income protector - hellens and white brokershellensandwhitebrokers.co.za/files/momentum income...

Income Protector

While we have taken reasonable care in compiling this broker guide, Momentum, a division of MMI Group Limited, its subsidiaries and associates do not warrant the accuracy of information contained in the broker guide and disclaim all liability for any loss, damage or expense of any nature whatsoever that may be attributed, directly or indirectly, to reliance placed on information contained in this broker guide. Where there is a conflict between provisions of this broker guide and the provisions of the policy contract, the provisions of the policy contract will prevail. In this brochure, references to the male gender include the female gender and vice versa.

Momentum, a division of MMI Group Limited, an authorised financial services and credit provider.

Broker Guide 1 August 2015

Income Protector

Description .......................................................................................................................................................................... 2

Special conditions ............................................................................................................................................................... 2

Definition of income ............................................................................................................................................................. 2

Type of benefit .................................................................................................................................................................... 3

Eligible lives ........................................................................................................................................................................ 3

Age limits ............................................................................................................................................................................. 3

Benefit term ......................................................................................................................................................................... 3

Benefit limits ........................................................................................................................................................................ 3

Momentum Interactive ......................................................................................................................................................... 3

Premium patterns ................................................................................................................................................................ 3

Premium guarantee ............................................................................................................................................................. 4

Increase options .................................................................................................................................................................. 4

Additional features .............................................................................................................................................................. 4

Ancillary benefits ................................................................................................................................................................. 5

Beneficiaries and cessions .................................................................................................................................................. 5

Waiting period ..................................................................................................................................................................... 5

Off period ............................................................................................................................................................................ 6

Claim event ......................................................................................................................................................................... 6

Claim amount ...................................................................................................................................................................... 8

Benefit reductions ............................................................................................................................................................. 10

Income tax ......................................................................................................................................................................... 11

Annual Income Commutation Option ................................................................................................................................ 11

Guaranteed insurability ..................................................................................................................................................... 12

Conversion option ............................................................................................................................................................. 12

Benefit termination events ................................................................................................................................................. 12

Factors affecting monthly benefit payments ...................................................................................................................... 12

Ongoing assessment events ............................................................................................................................................. 13

Functional impairment claim events for Income disability and impairment benefits .......................................................... 14

Critical illness claim events for Income disability and impairment benefits ........................................................................ 26

Critical illness benefit definitions ....................................................................................................................................... 31


Income Protector Description

Momentum will pay a monthly claim amount if:

• the insured life is temporarily or permanently disabled as a result of a bodily injury or

illness to such an extent that he is continuously unable to perform the main duties of his

own occupation on a total or partial basis

OR

• the insured life meets the requirements of one of the defined impairment or illness claim

events.

Special conditions

The claim amount is paid monthly in arrears.

A proportionate payment will be made in respect of any part of a month should the insured

life be rehabilitated before the payment date.

Following rehabilitation, the insured life will retain his cover.

The premium will be waived for this benefit while a claim is being paid.

The policyholder and the insured life must be the same person if the benefit is owned by a

natural person. The policyholder must own 100% of the policy.

Only one Income Protector may be taken per policy.

Annual premiums are not allowed on the Income Protector.

Definition of income

Income is defined as one of the following:

Gross Taxable Income

• The total sum of all taxable income payable or benefits receivable on account of the

insured life's employment, or any services rendered by the insured life.

Cost to Company income

This equals Gross Taxable Income plus:

• the value of any fringe benefits (as provided for in the Income Tax Act) awarded to the

employee,

• retirement fund contributions made by the life insured’s employer,

• the cost of any other benefits paid for by the insured life’s employer, and

• any dividends received by the life insured due to shareholding or member’s interest held

in the employer (where the employer is a company or close corporation).

Gross Professional Income (professionals only)

• For professionals that charge a fee for services this equals the sum of the professional

fees and the net income from trading activities, after deducting business overheads

expenses.


Net income is defined as:

• Income (as defined above) less income tax payable on this Income (determined by

applying the relevant year of assessment’s income tax tables).

Momentum will use the income definition that results in the highest net income when

calculating loss of income or benefit reductions.

Pre-disability net income will be increased by inflation from the date of the claim event to the

date on which the loss of income is calculated.

Type of benefit

Stand-alone

Eligible lives

All lives are eligible subject to age limits and underwriting.

Age limits

Minimum entry age 15 next birthday

Chosen expiry age

(next birthday)

Maximum entry age (next birthday)

Level 5% Compulsory 6% or 7%

Compulsory

To age 55 50 45 40

To age 60 55 50 45

To age 65 60 55 50

To age 70 60 55 50

Benefit term

To the chosen expiry age

Minimum term - 5 years

Benefit limits

Benefit limits

Minimum monthly benefit amount R2 000

Maximum monthly benefit amount R110 000

R150 000 (Professionals)

The monthly benefit amount is limited to 75% of the insured life's net monthly income.

The combined insured amount under the Income Protector and Temporary Income Protector

will be limited to ensure that the insured life will not be able to receive a benefit exceeding

100% of net income in a given month.

Momentum Interactive

The policyholder may choose to link this benefit to Momentum Interactive.

Premium patterns

Level


Compulsory (5%, 6% or 7%)

Premium guarantee

The premium guarantee term will be calculated.

Increase options

Choice between

Premium pattern Benefit increases

Level 0%, 5%, 7.5%, 10%, CPI

Compulsory (5%, 6%, 7%) 0%, 5%, 7.5%, 10%, CPI

If the insured life chose to have voluntary benefit amount increases, then:

• the monthly pre-claim benefit amount will increase on every benefit anniversary date,

and

• the monthly post-claim benefit amount will increase on the claim anniversary date, at

the chosen benefit increase percentage limited to a maximum of the general increase in

the CPI.

If the CPI increase option is selected, pre-claim increases will be limited to 15% per year

and post-claim increases will be limited to 10% per year.

Claim increase booster for young professionals

• In addition to the above increase, the monthly post-claim benefit amount will increase

by an additional percentage for professional occupations (as defined by Momentum).

This additional increase will be based on the insured life’s age next birthday on the

claim anniversary.

Age next birthday Percentage increase

26 and younger 15%

27 12%

28 9%

29 6%

30 3%

31 and older 0%

• Once the insured life turns 31 next birthday, only the monthly post-claim benefit amount

increase will apply.

• The insured life must have selected benefit amount increase to qualify for the claim

increase booster.

• The post-claim benefit amount increase is calculated as:

− Minimum (benefit amount increase and CPI) plus

− Additional increase percentage as shown in the table above

Additional features

Free cover


Retirement Booster (only available if the policyholder has a qualifying retirement annuity).

Ancillary benefits

Longevity ProtectorTM – Income Protector

Complete Family Protector– Income Protector

Income Enhancer – Income Protector

Beneficiaries and cessions

The policyholder may not nominate any beneficiaries.

Cessions are not allowed.

Waiting period

The policyholder may choose one of the following waiting periods:

• 7 days (only applicable to self-employed individuals)

• 1 month

• 3 months

• 6 months

• 12 months

• 24 months.

Premiums are payable during the waiting period.

If the insured life dies within the waiting period, a disability claim will not be paid.

The first monthly claim amount payment will be made only after the insured life has been

disabled for the waiting period that he chose.

Claim amount payments for functional impairment, critical illness or fracture and

hopitalisation will only be made after the waiting period has expired.

7-day waiting period

• The premium due under this benefit will be waived, after the insured life has been

continuously disabled for at least 28 days.

• The claim amount payments will be made every seven days after the waiting period has

expired.

• The insured life may qualify for a retrospective payment from day one of benefits after

the 7-day waiting period in respect of disability. The first payment will be made seven

days after the claim event occurred.

• After the insured life has been continuously disabled for 28 days, claim payments will be

made monthly in arrears.

• A proportionate payment will be made in respect of any part of a month that the insured

life is rehabilitated before the payment date.

• In order to qualify for a retrospective payment the insured life must be disabled for at

least seven days and the insured life's disability must NOT be as a result of one of the

following:

− Cosmetic surgery

− Influenza and bronchitis*

− Mental or psychiatric disorders*

− Gastric influenza*


− Gastritis*

− Constipation*

− Diarrhoea*

− Headaches and migraines*

− Stress-related disorders

− Chronic fatigue syndrome

− Laryngitis, sinusitis and pharyngitis

− Abortions

− Surgical procedures for infertility

− Back injury

− Fibromyalgia

*These conditions will be covered if they require hospitalisation for longer than 24 hours.

Off period

An "off period" of three months applies.

This means that if the insured life is rehabilitated and claims again for the same cause within

the three months, the waiting period will be waived.


The "off period" will only apply after the policyholder has been continuously disabled for at

least 28 days.

Claim event

The insured life can qualify for a claim under either:

• occupational disability or

• impairment or illness.

Occupational disability

• Temporary or permanent disability caused by a bodily injury or an illness to such an

extent that the insured life is continuously unable to perform the main duties of his own

occupation on a total or partial basis.

• A claim amount will only be paid if the insured life is unable to perform at least 25% of

the main duties of his own occupation. The claim amount payment will end once the

insured life has recovered to the extent that he can perform more than 75% of the main

duties of his own occupation.

• The claim amount will be calculated according to the loss of income or the severity of

disability criteria.

