Definition -

Surgery for disease of the aorta requiring excision and surgical replacement of any part of the diseased aorta with a graft. Aorta means the thoracic and abdominal aorta but not its branches. The surgery must be determined to be Medically Necessary by a Specialist.

Exclusions - This coverage excludes angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non- surgical procedures.

Definition - Definite diagnosis of a chronic persistent bone marrow failure, confirmed by biopsy, which results in anemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following:

• marrow stimulating agents;
• immunosuppressive agents; or
• bone marrow transplantation.

The diagnosis of Aplastic Anemia must be made by a Specialist.

Definition - Definite diagnosis of meningitis, confirmed by cerebrospinal fluid showing the presence of pathogenic bacteria. The presence of pathogenic bacteria must be confirmed by culture or other generally medically accepted microbiological testing. The Bacterial Meningitis must result in objective neurological deficits persisting for at least 90 days from the date of diagnosis.

The diagnosis of Bacterial Meningitis must be made by a Specialist.

Neurological deficits must be detectable by the Specialist and may include, but are not restricted to, measurable loss of hearing or vision, measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia (difficulty with speech), dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination or new-onset seizures undergoing treatment. Headache or fatigue is not considered a neurological deficit.

Exclusions - This coverage excludes viral meningitis.

Definition - Definite diagnosis of a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The Participant must have undergone surgery or radiation treatment or the tumour must have caused irreversible objective neurological deficits.

These deficits must be corroborated by diagnostic imaging showing changes that are consistent in character, location and timing with the neurological deficits.

The diagnosis of Benign Brain Tumour must be made by a Specialist.

Neurological deficits must be detectable by the Specialist and may include, but are not restricted to, measurable loss of hearing or vision, measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia (difficulty with speech), dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination, or new-onset seizures undergoing treatment. Headache or fatigue will not be considered a neurological deficit.

Exclusions - No benefit is payable under this condition for pituitary adenomas less than 10 mm, vascular malformations; cholesteatomas or infectious or inflammatory tumours.

90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations, leading directly or indirectly to a diagnosis of any benign brain tumour, regardless of when the diagnosis is made; or
• a diagnosis of any benign brain tumour.

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Benign Brain Tumour or, any critical illness caused by any benign brain tumour or its treatment.

Definition - Definite diagnosis of the total and irreversible loss of vision in both eyes, evidenced by:

• the corrected visual acuity being 20/200 or less in both eyes; or
• the field of vision being less than 20 degrees in both eyes.

The diagnosis of Blindness must be made by a Specialist.

Definition - Definite diagnosis of a malignant tumour. This tumour must be characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Types of cancer include carcinoma, melanoma, leukemia, lymphoma, and sarcoma.

The diagnosis of Cancer must be made by a Specialist and must be confirmed by a pathology report.

For purposes of this condition:

• T1a or T1b prostate cancer means a clinically inapparent tumour that was not palpable on digital rectal examination and was incidentally found in resected prostatic tissue.
• The term gastrointestinal stromal tumours (GIST) classified as AJCC Stage 1 means:
• The terms Tis, Ta, T1a, T1b, T1 and AJCC Stage 1 are as defined in the American Joint Committee on Cancer (AJCC) cancer staging manual, 8^th Edition, 2018.
• The term Rai stage 0 is as defined in KR Rai, A Sawitsky, EP Cronkite, AD Chanana, RN Levy and BS Pasternack: Clinical staging of chronic lymphocytic leukemia. Blood 46:219, 1975.

gastric and omental GISTs that are less than or equal to 10 cm in greatest dimension with five or fewer mitoses per 5 mm², or 50 per HPF; or

small intestinal, esophageal, colorectal, mesenteric and peritoneal GISTs that are less than or equal to 5 cm in greatest dimension with 5 or fewer mitoses per 5 mm², or 50 per HPF.

Exclusions - No benefit is payable under this condition for the following:

• lesions described as benign, non-invasive, pre-malignant, of low or uncertain malignant potential, borderline, carcinoma in situ or tumours classified as Tis or Ta;
• malignant melanoma of skin that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis;
• any non-melanoma skin cancer, without lymph node or distant metastasis. This includes but is not limited to, cutaneous T cell lymphoma, basal cell carcinoma, squamous cell carcinoma or Merkel cell carcinoma;
• prostate cancer classified as T1a or T1b, without lymph node or distant metastasis;
• papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest dimension and classified as T1, without lymph node or distant metastasis;
• chronic lymphocytic leukemia classified as Rai stage 0 without enlargement of lymph nodes, spleen or liver and with normal red blood cell and platelet counts;
• gastro-intestinal stromal tumours classified as AJCC Stage 1;
• grade 1 neuroendocrine tumours (carcinoid) confined to the affected organ, treated with surgery alone and requiring no additional treatment, other than perioperative medication to oppose effects from hormonal oversecretion by the tumour; or
• thymomas (stage 1) confined to the thymus, without evidence of invasion into the capsule or spread beyond the thymus.

