Critical Illness Cover

An insurer must not turn down claims unreasonably, and must fairly assess whether a policyholder has met the policy definition of total permanent disability based on their ability to perform the material and substantial duties of their own

An insurer must not unreasonably decline a critical illness claim, and cannot rely on a pre-existing risk exclusion unless it is fairly established that the policyholder was aware of an increased risk before cover commenced.

Insurers must handle claims promptly and fairly, and must communicate clearly with claimants about timescales and processes involved.

An insurer must deal with a claim promptly and fairly and not unreasonably decline it, applying policy definitions that are clear and correctly communicated to the consumer.

An insurer must deal with claims promptly and fairly, and not unreasonably decline them; the policy requires clear medical prognosis that disability will last throughout life with no prospect of improvement.

An insurer must handle claims promptly and fairly, and should assess PTD claims based on the policyholder's ability to carry out their normal occupation as defined in the policy terms.

An insurer is entitled to reasonably request additional information from third parties to validate a claim before determining liability, provided the policyholder has given appropriate authorization.

A critical illness policy definition of 'irreversible' hearing loss requires that the condition cannot be reasonably improved by medical treatment or surgical procedures available on the NHS, not that it must be completely reversed.

An insurer can decline a TPD claim where the claimant fails to provide specialist confirmation that their disability will last throughout life with no prospect of improvement whilst still covered under the policy.

Pre-existing condition exclusions in group critical illness policies apply fairly when a condition existed (was diagnosed, treated, or known) prior to the date of policy inclusion, regardless of whether the claimant was aware of the full di

A critical illness policy can only pay out when the policyholder meets one of the specified covered conditions listed in the policy terms.

An insurer must not make material errors about policy terms and must provide fair compensation for service failures even where the underlying claim decision was correct.

A financial adviser must provide advice that balances suitable cover with the client's stated affordability constraints, and the suitability of that advice is assessed based on circumstances at the time of the sale, not with hindsight.

An insurer must assess claims fairly and promptly by reviewing medical evidence before determining liability, though it should aim to be clear about policy requirements from the outset.

Under CIDRA 2012, an insurer can apply proportionate remedies for careless misrepresentation if they would have offered the policy at different terms had the consumer disclosed all material facts.

Under CIDRA 2012, a consumer must take reasonable care not to make a misrepresentation when taking out insurance, and an insurer can refuse a claim if the misrepresentation is qualifying and the consumer failed to meet the reasonable care s

Under CIDRA 2012, an insurer may unwind a policy from inception if the consumer failed to take reasonable care when answering health questions, resulting in a qualifying misrepresentation.

A critical illness policy only pays out when the policyholder is diagnosed with a condition that meets the policy's definition; a misdiagnosis that is later corrected does not trigger a valid claim if the final confirmed diagnosis is not co

An insurer may cancel a policy following a discussion about overinsurance if the policyholder is given clear information about which policy is being cancelled and the option to seek independent advice.

An insurer must assess claims according to the definition of total and permanent disability specified in the policy schedule, which cannot be changed or substituted after policy inception.