**C**

**CAESAREAN OPERATION**

A caesarean operation is delivery of a child through an incision in the
abdominal and uterine wall. The operation may be done because of
convulsion or toxic condition directly due to the processes of
pregnancy. The operation may become necessary due to other diseases such
as heart involvement, or due to small or irregular pelvic outlet,
uterine obstruction or a preference for this method of delivery.

**Underwriting Requirements**

Where this operation has occurred, the cause must be known. Where
information is inadequate or it is known the operation was due to heart
or other disease, an APS (VA Form 29-8158) will be required. Where the
operation was necessary due to heart or other disease, rate under the
specific disease.

  ---------------------------------------------------- ------------------
  If the operation was due to pelvic or uterine        0
  abnormalities                                        

  Where there has been a subnormal delivery,           0
  sterilization, or uncomplicated menopause            
  ---------------------------------------------------- ------------------

**CANCER**

Cancer is a common term for any malignant tumor, which includes
epithelioma, carcinoma and sarcoma. Epithelioma is cancer of skin.
Carcinoma is overgrowth of epithelial cells. Sarcoma is cancer of
non-epithelial tissue such as bone.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Cancer                                               See Tumor section

  ---------------------------------------------------- ------------------

**CANDIDIASIS**

Candidiasis is a fungal infection usually limited to the skin and mucous
membranes. It may become life threatening in weak patients or patients
with suppression of the immune system. The CDC considers bronchial or
pulmonary candidiasis as sufficient grounds for the diagnosis of AIDS if
the patient tested positive for HIV.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required if under treatment at the time
application was made.

  ---------------------------------------------------- ------------------
  Recovered                                            0

  Under treatment -- 6 months                          0

  After completion of treatment: bronchial, pulmonary, 25
  esophageal                                           

  Disseminated                                         See AIDS
  ---------------------------------------------------- ------------------

#### **CARBON MONOXIDE POISONING**

Carbon monoxide poisoning is a condition caused by inhaling carbon
monoxide, a colorless and odorless gas. When inhaled, it displaces the
oxygen in the blood, causes oxygen starvation, and results in partial to
fatal asphyxiation.

The gas is present in exhaust of oil or gasoline motors, near stoves in
houses and in industries, in mines and wherever illuminating gases are
found or used. Knowledge of the extent and circumstances of exposure is
the basis for underwriting action.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required within 2 years to determine the
extent and circumstances of exposure, where circumstances are not
suggestive of attempted suicide. If attempted suicide is involved, rate
under Suicide (Attempted).

  ---------------------------------------------------- ------------------
  Within 2 months of single attack                     

  Not unconscious, on recovery                         0

  With unconsciousness                                 25

  After 3 months                                       0

  Multiple attack                                      

  Due to exposure in occupation                        200

  After 6 months of termination of exposure            0
  ---------------------------------------------------- ------------------

**CARBUNCLES (Boils)**

A carbuncle is a collection of boils in close proximity with each other.
These areas of infection unite by undermining the underlying tissues.
The back of the neck is a common location. As with boils, they may be
caused by infection through the follicles or sweat glands, or accompany
digestive or diabetes.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+-----------------------------------------------------+----------------+
| #### If present at time of application              |                |
+-----------------------------------------------------+----------------+
| ####  Single occurrence                             | 0              |
+-----------------------------------------------------+----------------+
| ####  Evidence of frequent recurrence, not known to | 25             |
|  be associated with digestive disorders or diabetes |                |
+-----------------------------------------------------+----------------+
| ####  After recovery                                | 0              |
+-----------------------------------------------------+----------------+
| ####  Secondary to other disease                    | RFC            |
+-----------------------------------------------------+----------------+

CARDIAC DIAGNOSTICS

Numerous tests have been developed to assess the structure and function
of the heart. These vary from the traditional electrocardiogram to
other, more complicated tests which may be expensive, time consuming and
invasive. All these tests have problems in their interpretations, and
decisions as to the importance of individual tests must incorporate the
overall clinical procedure.

[Cardiac Catheterization, Coronary Angiograms]{.underline}

Cardiac catheterization is the most accurate way to evaluate anatomy. In
this procedure, a catheter (tube) is introduced into the heart via the
groin or arm. Radiocontrast material can be injected within the heart
chambers and/or coronary arteries.

These studies allow accurate assessment of the coronary arteries, heart
valves and chambers. Coronary artery disease, valvular disorders and
congenital heart diseases can all be evaluated. Ejection fraction and
intracardiac pressure can be measured.

[Chest X-Ray]{.underline}

The ordinary chest x-ray is useful for evaluating heart size and
configuration, abnormalities of the lung and also of the chest wall and
mediastinum. Many factors influence the chest x-ray (see Cardiomegaly).
It is important also to note that there may be serious abnormalities of
heart or lung functions in the presence of a normal x-ray.

[Echocardiogram, Doppler Echocardiogram, Exercise
Echocardiogram]{.underline}

Echocardiography utilizes high frequency sound waves to assess structure
and blood flow through the heart.

M-mode (one dimensional) and 2D (two dimensional) echo allow accurate
measurement of myocardial wall thickness and contractility, valve
structure and intra-cardiac dimensions. The internal diameter of the
left ventricle (LVID) is an excellent measure of heart size.

Doppler echo measures blood flow through the heart chambers and valves
and is useful for calculating ejection fraction, shunts and valve
opening sizes.

In exercise echocardiography, the subject undergoes echo testing after
exercise. Exercise induced ischemia may be accompanied by ventricular
wall motion abnormalities which can be identified by echo.