90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations leading directly or indirectly to a diagnosis of any cancer (covered or not covered under this policy), regardless of when the diagnosis is made; or
• a diagnosis of any cancer (covered or not covered under this policy).

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Cancer, or any critical illness caused by any cancer or its treatment.

Definition - Definite 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. The diagnosis of Coma must be made by a Specialist.

Exclusions - This coverage excludes:

• a medically induced coma;
• a coma that result directly from alcohol or drug use; and
• a diagnosis of brain death.

Definition - Heart surgery to correct narrowing or blockage of 1 or more coronary arteries with bypass graft(s). The surgery must be determined to be Medically Necessary by a Specialist.

Exclusions - This coverage excludes angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

Definition - Definite diagnosis of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz.

The diagnosis of Deafness must be made by a Specialist.

Definition - Definite diagnosis, made by a Specialist, of dementia which must be characterized by a progressive deterioration of memory and at least one of the following areas of cognitive function:

• aphasia (a disorder of speech);
• apraxia (difficulty performing familiar tasks);
• agnosia (difficulty recognizing objects); or
• disturbance in executive functioning (for example, inability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behaviour), which is affecting daily life.

The Participant must exhibit:

• dementia of at least moderate severity, which must be evidenced by a Mini Mental State Exam of 20/30 or less, or equivalent score on another generally medically accepted test or tests of cognitive function; and
• evidence of progressive worsening in cognitive and daily functioning either by serial cognitive tests or by history over at least a 6 month period.

Exclusions - This coverage excludes affective or schizophrenic disorders or delirium.

Reference to the Mini Mental State Exam is to Folstein MF, Folstein SE, McHugh PR, J Psychiatry Res. 1975; 12(3):189.

Definite diagnosis of death of heart muscle due to obstruction of blood flow that results in a rise and fall of cardiac biomarkers to levels considered diagnostic of acute myocardial infarction, with at least one of the following:

• heart attack symptoms;
• new electrocardiographic (ECG) changes consistent with a heart attack; or
• development of new pathological Q waves on ECG following an intra-arterial cardiac procedure including, but not limited to, coronary angiography or angioplasty.

The diagnosis of Heart Attack must be made by a Specialist.

Exclusions - No benefit is payable under this condition for:

• ECG changes suggestive of a prior myocardial infarction;
• other acute coronary syndromes, including angina pectoris and unstable angina; or
• elevated cardiac biomarkers or symptoms that are due to medical procedures or diagnoses other than heart attack.

Definition - Surgery to replace any heart valve with either a natural or mechanical valve or to repair heart valve defects or abnormalities. The surgery must be determined to be Medically Necessary by a Specialist.

Exclusions - This coverage excludes angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.

Definition - Definite diagnosis of chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated. The diagnosis of Kidney Failure must be made by a Specialist.

Definition - Definite diagnosis of the total inability, due to disease or injury, to independently perform at least 3 of 6 Activities of Daily Living:

• with or without the aid of assistive devices;
• with no reasonable chance of recovery; and
• for a continuous period of at least 90 days.

The diagnosis of Loss of Independent Existence must be made by a Physician and supported by an independent home care assessment made by an occupational therapist or equivalent.

No additional Survival Period is required once the conditions described above are satisfied.

Activities of Daily Living: The following 6 activities:

• Bathing: washing oneself in a bathtub, shower or by sponge bath;
• Dressing: putting on and removing necessary clothing, braces, artificial limbs or other surgical appliances;
• Toileting: getting on and off the toilet and maintaining personal hygiene;
• Bladder and bowel continence: managing bladder and bowel function with or without protective undergarments or surgical appliances so that hygiene is maintained;
• Transferring: moving in and out of a bed, chair or wheelchair; and

• Feeding: consuming food or drink that already have been prepared and made available.

Definition - Definite diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation.

The diagnosis of Loss of Limbs must be made by a Specialist.

Definition - Definite diagnosis of the total and irreversible loss of the ability to speak as the result of physical injury or disease, for a period of at least 180 days. The diagnosis of Loss of Speech must be made by a Specialist.

Exclusions - This coverage excludes all psychiatric related causes.

