Making a Critical Illness Insurance Claim

Canadians are much more likely to develop a critical illness by age 65 than they are to die, but what do you need to do to claim on your critical illness policy?

The first step in collecting on a Critical Illness insurance policy is to contact your insurance advisor or your insurance company directly to let them you would like to file a Critical Illness claim.

Depending on the provisions of your policy, the company will let you know how long you must wait in order to collect your Critical Illness Benefit. The necessary paperwork will likely include the following.

1. A Claim Statement

How to claim benefits

You must make any claim for a payment of benefits in writing to your insurer’s provincial office or head office. The office must receive the notice of claim within 30 days of the date that a claim arises.

Within 90 days of the date a claim arises, under the contract, you must provide reasonable proof of the accident or the start of the sickness or disability and the resulting loss. You must also prove the right of the claimant to receive payment and his or her age, as well as the age of the beneficiary, if relevant.

The insurer might also ask you to explain the cause, nature, or duration of the accident, sickness, or disability for which you’re claiming a benefit under the policy.

Failure to give notice or proof

If you fail to notify the insurer of the illness, or fail to provide satisfactory proof within the time prescribed in the statutory condition, this is how the insurer will determine any benefit payable.

The insurer will pay a benefit if:

  • They determine that the insured is functionally dependent and has satisfied the waiting-period for a care benefit
  • They determine that the insured qualifies for a critical illness benefit and has satisfied the waiting period for the critical illness benefit
  • You notify them as soon as reasonably possible and within one year from the date the insured person appeared to be functionally dependent or qualified for a critical illness benefit
  • They receive satisfactory proof that it was not reasonably possible for you to give them
    notice or proof within the time prescribed

In all cases, you must provide proof of claim within one year of the date a claim arises under the

The insurer will furnish forms for proof of claim

Within 15 days of receiving a notice of claim, the insurer will send you the proof of claim forms. If you do not receive the proof of claim forms within 15 days, you may submit the proof of claim to them in a written statement that includes the cause, nature, and extent of the accident, sickness, or disability
and the resulting loss that is the basis of the claim.

Rights of examination

The insurer may require that the insured be examined while the claim is pending. In the case of the death of the insured, they may also require an autopsy (subject to any law of the applicable jurisdiction relating to autopsies). These conditions must be satisfied before they will pay a claim.

Payment of claim

The insurer will pay all benefits payable under this contract within sixty days after they have received
proof of claim.

Limitations of actions

An action or proceeding against the insurer for the recovery of a claim under this policy must begin within one year of the date the insurance money became payable or would have become payable if the
claim had been valid.

Every action or proceeding against an insurer for the recovery of insurance money payable under
the contract is absolutely barred unless commenced within the time set out in the Insurance Act or
other applicable legislation.

Provincial variations

If necessary, the provisions described will be adjusted to meet the minimum
requirements of law within the claimant’s province or territory.

Other factors to be aware of

If the policy is under two years old, or if the insurance company suspects something may be offside, the insurance company will likely scrutinize your claim more closely.

If the you are having difficulties with your Critical Illness insurance claim, you can visit our Insurance Claims Problems Page for some free advice from lawyer Andy Suboch.

LSM Insurance Tip: Make sure you keep your Critical Illness policy in a safe spot and your family knows about this policy. Some Critical Illness Insurance policies have a return-of-premium benefit if the insured passes away

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  • sritharan
    April 8, 2015 at 7:59 pm

    i had a thyroid cancer on 2012 . i am still following up the doctor. i have credit protection critical illness insurance mortgage and line off credit i make claim they paid the line of credit but they denied the mortgage insurance. they are reason i claim after 90 days . but i apply the same form with line of credit and mortgage they paid the line of credit . please advise

    • LSM Insurance
      April 9, 2015 at 7:00 am

      Thanks for the note. I would verify with the insurer why the denied the claim and ask for the response in writing.

  • SallyHuynh
    May 28, 2013 at 12:47 am

    Can you sent me a Group CII form?
    i couldn’t find it online.
    Thank you

    • LSM Insurance
      May 28, 2013 at 8:21 am

      Thanks Sally. The form would depend on the insurance company. Your group administrator, or broker should be able to get you the necessary paperwork or you can call the insurance company directly. Good luck.