[Electrocardiogram]{.underline}

The electrocardiogram is a graphic recording of the heart beat. It
identifies heart rate and rhythm, disturbances in simple impulse
conduction through the heart and disorders of myocardium such as
hypertrophy and ischemia. It is a major diagnostic tool to detect acute
myocardial infarction and often, but not always, shows scars from old
healed infarction. It cannot reliably prove or disprove coronary artery
disease unless evidence of a myocardial infarction is unequivocal.

[Holter Monitor, 24 Hour Ambulatory Monitoring]{.underline}

A Holter Monitor provides a 24 hour record or heart rate and rhythm
occurring with normal activities. It is the best test to identify
arrhythmias that occur episodically and are not apparent on resting ECG.
It can also identify "silent ischemia", myocardial ischemia that occurs
throughout the day or with certain activities but which produce no
angina.

[MUGA Study]{.underline}

To perform MUGA (multigated angiocardiography) studies, a radionuclide
is injected into a peripheral vein and radiographic counts are made over
the heart. Myocardial contractility, ejection fraction, ventricular
volumes and other parameters of ventricular function can be determined
with this technique.

[Treadmill Test, Exercise Electrocardiogram]{.underline}

The ECG is monitored while the subject exercises following a standard
format (Bruce Protocol, Naughton Protocol) toward a target heart rate.
It is useful in the evaluation of chest pain.

A normal treadmill test suggests that chest pain is noncardiac in origin
and often obviates the need for more extensive testing. Abnormal
responses include chest pain, ST changes of myocardial ischemia, drops
or extreme elevations in blood pressure.

[Thallium Scan]{.underline}

Thallium is a radioactive isotope which concentrates in myocardium when
injected in the blood stream.

The subject is exercised in the standard manner on a treadmill,
following which thallium is injected into a peripheral vein. The heart
is then scanned radiographically immediately and after a three hour
delay. Areas of ischemia will not pick up the isotope, but will
"reperfuse" after the rest phase and appear normal in the later scan.
Areas of scarring will not show isotope on either scan.

**CAROTID BRUIT**

The main blood supply to the brain goes through the carotid arteries in
the neck. When these are partially obstructed by atherosclerotic plaques
a bruit (murmur like sound) may result.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------ ----------------
  Present                                                

  No symptoms                                            

  Not investigated                                       75

  Investigated                                           

  Stenosis less than 30%                                 0

  Stenosis 30% or more                                   100-55

  Symptomatic                                            R

  History -- treated surgically                          55
  ------------------------------------------------------ ----------------

**CELIAC DISEASE, GLUTEN ENTEROPATHY, SPRUE**

All result from impaired absorption of nutrients from the small bowel
and are characterized by weight loss, diarrhea or other intestinal
symptoms, and anemia of various types.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Present                                           

  Well controlled                                   50-0

  Others                                            Refer to Section
                                                    Chief

  Recovered                                         0
  ------------------------------------------------- ---------------------

**CENTRAL NERVOUS SYSTEM (Diseases of)**

##### The following nervous diseases are associated with congenital or acquired defects, or with changes and degeneration in the central nervous system or musculature of the body. They give a uniformly poor prognosis. Since many of them are subject to remissions and intervening periods of seemingly normal health, they may be encountered in review of insurance applications.

## [Huntington's Chorea]{.underline}

Huntington's Chorea is a hereditary neurological disorder with onset in
mid-life which leads inexorably to progressive deterioration and death.
The disease has persisted because the onset is after the usual child
bearing years. Fifty percent of the offspring of an affected parent can
be expected to develop the disease. Testing now allows identification of
asymptomatic carriers and permits counseling and appropriate planning.

##### Underwriting Requirements

An APS (VA Form 29-8158) is required.

+-----------------------------------------------------+----------------+
| ### Present                                         | R              |
+-----------------------------------------------------+----------------+
| Parent with Huntington's Chorea, no testing done to | R              |
| determine genetic status, or positive test          |                |
+-----------------------------------------------------+----------------+
| Negative genetic testing                            | 0              |
+-----------------------------------------------------+----------------+

**[Hydrocephalus]{.underline}**

Hydrocephalus is an abnormal intracranial accumulation of cerebral
spinal fluid. An acute symptomatic form in adults requires emergency
treatment and usually responds dramatically to treatment of the
underlying disorder, or shunting. A chronic symptomatic form may not
respond to treatment.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  Cause known, treated, no sequelae                  100

  Others                                             Refer to Section
                                                     Chief
  -------------------------------------------------- --------------------

**[Multiple (or Disseminated) Sclerosis (Amyotrophic Lateral
Sclerosis)]{.underline}**

Multiple sclerosis is a chronic, progressive disease syndrome of the
central nervous (brain and spinal cord) system or, rather a series of
syndromes based on several different causative factors. It is usually
insidious though the onset of the first symptoms may be quite sudden.
The cause is not known but vitamin deficiency and allergy are suspected
in rare instances. It is characteristically noted for its spontaneous
remissions and exacerbations with complete or partial (usually
temporary) recovery from symptoms in the earlier stages and with
ultimate development of permanent lesions with associated clinical
downhill progression. It is usually found in individuals 20 to 40. The
duration is from l to 2 years in the acute rapid progressive type and up
to 20-odd years in the chronic slow progressive type. The average
duration is from 7 to 9 years.

The characteristic signs and symptoms are intentional tremor, nystagmus,
scanning speech, urinary bladder involvement, impaired vision, ataxia
(gait), changes in reflexes, and in advance cases, often mental
disturbance and paralysis. The paralysis is sometimes found in the early
stage.

**Underwriting Requirements**

APS (VA Form 29-8158) and medical examination required in all cases.