Definition - Definite diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be Medically Necessary. To qualify under Major Organ Failure on Waiting List, the Participant must become enrolled as the recipient in a recognized transplant centre in Canada or the United States of America that performs the required form of transplant surgery. For the purposes of the Survival Period, the date of diagnosis is the date of the Participant’s enrolment in the transplant centre. The diagnosis of the major organ failure must be made by a Specialist.

Definition - Definite diagnosis of irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, such that an organ transplant is Medically Necessary.

To qualify under Major Organ Transplant, the Participant must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The diagnosis of the major organ failure must be made by a Specialist.

Definition - Definite diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy, or pseudo bulbar palsy, and limited to these conditions.

The diagnosis of Motor Neuron Disease must be made by a Specialist.

Definition - Definite diagnosis of at least one of the following occurring after the effective date of coverage:

• two or more separate clinical attacks confirmed by at least one magnetic resonance imaging (MRI) of the nervous system, showing multiple lesions of demyelination;
• a single attack, with objective neurological deficits lasting more than 6 months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination; or
• a single attack, confirmed by repeated MRI of the nervous system, which shows multiple new lesions of demyelination which have developed at intervals at least one month apart.

The diagnosis of Multiple Sclerosis must be made by a Specialist.

Neurological deficits must be detectable by a Specialist and may include, but are not restricted to, measurable loss of hearing or vision, measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia (difficulty with speech), dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination, or new-onset seizures undergoing treatment. Headache or fatigue will not be considered a neurological deficit.

Exclusions - No benefit is payable for the following:

• solitary sclerosis;
• clinically isolated syndrome;
• radiologically isolated syndrome;
• neuromyelitis optica spectrum disorders; or
• suspected multiple sclerosis or probable multiple sclerosis.

1-Year Exclusion: No benefit will be payable under this condition if, within the first year following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations leading directly or indirectly to a diagnosis of multiple sclerosis regardless of when the diagnosis is made; or
• a diagnosis of multiple sclerosis.

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Multiple Sclerosis or, any critical illness caused by multiple sclerosis or its treatment.

Definition - Definite diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis, haemorrhage or embolism with:

• acute onset of new neurological symptoms; and
• new objective neurological deficits on clinical examination, persisting continuously for more than 30 days following the date of diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing showing changes that are consistent in character, location and timing with the new neurological deficits.

The diagnosis of Stroke must be made by a Specialist.

Neurological deficits must be detectable by a Specialist and may include, but are not restricted to, measurable loss of hearing or vision , measurable changes in neuro-cognitive function, objective loss of sensation, paralysis, localized weakness, dysarthria (difficulty with pronunciation), dysphasia, (difficulty with speech) dysphagia (difficulty swallowing), impaired gait (difficulty walking), difficulty with balance, lack of coordination, or new-onset seizures undergoing treatment. Headache or fatigue will not be considered a neurological deficit.

Exclusions - No benefit is payable under this condition for:

• transient ischaemic attacks;
• intracerebral vascular events due to trauma;
• ischaemic disorders of the vestibular system;
• death of tissue of the optic nerve or retina without total loss of vision of that eye; or
• lacunar infarcts which do not meet the definition of Stroke as described above.

Definition - Definite diagnosis of infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the Participant’s normal occupation, which exposed the person to HIV contaminated body fluids.

The accidental injury leading to the infection must have occurred after the effective date of the coverage.

Payment under this condition requires satisfaction of all of the following:

a) The accidental injury must be reported to Blue Cross within 14 days of the accidental injury;

b) A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative;

c) A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;

d) All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America; and

• The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines.

The diagnosis of Occupational HIV Infection must be made by a Specialist.

Exclusions - No benefit is payable under this condition if:

• The Participant has elected not to take any available licensed vaccine offering protection against HIV;
• A licensed cure for HIV infection becomes available prior to the accidental injury; or
• HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

Definition - Definite diagnosis of the total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event.

The diagnosis of Paralysis must be made by a Specialist.

Parkinson’s Disease:

Definition - Definite diagnosis of primary Parkinson’s Disease, a permanent neurologic condition which must be characterized by bradykinesia (slowness of movement) and at least one of: muscular rigidity or rest tremor. The Participant must exhibit objective signs of progressive deterioration in function for at least one year, for which the treating neurologist has recommended dopaminergic medication or other generally medically accepted equivalent treatment for Parkinson’s Disease.

Specified Atypical Parkinsonian Disorders:

Definition - Definite diagnosis of progressive supranuclear palsy, corticobasal degeneration or multiple system atrophy.

The diagnosis of Parkinson’s Disease or a Specified Atypical Parkinsonian Disorder must be made by a neurologist.

