Critical Illness Claims Process: Step-by-Step Guide

Making a critical illness claim can feel overwhelming when you're already dealing with a serious diagnosis. Understanding the claims process before you need it helps ensure a smooth, successful claim when the time comes. This comprehensive guide walks you through every step.

Overview: What to Expect

Typical Claims Timeline

Standard claim (no complications):

Notification to initial assessment: 1-3 days
Medical evidence gathering: 2-6 weeks
Decision: 1-2 weeks after evidence received
Payment: 3-5 working days after approval
Total time: 4-10 weeks

Complex claim (additional evidence needed):

As above, plus:
Specialist reports requested: 4-8 weeks
Independent medical examination: 2-4 weeks
Additional investigations: 2-8 weeks
Total time: 3-6 months

Disputed claim:

Initial decline: After evidence review
Appeal submitted: Your timeline
Appeal review: 4-8 weeks
Financial Ombudsman (if needed): 6-12 months
Total time: 6-18+ months

Key Success Factors

✓ Early notification - Tell insurer as soon as diagnosed
✓ Complete disclosure - Provide all requested information
✓ Medical evidence - Ensure diagnosis meets policy definition
✓ Timely responses - Reply to insurer requests quickly
✓ Accurate records - Keep copies of all correspondence
✓ Professional support - Use adviser if claim complex

Step 1: Understanding Policy Definitions

Before making a claim, verify your condition meets the policy definition.

Common Critical Illnesses and Their Definitions

Cancer

Typical policy definition:

"A malignant tumour characterised by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The term malignant tumour includes leukaemia, sarcoma, lymphoma and Hodgkin's disease."

Usually excluded:

Carcinoma in situ (pre-cancerous, Stage 0)
Basal cell carcinoma (skin cancer)
Squamous cell carcinoma under 2cm (small skin cancer)
Early stage prostate cancer (TNM classification T1a or T1b, Gleason score 6 or below)
Chronic lymphocytic leukaemia (stage 0 or A, Binet staging)

Example:

Sarah, 42, diagnosed with DCIS (ductal carcinoma in situ) in breast:

DCIS is Stage 0 breast cancer (pre-invasive)
Policy definition requires invasive malignant cancer
DCIS does not meet definition
Claim declined (correct decision under policy terms)

After treatment:

If DCIS progresses to invasive breast cancer: Would meet definition
If surgery removes all DCIS and no invasive cancer: No claim possible

Key point: Check exact cancer diagnosis and staging against policy definition before claiming.

Heart Attack

Typical policy definition:

"Death of heart muscle due to inadequate blood supply that has resulted in all of the following evidence of acute myocardial infarction:

New characteristic electrocardiographic (ECG) changes

The characteristic rise of cardiac enzymes or Troponins

Typical chest pain"

Usually excluded:

Angina (chest pain from insufficient blood flow, but no heart muscle death)
Elevation of cardiac biomarkers alone (without ECG changes or symptoms)
Non-ST segment elevation myocardial infarction (NSTEMI) if policy older (some modern policies do cover)

Example:

John, 58, chest pain, admitted to hospital:

Troponin levels elevated (indicating heart muscle damage)
ECG shows changes consistent with heart attack
Typical chest pain experienced
Diagnosis: Acute myocardial infarction
All three criteria met: ✓ ECG changes, ✓ Troponin rise, ✓ Chest pain
Claim approved

Counter-example:

David, 52, chest pain during exercise stress test:

Troponin levels normal
ECG shows ST-segment depression (indicates angina, not heart attack)
Chest pain present
Diagnosis: Angina, not heart attack
Criteria not met (no Troponin rise, no heart muscle death)
Claim declined (correct - angina excluded from standard policies)

Stroke

Typical policy definition:

"Cerebrovascular accident producing neurological sequelae lasting at least 24 hours. This includes infarction of brain tissue, intracranial and/or subarachnoid haemorrhage. There must be permanent neurological deficits with persisting clinical symptoms."

Usually excluded:

Transient ischaemic attack (TIA) - symptoms resolve within 24 hours
Traumatic injury to brain
Stroke without permanent symptoms

Key point: "Permanent" typically means symptoms lasting at least 24 hours. Some policies require longer (weeks to months).

