The critical illness insurance policies available in the market generally provide coverage for critical illnesses, such as cancer, heart disease and stroke. However, the predetermined list of critical illnesses, the coverage for early-stage conditions and surgical procedures, such as precancerous lesions, carcinoma-in-situ or percutaneous coronary intervention (commonly known as angioplasty), vary among policies. You should carefully read the policy provisions before taking out a policy, especially the terms on coverage and claims conditions, to avoid any potential disagreements with your insurer because of any misunderstanding of the provisions.
In addition, the definition of the same covered illness, such as cardiomyopathy, varies among insurers, so make sure you clearly understand the definitions of the covered critical illnesses and surgical procedures in a specific policy. The policy terms generally outline the diagnostic criteria and specific descriptions of the medical conditions associated with each critical illness and surgical procedure, and there may also be a requirement that the diagnosis must be clinically confirmed by relevant specialists or through specific assessments. When you make a claim, the insurer will assess whether your diagnosis meets the relevant policy terms and definitions to determine reasonable claims payment.
Some critical illnesses, such as cancer or stroke, may strike more than once. Therefore, many insurers offer critical illness insurance plans with “multiple claims” feature. When buying this type of critical illness insurance plans, you should pay attention to and make sure you understand the features of “multiple claims”, including any additional terms and conditions for the second or subsequent claims, the definitions of "new disease", "recurrence" and waiting period between diagnoses. Take critical illness policies that cover early-stage severe illnesses as an example, if a second claim for carcinoma-in-situ is filed, some policies may cover only an organ this is different from that of the first claim and allow one claim at most for the same organ with carcinoma-in-situ. You must read the relevant terms and conditions in detail or consult your insurer or insurance intermediary before taking out a policy.
Additionally, even if the policy offers “multiple claims”, generally there are benefit limits (e.g. 25% or 30% of the original sum insured) and restrictions on the number of claims for each type of major condition and early-stage illness, so make sure you understand the policy terms and conditions clearly.
Critical illness insurance policies typically have a “waiting period”, generally ranging from 60 to 90 days following the effective date of the policy depending on individual policy terms. Generally, claims are not payable if a symptom of a critical illness appears or an insured illness is diagnosed during the waiting period. For specific diseases, such as gynaecological diseases or autism, the policy may have a longer waiting period of up to 180 days or even a year. It is important to note that the waiting period may also apply to when a policy is upgraded (e.g. increase of sum assured) or upon policy reinstatement; that is, the waiting period will begin from the commencement date of the upgrade or reinstatement.
In addition, for a policy with “multiple claims”, a waiting period, normally ranging from 1 to 5 years, may be required between each claim. This means a new diagnosis or recurrence of covered illness is not eligible for claims if it occurs during the waiting period. The actual length of the waiting period varies depending on the specific policy terms. You should carefully read the policy terms and conditions to be sure you understand the details of “waiting period”.
Critical illness insurance is designed primarily to provide a lump-sum payment as financial support if the insured person is diagnosed with a critical illness. Some policies may have a "survival period" clause, which stipulates a certain period of time in which the insured person must survive from the date of diagnosis of a critical illness or completion of a surgical procedure to be entitled to claim payment. The survival period is typically between 14 and 30 days. The actual number of days of the survival period is subject to the policy terms and conditions of individual insurers.
If the insured person unfortunately passes away within the "survival period", the insurer will not pay out the critical illness claim benefit. However, some critical illness policies may include a death protection. If the insured person passes away within the survival period, the “death benefit” is payable, though the benefit amount is generally less than the total sum assured of the critical illness benefit.
Exclusions refer to situations that are not covered by an insurance policy. You should carefully read the exclusions defined in the product information, as well as the policy terms and conditions. Common exclusions in critical illness insurance include pre-existing conditions and symptoms, as well as any illness caused by, or associated with, Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex or Human Immunodeficiency Virus (HIV), alcohol or drug abuse, or any mutations, derivations or variations thereof, and acts related to war and terrorism.
“Utmost good faith” is an important principle in insurance contracts. You are obliged to disclose proactively and honestly all personal health conditions and medical history, including any abnormal findings in previous medical check-ups, at the time of insurance application to help the insurer identify high-risk features and decide whether to take the risk and if so, what premium and terms to offer. A misrepresentation or non-disclosure of your health condition and medical history, which are material facts, may affect your future claims and the validity of the policy because the insurer will be unable to make a fair and accurate underwriting decision for the application, regardless of whether the material facts relate directly to the illness that leads to the claim. If you are in doubt as to whether a fact should be declared, it is advisable to disclose it to the insurer for further consideration for making its underwriting decision.
Many critical illnesses are affected by genetic factors. In addition to health information and age, the underwriting questionnaire from most insurers inquires about your family medical history (including any diseases and the age of onset) for risk assessment. Certain information would directly affect the insurer’s underwriting decision, including the calculation of the premium level. You should therefore understand your family medical history and disclose it honestly and completely.
Critical illness insurance policies generally have a time limit for lodging a claim. Normally, you are required to notify your insurer and submit the completed claim form within a specified period (e.g. 90 days) after the date of your diagnosis of a critical illness. When making a claim, you will need to provide medical documentation issued by your attending doctor, hospital or relevant clinic to prove that you have been diagnosed with the insured critical illness. This documentation may include medical records, laboratory reports and pathology reports. The insurer may also ask you to submit other relevant supporting documents, such as proof of identity, medical receipts and surgical records, depending on the specific claim and policy requirements. Read the claim procedure of your insurer carefully and note the filing deadline and required documents. If you are in doubt, consult your insurer or intermediary to ensure that the claim process goes smoothly.
The above information is for reference only. For the coverage, exclusions, benefit limits and premium levels of a specific insurance plan, please refer to the relevant policy terms.