Denied Critical Illness Claim? Our Life Insurance Lawyers Will Fight and Win
Our life insurance dispute law firm knows how devastating it can be when a claim under a critical illness policy is denied—especially when the policyholder is facing serious health challenges. Critical illness policies are meant to provide fast, meaningful financial support after a major medical diagnosis. Unfortunately, many claims are denied due to confusing policy language, strict medical criteria, or unfair insurer tactics. If your critical illness claim has been denied, our experienced attorneys will fight for the benefits you were promised.
What Is a Critical Illness Policy?
A critical illness policy is a specialized insurance product that pays a lump-sum benefit if the policyholder is diagnosed with a serious medical condition listed in the policy. The purpose of the benefit is to provide financial relief during a medical crisis. It may be used for out-of-pocket medical costs, home modifications, living expenses, debt payments, or anything else the policyholder needs during recovery. Unlike life insurance, which pays out after death, a critical illness policy is triggered by a qualifying diagnosis while the policyholder is still alive.
Common Features of Critical Illness Policies
Covered Conditions
Most critical illness policies provide a list of qualifying diagnoses. Commonly covered conditions include heart attack, stroke, major organ failure, cancer, paralysis, and coronary artery bypass surgery. The policy will typically define what constitutes a qualifying diagnosis for each condition. For instance, not all types or stages of cancer may qualify.Waiting Periods
Many policies include a waiting period after issuance, usually ranging from 30 to 90 days. Claims filed within this period are generally not eligible for benefits. This waiting period is designed to prevent immediate claims based on pre-existing or soon-to-develop conditions.Benefit Amount
The benefit is usually a tax-free lump sum that is either a fixed dollar amount or a percentage of the policy’s total face value. Some policies may pay partial benefits for early-stage diagnoses or less severe conditions.Exclusions
Like all insurance products, critical illness policies come with exclusions. These are specific conditions or circumstances under which the policy will not pay benefits. Policyholders must understand these limitations before relying on the coverage.
Exclusions That May Lead to Denial of a Critical Illness Claim
Pre-existing Conditions – If a condition existed before the policy was issued, benefits may be denied, even if it wasn’t disclosed.
Self-inflicted Conditions – Illnesses or injuries resulting from intentional acts may be excluded.
Substance Abuse – Conditions linked to drug or alcohol use may be excluded from coverage.
Criminal Activity – Claims arising from injuries or illnesses caused during the commission of a crime may be denied.
Certain Cancers – Some policies exclude early-stage cancers or specific types like non-invasive carcinoma in situ.
Mental Health Conditions – Many policies exclude psychiatric diagnoses such as depression or PTSD.
High-Risk Occupations – Coverage may be denied for individuals in high-risk jobs like military service or deep-sea diving.
War or Terrorism – Illnesses or injuries sustained during acts of war or terrorism are often excluded.
Pregnancy or Childbirth Complications – Most policies do not cover complications related to pregnancy or delivery.
Experimental Treatments – Conditions treated only with experimental or unapproved therapies may not qualify for benefits.
Reasons Insurers Deny Critical Illness Claims
Despite serious medical diagnoses, insurance companies often deny claims based on technicalities. Common justifications include:
Failure to Disclose Pre-Existing Conditions – If the insured failed to reveal a previous diagnosis or symptoms, even if unrelated, the claim may be denied.
Failure to Meet Medical Criteria – If the diagnosis does not meet the policy’s strict definition (e.g., minor heart attack vs. major), the benefit may be withheld.
Misrepresentation of Medical History – Inaccuracies on the application can give the insurer grounds to rescind the policy.
Claim Filed During Waiting Period – If the diagnosis occurs before the waiting period ends, no benefit is payable.
Policy Exclusions – The illness or circumstances may fall under one of the policy’s listed exclusions.
Non-Compliance with Treatment – If the insured refuses treatment or fails to follow medical advice, insurers may argue that benefits are not payable.
If your claim has been denied for any of these reasons, do not accept the insurer’s decision as final. Our life insurance lawyers have a strong track record of reversing unfair denials and recovering critical illness benefits for policyholders and their families.
FAQ: Critical Illness Insurance and Denied Claims
What is the purpose of a critical illness policy?
It provides a lump sum payment to the insured after being diagnosed with a covered serious illness. The funds can be used for medical expenses, lost income, or any personal need.
Is critical illness insurance the same as life insurance?
No. Critical illness pays during the policyholder’s lifetime after diagnosis of a qualifying illness. Life insurance pays a death benefit to beneficiaries after the policyholder’s passing.
What illnesses are commonly covered by critical illness policies?
Covered conditions typically include cancer, heart attack, stroke, kidney failure, major organ transplants, and severe burns. Policies vary, so always check the list of covered illnesses.
Can a claim be denied if the illness is not severe enough?
Yes. Insurers often use narrow definitions. For example, only specific stages of cancer or severity of a stroke may qualify. Medical records must match the policy’s definitions.
What happens if I’m diagnosed within the waiting period?
If a diagnosis occurs during the waiting period—often the first 30–90 days after purchase—the insurer may deny the claim.
Are mental illnesses covered under critical illness policies?
Most critical illness policies exclude mental health conditions, including depression, anxiety, and PTSD.
Can insurers deny a claim due to pre-existing conditions?
Yes. If the condition was present or being treated before the policy’s effective date, the claim may be denied based on pre-existing condition exclusions.
Can a claim be denied if I failed to follow my doctor’s advice?
Yes. If the insurer believes non-compliance with treatment worsened your condition, they may attempt to deny your claim.
Are all cancers covered under critical illness insurance?
No. Early-stage cancers, pre-cancerous conditions, and certain skin cancers may be excluded. Coverage depends on the policy’s definitions.
Can I appeal a denied critical illness claim?
Yes. Denials can be challenged with proper medical documentation, expert opinions, and legal arguments. Our attorneys regularly overturn these decisions.
How do I know if my condition meets the policy criteria?
You’ll need a diagnosis and supporting documentation that aligns with the policy’s specific definition of the illness. Legal review can help determine eligibility.
What if I made an honest mistake on my application?
If the insurer claims misrepresentation, they may try to rescind the policy. We can help show the mistake was unintentional and should not affect your benefits.
Do I need legal help if my critical illness claim is denied?
Yes. Insurers rely on strict interpretations and technical denials. An experienced attorney can protect your rights and recover the benefits you deserve.