SUN LIFE ASSURANCE COMPANY OF CANADA One Sun Life Executive Park, Wellesley Hills, MA (800)

Transcription

1 SUN LIFE ASSURANCE COMPANY OF CANADA One Sun Life Executive Park, Wellesley Hills, MA (800) GROUP CRITICAL ILLNESS INSURANCE OUTLINE OF COVERAGE THE CERTIFICATE PROVIDES LIMITED BENEFITS. BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the Company. This coverage is designed only as a supplement to a comprehensive health insurance policy and should not be purchased unless you have this underlying coverage. Persons covered under Medicaid should not purchase it. Read the Buyer s Guide to Specified Disease Insurance to review the possible limits on benefits in this type of coverage. The Guide is also available from the Company. Read Your Certificate Carefully - This outline of coverage provides a very brief description of the important features of coverage. This is not the insurance contract and only the actual Policy provisions will control. The Certificate and the Policy into which it is incorporated sets forth in detail the rights and obligations of both you and your insurance company and the terms and conditions under which benefits are paid. It is, therefore, important that you READ YOUR CERTIFICATE CAREFULLY! Critical Illness coverage is designed to provide, to persons insured, restricted coverage paying benefits ONLY when a covered critical illness ( Critical Illness ) is diagnosed. Coverage is not provided for basic hospital, basic medicalsurgical, or major medical expenses. You may be able to enroll your spouse and/or dependent children. Note to Employees Covered or Considering Coverage under Health Savings Accounts (HSA) Established in Connection with High Deductible Health Plans (HDHP): Based on the limited available regulatory guidance, Sun Life believes its Critical Illness Insurance is appropriate for use with an HSA and may be purchased when the employee and/or their family members are covered under an HDHP. However, Sun Life cannot provide legal or tax advice. If there are legal or tax questions, we suggest that you consult your own legal or tax advisor before purchasing this insurance. BENEFITS The following conditions, subject to the election of your employer, MAY be covered under your Certificate up to 100% of the Insurance Amount. The Insurance Amount is the amount of insurance you have been approved for. Circulatory Conditions Category: Heart Attack, Stroke, End-stage Heart Failure, Coronary Artery Disease*, Cancer Conditions Category: Cancer, Non-Life Threatening Cancer* Other Conditions Category: Benign Brain Tumor, Coma, Major Organ Failure, Paralysis, Severe Burns Childhood Conditions Category: Cerebral Palsy, Complex Congenital Heart Disease, Cystic Fibrosis, Type I Diabetes Mellitus, Muscular Dystrophy 13-SD-OOC-01 Page 1

2 *These conditions generally provide a payment of no more than 25% of the Insurance Amount. The company, subject to the election of your employer, may issue insurance in amounts up to $100,000. To determine the benefit payable, the company will multiply the Insurance Amount by the benefit percentage for the applicable covered condition. MAXIMUM BENEFIT The company will only pay one benefit for each Covered Condition. We will not pay more than 100% of the benefit payable for Covered Conditions in the same category nor more than 200% of the benefit payable for all the Covered Conditions shown. If elected by your employer, additional benefits may be paid when there is a recurrence of a Covered Condition for which we previously paid a benefit. These benefits are subject to the terms and conditions of the Certificate and the Recurrence Benefit Rider. DEFINITIONS OF CONDITIONS The definitions applicable to your Certificate may vary by state insurance law and regulation. Circulatory Conditions Category: Heart Attack means the death of heart muscle due to acute obstruction of a coronary artery that results in a rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction and includes at least one of the following: heart attack symptoms; new electrocardiogram (ECG) changes consistent with a Heart Attack; or development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty. Heart Attack excludes: elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves; or silent myocardial infarction, including ECG or imaging changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition as described above. Stroke (cerebrovascular accident) means an acute cerebrovascular event caused by intra-cranial thrombosis or hemorrhage, or cerebral embolism from an extra-cranial source, with: acute onset of new neurological symptoms; and new objective neurological deficits on clinical examination which persist for 30 days following the date of diagnosis. Stroke excludes any of the following: transient ischemic attacks; intracranial vascular events due to trauma; or lacunar infarcts which do not meet the definition of stroke as described above. End-stage Heart Failure means irreversible failure of the heart which is not remediable by medical or device therapy or by surgical therapy other than heart transplant. Coronary Artery Disease means a narrowing or blockage of one or more coronary arteries for which a cardiologist recommends that coronary artery bypass surgery utilizing venous or arterial grafts occur within 60 days following the date of the recommendation. 13-SD-OOC-01 Page 2