OR

Impairment or illness

The insured life can qualify for a claim under:

• functional impairment or

• critical illness or

• fracture and hospitalisation

Momentum will pay for the event that provides the highest payout if the insured life qualifies

for a claim amount payment under more than one of the impairment or illness claim events.


If the insured life still qualifies for a functional impairment claim after a critical illness, fracture

or hospitalisation claim has been paid, we will continue to pay the defined payment for the

balance of the payment period.

Functional impairment:

• The claim events are not in any way linked to the insured life's ability to perform

occupational activities.

• The claim amount is based on the severity of a medical impairment which occurs after

the starting date of the benefit as diagnosed by an appropriate specialist (registered

with the Health Professions Council of South Africa (HPCSA)) and resulting in the

specified functional restrictions defined below.

• The insured life will not be able to claim under functional impairment after the chosen

expiry age.

• The insured life must undergo reasonable optimal treatment and his functional

impairment will be determined after he has reached (reasonable) Maximal Medical

Improvement (MMI). At this stage, a specialist approved by Momentum must declare

the functional impairment total, permanent and continuous for the foreseeable future.

The insured life will not be required to undergo reasonable optimal treatment if a

specialist, that Momentum has approved, has established that the functional impairment

is permanent and that further treatment will not lessen the severity of the condition.

− Reasonable optimal treatment: This is the treatment that Momentum may reasonably

expect the insured life to undergo according to the guidelines for the specific condition

under the generally accepted medical practice at claim stage. It is expected that the

insured life comply with his treatment routine.

− Maximal Medical Improvement (MMI): A condition or state that is well stabilised and

unlikely to change substantially in the next year with or without medical treatment.

There may be some change over time, but further recovery is not expected.

• A panel of accredited medical specialists will determine how many Activities of Daily

Living (ADL) the insured life is able to perform.

• A claim will be admitted only if the claim event is a permanent condition.

• Momentum will pay for the event that provides the highest payout if the insured life

qualifies for a claim amount payment under more than one of the impairment events.

OR

Critical illness

• Momentum will pay a percentage of the benefit amount if the insured life meets the

requirements of one of the defined critical illnesses claim events.

• A critical illness claim amount payment is only applicable to benefits with a 7-day, one

month or three month waiting period.

• Momentum will not pay for a subsequent critical illness claim event that occurs while the

insured life is receiving a critical illness claim amount payment.

OR


Fracture and hospitalisation

• Momentum will pay a percentage of the benefit amount if the insured life meets the

requirements of one of the defined fracture and hospitalisation claim events.

• A fracture and hospitalisation claim amount payment is only applicable to benefits with a

7-day or one month waiting period.

• Momentum will pay for the event with the longest payment period if the insured life

qualifies for a payment under more than one of the defined fracture or hospitalisation

claim events.

• Momentum will not pay for a subsequent claim event for fracture or hospitalisation that

occurs while the insured life is receiving a fracture and hospitalisation claim amount

payment.

Fracture and hospitalisation Waiting period

7-day 1-month Other

Thigh N/A

Pelvis N/A

Leg between knee and foot N/A

Kneecap N/A

Upper arm N/A

Shoulder blade N/A

Hand requiring plaster or surgery N/A N/A

Forearm above the wrist N/A N/A

Collarbone N/A N/A

Hospitalisation longer than a week N/A N/A

Claim amount

The monthly claim amount will be the higher of the claim amount calculated according to the

following assessment criteria:

• loss of income

• severity of disability

• severity of impairment or illness

Loss of income

• Momentum will pay the actual loss of income up to the maximum of the benefit amount.

• The actual loss of income is calculated as being the difference between the insured

life’s net pre-disability income and any net income that the insured life earns during the

period of disability.

• Two years after the claim event the actual loss of income is calculated as the difference

between 75% of the insured life’s net pre-disability income and any net income that the

insured life earns during disability.


Net income refers to gross income less income tax payable on this income (determined by

applying the relevant year of assessment’s income tax tables).

Severity of disability

• The severity of disability assessment criteria, including the partial claim upgrade, will

only apply during the first year after the claim event. For professional occupations this

criteria will apply for the first two years after the claim event.

• The claim amount will be between 25% and 100% of the benefit amount, depending on

the extent to which the insured life is unable to perform the main duties of his own

occupation.

• Partial claim upgrade

− If the full benefit amount has been paid for a continuous period of three months, the

insured life will qualify for a partial claim upgrade.

− Momentum will continue to pay the full benefit amount after the three month period,

provided that the insured life is partially disabled

− The full benefit amount will only be paid while the severity of disability assessment

criteria applies (first year after the claim event or first two years after the claim event for

professionals).

Severity of impairment or illness

• Momentum will pay a percentage of the benefit amount for a specified payment period if

the insured life meets any of the requirements for functional impairment, critical illness

or fracture and hospitalisation claim events.

Functional impairment

Severity level Payment percentage Payment period

25% 25% 2 years

50% 50% 5 years

75% 75% Until benefit expiry

100% 100% Until benefit expiry

Critical illness

Severity level

Payment percentage

Payment period

7-day

waiting period

1-month waiting period


Other waiting periods

100% 100% 6 months 5 months 3 months No payment




Payment percentage

Payment period

7-day waiting

period


Other waiting periods

Thigh 100% 3 months 2 months No payment

Pelvis 100% 3 months 2 months No payment

Leg between knee

and foot 100% 2 months 1- month No payment

Kneecap 100% 2 months 1- month No payment

Upper arm 100% 2 months 1- month No payment

Shoulder blade 100% 2 months 1-month No payment

Hand requiring

plaster or surgery 100% 1-month No payment No payment

Forearm above

the wrist 100% 1-month No payment No payment

Collarbone 100% 1-month No payment No payment

Hospitalisation

longer than a

week 100% 1-month No payment No payment

• The daily claim amount will be calculated as 1/30 of the monthly benefit amount.

• The monthly claim amount will be reduced by any benefit reduction as described below.

• Please note: Any outstanding debt will be deducted from the claim amount.

Benefit reductions

The claim amount will be reduced if:

• the benefit amount exceeds 75% of the insured life’s pre-disability net income or

• the policyholder is receiving a disability income from another insurance policy contract

as a result of the insured life’s disability.

Benefit amount exceeds 75% of pre-disability net income

• The benefit amount will be reduced to ensure that it does not exceed 75% of the

insured life’s pre-disability net income.

Income from other income disability policy contracts

• In the first two years after a claim, the claim amount will be reduced to ensure that the

total of the claim amount payment and the income from the other policy contract does

not exceed 100% of the insured life’s pre-disability net income.


• After two years this will be done to ensure that the total does not exceed 75% of the

insured life’s pre-disability net income.

Pre-disability net income will be calculated as the insured life’s net income (as defined under

Definition of income) averaged over the period of 12 months immediately preceding the date

of disability.

Any Functional Protector or Complete Functional Protector claim amount paid to the

policyholder will not be taken into account in the benefit reduction calculations.

Payments for lump sum disability benefits are specifically excluded for the benefit reduction

calculation.

Income tax

If the benefit is owned by a natural person, the premiums are not tax-deductible.

The claim amount payable in terms of this benefit will be tax-free.

Annual Income Commutation Option

If the insured life is totally and permanently disabled, the policyholder will have the option to

convert up to one year’s monthly claim amount payments for this benefit and have it paid out

as a lump sum.

The commutation feature may only be accessed after permanency has been established,

but not before the second claim anniversary.

Every year on the claim anniversary, from the second claim anniversary onwards, the

policyholder will have the option to convert either 0%, 25%, 50%, 75% or 100% of one

year’s monthly claim amount payments for this benefit to a lump sum payment.

Momentum will notify the policyholder as soon as permanency has been established, of the

option to convert. This feature must be exercised not later than two months before the

subsequent claim anniversary.

Conversion of the full monthly payment

• If the policyholder chooses to convert 100% of one year’s monthly claim amount

payments, it will be paid in the form of a single lump sum amount.

• This payment will be made on the next available payment date, following the


Conversion of a portion of the monthly payment

• If the policyholder chooses a lump sum conversion percentage that is less than 100%,

the first payment following the subsequent claim anniversary will consist of one year’s

monthly accumulated claim payments that are calculated using the chosen percentage.

• The monthly payments following the lump sum payment will also be calculated using

the chosen conversion percentage.

• The first payment will be made on the next available payment date, following the


The current commutation factor is 11.5 for the lump sum calculations.


Guaranteed insurability

Momentum will allow policyholder to increase the benefit amount without any medical

underwriting after the benefit anniversary if the insured life's income increases at a rate that

exceeds the maximum voluntary benefit amount increase percentage.

The total annual increase (annual voluntary benefit amount increase plus the guaranteed

insurability increase) will be limited to twice the inflation rate used for increases by

Momentum at that point, capped to 20%.

This additional benefit amount increase may not be exercised if:

• the insured life is over the age of 55

• voluntary benefit amount increases were not selected

• The insured life is already disabled or was disabled during the 12 months preceding the

date of the benefit amount increase

• a health loading applies to the insured life

Momentum must receive a written request to increase the benefit amount within one month

after the benefit anniversary.

Conversion option

The policyholder has the option to convert this benefit to one of the following benefits:

• Functional Protector

• Comprehensive Functional Protector

These benefits pay a monthly claim amount for the remainder of the insured's life if he is

permanently impaired.

The benefit amount being converted is subject to the maximum benefit limit for the chosen

benefit at the time of the conversion.

