When applying for critical illness most people may consider they are taking out a policy that will pay out in the event of a major illness, such as heart attack, stroke, cancer, multiple sclerosis, angioplasty or major organ transplantation. However, critical illness benefits also cover other conditions that may be equally devastating.
The conditions may not only be caused by disease, but can also be caused by trauma or accident.
Coma
According to the ABI, a coma is "a state of unconsciousness with no reaction to external stimuli or internal needs, persisting continuously with the use of life support systems for a period of at least 96 hours and resulting in permanent neurological deficit. Coma secondary to alcohol or drug abuse is not covered."
Coma can be described as a complete lack of consciousness, awareness of external surroundings, and the inability to respond meaningfully to external stimuli. A coma can be caused by a number of conditions or precipitating factors:
l Tumours.
l Intoxication (drug, alcohol or toxin).
l Physical injuries to the brain, an example may be trauma following a road traffic accident.
l Strokes can cause a sudden loss in consciousness, as there may be a rupture or blockage of the vessels carrying oxygenated blood to the brain.
l Seizure activity such as epilepsy.
The type of coma depends upon the origin of the trauma. Simple concussions can cause loss of consciousness for a short period of time. However, a lack of oxygen to the brain may result in a coma that can last for several weeks and can often be fatal. Investigations that can be carried out are as follows:
l CT scan of the head: a series of x-rays taken at different levels of the brain that allows the direct visualisation of the skull and intracranial structures.
l EEG (electroencephalogram): a procedure that uses electrodes on the scalp to record electrical activity of the brain.
l X-rays of the head.
The longer a person is in a coma, the less promising the outcome tends to be.
One study suggested that if the coma is fewer than 12 hours in duration then there may be little damage. If the coma lasts more than 12 hours the recovery may be slow and incomplete. However, it can be difficult to predict the level of recovery.
The initial stage of recovery includes intensive medical procedures. Long-term management can involve considerable concerns, such as physiotherapy to joints and muscles; risk of deep vein thrombosis; and maintenance of an adequate oxygenated blood supply, with artificial ventilation.
After the acute care stage and following awakening from coma there can be a long road to rehabilitation. The rate of recovery may be most rapid during the initial weeks. Following this there can be a slow down in the rate of recovery.
This process has to be faced by both the patient and their family. The process will have to address many of the effects of prolonged coma or permanent neurological deficit, which can include:
l Intellectual impairment.
l Speech problems.
l Behavioural changes, and a variety of physical disabilities.
Since recovery can continue for years, the need for help in coping with the stress of such long term care giving is very real and as such there may be a need for financial assistance.
When considering a critical illness claim for coma it is more likely that the cause may have been trauma, as such causes like a stroke or tumour may be covered by these specific conditions. As per the definition, we would not consider a simple concussion as a claim, because there is no long-term neurological deficit. However, a claim may be considered following "a coma lasting more than 96 hours which required life support and resulted in permanent neurological deficit." As already discussed there will almost certainly be a need for some financial expenditure, such as ongoing nursing, an occupational/speech therapist or special equipment to cope with any ongoing disablement.
The definition states that a claim will not be paid if the coma is secondary to alcohol or drug abuse. In some cases there may not be an obvious link between alcohol, drug abuse and the coma. However, in others there may be a clear-cut link, for example when the life assured has been admitted to hospital due to a coma following a drug overdose.
Blindness
The ABI defines blindness as "total, permanent and irreversible loss of sight in all eyes."
Consider what would happen if you lost your eyesight. How would this affect your lifestyle? Blindness is the inability to see or perceive visual stimuli which can be caused by disease, tumour, or by trauma and visual impairment can be total or partial.
A claim would only be considered where blindness was total, permanent and irreversible in both eyes. This is because partial blindness can be corrected by surgery, or by the use of glasses or contact lenses. Also, a claim would not be considered where blindness is temporary, for example, exposure to chemicals or bright light as after a period of time eyesight will be restored.
However, if a person was totally blind there would almost certainly be a financial need, whether to cover loss of earnings or to provide assistance or medical aids.
Deafness
Deafness is defined as "total, permanent and irreversible loss of all hearing in both ears," by the ABI.
Where deafness is partial this can be aided by surgery or by the use of hearing aids and is outside the scope of the definition. Also, a claim would not be considered where deafness is temporary, for example, damage to hearing following exposure to extreme noise including explosions, where after a period of time hearing may improve. A claim would only be considered where deafness is total, permanent and irreversible, as there may be a need for financial help, to replace loss of income.
Burns
Third degree burns are recognised by the ABI as "third degree burns covering at least 20% of the body surface area."
Skin is very important it protects the body from infection, regulates body temperature and allows people to touch and feel.
Burns are classified according to the amount of damage and to what depth the damage is. First degree burns (superficial) only affect the outer layer of the skin (epidermis). Second degree (partial-thickness) burns are those where the outer layer of the skin has been burned through and the second layer (dermis) of skin is also burned. However, extensive third degree burns can require treatment at a burn care unit. With third degree burns (full-thickness) all the layers of the skin are damaged and sometimes nerve, tendon, muscle and even bone can be damaged.
Burns can also be classified by the amount of the body affected those affecting 15 to 20% of an adult's body are major injuries.
First and second degree burns can normally be treated with simple first aid measures, dependent upon the area affected and are hence outside the scope of the cover. The initial treatment for third degree burns will depend upon the extent and depth of the injuries. Major burns can be fatal or disfiguring, and can cause both physical and emotional distress. However, if the burns are deep and covering a large part of the body, skin grafts may be necessary. This process can take many months, even years to complete. Therefore, if time is needed to treat burns then there may be loss of income or even the need for elective plastic surgery. If the burns were superficial there would be less need for extended time off work or major surgery.
The cover traditionally provided by these critical illnesses has been priced on the basis that only the more severe forms are covered by the definition. If the definitions were widened to include the others discussed then this would have a dramatic effect on the number of claims submitted and paid, which as a consequence would result in a dramatic increase in premiums.
Martin Williams is a life and disability underwriter at Scottish Equitable Protect