Example:

Margaret, 67, sudden weakness right side, speech difficulty:

CT scan confirms ischaemic stroke (blood clot in brain)
Symptoms persist after 24 hours
6 weeks post-stroke: Partial right-side weakness remains, speech slightly slurred
Permanent neurological deficit confirmed
Claim approved

Counter-example:

Robert, 55, sudden numbness left arm, difficulty speaking:

Initially thought to be stroke
Symptoms completely resolve after 3 hours
MRI shows no brain damage
Diagnosis: TIA (transient ischaemic attack)
No permanent neurological deficit
Claim declined (TIA excluded)

Multiple Sclerosis

Typical policy definition:

"A definite diagnosis of multiple sclerosis by a consultant neurologist confirmed by typical MRI findings and neurological abnormalities persisting for at least 6 months."

Requirements:

Diagnosis by specialist (neurologist)
MRI evidence
Symptoms persisting 6+ months

Example:

Emma, 38, experiencing vision problems, numbness:

MRI shows multiple lesions in brain and spinal cord
Neurologist diagnoses relapsing-remitting MS
Symptoms persist for 7 months
Further MRI confirms progression
All criteria met
Claim approved

Waiting period consideration:

Diagnosed month 1
Must wait until month 6+ to claim
Some insurers require evidence of progression or second relapse
Check specific policy wording

Step 2: Notification of Claim

Notify insurer as soon as diagnosis confirmed - don't delay.

How to Notify

Option 1: Telephone (Fastest)

Call the claims number:

Found in policy documents
Often 24/7 dedicated claims line
Speak directly with claims handler

What you'll need:

Policy number
Your name and address
Details of diagnosis
Date of diagnosis
Treating hospital/consultant name

What happens:

Claims handler opens your file
Asks preliminary questions
Explains process and timescales
Sends claim forms within 24-48 hours

Example call:

You: "I need to make a critical illness claim. I've been diagnosed with bowel cancer."
Handler: "I'm sorry to hear that. Let me help you. Can I take your policy number please?"
You: "It's L&G123456789."
Handler: "Thank you. Can you confirm your full name and date of birth?"
You: "Sarah Johnson, 15th March 1982."
Handler: "And when were you diagnosed?"
You: "Last Tuesday, 12th November, following a colonoscopy."
Handler: "Which hospital are you being treated at?"
You: "Royal Marsden Hospital. My oncologist is Dr. Michael Carter."
Handler: "Thank you Sarah. I've opened a claim for you. I'll email you claim forms today. You'll need to provide written consent for us to contact your doctors. I'll also send you information about our support services. Is there anything you need immediately?"

Option 2: Online

Most insurers now offer online claims submission:

Log into customer portal
Click "Make a claim"
Complete online form
Upload supporting documents
Receive acknowledgement immediately

Advantages:

Submit 24/7
Attach documents immediately
Automatic confirmation
Track progress online

Option 3: Via Your Adviser

If you used a financial adviser to arrange cover:

Benefits of adviser support:

They handle paperwork
Chase progress on your behalf
Ensure all information provided correctly
Act as intermediary with insurer
No cost (adviser already paid via commission)

Process:

Contact your adviser
They notify insurer on your behalf
Coordinator throughout claims process
Particularly valuable if claim complex or disputed

What Happens After Notification

Within 24-48 hours:

Claims handler assigned to your case
Acknowledgement letter/email sent
Claim forms sent (or accessible online)
Initial guidance provided

Claim reference number issued:

Use this in all correspondence
Needed when calling for updates
Helps track your claim

Step 3: Completing Claim Forms

Claim forms gather essential information about your diagnosis and circumstances.

