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What you should know about your critical illness cover: the exclusions to your policy

Get to know your critical illness policy. As it is important to know what the critical illness insurance will cover, it is also of equal importance to know what they will not cover – the exclusions. That way, you know what to expect when you need to make a claim.

Critical Illness Cover Exclusions

Here are some exclusions that are part of the Statement of Best Practice for Critical Illness Cover published by the Association of British Insurers. They are commonly included in most critical illness policies:

Alcohol or drug abuse. The critical illness cover will not pay for injuries or illness directly resulting from:

  • Consumption of too much alcohol
  • Overdosing on drugs, whether these are prescribed lawfully or otherwise
  • The use or abuse of controlled drugs in a way that is not in accordance with a lawful prescription. Medications may only be taken with your doctor’s advice and prescription.

Illegal or criminal acts. This means that if you are involved in a criminal act and are injured in the process, the policy will not pay your claim.

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Aviation. This means any flying that you do other than as a passenger of a commercial flight. If you are operating a private aircraft as a pilot or passenger, this is commonly not included in the policy.

Hazardous activities, sports and pastimes. These include activities such as mountaineering, caving, boxing, climbing, martial arts, jet skiing, underwater diving and pot-holing. Critical illness policies will also exclude racing, trial or timed motor sports such as yacht racing or power-boat racing, as well as horse-racing.

HIV/AIDS. Any condition or infection that is due to HIV/AIDS is not payable by the cover. Also, HIV is only payable when this is a result of a blood transfusion, a physical assault or contracted while the claimant is working and doing his normal duties in an eligible occupation.

Living abroad?

Here are some things you need to know about your policy:

  • The Isle of Man and the Channel Islands are usually excluded in the cover.
  • To be payable, a diagnosis of a critical illness should be made by a doctor that is practicing in the UK or any of the countries included.

Living Abroad. Usually, you must be a resident of the European Union or any country listed as “acceptable countries” in the policy. Critical illnesses obtained while living outside of the “acceptable countries” for more than 13 consecutive weeks in the span of 12 months may not be payable under the policy. The same goes for where you obtain your diagnosis of the critical illness.

Self-inflicted injuries. This includes attempted suicide.

Unreasonable failure to follow the doctor’s advice. This will also include your failure to obtain any medical advice after you have noticed some symptoms.

Civil commotion, riot or war. Injuries resulting from war, invasion, hostilities, revolution or the claimant’s participation in a civil commotion or riot are not covered.

Please note that these exclusions may vary depending on the insurance company issuing the policy. So the best thing is to read your policy, including the fine print.

How About Critical Illness for Pre-existing Conditions?

Please note that you need to disclose of any pre-existing conditions that you have. Otherwise, the insurance company reserves the right to cancel your policy and refund your premiums. The insurance company may also deny you any future claims due to your failure to disclose of key information regarding your application.

Some Exclusions for Critical Illnesses

There are also exclusions made for each specific critical illness. It may fall under:

Criteria for Exclusion Affected Critical Illnesses

Age

There are some critical illness covers that will not pay the claim if the critical illness is contracted before a certain age, usually pegged at 60 years old:

  • Alzheimer’s Disease
  • Motor neurone disease
  • Parkinson’s Disease

Severity

Some critical illnesses are only payable if it falls under a certain level of severity. Here are some examples:

  • Cancer. Should be marked by malignant cells. Pre-malignant and non-invasive cancers are excluded.
  • Heart attack. A heart attack that results in death of heart muscle. Angina and other acute coronary syndromes are excluded.
  • Kidney failure. Payable only when regular dialysis is medically required.
  • Paralysis or loss of limbs. Some policies may not pay out if only one limb is affected.
  • Stroke. Should result in death of brain tissue. Transient ischaemic attacks are excluded.
  • Third degree burns. This is not payable if the damage does not affect at least 20% of the body’s surface area.

For disease only

Some critical illnesses that require surgery are sometimes payable for disease only. If the surgery is necessitated by an injury caused by an accident, these may not be payable. For instance, if you need aorta graft surgery because you were injured while indulging in a hazardous sport that resulted in your needing aorta graft surgery, this may not be payable under the policy.

Some critical illnesses which are payable only when it is caused by disease are:

  • Aorta graft surgery

Symptoms must be permanent or the damage must result in persisting clinical symptoms

There are critical illnesses where the symptoms must be permanent to be payable:

  • Benign brain tumour
  • Blindness/Deafness/Loss of Speech. Should be permanent and irreversible.
  • Coma. Should result in permanent neurological deficit with persisting clinical symptoms.
  • Loss of hands or feet. The severance must be permanent.
  • Motor neurone disease. Must result in permanent clinical impairment of motor function.
  • Multiple sclerosis
  • Traumatic head injury

Only for a particular procedure

Some critical illnesses that cover surgery will only pay for a particular type of procedure:

  • Coronary artery by-pass grafts. Only for median sternotomy where there is a need to divide the breastbone.
  • Heart valve replacement or repair. The same exclusion as above applies.

Time frame

This mainly covers terminal illness. Usually terminal illness is not payable under a critical illness claim if the terminal illness is contracted within the last 12 months before the cover expires.

Know more about timelines in the policy by reading our article The Deadlines of Your Critical Illness Cover.

Please note that these are based on the ABI definitions. There are, however, some critical illness covers that provide ABI+ (improved than the ABI definitions) or their own definition (usually when ABI has not provided a standard definition for a particular critical illness).

Last updated on: 18.1.2013

 

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