  --------------------------------------------------------- -------------
  Suspected or single mild attack with full recovery or two 
  such episodes separated by more than 2 years, currently   
  no evidence of disease                                    

  Within 2 years of last attack                             100

  3-4 years since last attack                               75

  After 4 years since last attack                           0

  Definite MS, multiple attacks, minimal impairment,        
  independent                                               

  Within 2 years of last attack                             300

  Within 3-5 years of last attack                           200

  Within 6-10 years of last attack                          100

  After 10 years since last attack                          0

  Moderate impairments, more frequent attacks               

  Present, residuals                                        Add 100 to
                                                            above ratings

  Severe neurological abnormalities, wheelchair, bladder    R
  problems, unable to work, speech or swallowing problems   
  or rapidly progressive symptoms                           
  --------------------------------------------------------- -------------

**[Myasthenia Gravis]{.underline}**

This is an autoimmune disorder leading to episodic muscle weakness. It
may involve only eye muscle or maybe more generalized. It can be
associated with thymictumas or other disorders.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------------- -------------------
  Ocular form                                         

  Within 1^st^ year                                   Refer to Section
                                                      Chief

  Within 2^nd^ -- 3^rd^ year                          75

  After 3^rd^ year                                    0

  Generalized form                                    

  Present, stable                                     

  Within 1^st^ year                                   Refer to Section
                                                      Chief

  Within 2^nd^ -- 3^rd^ year                          125

  Within 3^rd^ -- 5^th^ year                          75

  After 5 years                                       0

  Other: Myasthenia crisis, swallowing or respiratory R
  problem                                             
  --------------------------------------------------- -------------------

**[Myelitis]{.underline}**

Myelitis is an inflammation of the spinal cord and nerve roots and may
be due to viral (Polio, Cox sackie, herpes zoster, etc. or bacterial
infections or AIDS related.).

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------- -------------------------------
  Without residual impairment             0

  With residual impairment                

  Within 6 months of recovery             Refer to Section Chief

  After 6 months                          Rate for Poliomyelitis with
                                          residual impairment

  AIDS                                    R
  --------------------------------------- -------------------------------

**[Syringomyelia]{.underline}**

Syringomyelia is a neurological disorder caused by an expanding
fluid-filled cavity in the spinal cord. The onset is frequently in the
young adult years and the course is variable. Life threatening
neurological dysfunction may occur in spite of attempted drainage of the
cavity.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  Selected cases apparently in remission more than 3 200
  years, able to perform normal activities           

  Others                                             R
  -------------------------------------------------- --------------------

## [Other Central Nervous System Disorders]{.underline}

  ---------------------------------------------- ------------------------
  Amyotophic Lateral Sclerosis (ALS)             R

  Friedreich's Ataxia                            R

  Landry's paralysis                             R

  Meningocele                                    Rate as Spina Bifida
                                                 Occulta

  Motor or sensory aphasia                       R

  Myotonia dystrophies                           R

  Posterolateral Sclerosis                       R

  Progressive muscular atrophy or dystrophy      R
  ---------------------------------------------- ------------------------

**CEREBRAL ATROPHY**

**(Pick's Disease -- Arnold Pick)**

This is a slowly developing dementia, which is due to marked atrophy of
the frontal lobes. It occurs more often in women than men. It is
characterized by progressive degeneration of the higher mental functions
and gradual development of aphasia. The disease may last for 10 years or
more. There is gradual emotional dullness, loss of moral judgment,
stereotype of speech and action, and progressive dementia, but no
delusions, hallucinations, or confabulation. There is focal atrophy of
cortical cells but no arteriosclerotic changes. This may resemble a
functional psychosis but examination reveals organic syndrome.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------- --------------------------------------------
  Cerebral atrophy           Rate as Psychiatric Disorders -- Psychotic
                             Disorders

  -------------------------- --------------------------------------------

**CEREBRAL HEMORRHAGE**

**(Apoplexy Cerebral Accident)**

Bleeding within the skull is referred to by several technical terms,
which are both descriptive and tend to indicate location of the
bleeding.

**Subarachnoid bleeding** -- indicates bleeding beneath one of the
linings of the skull or membranes covering the brain.

**Cerebral hemorrhage** - hemorrhage (bleeding) into the cerebrum (main
substance of the brain).

**Apoplexy (stroke)** -- a type of cerebral hemorrhage usually due to
**arteriosclerosis** (hardening of the arteries) in which there is a
spontaneous rupture of a blood vessel.

**Intracranial hemorrhage** -- might be caused by an external blow to
the head or fall on the head.

**Cerebral accident** -- any bleeding within the skull.

**Arterial thrombosis** -- a localized obstruction of the blood supply
to the brain caused by formation of a blood clot.

**Arterial embolism** -- the lodging in the blood vessel of a floating
obstruction.

Varying degrees of temporary or permanent paralysis (paraplegia and
hemiplegia) may result from any of these conditions. Although in some
cases remarkable improvement occurs, the tendency is to recurrences with
fatal results.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------------------- -----------------
  Single episode -- no more than mild residuals, after  100
  return to normal duties\*                             

  Multiple episodes                                     R
  ----------------------------------------------------- -----------------

\*If there are residuals and they are severe consider addition of +50.

**CEREBRAL PALSY**

**(Spastic Paralysis)**

Cerebral Palsy is commonly known as spastic paralysis, is a congenital
disorder of the central nervous system with or without mental
involvement, and manifested mainly by disordered muscular movements
involving all limbs to varying degrees, and lack of coordination
affecting gait and speech. Since such a disorder originates primarily in
childhood, cases involving this condition will be extremely rare.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------- ---------------
  If diagnosis is definitely established, no mental       55
  involvement and ambulatory with braces                  

  Others                                                  125
  ------------------------------------------------------- ---------------

**CEREBRAL THROMBOSIS**

Cerebral thrombosis is a clotting of blood in a narrowed blood vessel in
the brain so that the blood supply is diminished to that portion and is
manifested by symptoms similar to those of apoplexy. This is associated
with arteriosclerosis or atherosclerosis.

