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Critical Illness

A lump sum on the diagnosis of a listed illness, paid whatever the treatment costs and whether or not anything was spent.

Also calledCritical Illness Benefit · CI Rider

File/Claims library/Health, life and accident/Illness, hospital and life

First thing, todayThe claim turns on the diagnosis meeting the definition in the policy, so collect the reports that establish it from the start.

Three deadlines
  • Tell the insurer now, not after the assessment.
  • Pre-authorisation, or intimation before a planned admission, and within the hours the policy allows after an emergency one.
  • Every document within the time the insurer asks for it.
An itemised hospital bill, an authorisation form and a health card
An itemised hospital bill, an authorisation form and a health card. An illustration.

When you would claim

  • Diagnosis of an illness named in the policy's list
  • A procedure named in the list, once it has been carried out
  • Survival past the period the policy sets after diagnosis
  • A claim under a rider attached to a life or health policy

What insurers most often rely on

  • The diagnosis not meeting the policy's own definition, which is usually narrower than the word in ordinary use
  • Illness first diagnosed inside the waiting period
  • A pre-existing condition the insurer says was known
  • Survival period not completed
  • Reports that establish the date of diagnosis being missing

Most are answered by the treating doctor in a paragraph, once somebody asks for the right paragraph.

The documents

ask the hospital on the day

9 items. A hospital will hand you most of them on the day if you ask at the desk, and take three weeks over them if you ask in a month. Ask on the day.

  • Claim form and the policy schedule with the list of illnesses
  • The diagnosis, from the specialist, in the words the policy uses
  • Investigation reports that establish it, with the dates
  • Hospital records and the discharge summary, where there was admission
  • Treating doctor's certificate on the date of first diagnosis
  • Identity and age proof
  • Cancelled cheque and bank details in the insured's name, for the NEFT payment
  • Details of any other insurance covering the same illness
  • The benefit claimed, read against the policy’s own list of illnesses and the survival period it sets
Admission to dischargeThree dates and the gap between them is most of what a health insurer queries. Note the hour of the emergency admission too: several wordings count in hours, not days.

Next

What the first day looks like

There is no playbook for this and there will not be one, because the first day is short. Tell the insurer or the TPA inside the hours the policy allows, keep every original the hospital gives you, and do not let a discharge happen before the pre-authorisation query has been answered in writing.

Call 92514 56334

Read the benefit table

This pays a benefit, not a loss. The capital sum insured and the policy's own table decide the figure, and no amount of receipts moves it. What is worth reading before a claim is which events are on that table and what each is worth.

Filed under: Health, life and accident · Illness, hospital and life

Claims that sit next to this one

the same person, a different trigger

Health Insurance

the bill, as against the diagnosis

Group Term Life

the cover that pays on death

Personal Accident

accident rather than illness

Hospital bill cut, or a policy nobody will explain to you? Report a loss or call 92514 56334.