Which Illnesses Does Critical Illness Insurance Cover?

Common Critical Illness Insurance Claims

According to Aviva, the top seven reasons for making a Critical Illness Insurance claim on one of its policies in 2017 were:

• Cancer
• Heart attack
• Stroke
• Multiple sclerosis
• Benign brain tumour
• Coronary artery bypass graft
• Heart valve replacement / repair.

However, these are all very broad terms for specific critical health events. It’s important when you take out a policy that you do so fully informed, knowing what is and isn’t covered.

For instance, not every incidence of cancer will be covered – lower grade, in-situ cancers (i.e. those that have not spread) may not always be covered.

Below we explore the definitions of these seven critical illnesses to help you understand what will and won’t be covered if you ever, unfortunately, need to make a claim.

Behind the Illnesses: Critical Illness Definitions Explained

As mentioned, when you’re diagnosed with a critical illness you’ll need to be diagnosed with a specific form of that illness. It will also have to be of a specific severity to make a claim.

Below we’ve laid out the top seven critical illnesses that made up the bulk of Aviva’s 2017 claims and provided the definitions of those illnesses to provide a better idea of the circumstances under which you’ll be able to claim.

Cancer

The Jargon

Any malignant tumour positively diagnosed by histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue.

‘Malignant tumours’ includes cancers such as leukaemia, sarcoma and lymphoma (except cutaneous lymphoma confined to the skin).

The following cancers are excluded:

• Pre-malignant cancer
• Non-invasive cancer
• Cancer in-situ
• Cancer with borderline malignancy
• Cancer with low malignant potential
• All tumours of the prostate unless histologically classified as having a Gleason score of 7 or above, or having progressed to at least TNM classification T2bN0M0
• Any skin cancer (including cutaneous lymphoma) other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer later of skin) unless the skin cancer has been confirmed as malignant and has spread to the lymph nodes or distant organs.

What This Means…

• Malignant: Malignant tumours are those which have no self-limit to their growth, are capable of invading into adjacent tissues and are potentially able to spread to more distant tissues.
• Tumour: An abnormal growth of tissue, whether benign (non-cancerous) or malignant.
• Histological: Histology is the scientific, microscopic analysis of tissue.
• Leukaemia: Cancer of the blood and bone marrow.
• Sarcoma: A malignant tumour of connective tissue.
• Lymphoma: A type of cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body.
• Cutaneous lymphoma: A rare type of lymphoma that affects the skin.
• Cancer in-situ: A group of abnormal cells that has not spread beyond where they first formed.
• Gleason score: A Gleason score is a way to grade prostate cancer. A score of 6 is low grade, 7 is intermediate grade, and a score of 8 to 10 is high grade cancer.
• TNM classification T2bN0M0: TNM stands for tumour, node, metastasis. It’s another way of grading prostate cancer. T2bN0M0 is a stage on that grade.

Heart Attack

The Jargon

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 changes
• The characteristic rise of cardiac enzymes or troponins.

The evidence must show a definite acute myocardial infarction.

For the above definition, the following are not covered:

• Other acute coronary syndromes
• Angina without myocardial infarction.

What This Means…

• Death of heart muscle: During a heart attack, the blood supply to the heart is interrupted and as a result the muscle (the myocardium) starts to die.
• Acute myocardial infarction: Myocardial infarctions are commonly known as heart attacks. This occurs when blood flow decreases or stops to a part of the heart, often as a result of a blood clot blocking important blood vessels, damaging the heart muscle.
• Electrocardiographic: Electrocardiography is a recording of the electrical activity of the heart using electrodes placed on the skin.
• Cardiac enzymes or troponins: When the heart becomes damaged, troponin is released into the blood. This is elevated in the blood within 3 or 4 hours after injury and may remain elevated for 10 to 14 days.
• Other acute coronary syndromes: Acute coronary syndrome describes a range of conditions associated with sudden, reduced blood flow to the heart, of which heart attack or myocardial infarction is the only one covered by this definition.
• Angina: Chest pain caused by reduced blood flow to the heart. Excluded unless a heart attack is also present.

Stroke

The Jargon

The death of brain tissue due to inadequate blood supply or haemorrhage within the skull resulting in either:

• Permanent neurological deficit with persistent clinic symptoms; or
• Definite evidence of brain tissue death or haemorrhage on a brain scan; and
• Neurological deficit with persistent clinical symptoms lasting at least 24 hours.

For the above definition, the following is not covered:

• Transient ischaemic attack
• Death of tissue due to optic nerve or retina / eye stroke.

What This Means…

Death of brain tissue: When a stroke occurs, blood supply to an area of the brain is cut off or restricted, resulting in brain tissue dying

• Haemorrhage: The escape of blood from a ruptured blood vessel
• Permanent neurological deficit: A permanent neurologic deficit refers to a permanent abnormal function of a body area due to weaker function of the brain resulting from tissue death. Examples include:
  • Abnormal reflexes
  • Inability to speak
  • Loss of balance
  • Vision changes
  • Walking problems
  • Weakness of the arms or legs.
• Transient ischaemic attack: Commonly known as a ‘mini-stroke’, this involves a temporary cutting off of the blood supply to an area of the brain where the blood supply is later restored. Symptoms typically last minutes to hours rather than becoming permanent and are usually resolved within 24 hours.
• Eye stroke: Caused by poor circulation in the blood vessels that supply the front portion of the optic nerve, essentially a bundle of nerve fibres and blood vessels that connects the brain to the eye.

Multiple Sclerosis

The Jargon

Where there have been symptoms and you’ve received a definite diagnosis of multiple sclerosis from a consultant neurologist. There must have been clinical impairment of motor or sensory function caused by multiple sclerosis.