Medical underwriting will be required if:

• any specific exclusion applies to this benefit, or

• a health or occupational loading applies to this benefit.

Benefit termination events This benefit ends on the earliest of:

• The death of the insured life.

• The end of the benefit term.

• Conversion to a Functional Protector or a Comprehensive Functional Protector.

• The cancellation of the policy or benefit as a result of:

− any event covered in the policy contract

− notification from the policyholder.

Factors affecting monthly benefit payments

The benefit payments end if:

• the insured life is no longer qualifies for a claim amount payment

• the benefit ends

• the insured life is not receiving the medical treatment suitable to his condition.


Ongoing assessment events


• Once a claim has been admitted and Momentum has started making the claim

payments, the insured life's health will be assessed at the end of every 7-day period.

• After the insured life has been disabled for at least 28 days, the insured life's health will

be assessed from time to time as Momentum may see fit.

• After the insured life has been disabled for at least 28 days, Momentum will cover the

cost of the reassessment by a doctor chosen by Momentum.

All waiting periods (except 7-day)

• Once a claim has been admitted and Momentum has started paying the monthly claim

amount, the insured life's health will be assessed from time to time.

• Momentum will cover the cost of the reassessment by a doctor chosen by Momentum.

General

• The ongoing assessment may be waived for the impairment or illness claim events.

• These assessments will determine whether the insured life still qualifies for a claim and

has been receiving such medical treatment as is appropriate for his condition. The

benefit payments will end if the insured life no longer qualifies for a claim. The insured

life will then need to start paying the applicable premium again.

• If the insured life fails to undergo the reassessment within three months of Momentum's

notification, the claim payments may be cancelled

• Following rehabilitation, the monthly benefit amount will start at the level of the last

benefit payment, and will increase on every benefit anniversary.


Functional impairment claim events for Income disability and impairment benefits

Impairment Description Payout %

Cardiovascular

system

• New York Heart Association (NYHA) Class III**

OR

• Ejection fraction (EF) <45%

50%

• New York Heart Association (NYHA) Class lV

OR

• Ejection fraction (EF) <40%

100%

** Regurgitant valve dysfunction and all cardiac diseases will be assessed on the basis of heart

function with NYHA OR LVEF after the insured life has reached the stage of "Maximum Medical

Improvement" (MMI). (Examples of diseases and disorders that will fall under this category:

Myocardial infarction, ischaemic heart disease, valvular disease and cardiomyopathy).

Arrhythmia

• Recurrent symptoms that require medical attention despite the use of dietary

therapy or drugs and of an artificial pacemaker, and a cardiac arrhythmia is

documented with an ECG

OR

• The insured life has recovered from surgery, a catheter procedure, or implantable

cardioverter defibrilator placement to treat arrhythmia and meets above criteria for

impairment

WITH

• The insured life is able to lead an active life and symptoms due to arrhythmia are

limited to infrequent palpitations and/or episodes of light-headedness,

presyncope, or temporary inadequate cardiac output.

50%

• Symptoms due to documented cardiac arrhythmia that is constant AND that

interfere with ordinary daily activities (functional class III or IV of the New York

Heart Association or ejection fraction (EF) < 45%).

OR

• The insured life has recovered from surgery, a catheter procedure, or implantable

cardioverter defibrilator placement to treat arrhythmia and continues to have

symptoms that cause the impairment outlined above.

WITH

• The insured life continues to have episodes of syncope that are either due to, or

have a high probability of being related to, arrhythmia. To fit into this category of

impairment, symptoms must be present despite use of dietary therapy, drugs, or

artificial pacemakers.

100%

Peripheral arterial

disease

Abnormal Doppler readings, cold leg, dependent rubor and pain on exercise as

confirmed by a vascular surgeon. 50%

No palpable pulses confirmed by absent Doppler readings, or severe vascular 100%



ulceration or gangrene as confirmed by a vascular surgeon.

Peripheral venous

disease

Severe deep and widespread vascular ulceration with evidence of veno-occlusive

disease as confirmed by a vascular surgeon. 50%

Hypertension

Uncontrolled, treatment-resistant hypertension, with end organ damage.

Will be assessed under the following:

• Cardiovascular impairment: refer to cardiovascular parameters.

• Renal impairment: refer to renal parameters.

• Neurological impairment: refer to aphasia, cranial nerves and hemiplegia.

• Visual impairment: refer to visual parameters.

Red blood cell

disorders

Hb 5-8g/dL and 2-3U transfusion every 4-6 weeks. 50%

Hb 5-8g/dL and 2-3U transfusion every 2 weeks. 100%

White blood cell

disorders

Scoring 4 or more on the Activities of Daily Living Scale (ADL). 50%


Clotting disorders Scoring 4 or more on the Activities of Daily Living Scale (ADL). 50%


Respiratory system

Impaired airflow with

• FEV1 ≤50%

OR

• FVC ≤50%

OR

• DCO ≤50%

50%

Impaired airflow with

• FEV1 ≤40%

OR

• FVC ≤40%

OR

• DCO ≤40%

100%

FEV1 stands for "Forced expiratory volume in 1 second".

FVC stands for "Forced vital capacity".

DCO stands for "Diffusing capacity for carbon monoxide".

A pulmonologist must perform the above tests and 3 readings should be recorded over a period of 3

months.

Pulmonary function tests, performed on standardised equipment with validated administration

techniques, provide the framework for evaluation of respiratory system impairment. Spirometric

testing equipment and administration techniques must conform to the guidelines of the 1994 ATS

(American thoracic society) Statement on Standardisation of Spirometry.



Gastro-intestinal tract

and Liver and Biliary

disease

• 15% weight loss below desirable weight due to organic disease of the gastro-

intestinal tract as confirmed by a gastroenterologist or other specialist (refer to

tables in AMA Guide)

OR

• Progressive chronic liver disease with at least 2 of the following:

− S-bilirubin in the range of 34-51 micromol/L

− S-albumin in the range of 30-35 g/L

− Prothrombin time: 4-6 sec prolonged / INR: 1.7-2.3

− Ascites easily controlled with medical therapy.

OR

• Partial faecal incontinence unresponsive or not amenable to therapy with medical

evidence of organic disease. Please also refer to comments under Anorectal

Impairment

OR

• Irreducible hernia after failed surgical repair for hernia with prior complications.

50%

• Greater than 25% weight loss below the desirable weight due to organic disease

of the Gastro intestinal tract as confirmed by a gastroenterologist or other

specialist (refer to tables in AMA-guide).

OR

• Progressive chronic liver disease with at least 2 of the following:

− S-bilirubin more than 51 micromol/L

− S-albumin less than 30 g/L

− Prothrombin time, more than 6 sec prolonged /

INR > 2.3

− Poorly controlled ascites

− Advanced hepatic encephalopathy.

OR

• Irreparable biliary tract obstruction with cholangitis, persistent jaundice and

progressive liver disease as certified by surgeon or gastroenterologist.

OR

• Complete faecal incontinence unresponsive or not amenable to therapy with

medical evidence or organic disease

OR

• Inability to swallow and confirmed physiological/neurological disorder where

medical intervention has been indicated.

OR

• Irreparable hernia with ongoing bowel dysfunction as evidenced by ongoing and

recurrent diarrhoea, bloody stool with or without stomach cramps or constipation

or recurrent bowel dysfunction.

100%

Anorectal impairment

Insured life has no reflex regulation or voluntary control of the anus or rectum due to

permanent impairment where medical evidence of organic pathology has been proven.

(See Gastro-intestinal Tract).

100%



Impairment of the

bladder

The insured life has no reflex regulation or voluntary control of the bladder due to

permanent impairment where medical evidence of organic pathology has been proven. 100%

Renal system

End-stage renal disease with a creatinine clearance of 28-42ml/min (40-60L/24h) as

confirmed by a urologist or nephrologist. 50%

• End-stage renal disease with a creatinine clearance below 28ml/min (40L/24h).

OR

• Renal function deterioration that requires permanent peritoneal dialysis or

haemodialysis as confirmed by a urologist or nephrologist.

100%

Endocrine system.



Eg. Hypothalamic pituitary axis, hypoadrenalism, hyperadrenocorticism, phaeochromocytoma

Diabetes Mellitus -

Type 1 and 2

Momentum will consider a claim if there is end organ damage under the following:

• Cardiovascular impairment - refer to cardiovascular parameters.

• Renal impairment - refer to renal parameters.

• Visual impairment - refer to visual parameters.

Gait disorders

Rises and maintains standing position with difficulty and cannot walk without assistance. 50%

Cannot stand without help, mechanical support and/or an assistive device. 100%

A gait disorder only refers to disorders of the cerebellum.

Impairment of

consciousness and

awareness

Irreversible unconsciousness/coma of an organic nature and not amenable to therapy. 100%

Psychiatric condition

Scoring 4 or more on the Activities of Daily Living Scale. Diagnosis according to DSM lV

classification and certification by a specialist psychiatrist. 50%

Scoring 6 or more on the Activities of Daily Living Scale. Diagnosis according to DSM lV

classification and certification by a specialist psychiatrist. 100%

Epilepsy

• Uncontrolled, treatment-resistant, generalised seizures or epilepsy as certified by a

specialist or neurologist to verify reasonable treatment with loss of independent

existence.

OR

• Permanent neurological deficits of focal or generalised nature confirmed

radiologically and clinically by a specialist or neurologist.

