General Exclusions of Critical Illness Insurance

To prevent insurance abuse by policyholders, general critical illness insurance policies usually have exclusions. Here are some common exclusions:

A Disease With Symptoms That First Appear Within 90 Days (Waiting Period) After The Policy Takes Effect

(i) Diseases with symptoms or signs that first appear within 90 days (waiting period) after the policy becomes effective (except for diseases diagnosed within 90 days of an accident that directly caused the disease).

(ii) The cause and/or condition of any serious surgery performed on the insured that occurs within 90 days (waiting period) after the policy becomes effective (except for surgery performed within 90 days of an accident that directly caused the need for surgery).

Pre-existing Illness

(i) Pre-existing conditions:

• Including those that have been diagnosed before applying for the policy; or
• Those that have shown obvious symptoms or signs; or
• Those that have received medical advice or treatment for the illness.

(ii) Unknown pre-existing conditions:

• Not detected before applying for the policy; or
• No obvious symptoms or signs; or
• Illnesses that have not been diagnosed or treated by a doctor.

Drug Abuse

Death caused by dependence on or excessive use of drugs, alcohol, narcotics, or similar substances.

Diseases Caused By Human Immunodeficiency Virus (HIV) Infection, Including Acquired Immune Deficiency Syndrome (AIDS)

(i) Any disease, injury, toxin, or infection (except for infections directly caused by accidental cuts or wounds); or

(ii) Including any infection with any human immunodeficiency virus (HIV) and/or any related disease; or

(iii) Including AIDS and/or any mutations, derivatives, or variations.

Intentional Self-harm

(i) Intentional self-harm; or

(ii) Attempting or threatening suicide, regardless of mental clarity; or

(iii) Engaging in illegal activities; or

(iv) Violating or attempting to violate the law or evading arrest.

Death Within 14 days (Survival Period) After Diagnosis or Surgery

(i) The insured person fails to survive for at least 14 days from the date of diagnosis of a critical illness or completion of a major surgical procedure.

The exclusions listed above are just some common exclusions. The specific terms of different critical illness insurance plans may vary depending on the insurance company.

For example, some insurance companies may have a waiting period of around 30 days, while others may have a limit of 90 days. It is recommended to carefully read the compensation criteria before applying for insurance to avoid disputes.

“Additional exclusions” refer to exclusions added by insurance companies on top of existing exclusions due to the higher risk of the applicant making a claim based on their personal health condition.

In addition, insurance companies may consider adding an “Additional Premium” (i.e., Loading), ranging from 10% to 25%, or even multiples thereof, depending on the judgment of each insurance company, to handle additional exclusions.

If the relevant high-risk factors are no longer present after a certain period of time, the insured person can apply to the insurance company to undergo the underwriting process again, in order to be exempted from additional exclusions or premiums.

Generally speaking, as long as the insured person fulfills their responsibilities properly, critical illness insurance claims are rarely rejected.

The following are two reasons that may affect critical illness insurance claims:

The Insured Person Did Not Pay The Premium On Time

Most insurance companies have a “Grace Period” during which the policy remains effective even if the insured person fails to pay the premium. However, before receiving the outstanding premium, the insurance company has the right to refuse to pay compensation. If the insured person still does not pay the premium after the grace period, the policy will be immediately terminated, and no critical illness coverage will be provided.

The Insured Person Did Not Truthfully Disclose His/ Her Personal Condition

During underwriting, the insured person must truthfully disclose his/ her personal health condition, including medical history, family medical history, and whether he/ she smoke. If it is discovered that false information was provided, the insurance company may increase the premium or add exclusions, or even cancel the policy directly, even if the insured person meets the claim conditions.

Here, I would like to remind everyone to truthfully disclose their personal situation when applying for insurance and to pay the premium on time after purchasing insurance, otherwise there is a high chance of being denied by the insurance company.

In 2021, the Insurance Complaints Bureau handled a total of 607 insurance claim disputes, of which 76 complainants successfully received compensation, involving a total amount of HK$7.53 million.

In other words, being denied a claim may not necessarily be the fault of the insured person. It may also be due to ambiguous terms and conditions of the insurance company or erroneous judgments.

If you are not satisfied with the insurance company’s compensation decision, you can download a written complaint form from The Insurance Complaints Bureau. After filling in your personal information and the details of your complaint, you can submit it along with the following documents by mail, fax, or email to the Complaints Bureau:

1. Complete policy and policy application form
2. Claim form
3. Medical or laboratory reports
4. Insurance company’s final decision document