What This Means…

• Multiple sclerosis: A condition that can affect the brain and spinal cord, causing a wide range of potential symptoms that includes problems with vision, arm or leg movement, sensation or balance.
• Neurologist: A doctor specialising in diagnosis and treatment of conditions affecting the brain and nervous system.
• Impairment of motor or sensory function: Motor impairment is partial or total loss of function of a body part that includes lack of muscle control or total paralysis.

Benign Brain Tumour

The Jargon

A benign brain tumour that results in permanent symptoms or requires invasive surgery.

A non-malignant tumour or cyst originating from the brain, cranial nerves or meninges within the skull, resulting in permanent neurological deficit with persisting clinical symptoms or requiring invasive surgery.

For the above definition, the following are excluded:

• Tumours of the pituitary gland
• Tumours originating from bone tissue
• Angioma and cholesteatoma.

What This Means…

• Benign tumour: In contrast to a malignant tumour, which is cancerous and has the ability to invade nearby tissue and / or spread to other parts of the body, a benign tumour is a mass of unusual cells but without the characteristics of a malignant tumour that would allow it to spread throughout the body.
• Brain cyst: A fluid-filled sac that forms in the brain.
• Cranial nerves: A group of ten nerves that emerge directly from the brain (including the brainstem).
• Meninges: The membranes that cover the brain and spinal cord.
• Permanent neurological deficit: Refers to a permanent abnormal function of a body area due to weaker function of the brain. This may be because the cyst or tumour is blocking the correct flow of cerebrospinal fluid through the brain. Examples include:
  • Abnormal reflexes
  • Inability to speak
  • Loss of balance
  • Vision changes
  • Walking problems
  • Weakness of the arms or legs.
• Pituitary gland: A tiny gland about the size of a pea that sits just behind the nasal cavity and is responsible for producing a variety of hormones, or stimulating the production of a variety of hormones, that travel around the body controlling many different bodily functions. Despite its location and attachment to the brain, many experts regard it as separate from the brain and thus do not class pituitary tumours as brain tumours.
• Angioma: A cluster of abnormal blood vessels, often found in the brain and spinal cord.
• Cholesteatoma: An abnormal but non-cancerous skin growth that can develop in the middle section of your ear, behind the eardrum.

Coronary Artery Bypass Graft

The Jargon

The undergoing of surgery on the advice of a consultant cardiologist to correct narrowing or blockage of one or more coronary arteries with bypass grafts.

What This Means…

• Coronary artery bypass graft: Over time, the major blood vessels leading to the heart can become clogged or narrowed with fatty deposits known as plaques. This can reduce vital bloody supply and therefore oxygen to the heart. A coronary artery bypass graft is a surgical procedure that involves taking a blood vessel from another part of the body (usually the chest, leg or arm) and attaching (‘grafting’) it above and below the narrowed / blocked section of a blood vessel leading to the heart to improve blood flow.
• Cardiologist: A doctor specialising in diagnosis and treatment of conditions involving the heart and circulatory system.
• Coronary arteries: Major blood vessels that carry blood to the heart muscle, allowing it to continue to function.

Heart Valve Replacement / Repair

The Jargon

The undergoing of surgery on the advice of a consultant cardiologist to replace or repair one or more heart valves.

What This Means…

• Heart valves: There are four major valves in the human heart. These normally allow blood to flow in only one direction through the heart, opening and closing depending on the difference in blood pressure on either side of the valve. Sometimes these valves cease to function correctly and allow either regurgitation (the incorrect back flow of blood through the heart) or suffer from stenosis, when a valve is narrow and restricts blood flow. Both can result in the need for surgical intervention to repair or replace a valve.

Do I Need Critical Illness Insurance or Income Protection?

While Critical Illness Insurance will pay out a tax-free lump sum if you suffer from a critical illness, there are some limitations on this.

As outlined above, you need to become ill with a specific type and grade of critical illness to make a claim.

This means, for example, that some less serious cases of cancer are not covered. Another example is the case of a transient ischaemic attack or mini-stroke, which isn’t covered under the definition of stroke.

Critical Illness Insurance also demands that the illness be critical by the very nature of the policy.

As such, this means that less serious conditions simply aren’t covered because they don’t meet the definition of being ‘critical’.

With Income Protection, on the other hand, there’s no requirement for the illness to be critical in order to make a claim. The only barrier to claiming is whether or not the illness has prevented you from working for longer than your chosen deferred period.

Providing this is the case, you can make a claim on an Income Protection policy, which will be paid in the form of an ongoing monthly income. The best policies will continue to pay out for as long as you need it, right up until retirement if necessary.

Musculoskeletal claims (including bad backs) and mental health problems make up the majority of claims when it comes to Income Protection. While these conditions are by no means critical, they can nonetheless be debilitating and prevent you from working.

Difference Between Income Protection and Critical Illness Cover

Income Protection Claims Statistics

Below is a chart compiled from The Exeter’s 2017 claims statistics for Income Protection.

As you can see, nearly half of claims are made up of musculoskeletal issues and back pain, with a further 7% made up of mental health problems.

Neither of these are deemed ‘critical’ as defined by a Critical Illness Insurance provider yet clearly result in many successful Income Protection claims each year.

Expert Critical Illness Insurance Advice

As you can see, there are lots of factors to consider when you’re looking at Critical Illness Insurance.

You need to carefully examine not just the number of critical illnesses covered but also the definitions of those illnesses and understand how these definitions will work should you need to make a claim.

We have access to an industry-exclusive tool that allows us to ‘rank’ Critical Illness Insurance policies based on which ones are the most likely to pay out for an individual in your demographic, allowing us to tailor advice to your needs.

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