Can My Insurance Company Deny My Critical Illness Claim?

Having a critical illness insurance policy in place offers a sense of security and financial protection in times of medical emergencies. Unfortunately, there are instances where insurance companies deny critical illness claims, leaving policyholders confused and frustrated. While critical illness insurance denials can be devastating, it is important to understand the common factors behind denials of critical illness claims by insurance companies.

Critical Illness Policy Exclusions

Insurance policies for critical illness coverage often have very specific exclusions and limitations regarding critical illnesses. It is important for policyholders to understand these exclusions and ensure that their claim falls within the covered conditions. For example, some policies may not cover certain types of cancer or pre-existing chronic conditions.  While multiple sclerosis may be covered, often systemic sclerosis is not.  An insurance company will not pay out benefits under a critical illness policy unless the specific illness you have is listed in the policy.

Waiting Periods for Critical Illness Claims

Certain critical illness policies have waiting periods for specific illnesses before a claim can be made. The waiting period usually begins from the date the policy is effective or from the diagnosis of a critical illness. If a claim is made before the waiting period is completed, it can be denied. Policyholders need to be aware of waiting periods and adhere to the specified timelines to avoid having their claim denied.

Pre-Existing Conditions

One of the main reasons for denying a critical illness claim is due to pre-existing conditions. Insurance policies often exclude claims relating to pre-existing conditions and as such those claims do not attract coverage. It is vital for insureds to carefully review the specific wording of their policy to understand exclusions related to pre-existing conditions and how they may factor into a claim.

Failure to Disclose Information

It is essential to provide accurate and complete information about your medical history when you initially apply for critical illness insurance.  If you fail to disclose pre-existing conditions or if you provide misleading information (whether it is intentional or not), this can result in a denial of your critical illness benefits claim.  When you make a claim, insurance companies will examine the information you provided during the application process, and they will look for any inconsistency they can find to use as a reason to deny your claim.

Inadequate Medical Documentation

To process a critical illness claim, insurance companies require thorough medical documentation supporting the diagnosis.  Some claims require the support of a specific medical specialist in order for the claim to be covered.  Insufficient documentation can lead to a denial of your critical illness claim.

Non-disclosure of Lifestyle

Insurance policies often require policyholders to disclose their lifestyle habits, such as smoking, alcohol consumption, or participation in hazardous activities such as flying planes or skydiving. If your critical illness is linked to undisclosed lifestyle habits, your claim may be rejected. It is important for policyholders to be completely honest about their lifestyle choices during the application process to avoid a denial of a legitimate claim for critical illness benefits.

Critical Illness Claims and Timelines

Once your critical illness claim has been denied there are specific timelines in which you have to act or you can be statute barred from fighting for your insurance benefits.

Contact the experienced insurance denial lawyers at Taylor & Blair LLP for a free consultation if your critical illness claim has been denied.