstanding any
other definition which may be found elsewhere, “carcinomain-situ” means a focal autonomous new growth of cancer
cells which has not yet resulted in the invasion of normal
tissue beyond the basement membrane. “Invasion” shall
mean an infiltration and/or active destruction of normal
tissue.
The diagnosis of carcinoma-in-situ must always be positively
diagnosed upon the basis of a microscopic examination of
fixed tissue. In the case of the uterine cervix, the tissue must
be provided from a cone biopsy or colposcopy with cervical
biopsy and, in the case of breast by a biopsy, before the claim
is entitled. A clinical diagnosis will not be sufficient.
Ductal carcinoma-in-situ (DCIS) of the breast is covered to a
benefit payment of 100% of the cancer benefit, if it results
directly in the removal of the entire breast. The procedure
must be performed specifically to arrest the spread of
malignancy, and be considered the appropriate and necessary
treatment.
The following criteria for the tumour of the covered organs
must all be satisfied:
Cervix:
Dysplastic changes usually beginning at the squamocolumnar
junction in the uterine cervix that may be precursors of
invasive adeno or squamous cervical carcinoma:
A) The tumour should be classified as Carcinoma-in-situ.
Cervical Intraepithelial Neoplasia (CIN) classification
including CIN-1, CIN-2, and CIN-3 (severe dysplasia
without CIS) are specifically excluded.
B) AdenoCarcinoma-in-situ (AIS)
Vagina:
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The tumour should be classified as Vaginal Intraepithelial
Neoplasm (VaIN III) severe dysplasia or Carcinoma-in-situ.
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Vulva:
The tumour shall be classified as intraepithelial carcinoma,
Vulval Intra-epithelial Neoplasia (VIN III) vulval
Carcinoma-in-situ, FIGO Stage 0 or Tis according to the
TNM method.
Breast:
Ductal Carcinoma-in-situ (DCIS): The tumour is
characterised by cells that resemble those seen in invasive
cancer, but that have not invaded through the basement
membrane into surrounding tissues and thus lack the
histological feature that is the hallmark of invasive cancer.
Specifically excluded is Lobular Carcinoma-in-situ (LCIS) of
the breast, as this shall not be covered under this benefit.
WomensCare Specific conditions
For the purpose of this benefit the following definitions apply;
Osteoporosis Fractures
A condition of reduced bone mass with decreased cortical thickness and a decrease in the
number and size of the trabeculae of cancellous bone (but normal chemical composition),
resulting in increased fracture incidence. Osteoporosis is defined as having a bone mineral
density (BMD) which is at least 2.5 standard deviations below the mean of the population.
Only osteoporosis fractures of the hip and vertebra are covered after confirmatory diagnosis of
osteoporosis as described above.
Chronic Auto-immune Hepatitis
A chronic necro-inflammatory liver disorder of unknown cause associated with circulating
auto-antibodies and a high serum globulin level. The following criteria for a valid claim must
all be satisfied:
1.
Hypergammaglobulinaemia
2.
The presence of at least one of the following auto-antibodies:
a)
anti-nuclear antibodies
b)
anti-smooth muscle antibodies
c)
anti-actin antibodies
d)
anti-LKM-1 antibodies.
A specialist in diseases of the liver must confirm the diagnosis of auto-immune hepatitis.
Severe Endometriosis
Endometriosis is defined as the presence of endometrial tissue (normally lining of the uterus)
outside the uterus, usually in the pelvic cavity. Severe endometriosis is defined as a partial or
complete obliteration of the cul-de-sac (Pouch of Douglas) by endometriotic adhesions, and/or
the presence of endometriomas (ovarian cysts containing endometriotic material), and/or the
presence of deep endometriotic deposits involving the pelvic side wall, cul de sac and broad
ligaments, and involving the wall of the bladder, ureter and bowel.
The diagnosis of severe endometriosis must be made as a result of a laparoscopy after a
suggestive history and clinical examination. Severe endometriosis requires the surgical
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mobilisation of the rectum, excision of deposits from the rectum and other parts of the pelvis,
and freeing of adhesions.
Mild and moderate endometriosis and adenomyosis are specifically excluded.
Systemic lupus erythematosus with nephritis
A multi-system, multifactorial, auto-immune disorder which is characterised by the
development of auto-antibodies directed against various self-antigens. Only systemic lupus
erythematosus involving the kidneys (class III to class VI Lupus nephritis, established by renal
biopsy, and in accordance with the WHO classification as noted below) are covered by this
policy. Other forms, discoid lupus and those forms with haematological and joint involvement,
will be specifically excluded. A certified doctor specialising in Internal Medicines, Nephrology
or Rheumatology must support the final diagnosis.
