In 2007, the China Insurance Regulatory Commission standardized the industry standards for critical illness and issued the Specification for the Use of the Definition of Critical Illness Insurance:
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In order to make it easier for consumers to choose critical illness insurance products and protect consumers' rights and interests, insurance institute of china and Chinese Medical Association jointly formulated the disease definition of critical illness insurance (hereinafter referred to as "disease definition") in combination with the development of critical illness insurance in China and the progress of modern medicine and drawing lessons from international experience.
In order to guide insurance companies to use disease definitions, China Insurance Association has specially formulated the Specification for the Use of Disease Definitions in Critical Illness Insurance (hereinafter referred to as the Specification).
According to the origin, development and characteristics of critical illness insurance, "disease" in this specification refers to the disease, disease state or operation agreed in the critical illness insurance contract.
Scope of application of 1
The definition of disease in this specification is based on the development of adult critical illness insurance at home and abroad, combined with the progress of modern medicine. Therefore, this specification is applicable to critical illness insurance, mainly adults (18 years old or older) during the insurance period.
2 principles of use
2. 1 The insurance company named the product critical illness insurance, and the insurance period was mainly for adults (18 years old or older). The diseases covered by the product should include malignant tumor, acute myocardial infarction, sequelae of stroke, coronary artery bypass grafting (or coronary artery bypass grafting), major organ transplantation or hematopoietic stem cell transplantation, end-stage renal disease (or uremia stage of chronic renal failure) within the scope of this specification. In addition to these six diseases, insurance companies can choose to use other diseases within the scope of this specification; At the same time, the above diseases should use the names and definitions of diseases in this specification.
2.2 According to the market demand and empirical data, insurance companies can add other diseases beyond the scope of this specification to the critical illness insurance products and define them by themselves.
2.3 In the critical illness insurance clauses and supporting publicity materials, the disease types specified in this specification should be arranged in the order listed in 3. 1 of this specification, and placed before the disease types added by insurance companies themselves; At the same time, the two should be distinguished.
2.4 When an insurance company sets the exclusion liability for critical illness insurance, the situation that the insurance company does not assume insurance liability for the disease, disease state or operation of the insured cannot exceed the scope specified in 3.2 of this specification.
3. Relevant provisions of critical illness insurance clauses.
The names, definitions, exclusions and definitions of terms in the critical illness insurance Clause shall conform to the specific provisions of this Code.
3. 1 Name and definition of diseases in critical illness insurance
If the insured suffers from a disease that meets the conditions described in the following definition of disease, it should be definitely diagnosed by an expert.
3. 1. 1 malignant tumor
It refers to diseases in which malignant cells grow and spread uncontrollably, infiltrate and destroy surrounding normal tissues, and can spread and transfer to other parts of the body through blood vessels, lymphatic vessels and body cavities. According to the results of pathological examination, the clinical diagnosis belongs to the category of malignant tumor in the International Statistical Classification of Diseases and Related Health Problems (ICD- 10) of the World Health Organization.
The following diseases are not covered:
(1) carcinoma in situ;
(2) Chronic lymphoblastic leukemia corresponding to stage A of Binet staging scheme;
(3) Hodgkin's disease equivalent to Ann Arbor stage I;
(4) Skin cancer (excluding malignant melanoma and metastatic skin cancer);
(5) Prostate cancer 5)TNM staging t 1n0m 0≤0 (note);
(6) Malignant tumor during HIV infection or AIDS.
Note: If the critical illness insurance is for women, this item is not included.
3. 1.2 acute myocardial infarction
Refers to partial myocardial necrosis caused by insufficient blood supply in the corresponding area due to coronary artery occlusion. At least three conditions must be met:
(1) Typical clinical manifestations, such as acute chest pain;
(2) Recent ECG changes suggest acute myocardial infarction;
(3) Myocardial enzymes or troponin increased in diagnosis, or showed dynamic changes consistent with acute myocardial infarction;
(4) After 90 days of onset, it was confirmed that the left ventricular function decreased, such as the left ventricular ejection fraction was less than 50%.
