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You may know that critical illness insurance covers cancer and heart attack, among several other conditions. But did you know you have to satisfy the definitions of the illnesses covered to qualify for the lump sum payment?
What are these definitions? And do they vary between insurance companies?
In this post, we provide the definitions for all 26 critical illnesses covered. So if you want to know if a specific cancer diagnosis is covered, you’re in the right place.
What Illnesses Does Critical Illness Insurance Cover?
Critical illness insurance pays you a tax-free lump sum amount if you are diagnosed with a covered condition. The benefit provides financial protection during a challenging time when your primary focus should be on recovery.
While most people are familiar with the critical illnesses of cancer and heart attack, a typical policy covers up to 26 medical conditions.
Below is a list of the 26 critical illnesses covered by most insurance policies in Canada. Some critical illness plans only cover 25 conditions, with acquired brain injury being left out.
Also, some insurance companies offer a budget friendly basic critical illness plan that only covers the four major illnesses: life-threatening cancer, heart attack, coronary artery bypass surgery, and stroke. These covered conditions account for most critical illness insurance claims. Therefore, they’re suitable for people concerned about the financial risks these critical illnesses pose but want a more affordable plan than the traditional ones.
Covered conditions |
|---|
Acquired brain injury |
Aortic surgery |
Aplastic anaemia |
Bacterial meningitis |
Benign brain tumour |
Blindness |
Coma |
Coronary artery bypass surgery |
Deafness |
Dementia, including Alzheimer’s disease |
Heart attack |
Heart valve replacement or repair |
Kidney failure |
Life-threatening cancer |
Loss of independent existence |
Loss of limbs |
Loss of speech |
Major organ failure on waiting list |
Major organ transplant |
Motor neuron disease |
Multiple sclerosis |
Occupational HIV infection |
Paralysis |
Parkinson’s disease and specified atypical Parkinsonian disorders |
Severe burns |
Stroke |
Your diagnosis must fall under the definitions below to qualify for a one-time lump sum payment. Every insurance company may define a covered critical illness differently, so read your policy carefully to ensure you understand your coverage.
Also, some covered conditions require you to satisfy a survival period before the critical illness policy pays a benefit. This can range from 30 days for medical conditions like stroke and heart attack to one year for Parkinson’s disease.
Lastly, you should note the exclusions for each covered condition. These are events that won’t result in a payout.
Acquired brain injury
Acquired brain injury means new damage to brain tissue caused by a traumatic injury, anoxia, hypoxia or encephalitis resulting in signs and symptoms of neurological impairment that:
- Are present and verifiable on clinical examination or neuro-psychological testing;
- Are corroborated by magnetic resonance imaging (MRI) or computerized tomography (CT) studies of the brain showing changes that are consistent in character, location and timing with the new damage; and
- Persist for a period of at least 180 days from the date of the new damage
No benefit will be paid under acquired brain injury for either of the following:
- An abnormality seen on imaging studies of the brain without definite related signs and symptoms
- Neurological signs occurring without symptoms or imaging abnormalities
Aortic surgery
Aortic surgery means the undergoing of surgery for disease of the aorta requiring excision and surgical replacement of any part of the diseased aorta with a graft. Aorta means the thoracic and abdominal aorta but not its branches. The survival period for aortic surgery is 30 days.
Exclusion: No benefit will be paid under aortic surgery for angioplasty, intra-arterial procedures, percutaneous transcatheter procedures or non-surgical procedures.
Aplastic anaemia
Aplastic anaemia means chronic persistent bone marrow failure, confirmed by biopsy, which results in anaemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following:
- Marrow stimulating agents
- Immunosuppressive agents
- Bone marrow transplantation
Bacterial meningitis
Bacterial meningitis is confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of diagnosis.
Exclusion: No benefit will be paid under bacterial meningitis for viral meningitis.
Benign brain tumour
Benign brain tumour means a non-malignant tumour located in the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The tumour must require surgery or radiation treatment or cause irreversible objective neurological deficits.