  --------------------------------------- -------------------------------
  Cerebral thrombosis                     Apply rules for Cerebral
                                          Hemorrhage

  --------------------------------------- -------------------------------

**CEREBRALSPINAL MENINGITIS AND**

**EPIDEMIC CEREBROSPINAL MENINGITIS**

Cerebrospinal meningitis and epidemic cerebrospinal meningitis are acute
contagious inflammatory diseases involving the membranes covering the
brain or spinal cord or both. Symptoms characterizing this condition are
severe headache, vomiting, high fever accompanied by stiffness in neck
and back. The disease may be caused by virus infections or through
contact with a carrier of disease and occasionally following skull
fracture. It is also a complication to be watched for in otitis media,
mastoiditis and ruptured brain abscess.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  No complications or residuals, upon recovery      0

  With complications or residual symptoms           

  Within 1 year                                     150

  After 1 year                                      Rate for residual
                                                    symptoms or sequelae
  ------------------------------------------------- ---------------------

**CEREBRAL VASCULAR SPASM**

Cerebral vascular spasm refers to a temporary spasm of blood vessels in
the brain usually associated with nervous tension, but may be the
forerunner of serious disease, with transient symptoms. It may be caused
by nicotine toxicity or some other temporary toxic state. Actual
vascular disease, aneurysm, thrombosis, embolism, hemorrhage, etc.,
should be ruled out.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------------- --------------
  No hypertension or other cardiovascular disease, the     
  urine is normal, and no recurrence                       

  Within 1 year                                            100

  Within 2 -- 3 years                                      50

  After 3 years                                            0

  With complications, or recurrent, cause undetermined     400

  If cause determined                                      RFC
  -------------------------------------------------------- --------------

**CHANCROID**

Chancroid, or soft chancre, is a contagious non-syphilitic venereal
ulcer, which may resemble a syphilitic chancre in appearance.

**Underwriting Requirement**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------ ----------------------
  If present at time of application, syphilis      75
  excluded                                         

  After recovery                                   0

  If syphilis is involved                          Rate for Syphilis
  ------------------------------------------------ ----------------------

**CHONDROMA**

A chondroma is a tumor that develops in the cartilage of bones and
joints.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Present                                              

  Single                                               0

  Multiple                                             55

  History, removed, after recovery                     0
  ---------------------------------------------------- ------------------

**CHRONIC FATIGUE SYNDROME (CFS)**

Fatigue is a very common complaint, but recently a syndrome of chronic
disabling fatigue, which is unexplainable and resistant to treatment,
has received considerable attention. Originally thought to be a chronic
form of mononucleosis, its true cause remains unknown.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------ ----------------------
  Present, disabled                                Refer to Section Chief

  Able to perform normal duties                    0

  History                                          0
  ------------------------------------------------ ----------------------

**CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)**

COPD is a degenerative disorder of the lungs with reduced ability to
expire air because of a combination of chronic bronchitis and emphysema.
Sometimes there is an element of asthma. Many cases of COPD are the
result of cigarette smoking.

Prolonged irritation of the bronchial airways with cough, excessive
mucus production, frequent infections and impaired airflow is the
bronchitis component of COPD. If airflow can be improved with
bronchodilator drugs, then an element of asthma is present and the
condition may be called asthmatic bronchitis.

Destruction of lung tissue with reduced ability to exchange gases
between the blood and inspired air is the emphysema component of COPD.
Dyspnea is the hallmark of emphysema.

For underwriting purposes, COPD may be classified as follows:

**Mild** -- no impairment of exercise tolerance; capable of heavy labor.

**Moderate** -- occasional lung infections, regular use of medication;
capable of climbing stairs, shoveling snow, playing tennis, swimming.

**Severe** -- frequent lung infections; regular use of medication
including daily steroid drugs; weight loss; appearance may be plethoric
or dusky; capable of walking on level ground, light house-work,
sedentary employment.

**Extreme** -- disabled from sedentary employment by lung disease; short
of breath at rest or with slow walk on level ground or minimal activity
such as washing dishes or driving a car.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Mild                                                 75

  Moderate                                             150

  Severe                                               300

  Extreme                                              R
  ---------------------------------------------------- ------------------

CONGENITAL HEART DISEASE

Congenital malformations of the heart vary widely in severity and may be
associated with malformations of other organs. In most cases, cardiac
catheterization and surgery reports, even if many years old, are
essential for proper classification.

**[Atrial and Ventricular Septal Defects (ASD and VSD)]{.underline}**

An ASD is an abnormal opening in the wall between the atria of the heart
(interatrial septum). A systolic murmur in the left upper chest is
usual.

A VSD is an abnormal opening in the wall between the two ventricles of
the heart (interventricular septum). A systolic murmur at the left
sternal border is expected.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------------- -------------------
  Present, unoperated                                 

  Ages 15-49                                          200

  Ages 50 and up                                      125

  Corrected by surgical operation, returned to normal 0
  activities, no residual murmurs                     

  With residual murmur                                Refer to Section
                                                      Chief
  --------------------------------------------------- -------------------

## [Patent Ductus Arteriosus]{.underline}

Patent ductus arteriosus is an opening (connection) between the aorta
and left pulmonary artery.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------- -------------------------------
  Unoperated                              R

  Repaired by operation                   0

  With murmur heard after surgery         Rate for murmur or valvular
                                          disease
  --------------------------------------- -------------------------------

## [Coarctation of the Aorta]{.underline}

Coarctation is a congenital narrowing of the aorta. Significant
narrowing produces hypertension in the arms and obstruction to blood
flow in the lower body and legs. Left ventricular hypertrophy may occur.