100%

Dementia

Must fall into the CDR 1.0 rating (refer to Clinical Dementia Rating table). 50%

Must fall into the CDR 2.0 rating (refer to Clinical Dementia Rating table). 100%

Aphasia A total and permanent loss of the ability to express himself by speech, writing, or signs,

or to comprehend spoken or written language, due to injury or disease of the brain as 100%



confirmed by a specialist or neurologist.

There must be permanent deficits in the formal aspects of language such as naming,

word choice, comprehension, spelling and syntax.

Hearing

Total, permanent and irreversible loss of hearing in one ear, as confirmed by audiometry

and an ear, nose and throat surgeon. 25%

60% Binaural hearing loss measured by audiometry and interpretation of Decibel sum of

the hearing thresholds at 500, 1000, 2000 and 3000 Hz. An ear, nose and throat

surgeon needs to confirm this.

50%

Total, permanent and irreversible loss of hearing in both ears, as confirmed by

audiometry and an ear, nose and throat surgeon. 100%

Visual

Total, permanent and irreversible loss of sight of one eye as confirmed by an

ophthalmologist. 25%

• Bilateral visual impairment of 50%; that is a reading of 20/125 (or equivalent

measure) in both eyes as confirmed by an ophthalmologist.

OR

• Diabetic retinopathy grade III. An ophthalmologist needs to confirm this.

OR

• Permanent Hemianopia. An ophthalmologist needs to confirm this.

OR

• Hypertensive retinopathy grade III. An ophthalmologist needs to confirm this.

50%

• Bilateral visual impairment of 70% that is a reading of 20/200 in both eyes as

confirmed by an ophthalmologist.

OR

• Diabetic retinopathy grade IV. An ophthalmologist needs to confirm this.

OR

• Hypertensive retinopathy grade IV. An ophthalmologist needs to confirm this.

100%

Speech

50% Speech impairment as confirmed by an ear, nose and throat surgeon, neurologist

or neurosurgeon. 50%

Total, permanent and irreversible loss of the ability to speak due to injury or disease, as

confirmed by an ear, nose and throat surgeon, neurologist or neurosurgeon. 100%

Facial disorders

and/or disfigurement

Total distortion of normal facial anatomy with disfigurement so severe that it precludes

(prevents) social acceptance, as confirmed by an ear, nose and throat specialist and/or

neurosurgeon and/or or maxillofacial specialist.

100%

Cranial nerve Vll

(Facial Nerve)

Severe unilateral facial paralysis with 75% loss of function as defined bya score of

Grade V or VI according to the House-Brackman Facial Nerve Palsy Grading System

which can be described as: A permanent condition with no or slight movement of one

half of the face with asymmetry at rest and incomplete or no eyelid closure and slight or

no movement of the mouth due to facial nerve impairment.

100%



Cranial nerve Vlll

(Vestibulocochlear

Nerve)

Nerve damage with moderately-severe disequilibrium scoring 6 or more on the Activities

of Daily Living scale (ADL). 100%

Cranial Nerves lX, X,

Xll

Paralysis with moderately-severe dysarthria or dysphagia with hoarseness, nasal

regurgitation and aspiration of liquids or semi-solid foods. 50%

Paralysis with severe inability to swallow or handle oral secretions without choking, with

need for assistance and suctioning where organic pathology has been medically proven. 100%

Neurological

impairment of

respiration

The insured life has no capacity for spontaneous respiration where organic pathology

has been medically proven. 100%

Cancer

• Scoring 40 on the Karnofsky Performance Index.

OR

• At least a stage III cancer defined as carcinoma within organ and extension outside

organ of origin with or without regional lymph node involvement and/or distant

metastasis after MMI.

100%

Chronic back and

neck conditions

The neck and lower back are part of the spine. The spinal regions are:

• Cervical region (C1-C7)

• Thoracic region (T1-T12) and

• Lumbosacral region (L1-S1).

The C7 to T1 joint will be classified in the cervical region, and the T12 to L1 joint in the thoracolumbar

region.

At least two of the five diagnoses listed below must be made by an orthopaedic- or

neurosurgeon per region. Only one claim for spinal condition will be allowed per spinal

region.

25% per

region

At least three of the five diagnoses listed below must be made by an orthopaedic- or

neurosurgeon per region Only one claim for spinal condition will be allowed per spinal

region. A maximum of two claims will be allowed.

50% per

region

• At least four of the five diagnoses listed below must be made by an ortopaedic- or

neurosurgeon per region. A maximum of one claim will be allowed.

OR

• Confirmed diagnosis of Cauda equina

100% per

region

List of five diagnosis:

1. 50% or more compression of a vertebral body or multiple level compression fractures giving rise

to kyphotic deformity.

Clinically significant radiculopathy (motor and sensory deficit or muscle atrophy and clinical

signs of nerve tension (positive Laseque and Stretch signs) and radiological evidence at the

same site as clinically found.

2. NB – We will not accept radiological signs of nerve compression without clinical evidence of

neurological involvement as proof of functional impairment.

3. Alteration of motion segment integrity (instability) using flexion and extension radiographs (X-



rays): translation instability of at least 5mm or more particularly with neurological deficit.

4. Multiple back or cervical operations (i.e. two or more on separate occasions within a period of 5

years) comprising laminectomy, discectomy or fusion, or a combination thereof.

5. Chronic pain syndrome due to:

• a chronic spinal condition as certified by an orthopaedic or neurosurgeon

• duration of two years or more

evaluation and reasonable treatment by a multidisciplinary pain clinic

Paraplegia The total and permanent loss of the functioning of both legs due to injury or disease of

the spinal cord as confirmed by a neurologist or neurosurgeon. 100%

Quadriplegia The total and permanent loss of the functioning of both upper and both lower limbs due

to injury or disease of the spinal cord as confirmed by a neurologist or neurosurgeon. 100%

Hemiplegia The total and permanent loss of the functioning of only one side of the body due to brain

injury or disease as confirmed by a neurologist or neurosurgeon. 100%

Diplegia

The total and permanent loss of the functioning of both sides of the body, where the

legs are affected more than the arms due to injury or disease of the spinal cord as

confirmed by a neurologist or neurosurgeon.

100%

Loco

motor

system

Upper

extremities

36% or more impairment of an upper limb. 25%



80% or more impairment of both upper limbs. 100%

Example:

The total and permanent loss of:

• One hand is a 90% impairment of an upper limb.

• One thumb is a 36% impairment of an upper limb.

• Thumb, index and ring fingers are a 51% impairment of an upper limb.

Lower

extremities

40% or more impairment of a lower limb. 25%

60% or more impairment of a lower limb. 50%

80% or more impairment of a lower limb 75%

70% or more impairment of both lower limbs. 100%

Example:

The total and permanent loss of:

• foot is a 45% impairment of a lower limb

• toes are not included

Combinatio

n of upper

and lower

extremities

80% or more impairment of both an upper and a lower limb. 100%

We will assess the percentage of functional impairment according to:

• Abnormal motion

• Sensory loss or motor loss and

• Amputation



As per the most current edition of the AMA guidelines for the Evaluation of Permanent Impairment

Major burns

Third-degree burns

At least 10% of total body surface 25%



Skin disorders

Skin disorders affecting > 50% body surface area including hands. 50%

Permanent irreversible skin disorders that is systemic in nature and on continuous

treatment for at least three months. 100%

Activities of Daily

Living (ADL)

Score of 4 or more on the Activities of Daily Living (ADL) scale. 50%

Score of 6 or more on the Activities of Daily Living (ADL) scale. 100%

This category caters for any diseases and disorders that may not fall into any of the Schedule of

Definitions as listed above, but might still incapacitate the insured life enough to warrant an impairment

benefit.

An insured life with a combination of symptoms and signs that do not qualify for a benefit under any one

system listed in the Schedule of Definitions above will be assessed under the Activities of Daily Living

(ADL) category.

These Activities of Daily Living (ADL) will be used to determine the level of impairment.


Activities of Daily Living Scale

The Activities of Daily Living Scale works on a points system, with a maximum of 6 points

being scored in any one category. Only one item in each of the seven categories may be

checked before the total score is calculated.

The level of benefit that we pay depends on the score achieved as follows:

% of Benefit Score

50% Score of 4 or more

100% Score of 6 or more.

The insured life must be totally and continually unable to perform the specified Activity of

Daily Living, with no possibility of improvement in the future (i.e. Maximum Medical

Improvement must have been reached). Suitable treatment and/or rehabilitation options

must be followed before the benefit is paid.

The scales are used to assess the insured life's current ability to perform the following

activities, with the use of the appropriate assistive aids and appliances where necessary.

Where an assistive device is available but the insured life's chooses not to make use of it,

the criteria will be assessed based on the ability to perform the task with the use of the

assistive device. Note that one and only one criterion may be selected in each category.

Activity Definitions

1. Washing

Level 1:

The insured life is able to wash without physical assistance or

supervision, and may enter and exit the bath or shower without the

assistance of another person.

0

Level 2:

The insured life needs some supervision with bathing or showering and

needs the assistance of another person when entering and exiting the

bath.

1

Level 3: The insured life relies entirely on the assistance of another person to

wash, bath or shower. 2

2. Dressing

Level 1:

The insured life can independently put on or take off all garments usually

worn, including securing and unfastening garments, and if appropriate,

any braces, artificial limbs or other surgical appliances

0

Level 2:

The insured life always requires the assistance of another person in

fastening garments and, if appropriate, any braces, artificial limbs or

other surgical appliances usually worn, but can dress himself.