Exclusion: No benefit will be paid under benign brain tumour for pituitary adenomas less than 10 mm.
Blindness
Blindness means the total and irreversible loss of vision in both eyes, evidenced by either of the following:
- The corrected visual acuity being 20/200 or less in both eyes
- The field of vision being less than 20 degrees in both eyes
Coma
Coma means a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least 96 hours and for which period the Glasgow coma score must be 4.0 or less.
Exclusion: No benefit will be paid under coma for a medically induced coma.
Coronary artery bypass surgery
Coronary artery bypass surgery means the undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts.
The survival period for coronary artery bypass surgery is 30 days.
Exclusion: No benefit will be paid under coronary artery bypass surgery for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
Deafness
Deafness means the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz.
Dementia, including Alzheimer's disease
Dementia, including Alzheimer’s disease, must be characterized by a progressive deterioration of memory and at least one of the following areas of cognitive function:
- Aphasia (a disorder of speech)
- Apraxia (difficulty performing familiar tasks)
- Agnosia (difficulty recognizing objects)
- Disturbance in executive functioning (e.g. inability to think abstractly and to plan, initiate, sequence, monitor and stop complex behaviour), which is affecting daily life
You must exhibit both:
- Dementia of at least moderate severity, which must be evidenced by a Mini Mental State Exam of 20/30 or less, or equivalent score on another generally medically accepted test or tests of cognitive function; and
- Evidence of progressive worsening in cognitive and daily functioning either by serial cognitive tests or by history over at least a 6 month period
Exclusion: No benefit will be paid under dementia, including Alzheimer’s disease for affective or schizophrenic disorders or delirium.
Heart attack
Heart attack means the death of heart muscle due to obstruction of blood flow that results in the rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:
- Heart attack symptoms
- New electrocardiogram (ECG) changes consistent with a heart attack
- Development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty
The survival period for heart attack is 30 days.
Exclusion: No benefit will be paid under heart attack for elevated biochemical cardiac markers after an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves.
ECG changes suggesting a prior myocardial infarction don’t satisfy the above definition of heart attack.
Heart valve replacement or repair
Heart valve replacement or repair means undergoing surgery to replace any heart valve with either a natural or mechanical valve or to repair heart valve defects or abnormalities.
The survival period for heart valve replacement or repair is 30 days.
Exclusion: No benefit will be paid under heart valve replacement or repair for angioplasty, intra-arterial procedures, percutaneous trans-catheter procedures or non-surgical procedures.
Kidney failure
Kidney failure means chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated.
Life-threatening cancer
Life-threatening cancer means a tumour that must be characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Types of cancer include carcinoma, melanoma, leukemia, lymphoma and sarcoma.
Exclusion: No benefit will be paid under life-threatening cancer for any of the following:
- Lesions described as benign, pre-malignant, uncertain, borderline, non-invasive, carcinoma in situ (Tis), or tumours classified as Ta
- Malignant melanoma skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulc erated or is accompanied by lymph node or distant metastasis
- Any non-melanoma skin cancer, without lymph node or distant metastasis
- Prostate cancer classified as T1a or T1b, without lymph node or distant metastasis
- Papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis
- Chronic lymphocytic leukemia classified less than Rai stage 1
- Malignant gastrointestinal stromal tumours (GIST) and malignant carcinoid tumours, classified less than American Joint Committee on Cancer (AJCC) stage 2
Loss of independent existence
Loss of independent existence means the total inability to perform, by oneself, at least two of the following six activities of daily living for a continuous period of at least 90 days with no reasonable chance of recovery.
Activities of daily living are:
Bathing: the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of assistive devices
Dressing: the ability to put on and remove necessary clothing, braces, artificial limbs or other surgical appliances with or without the aid of assistive devices
Toileting: the ability to get on and off the toilet and maintain personal hygiene with or without the aid of assistive devices
Bladder and bowel continence: the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained
Transferring: the ability to move in and out of a bed, chair or wheelchair, with or without the aid of assistive devices
Feeding: the ability to consume food or drink that already have been prepared and made available, with or without the use of assistive devices
Loss of limbs
Loss of limbs means the complete severance of two or more limbs at or above the wrist or ankle joint as the result of an accident or medically required amputation.