Coarctation of the aorta may be associated with aortic stenosis, patent
ductus arteriosus, mitral insufficiency and Turner's syndrome.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+-------------------------------------------+------------+------------+
| Unoperated                                |            |            |
+-------------------------------------------+------------+------------+
| Described as trivial and surgery not      | 0          |            |
| required                                  |            |            |
+-------------------------------------------+------------+------------+
| Others                                    | R          |            |
+-------------------------------------------+------------+------------+
| Surgically repaired with graft, returned  | Under      | Age 20 and |
| to normal activities                      |            | [over]{.   |
|                                           | [age       | underline} |
|                                           | 20]{.      |            |
|                                           | underline} |            |
+-------------------------------------------+------------+------------+
| Within 1 year                             | 55         | 100        |
+-------------------------------------------+------------+------------+
| Within 2^nd^ year                         | 30         | 55         |
+-------------------------------------------+------------+------------+
| Within 3^rd^ year                         | 0          | 30         |
+-------------------------------------------+------------+------------+
| After 3 years                             | 0          | 0          |
+-------------------------------------------+------------+------------+
| For end to end anastomosis (no graft)     | Reduce by  |            |
|                                           | 50 debits  |            |
+-------------------------------------------+------------+------------+
| Persisting heart enlargement -- 2 years   |            |            |
| after surgery                             |            |            |
+-------------------------------------------+------------+------------+
| Up to 20%                                 | 125        |            |
+-------------------------------------------+------------+------------+
| 20% and up                                | R          |            |
+-------------------------------------------+------------+------------+
| With murmur or high blood pressure        | Sum debits |            |
+-------------------------------------------+------------+------------+

## 

## [Dextrocardia]{.underline}

This is a congenital condition in which the heart is transposed to the
right side. When other organs are also transposed, the condition is
called situs inversus. If the heart alone is transposed, a considerable
risk of other congenital abnormalities exists.

  -------------------------------------------- --------------------------
  No other evidence of cardiovascular disease, 0
  with or without situs inversus               

  -------------------------------------------- --------------------------

## [Pulmonic Stenosis, Pulmonic Insufficiency]{.underline}

Virtually all pulmonic stenosis is congenital and most cases of pulmonic
insufficiency result from repair of pulmonic stenosis. Murmurs related
to the pulmonary valve are best heard at the upper left sternum,
stenosis causing a systolic murmur and insufficiency a diastolic murmur.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------- --------------------------
  Unoperated, no hemodynamic data              

  Normal heart size, no RVH, normal ECG,       0
  described as trivial or mild, repair not     
  advised                                      

  Others                                       100
  -------------------------------------------- --------------------------

## [Tetralogy of Fallot]{.underline}

Tetralogy of Fallot is a combination of abnormalities that can usually
be corrected surgically (ventricular septal defect, overriding aorta,
pulmonic stenosis, and right ventricular hypertrophy).

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Unoperated                                           R

  Operated, complete correction and return to normal   200
  activities                                           
  ---------------------------------------------------- ------------------

**CONTUSION**

Head injuries that may be of significance to longevity are concussions
(unconsciousness of varying duration), contusions (injury to the brain)
or skull fractures.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Cerebral concussion or contusion                  

  Unconsciousness less than 12 hours, or totally    0
  disabled less than three months -- no sequelae    

  Others -- no sequelae                             0

  With post-concussion syndrome (persisting         30-0
  symptoms such as headaches, dizzy spells,         
  double-vision, etc.)                              

  Fractured skull                                   

  Unconscious less than 2 hours, disabled less than 0
  one month -- no sequelae                          

  Others                                            Refer to Section
                                                    Chief
  ------------------------------------------------- ---------------------

**CONVULSIONS**

Convulsions, spasms and fits, are terms for violent involuntary
(uncontrollable) muscular contractions, or series of contractions,
affecting either a part or all of the body accompanied by loss of
consciousness. They are considered a symptom rather than a disease, and
may occur in a variety of conditions. Epilepsy, alcoholism, kidney
diseases and toxemias of pregnancy are among the various causes.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Cause determined -- history of occurrence in      0
  childhood up to age 10, not more that two         
  isolated attacks, transient, no sequelae, nervous 
  system normal                                     

  Cause known                                       RFC

  Others                                            Suspect and rate as
                                                    Epilepsy
  ------------------------------------------------- ---------------------

CORONARY ARTERY DISEASE

[Coronary Occlusion, Myocardial Infarction (MI), Coronary Thrombosis,
Heart Attack (With or Without Thrombolytic Therapy)]{.underline}

Ratings are based on the seriousness of the disease as indicated by the
findings after recovery. The degree of seriousness is classified into
one of three grades with ratings as follows:

  ----------------------- ----------------------- -----------------------
  Grade I                 Grade II                Grade III

  125                     225                     325
  ----------------------- ----------------------- -----------------------

Grades of severity:

The following characteristics are typical of the findings in the various
grades and should be used to help classify proposed insured with a
history of coronary occlusion, myocardial infarction or coronary
thrombosis. However, special efforts should not be made to develop any
specific item not provided by medical record.

