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  The Basics of Critical Illness Insurance by Insureme.com  

People are living longer today. Although survival rates are on the rise for many medical conditions, a debilitating illness and the costs associated with loss of income can lead to medical bankruptcy.

In a 2007 Thomson Reuters survey, 12 percent of late-stage colon cancer patients surveyed had spent more than $25,000 out of pocket for medication alone.

More alarming is a 2008 study by the American Cancer Society and the Kaiser Family Foundation that found 20 percent of people with health insurance still can't afford cancer therapy. In fact, the survey found that a year of treatment for blood cancers such as leukemia reached $1 million in 2008, maxing out the limits of most health insurance policies.

Even with advanced medicine and a health insurance policy on your side, if you are diagnosed with a life-threatening illness, there is a possibility that you would not be able to afford the treatments recommended and needed. Critical illness insurance can help.

What does it cover?

Some medical conditions covered by critical illness insurance
Heart attack Stroke
Kidney failure Paraplegia
Organ transplant Alzheimer's disease
Blindness, deafness Multiple sclerosis
Coma Coronary artery bypass graft
HIV (medical personnel only) aortic surgery
Angioplasty heart valve surgery
Loss of sight/speech/hearing Severe burns
Cancers that have spread Cancers that have not spread

Critical illness insurance provides a payment if you experience a critical illness that is covered under the policy contract. You don't have to be disabled to collect. Unlike disability insurance, you don't have to be employed. For example, Aflac offers an individual critical illness policy that pays $5,000 if you develop a condition that is covered, with another $2,500 benefit for any recurrence.

A critical illness insurance payment is typically made in a lump sum and can be spent however you please — use the money for medical bills, a wheelchair, retrofitting your home, your mortgage or other bills, home health care or even a Hawaiian vacation. Medical conditions that qualify usually include serious injuries, diseases and major surgeries.

Critical illness insurance can be purchased several ways, including:

  • On your own as an individual policy.
  • As part of workplace benefits, either through employer-paid benefits or payroll deduction (where you pay the premiums and they are deducted from your paycheck).
  • As a supplement to a health insurance policy.
  • As a supplement to a life insurance policy.

Video on Critical Illness Benefits

Ken Smith, President of the National Association for Critical Illness Insurance and director of Assurity Life Insurance Co.'s critical illness and disability income lines, estimates that 75 percent of critical illness policies are purchased through workplace benefits.

Some insurance companies bundle critical illness coverage into categories, and you can make claims in multiple categories. For instance, one category could cover cancer-related conditions, another heart-related conditions and a third category for organ transplants, kidney failure or severe burns. You can buy a policy that pays for one category of conditions or a policy that covers all three condition categories.

Example of critical illness policy payouts
Diagnosed covered condition Category Lump-sum benefit payment
Condition: lung cancer Category 1: Cancer policy $15,000
Two years later, coronary artery bypass graft Category 2: Heart condition policy $3,750
The next year, stroke Category 2: Heart condition policy $11,250
Three years later, kidney failure Category 3: Other $15,000
Total benefit paid: $45,000
Source: MetLife

For example, if you buy a policy with multiple categories and you suffer a severe stroke that has the potential to happen again, you might receive 25 percent of the benefit amount, and the remaining 75 percent could cover another condition or a recurrence of the same condition while the policy is in force.

Critical illness insurance limits typically run from $10,000 to $1 million. Mutual of Omaha recommends purchasing a policy that covers these three factors:

  • 12 to 18 months of income.
  • Your mortgage payments for three to five years.
  • The total of your outstanding credit card debt.

Examine your policy's waiting period, also called the "elimination period," which is the time you have to wait after diagnosis before receiving the insurance payment. For most policies, if you die of the critical illness during the waiting period (and have no special rider to cover that), no benefits will be paid to you or your estate.

Before buying a policy, understand its exclusions and limitations. Typical exclusions include critical illnesses that are diagnosed during your policy's waiting period, self-inflicted injury, suicide and illegal activity. Other exclusions may include balloon angioplasty surgery, pre-malignant conditions or conditions with malignant potential, and most skin cancers.

