IRDA GUIDELINES
1. OBJECTIVE: IRDAI (Health Insurance) Regulations, 2016 were notified
on 18-07-2016. As specified in Schedule – III of the Regulations; the Authority
has to specify certain Guidelines, Regulatory Returns and Formats etc., for
compliance by all Insurers and TPAs, as may be applicable. The objective of this
circular is to set out the said regulatory requirements that every Insurer and
TPA shall comply with.
2. APPLICABILITY: This circular is applicable to all Insurers and TPAs,
wherever applicable.
3. LEGAL AND OTHER PROVISIONS:
This circular is issued under the provisions of Section 34 (1) of Insurance Act,
1938 and under the powers vested with Regulation 2 (i) (o) of IRDAI (Health
Insurance) Regulations, 2016.
Standard definitions for 42 commonly used terms in health insurance policies
are prescribed in Chapter I of this Circular.
Standard nomenclature and procedures for 22 Critical Illnesses are prescribed
in Chapter II of this Circular.
Items for which optional cover may be offered by Insurers are prescribed in
Chapter III of this Circular.
Standards and Benchmarks for hospitals in the provider network are prescribed
in Chapter IV of this Circular.
Health Insurance Returns to be filed by all Insurers are prescribed in Chapter V
of this Circular.
CHAPTER I
Standard Definitions of terminology to be used in
Health Insurance Policies
1. Accident: An accident means sudden, unforeseen and involuntary event
caused by external, visible and violent means
2. Any one illness: (not applicable for Travel and Personal Accident
Insurance) Any one illness means continuous period of illness and
includes relapse within 45 days from the date of last consultation with the
Hospital/Nursing Home where treatment was taken.
3. Cashless facility: Cashless facility means a facility extended by the
insurer to the insured where the payments, of the costs of treatment
undergone by the insured in accordance with the policy terms and
conditions, are directly made to the network provider by the insurer to
the extent pre-authorization is approved.
4. Condition Precedent: Condition Precedent means a policy term or condition
upon which the Insurer's liability under the policy is conditional upon.
5. Congenital Anomaly: Congenital Anomaly means a condition which is present
since birth, and which is abnormal with reference to form, structure or position.
a) Internal Congenital Anomaly Congenital anomaly which is not in the visible
and accessible parts of the body.
b) b) External Congenital Anomaly Congenital anomaly which is in the visible
and accessible parts of the body
6. Co-Payment: Co-payment means a cost sharing requirement under a health
insurance policy that provides that the policyholder/insured will bear a specified
percentage of the admissible claims amount. A co-payment does not reduce the
Sum Insured.
7. Cumulative Bonus: Cumulative Bonus means any increase or addition in
the Sum Insured granted by the insurer without an associated increase in
premium.
8. Day Care Centre: A day care centre means any institution established for
day care treatment of illness and/or injuries or a medical setup with a hospital
and which has been registered with the local authorities, wherever applicable,
and is under supervision of a registered and qualified medical practitioner AND
must comply with all minimum criterion as under –
i) has qualified nursing staff under its employment
; ii) has qualified medical practitioner/s in charge;
iii) has fully equipped operation theatre of its own where surgical procedures
are carried out;
iv) maintains daily records of patients and will make these accessible to the
insurance company’s authorized personnel.
9. Day Care Treatment: Day care treatment means medical treatment, and/or
surgical procedure which is: i. undertaken under General or Local Anesthesia in
a hospital/day care centre in less than 24 hrs because of technological
advancement, and ii. which would have otherwise required hospitalization of
more than 24 hours. Treatment normally taken on an out-patient basis is not
included in the scope of this definition. (Insurers may, in addition, restrict
coverage to a specified list).
10. Deductible: Deductible means a cost sharing requirement under a health
insurance policy that provides that the insurer will not be liable for a specified
rupee amount in case of indemnity policies and for a specified number of
days/hours in case of hospital cash policies which will apply before any benefits
are payable by the insurer. A deductible does not reduce the Sum Insured.
