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Making a Claim On a Critical Illness Policy? What Is the Process?

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If you are thinking of making a claim on a Critical Illness Insurance policy, you can often be apprehensive. You might be worried about the process or something you left out about your medical history when you applied for the Non-disclosure insurance. We will go through the process here and what you might expect to see along with some handy tips and comments.

When you are making a claim, you can normally do this online of over the phone. They will ask some initial questions about the condition you have been diagnosed with along with some information about your GP and supervising consultant. The insurance company will normally give you a call to clarify some of your answers. Some insurance companies will ask you to confirm the information you provided when you applied for the insurance. Often this may be referred to as ‘fishing’. Insurance companies are only able to seek information that confirms an insured event occurs, meaning that they can not request or access information without reasonable concerns. An example may be that you took insurance out in 2011 and the insurance company ask when you stopped smoking. If you said on the application you stopped in 2007 but when the insurance company phone you say 2009, they may consider it reasonable to request information about your smoking habits at that time. This can delay your claim as GP’s can sometimes take 8 weeks to respond to request for medical information.

Furthermore, we have seen insurance providers obtain full medical records which they have then picked up more potential non-disclosures from. This is of course highly contentious, and we have successfully challenged insurance companies many times on this practice. In short, if you do not know or feel comfortable, just say you can not remember and advise them you will need to check your medical records. This should not slowdown or stop your claim.

The next stage is for the insurance company to write to your GP and specialist. They will often ask questions along the lines of, when did you first start experiencing symptoms, when did you first attend the GP, what treatment are you undergoing along with copies of histology reports etc. Remember the ABI guidelines, only to ask questions that confirmed the insured event happened? Well, most insurance companies also ask slightly underhanded questions like, ‘has the client ever been asked to cut down on their alcohol consumption’, ‘has the client ever smoked’, ‘what was their last three height and weight readings’. Sometimes the answer to these questions can lead to a Critical Illness policy being rejected or rated. We have seen instances where insurance companies request full medical records straight away. The Financial Ombudsman’s longstanding view it that a claim against a policy is not an opportunity to underwrite the policy again.

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Of course, there are instances where the insurance company have a right to ask those questions if they have reasonable grounds to suspect non-disclosure. An example might be someone diagnosed with alcohol related liver cancer which is normally a result of many years of alcohol abuse. This is reasonable grounds for the insurance company to confirm your drinking habits.

Once the information has been received by the insurance provider, they will decide on your claim. Sometimes though they may request more information from your medical providers to confirm possible non-disclosures or for clarification on your diagnosis.

The whole process should take no more than 8 weeks.

The decision an insurance company can take are:

  • Pay the claim in full.
  • Partially pay the claim (some non-disclosures will result in this)
  • Cancel the policy and refund the premiums (non-disclosure that would have resulted in the initial application being declined)
  • Cancel the policy with no refund of premiums (where there has been a wilful non-disclosure)

Resolute Claims can help people who are experiencing difficulties in making a claim on their Critical Illness Cover. We offer an 70% reduced fee where customers are looking for help claiming on their insurance (rather than our full fee for overturning a rejected Critical Illness claims). We will answer all the questions for you and ensure that your insurance provider acts fairly. Even if you would like to chat through your concerns we are here to help with free information and guidance.

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