Critical illness insurance may provide for the arrangement of treatment, payment for agreed medical services or a lump-sum payout once a diagnosis is confirmed. The specific format, list of illnesses and limits are determined by the contract.
Contents
  1. How the programme works
  2. What may be covered
  3. Formats of insurance protection
  4. Limitations
  5. How to choose a programme
  6. Making a claim after a diagnosis

How critical illness insurance works

The programme is designed to provide financial protection in the event of a first-time diagnosis of an illness, or the need for a medical intervention, specified in the contract. After a claim is made, the insurer checks the diagnosis, the date it was established, the medical criteria and compliance with the terms of insurance.

The name of an illness alone is not always sufficient. The contract may contain a precise medical definition and requirements for the stage, severity, test results and method of treatment. Therefore, the list on a promotional page must be compared with the full terms.

Important: an insurance policy does not replace a doctor's consultation, diagnosis or the state guarantees of medical care. If you have symptoms or your condition worsens, you must seek help from a medical organisation without waiting for the insurer's decision.

Which illnesses and procedures may be considered

The list differs between insurance companies. A programme may include certain oncological diseases, heart and vascular surgery, neurosurgical procedures, organ transplantation or other conditions expressly described in the contract.

  • oncological diseases, subject to the type and the diagnostic criteria;
  • coronary artery bypass surgery or other agreed procedures;
  • heart valve surgery;
  • certain neurosurgical operations;
  • organ or tissue transplantation on the specified terms;
  • other critical conditions listed in the programme.

A policy may cover hospitalisation, surgery, consultations, tests, medicines during treatment, medical transportation and accommodation for an accompanying person. However, each type of expense must be included, agreed and subject to a limit.

Formats of insurance protection

Format How assistance is provided What to check
Lump-sum payout A fixed amount on a confirmed insured event The definition of the diagnosis, and the amount and number of payouts
Arrangement of treatment The insurer or a service company agrees the clinic and services Geography, the network of clinics and the need for prior approval
Reimbursement of expenses Payment of documented, agreed costs up to the limit The list of expenses, documents and the deductible
Second medical opinion An independent review of medical records Timeframes, the language of the documents and who selects the expert

Some programmes combine several formats. For example, they arrange a second opinion and then treatment at an agreed clinic. Others provide only a lump-sum payout, which the insured manages independently.

Limitations and exclusions

  • a waiting period during which certain diagnoses are not yet covered;
  • illnesses and symptoms that existed before the contract was concluded;
  • a diagnosis that does not meet the medical definition in the policy;
  • age restrictions on joining and renewal;
  • lack of prior approval of the clinic or treatment;
  • experimental methods and methods not included;
  • exceeding the overall or a special limit;
  • inaccurate information in the application or medical questionnaire.

The rules on pre-existing conditions deserve particular attention. The insurer may request a questionnaire, test results or medical records. Answers must be complete and truthful.

How to choose a programme

  1. Compare the full list of diagnoses and the medical definitions.
  2. Decide whether you need a lump-sum payout or the arrangement of treatment.
  3. Check the sum insured, the limits on services and the deductible.
  4. Clarify the waiting period and the terms on pre-existing illnesses.
  5. Study the geography of treatment and the network of available clinics.
  6. Check the costs of flights, accommodation and accompaniment.
  7. Find out the prior approval procedure.
  8. Compare the age restrictions and the term of the contract.

The price depends on age, the sum insured, the set of diagnoses, the geography of treatment, the term and the state of health. A cheaper programme may have a shorter list of illnesses or stricter definitions, so you should compare identical cover.

What to do after a diagnosis

  1. Continue to follow your doctor's instructions and do not delay necessary care.
  2. Notify the insurer in the manner and within the time specified in the contract.
  3. Request a case number and the official list of documents.
  4. Provide medical reports, test results and discharge summaries.
  5. Do not pay for expensive treatment without agreement, if the terms require it.
  6. Keep referrals, invoices, receipts and correspondence.
  7. Obtain a written decision on acceptance of the event and on the next steps.

The insurer may send the documents for a medical examination or request additional information. A second opinion often requires a full set of test results in a legible format. The translation of documents and the method of sending them should be agreed in advance.

Which documents may be required

  • an application and details of the insurance contract;
  • proof of identity;
  • extracts from the medical record;
  • doctors' reports and examination protocols;
  • results of tests and instrumental diagnostics;
  • the treatment plan and a referral to the clinic;
  • invoices and proof of payment, in the case of reimbursement of expenses;
  • other documents needed to verify the insured event.

Frequently asked questions

Is every oncological diagnosis covered?

Not necessarily. Cover depends on the medical definition, the stage, the type of illness, the waiting period and the contract's exclusions.

Can I choose a foreign clinic myself?

Only if the programme allows it. When treatment is arranged, the clinic is often selected, or approved in advance, by the insurer and the service company.

Does the policy replace health insurance?

No. It is specialised cover for a limited list of serious conditions. Everyday medical care requires a separate programme or another source of funding.

Conclusion

Critical illness insurance is useful only with clear medical criteria, an adequate limit and a clear approval procedure. Before arranging cover, you must study the definitions, the waiting period and the exclusions carefully.

This material is for information purposes only and is not medical advice. The terms of insurance are determined by the contract with a licensed insurance company.