Most critical illness policies are issued for a minimum of 2 years and a maximum of 20 to 25 years. If you are over age 65, most insurers will not sell you a policy. If you purchase a policy in your early 60s, the cost will be steep.

Scott Kreinke, Senior Vice President of Product Lines at Assurant Health, says, "The critical illness supplemental polices that we market with major medical policies typically have exclusions relative to how long it will take for the insured to get paid 100 percent of the benefit. There is usually a 90-day elimination period before it covers an illness that occurred in the first year, which is usually 50 percent of the benefit." Assurant Health sells supplemental critical illness policies only to customers who purchase major medical plans.

While individual and worksite policies are medically underwritten, meaning the price is based on your individual factors, if you buy a group plan it is considered "guaranteed issue." For group plans, the price is determined by your age and the number of people who work for the company, and no medical questions are asked. However, group plans will exclude coverage for any conditions you had before the policy took effect.

If you are buying an individual policy, you will likely have a phone interview from the insurer's underwriting department, as well as oral fluid and blood and urine tests. If you have a heart condition or family members with a heart condition, you could be required to take a medical examination, EKG, paramedical examination, treadmill electrocardiogram (TEKG) and, if you are a smoker, a chest X-ray.

Critical illness insurance is priced with several factors in mind, according to Smith. Your age, height, weight, family's health history and conditions you have now that could lead to more serious conditions are considered. An individual critical illness plan usually starts at $50 a month and goes up, depending on your age and the amount of the benefit you chose.

A group plan purchased through work can cost $4 to $5 a month, depending on your age. For example, a nonsmoking 18- to 24-year-old employee could pay $2 a month for a group critical illness insurance plan. An employee in their 40s could pay about $18 a month. Someone between age 60 to 64 could pay $46 a month for the same coverage.

When it comes to family history, you could be declined if you are a female under age 50 and who has two or more first-degree relatives who have been diagnosed with breast cancer. This can include a mother, a sister or an aunt. If you have two or more first-degree relatives who have been diagnosed with cancer, heart disease or kidney disease before the age 65, you would likely be charged more for the policy or declined, depending on the insurer.

You pay premiums until the "termination age" of the policy. The typical termination age of a policy is when the policy pays out the maximum benefit.

"If you died from a heart attack and the maximum benefit is $50,000, and the cost of treating you for a heart attack reaches the full maximum benefit, insurance would pay out the full maximum and then the policy would terminate," says Jeanne Reynolds, spokesperson for Colonial Life.

The insurance company will generally cancel policies if premiums aren't paid, if the maximum payout is made, if you die or if you request cancellation.

You won’t get your money back or a reimbursement if you cancel or if you never get sick, unless you buy a critical illness policy with a "premium return" feature. For instance, if you die during the policy's waiting period and have a return-of-premium death rider, any premium you paid will be returned to the beneficiary listed on your policy or your estate. To receive the returned premium, you cannot die from a condition or event that is excluded or that isn't defined in the policy. For example, if your policy does not cover an aneurysm, and you die from one, your family cannot take advantage of the return-of-premium death rider. If you die from an excluded illness such as skin cancer, premiums will not be refunded.

Conseco Insurance Group's 2009 study, "Supplemental Health Insurance: A Must for Americans in the Current Economy," highlights what look for in a critical illness policy:

  • Lump-sum benefits, which are paid when you are diagnosed with a common catastrophic illness.


  • Indemnity benefits, which offset the medical costs associated with hospital and ICU stays, chemotherapy, radiation and corrective or preventive surgery.


  • Premium-return feature, which returns the premium to you if you keep the coverage for a certain period of time without making a claim.


  • Transportation benefits, which help you cover the cost of travel to and from a medical center for treatment.


  • Coverage for regular diagnostic tests, such as mammograms, pap smears and colon screenings.


Learn how easy and convenient shopping for health insurance can be. Call to get your free Critical Illness quote today!

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