Standard Information Required

Personal Information

Full name and address
Date of birth
National Insurance number
Contact details (phone, email)
Employment details

Policy Information

Policy number
Start date of policy
Premium payment confirmation
Any changes to policy since start

Medical Information

Diagnosis: Exact medical diagnosis
Date of diagnosis: When formally diagnosed
Symptoms: When symptoms first appeared
Treatment: Hospital, consultant, GP
Current status: Ongoing treatment, prognosis
Other medical history: Relevant health history

Consent Forms

GP records: Authorisation to access your GP records
Hospital records: Access to hospital notes and test results
Consultant reports: Permission to contact specialists
Ongoing updates: Consent for ongoing information requests

Financial Information

Other insurance: Any other critical illness or life policies
Payment details: Bank account for claim payout (if approved)

Common Mistakes to Avoid

❌ Incomplete forms - Fill in every section or write "N/A" if not applicable
❌ Delayed submission - Don't sit on forms for weeks
❌ Missing signatures - Unsigned forms will be returned
❌ Wrong diagnosis date - Provide actual diagnosis date, not first symptoms
❌ Incomplete medical details - Include all relevant information

Example: Completing Medical Information Section

Question: "Please provide details of your diagnosis."

❌ Bad answer:

"Cancer"

Why bad: Too vague. Doesn't specify type, stage, or confirming tests.

✓ Good answer:

"Invasive ductal carcinoma of the right breast, diagnosed 15th November 2024 via core needle biopsy following abnormal mammogram on 28th October 2024. Histology confirmed ER+/PR+/HER2- invasive cancer, Grade 2, Stage 2A (T2N0M0). Oncologist: Dr Sarah Matthews, Royal Marsden Hospital. Treatment plan: Lumpectomy scheduled 3rd December 2024, followed by adjuvant chemotherapy and radiation therapy."

Why good:

Specific cancer type
Exact diagnosis date
Method of diagnosis
Staging information
Treating consultant and hospital
Treatment plan

This level of detail helps claim assessor immediately understand your condition and whether it meets policy definition.

Step 4: Medical Evidence Gathering

Insurer requests medical evidence from your healthcare providers.

What Evidence Is Requested?

GP Records

What's included:

Complete medical history
Past consultations
Chronic conditions
Medication history
Referral letters
Historical health issues

Timeline: Usually available within 2-4 weeks

Purpose:

Verify diagnosis
Check for pre-existing conditions (if relevant to policy contestability)
Understand full health picture

Hospital Records

What's included:

Admission notes
Discharge summaries
Test results (blood, imaging, pathology)
Surgical reports
Treatment plans

Timeline: 3-6 weeks (hospitals often slower than GPs)

Purpose:

Confirm diagnosis
Verify severity
Check policy definition criteria met

Specialist Reports

What's included:

Consultation notes
Diagnostic findings
Staging information (for cancer)
Prognosis
Treatment recommendations

Timeline: 2-6 weeks

Purpose:

Expert confirmation of diagnosis
Detailed condition assessment
Confirm policy definition requirements

Diagnostic Test Results

Depending on condition:

Cancer:

Biopsy reports
Pathology reports
Imaging (CT, MRI, PET scans)
Staging investigations

Heart Attack:

ECG results
Cardiac enzyme/Troponin levels
Angiogram results
Echocardiogram

Stroke:

CT or MRI scans
Neurological examination findings
Evidence of permanent deficit

MS:

MRI scans showing lesions
Evoked potential tests
Spinal fluid analysis (if performed)

Your Role in Evidence Gathering

What you can do to speed up process:

Inform your doctors:
- Tell GP and consultants about claim
- Explain insurer will request records
- Provide claim reference number
Sign consent forms immediately:
- Don't delay returning consent forms
- Without consent, nothing can be requested
- Common cause of delays
Follow up with providers:
- After 2-3 weeks, call GP surgery: "Has [insurer name] requested my records yet?"
- If yes: "When will they be sent?"
- Chase hospital records department if needed
Provide copies if you have them:
- Discharge summaries
- Test results given to you
- Consultant letters
- Helps claim progress while awaiting official records

Typical Evidence Timeline

Week	Activity
Week 0	Diagnosis, claim notified
Week 1	Claim forms completed and returned
Week 1-2	Insurer sends evidence requests to medical providers
Week 2-4	GP records received
Week 3-6	Hospital records received
Week 4-8	Specialist reports received
Week 6-10	All evidence compiled, claim assessed
Week 8-12	Decision made and communicated
Week 8-13	Payment issued (if approved)

Note: This is best-case scenario. Delays in medical records can extend timeline significantly.

Step 5: Claim Assessment

Claims assessor reviews all evidence against policy terms.