The World Health Organisation (WHO) classification of lupus renal disease is as follows:
Class I
normal histology;
Class II-A
normal light microscopy but mesangial immune complex
deposition;
Class II-B
immune complex deposits plus mesangial proliferation on
light microscopy;
Class III
peripheral capillary loop proliferation in a segmental
distribution and involving less than 50% of the glomeruli;
Class IV
proliferation in a global distribution and greater than 50% of
the glomeruli involved;
Class V
diffuse basement membrane thickening;
Class VI
chronic glomerulosclerosis.
WomensCare Pregnancy complications benefit
For the purpose of this benefit the following definitions apply:
Ectopic Pregnancy
The development of the fertilised ovum outside of the uterine cavity (ovary, fallopian tube,
abdominal cavity). The ectopic pregnancy has to be terminated by laparoscopy or laparotomy
in order to claim under this benefit.
Eclampsia
The occurrence of grandmal seizures in the presence of hypertension, proteinuria and oedema
complicating a pregnancy, and not being due to other causes such as epilepsy.
HELLP Syndrome
This may be associated with Pre-eclampsia or Eclampsia and is characterised by Haemolysis,
elevated liver enzymes and low platelet count.
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Disseminated Intravascular Coagulation (DIC)
Over activation of the coagulation and fibrinolytic system resulting in microvascular
thrombosis and consumption of platelets and coagulation factors. DIC complicating pregnancy
may follow any major haemorrhage, pre-eclampsia, amniotic fluid embolism, endotoxic shock,
and when foetal death occurs after 20 weeks.
Only disseminated intravascular coagulation as a result of complication of pregnancy is
covered.
WomensCare Children's congenital abnormality benefits
For the purpose of this benefit the following definitions apply:
Down’s Syndrome (Trisomy 21, Mongolism)
A specific chromosomal abnormality, specifically an autosomal aberration, identified by an
extra chromosome 21 and characterised by muscular hypotonicity, microcephaly,
brachycephaly and a flattened occiput. Diagnosis must be supported by retardation of physical
and mental development.
Spina Bifida
Congenital defective closure of the bone encasement of the spinal cord through which the cord
and meninges may or may not protrude. Only Spina Bifida associated with a meningeal cyst
(meningocele) or a cyst containing both meninges and spinal cord (meningomyelocele) or only
spinal cord (myelocele) shall be covered.
Transposition of the Great Vessels
The condition in which the aorta arises from the right ventricle and the pulmonary artery arises
from the left ventricle as diagnosed by a consultant cardiologist and with supporting evidence
in the form of an echocardiogram or cardiac catheterisation.
Ventricular Septal Defect
A Ventricular Septal Defect is an abnormal opening in the ventricular septum that allows blood
to pass from the left to the right ventricle of the heart. Claims shall only be payable if the
condition undergoes surgical closure, as recommended by a Paediatric Cardiologist. Intra
arterial and catheter techniques are specifically excluded.
Tetralogy of Fallot
Tetralogy of Fallot is an anatomic abnormality of the heart with severe or total right ventricular
outflow tract obstruction and a ventricular septal defect allowing right ventricular
deoxygenated blood to bypass the pulmonary artery and enter the aorta directly, as confirmed
by an echocardiogram.
Infantile Hydrocephalus
It is characterised by enlargement of the cerebrospinal fluid spaces resulting from obstruction
of flow pathway between the secretion sites in the ventricles and the absorption sites in the
subarachnoid space. The benefit will only be paid if in the opinion of a consultant neurologist
the condition necessitates the insertion of a shunt.
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Cleft palate, Cleft lip and palate
A congenital fissure of the palate often associated with separation of the lip extending into the
nose. Clefts can occur on one or both sides of the upper lip. The benefit will only be paid for
those cases with cleft palate, or cleft palate and cleft lip. There is no benefit payable for cases
of cleft lip alone.
11.
Key terms
condition(s)
A treatment, illness, surgical procedure or event as
specified in this appendix which leads to a claim being
paid under the specified definition.
registered medical practitioner
A person (other than you, your spouse/partner, an insured
or a relative) who is registered in terms of the Medical
Practitioners Act 1968.
risk commencement date
The commencement date of the policy, being the date on
which the policy was issued.
specialist(s)
A registered medical practitioner who has an approved
fellowship in one of the approved surgical, anaesthetic or
traditional non-surgical colleges and who is registered with
the New Zealand Medical Council. These include, but are
not limited to, the following disciplines: general surgery,
orthopaedic surgery, urology, neurosurgery,
anaesthesiology, cardiology, endocrinology,
gastroenterology, haematology, paediatrics, gynaecology,
obstetrics, neurology, oncology, renal specialists, and
rheumatology.
the schedule
The latest (in time) schedule of policy details including
endorsements that forms part of this policy document.
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