Arizona Critical Illness Insurance Limitations and Exclusions
Covered Conditions and related Limitations, Exclusions, and reductions1
- Alzheimer’s Disease – must require substantial physical assistance to perform at least 2 Activities of Daily Living (ADLs) for at least 90 days; excludes other forms of dementing organic brain disorders and psychiatric illnesses.
- Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) – must require substantial physical assistance to perform at least 2 ADLs for at least 90 days; excludes other motor-neuron diseases.
- Benign Brain Tumor – excludes tumors of the skull, pituitary adenomas, angiomas and germinomas.
- Carcinoma in Situ2 (25% benefit) – excludes carcinoma and melanoma in situ of the skin and all skin cancers, and evidence of cancer cells or cancer genetic material detected by molecular or biochemical probes only with no lesion amenable to tissue diagnosis.
- Coma – must be due to disease and last at least 7 days; excludes medically-induced comas and comas directly resulting from alcohol or drug use.
- Coronary Artery Disease Requiring Coronary Artery Bypass Graft2(25% benefit)
- Heart Attack2 – excludes sudden cardiac arrest and any heart attack occurring during or within 24 hours of a cardiac or coronary artery procedure.
- Invasive Cancer2 – excludes certain chronic lymphocytic leukemias; tumors that are nonmalignant, benign, premalignant, noninvasive, dysplasia, or carcinoma in situ; certain skin cancers; certain prostate cancers; microcarcinoma of the thyroid; certain noninvasive papillary cancer of the bladder; and evidence of cancer cells or cancer genetic material detected by molecular or biochemical probes only with no lesion amenable to tissue diagnosis.
- Loss of Hearing (both ears)3,4
- Loss of Sight (both eyes)3,4
- Loss of Speech3,4 – excludes congenital birth defects and developmental delays.
- Major Organ Failure2 – must be listed with United Network of Organ Sharing (UNOS) or have a suitable donor, or for kidney failure, dialysis is initiated; excludes bone marrow failure resulting from cancer treatment and failure of organs other than bone marrow, heart, kidney, liver, lung and pancreas.
- Multiple Sclerosis – must have qualifying neurological deficits for at least 6 months.
- Occupational Infectious Disease resulting in HIV or Hepatitis B, C or D – accidental exposure must occur while performing normal job duties for which you are paid; excludes infections from IV drug use or sexual transmission; reporting requirements apply.
- Paralysis – requires permanent, complete and irreversible loss of use of two or more arms or legs due to disease, which has continued for 90 days.
- Parkinson’s Disease – must progress to Stage 4 on the Hoehn and Yahr scale; excludes other Parkinsonian syndromes or substance-induced diseases; initial diagnosis of any stage must occur while insured under this policy.
- Skin Cancer ($250 benefit)
- Stroke2 – must have qualifying neurologic deficit measured 30 days or more after the event; excludes symptoms due to TIA’s, migraines, hypoxia, traumatic injury to brain tissue or blood vessels, and vascular disease affecting the eye, optic nerve or vestibular functions.
The following conditions apply only to Dependent Children diagnosed prior to the age of 18 and while insured under the policy.5
- Cerebral Palsy – excludes similar conditions
- Cleft Lip/Palate
- Cystic Fibrosis
- Down Syndrome
- Muscular Dystrophy
- Spina Bifida – excludes spina bifida occulta
Benefits are payable for a first occurrence of a different covered condition if more than 12 months has elapsed since the prior critical illness. Total payment for all critical illnesses resulting from the same illness or disease will not exceed the Scheduled Benefit amount.
A spouse may be covered for up to 50% of the employee benefit amount. Dependent Children are automatically covered at 25% of the employee benefit amount for both Childhood Conditions and other covered Critical Illnesses.
1 Refer to the policy for definitions applicable to all terms used in this document, and for other applicable terms and conditions, and relevant clinical and diagnostic criteria. Proof of diagnosis and submission of medical records are required. Claim procedures must be satisfied. Limitations and exclusions must not apply.
2 These conditions (Carcinoma in Situ, Coronary Artery Disease, Heart Attack, Invasive Cancer, Major Organ Failure, and Stroke) pay a benefit for multiple occurrences of the same critical illness if more than 12 months has elapsed between occurrences, and no treatment is received for at least 12 months. All other conditions listed above do not pay for multiple occurrences of the same illness.
3 Must be due to disease, total and irrevocable, which cannot be partially or totally corrected by any procedure, aid or device.
4 A Dependent Child must be at least 3 years old on the date of diagnosis. If the child is diagnosed before age 3, a benefit will be paid if the child is insured at the time of the initial diagnosis, the diagnosis is confirmed on or after the child reaches age 3, and the child remains insured.
5 Childhood Conditions diagnosed prior to birth are covered if the member was insured under the policy at the time of diagnosis and the Dependent Child became insured at live birth.
General Limitations and Exclusions
Benefits will not be paid for a critical illness caused by, contributed to, or resulting from willful self-injury or self-destruction, while sane or insane; war or act of war; voluntary participation in an assault, felony, criminal activity, insurrection, or riot; duty as a member of a military organization; conditions diagnosed outside of the United States unless the diagnosis can be confirmed by a licensed physician in the United States; the use of any drug, narcotic, or hallucinogen not prescribed for the covered person by a licensed physician, or if prescribed, not used in a manner consistent with that prescription; the use of alcohol, including the operation of a motor vehicle if, at the time of operation, the operator’s alcohol concentration exceeds the legal limit allowed by the jurisdiction where the injury occurs; a cosmetic surgery or other elective procedures that are not medically necessary; or a preexisting condition.
No benefits will be paid for any critical illness incurred while residing outside the United States for more than 6 months; incurred while incarcerated in any type of penal or detention facility; or for which proof is submitted by a physician who is part of the covered person’s immediate family.
The covered person must incur the critical illness and the initial diagnosis of any stage of the illness must be made while insured for that critical illness under this policy.
Preexisting Condition Limitation
A Preexisting Condition is any sickness or injury, including all related conditions and complications, or a pregnancy, for which a covered person received medical treatment, consultation, care, or services, or was prescribed or took prescription medications in the 6 month period before they became insured under the policy.
No benefits will be paid for a critical illness that results from a Preexisting Condition until the covered person has been insured for 12 months. After 12 months, the Member must be actively at work for one full day or the Dependent must be insured for one full day for their illness to be covered.
CRITICAL ILLNESS INSURANCE PROVIDES LIMITED BENEFITS. This summary is not an insurance contract or a complete statement of its provisions. It does not modify or change the provisions of any policy or rider. If there is a discrepancy, the policy is the final arbiter of the coverage. For cost and coverage details, contact your Principal® financial representative.
Critical Illness insurance from Principal® is issued by Principal Life Insurance Company, Des Moines, IA 50392.
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