Twenty-seven major diseases are not within the scope of the Code.
I. Malignant tumor
It refers to diseases in which malignant cells grow and spread uncontrollably, infiltrate and destroy surrounding normal tissues, and can spread and transfer to other parts of the body through blood vessels, lymphatic vessels and body cavities. According to the results of pathological examination, the clinical diagnosis belongs to the category of malignant tumor in the International Statistical Classification of Diseases and Related Health Problems (ICD- 10) of the World Health Organization.
The following diseases are not covered: (1) carcinoma in situ;
(2) Chronic lymphoblastic leukemia corresponding to stage A of Binet staging scheme; (3) Hodgkin's disease equivalent to Ann Arbor stage I;
(4) Skin cancer (excluding malignant melanoma and metastatic skin cancer); (5) Prostate cancer with TNM stage of (5)t 1n0m 0 or less; (6) Malignant tumor during HIV infection or AIDS.
Second, acute myocardial infarction
Refers to partial myocardial necrosis caused by insufficient blood supply in the corresponding area due to coronary artery occlusion. At least the following three conditions must be met: (1) typical clinical manifestations, such as acute chest pain; (2) Recent ECG changes suggest acute myocardial infarction;
(3) Myocardial enzymes or troponin increased in diagnosis, or showed dynamic changes consistent with acute myocardial infarction; (4) After 90 days of onset, it was confirmed that the left ventricular function decreased, such as the left ventricular ejection fraction was less than 50%.
Third, sequelae of stroke.
Refers to cerebrovascular hemorrhage, embolism or infarction caused by sudden change of cerebrovascular disease, which leads to permanent sexual dysfunction of nervous system. Permanent dysfunction of nervous system means that one or more of the following disorders still exist after 80 days of diagnosis/kloc-0:
(1) "complete loss of limb function", with one or more limbs (see 7.2 for explanation); (2) "complete loss of language ability or chewing and swallowing ability" (see 7.2 for explanation);
(3) completely lost the ability to live independently, unable to independently complete three or more of the "six basic activities of daily life" (see 7.2).
Four, major organ transplantation or hematopoietic stem cell transplantation
Major organ transplantation refers to allograft of kidney, liver, heart or lung due to corresponding organ failure. Hematopoietic stem cell transplantation refers to allogeneic transplantation of hematopoietic stem cells (including bone marrow hematopoietic stem cells, peripheral blood hematopoietic stem cells and umbilical cord blood hematopoietic stem cells) due to hematopoietic dysfunction or malignant tumor of hematopoietic system.
Five, coronary artery bypass grafting (or coronary artery bypass grafting)
Refers to coronary artery bypass grafting for the treatment of severe coronary heart disease.
Non-thoracoscopic interventional surgery and endoscopic surgery, such as coronary stent implantation, balloon dilatation of cardiac catheter and laser radio frequency technology, are not covered.
Six, end-stage renal disease (or uremia stage of chronic renal failure)
Refers to chronic irreversible renal failure, reaching uremia stage, and having received regular dialysis or kidney transplantation for at least 90 days after diagnosis.
Seven, multiple limb loss
Refers to the complete disconnection of two or more limbs from the proximal end of wrist joint or ankle joint (near the trunk end) due to illness or accidental injury.
Eight, acute or subacute severe hepatitis
Refers to the diffuse necrosis of liver tissue caused by hepatitis virus infection, which leads to acute liver failure. After serological or virological examination, all the following conditions must be met:
(1) Severe jaundice or jaundice rapidly aggravates; (2) Hepatic encephalopathy;
(3)B-ultrasound or other imaging examination showed that the liver volume was rapidly reduced; (4) Progressive deterioration of liver function.
Nine, benign brain tumor
Benign tumors of finger and brain have caused increased intracranial pressure, and the clinical manifestations are papilla edema, mental symptoms, epilepsy and motor sensory disturbance, which are life-threatening. The diagnosis must be made by imaging examination such as brain tomography (CT), magnetic resonance (MRI) or positron emission tomography (PET), and at least one of the following conditions must be met:
(1) Craniotomy for complete or partial removal of brain tumor. (2) The radiotherapy of brain tumor was actually implemented.
Pituitary tumors, brain cysts and cerebrovascular diseases are not covered.
Ten, chronic liver failure decompensated period
Refers to liver failure caused by chronic liver disease. All the following conditions must be met: (1) persistent jaundice; (2) ascites;
(3) Hepatic encephalopathy;
(4) Congestive splenomegaly with hypersplenism or esophageal and gastric varices. Liver failure caused by alcoholism or drug abuse is not covered.
Eleven, encephalitis sequela or sequelae of meningitis.
Refers to the permanent sexual dysfunction of the nervous system caused by encephalitis or meningitis. Permanent dysfunction of nervous system means that one or more of the following disorders still exist after 80 days of diagnosis/kloc-0:
(1) complete loss of function of one or more limbs; (2) complete loss of language ability or chewing and swallowing ability;
(3) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities.
Twelve, deep coma
Refers to the loss of consciousness due to illness or accidental injury, unresponsiveness to external stimuli and internal needs, coma degree of 5 or less according to Glasgow coma scale, and continuous use of life support systems such as ventilators for more than 96 hours.
Deep coma caused by alcoholism or drug abuse is not covered.
Thirteen, binaural deafness
Refers to the "permanent irreversible" binaural hearing loss caused by illness or accidental injury (see 7.2). At the speech frequencies of 500 Hz, 1000 Hz and 2000 Hz, the average hearing threshold is greater than 90 dB, which is confirmed by pure tone hearing test, acoustic immittance test or auditory evoked potential test.