(Insurers to define whether the deductible is applicable per year, per life or per
event and the manner of applicability of the specific deductible)
11. Dental Treatment: Dental treatment means a treatment related to teeth
or structures supporting teeth including examinations, fillings (where
appropriate), crowns, extractions and surgery.
12. Disclosure to information norm: The policy shall be void and all
premium paid thereon shall be forfeited to the Company in the event of
misrepresentation, mis-description or non-disclosure of any material fact.
13. Domiciliary Hospitalization: Domiciliary hospitalization means medical
treatment for an illness/disease/injury which in the normal course would require
care and treatment at a hospital but is actually taken while confined at home
under any of the following circumstances
: i) the condition of the patient is such that he/she is not in a condition to be
removed to a hospital, or
ii) the patient takes treatment at home on account of non-availability of room in
a hospital.
14. Emergency Care: Emergency care means management for an illness or
injury which results in symptoms which occur suddenly and unexpectedly, and
requires immediate care by a medical practitioner to prevent death or serious
long term impairment of the insured person’s health.
15. Grace Period: Grace period means the specified period of time
immediately following the premium due date during which a payment can be
made to renew or continue a policy in force without loss of continuity benefits
such as waiting periods and coverage of pre-existing diseases. Coverage is not
available for the period for which no premium is received.
16. Hospital : A hospital means any institution established for in-patient care
and day care treatment of illness and/or injuries and which has been registered
as a hospital with the local authorities under Clinical Establishments
(Registration and Regulation) Act 2010 or under enactments specified under the
Schedule of Section 56(1) and the said act Or complies with all minimum
criteria as under:
i) has qualified nursing staff under its employment round the clock;
ii) has at least 10 in-patient beds in towns having a population of less than
10,00,000 and at least 15 in-patient beds in all other places;
iii) has qualified medical practitioner(s) in charge round the clock;
iv) has a fully equipped operation theatre of its own where surgical procedures
are carried out;
v) maintains daily records of patients and makes these accessible to the
insurance company’s authorized personnel;
17. Hospitalization : Hospitalization means admission in a Hospital for a
minimum period of 24 consecutive ‘In-patient Care’ hours except for specified
procedures/ treatments, where such admission could be for a period of less than
24 consecutive hours.
18. Illness: Illness means a sickness or a disease or pathological condition
leading to the impairment of normal physiological function and requires medical
treatment
(a) Acute condition - Acute condition is a disease, illness or injury that is likely
to respond quickly to treatment which aims to return the person to his or her
state of health immediately before suffering the disease/ illness/ injury which
leads to full recovery
(b) Chronic condition - A chronic condition is defined as a disease, illness, or
injury that has one or more of the following characteristics:
1. it needs ongoing or long-term monitoring through consultations,
examinations, check-ups, and /or tests
2. it needs ongoing or long-term control or relief of symptoms
3. it requires rehabilitation for the patient or for the patient to be specially
trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur
19. Injury: Injury means accidental physical bodily harm excluding illness or
disease solely and directly caused by external, violent, visible and evident
means which is verified and certified by a Medical Practitioner.
20. Inpatient Care : Inpatient care means treatment for which the insured
person has to stay in a hospital for more than 24 hours for a covered event.
21. Intensive Care Unit: Intensive care unit means an identified section, ward
or wing of a hospital which is under the constant supervision of a dedicated
medical practitioner(s), and which is specially equipped for the continuous
monitoring and treatment of patients who are in a critical condition, or require
life support facilities and where the level of care and supervision is considerably
more sophisticated and intensive than in the ordinary and other wards.
22. ICU Charges: ICU (Intensive Care Unit) Charges means the amount
charged by a Hospital towards ICU expenses which shall include the expenses
for ICU bed, general medical support services provided to any ICU patient
including monitoring devices, critical care nursing and intensivist charges.
23. Maternity expenses: Maternity expenses means;
a) medical treatment expenses traceable to childbirth (including complicated
deliveries and caesarean sections incurred during hospitalization);
b) expenses towards lawful medical termination of pregnancy during the policy
period.
