FAQ - Critical Illness

What are the Exclusions and Waiting period under the Critical Illness Policy?

Critical Illness Plan covers an individual against Serious Illness which has a debilitating effect on their lifestyle, financial conditions and require a considerable amount of money to take care of the treatments. Sometimes it also leads to loss of income due to inability to work or require a long leave post the treatment. However, before buying a Critical Illness Plan, it is important to read the Policy Terms & Conditions Carefully. If you tend to ignore it, there are instances where you are bound to face claim rejection. 

Let us have a look at the Major Terms & conditions under a Critical Illness Policy:

Pre-existing diseases are those medical conditions that existed even before the insured had applied for a policy. Normally any pre-existing ailments are not covered from day 1. Most Policies cover PED or Pre-Existing Diseases after a waiting period of two years or four years. However, it does not guarantee that the other diseases linked to the PED will be covered during the waiting period.  

Waiting Period: Under a Critical Illness Plan any treatment diagnosed within first 90days since the inception of the policy is not covered. Following shall only Include:-

A. First Diagnosis of the below-mentioned Illness more specifically described below:-

  1. Cancer
  2. Kidney Failure (End Stage Renal Failure)
  3. Primary Pulmonary Arterial Hypertension
  4. Multiple Sclerosis

B. Undergoing for the first time of the following surgical procedures, more specifically described below:-

  1. Major Organ Transplant
  2. Coronary Artery Bypass Graft
  3. Aorta Graft Surgery
  4. Heart Valve Surgery

Occurrence for the first time of the following medical Events:

  1. Stroke
  2. Myocardial Infarction (First Heart Attack)
  3. Coma
  4. Total Blindness
  5. Paralysis

Survival Period: Most critical illness policies or rider comes with a survival period clause. The claim will be paid for any listed critical illness only if the policyholder survives for a period of minimum 30 days from the date of the first diagnosis of the illness. In case the insured dies with the survival period, no compensation shall be paid to the nominee. However, there are certain life Insurance companies which do not have any clause for Waiting Period or Survival Period.

Some of the standard permanent exclusions followed by most insurers are:

  • Pre-existing illness will be covered only after the initial waiting period as specified in the policy document.
  • Any treatment for sexually transmitted diseases, HIV/ AIDS is not covered.
  • Any self-inflicted injury or injury due to suicide attempt is not covered.
  • Any injury caused under the influence of alcohol, drugs etc. is not covered.
  • Injury due to participation in adventure sports/activities such as racing, diving, scuba diving, parachuting etc is not covered
  • Any treatment arising of pregnancy, miscarriage, maternity or birth, etc is not covered.
  • War, terrorism, civil war, navy or military operations
  • Any dental care treatment or cosmetic surgery will not be covered.
  • Any treatment/surgery for change of sex.
  • Cost of Donor Screening or treatment, unless specifically covered and specified in the Policy Schedule
  • Treatment which are carried Outside India.
  • Treatment to assist Reproduction.
  • Any mental illness/ psychiatric or psychological therapy.

For a Complete list of Exclusions, it is advisable to read the policy document of the specified company.