Policy Exclusions and Claim Denials in Critical Illness Insurance: What You Need to Know

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Critical illness insurance, as the name suggests, offers coverage against the diagnosis of severe health conditions such as cancer, heart attack, paralysis, and more. It provides a lump-sum payment upon the diagnosis of any of these critical illnesses after the policy purchase.

The policy encompasses a range of diseases and medical events, offering financial support for various illnesses such as dialysis due to kidney failure, multiple types of cancer (lung, throat, breast, liver, etc.), paralysis, neurological diseases with permanent symptoms, multiple sclerosis, meningitis with aplastic anaemia, last-stage liver or lung diseases, Parkinson’s disease, major organ transplants, Alzheimer’s disease, benign brain tumours, coma, myocardial infarction, CABG, major burns, stroke, total blindness, motor neuron disorders, and more.

Exclusions in Critical Illness Policies

While critical illness insurance covers major ailments, it’s essential to note certain exclusions that may not fall under coverage. These exclusions include:

  • Initial waiting period: Critical illness diagnosis must occur after this waiting period lapses for coverage.
  • Illnesses existing before policy purchase
  • Congenital diseases or birth defects
  • Specific treatments related to pre-existing conditions

Additionally, general exclusions may involve coverage restrictions for sexually transmitted diseases, mental illnesses, self-inflicted injuries, participation in criminal activities, and incidents related to war or nuclear, chemical, or biological attacks.

Why are critical illness claims denied

While critical illness insurance provides a safety net, there are common reasons why claims may be denied:

  1. Pre-existing disease: A previously existing illness might lead to claim rejection
  2. Non-disclosure or misrepresentation: Critical illness insurance is a valuable resource, but being well-informed about its scope, limitations, and requirements is crucial to maximizing its benefits during times of need.
  3. Policy exclusions: If the diagnosed illness falls under the policy’s exclusion list, the claim may not be honoured.
  4. Failure to meet policy criteria: Some policies have specific criteria regarding the severity or stage of the illness required for a pay-out. If the illness doesn’t meet these criteria, the claim might be denied.
  5. Policy lapses: Failure to pay premiums or maintain the policy according to the terms can lead to lapses, resulting in claim denials.

Tips to navigate exclusions and claim denials

  1. Read the policy carefully: Understand the policy terms, including exclusions, waiting periods, and covered illnesses before purchasing.
  2. Provide accurate information: Disclose all relevant medical history truthfully during the application process to avoid claim denials due to non-disclosure.
  3. Seek clarifications: If unsure about any aspect of the policy, seek clarification from the insurer or insurance agent before purchasing.
  4. Review policy renewals: Regularly review policy renewals to ensure continued coverage and understand any changes in terms or exclusions.
  5. Appeal claim denials: If a claim is denied and you believe it’s unjust, consider appealing the decision by providing additional documentation or seeking assistance.

Insurance Samadhan


In conclusion, critical illness insurance offers substantial relief during challenging health circumstances, but understanding its coverage, exclusions, and reasons for claim denials is crucial. Regularly reviewing and comprehending policy terms ensures adequate coverage when it’s most needed. Always seek guidance from insurance professionals for personalized advice regarding critical illness insurance.

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