Frequently Asked Questions

Serious Illness normally covers a lump sum in the same way a Critical Illness policy does. The main difference is the amount paid out is dependent on the ‘severity’ of the illness. For example, a stage one breast cancer diagnosis may result in a pay-out of 25% of the sum assured, whereas a stage four breast cancer diagnosis may lead to a pay-out of 100%.

A common question is “what is classed as a Critical Illness”. Most insurance providers list all the conditions they cover in their policy documents. Examples of standard covered conditions are: cancer (excluding lesser forms), heart attacks (of specified severity) along with certain types of neurological and inflammatory conditions.

Critical Illnesses can vary between providers but there are standard definitions that insurance companies must use to call the product “Critical Illness” cover. You can find more information on the standard definitions of Critical Illnesses from the ABI. View ABI Guide

You normally need to claim against your Critical Illness policy within 6 months. This can often be extended for two reasons. The first is if your condition has stopped you claiming (or the emotional/mental health impacts have stopped you). The second is that you did not know your policy contained Critical Illness cover.

ABI records state that around 1 in 10 claims are declined (around £160,000,000 per year). We are unsure if that includes claims where the claim is declined over the phone during the initial conversation and claims that have been declined due to non-disclosure and the policy cancelled (since inception).

Most policies will consider Multiple sclerosis as a qualifying medical condition.

Conditions such as ME can trigger a Critical Illness pay out depending on the severity of your condition. ME would normally be payable under Total Permanent Disability Insurance which can be part of Critical Illness cover.

Generally, all cancers are covered. The main exclusions are around pre-cancerous conditions and certain types of skin cancer. Cancers like prostate cancers normally need to be above T2b-N0-M0.

Conditions such as Fibromyalgia can trigger a Critical Illness pay out depending on the severity of your condition. Fibromyalgia would normally be payable under Total Permanent Disability Insurance which can be part of Critical Illness cover.

Conditions such as CFS can trigger a Critical Illness pay out depending on the severity of your condition. Chronic Fatigue Syndrome can also be present with several other conditions such as Fibromyalgia, Anxiety, Depression or Arthritis. CFS would normally be payable under Total Permanent Disability Insurance which can be part of Critical Illness cover.

Most policies will pay out for rheumatoid arthritis but only for a certain severity and if this impacting set “daily living tasks.”

Policies differ in relation to HIV and AIDS. Older policies will only pay out if the condition is not “self-inflicted”, which (very broadly) means that certain behaviours such as drug use were not the reason for contracting the condition. Other policies will cover once the viral load has reached a certain level.

Some older policies require specific ‘evidence’ to show that someone has suffered a heart attack. Some policies may use wording such as, “the characteristic rise of cardiac enzymes or troponins recorded at the following levels or higher”. Troponins are a mixture of enzymes that can indicate (among other conditions) you have suffered a MI (heart attack). The NHS state that any levels above 0.4 ng/ml would indicate this. Most newer policies indicate levels must be raised or have levels in line with ABI standard guidelines (Troponin T > 200 ng/L (0.2 ng/ml or 0.2 ug/L) Troponin I > 500 ng/L (0.5 ng/ml or 0.5 ug/L)). Some older policies (pre-2018) may have higher levels.

We have been able to successfully challenge these types of decisions.

Many insurance companies refuse a Critical Illness pay out because their cancer is classed as non-invasive, pre-malignant or cancer in situ. This can be a complex situation especially if your Critical Illness claim has been declined because of borderline malignancy. Often the insurance companies’ chief medical officer (CMO) has a differing opinion to your consultant. Resolute Claims are highly experienced in this type of scenario. If you feel that your Critical Illness claim has been unfairly rejected speak to us today.

Critical Illness claims can be rejected for two main reasons. Firstly, because your condition does not meet the required definition in the policy. If you Critical Illness does not meet the policy definition, it is important you seek guidance around this. We have experts on hand who can review your condition against the illness covered by your insurance company. In recent years insurance companies have often miscategorised medical conditions that have led to claims being unpaid. The second common reason a claim may be declined is non-disclosure. This means that during the assessment of your claim the insurance company may have identified a piece of information that wasn’t included in your application (that they feel should have been). Insurance companies sometimes chose to take these non-disclosures out of context and apply incorrect remedial actions. We are seeing an ever-increasing number of claims rejected because of non-disclosure. Non-disclosure decisions can be successfully challenged, for more information please speak to one of our specialists.

Appealing a rejected Critical Illness Insurance Claim can be complex and relies on an evidence based, logical and structured argument rather than appealing to the good nature of an insurance provider. If your insurance claim has been denied it is important to get all the information to hand, including what medical information has been looked at, to review the insurance companies’ terms and conditions and look over the appropriate regulations. Resolute Claims offer a free information and guidance service that can provide further information on your next steps.

Insurance companies will often have exclusions in relation to Angioplasties. The types of exclusions depend on how old your policy is and your insurance provider.

If you don’t agree with an insurance companies’ decision you can take your claim to the Financial Ombudsman Service (FOS). You normally need to complain to the insurance company in the first instance. They have eight weeks to respond (although they make take longer if they need to obtain medical information). After eight weeks you can refer your complaint to FOS. We may still be able to help with claims that have been previously reviewed by the Financial Ombudsman. For more information give us a call.

You may need help when it comes to appealing a denied Critical Illness insurance claim. Resolute Claims offer a free and impartial guidance service that can give you handy hints and tips and how to appeal a declined Critical Illness claim. We can also offer our advocacy service where we can fight insurance companies on your behalf.