3. 1.3 sequelae of stroke
Refers to cerebrovascular hemorrhage, embolism or infarction caused by sudden change of cerebrovascular disease, which leads to permanent sexual dysfunction of nervous system. Permanent dysfunction of nervous system means that one or more of the following disorders still exist after 80 days of diagnosis/kloc-0:
(1) complete loss of function of one or more limbs;
(2) complete loss of language ability or chewing and swallowing ability;
(3) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities.
3. 1.4 major organ transplantation or hematopoietic stem cell transplantation
Major organ transplantation refers to allograft of kidney, liver, heart or lung due to corresponding organ failure.
Hematopoietic stem cell transplantation refers to allogeneic transplantation of hematopoietic stem cells (including bone marrow hematopoietic stem cells, peripheral blood hematopoietic stem cells and umbilical cord blood hematopoietic stem cells) due to hematopoietic dysfunction or malignant tumor of hematopoietic system.
3. 1.5 coronary artery bypass grafting (or coronary artery bypass grafting)
Refers to coronary artery bypass grafting for the treatment of severe coronary heart disease.
Non-thoracoscopic interventional surgery and endoscopic surgery, such as coronary stent implantation, balloon dilatation of cardiac catheter and laser radio frequency technology, are not covered.
3. 1.6 End-stage renal disease (or uremia stage of chronic renal failure)
Refers to chronic irreversible renal failure, reaching uremia stage, and having received regular dialysis or kidney transplantation for at least 90 days after diagnosis.
3. 1.7 Multiple limb loss
Refers to the complete disconnection of two or more limbs from the proximal end of wrist joint or ankle joint (near the trunk end) due to illness or accidental injury.
3. 1.8 Acute or subacute severe hepatitis
Refers to the diffuse necrosis of liver tissue caused by hepatitis virus infection, which leads to acute liver failure. After serological or virological examination, all the following conditions must be met:
(1) Severe jaundice or jaundice rapidly aggravates;
(2) Hepatic encephalopathy;
(3)B-ultrasound or other imaging examination showed that the liver volume was rapidly reduced;
(4) Progressive deterioration of liver function.
3. 1.9 benign brain tumor
Benign tumors of finger and brain have caused increased intracranial pressure, and the clinical manifestations are papilla edema, mental symptoms, epilepsy and motor sensory disturbance, which are life-threatening. The diagnosis must be made by imaging examination such as brain tomography (CT), magnetic resonance (MRI) or positron emission tomography (PET), and at least one of the following conditions must be met:
(1) Craniotomy for complete or partial removal of brain tumor.
(2) The radiotherapy of brain tumor was actually implemented.
Pituitary tumors, brain cysts and cerebrovascular diseases are not covered.
3. 1. 10 decompensated chronic liver failure
Refers to liver failure caused by chronic liver disease. All the following conditions must be met:
(1) persistent jaundice;
(2) ascites;
(3) Hepatic encephalopathy;
(4) Congestive splenomegaly with hypersplenism or esophageal and gastric varices.
Liver failure caused by alcoholism or drug abuse is not covered.
3. 1. 1 1 encephalitis sequela or meningitis sequelae.
Refers to the permanent sexual dysfunction of the nervous system caused by encephalitis or meningitis. Permanent dysfunction of nervous system means that one or more of the following disorders still exist after 80 days of diagnosis/kloc-0:
(1) complete loss of function of one or more limbs;
(2) complete loss of language ability or chewing and swallowing ability;
(3) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities.
3. 1. 12 deep coma
Refers to the loss of consciousness due to illness or accidental injury, unresponsiveness to external stimuli and internal needs, coma degree of 5 or less according to Glasgow coma scale, and continuous use of life support systems such as ventilators for more than 96 hours.