What the Assessor Checks

1. Policy is Active and Premiums Current

Checks:

Policy in force on diagnosis date
All premiums paid up to date
No lapse in cover
Policy not cancelled

Example issue:

Michael's heart attack:

Diagnosed: 15th November 2024
Monthly premium due: 1st November 2024
Premium not paid (direct debit failed due to insufficient funds)
Policy lapsed on 15th November (2-week grace period expired)
Claim declined - no cover in force on diagnosis date

Prevention: Keep premiums current. Set up payment reminders.

2. Diagnosis Meets Policy Definition

Assessor compares:

Medical evidence provided
Policy definition of condition
All criteria must be met

Example:

Policy definition of heart attack requires:

✓ New ECG changes
✓ Cardiac enzyme rise
✓ Typical chest pain

Medical evidence shows:

✓ ECG: ST-segment elevation consistent with MI
✓ Troponin: Significantly elevated (850 ng/L)
✓ Patient history: Central crushing chest pain

Result: All three criteria met → Diagnosis meets definition → Claim proceeds

3. Condition Not Excluded

Checks for:

Pre-existing condition exclusions (if policy has waiting period)
Specifically excluded conditions (e.g., carcinoma in situ)
Exclusions due to non-disclosure at application

Pre-existing condition example:

Emma's cancer claim:

Policy started: 1st January 2023
Cancer diagnosed: 15th November 2024
Policy has 12-month pre-existing condition exclusion
Medical evidence shows: First GP visit for symptom was March 2022
Colonoscopy showed polyps: May 2022 (before policy started)
Polyps monitored but not disclosed on application
Question: Is this pre-existing?

Insurer's assessment:

Symptoms present before policy start
Medical investigations before policy start
Not disclosed on application
Claim declined for non-disclosure of pre-existing condition

If Emma had disclosed:

Insurer would have requested medical details at application
Likely outcome: Policy issued with exclusion for bowel conditions for 2-5 years
After exclusion period, full cover
Or: Policy declined at application stage if risk too high

Key learning: Always disclose all medical history at application, even seemingly minor issues.

4. Application Was Accurate

Assessor reviews:

Original application form
Answers to medical questions
Consistency with GP records

Looking for material non-disclosure:

Failure to disclose relevant medical history
Incorrect answers to questions
Omission of important information

Example:

Robert's stroke claim:

Policy application (2 years ago):
- Question: "Have you had high blood pressure in the last 5 years?"
- Answer: "No"
GP records show:
- Blood pressure readings consistently 150/95+ for 3 years before application
- Prescribed blood pressure medication 18 months before application
- Regular monitoring for hypertension

Insurer's position:

Clear non-disclosure of material fact
If disclosed, policy would have been loaded (higher premium) or hypertension excluded
Claim declined for non-disclosure

Robert's potential recourse:

If GP diagnosed but Robert genuinely unaware (poor communication), may argue non-disclosure wasn't deliberate
Financial Ombudsman may consider individual circumstances
Outcome uncertain

Prevention: Be thorough and honest on application. If unsure, over-disclose rather than under-disclose.

Step 6: Additional Requirements

Sometimes assessor needs more information.

Common Additional Requests

Independent Medical Examination (IME)

When required:

Large claims (£500,000+)
Unclear diagnosis from records
Conflicting medical information
Condition severity in question

What happens:

Insurer arranges appointment with independent doctor (specialist in relevant field)
Usually at their medical centre or sometimes your home
Physical examination
Review of all medical records
Doctor prepares report for insurer

Timeline: 2-4 weeks to arrange, 1-2 weeks for report

Your rights:

Can bring someone with you
Can request different location if mobility issues
Can ask for copy of report

Example:

Lisa's MS claim:

Diagnosis confirmed by neurologist
Policy requires "neurological abnormalities persisting for at least 6 months"
Lisa diagnosed 7 months ago
Records unclear on severity of ongoing symptoms
IME requested:
- Independent neurologist examines Lisa
- Confirms ongoing neurological deficits
- Report states: "Persistent right-sided weakness, impaired coordination, visual disturbances"
- Claim approved based on IME confirmation

Further Specialist Reports

Why requested:

Initial reports don't fully address policy definition
Need specialist opinion on specific aspect
Prognosis unclear