3 Cancer Conditions Category: Cancer means a tumor characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Cancer excludes: carcinoma in situ; evidence of cancer cells or cancer genetic material detected by molecular or biochemical probes only (including, but not limited to, proteomic or DNA/RNA-based techniques) with no lesion amenable to tissue diagnosis; or any non-melanoma skin cancer that has not become metastasized. Non-Life Threatening Cancer is limited to the following: chronic lymphocytic leukemia that has not progressed beyond Rai stage 0; Stage 1A (T1a) malignant melanoma (melanoma less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion); Stage A (T1a or T1b) prostate cancer; papillary microcarcinoma of the thyroid, which for the purposes of the Policy means a papillary carcinoma of the thyroid (1 cm or less in diameter) and confined to the thyroid; noninvasive papillary cancer of the bladder histologically described as TNM classification TaN0M0; and ductal carcinoma in situ (DCIS)of the breast. Non-Life Threatening Cancer excludes any of the following: pre-malignant lesions; any carcinoma in situ except ductal carcinoma in-situ of the breast; evidence of cancer cells or cancer genetic material detected by molecular or biochemical probes only (including but not limited to proteomic or DNA/RNA-based techniques) with no lesion amenable to tissue diagnosis. Other Conditions Category: Benign Brain Tumor means a non-malignant tumor located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumor must require surgical or radiation treatment or cause irreversible objective neurological deficit(s). The diagnosis of benign brain tumor must be made by a Specialist Physician. Benign Brain Tumor excludes pituitary adenomas less than 10 mm. in diameter. Coma means a confirmed diagnosis of a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least 96 hours, and for which period the Glasgow coma score must be 4 or less. Coma excludes any of the following: a medically induced coma; or a coma which results directly from alcohol or drug use. Major Organ Failure means the irreversible end-stage failure of bone marrow, kidney, liver or lung function, and: for kidney failure only, in the absence of a listing on UNOS, ongoing dialysis (either hemo or peritoneal) on a permanent basis, shall be conclusive proof of irreversible end-stage kidney failure; or for all organs listed above, a transplant is recommended as soon as an appropriate donor is located, and the Insured o is either listed with the United Network of Organ Sharing (UNOS); or o a suitable donor is found without a UNOS listing. Major Organ Failure excludes any of the following: bone marrow failure that results from the treatment process for cancer; failure of any other organ not listed above; and autologous bone marrow transplant in which the Insured s own bone marrow is used. 13-SD-OOC-01 Page 3

4 Paralysis means total and irrecoverable loss of function of two or more limbs as a result of injury to or disease of the spinal cord. The loss must be present for a continuous period of at least 90 days and be expected to be permanent. Limb is defined as the complete arm or the complete leg. Severe Burns means third-degree burns over at least 20% of the body surface. Childhood Conditions Category: Cerebral Palsy means nonprogressive, neurological defect affecting muscle control. Complex Congenital Heart Disease means a confirmed Diagnosis of at least one of the following covered heart conditions: coarctation of the aorta; Ebstein's anomaly; Eisenmenger syndrome; Tetralogy of Fallot; transposition of the great vessels; or any other congenital cardiac condition that requires life-saving, open heart surgery to survive. It also means any one of the following specific conditions that require life-saving, open heart surgery to survive: aortic stenosis; atrial septal defect; discrete subvalvular aortic stenosis; pulmonary stenosis; or ventricular septal defect. The Diagnosis of Complex Congenital Heart Disease must be made and the surgery must be recommended by a Specialist Physician and supported by cardiac imaging acceptable to us. Cystic Fibrosis, also known as mucoviscidosis, means a recessive genetic disease affecting most critically the lungs and also the pancreas, liver, and intestine. It is characterized by abnormal transport of chloride and sodium across the epithelium leading to thick viscous secretions. Type 1 Diabetes Mellitus means the Insured has total insulin deficiency and continuous dependence on exogenous insulin for survival. Dependence on insulin must persist for a continuous period of at least three months. Muscular Dystrophy means one of a group of muscle diseases characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue. WAITING PERIODS Cancer, Non-Life Threatening Cancer and Benign Brain Tumor Benefit Waiting Periods: No benefit will be payable for Cancer, Non-Life Threatening Cancer and Benign Brain Tumor and the Insured s insurance for these Conditions will terminate if, within 30 days following the later of: the date we receive enrollment information for the Insured s insurance; and the effective date of the Insured s insurance, the Insured has any of the following: a. signs, symptoms or investigations, that lead to diagnosis of any cancer (covered or excluded under this insurance), regardless of when the diagnosis is made, or b. a Diagnosis of any cancer (covered or excluded under this insurance). 13-SD-OOC-01 Page 4

5 Childhood Conditions Benefit Waiting Period: No benefit will be payable for any Childhood Condition and the Insured s insurance for such Childhood Condition will terminate if, within 30 days following the effective date of the Dependent Child s insurance, the Dependent Child has any of the following: a. signs, symptoms or investigations, that lead to diagnosis of such Childhood Condition (covered or excluded under this insurance), regardless of when the diagnosis is made, or b. a Diagnosis of such Childhood Condition (covered or excluded under this insurance). OTHER EXCLUSIONS AND LIMITATIONS The limitations and exclusions applicable to your Certificate may vary by state insurance law and regulation. The company will not pay any benefit for any Critical Illness diagnosed outside the United States or Canada. The company will not pay a benefit for any Critical Illness that is due to or results from, intentionally self-inflicted injuries, elective plastic or cosmetic surgery, active military duty, participation in war or in a riot, rebellion or insurrection, committing or attempting to commit an assault, felony or other criminal act, your engagement in dangerous conduct or hazardous activity where there is a likelihood of death or serious injury, being legally intoxicated or under the influence of any narcotic unless taken on the advice of a Physician and taken as prescribed or improper or illegal use of inhalants or huffing. The company will not pay a benefit for any Critical Illness that is diagnosed in the first twelve months following the effective date of insurance and results from a pre-existing condition. Pre-existing condition means during the six months prior to any Insured s effective date of insurance or the effective date of an increase in any Insured s amount of insurance, any condition for which any insured: sought medical treatment, consultation, advice, care or services, including diagnostic measures for the condition, regardless of whether the condition was diagnosed or suspected at that time; took prescribed drugs or medicines for the condition; or had symptoms for which an ordinarily prudent person would have consulted a health care provider for Diagnosis, care or Treatment. GENERAL Premium rates for the coverage may change. Critical Illness insurance coverage is subject to termination as stated in the Policy. 13-SD-OOC-01 Page 5