Deep coma caused by alcoholism or drug abuse is not covered.
3. 1. 13 Deafness in both ears
Refers to permanent and irreversible binaural hearing loss caused by illness or accidental injury. At the speech frequencies of 500 Hz, 1000 Hz and 2000 Hz, the average hearing threshold is greater than 90 dB, which is confirmed by pure tone hearing test, acoustic immittance test or auditory evoked potential test.
Note: If the insurance company only undertakes the protection responsibility of the insured after a certain age, it must be indicated in the definition of the disease.
3. 1. 14 blindness
Refers to the permanent and irreversible loss of binocular vision due to illness or accidental injury, and the better eye must meet at least one of the following conditions:
(1) Loss or enucleation of eyeball;
(2) The corrected visual acuity is less than 0.02 (the international standard visual acuity chart is adopted, and it should be converted if other visual acuity charts are adopted);
(3) The visual field radius is less than 5 degrees.
Note: If the insurance company only undertakes the protection responsibility of the insured after a certain age, it must be indicated in the definition of the disease.
3. 1. 15 paralysis
Refers to the permanent and complete loss of limb function of two or more limbs due to illness or accidental injury. Permanent complete loss of limb function means that two of the three major joints of each limb are still completely stiff or unable to move with consciousness after 180 days of disease diagnosis or accidental injury 180 days.
3. 1. 16 heart valve surgery
Refers to the operation of heart valve replacement or repair by thoracotomy for the treatment of heart valve diseases.
3. 1. 17 Severe Alzheimer's disease.
Refers to the progressive and irreversible changes in the brain, resulting in a serious decline or loss of intelligence. The clinical manifestations are obvious cognitive impairment, abnormal behavior and decreased social ability, and daily life must be continuously monitored by others. Must be diagnosed by brain tomography (CT), magnetic resonance imaging (MRI) or positron emission tomography (PET) and other imaging examinations, completely losing the ability of independent living, unable to independently complete three or more of the six basic daily activities.
Neurosis and mental illness are not covered.
Note: If the insurance company only undertakes the protection responsibility of the insured before a certain age, it must be indicated in the definition of the disease.
3. 1. 18 Severe brain injury
Refers to the permanent sexual dysfunction of the nervous system caused by the injury of important parts of the brain caused by mechanical external force on the head. The diagnosis must be made by brain tomography (CT), magnetic resonance imaging (MRI) or positron emission tomography (PET). Permanent dysfunction of nervous system means that one or more of the following disorders still exist after 80 days of brain injury/kloc-0:
(1) complete loss of function of one or more limbs;
(2) complete loss of language ability or chewing and swallowing ability;
(3) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities.
3. 1. 19 Severe Parkinson's disease
It is a degenerative disease of the central nervous system with clinical manifestations of paralysis agitans and ataxia. All the following conditions must be met:
(1) Drug treatment can't control the disease;
(2) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities.
Secondary Parkinson's disease is not covered.
Note: If the insurance company only undertakes the protection responsibility of the insured before a certain age, it must be indicated in the definition of the disease.
3. 1.20 Severe third-degree burns
Refers to the degree of burn, and the third-degree burn area reaches 20% or more of the total body surface area. The body surface area is calculated according to China's new nine-point method.
3. 1.2 1 severe primary pulmonary hypertension
It refers to a chronic disease in which the pulmonary artery pressure continues to increase for unknown reasons, resulting in permanent and irreversible limitation of physical activity, reaching Grade IV of new york Cardiology Association, and the average resting pulmonary artery pressure exceeds 30mmHg.
3. 1.22 Severe motor neuron disease
It is a group of progressive degenerative diseases of motor neurons in the central nervous system, including progressive spinal muscular atrophy, progressive bulbar palsy, primary lateral sclerosis and amyotrophic lateral sclerosis. Must meet the conditions of complete loss of independent living ability and inability to independently complete three or more of the six basic daily activities.
