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How critical illness insurance claims work

Published June 2019

Making a critical illness insurance claim isn’t much more complex than any other insurance, but there’s some key points you need to know.

Critical illness insurance – also known as trauma insurance – will pay you a lump sum if you’re diagnosed with a critical illness that is defined in your policy. Payments are generally not subject to tax. 

In some cases you may only receive a partial payment for particular illnesses or injuries so make sure you know which ones these are by referring to the product disclosure statement before choosing a policy.

The lump sum payment has no restrictions on how you use it, so while it could help out with your medical bills, you could also use it to make structural changes to your home if your medical condition requires it, or to pay for a carer or support person, or anything else at all.

Unlike income protection insurance, which pays you a percentage of salary if you’re unable to work through illness or injury, critical illness insurance pays you a lump sum amount. Critical illness insurance also continues to cover you whether you are in paid employment or not, which is not generally the case for income protection insurance.

How to make a claim

In the unfortunate event you need to make a critical illness claim, you need to contact your insurer as soon as possible.

When you make contact, have your policy number ready as well as the date and details of the event that has caused you to make the claim. Your insurer will let you know what you need to do and what documents you need to provide in order to lodge your claim.

Lodging your claim

Your insurer will send you a claim form with sections that need to be completed by you and your doctor or specialist. Generally, your doctor will also need to provide a statement outlining your condition and your medical history.

Other information your insurer might require includes:

  • documents to verify the event that is causing the claim
  • proof of your identify, such as your passport or driver’s licence
  • any other documents relating to your medical history.

Be honest and upfront - if you have to change or correct your story later your insurer may have some doubts about your claim, and reject or delay processing it in order to make further inquiries. You will also need to co-operate with any specialists they may employ to assess your claim, such as a doctor or investigator.

Always confirm the next steps of the claims process with the insurance provider and the expected time of completion of those steps. This will help you to understand the timeframe involved with settling your claim.

Many insurance providers have subscribed to the FSC Life Insurance Code of Practice which contains minimum standards for handling your claim. The Code can be found at

Why might my claim be rejected?

There may be occasions when an insurer denies a claim. One reason may be because you don’t satisfy the policy’s definition of a critical illness. This is why it’s important to fully understand the circumstances under which your insurer will pay your claim.

Other reasons a claim may be denied include:

  • an exclusion applies
  • relevant information wasn’t disclosed when buying the policy
  • the claim was made within an initial exclusion period.

What to do if your claim is rejected

If your claim is denied your insurer must specify the reasons why. There are actions you can take if you are unhappy with their decision. For example, you can object and ask for your claim to be reviewed by your insurer’s internal dispute resolution body. If your claim is still denied, and you wish to take it further, you can contact the Australian Financial Complaints Authority on 1800 931 678 or

Critical illness cover offers peace of mind if you suffer a medical crisis. However, it’s important to fully understand what you will be covered for if you need to make a claim.

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This information is current as at date of publication and is subject to change.

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