Unlike disability benefits claims, in many critical illness policies the analysis of whether the specific policy criteria are met is determined at the point at which diagnosis was made rather than on an ongoing basis.
As such, it is possible to have a viable critical illness claim even if you have recovered fully from your illness, and you are not impaired in any way.
In critical illness claims it is most common to see a denial take one of the following forms:
The claimant has not met the survival period required under the policy;
It is not uncommon to find wording in a critical illness policy that refers to a “qualifying period” or a “survival period”. The time frame of the “survival period” or “qualifying period” usually ranges anywhere from 30-90 days with 30 days being most common.
The wording in the policy often suggests that no benefit shall unless the insured survives a certain number of days after the date of diagnosis of a covered illness/condition.
The claimant does not have a condition that would constitute a “covered condition” or “covered critical illness” under the policy;
Critical illness policies contain a list of covered illnesses that are often defined by set criteria in the policy document. The policy wording may have been carefully designed by the policy drafters or it may be standardized wording.
To access critical illness benefits your condition needs to fit under one of the covered conditions. Insurers will often dispute that an insured has a specified condition if they do not fall within the four corners of the set criteria.
The claim is denied based on an exclusion clause; or
The most common denials on the basis of exclusion clauses, tend to relate to either the “pre-existing condition” exclusion or the “90 day exclusion”, both of which may relate to a period of time existing either before or after the effective date of insurance. The requirement being that the insured’s symptoms or condition/s should not have manifested during that time frame.
In order to evaluate whether an exclusion clause applies, in addition to carefully assessing policy wording, it is necessary to carefully analyze all the medical information for the period in question.
The claim is denied due to misrepresentation or non-disclosure.