Can Insurance Companies Use Their Own Definitions of Common Critical Illnesses Such As Heart Attack, Cancer or Stroke?

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 diseases, and Multiple Sclerosis may qualify you. The problem lies in the fact that the typical definition of a critical illness may not necessarily be the same definition you find in your policy documents.

For example, it's entirely possible to have a heart attack and not receive any form of payment- and the same goes for cancer, and dozens of other conditions considered "critical illnesses". Let's use the definition of a heart attack, for example. Typically insurance companies do not use the consumers' definition of heart attack or even the medical industry's definition- they use their own. Here's the definition of heart attack from The University of Maryland Medical Center:

"A heart attack occurs when blood flow to a part of your heart is blocked for a long enough time that part of the heart muscle is damaged or dies."

While this certainly sounds like a heart attack to most of us, the definition of the same condition found in a critical illness policy might read something like this:

"Heart Attack means the death of heart muscle due to obstruction of blood flow, that results in the rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least 1 of the following:

  • heart attack symptoms;
  • new electrocardiogram (ECG) changes consistent with a heart attack
  • development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.

Exclusion: No benefit will be payable under this Critical Illness Insured Condition for elevated biochemical cardiac markers after an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves.For greater certainty, ECG changes suggesting a prior myocardial infarction does not satisfy the above definition of Heart Attack.

The diagnosis of heart attack must be made by a specialist."

The insurance company's definition of a critical illness is often far more detailed and complex, resulting in fewer payouts on their behalf. Remember, insurance companies are out to make money! For that reason, it is essential to check with your critical illness insurance lawyer to help identify the specific provisions of your contract.

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