Note: If the insurance company only undertakes the protection responsibility of the insured before a certain age, it must be indicated in the definition of the disease.
3. 1.23 Loss of language ability
Refers to the complete loss of language ability due to illness or accidental injury. After at least 12 months of active treatment (complete vocal cord resection is not limited by this time), it still cannot be recovered by existing medical means.
The loss of language ability caused by mental and psychological factors is not covered.
Note: If the insurance company only undertakes the protection responsibility of the insured after a certain age, it must be indicated in the definition of the disease.
3. 1.24 Severe aplastic anemia
Anemia, neutropenia and thrombocytopenia caused by chronic persistent failure of bone marrow hematopoietic function. All the following conditions must be met:
(1) The results of bone marrow puncture or bone marrow biopsy support the diagnosis;
(2) Peripheral blood pictures must meet the following three conditions:
① Absolute value of neutrophils ≤ 0.5×109/L;
② Reticulocyte < 65438 0%;
③ Absolute value of platelets ≤ 20×109/L.
3. 1.25 aortic surgery
Refers to the operation of removing, replacing and repairing damaged aortic vessels through thoracotomy or laparotomy for the treatment of aortic diseases. Aorta refers to thoracic aorta and abdominal aorta, excluding branch vessels of thoracic aorta and abdominal aorta.
Intra-arterial angioplasty is not covered.
3.2 critical illness insurance's Exclusion Liability
The insurance company shall not be liable for the insured's illness, illness or operation due to one of the following circumstances:
3.2. 1 The insured and beneficiary intentionally kill or hurt the insured;
3.2.2 The insured intentionally hurts himself, intentionally commits a crime or resists arrest;
3.2.3 The insured takes, smokes or injects drugs;
3.2.4 The insured is drunk driving, driving without a valid driver's license or driving a motor vehicle without a valid driver's license;
3.2.5 The insured is infected with HIV or suffers from AIDS;
3.2.6 War, military conflict, riot or armed rebellion;
3.2.7 Nuclear explosion, nuclear radiation or nuclear pollution;
3.2.8 Hereditary disease, congenital malformation, deformation or chromosomal abnormality.
3.3 Definition of terms
3.3. 1 Six basic activities in daily life
The six basic activities in daily life refer to: (1) Dressing: I will dress and undress myself; (2) moving: moving from one room to another; (3) Action: get on and off the bed or get on and off the wheelchair by yourself; (4) Go to the toilet: control yourself to urinate; (5) Eating: take food out of the prepared bowl or plate and put it in the mouth; (6) Bathing: shower or bathe yourself.
3.3.2 complete loss of limb function
Of the three main joints of a limb, two are rigid or unable to move with consciousness. Limb refers to the whole upper limb including shoulder joint or the whole lower limb including hip joint.
3.3.3 complete loss of language ability or chewing and swallowing ability
The complete loss of language ability refers to the inability to emit any three of the four sounds (including lip sound, tongue sound, mouth flap sound and throat sound), or the complete loss of vocal cords, or aphasia due to the injury of brain language center.
The complete loss of chewing and swallowing ability refers to the state of organic or functional disorder caused by reasons other than teeth, which makes it impossible to chew and swallow, except for liquid food.
Permanent irreversibility
It means that after 180 days of active treatment from the date of diagnosis or accidental injury, it still cannot be recovered by existing medical means.
expert
A specialist should meet the following four qualifications at the same time: (1) having a valid China people's * * * and China's "Physician Qualification Certificate"; (2) Have a valid practicing certificate of People's Republic of China (PRC) doctors and register with relevant departments on schedule; (3) A valid certificate of the title of physician with the title of attending physician or above in People's Republic of China (PRC); (4) have been engaged in clinical work for more than three years in the corresponding departments of hospitals above the second level.
3.3.6 HIV infection or AIDS
HIV refers to human immunodeficiency virus, abbreviated as HIV in English. AIDS refers to acquired immunodeficiency syndrome caused by human immunodeficiency virus, abbreviated as AIDS in English.
