The original publishing date is March 10, 2020, and the content was revised and updated on December 24, 2024.
A critical illness insurance policy helps protect your finances if your claim is denied after being diagnosed with a serious condition, such as a heart attack, stroke, or cancer. Depending on the type of policy, coverage may include long-term disability benefits or financial support during recovery. These conditions often incur high medical expenses and can restrict a patient’s ability to work, impacting their income. The insurance provider offers compensation in the form of a lump-sum payment, which can cover medical treatments, replace lost income, or help with other expenses.
Most of the time, the insurance benefits payout rapidly after diagnosis – generally within one month. However, this is still contingent on the insurance company investigating the claim and deciding whether a critical illness is truly involved. A critical illness lawyer can provide guidance throughout the process to ensure the policyholder receives the compensation they are entitled to, helping them navigate any challenges with the insurer. These are some of the factors that might cause them to deny a claim.
Three Situations Where A Critical Illness Insurance Claim Could Be Denied
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The Condition is Not Covered
As with most types of insurance, there are different levels of coverage you can receive. Some cover more illnesses and medical conditions than others. If you became critically ill with a condition not covered by the policy, the claim would be denied.
It’s important to understand that covered critical illness insurance policies often specify exclusions in their contract, meaning certain illnesses or conditions may not qualify under the insurance coverage. Additionally, critical illness and long-term disability insurance policies may vary depending on the insurer’s terms, making it essential to review what’s included before you first apply.
Likewise, some severe illnesses may not reach the level of being critical illnesses and would therefore not be covered either.
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An Unclear Diagnosis
Your insurance company will be looking carefully at all the materials sent over by your doctor, containing their diagnosis and supporting evidence. It is important your doctor be as thorough and precise as possible. If their diagnosis does not fit the definition of critical illnesses covered by the policy, they could be denied.
A diagnosis of a covered illness or condition must meet the policy’s stringent requirements to avoid delays in the payout. Failing to meet these criteria can result in a waiting period that impacts financial support, leaving the insured vulnerable during recovery.
In addition, hard documentation is expected. Be sure to send any and all paperwork requested, to improve your chances of approval.
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Misrepresentation or Non-disclosure on The Paperwork
In short, if a person lied or left critical information off of their insurance paperwork, that would be grounds to deny the benefits. For example, a person might omit a pre-existing condition to try to lower their premiums, but those sorts of omissions can lead to the policy itself being revoked. Disclosing pre-existing conditions during the application process is crucial, since insurance companies rely on this information to assess eligibility accurately. If your claim is denied, our insurance advisors can help navigate legal options or encourage you to appeal through the appropriate process.
Plus, of course, you need to be current on your insurance payments to keep the insurance policy active.
Desjardins provides critical illness policies in the Toronto area, covering up to 26 different medical conditions. These policies offer a lump sum payment to help you manage financial challenges if diagnosed with a covered critical illness, such as kidney disease or another serious illness. Whether you need to restore your finances or replace lost income, long-term disability, and critical illness benefits can offer essential support during recovery.
To learn more or get a free consultation on the right coverage for you, contact us today. Don’t give up if your critical illness claim denied status arises—our advisors are here to help.