Loss of speech
Loss of speech means the total and irreversible loss of the ability to speak as a result of physical injury or disease for a period of at least 180 days.
Exclusion: No benefit will be paid under loss of speech for all psychiatric related causes.
Major organ failure on waiting list
Major organ failure on waiting list means irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under major organ failure on waiting list, you must become enrolled as the recipient in a recognized transplant centre in Canada or the United States that performs the required transplant. For greater certainty, the date of diagnosis is the date of your enrollment in the transplant centre.
Major organ transplant
Major organ transplant means irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under major organ transplant, the insured must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow and limited to these entities.
Motor neuron disease
Motor neuron disease means one of the following, limited to these conditions:
- Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
- Primary lateral sclerosis
- Progressive spinal muscular atrophy
- Progressive bulbar palsy
- Pseudo bulbar palsy
Multiple sclerosis
Multiple sclerosis means at least one of the following:
- Two or more separate clinical attacks, confirmed by magnetic resonance imaging (MRI) of the ner vous system, showing multiple lesions of demyelination
- Well-defined neurological abnormalities lasting more than six months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination
- A single attack, confirmed by repeated MRI imaging of the nervous system, which shows multiple lesions of demyelination which have developed at intervals at least one month apart
Occupational HIV infection
Occupational HIV infection means infection with human immunodeficiency virus (HIV) resulting from accidental injury during the course of the your normal occupation, which exposed you to HIV contaminated body fluids.
The accidental injury leading to the infection must have occurred following the later of the date of issue of the policy or the effective date of last reinstatement of the policy.
Payment under occupational HIV infection requires satisfaction of all of the following:
- The accidental injury must be reported to us within 14 days of the accidental injury
- A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative
- A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive
- All HIV tests must be performed by a duly licensed laboratory in Canada or the United States
- The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States workplace guidelines
Exclusion: No benefit will be paid under occupational HIV infection if either:
- The insured has elected not to take any available licensed vaccine offering protection against HIV
- A licensed cure for HIV infection has become available prior to the accidental injury
Non-accidental injury including, but not limited to, sexual transmission or intravenous (IV) drug use doesn’t satisfy the definition of an occupational HIV infection.
Paralysis
Paralysis means total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event.
Parkinson's disease and specified atypical Parkinsonian disorders
Parkinson’s disease means primary Parkinson’s disease, a permanent neurologic condition which must be characterized by bradykinesia (slowness of movement) and either muscular rigidity or rest tremor. You must exhibit objective signs of progressive deterioration in function for at least one year, for which the treating neurologist has recommended dopaminergic medication or other generally medically accepted equivalent treatment for Parkinson’s disease.
Specified atypical Parkinsonian disorders mean progressive supranuclear palsy, corticobasal degeneration, or multiple system atrophy.
Exception: No benefit will be paid under Parkinson’s disease and specified atypical Parkinsonian disorders for any other type of Parkinsonism.
Severe burns
Severe burns mean third degree burns over at least 20% of the body surface.
Stroke
Stroke means an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source, with both:
- Acute onset of new neurological symptoms
- New objective neurological deficits on clinical examination
These new symptoms and deficits must be confirmed by diagnostic imaging testing and persist for more than 30 days following the date of diagnosis.
The survival period for stroke is 30 days.
Exclusion: No benefit will be paid under stroke for either:
- Transient ischaemic attacks
- Intracerebral vascular events due to trauma
Lacunar infarcts, which don’t have the neurological symptoms and deficits set out above and that persist for more than 30 days, don’t satisfy the definition of stroke.
Which Illnesses Pay Out A Partial Benefit?