If HIV or its antibody in human blood or other samples is positive and there are no clinical symptoms or signs, it is HIV infection; If obvious clinical symptoms or signs appear at the same time, it is AIDS.
3.3.7 Genetic diseases
Refers to diseases caused by mutation or distortion of genetic materials (chromosomes and genes) of germ cells or fertilized eggs, usually manifested as vertical transmission from parents to offspring.
3.3.8 Congenital malformation, deformation or chromosomal abnormality
Refers to the deformity, deformation or chromosome abnormality of the insured at birth. Congenital malformations, malformations and chromosomal abnormalities are determined according to the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD- 10).
4. Relevant provisions on publicity materials for critical illness insurance.
In the publicity materials of critical illness insurance, if the protected disease name appears alone, the following main title and subtitle should be combined.
4. 1 malignant tumor-exclude some early malignant tumors.
4.2 Acute myocardial infarction
4.3 Sequela of Stroke-Permanent Sexual Dysfunction
4.4 major organ transplantation or hematopoietic stem cell transplantation-allogeneic transplantation.
4.5 Coronary Artery Bypass Grafting (or Coronary Artery Bypass Grafting)-Thoracotomy is required.
4.6 End-stage renal disease (or uremia stage of chronic renal failure)-dialysis treatment or kidney transplantation is needed.
4.7 Multiple limb loss-complete amputation
4.8 Acute or subacute severe hepatitis
4.9 Benign brain tumor-requires craniotomy or radiotherapy.
4. 10 decompensated period of chronic liver failure-excluding alcoholism or drug abuse.
4. 1 1 encephalitis sequela or sequelae of meningitis-permanent sexual dysfunction.
4. 12 deep coma-excluding alcoholism or drug abuse.
4. 13 binaural deafness-permanent irreversibility
Note: If the insurance company only undertakes the protection responsibility of the insured after a certain age, it must be indicated in the subtitle.
4. 14 blindness-permanent irreversibility
Note: If the insurance company only undertakes the protection responsibility of the insured after a certain age, it must be indicated in the subtitle.
4. 15 paralysis-permanent complete paralysis
4. 16 heart valve surgery-requires thoracotomy.
4. 17 Severe Alzheimer's disease-complete loss of independent living ability.
Note: If the insurance company only undertakes the protection responsibility of the insured before a certain age, it must be indicated in the subtitle.
4. 18 Severe brain injury-permanent sexual dysfunction
4. 19 severe Parkinson's disease-complete loss of independent living ability
Note: If the insurance company only undertakes the protection responsibility of the insured before a certain age, it must be indicated in the subtitle.
4.20 Severe third-degree burns-at least 20% of body surface area.
4.2 1 severe primary pulmonary hypertension with heart failure.
4.22 Severe motor neuron disease-complete loss of autonomous living ability
Note: If the insurance company only undertakes the protection responsibility of the insured before a certain age, it must be indicated in the subtitle.
4.23 Loss of language ability-complete loss and active treatment for at least 12 months.
Note: If the insurance company only undertakes the protection responsibility of the insured after a certain age, it must be indicated in the subtitle.
4.24 Severe aplastic anemia
4.25 Aortic surgery-requires thoracotomy or laparotomy.
5 Supplementary clauses
5. 1 insurance institute of china established a permanent institution to study the progress of medical practice of diseases related to critical illness insurance, and organized personnel to regularly revise the definitions and norms of diseases.
5.2 This specification shall come into force as of the date of promulgation. 1, after August, 2007, the critical illness insurance contracts signed by insurance companies with adults (18 years old or older) during the insurance period shall conform to this specification. An insurance company shall provide relevant services for the critical illness insurance contracts signed before the implementation of these Standards.
5.3 insurance association of china is responsible for the interpretation of this specification.
You'd better look at the provisions of the corresponding insurance clauses.