1

Level 3:

The insured life cannot dress himself at all and needs the assistance of

another person in the selection and application of all garments, including

all braces, artificial limbs or other surgical appliances.

2

3. Eating and

feeding

Level 1: The insured life is able to eat independently once the food has been

prepared and made available. 0

Level 2: The insured life is able to feed himself, but some assistance is always

required (e.g. in cutting food). 1



Level 3: The insured life must always be fed by another person due to his

physical inability to feed himself. 2

4. Toileting

Level 1:

The insured life has full control over bladder and bowel functions or

possibly experiences infrequent incontinence but takes his own

precautionary measures so that physical assistance is not required.

0

Level 2:

The insured life experiences periodic occurrences of incontinence

despite having taken precautionary measures such as the use of

protective undergarments or surgical appliances.

1

Level 3: The insured life has total incontinence of bladder or bowel, or provision of

a permanent catheter or colostomy is required. 2

5. Physical activity

Level 1:

The insured life is able to move independently between indoor rooms on

a level surface with at most the aid of a walking cane or other assistive

device (including a wheelchair).

0

Level 2:

The insured life requires partial physical assistance from another person,

even with the use of support apparatus and a walking cane or other

assistive device (including a wheelchair), in order to move between

rooms on a level surface.

1

Level 3:

The insured life requires constant physical assistance from another

person for mobility between indoor rooms, despite the use of appropriate

support apparatus, walking cane or wheelchair.

2

6. Transferring

Level 1:

The insured life moves independently of the assistance of another

person, and may transfer from bed to chair independently with, at most,

the assistance of a walking cane or other ambulatory device.

0

Level 2:

The insured life moves independently of physical assistance but uses

support apparatus and transfers from bed to chair can be achieved with,

at most, the assistance of a walking cane or other ambulatory device.

1

Level 3:

The insured life relies partially on the assistance of another person to

move. Transfers between bed and chair can only be achieved with the

assistance of another person.

2

Level 4: The insured life is bedridden and relies entirely on the assistance of

another person for transfers. 4

7. Cognitive Impairment

Level 1:

The insured life's cognitive ability is unimpaired regardless of any

presence of irreversible cognitive deterioration or damage that is organic

in nature.

0

Level 2:

The insured life medically requires periodic assistance or direct

supervision to perform activities of daily living, due to deterioration in or

damage to cognitive ability, which is irreversible and organic in origin.

This must be measured by clinical evidence and standardised

neuropsychological testing that a neurologist or psychiatrist has

2



confirmed.

Level 3:

The insured life medically requires constant assistance to perform the

above activities of daily living, due to deterioration in or damage to

cognitive ability that is irreversible and organic in nature. This must be

measured by clinical evidence and standardised neuropsychological

testing that a neurologist or psychiatrist has confirmed.

6


Clinical Dementia Rating (CDR)

Impairment level and CDR Score

None - 0 Question - 0.5 Mild - 1.0 Moderate - 2.0 Severe - 3.0

Memory (M)

No memory loss or sight

inconsistent forgetfulness

Consistent sight forgetfulness;

partial recollection of events; "benign"

forgetfulness

Moderate memory loss; more marked for recent events; defect interferes with everyday

activities

Severe memory loss; only highly learned material

retained; new material rapidly

lost

Severe memory loss; only

fragments remain

Orientation (O) Fully oriented

Fully oriented except for slight

difficulty with time relationships

Moderate difficulty with time

relationships; oriented for place at examination;

may have geographic

disorientation elsewhere

Severe difficulty with time

relationships; usually

disoriented to time, often to

place

Oriented to person only

Judgement and problem solving

(JPS)

Solves everyday problems and

handles business and financial affairs well;

judgement good in relations to past performances

Slight impairment in solving problems,

similarities and differences

Moderate difficulty coping with problems,

similarities and differences; social judgement usually

in place.

Severely impaired in handling problems,

similarities and differences; social judgement usually

impaired

Unable to make judgements or solve problems

Community Affairs (CA)

Independent function at usual

level in job, shopping,

volunteer and social groups

Slight impairment in these activities

Unable to function independently at these activities,

although may still be engaged in some; appears

normal to casual inspection

No pretence of independent

function outside home Appears

well enough to be taken to functions outside a family

home

No pretence of independent

function outside home Appears too

ill to be taken to functions outside

a family home

Home and Hobbies (HH)

Life at home , hobbies, and intellectual

interests well maintained

Life at home, hobbies and intellectual

interests slightly impaired

Mild but definite impairment of

function at home; more difficult

chores abandoned; more

complicated hobbies and

interests abandoned

Only simple chores preserved;

very restricted interests, poorly

maintained.

No significant function in home

Personal Care (PC)

Fully capable of self-care

Fully capable of self-care Needs prompting

Requires assistance in

dressing, hygiene, keeping of

personal effects

Requires much help with personal

care; frequent incontinence.


Critical illness claim events for Income disability and impairment benefits

This section is to be used in conjunction with Critical Illness Benefit definitions which may be

found at the end of the Critical Illness Benefit section.

Claims category Claim event Payout

percentage

Cancer Acute Lymphocytic Leukaemia (ALL)(adults) 100%

Cancer Acute Myeloid Leukaemia (AML) 100%

Cancer Bone marrow transplant 100%

Cancer Brain tumour WHO (Grade II) with neurological deficit 100%

Cancer Brain tumour WHO (Grade III) 100%

Cancer Brain tumour WHO (Grade IV) 100%

Cancer Carcinoma within organ and extension outside organ of origin with or without

regional lymph node involvement and/or distant metastasis (stage II) 100%


regional lymph node involvement and/or distant metastasis (stage III) 100%


regional lymph node involvement and/or distant metastasis (stage IV) 100%

Cancer Chronic Lymphocytic Leukaemia (CLL) (stage 0 or I on the Rai classification) 100%

Cancer Chronic Lymphocytic Leukaemia (CLL) (stage II on the Rai classification) 100%

Cancer Chronic Lymphocytic Leukaemia (CLL) (stage III on the Rai classification) 100%

Cancer Chronic Lymphocytic Leukaemia (CLL) (stage IV on the Rai classification) 100%

Cancer Chronic Myeloid Leukaemia (CML) (not requiring bone marrow transplant) 100%

Cancer Chronic Myeloid Leukaemia (CML) (requiring bone marrow transplant) 100%

Cancer Female cancers (stage II), examples include breast cancer, cervical,

endometrial, Fallopian tube, gestational trophoblastic, ovarian, uterine, vulvular 100%

Cancer Female cancers (stage III), examples include breast cancer, cervical,


Cancer Female cancers (stage IV), examples include breast cancer, cervical,


Cancer Hairy cell leukaemia 100%

Cancer Hodgkin’s disease (stage I on the Ann Arbor classification system) 100%

Cancer Hodgkin’s disease (stage II on the Ann Arbor classification system) 100%

Cancer Hodgkin’s disease (stage III on the Ann Arbor classification system) 100%



percentage

Cancer Hodgkin’s disease (stage IV on the Ann Arbor classification system) 100%

Cancer Invasive malignant melanomas (stage II) 100%

Cancer Invasive malignant melanomas (stage III) 100%

Cancer Invasive malignant melanomas (stage IV) 100%

Cancer Lentigo melanoma’s with (stage II) 100%

Cancer Lentigo melanoma’s with (stage III) 100%

Cancer Lentigo melanoma’s with (stage IV) 100%

Cancer Multiple myeloma (stage I on the Durie-Salmon Scale) 100%

Cancer Multiple myeloma (stage II on the Durie-Salmon Scale) 100%

Cancer Multiple myeloma (stage III on the Durie-Salmon Scale) 100%

Cancer Multiple myeloma (stage IV on the Durie-Salmon Scale) 100%

Cancer Non-Hodgkin’s disease (Stage I on the Ann Arbor classification system) 100%

Cancer Non-Hodgkin’s disease (stage II on the Ann Arbor classification system) 100%

Cancer Non-Hodgkin’s disease (stage III on the Ann Arbor classification system) 100%

Cancer Non-Hodgkin’s disease (stage IV on the Ann Arbor classification system) 100%

Cancer Prostate cancer (stage III) 100%

Cancer Prostate cancer (stage IV) 100%

Cardiac and arterial

system Heart transplant 100%


system Heart valve replacement 100%


system Major surgery to dissect and surgically graft an aortic aneurysm 100%


system Peripheral artery disease with gangrene or loss of limb 100%


system Primary pulmonary hypertension 100%


system

The undergoing of surgery to correct the narrowing of, or blockage to, three or

more coronary arteries, by means of a by-pass graft (CABG) 100%


system

Cardiomyopathy resulting in permanent and irreversible physical impairment to

the degree of at least class IV of the NYHA classification of cardiac impairment

or an ejection fraction < 40% 100%

Cardiac and arterial Carotid artery disease: Narrowing of two carotid arteries requiring either bypass 100%



percentage

system grafting or endarterectomy


system Irreversible heart failure with NYHA IV or an ejection fraction < 40% 100%


system Moderate heart attack of specified severity 100%


system Heart attack with permanent mild impairment in function 100%


system Heart attack with permanent severe impairment in function 100%

Catch-all

Any disease, where the severity of the disease that has resulted in a Whole

Person Impairment (WPI) > 35% and the percentage is dependent on the

system or systems that are affected. It will be assessed according to the criteria

stipulated in AMA Guidelines 6th Edition.

