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• affects 1 in 4 women / 1 in 5 men before retirement
• 94.1% of the critical illness claims are paid
• protect yourself and your family if you get seriously ill

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Dos and Don’ts when making critical illness insurance claims

Finding out the bad news from your doctor is a difficult time for you and your family but your critical illness cover can be a solid wall you can lean on. Especially when you know that you can make a claim and receive payment to help you with the expenses you need for your treatment.

Based on claims reports provided by major insurers, the percentage of claims paid ranges from 91% to as high as 98%. One factor in having a successful critical illness claim is lodging the claim properly.

Here are some simple dos and don’ts you need to remember when making a claim:

Do:

• Give full disclosure. Although it’s too late for this, it is important to note that you need to give your actual health status at the time of your application. Failure to do so may mean having your critical illness claim denied.

What information do I need to provide when making a critical illness claim?

Here are the documents you need to provide:

• Filled up claims form.
• Your doctor’s medical report. Usually your doctor should be practicing in an “approved” country and is a specialist on the disease being diagnoses.
• Laboratory and diagnostic reports.
• Personal information and contact details.

Read this article for more information on what to present when making a claim.

• Get documentation. It is best that you keep all your medical records. You will need to present these when you make a claim.

• Inform your insurance company at once. As soon as you are diagnosed with a health condition that is covered by your policy, you need to inform your insurance company about it. That way, you can get the ball rolling and the claims process started. This helps to ensure that you get your claim earlier and that you are informed as to what documents you will need to make your claim.

  To ensure timeliness and successful claiming it is best to know very well the deadlines in your policy. (Read more on the timelines and “deadlines” of critical illness policies here)

• Be prepared to make an appeal if your claim is denied. In case your claim gets denied, you can still make an appeal. Having your claim denied at the first pass is not the end of the road for you. You can work with the insurance claims adjuster to see what additional information is needed to bolster your claim.

Don't miss:

• Top 5 reasons why a critical illness claim is denied
• Do critical illness insurers really pay out: what the statistics shows
• Top 10 critical illnesses that will pay out
• When are you suspected to get critically ill?

Don’t:

• Assume that you are covered. It is important to know exactly what your policy covers. There may be differing definitions of a covered illness, so you need to check under what conditions the illness is payable. Remember that the company will pay only if your claim falls under the definition of the policy. If they don’t, your claim may be denied for not meeting the criteria.

  For instance, there are some cancers that are not covered – some cancers that are not critical and may be treated will often not be payable under the critical illness policy. There may also be conditions covering your age, the country where you received the diagnosis and other details.

• Fill up the application form if you are unsure of the details. If there is a medical detail in the claims form you are not sure about, ask your doctor first before writing anything down. Be sure not to leave any gaps – the insurer may not always contact your doctor to check gaps in your application form.

• Fail to pay your premiums. Again, this may be late in the game, but your failure to pay your premiums after the grace period may mean that your policy is no longer in force. Also, you need to continue with the premium payments while your claim is being processed.

• Make any fraudulent claims. For one, the insurance company will thoroughly check the veracity of your claim. If they find out that you have been making a false claim, they will deny your claim. Also, they may “blacklist” you and this may affect any future applications to other insurance companies. You may also face charges due to your fraudulent claim.

What are the reasons why some serious illnesses get denied a cover?

• The illness being claimed is not covered in the policy. To learn how the usual critical illnesses are defined here is a list of covered serious illnesses and their definitions
• The illness does not meet the definition in the policy
• The illness is excluded. Know more about the exclusions by reading The exclusions to your critical illness policy
• The client gave incomplete or inaccurate medical information that would have caused the application to be denied or refused cover.

Can you make an appeal when your claim is denied?

If your claim is denied, you can still lodge an appeal, first, to your insurer and then to a government agency. If you feel that your claim is a valid one, you can file an appeal with the insurance company. You should provide the grounds by which you are filing your appeal. If you have further evidence with regards to your claim, this is the time to present it for review.

If, after the appeal, the claim is still denied, you can write a complaint to the Financial Ombudsman Service.

Last updated on: 18.1.2013

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