1-Year Exclusion: No benefit is payable for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders if, within the first year following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations leading directly or indirectly to a diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of parkinsonism, regardless of when the diagnosis is made; or
• a diagnosis of Parkinson’s Disease, a Specified Atypical Parkinsonian Disorder or any other type of parkinsonism.

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or, any critical illness caused by Parkinson’s Disease or Specified Atypical Parkinsonian Disorders or its treatment.

Exclusions - No benefit is payable under Parkinson’s Disease and Specified Atypical Parkinsonian Disorders for any other type of parkinsonism.

Definition - Definite diagnosis of third-degree burns over at least 20% of the body surface. The diagnosis of Severe Burns must be made by a Specialist.

Definition - An interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood. The procedure must be determined to be Medically Necessary by a Specialist.

Definition - A non-invasive cancer that must be confirmed by biopsy. The diagnosis of ductal carcinoma in situ of the breast must be made by a Specialist.

90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations, that lead to a diagnosis of Cancer, regardless of when the diagnosis is made; or
• a diagnosis of Cancer.

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for cancer, or any critical illness caused by any cancer or its treatment.

Definition - The diagnosis of stage A (T1a or T1b) prostate cancer must be made by a Specialist and confirmed by pathological examination of prostate tissue.

90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations, that lead to a diagnosis of Cancer, regardless of when the diagnosis is made; or
• a diagnosis of Cancer.

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for cancer, or any critical illness caused by any cancer or its treatment.

Definition - A melanoma confirmed by biopsy to be less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion. The diagnosis of state 1A malignant melanoma must be made by a Specialist.

90-Day Exclusion: No benefit is payable under this condition if, within the first 90 days following the effective date of coverage, the Participant has any of the following:

• signs, symptoms or investigations, that lead to a diagnosis of Cancer, regardless of when the diagnosis is made; or
• a diagnosis of Cancer.

Medical information about the diagnosis and any signs, symptoms or investigations leading to the diagnosis must be reported to Blue Cross within 6 months of the date of the diagnosis. If this information is not provided within this period, Blue Cross has the right to deny any claim for cancer, or any critical illness caused by any cancer or its treatment.

Definition - an organic defect in brain development characterized by failure to develop communicative language or other forms of social communication, with the diagnosis confirmed either by a pediatric psychiatrist or a pediatrician before the Child’s third birthday.

Definition - a definitive diagnosis of Cerebral Palsy, a non-progressive neurological defect characterized by spasticity and in coordination of movements.

Definition - any one or more diagnosis(es) from the following lists of heart conditions:

List A

a) Total Anomalous Pulmonary Venous Connection;

b) Transposition of The Great Vessels;

c) Atresia of any heart valve;

d) Coarctation of the Aorta;

e) Single Ventricle;

f) Hypoplastic Left Heart Syndrome;

g) Double Outlet Left Ventricle;

h) Truncus Arteriosus;

i) Tetralogy of Fallot;

j) Eisenmenger Syndrome;

k) Double Inlet Ventricle;

l) Hypoplastic Right Ventricle; or

• Ebstein's Anomaly.

The above conditions are covered after a 30-day Survival Period, beginning from the later of the date of diagnosis or birth. The diagnosis of any of the conditions in List A must be made by a qualified pediatric cardiologist and supported by appropriate cardiac imaging.

List B

a) Pulmonary Stenosis;

b) Aortic Stenosis;

c) Discrete Subvalvular Aortic Stenosis;

d) Ventricular Septal Defect; or

e) Atrial Septal Defect.

The above conditions are covered only when open heart surgery is performed for correction of the condition after a 30-day Survival Period from the later of the date of diagnosis or birth. The diagnosis of any of the conditions in this List B must be made by a qualified pediatric cardiologist and supported by appropriate cardiac imaging. The surgery must be recommended by a qualified pediatric cardiologist and performed by a cardiac surgeon in Canada.

Definition - a definitive diagnosis of Cystic Fibrosis with evidence of chronic lung disease and pancreatic insufficiency.

Definition - a definitive diagnosis of Down Syndrome by a qualified Specialist.

Definition - a definitive diagnosis of Muscular Dystrophy, characterized by well-defined neurological abnormalities, confirmed by electromyography and muscle biopsy.

Definition - a diagnosis of Type 1 Diabetes Mellitus, characterized by absolute insulin deficiency and continuous dependence on exogenous insulin for survival. The diagnosis must be made by a qualified pediatrician or endocrinologist licensed and practicing in Canada, and there must be evidence of dependence on insulin for a minimum of 3 months.