Any Whole Person Impairment as a result of traumatic injury or mental and

behavioural disorders will not be covered by this category. WPI scores are

determined when the condition is permanent at optimal treatment.

A payment will only be made under this category if the condition suffered from

does not qualify for a claim payment under any of the other categories listed

above.

100%

Connective tissue

diseases

A connective tissue disease (listed below) resulting in definite objective

evidence of involvement of three or more of the following organ systems:

− Cardiovascular

− Neurological

− Respiratory

− Renal

− Gastrointestinal

− Musculoskeletal

Only the Connective tissue diseases listed below are covered under this

definition:

− Progressive systemic sclerosis (scleroderma)

− Rheumatoid arthritis

− Systemic lupus erythematosis

− Sarcoidosis

− Polyarteritis nodosa

− Giant cell arteritis

− Wegener's granulomatosis

100%

ENT System Total loss of hearing in both ears 100%



percentage

Gastrointestinal

System Cirrhosis of the liver classified as Child-Pugh class A or higher 100%

Gastrointestinal

System End-stage liver failure 100%

Gastrointestinal

System Fulminant hepatic necrosis 100%

Gastrointestinal

System Complete hepatectomy 100%

Gastrointestinal

System Liver and pancreas transplant 100%

Gastrointestinal

System Complete pancreatectomy 100%

HIV/AIDS Accidental HIV 100%

HIV/AIDS Aids 100%

Major burns At least 30% body surface area 100%

Musculoskeletal

system Paraplegia, Hemiplegia, Diplegia and Quadriplegia 100%

Musculoskeletal

system

The total, permanent and irreversible loss of use of or loss of either both arms or

both legs 100%

Nervous system

Benign brain tumour WHO (Grade I) including intracranial tumours causing

damage to the brain that are non-removable or only partially removable by

surgery and cause permanent neurological deficit. (Pituitary micro-adenomas

are excluded.)

100%

Nervous system Cerebral malaria 100%

Nervous system

A permanent hemiparesis, paralysis or cranial nerve deficit that the insured life

sustained in an accident or because of brain surgery or disease, as proved by a

neurological assessment (excluding Bell’s palsy). 100%

Nervous system Permanent moderate to severe impairment of intellectual capacity as a result of

brain damage, systemic hypoxia or disease (excluding depression) 100%

Nervous system Motor neuron disease 100%

Nervous system Multiple sclerosis 100%

Nervous system Muscular dystrophy 100%

Nervous system Parkinson’s disease 100%

Nervous system Total aphasia 100%



percentage

Nervous system

Coma: A state of unconsciousness not induced by sedation and resulting in

permanent neurological deficit. Glasgow Coma Scale reading of 10 or less with

no reaction to external stimuli or internal needs and persisting continuously for

more than 96 hours with the use of life support systems such as ventilators or

intravenous nourishment

100%

Nervous system Alzheimer’s disease 100%

Nervous system Dementia 100%

Nervous system Myasthenia gravis 100%

Nervous system

Stroke with mild impairment

Can function independently, but has impairment as measured by:

– the inability to do 3 or more advanced ADL’s, or

– a WPI of 11% to 20%.

100%

Nervous system

Stroke with moderate impairment

Cannot function independently, as measured by:

– the inability to do 6 or more advanced ADL’s, or

– a WPI of 21% to 35%.

100%

Nervous system

Stroke with severe impairment

Needs constant assistance, as measured by:

– the inability to do 3 or more basic ADL’s, or

– a Whole Person Impairment (WPI) of greater than 35%

100%

Respiratory system

Irreversible end stage respiratory failure (FEV1 < 1 litre for obstructive lung

disease or FVC < 1 litre for restrictive lung disease with clinical signs and

symptoms, or FEV1 < 40% predicted or FVC < 40% predicted OR Severe

irreversible changes in pulmonary function tests with permanent DCO 41-45%

(obstructive and/or restrictive)

100%

Respiratory system Lung transplant 100%

Respiratory system Presence of irreversible cor pulmonale 100%

Severe aplastic

anaemia Severe aplastic anaemia 100%

Terminal illness Terminal illness 100%

Urinary tract End stage renal failure with dialysis as confirmed by a nephrologist 100%

Urinary tract Kidney transplant 100%

Visual The total, permanent and irreversible loss of sight in both eyes 100%


Critical illness benefit definitions Momentum requires proof that all the critical illness definitions in this guide have been met

according to the general accepted medical practice.

1. Cancer

Cancer develops when cells in the body begin to grow out of control. Normal cells grow,

divide, and die. Instead of dying, cancer cells continue to grow and form new abnormal cells.

Cancer cells often travel to other body parts where they grow and replace normal tissue.

The diagnosis must be confirmed with histology and supported by appropriate specialist

reports with disease staging and relevant oncology treatment.

The following are specifically excluded, unless specifically defined as a claim event:

• all skin cancers, (except invasive malignant melanoma's and lentigo melanoma's that

progressed to at least TNM classification of T1aN0M0)

• all conditions which are histologically described as pre-malignant or cancer in situ

unless specifically listed as a claim event

• All in situ cancer (that are specifically listed) must be supported by the appropriate

histological and imaging (i.e. CT and/or MRI) findings

• All Grade I brain tumours (WHO classification) will be considered under the benign

brain tumour category

• Histological confirmation is required for Brain tumours (WHO grade II to IV) and there is

no requirement to undergo treatment for these

2. Cardiac and arterial system

The cardiac and arterial system combined is known as the cardiovascular system. The

cardiovascular system circulates blood throughout the body, includes the heart, veins, and

arteries. Its main function is to transport oxygen and nutrients to all areas of the body and

removes carbon dioxide and other wastes.

All Cardiac events that occur within 30 days of each other will be considered as a single

claim event. The number of payments for coronary artery stenting will be limited to 3

payments.

Heart attack

Myocardial infarction (MI) / heart attack is the irreversible death of heart muscle secondary

to prolonged ischemia. This usually results from an imbalance between oxygen supply and

demand. The appearance of raised cardiac enzymes in the circulation generally indicates

death of heart muscle. Acute myocardial infarction (MI) refers to the spectrum of clinical

presentations ranging from ST-segment elevation heart attacks (STEMI) to non–ST-

segment elevation heart attacks (NSTEMI).

A full cardiologist's or cardiac specialist's report confirming that the signs and symptoms

equate to the diagnosis; with raised cardiac enzymes and relevant ECG findings should be

compatible with diagnosis of myocardial infarction. The evidence must show a definite acute

myocardial infarction. Other acute coronary syndromes, including but not limited to angina,

are not covered by this definition.


Level C: Moderate heart attack of specified severity

This is defined as the death of heart muscle, due to inadequate blood supply, as evidenced

by any of the following combinations of criteria:

1. Compatible clinical symptoms AND raised cardiac biomarkers

OR

2. Compatible clinical symptoms AND new pathological Q-waves on ECG as defined in

the ASISA definitions.

OR

3. New pathological Q-waves on ECG as defined in Annexure A (b) AND raised cardiac

biomarkers

OR

4. ST-segment and T-wave changes on ECG indicative of myocardial injury as defined in

the ASISA definitions AND raised cardiac biomarkers

Where raised cardiac biomarkers are referenced above, they are defined as any one of the

following Troponin or Non-Troponin Markers:

• Trop T > 1.0ng/ml (1000 ng/L) or

• Trop I > 0.5 ng/ml (500ng/L), or

• Raised CK-MB mass (defined below), or

− Raised 2 times or more above the upper limit of normal laboratory reference range in

acute presentation phase

− Raised 4 times or more above the upper limit of normal laboratory reference range

post intervention

• Total CPK elevation (defined below)

− Raised 2 times or more the upper limit of normal laboratory reference range in acute

presentation phase, with at least 6% being CK-MB

Please refer to the ASISA claim event definitions (at the end of the critical illness definitions)

for details on reference ranges, including Sensitive Troponin Markers)

Notes:

If more than one functional criterion is impaired, but their values do not conform to one

severity level (for example one impaired value is Level A and another Level B), the final

severity level should be determined by giving preference to the more objective criteria, i.e. in

the following order:

i. LVEF

ii. LVEDD

iii. Ultrasound FS

iv. METS

v. NYHA


Percutaneous Transluminal Coronary Angioplasty (PTCA) and Coronary Artery Bypass Grafting (CABG).

Severe ischaemic heart disease for which a cardio-thoracic surgeon performs a balloon

angioplasty with/without stent, laser treatment, rotablation, atherectomy or bypass surgery

with vascular grafts. Keyhole techniques are included.

Narrowing of a carotid artery

Narrowing of either one or both of the carotid arteries, proven by an arteriogram, and the

narrowing being at least 70% or of such a severity that it requires surgical repair by carotid

artery bypass grafting, endarterectomy or the insertion of a stent.

Conditions of the aorta

A aortic aneurysm threatening to rupture, and of sufficient severity that it requires bypass

surgery by a surgeon to repair the aneurysm. Keyhole bypass surgery techniques are

included.

Momentum specifically exclude surgery to the branches of the aorta.

Cardiac valvular disease

The heart valves control the blood flow through the heart. The valves may be abnormal at

birth or become diseased due to rheumatic fever and certain infectious diseases. Depending

on the severity of the valve lesion, it requires open-heart surgery for the repair (valvotomy

and valvuloplasty) or a valve replacement by an artificial valve. Keyhole techniques are

included.

