Critical illness insurance claims: Legal support for denied payouts

What is critical illness insurance?

Critical illness insurance is designed to provide financial protection in the event of a serious medical diagnosis that prevents an individual from continuing to work. Unlike life insurance, which pays out upon death, critical illness insurance offers a lump sum payment upon diagnosis of a qualifying condition. Such financial support is intended to ease the burden of lost income and allow the policyholder to focus on recovery.

However, the interpretation and enforcement of critical illness policy terms can often be complex. Coverage varies significantly between providers, and disputes over eligibility and entitlement are increasingly common. We provide expert legal advice and representation to individuals whose claims have been unfairly denied, ensuring that insurers are held to account and that our clients receive the benefits to which they are contractually entitled.

What conditions are typically covered?

Most critical illness policies specify a list of medical conditions that qualify for a payout. These commonly include:

• Heart attack
• Stroke
• Alzheimer’s disease
• Certain types of cancer

Depending on the insurer and policy wording, additional conditions may be covered, such as:

• Traumatic brain injury
• Paralysis
• Loss of sight or hearing
• Other serious and long-term impairments

Given the specificity of coverage, it is essential that you carefully review the insurance policy to ensure your individual health risks are adequately covered.

Why are critical illness claims denied?

Insurers may reject claims for several reasons, which may include:

• Non-disclosure: Failure to disclose relevant medical history at the time of the application. This may be classified as innocent, careless, or deliberate, each with different legal implications for your entitlement.
• Fraud allegations: Claims may be denied if the insurer suspects dishonesty, such as falsified medical records or misrepresentation of symptoms.
• Policy exclusions: Denials may arise if the condition is not listed, lifestyle factors contributed to the illness, or errors were made during the application process.

Each of these grounds can be challenged and our specialist team of insurance experts can assess the insurer’s reasoning and advise on the merits of your potential claim.

How can Ellis Jones help?

We recognise the financial and emotional toll that a denied insurance claim can impose during a time of medical vulnerability. Our dedicated team of insurance dispute experts is committed to resolving disputes efficiently and effectively.

We act exclusively on behalf of the insured, leveraging our in-depth sector knowledge with a proactive and client-focused approach to pursue the compensation you may be entitled to.

Get in touch with our insurance experts today

Please get in touch on a no-obligation basis by telephone on 01202 057733 or by email on insurance@ellisjones.co.uk, if you would like us to discuss the position with you and provide details of how we can progress your matter.