Страхование критических заболеваний: виды и условия выплат.

Critical illness insurance, otherwise known as critical illness cover or a dread disease policy, is an insurance product in which the insurer is contracted to typically make a lump sum cash payment if the policyholder is diagnosed with one of the specific illnesses on a predetermined list as part of an insurance policy. The policy may also be structured to pay out regular income and the payout may also be on the policyholder undergoing a surgical procedure, for example, having a heart bypass operation. The policy may require the policyholder to survive a minimum number of days (the survival period) from when the illness was first diagnosed. The survival period used varies from company to company, however, 14 days is the most typical survival period used. In the Australian market, survival periods are set between 8 – 14 days. The contract terms contain specific rules that define when a diagnosis of a critical illness is considered valid. It may state that the diagnosis need be made by a physician who specialises in that illness or condition, or it may name specific tests, e. g. EKG changes of a myocardial infarction, that confirm the diagnosis. In some markets, however, the definition of a claim for many of the diseases and conditions have become standardised, thus all insurers would use the same claims definition. The standardisation of the claims definitions may serve many purposes including increased clarity of cover for policyholders and greater comparability of policies from different life offices. For example, in the UK the Association of British Insurers (ABI) has issued a Statement of Best Practice which includes a number of standard definitions for common critical illnesses. There are alternative forms of critical illness insurance to the lump sum cash payment model. These critical illness insurance policies directly pay health providers for the treatment costs of critical and life threatening illnesses covered by the policyholder’s insurance policy, including the fee of specialists and procedures at a select group of high ranking hospitals up to a certain amount per episode of treatment as set out in the policy.

Typical critical illness insurance products refer to policies where the insurer pays the policyholder a pre determined lump sum cash payment if the policyholder is diagnosed with a critical illness listed in the policy. However, alternative forms of critical illness cover provide direct payment to health providers to cover the high medical costs in treating critical illnesses such as cancer, cardiovascular procedures and organ transplants. The maximum amount is set out in the insurance policy and defined per episode of treatment. These critical illness insurance products generally pay hospitals directly to avoid policyholder’s incurring out of pocket expenses and lengthy reimbursement processes. In most instances of this alternative to the lump sump critical illness insurance, policyholders may decide where they will receive treatment among a pre selected group of hospitals. Some forms of critical illness insurance also offer policyholders the option to travel to highly specialised hospitals in other countries to receive treatment. These policies usually include travel and accommodation expenses for the policyholder and a companion, as well as other concierge services such as translators or personal nurses.

Applicants are assessed for risk by a process of underwriting. Underwriting may take place in an automated underwriting computer filtering system. However the most detailed and holistic underwriting is still performed by experienced life insurance underwriters. The underwriting process for critical illness is similar to life insurance underwriting in that it takes into account factors such as age, gender, smoking status, past medical history, family history, alcohol consumption, and body mass index. In the case of critical illness however, there is an increased emphasis on family history, smoking and bodymass index are risk factors that can demonstrate a marked increase risk with respect to critical illness cover. Having underwritten an applicant in full, an underwriter can decide to accept the risk at the standard rate, or they may decide than an extra charge is warranted, or they may decide to apply exclusions of particular illnesses. If there is any amendment by an underwriter to the terms of acceptance, this has to be agreed by the applicant before the policy can proceed to issue.

In South Africa, the UK, Ireland, Australia and New Zealand, critical illness insurance has become a well established form of insurance. Critical illness insurance continues to grow in popularity and has recently been accepted into other territories including the far east and the United States. In markets where the product is newer, many insurers choose to use the expertise of reinsurers with worldwide exposure as well as overseas insurers who have sold the product for a number of years. The expertise may come in the form of data provided as well as assistance with the product design features of the product.

Critical Illness insurance, also known as Trauma Insurance in Australia is characterised by lump sum payments for listed medical events. Unlike in the United Kingdom, Trauma Insurance conditions are not standardised and market competition is based on both premium and policy definitions. It is not uncommon for an Australian Trauma Insurance policy to list 40+ definitions, including Cancer, Heart Attack, Strokes. Around 85% of Trauma Insurance claims paid in Australia are for either Cancer or Heart Disease. It is not uncommon for policies to also offer partial payments, if the condition suffered does not meet the full definition required for a full claim payout. Trauma Insurance policies in Australia are most commonly linked to life insurance policies, however can be taken as a stand alone policy and where a Trauma Insurance policy is linked, it will normally deduct the balance of the insured Life Insurance amount. Trauma Insurance policies in Australia when used to provide personal protection, are generally not tax deductible and any claim proceeds are not taxable. Trauma Insurance is not offered in Superannuation as the definitions available for payment do not always align with the required conditions of release.