Example:

David's cancer claim:

Diagnosed with prostate cancer
Policy excludes early-stage prostate cancer (T1a/T1b, Gleason 6 or below)
Initial pathology report unclear on staging
Further report requested: Detailed pathology review by specialist uropathologist
Result: Confirms T2a staging, Gleason 7
Claim approved (doesn't meet exclusion criteria)

Telephone Interview

Purpose:

Clarify aspects of claim
Understand timeline of symptoms and diagnosis
Fill gaps in written evidence

Tips for interview:

Be honest and consistent
Don't speculate - say "I don't remember" if unsure
Have medical timeline written out for reference
Keep answers concise and relevant

Step 7: Decision Notification

Insurer communicates their decision.

Claim Approved

What you receive:

Written approval letter
Confirmation of sum assured being paid
Payment timeline (usually 3-5 working days)
Tax information (claims are tax-free)
Policy termination confirmation
Information on continued support services (if available)

Example approval letter excerpt:

"We are pleased to confirm that we have approved your critical illness claim. Following our review of your medical evidence, we can confirm that your diagnosis of invasive breast cancer meets the definition of cancer under your policy.

Payment details:

Sum assured: £150,000

Payment date: 22nd November 2024

Bank account: ****1234

Your critical illness policy will terminate upon payment of this claim. However, your life insurance policy (if separate) remains in force.

The claim payment is tax-free and does not need to be declared to HMRC..."

Next steps:

Funds typically in account within 3-5 working days
No tax implications
Policy ends (unless buyback option - see separate guide)
Life insurance continues if separate policy

Claim Declined

Reasons for decline:

Doesn't meet policy definition
- Example: DCIS (Stage 0 cancer) when policy requires invasive cancer
Pre-existing condition not disclosed
- Condition present before policy start and not disclosed
Policy not in force
- Premiums not up to date on diagnosis date
Non-disclosure at application
- Failed to reveal material medical history
Condition excluded
- Falls under specific policy exclusions

What the letter includes:

Reason for decline
Which policy term/definition not met
Evidence reviewed
Right to appeal
Next steps

Example decline letter excerpt:

"Following our review of your claim, we regret to inform you that we are unable to accept your claim for critical illness benefit.

Reason for decline: Your diagnosis of ductal carcinoma in situ (DCIS) does not meet our policy definition of cancer. Our policy requires: 'A malignant tumour characterised by the uncontrolled growth and spread of malignant cells and the invasion of tissue.'

DCIS is classified as Stage 0 breast cancer and is pre-invasive (has not invaded surrounding tissue). As such, it does not meet the requirement for invasion.

Your rights: If you believe this decision is incorrect, you have the right to appeal. Please refer to our appeals process enclosed..."

Step 8: If Your Claim Is Declined

Don't accept decline without review - many declined claims are overturned on appeal.

Understanding the Decline

First step: Understand exactly why claim was declined

Read decline letter carefully
Request full file - insurer must provide all information they hold
Identify the specific issue:
- Definition not met?
- Non-disclosure?
- Pre-existing condition?
- Missing evidence?

Gathering Counter-Evidence

If you believe decline is wrong:

Get Expert Medical Opinion

Scenario: Claim declined because diagnosis doesn't meet definition

Action:

Request second opinion from specialist
Ask specialist to address specific policy definition
Get written report confirming diagnosis meets criteria

Example:

Tom's heart attack claim declined:

Insurer says: "No typical chest pain reported"
Policy requires: ECG changes + Troponin rise + typical chest pain
Tom did have chest pain but described as "indigestion-like discomfort"
Cardiologist's report didn't use term "typical chest pain"

Tom's appeal:

Obtains report from cardiologist specifically addressing pain
Report states: "Patient's symptoms of central chest discomfort radiating to left arm are typical of myocardial infarction"
Decline overturned - chest pain was typical, just not initially described that way

Review Application for Errors

Scenario: Declined for non-disclosure

Check:

What exactly was asked on application?
What did you answer?
What insurer says you didn't disclose?
Was question ambiguous?
Did you reasonably interpret question differently?