14. Blindness
Refers to the permanent and irreversible loss of binocular vision due to disease or accidental injury, and one eye with good eyes must meet at least one of the following conditions: (1) eyeball loss or enucleation;
(2) The corrected visual acuity is less than 0.02 (the international standard visual acuity chart is adopted, and it should be converted if other visual acuity charts are adopted); (3) The visual field radius is less than 5 degrees. Fifteen, paralysis
Refers to the permanent and complete loss of limb function of two or more limbs due to illness or accidental injury. Permanent complete loss of limb function means that two of the three major joints of each limb are still completely stiff or unable to move with consciousness after 180 days of disease diagnosis or accidental injury 180 days. Sixteen, heart valve surgery
Refers to the operation of heart valve replacement or repair by thoracotomy for the treatment of heart valve diseases.
Seventeen, severe Alzheimer's disease.
Refers to the progressive and irreversible changes in the brain, resulting in a serious decline or loss of intelligence. The clinical manifestations are obvious cognitive impairment, abnormal behavior and decreased social ability, and daily life must be continuously monitored by others. Must be diagnosed by brain tomography (CT), magnetic resonance imaging (MRI) or positron emission tomography (PET) and other imaging examinations, completely losing the ability of independent living, unable to independently complete three or more of the six basic daily activities.
Neurosis and mental illness are not covered.
Our company only undertakes the insurance liability for the insured who is diagnosed with this disease before the age of 65. Eighteen, severe brain injury
Refers to the permanent sexual dysfunction of the nervous system caused by the injury of important parts of the brain caused by mechanical external force on the head. The diagnosis must be made by brain tomography (CT), magnetic resonance imaging (MRI) or positron emission tomography (PET). Permanent dysfunction of nervous system means that one or more of the following disorders still exist after 80 days of brain injury/kloc-0:
(1) complete loss of function of one or more limbs; (2) complete loss of language ability or chewing and swallowing ability;
(3) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities.
Nineteen, severe Parkinson's disease
It is a degenerative disease of the central nervous system with clinical manifestations of paralysis agitans and ataxia. All the following conditions must be met: (1) The disease cannot be controlled by drug treatment;
(2) completely lost the ability to live independently, unable to independently complete three or more of the six basic daily activities. Secondary Parkinson's disease is not covered.
Our company only undertakes the insurance liability for the insured who is diagnosed with this disease before the age of 65. Twenty, severe ⅲ degree burns.
Refers to the degree of burn, and the third-degree burn area reaches 20% or more of the total body surface area. The body surface area is calculated according to China's new nine-point method.
Twenty-one, severe primary pulmonary hypertension
It refers to a chronic disease in which the pulmonary artery pressure continues to increase for unknown reasons, resulting in permanent and irreversible limitation of physical activity, reaching Grade IV of new york Cardiology Association, and the average resting pulmonary artery pressure exceeds 30mmHg. Twenty-two, loss of language ability
Refers to the complete loss of language ability due to illness or accidental injury. After at least 12 months of active treatment (complete vocal cord resection is not limited by this time), it still cannot be recovered by existing medical means.
The loss of language ability caused by mental and psychological factors is not covered. 23. Severe aplastic anemia
Anemia, neutropenia and thrombocytopenia caused by chronic persistent failure of bone marrow hematopoietic function. All the following conditions must be met: (1) The results of bone marrow puncture or bone marrow biopsy support the diagnosis; (2) Peripheral blood pictures must meet the following three conditions:
① Absolute value of neutrophils ≤ 0.5×109/L; ② Reticulocyte < 65438 0%;
③ Absolute value of platelets ≤ 20×109/L.
Twenty-four, aortic surgery
Refers to the operation of removing, replacing and repairing damaged aortic vessels through thoracotomy or laparotomy for the treatment of aortic diseases. Aorta refers to thoracic aorta and abdominal aorta, excluding branch vessels of thoracic aorta and abdominal aorta.
Intra-arterial angioplasty is not covered. 25. Multiple sclerosis
The insured suffers from multifocal (multifocal) lesions of the nervous system (at least once in 6 months) caused by demyelinating lesions of the brain and spinal cord. Its clinical manifestation is that the symptoms and signs of nervous system damage attack at least once, involving optic nerve, brain stem and spinal cord, accompanied by ataxia or sensory disturbance.
Evidence of nervous system injury, such as CT scan and MRI, must be provided when making claims.
Twenty-six, end-stage lung disease
When the insured suffers from terminal lung disease and chronic respiratory failure, all the following conditions must be met: (1) FEV 1 is lower than 0.75 liters continuously;
(2) Patients with hypoxia must be given extensive and continuous oxygen therapy; (3) The arterial blood gas analysis showed that the oxygen partial pressure was lower than 55mmHg.
The above three corresponding documents or inspection reports must be provided when making claims. Twenty-seven, brain surgery
The insured has indeed performed craniotomy under general anesthesia (excluding skull drilling). Brain surgery caused by trauma is not covered.
The diagnosis and operation report issued by the neurosurgeon must be provided when the claim is made.
Twenty-seven, brain surgery
The insured has indeed performed craniotomy under general anesthesia (excluding skull drilling).
Brain surgery caused by trauma is not covered.
The diagnosis and operation report issued by the neurosurgeon must be provided when the claim is made.