24. Medical Advice: Medical Advice means any consultation or advice from a
Medical Practitioner including the issuance of any prescription or follow-up
prescription.
25. Medical Expenses: Medical Expenses means those expenses that an
Insured Person has necessarily and actually incurred for medical treatment on
account of Illness or Accident on the advice of a Medical Practitioner, as long as
these are no more than would have been payable if the Insured Person had not
been insured and no more than other hospitals or doctors in the same locality
would have charged for the same medical treatment.
26. Medical Practitioner : Medical Practitioner means a person who holds a
valid registration from the Medical Council of any State or Medical Council of
India or Council for Indian Medicine or for Homeopathy set up by the
Government of India or a State Government and is thereby entitled to practice
medicine within its jurisdiction; and is acting within its scope and jurisdiction of
license. (Insurance companies may specify additional or restrictive criteria to
the above e.g. that the registered practitioner should not be the insured or close
member of the family. Insurance Companies may also specify definition suitable
to overseas jurisdictions where Indian policyholders are getting treatment
outside India as per the terms and conditions of a health insurance policy issued
in India)
27. Medically Necessary Treatment : Medically necessary treatment
means any treatment, tests, medication, or stay in hospital or part of a
stay in hospital which:
i) is required for the medical management of the illness or injury
suffered by the insured;
ii) must not exceed the level of care necessary to provide safe, adequate
and appropriate medical care in scope, duration, or intensity
iii) must have been prescribed by a medical practitioner
iv) must conform to the professional standards widely accepted in
international medical practice or by the medical community in India.
28. Network Provider (not applicable for Overseas Travel
Insurance): Network Provider means hospitals or health care providers
enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide
medical services to an insured by a cashless facility.
29. New Born Baby:
Newborn baby means baby born during the Policy Period and is aged
upto 90 days. .
30. Non- Network Provider:
Non-Network means any hospital, day care centre or other provider that
is not part of the network.
31. Notification of Claim:
Notification of claim means the process of intimating a claim to the
insurer or TPA
through any of the recognized modes of communication.
32. OPD treatment:
OPD treatment means the one in which the Insured visits a clinic /
hospital or
associated facility like a consultation room for diagnosis and treatment
based on the
advice of a Medical Practitioner. The Insured is not admitted as a day
care or in-patient.
33. Pre-Existing Disease (not applicable for Overseas Travel
Insurance):
Pre-Existing Disease means any condition, ailment or injury or related
condition(s) for which there were signs or symptoms, and / or were
diagnosed, and / or for which
medical advice / treatment was received within 48 months prior to the
first policy issued by the insurer and renewed continuously thereafter.
(Life Insurers may define norms for applicability of PED at
reinstatement).
34. Pre-hospitalization Medical Expenses
Pre-hospitalization Medical Expenses means medical expenses incurred
during predefined number of days preceding the hospitalization of the
Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which
the
Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is
admissible by
the Insurance Company.
35. Post-hospitalization Medical Expenses:
Post-hospitalization Medical Expenses means medical expenses incurred
during predefined number of days immediately after the insured person
is discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the
insured
person’s hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is
admissible by the
insurance company.
36. Qualified Nurse (not applicable for Overseas Travel
Insurance):
Qualified nurse means a person who holds a valid registration from the
Nursing Council of India or the Nursing Council of any state in India.
37. Reasonable and Customary Charges (not applicable for
Overseas Travel
Insurance):
Reasonable and Customary charges means the charges for services or
supplies, which are the standard charges for the specific provider and
consistent with the prevailing charges in the geographical area for
identical or similar services, taking into account the nature of the illness /
injury involved.
38. Renewal:
Renewal means the terms on which the contract of insurance can be
renewed on
mutual consent with a provision of grace period for treating the renewal
continuous for the purpose of gaining credit for pre-existing diseases,
time-bound exclusions and for all waiting periods.
39. Room Rent:
Room Rent means the amount charged by a Hospital towards Room and
Boarding
expenses and shall include the associated medical expenses.