Besides a full payout from the critical illnesses above, insurance companies also pay a smaller benefit for less severe conditions. The benefit is equal to 10% or 15% of your chosen lump sum amount up to $50,000.
The coverage amount doesn’t reduce after a partial benefit payout. For example, say you bought $100,000 of critical illness coverage. If you had one of the illnesses below and were later diagnosed with a covered critical illness that qualified for a full payout (e.g. life-threatening cancer), you would receive $15,000 first, then $100,000.
Covered conditions for partial benefits |
|---|
Coronary angioplasty |
Ductal breast cancer in-situ |
Early chronic lymphocytic leukemia |
Early prostate cancer |
Early thyroid cancer |
Gastrointestinal stromal tumours |
Grade 1 neuroendocrine tumours (carcinoid) |
Superficial malignant melanoma |
Here are the definitions as specified by the insurance policy.
Coronary angioplasty
Coronary angioplasty means undergoing an interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood.
The survival period for coronary angioplasty is 30 days.
Ductal breast cancer in-situ
Ductal breast cancer in-situ means ductal carcinoma in-situ of the breast, as confirmed by biopsy.
Early chronic lymphocytic leukemia
Early chronic lymphocytic leukemia is classified less than Rai stage 1, as confirmed by biopsy.
Early prostate cancer
Early prostate cancer means prostate cancer classified as T1a or T1b, without lymph node or distant metastasis, as confirmed by biopsy.
Early thyroid cancer
Early thyroid cancer means papillary thyroid cancer or follicular thyroid cancer, or both, that is less than or equal to 2.0 cm in greatest diameter and classified as T1, without lymph node or distant metastasis, as confirmed by biopsy.
Gastrointestinal stromal tumours
Gastrointestinal stromal tumours means tumours classified as AJCC Stage 1.
Grade 1 neuroendocrine tumours (carcinoid)
Grade 1 neuroendocrine tumours (carcinoid) means tumours confined to the affected organ, treated with surgery alone and requiring no additional treatment, other than perioperative medication to counteract the effects from hormonal oversecretion by the tumour.
Superficial malignant melanoma
Superficial malignant melanoma means skin cancer that is less than or equal to 1.0 mm in thickness, unless it is ulcerated or is accompanied by lymph node or distant metastasis, as confirmed by biopsy.
What Illnesses Does Critical Illness Insurance Cover For Children?
Children benefit from getting five more illnesses covered compared to adults. Coverage for these childhood critical illnesses last until age 25.
Covered conditions for children |
|---|
Cerebral palsy |
Congenital heart disease |
Cystic fibrosis |
Muscular dystrophy |
Type 1 diabetes mellitus |
Below are the definitions of the diagnosis you have to meet for a benefit payout.
Cerebral palsy
Cerebral palsy means a non-progressive clinical disordercharacterized by spasticity or incoordination of movements.
Congenital heart disease
Congenital heart disease means any one of the following heart defects described below:
- Total anomalous pulmonary venous connection
- Transposition of the great arteries
- Atresia of any heart valve
- Single ventricle
- Hypoplastic left heart syndrome
- Truncus arteriosus
- Tetralogy of Fallot
- Eisenmenger syndrome
- Ebstein’s anomaly
- Double outlet left or right ventricle
The following heart defects also satisfy the definition of congenital heart disease, if surgery is performed for correction of the heart defect:
- Coarctation of the aorta
- Pulmonary stenosis
- Aortic stenosis
- Discrete subvalvular aortic stenosis
- Ventricular septal defect
- Atrial septal defect
The diagnosis must be corroborated by cardiac imaging. The survival period for congenital heart disease is 30 days.
Non-surgical or trans-catheter techniques such as balloon valvuloplasty and percutaneous atrial septal defect closure don’t satisfy the definition of surgery.
Cystic fibrosis
Cystic fibrosis means a condition resulting in chronic lung disease or pancreatic insufficiency. The diagnosis must be confirmed by a positive sweat test.