+---------------------------+------------+-------------+-------------+
|                           | Grade I    | Grade II    | Grade III   |
+---------------------------+------------+-------------+-------------+
| 1\. Number of attacks     | One        | One or more | One or more |
+---------------------------+------------+-------------+-------------+
| 2\. Resumed work or       | Within 3   | Within 6    | More than 6 |
| normal duties             | months of  | months of   | months      |
|                           | attack     | attack      | after       |
|                           |            |             | attack      |
+---------------------------+------------+-------------+-------------+
| 3\. Angina                | None       | Occasional  | Fairly      |
|                           |            |             | frequent or |
|                           |            | no          | severe      |
|                           |            | n-disabling | episodes    |
|                           |            | episodes    |             |
+---------------------------+------------+-------------+-------------+
| 4\. ECG Findings          | None or    | Residuals   | More        |
|                           | stable     | of MI with  | extreme     |
|                           | residual   | moderate    | changes     |
|                           | of MI      | de          |             |
|                           |            | terioration |             |
+---------------------------+------------+-------------+-------------+
| 5\. Debits for diabetes,  | None       | Any number  | Any number  |
| overweight or other       |            |             |             |
| cardiovascular-renal      |            |             |             |
| impairment                |            |             |             |
+---------------------------+------------+-------------+-------------+
| 6\. Left ventricular      | 50% up     | Mi          | Severe      |
| function after recovery   |            | ld-moderate |             |
| (e.g., ejection fraction) |            | impairment  |             |
+---------------------------+------------+-------------+-------------+
| 7\. Number of diseased    | 1 major    | 2-3 major   | Left main   |
| vessels (greater than 70% | vessel     | vessels     | or severe   |
| occlusion)                | (RCA, LAD, |             | or diffuse  |
|                           | CFX)       |             | triple      |
|                           |            |             | vessel      |
+---------------------------+------------+-------------+-------------+

It should be remembered that these characteristics are not all inclusive
nor are they a substitute for good judgment. For instance, one extensive
MI can be worse than two of very limited extent. The factors
precipitating angina after an MI may be more significant than the
frequency or severity. Thus angina which occurs with only slight effort,
but infrequently, may be more significant than angina which occurs with
strenuous exercise, but on a predictable basis.

Of the items mentioned, left ventricular function after recovery appears
to be the most important predictor of future cardiac events. Cardiac
catheterizations which include ventriculograms may describe areas of
hypokinesis, dyskinesis, akinesis or a left ventricular aneurysm.
Depending on the extent of these findings, assumptions can be made about
LV function. Ejection fractions (EF) can be measured either at
catheterization or by echo or MUGA scan. It is not unusual for an EF to
improve after recovery from an MI or after CABG so the circumstances of
a reported EF must be considered. An EF obtained immediately after an MI
can be ignored with more recent and favorable findings.

Reports of enlarged cardiac chambers, or findings on a treadmill
exercise test of poor pulse response, falling blood pressure with
exercise or unexpectedly poor exercise tolerance may indicate impaired
LV function.

[Coronary Artery Bypass Graft (CABG), Percutaneous Transluminal Coronary
Angioplasty (PTCA)]{.underline}

A variety of procedures have been developed to correct or bypass
obstructions in the coronary arteries. The most common of these is CABG
which utilizes sections of saphenous vein removed from the leg, or a
transplanted internal mammary artery, to bypass local obstructions.
Alternatively, PTCA, a catheterization procedure in which a small
balloon dilates the coronary artery, may be used. Classification should
be based on the information available, i.e. special efforts should not
be made to learn the ejection fraction if it is not reported on the APS.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  ----------------------------------- -----------------------------------
  CABG                                

  Single vessel (no other diseased    75
  vessels)                            

  All others                          100

  Repeat CABG                         

  Same vessel(s)                      100

  Additional vessel(s)                125

  PTCA                                

  Single vessel (no other diseased    75
  vessels)                            

  All others                          100

  Repeat PTCA                         

  Same vessel(s)                      100 - 75

  Additional vessel(s)                125

  Failed PTCA followed by CABG        Rate as CABG
  ----------------------------------- -----------------------------------

In the case of either CABG or PTCA, if there is abnormal left
ventricular function (e.g., ejection fraction 49% or less), add 75.

Where there is angina or a subsequent MI, etc. following either
procedure, rate under the appropriate CAD section.

[Coronary Insufficiency, Silent Ischemia]{.underline}

The term coronary insufficiency as used by physicians is subject to wide
variation. Cases of prolonged chest pain associated with T wave or S-T
segment changes in the electrocardiogram should be rated under the
coronary occlusion rating schedule. When the term is used to describe
angina pectoris, the angina rating schedule will apply.

Silent ischemia is diagnosed by the finding of typical changes on a
treadmill test, thallium scan or Holter Monitor, indicating ischemia in
an otherwise asymptomatic person. Generally, the abnormal exercise test
ratings will apply.

[Angina Pectoris: Without Occlusion or Infarction]{.underline}

Angina pectoris is the typical pain of coronary origin. It has a
relatively sudden onset and is usually described as pressing or
squeezing, located in the anterior or left chest, with radiation to the
left shoulder and arm, or to other areas. It is precipitated by exercise
or emotion and is promptly relieved by rest or medication.

There may or may not be ECG changes. If there has been an occlusion or
infarction, rate under the appropriate schedule. Otherwise:

  ----------------------------------------------------- -----------------
  Angina diagnosed by objective diagnostic findings     125
  (positive exercise ECG, Angiography, etc.) in         
  addition to classical symptomatology                  

  Angina diagnosed by classical symptomatology only     100
  ----------------------------------------------------- -----------------

[Chest Pain]{.underline}

Chest pain is a very common symptom and is one of the most frequent
complaints for which medical attention is sought. Evaluation of chest
pain requires a detailed history, evaluation of diagnostic tests and
consideration of the attending physician's opinion at the time of
complaint. The history will include the type of pain, its mode of onset,
location and radiation, its duration and the effect of exertion,
emotion, and medication.

Chest pain can divided into three categories:

1.  Non-cardiac pain is due to a variety of causes, including anxiety,
    neuralgia, trauma to the rib cage, pleurisy and pulmonary
    infections. The pain is often sharp, fleeting, located in atypical
    areas and may be aggravated by cough, respiration or motion.
    Non-cardiac pain may be disregarded unless the cause is determined
    to be ratable.