40. Subrogation (Applicable to other than Health Policies and
health sections of Travel and PA policies):
Subrogation means the right of the insurer to assume the rights of the
insured person to recover expenses paid out under the policy that may be
recovered from any other source.
41. Surgery or Surgical Procedure:Surgery or Surgical Procedure
means manual and / or operative procedure (s) required for treatment of
an illness or injury, correction of deformities and defects, diagnosis and
cure of diseases, relief from suffering and prolongation of life, performed
in a hospital or day care centre by a medical practitioner.
42. Unproven/Experimental treatment:
Unproven/Experimental treatment means the treatment including drug
experimental therapy which is not based on established medical practice
in India, is treatment experimental or unproven.
CHAPTER II
Standard Nomenclature and Procedure for
Critical Illnesses
The following nomenclature and procedure are being prescribed for 22
critical illnesses that could form part of a health insurance policy. All
Insurers shall use the definitions without exception wherever the
products offer coverage to any of the Critical Illnesses specified herein.
All health insurance policies filed hereafter covering critical illnesses
shall use the nomenclature and procedure specified herein.
1. CANCER OF SPECIFIED SEVERITY
I. A malignant tumor characterized by the uncontrolled growth and
spread of
malignant cells with invasion and destruction of normal tissues. This
diagnosis
must be supported by histological evidence of malignancy. The term
cancer
includes leukemia, lymphoma and sarcoma.
II. The following are excluded –
i. All tumors which are histologically described as carcinoma in situ,
benign, pre-malignant, borderline malignant, low malignant potential,
neoplasm of unknown behavior, or non-invasive, including but not
limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2
and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of
metastases to lymph nodes or beyond;
iii. Malignant melanoma that has not caused invasion beyond the
epidermis;
iv. All tumors of the prostate unless histologically classified as having a
Gleason score greater than 6 or having progressed to at least clinical
TNM classification T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM
Classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described
as TaN0M0 or of a lesser classification,
[Link] Gastro-Intestinal Stromal Tumors histologically classified as
T1N0M0 (TNM Classification) or below and with mitotic count of less
than or equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
2. MYOCARDIAL INFARCTION
(First Heart Attack of specific severity)
I. The first occurrence of heart attack or myocardial infarction, which
means the
death of a portion of the heart muscle as a result of inadequate blood
supply to
the relevant area. The diagnosis for Myocardial Infarction should be
evidenced
by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of
acute myocardial infarction (For e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific
biochemical markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt
ischemic heart disease OR following an intra-arterial cardiac procedure.
4. OPEN CHEST CABG
I. The actual undergoing of heart surgery to correct blockage or
narrowing in one or
more coronary artery(s), by coronary artery bypass grafting done via a
sternotomy (cutting through the breast bone) or minimally invasive
keyhole
coronary artery bypass procedures. The diagnosis must be supported by
a
coronary angiography and the realization of surgery has to be confirmed
by a
cardiologist.
II. The following are excluded:
i. Angioplasty and/or any other intra-arterial procedures
4. OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES
I. The actual undergoing of open-heart valve surgery is to replace or
repair one or
more heart valves, as a consequence of defects in, abnormalities of, or
diseaseaffected
cardiac valve(s). The diagnosis of the valve abnormality must be
supported by an echocardiography and the realization of surgery has to
be
confirmed by a specialist medical practitioner. Catheter based techniques
including but not limited to, balloon valvotomy/valvuloplasty are
excluded.
5. COMA OF SPECIFIED SEVERITY
I. A state of unconsciousness with no reaction or response to external
stimuli or
internal needs. This diagnosis must be supported by evidence of all of the
following:
i. no response to external stimuli continuously for at least 96 hours;
ii. life support measures are necessary to sustain life; and
iii. permanent neurological deficit which must be assessed at least 30
days
after the onset of the coma.
II. The condition has to be confirmed by a specialist medical practitioner.
Coma
resulting directly from alcohol or drug abuse is excluded.
6. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
I. End stage renal disease presenting as chronic irreversible failure of
both kidneys
to function, as a result of which either regular renal dialysis
(haemodialysis or
peritoneal dialysis) is instituted or renal transplantation is carried out.
Diagnosis
has to be confirmed by a specialist medical practitioner.
7. STROKE RESULTING IN PERMANENT SYMPTOMS
I. Any cerebrovascular incident producing permanent neurological
sequelae. This
includes infarction of brain tissue, thrombosis in an intracranial vessel,
haemorrhage and embolisation from an extracranial source. Diagnosis
has to be
confirmed by a specialist medical practitioner and evidenced by typical
clinical
symptoms as well as typical findings in CT Scan or MRI of the brain.
Evidence of
permanent neurological deficit lasting for at least 3 months has to be
produced.
II. The following are excluded:
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular
functions.
8. MAJOR ORGAN /BONE MARROW TRANSPLANT
I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas,
that resulted from irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing
of
a transplant has to be confirmed by a specialist medical practitioner.
II. The following are excluded:
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
9. PERMANENT PARALYSIS OF LIMBS
I. Total and irreversible loss of use of two or more limbs as a result of
injury or
disease of the brain or spinal cord. A specialist medical practitioner must
be of
the opinion that the paralysis will be permanent with no hope of recovery
and
must be present for more than 3 months.
10. MOTOR NEURON DISEASE WITH PERMANENT SYMPTOMS
I. Motor neuron disease diagnosed by a specialist medical practitioner as
spinal
muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis
or
primary lateral sclerosis. There must be progressive degeneration of
corticospinal tracts and anterior horn cells or bulbar efferent neurons.
There must
be current significant and permanent functional neurological impairment
with
objective evidence of motor dysfunction that has persisted for a
continuous
period of at least 3 months.
11. MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS
I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and
evidenced by all of the following:
i. investigations including typical MRI findings which unequivocally
confirm
the diagnosis to be multiple sclerosis and
ii. there must be current clinical impairment of motor or sensory
function,
which must have persisted for a continuous period of at least 6 months.
II. Other causes of neurological damage such as SLE and HIV are
excluded.
12. ANGIOPLASTY
I. Coronary Angioplasty is defined as percutaneous coronary intervention
by way of
balloon angioplasty with or without stenting for treatment of the
narrowing or
blockage of minimum 50 % of one or more major coronary arteries. The
intervention must be determined to be medically necessary by a
cardiologist and
supported by a coronary angiogram (CAG).
II. Coronary arteries herein refer to left main stem, left anterior
descending,
circumflex and right coronary artery.
III. Diagnostic angiography or investigation procedures without
angioplasty/stent
insertion are excluded.
13. BENIGN BRAIN TUMOR
I. Benign brain tumor is defined as a life threatening, non-cancerous
tumor in the
brain, cranial nerves or meninges within the skull. The presence of the
underlying
tumor must be confirmed by imaging studies such as CT scan or MRI.
II. This brain tumor must result in at least one of the following and must
be
confirmed by the relevant medical specialist.
i. Permanent Neurological deficit with persisting clinical symptoms for a
continuous period of at least 90 consecutive days or
ii. Undergone surgical resection or radiation therapy to treat the brain
tumor.
III. The following conditions are excluded:
Cysts, Granulomas, malformations in the arteries or veins of the brain,
hematomas, abscesses, pituitary tumors, tumors of skull bones and
tumors of the
spinal cord.
14. BLINDNESS
I. Total, permanent and irreversible loss of all vision in both eyes as a
result of
illness or accident.
II. The Blindness is evidenced by:
i. corrected visual acuity being 3/60 or less in both eyes or ;
ii. the field of vision being less than 10 degrees in both eyes.
III. The diagnosis of blindness must be confirmed and must not be
correctable by
aids or surgical procedure.
15. DEAFNESS
I. Total and irreversible loss of hearing in both ears as a result of illness
or
accident. This diagnosis must be supported by pure tone audiogram test
and
certified by an Ear, Nose and Throat (ENT) specialist. Total means “the
loss of
hearing to the extent that the loss is greater than 90decibels across all
frequencies of hearing” in both ears.