Irreversible heart failure

Permanent, irreversible physical impairment of the heart function as defined by the New

York Heart Association or ejection fraction as confirmed by a cardiologist.

If the insured life dies as a result of heart failure, after the expiry of the relevant survival

period, but before the one month ejection fraction reading could be obtained, Momentum will

pay the full claim amount.

Cardiomyopathy

This means impaired ventricular function of variable aetiology, due to primary disease of the

heart muscle, and includes secondary disease such as ischaemic or hypertensive heart

muscle damage.

If the insured life dies as a result of cardiomyopathy, after the expiry of the relevant survival

period, but before the one month ejection fraction reading could be obtained, Momentum will

pay the full claim amount.

Peripheral artery disease

Disease of the blood vessels characterized by narrowing and hardening of the arteries that

supply the legs and feet. This causes a decrease in blood flow that can injure nerves and

other tissues. This must be confirmed by Doppler ultrasound or angioplasty or MRI scan and

confirmed by report from a specialist or vascular surgeon.


Primary pulmonary hypertension

Established primary pulmonary hypertension is the pathological increase of pulmonary

pressure due to structural, functional or circulatory disturbances of the lung leading to right

ventricular enlargement. The disease must result in permanent irreversible physical

impairment to the degree of at least Class IV of the New York Heart Association (NYHA)

classification of cardiac impairment . There must be proof that pulmonary pressure has

remained above 30mm Hg for a period of at least six months.

Definition of ejection fraction

A clinically used measure of systolic heart function is the "ejection fraction" (EF), i.e. the

percentage of blood the heart is able to eject during one beat. Echocardiography,

radionuclide angiography and left ventriculography are commonly used to measure the EF.

A normal EF is greater than 55%; EF’s of 40% to 50% indicate mild systolic dysfunction; ≤

40% indicate moderate to severe systolic dysfunction.

New York Heart Association (NYHA) Class IV

The insured life has cardiac disease resulting in inability to carry on any physical activity

without discomfort; symptoms of inadequate cardiac output, pulmonary congestion, systemic

congestion, or angina syndrome may be present, even at rest; if any physical activity is

undertaken, discomfort increased.

3. Connective tissue disease

An unequivocal diagnosis of an auto-immune or immune complex diseases as per the

appropriate international guidelines/criteria (American College of Rheumatology Criteria

where applicable). An appropriate consultant specialist must diagnose the disease. The

relevant blood test and tissue biopsies must support such diagnosis and appropriate disease

modifying medication must have been tried for a minimum continuous period of six months.

Only conditions specifically listed in the claim events will be covered by this definition.

4. ENT system

This relates to diagnoses and/- or interventions relating to the ears, including the inner and

middle ear, the nose, paranasal sinuses and throat. The diagnosis must be supported by an

ENT specialist report and accompanied by supporting objective diagnostic investigations

including blood tests or X-rays and CT or MRI scans.

5. Gastrointestinal system

This system includes the liver, biliary system, pancreas and gastrointestinal tract from the

oesophagus to the stomach through to the rectum.

Diseases or interventions must be related to primary organic pathology of the

gastrointestinal system, must not be related to drug or alcohol abuse and be diagnosed by

an appropriate consultant specialist supported by objective and relevant investigations

including blood tests, X-rays, scans and scopes as necessary .

Classification systems for cirrhosis

The Child-Pugh-Turcotte (CPT) classification system is widely used and validated way to

estimate prognosis in those with cirrhosis.3


Child-Pugh (Child-Pugh-Turcotte) Classification

Criterion 1 point 2 points 3 points

Serum albumin g/L >35 28-35 <28

Serum bilirubin

(total)3

<34 µmo\L

<2mg\dL)

34-50 µmo\L

(2-3 mg\dL))

>50 µmo\L

(>3 mg\dL))

International

Normalized Ratio

(INR)

<1.7

1.7-2.2 > 2.2

Ascites Absent Controlled

medically

Poorly controlled

Encephalopathy Absent

Controlled

medically

Poorly controlled

A score of 5-6 is class A (life expectancy 15-20 years); a score of 7-9 is class B (life

expectancy 4-14 years); a score of 10-15 is class C (life expectancy 1-3 years). This aligns

with a perioperative mortality (for abdominal surgery) of 10%, 30% and 80% respectively.

End-stage liver failure

End-stage liver failure or liver transplant as confirmed by a gastroenterologist due to

cirrhosis and resulting in permanent jaundice and one of the following:

• Ascites

• Encephalopathy

• Portal hypertension.

6. HIV/Aids

Accidental HIV

Infection by any Human Immunodeficiency Virus (HIV) or being diagnosed as having

Acquired Immuno-deficiency Syndrome (Aids), if the insured life can prove to the satisfaction

of Momentum that the infection is due to:

• The transfusion of infected blood or blood products from a South African blood

transfusion service that Momentum recognises, after the starting date of this policy, or

• Executing his professional duties as a medical or dental practitioner registered with the

Health Professions Council of South Africa (HPCSA) or a nurse registered with the SA

Nursing Council, or

• Receiving a transplanted organ that was previously infected with HIV, or

• Any other medical or dental procedure that the HPCSA recognises and that a medical

or dental practitioner registered with the HPCSA or a nurse registered with the SA

Nursing Council, has performed on the insured life, or

• Involvement in a road traffic accident, or

• Involvement in a violent crime, or

• Involvement in a rape or an indecent assault crime

http://en.wikipedia.org/wiki/Serum_albumin

http://en.wikipedia.org/wiki/Serum_albumin

http://en.wikipedia.org/wiki/Prothrombin_time%23International_normalized_ratio

http://en.wikipedia.org/wiki/Ascites

http://en.wikipedia.org/wiki/Hepatic_encephalopathy


Momentum will consider a claim if the following requirements were followed:

• Where the HIV is a result of the transfusion of blood or blood products or a transplanted

organ, the transfusion or organ donor service must accept liability for the incident.

• In the event of an accident, violent crime, rape, indecent assault or infection in the

execution of professional duties:

− An identified HIV test needs to be performed within 24 hours to confirm an HIV-

negative status before the event.

− Proof that the insured life has started the prescribed treatment, a course of anti-

retroviral drugs, and that the treatment course has been completed in full.

• In the event of an accident, violent crime, rape or indecent assault:

− The event must have been reported to the SAPS and a case number issued and/or

criminal case opened.

− A medical examination of the victim needs to have been performed directly after the

event.

− Medically documented proof of acute trauma and HIV infection suspicion must have

been submitted.

− Where the accidental HIV is a result of emergency assistance at the scene of a road

traffic accident or violent crime, an SAPS or eyewitness affidavit to prove assistance

must have been submitted.

Momentum must receive notification within 14 days of the occurrence of an event, where

there is suspicion of HIV infection.

An identified HIV test needs to be performed within 6 months of the event to confirm an HIV

positive status.

If there was no suspicion of HIV infection and it can be proven that the insured life

contracted HIV as a result of transfusion of infected blood or blood products or receiving a

transplanted organ, Momentum must receive notification within 6 months of the insured life

being tested positive for HIV.

Momentum reserves the right to obtain independent diagnostic blood testing of the insured

life (with proper identification, counselling and informed consent) .

Aids

The following must support the clinical manifestation of aids (the Acquired Immunodeficiency

Syndrome):

• the results of a positive HIV (Human Immunodeficiency Virus) antibody test or other

recognised test for the presence of aids (provided that, in all cases, Momentum accepts

the type of test),

• the insured life must have a CD4 cell count of less than 200

• and one of the following criteria must be met:

− the existence of at least three conditions of stage 3 according to the current WHO

Clinical Classification System

OR

− the diagnosis of at least one of the aids-defining diseases according to the current

WHO Clinical Classification System.


7. Major burns

Third-degree burns covering 30% of the body surface area according to the Lund and

Bowder body surface chart.

8. Musculoskeletal system

Confined to diseases, disorders or interventions of muscle, bone, joints and any directly

associated nerve supply. An orthopaedic or neurosurgeon must make the diagnosis and

diagnostic X-rays and CT or MRI scans must support it.

Diplegia

The total and permanent loss of function of both sides of the body, due to an injury or a

disease of the spinal cord that affects the legs more than the arms as a

neurologist/neurosurgeon confirmed.

Hemiplegia

The total and permanent loss of function of only one side of the body due to brain injury or

disease as a neurologist/neurosurgeon confirmed.

Paraplegia

The total and permanent loss of function of both legs due to injury or disease of the spinal

cord as a neurologist/neurosurgeon confirmed.

Quadriplegia

The total and permanent loss of function of both upper and both lower limbs due to injury or

disease of the spinal cord as a neurologist/neurosurgeon confirmed .

9. Nervous system

The nervous system comprises the central and peripheral nervous systems. The central

nervous system includes the brain, brainstem and spinal cord. The peripheral nervous

system contains the body’s other nerves. Made of billions of interconnected nerve cells , the

nervous system is a vast communication network linking all body parts and allowing us to

interact with our environment. Only central nervous system conditions as defined are

covered. A neurologist or neurosurgeon must confirm the diagnosis or intervention and the

deficit must be of a permanent nature and objective investigations including blood tests, X-

rays and CT or MRI-scans must support it.

