8. 1 major diseases
A major illness refers to the insured's first occurrence of a disease that meets the following definitions, or his first operation that meets the following definitions. The disease or operation should be definitely diagnosed by experts (see 8.2).
The following major diseases are defined by insurance institute of china and Chinese Medical Association.
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 with TNM stage of (5)t 1n0m 0 or less;
(6) Malignant tumor during HIV infection or AIDS.
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%.
Sequela of apoplexy
Refers to cerebrovascular hemorrhage, embolism or infarction caused by sudden changes in cerebrovascular diseases, and leads to permanent sexual dysfunction of the 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 limb function (see 8.3);
(2) complete loss of language ability or chewing and swallowing ability (see 8.4);
(3) The ability to live independently is completely lost, and it is impossible to independently complete three or more of the six basic activities of daily life (see 8.5).
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.
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.
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.
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.
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.
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.
Decompensated stage of 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.
Encephalitis sequela or sequelae of meningitis.
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.
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.
become deaf in both ears
Refers to the permanent irreversible binaural hearing loss caused by illness or accidental injury (see 8.6). 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.
During the policy anniversary of 0-3 years old, the insured's deafness in both ears is not covered.
Blindness of eyes
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.
Emotion is completely out of control
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.
Heart valve surgery
Refers to the operation of heart valve replacement or repair by thoracotomy for the treatment of heart valve diseases.
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.
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.
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.
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.
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.
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.
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.
During the anniversary of the 0-3-year-old policy, the insured's loss of language ability is not covered.
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.
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.
The following major diseases are diseases added by our company beyond the scope of diseases defined by insurance institute of china and Chinese Medical Doctor Association.
Severe multiple sclerosis
Refers to the irreversible dysfunction of various parts of the body caused by demyelination of the central nervous system, which requires a definite diagnosis by a neurologist and a diagnosis report with the results of CT or magnetic resonance examination. Irreversible dysfunction of body parts means that it has lasted for more than 180 days after being diagnosed with dysfunction.
The definite diagnosis provided by the neurologist must also include the following contents:
(1) clearly showed the clinical manifestations caused by optic nerve, brain stem and spinal cord injuries.
(2) Scattered multi-site lesions of the nervous system;
(3) There is a clear history of the above symptoms and repeated deterioration and reduction of nerve injury.
Severe 1 diabetes
Severe 1 type diabetes mellitus is a chronic hyperglycemia caused by absolute deficiency of insulin secretion, which has been dependent on exogenous insulin for more than 180 days. It must be determined by blood insulin, blood C peptide or urine C peptide, and the result is abnormal, which must be diagnosed by an endocrinologist. During the validity period of this additional insurance contract, at least the following 1 conditions shall be met:
(1) has proliferative retinopathy;
(2) Pacemaker must be implanted to treat heart disease;
(3) At least one toe needs to be removed due to gangrene.
Invasive mole (or malignant mole)
This kind of disease refers to the abnormal chorionic tissue of hydatidiform mole infiltrating into the myometrium of uterus or transferring to other organs or tissues, and has been treated by chemotherapy or surgery.
Systemic lupus erythematosus complicated with severe renal insufficiency
The protection of this disease is limited to women.
This kind of disease refers to an autoimmune connective tissue disease, which contains a large number of pathogenic autoantibodies and immune complexes, causing tissue damage. The diagnosis of systemic lupus erythematosus must be clearly diagnosed by a specialist and meet the following conditions:
(1) Clinical manifestations should meet at least the following four conditions:
① Butterfly erythema or discoid erythema;
② photosensitivity;
③ Ulcer of oral and nasal mucosa;
④ Non-malformed arthritis or multi-joint pain;
⑤ Pleurisy or pericarditis;
⑥ Nervous system injury (epilepsy or mental symptoms);
⑦ Abnormal hemogram (white blood cells below 4000/μl or platelets below 100000/μl or hemolytic anemia).
(2) The test results meet at least the following two conditions:
① Anti-dsDNA antibody was positive.
② Anti-Sm antibody was positive.
③ Positive antinuclear antibody;
④ Skin lupus band test (non-lesion site) or positive renal biopsy;
⑤ C3 is lower than normal.
(3) The renal function of lupus nephritis is weakened, and the clearance rate of endogenous creatinine is less than 30ml per minute.
Severe primary cardiomyopathy
Refers to a kind of myocardial pathological changes caused by unknown reasons, including primary dilated cardiomyopathy, primary hypertrophic cardiomyopathy and primary restrictive cardiomyopathy. The lesion must have caused ventricular dysfunction and obvious heart failure (which means that the heart function reaches Grade IV according to the new york Heart Association's cardiac function classification standard *), and the relevant hospital medical records show that the state of Grade IV heart failure lasts at least 180 days.
This disease must be diagnosed by experts. Cardiomyopathy secondary to systemic diseases or other organ system diseases is not covered.
* According to the grading standard of new york Heart Association, the cardiac function is Grade 4, which means that there are hospital medical records showing that patients can't carry out any activities and still have heart failure manifestations such as palpitation and dyspnea at rest.
8.2 experts
Experts should have the following four qualifications:
(1) has a valid People's Republic of China (PRC) doctor 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.
8.3 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.
8.4 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.
8.5 Six basic activities of daily life
The six basic activities of daily life refer to:
(1) Dressing: You can dress and undress yourself;
(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.
8.6 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.
8.7 Accidental injury
Refers to external, sudden, unintentional and non-disease objective events that harm the body.
8.8 Hospital
Refers to the public hospitals at or above the second level determined by People's Republic of China (PRC) and the national health department, but does not include psychiatric hospitals and medical institutions such as rehabilitation, recuperation, detoxification, withdrawal, nursing and pension. Its purpose is not to treat patients directly. Hospitals must have medical equipment that meets the standards stipulated in the relevant national hospital management rules, and qualified doctors and nurses are stationed in the hospital for 24 hours to provide medical and nursing services.
8.9 Driving without a valid driver's license
Refers to one of the following situations:
(1) driving without a license;
(two) driving a vehicle that does not conform to the driver's license;
(3) driving a vehicle with an unqualified driver's license;
(4) Driving with an unverified driver's license without the consent of the public security traffic management department;
(five) when learning to drive with a learning driver's license, there is no coach to guide the car, or not to learn to drive according to the prescribed time and route;
(six) other circumstances stipulated by the public security traffic management department without a valid driver's license.
8. 10 infected with HIV or suffering from 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.
8. 1 1 Hereditary 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.
8. 12 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).