Having an insurance policy doesn't necessarily mean a successful claim is guaranteed. Critical illness cover, in particular, has guidelines on what is and isn't covered. There could be certain circumstances where your claim could be denied, even if you’re sure you meet the criteria.
In this guide, we'll outline some of the main reasons for a claim denial and what your options are.
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What is critical illness insurance?
Critical illness insurance pays out a lump sum if you are diagnosed with a serious health condition listed in the policy. It typically covers medical conditions such as heart attacks, strokes, and cancer, amongst others. It can be bought alongside life insurance or as a standalone policy.
In essence, it could offer you a helping hand if your life is significantly impacted by a severe illness.
If you are unable to work, it may provide financial support to cover costs such as medical expenses, household costs, or any necessary lifestyle adjustments as you recover.
Why do critical illness claims get rejected?
There's a number of reasons why critical illness claims can be denied. Each insurer will have their own guidelines on what is covered and whether any specific criteria is required.
Understanding these reasons could help you prepare better and give your claim the best chance of success:
Non-disclosure or misrepresentation
Just like applying for life cover, you have to be completely honest and accurate with the information you provide. This includes any health conditions, medications, as well as lifestyle habits.
If, for example, you have a long-term condition you didn’t mention, or you left out that you are a smoker, your insurer might argue that you weren’t truthful when you took out the policy. Even if it wasn’t intentional, this kind of omission can lead to a rejected claim.
Waiting periods
Critical illness policies typically feature a specified waiting period. During this time, you won’t be able to make a claim, even if you’re diagnosed with a listed condition. This is intended to prevent you from taking out cover if you already suspect something is wrong.
If your illness is diagnosed or symptoms start during this period, your claim is likely to be rejected. Each insurer will have its own timeframe for waiting periods, so it's crucial to familiarise yourself with the specifics of your policy.
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Not meeting the policy definition
Insurance providers have their own individual definition when it comes to what counts as a critical illness. It’s not enough to just be diagnosed with a condition; it usually has to meet a specific set of criteria as well.
For example, if you are diagnosed with cancer, you may only be covered if it’s invasive or has reached a certain stage, while a stroke may need to result in lasting neurological damage. If your illness doesn’t match the definition exactly as set out in your policy, the claim can be declined.
Illness excluded by the policy
Some illnesses may not be covered by critical illness insurance. This is either due to specific exclusions in your policy or because they aren’t considered severe enough to warrant a payout.
Insurance providers often have a list of conditions that are explicitly excluded. This may include mild forms of cancer, certain mental health conditions, or illnesses linked to drug or alcohol misuse.
These details are usually tucked away in the policy documents, so it’s easy to miss them. If your condition falls under one of these exclusions, your claim will be rejected regardless of the impact it may have on your life.
Learn more about the illnesses typically covered by critical illness.
Policy not active at time of diagnosis
As with any insurance policy, your cover will usually stop if you don’t pay your premiums. If your payments have lapsed. If you’re diagnosed at this time, the insurer isn’t obliged to pay out. The same applies if the policy was cancelled, expired, or hadn’t officially started when you became ill.
What can I do if my claim is rejected?
If your claim is rejected, it doesn’t necessarily mean the end of the road. First and foremost, you need to understand exactly why the insurer turned it down. They should provide a clear explanation in writing
If it’s a case of missing information, you may only need to provide more documents and resubmit your claim. However, if it's a policy exclusion, there isn't much you can do to change the outcome unless you have grounds for a dispute.
If you still disagree with the decision, you can formally appeal it through the insurer’s complaints process. This might be in cases where the insurer does not believe your illness meets the policy's criteria.
You can also escalate the issue to the Financial Ombudsman Service. They’ll review your case independently and decide whether the insurer acted fairly. This process is free, and you don’t need a solicitor to make a complaint. However, legal advice can help if the case is complex.
How do I make a critical illness claim?
To start the claims process, you’ll need to get in touch with your insurer directly, usually by phone or email. Most providers have a dedicated claims team you can speak to during working hours.
When you call, they’ll ask for a few key details such as:
Your policy number
The condition you’ve been diagnosed with
Contact details for your GP or medical consultant
Once you’ve notified them, they’ll do some initial checks to see whether your condition is potentially covered under the policy. They may ask you to provide any letters or medical records you’ve already received from your doctor or consultant. They can also request these directly if needed.
After this, they’ll send you some straightforward forms to complete and return, either by email or post.
From that point on, your claims handler will take over and keep you updated throughout the process. You’ll still need to keep paying your premiums while the claim is being assessed.
Need advice on critical illness insurance?
If you're feeling unsure about critical illness cover, whether you’d be eligible, or you’ve got questions about making a claim, we’re here to help.
Our friendly advisers can talk you through how it all works, explain what’s covered (and what’s not), and help you understand whether a policy is right for your circumstances.
If you’re thinking about making a claim or just want to know where you stand, we’ll guide you through the process step by step.
Call our advice team on
01392 436 193
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