Muscular dystrophy
Muscular dystrophy means dystrophy of skeletal muscles confirmed by electromyography and muscle biopsy.
Spinal muscular atrophy does not satisfy the definition of muscular dystrophy.
Type 1 diabetes mellitus
Type 1 diabetes mellitus is characterized by insulin deficiency and continuous dependence on exogenous insulin for survival.
The survival period for type 1 diabetes mellitus is 90 days from the date of diagnosis, during which there must be evidence of dependence on insulin for survival.
What Doesn't Critical Illness Insurance Cover?
Every critical illness insurance policy has exclusions where no benefit will be payable. For example, the insurance company will not cover a life-altering illness resulting from self-inflicted injuries or committing a criminal offense. What else does critical illness insurance not cover?
Does critical illness insurance cover COVID-19?
While COVID-19 is not specifically excluded from critical illness policies, it’s also not a covered condition. Therefore, a COVID-19 diagnosis will not result in a claim payout. However, the virus can cause a covered critical illness like major organ failure, heart attack, or stroke, resulting in a payable claim.
Does critical illness insurance cover mental health?
No, mental disorders are not covered by critical illness coverage. However, disability insurance can cover lost income if you can’t work because of a mental health issue.
Does critical illness insurance cover death?
Some diseases like heart attack and stroke have a survival period before the insurer pays the claim. Unless you survive this period, your critical illness insurance policy does not pay a claim. Therefore, having life insurance will ensure that your family receives a payout when you die.
Does critical illness insurance cover pregnancy?
A critical illness policy doesn’t cover pregnancy or common complications of pregnancy like gestational diabetes, depression, or anxiety.
Does critical illness insurance cover diabetes?
Type 1 diabetes is a covered condition under a child’s critical illness policy and is covered until the child turns 25. Critical illness insurance does not cover type 2 diabetes. However, the insurance company will pay a claim if complications from diabetes cause a covered critical illness like a stroke or heart attack.
What Does Critical Illness Insurance Provide for Assistance?
Besides the insurance payout, a critical illness insurance plan may also provide coverage for assistance services for no additional cost. Several telemedicine companies partner with insurers to offer their services, so chances are you’ll have access to one of them.
Teladoc Medical Experts: Formerly known as Best Doctors, this service gives you and your family access to medical experts to help you navigate your medical condition, even if it’s not an illness covered by your policy.
Mediguide: Get a second opinion from a medical specialist to verify your diagnosis and recommend the best treatment plan.
Maple: Connect with a doctor in minutes and receive advice, prescription, labs, and more.
LifeWorks: Provides professional counselling, family support services, registered dietitians, and more to help you and your family deal with the emotional impact of a critical illness.
Looking For Critical Illness Insurance Coverage?
A serious illness can put your financial plan at risk, so critical illness insurance can help protect your wealth. It will cover living expenses if you become critically ill, allowing you to focus on recovery.
Because the definitions of critical illnesses vary among the insurers, it would be a mistake to compare insurance products solely on price without consideration of the coverage. But who has time to read critical illness policies from every provider? As insurance brokers, we do the legwork for you, so you don’t have to lift a finger.
Contact us at info@briansoinsurance.com or 604-928-1628 and let us help you find the best critical illness coverage based on premium, covered conditions, and your personal situation.
Get Your Critical Illness Insurance Quote Now
While we make every effort to keep our site updated, please be aware that timely information on this page, such as quote estimates, or pertinent details about companies, may only be accurate as of its last edit day. Brian So Insurance and its representatives do not give legal or tax advice. Please consult your own legal or tax adviser. This post is a brief summary for indicative purposes only. It does not include all terms, conditions, limitations, exclusions, and other provisions of the policies described, some of which may be material to the policy selection. Please refer to the actual policy documents for complete details which can be provided upon request. In case of any discrepancy, the language in the actual policy documents will prevail. A.M. Best financial strength ratings displayed are not a warranty of a company’s financial strength and ability to meet its obligations to policyholders.