2.  Suspicious chest pain is not clearly angina or coronary in origin
    but for a variety of reasons may be underwritten with more concern.
    Some of these reasons include:

```{=html}
<!-- -->
```
a.  Chest pain that requires diagnostic tests or hospitalization.

b.  Cases diagnosed as coronary artery disease but later called
    non-cardiac.

c.  Chest pain for which cardiac medications are prescribed, even on an
    empirical or trial basis.

d.  Chest pain that occurs in a high risk setting (male, smoker,
    diabetes, hypertension, abnormal lipids, etc.).

> Cases classified as suspicious chest pain should be rated under the
> angina schedule considered as "diagnosed by classical symptomatology
> only". Where coronary arteriograms are done and are normal, a
> reduction of 50 points in the debit for suspicious chest pain may be
> given.

1.  Pain of coronary origin. See the Angina Pectoris schedule.

**CORYZA**

Coryza is an acute infection of the membranes of the upper air passages.
It is also referred to a rhinitis or common cold. The condition deserves
a 0 rating if there is no complication. Ratings will be assigned only
for the complications if such exist.

**CRYPTOCOCCOSIS**

**(Cryptococcal Meningitis)**

A fungus disease primarily focused in the lungs and with characteristic
spread to the meninges. Occasionally it spreads to the kidneys, bones,
and skin. Cryptococcal meningitis is often found in AIDS patients.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------------- -----------------------
  Cryptococcal meningitis                         See AIDS

  Others                                          50
  ----------------------------------------------- -----------------------

**CRYPTOSPORIDIOSIS**

A rare, enteric protozoan infection associated with AIDS.

  ----------------------------------------------- -----------------------
  Cryptosporidiosis                               See AIDS

  ----------------------------------------------- -----------------------

**CURVATURE OF THE SPINE**

**Kyphosis** -- humpback or posterior curvature.

**Lordosis** -- hollow back or anterior curvature.

**Scoliosis** -- lateral, right or left curvature.

**Spondylolisthesis** -- forward displacement of lumbar vertebrae.

These deformities may be found alone or in combination. These may result
from extensive disease of the chest, tuberculosis of the spine (Pott\'s
disease), arthritis of the spine (spondylitis) infantile paralysis
disease of the hip, injury, rickets, build, or poor posture.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required if adequate description of the
curvature is not furnished with the application. When the curvature is
due to arthritis or infantile paralysis refer to those subjects

  ------------------------------------------------ ----------------------
  Slight curvature                                 0

  Moderate curvature                               10

  Marked curvature                                 55

  Severe, complicated by GU, GI disturbances,      Add 100 plus the
  paralysis, or use of crutches                    debits for the
                                                   complications
  ------------------------------------------------ ----------------------

**CUSHING'S SYNDROME**

Cushing's Syndrome is caused by high levels of the adrenal hormone,
Cortisol. Signs and symptoms include upper body obesity with rounded
face, thin, fragile skin with purple stretch marks, weak bones with
pathological fractures, depression, hypertension, diabetes, excessive
hair growth in women, menstrual irregularities and infertility.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Present                                           

  Due to administration of oral steroids            Rate for disease
                                                    being treated, no
                                                    less than 55

  Others                                            R

  History                                           

  Due to pituitary adenoma or hyperplasia           See Pituitary Tumor

  Others                                            

  Cause known                                       RFC

  Cause unknown                                     Refer to Section
                                                    Chief
  ------------------------------------------------- ---------------------

**CYANOSIS**

Cyanosis is blueness of the skin, due to insufficient oxygenation of the
blood. Cyanosis is encountered in serious heart disease and is a
dangerous sign indicating that the heart is failing to meet the burden
of carrying the blood through the lungs in the normal manner. It is
found also in conditions where the respiratory function is impaired. In
its early stages it is manifested by a blueness of the lips and the
fingernails.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  When cause is determined                           RFC

  When cause is undetermined                         400
  -------------------------------------------------- --------------------

**CYSTECTOMY**

A cystectomy is a surgical operation for removal of all or part
(partial) of urinary bladder. Total cystectomy is employed chiefly in
the radical treatment of:

1.  Infiltrating bladder tumors, which apparently have not extended
    beyond the organ but cannot be resected.

    Infiltrating tumors when the bladder is contracted by fibrosis
    following either preceding inflammation or treatment of the growth
    by electocoagulation, cautery, or radium.

    Rapidly recurring generalized papilomatosis -- these tumors being
    histologically benign but clinically malignant.

    Vesical exstrophy.

    Rare cases of intractable cystitis that is usually of the Hunner
    interstitial variety.

    Incurable vesicovaginal fistula.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------ ----------------
  Within 2 years                                         400

  Within 2 -- 5 years                                    300

  After 5 years                                          100
  ------------------------------------------------------ ----------------

**CYSTIC FIBROSIS**

Cystic fibrosis is an inherited disease primarily affecting the
gastrointestinal and respiratory systems. Usually is causes chronic
obstructive pulmonary disease (COPD) and pancreatic insufficiency. Thick
mucus tends to plug airways in the lung, leading to chronic cough,
respiratory infection and bronchiectasis. End stage lung disease occurs
as pulmonary hypertension and right ventricular hypertrophy (cor
pulmonale).

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------ ----------------
  Under age 20                                           R

  Age 20 and over                                        

  Mild disease, best cases                               400-125

  Others                                                 R
  ------------------------------------------------------ ----------------

**CYSTITIS**

Cystitis is an inflammation of the urinary bladder.

**Acute cystitis** -- usually of sudden onset, is characterized by
frequent and painful urination. Recovery is usually prompt after an
acute attack.

**Chronic cystitis** -- any attack in excess of 6 weeks\' duration. This
may be the result of serious infection of the bladder or of disease of
other parts of the genitourinary tract. The symptoms are the same as
those of the acute form but are milder in character. Hunner\'s ulcer is
a type of chronic cystitis with ulceration resistant to treatment.