16. END STAGE LUNG FAILURE
I. End stage lung disease, causing chronic respiratory failure, as
confirmed and
evidenced by all of the following:
i. FEV1 test results consistently less than 1 litre measured on 3 occasions
3
months apart; and
ii. Requiring continuous permanent supplementary oxygen therapy for
hypoxemia; and
iii. Arterial blood gas analysis with partial oxygen pressure of 55mmHg
or
less (PaO2 < 55mmHg); and
iv. Dyspnea at rest.
17. END STAGE LIVER FAILURE
I. Permanent and irreversible failure of liver function that has resulted in
all three of
the following:
i. Permanent jaundice; and
ii. Ascites; and
iii. Hepatic encephalopathy.
II. Liver failure secondary to drug or alcohol abuse is excluded.
18. LOSS OF SPEECH
I. Total and irrecoverable loss of the ability to speak as a result of injury
or disease
to the vocal cords. The inability to speak must be established for a
continuous
period of 12 months. This diagnosis must be supported by medical
evidence
furnished by an Ear, Nose, Throat (ENT) specialist.
II. All psychiatric related causes are excluded.
19. LOSS OF LIMBS
I. The physical separation of two or more limbs, at or above the wrist or
ankle level
limbs as a result of injury or disease. This will include medically
necessary
amputation necessitated by injury or disease. The separation has to be
permanent without any chance of surgical correction. Loss of Limbs
resulting
directly or indirectly from self-inflicted injury, alcohol or drug abuse is
excluded.
20. MAJOR HEAD TRAUMA
I. Accidental head injury resulting in permanent Neurological deficit to
be assessed
no sooner than 3 months from the date of the accident. This diagnosis
must be
supported by unequivocal findings on Magnetic Resonance Imaging,
Computerized Tomography, or other reliable imaging techniques. The
accident
must be caused solely and directly by accidental, violent, external and
visible means and independently of all other causes.
II. The Accidental Head injury must result in an inability to perform at
least three (3)
of the following Activities of Daily Living either with or without the use of
mechanical equipment, special devices or other aids and adaptations in
use for
disabled persons. For the purpose of this benefit, the word “permanent”
shall
mean beyond the scope of recovery with current medical knowledge and
technology.
III. The Activities of Daily Living are:
i. Washing: the ability to wash in the bath or shower (including getting
into
and out of the bath or shower) or wash satisfactorily by other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all
garments
and, as appropriate, any braces, artificial limbs or other surgical
appliances;
iii. Transferring: the ability to move from a bed to an upright chair or
wheelchair and vice versa;
iv. Mobility: the ability to move indoors from room to room on level
surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel
and
bladder functions so as to maintain a satisfactory level of personal
hygiene;
vi. Feeding: the ability to feed oneself once food has been prepared and
made available.
IV. The following are excluded:
i. Spinal cord injury;
21. PRIMARY (IDIOPATHIC) PULMONARY HYPERTENSION
I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary
Hypertension by a
Cardiologist or specialist in respiratory medicine with evidence of right
ventricular
enlargement and the pulmonary artery pressure above 30 mm of Hg on
Cardiac
Cauterization. There must be permanent irreversible physical
impairment to the
degree of at least Class IV of the New York Heart Association
Classification of
cardiac impairment.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest,
but less
than ordinary activity causes symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort.
Symptoms may be present even at rest.
III. Pulmonary hypertension associated with lung disease, chronic
hypoventilation,
pulmonary thromboembolic disease, drugs and toxins, diseases of the left
side of
the heart, congenital heart disease and any secondary cause are
specifically
excluded.
22. THIRD DEGREE BURNS
I. There must be third-degree burns with scarring that cover at least 20%
of the
body’s surface area. The diagnosis must confirm the total area involved
using
standardized, clinically accepted, body surface area charts covering 20%
of the
body surface area.
