Critical illness insurance promises financial protection during a health crisis. This can help you and your family maintain your lifestyle by giving you a financial safety net as you navigate a serious illness or debilitating medical condition. If a critical illness claim is rejected or only partially paid out it can compound an already distressing and challenging time. It’s therefore important to understand the main reasons critical illness insurance claims are rejected so that this doesn’t happen to you.
Non-Disclosure or misrepresentation
Much like life insurance, you must fully disclose your medical history, any pre-existing conditions, and lifestyle habits when applying for critical illness coverage. If you’re not completely truthful, or you fail to disclose relevant information, this could delay the claims process or result in your critical illness claim being rejected.
Policy exclusions
Critical illness policies will list specific conditions and illnesses that are covered by the policy. If your diagnosis isn’t included in the policy, then a claim might be denied. Common exclusions include pre-existing medical conditions, certain types and stages of cancer, chronic illnesses, age-related conditions, cosmetic procedures, mental health conditions and drug and alcohol related ailments. It’s therefore crucial to understand the policy’s terms regarding covered illnesses.
Waiting periods
Some policies have waiting periods before you are covered. If the critical illness occurs within this period, the claim might be rejected. You must typically wait at least a month before you can make a claim on your health insurance policy. If you become ill soon after taking it out, you should check how long the waiting period is and think about how you will support yourself during this time.
Failure to meet policy definitions
Claims might be denied if the diagnosed illness or medical condition doesn’t meet the specific criteria outlined in the policy. For instance, if the severity of the illness doesn’t match the policy’s definition of that specific condition.
Policy lapses or claims made after the policy has expired
Non-payment of premiums can invalidate the policy and result in a claim being rejected. If the policy isn’t active at the time of diagnosis because it has expired or been cancelled, then the claim will also be denied.
Fraudulent Claims
If fraudulent activity is suspected, such as fabricating medical evidence or misrepresenting the severity of your condition, your claim can be rejected.
The Brief Claims’ top tips to prevent a critical illness claim being rejected:
Tell the truth: make sure you provide accurate and detailed information about your current health, medical history, and lifestyle choices.
Read and re-read your policy: check the covered illnesses, waiting periods, and policy definitions.
Keep on top of payments: Make sure you pay your insurance premiums on time to keep the policy active.
Appealing a declined critical illness insurance claim
At The Brief Claims we understand that being told your critical illness claim has been rejected can be a devastating blow. Denials can be overturned so if your insurer has rejected your health insurance claim you can appeal it. The Brief Claims specialises in appealing unfair decisions by insurers. We offer free initial, no-obligation advice if you would like an expert to review the decision you’ve received from your insurer. We also work on a no-win, no-fee basis if we take on your case. Complete an online form and a member of our team will be in touch as soon as possible.