The clinical symptoms and signs must be compatible with the diagnosis and any

neurological deficit must be anatomically compatible with the primary lesion.

Stroke

Death of brain tissue due to inadequate blood supply or haemorrhage within the brain tissue

resulting in neurological deficit. A neurologist must confirm the diagnosis and objective

neuro-imaging investigations including CT or MRI-scans must support it. Any deficit must be

of a permanent nature. The clinical symptoms and signs must be compatible with the

diagnosis and any neurological deficit must be anatomically compatible with the primary

lesion.

Severity levels will be assessed by a full neurological examination by a specialist neurologist

or neuropsychologist after 3 months. The neurological domains to be assessed include

motor, speech, visual, sensory, language and cognition.


WPI figures are calculated as per the American Medical Association Guides to the

Evaluation of Permanent Impairment 6th edition.

Where we make reference to ADLs it is specifically the ASISA Stroke ADL list as below:

Basic activities of Daily Living

• Bathing – the ability to was/bathe oneself independently

• Transferring – the ability to move oneself from a bed to a chair or from a bed to a toilet

independently

• Dressing – the ability to take off and put on ones clothes independently

• Eating - the ability to feed oneself independently. This does not include the making of

food

• Toileting – the ability to use a toilet and cleanse oneself thereafter, independently

• Locomotion on a level surface – the ability to walk on a flat surface, independently

• Locomotion on an incline – the ability to walk up a gentle slope, or a flight of steps

independently

Advanced activities of Daily Living

• Driving a car – the ability to open a car door, change gears or use a steering wheel

• Medical care: the ability to prepare and take the correct medication

• Money management – the ability to do one’s own banking and to make rational financial

decisions

• Communicative activities: - the ability to communicate either verbally or written

• Shopping: - the ability to choose and lift groceries from shelves as well as carry them in

bags

• Food preparation – the ability to prepare food for cooking as well as using kitchen

utensils

• Housework – the ability to clean a house or iron clothing

• Community ambulation with or without assistive device, but not requiring a mobility

device – the ability to walk around in public places using only a walking stick if

necessary

• Moderate activities:-activities like moving a table, pushing a vacuum cleaner, bowling,

golf

• Vigorous activities: - able to partake in running, heavy lifting, sports

For above definition, the following are not covered:

1. Transient ischaemic attack/reversible ischaemic neurological deficit (as defined below)

A Transient Ischaemic Attack (TIA) occurs when the blood supply is momentarily

interrupted, but restored before any permanent damage can occur. It usually results in

one of more of the following symptoms:

• a loss of sensation

• dizziness

• lameness of a limb

• loss of speech

The symptoms only occur for a few minutes to hours and recovery is quick and

spontaneous with no evidence of infarction or haemorrhaging that exists on objective

neuro-imaging investigations including CT or MRI-scans.


2. Vascular disease affecting the eye or optic nerve.

3. Cerebral symptoms due to migraine.

Benign brain tumour

A life-threatening, non-cancerous tumour of the brain as confirmed by a neurologist or

neurosurgeon, giving rise to characteristic signs of increased intracranial pressure such as

papilloedema, mental symptoms, seizures and motor or sensory impairment.

The presence of the tumour must be confirmed by imaging studies such as a CT scan or

MRI scan.

Momentum specifically excludes benign tumours of the pituitary gland.

Muscular dystrophy

The diagnosis of muscular dystrophy confirmed by a consulting neurologist, and based on a

combination of all of the following:

• Clinical presentation including absence of sensory disturbance, normal cerebro-spinal

fluid and mild tendon reflex reduction

• Characteristic electromyogram

• Clinical suspicion confirmed by muscle biopsy

Myasthenia gravis

Myasthenia gravis is an autoimmune disease that gradually causes muscles to lose their

strength and function. Antibodies are made against receptors in the neuromuscular junction

(the area where nerve transmission makes a muscle do its work) and presents with

weakness in muscles groups. Unequivocal diagnosis of myasthenia gravis as confirmed by

a specialist or neurologist. The symptoms should be present despite optimal treatment.

Alzheimer's disease

This means the deterioration or loss of intellectual capacity, due to irreversible failure of

brain functioning. There must be a reduction in the executive functions of abstract thinking,

judgement and problem solving. The diagnosis must be confirmed by a neurologist and

based on clinical and radiological evidence and standardised tests and questionnaires for

Alzheimer's disease.

Dementia

This means the deterioration or loss of intellectual capacity, due to irreversible global failure

of brain functioning. There must be a reduction in the executive functions of abstract

thinking, judgement and problem solving. The diagnosis must be confirmed by a neurologist

and based on clinical and radiological evidence and standardised tests and questionnaires

for Dementia.

Motor neuron disease

Motor neurone disease of unknown aetiology is characterised by progressive degeneration

of corticospinal tracts and anterior horn cells or bulbar efferent neurones; these include

spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary

lateral sclerosis.


Claims shall only be admitted if the condition is confirmed by a neurologist as progressive

and resulting in symptoms as a result of irreversible damage to the nervous system.

Parkinson's disease

Slowly progressive degenerative disease of the brain that leads to shaking (tremors),

difficulty with walking, movement, and coordination. The diagnosis must be confirmed by a

consultant neurologist. The symptoms should be persistent despite optimal treatment with

various treatment regimes, which have been used for a period of at least 6 months.

Multiple sclerosis

The unequivocal diagnosis of multiple sclerosis confirmed by reliable history and clinical

findings from a neurologist and CT or MRI scans where demyelination in the brain and

spinal cord characterises the condition. More than one episode of well-defined neurological

symptoms and signs involving any combination of deficit in the optic nerves, brain stem,

spinal cord, co-ordination or sensory function that are persistent or progressive must

characterise the disease.

This policy does not cover a single episode of multiple sclerosis from which remission has

occurred.

Cerebral malaria

Diffuse symmetrical encephalopathy, i.e. unarousable coma accompanied by vital organ

dysfunction, requiring ICU admission. A specialist physician must confirm the diagnosis.

Total Aphasia

A total and permanent loss of the ability to express himself by speech, writing, or signs, or to

comprehend spoken or written language, due to injury or disease of the brain as confirmed

by a specialist or neurologist. There must be permanent deficits in the formal aspects of

language such as naming, word choice, comprehension, spelling and syntax.

10. Respiratory system

Disease involving the lungs resulting in airway dysfunction and reduced lung functions.

Treatment must be appropriate and maximal for the diagnosis. A pulmonologist or physician

specialist must make the diagnosis and appropriate objective diagnostic tests including

simple and advanced lung function tests where necessary, must support it.

Pulmonary Function Test

Pulmonary function test measure how well the lungs take in and exhale air and how

efficiently they transfer oxygen into the blood. Spirometry measures how well the lungs

exhale. The information gathered during this test is useful in diagnosing certain types of lung

disorders, but is most useful when assessing for obstructive lung diseases (especially

asthma and chronic obstructive pulmonary disease, COPD).

End-stage respiratory failure

End-stage respiratory failure or lung transplant as confirmed by a registered pulmonologist

as demonstrated by:


• FEV1 < 1 litre for obstructive lung disease or FVC < 1 litre for restrictive lung disease

with clinical signs and symptoms,

• FEV1 < 40% predicted or FVC < 40% predicted

• Severe irreversible changes in pulmonary function tests with permanent DCO 41-45%

(obstructive and/or restrictive).

• FEV1 test results consistently less than 1 litre with 3 x FVL at least one month apart and

one of the following:

− Requiring permanent supplementary oxygen therapy for hypoxaemia

− Arterial blood gas analyses with partial oxygen pressures of 55mmHg or less (PaO2 <

55mmHg)

− Dyspnoea at rest.

11. Severe aplastic anaemia

Chronic persistent bone marrow failure which results in anaemia, neutropenia and

thrombocytopenia requiring treatment with at least one of the following:

• Blood product transfusion

• Marrow stimulating agents

• Immunosuppressive agents

• Bone marrow transplantation.

The diagnosis must be confirmed by a haematologist.

12. Terminal illness

The insured life must be suffering from a disease which in the opinion of an appropriate

consultant, and supported by Momentum's Medical Officer, is likely to lead to death within 12

months from the date of notification.

13. Urinary tract

This includes the urinary tract from the kidneys through the bladder to the urethral opening.

The disease must cause renal dysfunction requiring ongoing therapy or surgical intervention.

An appropriate consultant specialist must make the diagnosis and must be supported by

blood tests for renal function, urine testing and clearance testing as necessary and other

scans or urinary tract X-rays as appropriate.

Heamodialysis and peritoneal dialysis are covered.

14. Visual

This includes the retina, optic nerve, anterior and posterior chamber of the globe, cornea,

lens.

The diagnosis or disease must be permanent or chronic and require ongoing specialist

treatment.

An ophthalmologist must confirm the diagnosis and objective test should confirm the

diagnosis and severity of any visual defect.

15. Catch-all

Any disease, where the severity of the disease that has resulted in a Whole Person

Impairment (WPI) > 35% and the percentage is dependent on the system or systems that

are affected. It will be assessed according to the criteria stipulated in AMA Guidelines 6th

Edition.


Any Whole Person Impairment as a result of traumatic injury or mental and behavioural

disorders will not be covered by this category.

WPI scores are determined when the condition is permanent at optimal treatment.

A payment will only be made under this category if the condition suffered from does not

qualify for a claim payment under any of the other categories listed above.

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