Example:

Sarah's cancer claim declined:

Insurer: "You didn't disclose family history of cancer"
Application question: "Does anyone in your immediate family have cancer?"
Sarah answered: "No"
Insurer found: Mother had breast cancer 15 years ago
Sarah's position: Mother's cancer was 15 years ago, question used present tense ("has"), she interpreted as current diagnosis
Also: Sarah understood "immediate family" as children and spouse, not parents

Appeal: Question was ambiguous regarding:

Timeframe (current vs. historical)
Definition of "immediate family"

Outcome: Financial Ombudsman agreed question was ambiguous, overturn decline

Internal Appeals Process

Step 1: Submit Internal Appeal

Within: Usually 30-90 days of decline (check policy terms)

Include:

Cover letter:
- State you're appealing decline
- Reference policy number and claim number
- Summarise why decline is wrong
- List supporting evidence attached
Supporting evidence:
- Additional medical reports
- Expert opinions
- Clarification letters
- Any evidence addressing decline reason
Request:
- Full review by different assessor
- Reconsideration of decision

Example appeal letter:

"I am writing to appeal the decline of my critical illness claim (Policy: L&G987654, Claim: CL12345).

My claim was declined on the basis that my diagnosis of Non-ST Elevation Myocardial Infarction (NSTEMI) does not meet your heart attack definition. However, I believe this decision is incorrect for the following reasons:

Your policy definition requires 'death of heart muscle due to inadequate blood supply with new ECG changes, cardiac enzyme rise, and typical chest pain.' All three criteria were met:

ECG showed new T-wave inversion in leads V1-V4

Troponin level was elevated at 580 ng/L

I experienced typical central crushing chest pain

NSTEMI is a recognised form of heart attack involving heart muscle death

Attached is a letter from my cardiologist, Dr James Wilson, confirming my NSTEMI diagnosis and explaining how it meets your policy definition

I respectfully request that you reconsider your decline decision in light of this evidence..."

Timeline: Insurer should respond within 8 weeks

Outcomes:

Accept appeal: Claim approved and paid
Partial accept: Offer settlement (e.g., if some doubt, may offer 50-75% of sum assured)
Maintain decline: Still declined, but with more detailed explanation

Financial Ombudsman Service

If internal appeal unsuccessful:

Eligibility:

Insurer has issued "final response" letter
Or 8 weeks passed since appeal with no response
Claim within last 6 years

Process:

Submit complaint to Ombudsman:
- Free service
- Online form or written complaint
- Provide all correspondence and evidence
Ombudsman reviews:
- Independent assessment
- Reviews all evidence
- Not bound by strict policy terms (considers fairness)
- Can request additional information from both parties
Decision:
- Uphold complaint: Insurer must pay claim (+ possible compensation)
- Not uphold: Insurer's decline stands
- Partial uphold: May order partial payment

Timeline:

Simple case: 3-6 months
Complex case: 6-12 months

Success rate:

Approximately 35-40% of critical illness complaints upheld or partially upheld

Example:

Emma's multiple sclerosis claim:

Declined: Symptoms hadn't persisted 6 months at time of claim (5.5 months)
Internal appeal: Declined (insurer strictly applied 6-month rule)
Ombudsman: Considered fairness
- Emma diagnosed and claimed in good faith
- Only 2 weeks short of 6-month requirement
- Symptoms clearly permanent
- Ombudsman decision: Claim should be paid - technical breach of 2 weeks unreasonable given clear diagnosis
Insurer ordered to pay: £120,000 + £200 compensation for distress

Key point: Ombudsman considers fairness, not just technical policy compliance.

Expert Tips for Successful Claims

1. Keep Excellent Records

From diagnosis onwards:

✓ Medical appointments:

Dates and consultant names
Test dates and results
Treatment timelines

✓ Insurance correspondence:

Every letter/email from insurer
Every phone call (date, time, person spoken to, what discussed)
All forms submitted (keep copies)

✓ Medical evidence:

Discharge summaries given to you
Test results provided
Consultant letters

Why: If dispute arises, contemporaneous records invaluable

2. Respond Promptly

Insurer requests information:

Respond within stated timeframe
If need extension, request it before deadline
Don't let correspondence sit unanswered

Delays cause:

Extended claim process
Potential claim decline for non-cooperation
Frustration and stress