**Interstitial cystitis** -- etiology is unknown in this inflammatory
disease of the bladder. Symptoms are pain and urinary frequency. No
therapy is more than 50% effective. Severe cases may require urinary
diversion. It can be debilitating and may be accompanied by depression.

**Neurogenic bladder** -- due to malfunction of the nerves that carry
messages from the brain to the bladder muscles.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+-----------------------------------------------------+----------------+
| Present at time of examination, treat as abnormal   |                |
| urine alone                                         |                |
+-----------------------------------------------------+----------------+
| Single, acute attack, after recovery                | 0              |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Chronic or repeated attacks                         |                |
+-----------------------------------------------------+----------------+
| Cause known                                         | RFC            |
+-----------------------------------------------------+----------------+
| Hunner's ulcer (chronic interstitial cystitis)      |                |
| present                                             |                |
+-----------------------------------------------------+----------------+
| Present                                             | 55             |
+-----------------------------------------------------+----------------+
| Recovered                                           | 0              |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| History of Hunner's Ulcer -- after recovery         |                |
+-----------------------------------------------------+----------------+
| Within 3 years of recovery                          | 25             |
+-----------------------------------------------------+----------------+
| After 3 years                                       | 0              |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Others, cause unknown -- the following debits will  |                |
| be added to any rating for abnormal urinalysis:     |                |
+-----------------------------------------------------+----------------+
| Within 1 year                                       | 20             |
+-----------------------------------------------------+----------------+
| Within 2 years                                      | 10             |
+-----------------------------------------------------+----------------+
| After 2 years                                       | 0              |
+-----------------------------------------------------+----------------+
| Interstitial cystitis                               |                |
+-----------------------------------------------------+----------------+
| Present                                             | 55             |
+-----------------------------------------------------+----------------+
| Recovered                                           | 0              |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Neurogenic bladder                                  |                |
+-----------------------------------------------------+----------------+
| Cause unknown                                       |                |
+-----------------------------------------------------+----------------+
| Severe, frequent or chronic urinary tract           | R              |
| infection; abnormal KFTS or urine                   |                |
+-----------------------------------------------------+----------------+
| > Urine and kidney function tests normal, treatment | 125            |
| > by diversion or intermittent or indwelling        |                |
| > catheter                                          |                |
+-----------------------------------------------------+----------------+
| Urine and kidney tests normal, urinary catheter or  | 0              |
| urinary diversion not required                      |                |
+-----------------------------------------------------+----------------+
| Cause known                                         | Rate for       |
|                                                     | greater of     |
|                                                     | cause or above |
|                                                     | schedule       |
+-----------------------------------------------------+----------------+

**CYSTOTOMY**

A cystotomy is a surgical operation on the urinary bladder. The more
common indications are stones, tumors, including papilomas, diverticula,
and bladder injuries.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------- --------------------------
  Uncomplicated                                

  With normal urine                            RFC

  With abnormal urine                          Add the debits for the
                                               abnormal urine to those of
                                               the cause

  Present -- rupture or stone                  100

  After recovery                               0
  -------------------------------------------- --------------------------

**CYSTS**

Cysts are common and may be congenital (thyroglossal duct cyst) or
acquired (sebaceous and pilonidal cyst). In general they consist of a
sac containing liquid or semisolid material. Cysts are usually harmless
but if large or multiple they may interfere with functions, such as
polycystic disease of kidneys. In some locations, malignancy must be
ruled out (ovary, thyroid) or when located in critical areas such as the
brain they can cause devastating effects.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+------------------------------------------------------+---------------+
| Bone                                                 |               |
+------------------------------------------------------+---------------+
| Present                                              | 0             |
+------------------------------------------------------+---------------+
| History, removed, after recovery                     | 0             |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+
| Bronchial cleft or thyroglossal duct                 |               |
+------------------------------------------------------+---------------+
| Present                                              |               |
+------------------------------------------------------+---------------+
| Small, asymptomatic, no recent change in size        | 0             |
+------------------------------------------------------+---------------+
| Others                                               | R - 0         |
|                                                      |               |
|                                                      | Refer to      |
|                                                      | Section Chief |
+------------------------------------------------------+---------------+
| History, removed, after recovery                     | 0             |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+
| Dermoid -- skin and surface mucous membrane          |               |
+------------------------------------------------------+---------------+
| Present                                              |               |
+------------------------------------------------------+---------------+
| Existing for 3 years or more, asymptomatic, not      | 0             |
| enlarging                                            |               |
+------------------------------------------------------+---------------+
| Others                                               | Refer to      |
|                                                      | Section Chief |
+------------------------------------------------------+---------------+
| History                                              | 0             |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+
| Other locations                                      |               |
+------------------------------------------------------+---------------+
| Present                                              | R             |
+------------------------------------------------------+---------------+
| History                                              |               |
+------------------------------------------------------+---------------+
| Malignancy excluded                                  | 0             |
+------------------------------------------------------+---------------+
| Malignancy suspected or confirmed                    | Apply rules   |
|                                                      | for Cancer    |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+
| Pilonidal or sebaceous                               |               |
+------------------------------------------------------+---------------+
| Present                                              | 0             |
+------------------------------------------------------+---------------+
| History, removed, after recovery                     | 0             |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+
| Others                                               | See specific  |
|                                                      | organ or      |
|                                                      | tissue        |
|                                                      | involved      |
+------------------------------------------------------+---------------+

**CYTOMEGALOVIRUS**

Cytomegalovirus infection causes a wide range of disorders from
asymptomatic infection to a syndrome resembling infectious mononucleosis
in otherwise healthy individuals, to serious disease in newborns and
immuno-compromised hosts.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------------- -------------------
  Present                                             Refer to Section
                                                      Chief

  Recovered                                           0
  --------------------------------------------------- -------------------