Ask A Lawyer about Critical Illnesses Insurance Claims

Welcome to our Ask A Lawyer blog series where we answer your most pressing questions about disability benefits.

In this post, we'll explore some common queries regarding critical illness insurance policies in Canada. Many people are uncertain about how to navigate the process of making a claim if they have been diagnosed with a serious illness, such as cancer, and have concerns about whether they will be eligible for critical illness benefits. Here are some answers to frequently asked questions about critical illness insurance that may help to shed some light on the matter.

Q: What factors do insurance companies use to determine if I am eligible to receive critical illness insurance benefits?

Under most policies, a critical illness is one that results in the loss of independence. Cancer, stroke, heart attack, heart surgery, kidney failure, organ transplantation, brain tumour, paralysis, coma, permanent disability, Alzheimer's, Parkinson's disease, and multiple sclerosis may qualify you. Check with your critical illness insurance lawyer to help identify the specific provisions of your contract.

Q: I have cancer and the insurance company says it’s not the right type of cancer and that I won't receive my critical illness insurance benefits?

A: The wording of your policy must be reviewed carefully to determine whether the type of cancer that has been diagnosed meets the criteria for a critical illness insurance payout. The law states that, if the policy wording is unclear, the proper interpretation would be to decide in favour of the claimant rather than the insurance company, as they drafted the wording.

Q: Can an insurance company deny a claim based on “material misrepresentation” if the health issue being contested is unrelated to the illness or injury that has prompted the claim for critical illness insurance benefits?

A: Yes. People often believe that if, for example, they have been diagnosed with a form of cancer, but the alleged misrepresentation is regarding high blood pressure, that those two items seem to be unrelated and the misrepresentation appears to be irrelevant. Claims denied based on material misrepresentation turn on the question of, firstly, whether the answer to the question was inaccurate, and secondly, whether the disclosure of the prior medical condition would have been “material” to the insurance company’s decision to issue the policy. If in doubt, contact an experienced insurance lawyer for further guidance and advice.

Want to learn more about Critical Illness Insurance? Share is there.


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