3. Be Honest and Consistent

In all communications:

Tell the truth
Be consistent across all statements
If you don't remember, say so (don't guess)
Don't exaggerate or minimise

Inconsistencies raise red flags:

Trigger more detailed investigations
Can jeopardise entire claim
May be interpreted as fraud

4. Get Professional Help if Needed

When to use adviser:

Claim is complex
Substantial sum assured (£250k+)
Initial decline
Medical evidence unclear
Insurer requesting lots of additional information

Adviser can:

Coordinate evidence gathering
Liaise with insurer
Present claim optimally
Appeal on your behalf
Escalate to Ombudsman if needed

Cost:

Many advisers provide claims support free (already paid via commission)
Some charge £500-£2,000 for claims support
Usually worth it for large or complex claims

5. Understand Your Policy

Before you claim:

Read policy document
Understand exact definition of your condition
Check waiting periods
Know what evidence is required

Prevents:

Claiming for non-covered condition
Disappointment from inevitable decline
Wasted time and stress

Tax Treatment of Claims

Good news: Critical illness payouts are tax-free

Income Tax

Claim payment:

No income tax payable
Not treated as income
Don't declare on tax return

Example:

Claim payout: £200,000
Income tax due: £0

Capital Gains Tax

Not applicable:

Critical illness payout is not a capital gain
No CGT implications

Inheritance Tax (IHT)

If policy in trust:

Payout outside your estate
No IHT implications
Passes directly to beneficiaries

If policy not in trust:

Payout becomes part of your estate
If you die within 7 years, may be subject to IHT
Usually not an issue as most critical illness policyholders survive and use funds

State Benefits

May affect means-tested benefits:

Universal Credit
Housing Benefit
Pension Credit
Council Tax reduction

£200,000 lump sum could disqualify you from benefits based on capital limits

Mitigation:

Spend on mortgage/debts immediately
Transfer to spouse if they need care
Set aside for specific expenses (home adaptations, etc.)
Seek benefits advice if you receive means-tested support

Using Your Payout

Once funds received, common uses:

1. Pay Off Mortgage/Debts

Most common use
Reduces financial burden during illness
Provides security for family

2. Fund Treatment

Private medical care
Experimental treatments not available on NHS
Access to specialists
Alternative therapies

3. Replace Income

If unable to work
Cover living expenses
Maintain family lifestyle

4. Home Adaptations

Wheelchair access
Stairlifts
Accessible bathroom
Ground-floor bedroom

5. Prepare for Future

Build emergency fund
Increase life insurance (if still available)
Set aside for children's education
Invest for long-term

Financial advice recommended:

Lump sum is one-time payment
Need to make it last
Tax-efficient strategies
Ensure money works for you

Summary: Keys to Successful Claim

✓ Know your policy - Understand what's covered and policy definitions
✓ Notify promptly - Tell insurer as soon as diagnosed
✓ Complete forms thoroughly - Provide all requested information
✓ Respond quickly - Don't delay replies to insurer requests
✓ Keep records - Document everything
✓ Be honest - Accuracy and consistency crucial
✓ Use support - Adviser, insurer support services, medical professionals
✓ Don't give up - Many declined claims successfully appealed

Timeline expectations:

Standard claim: 6-12 weeks
Complex claim: 3-6 months
Disputed claim: 6-18 months (with Ombudsman)

Most claims are approved:

Industry approval rate: 92-95%
Declines often for technical reasons (doesn't meet definition, excluded condition)
Many declines can be appealed successfully

Get Claims Support

Making a critical illness claim during an already difficult time can be overwhelming. Professional support can make the process smoother and improve success rates.

We Can Help:

✓ Claims guidance - Navigate the process step-by-step
✓ Evidence coordination - Help gather necessary medical evidence
✓ Insurer liaison - Communicate with insurer on your behalf
✓ Appeals support - Challenge unfair declines
✓ Ombudsman representation - Escalate to Financial Ombudsman if needed

Get expert claims support - we'll help ensure your claim is processed fairly and efficiently.

Note: This guide provides general information about critical illness claims processes. Specific policy terms and insurer procedures vary. Always check your policy documents and contact your insurer for definitive information about your specific claim.