How to make a critical illness insurance claim in Canada

To make a critical illness claim, contact your insurer or advisor, then send three things: your own claimant statement, an attending physician statement from your doctor or specialist, and an authorization that lets the insurer collect your medical records. The insurer checks the diagnosis against the policy’s definition of the condition, waits out any survival period, and pays the benefit as a lump sum. How long it takes depends mostly on how quickly your medical records arrive. Your ability to work is not a factor. How the coverage works is in our critical illness insurance guide.

Step by step

1. Start the claim. Call your insurer or your advisor, or use the insurer’s claim page. Claim forms are usually available to download.
2. Complete the claimant statement. This is your part of the claim: your details, the condition, and the dates.
3. Have your doctor complete the attending physician statement. A specialist usually needs to confirm the diagnosis. The insurer will ask for supporting reports, such as the pathology report for cancer, or ECG, lab and angiography results for a heart attack. You usually pay any fee the doctor charges for completing the form; the insurer may pay fees for hospital and specialist records it requests.
4. Sign the authorization so the insurer can collect your medical records directly.
5. Talk to the claims specialist. Many insurers call to review the claim; one says its claim specialist will contact you within 10 business days.

The claim can be made by you, the policy owner, a beneficiary entitled to claim, or someone acting for any of them. If you cannot sign, a person holding your power of attorney for property can usually sign for you.

Deadlines

For individual accident and sickness policies, provincial insurance law in Ontario, British Columbia and Alberta sets statutory conditions: give written notice of the claim within 30 days and proof of claim within 90 days. If that was not reasonably possible, the claim still counts if you give notice and proof as soon as you reasonably can, and no later than one year after the claim arose. The insurer must send claim forms within 15 days of notice, and pay within 60 days of receiving proof.

Quebec’s Civil Code has similar rules: written notice within 30 days of becoming aware of the illness and the information within 90 days, with a late claim accepted only if acting on time was impossible and the information reaches the insurer within one year. The insurer must pay within 60 days of receiving the required proof.

Your contract explains how these deadlines apply to it, and some insurers close a file if the claim forms are not returned within 90 days, though they will still consider a late claim with a good reason for up to a year. Outside Quebec, group and creditor coverage are not covered by these statutory conditions and follow their own terms, which can be as short as 90 days, so check your certificate. Start the claim as soon as you can, even if the survival period has not ended yet.

Why some claims take longer

• The survival period. For conditions such as heart attack and stroke, you must survive a set period, usually 30 days, before the benefit is payable. For surgeries, it runs from the surgery.
• Medical records. The industry’s consumer guide notes that the decision time depends mostly on how quickly doctors and hospitals respond.
• The first two years. If the diagnosis comes within two years of the policy starting or being reinstated, the insurer will usually review your application against your medical records, because it can contest the policy for non-disclosure in that period.

One major insurer says most claims on coverage bought through an advisor, across all its products, are settled within a month, and claims that need more information take longer. Keep paying premiums while the claim is reviewed so the policy stays in force; some insurers refund the premiums paid while the claim was being reviewed if it is approved.

When the claim is paid

The benefit is paid as a lump sum, usually by cheque or direct deposit, to the policy owner or a named payee. A full claim usually ends the critical illness policy, while a partial benefit for an early-stage condition usually does not. On a policy you own personally, the benefit is generally received tax free. If your insurer were to fail, Assuris guarantees you keep up to $250,000 of a critical illness benefit or 90 percent of it, whichever is higher.

If your claim is denied

1. Get the reasons in writing. Common reasons include a diagnosis that does not meet the policy’s definition, the 90 day cancer exclusion, and non-disclosure on the application. Our guide to whether critical illness insurance is worth it covers them.
2. Send new information. Updated test results or a specialist’s opinion can change the outcome. Some insurers set a deadline for this, such as 90 days.
3. Use the insurer’s complaint process until you receive its final position in writing.
4. Go to the OmbudService for Life and Health Insurance. It is free. You can usually go to it once you have the insurer’s final position, or if the insurer has not responded within 90 days. It aims to finish its review within 120 days. Its recommendations are not binding, but it reports that insurers have accepted its senior-level recommendations. In Quebec, you can also ask the insurer to transfer your complaint file to the Autorité des marchés financiers, which may offer mediation or conciliation.
5. Watch the time limit for going to court. In Ontario it is generally two years from when you knew you had a claim; in British Columbia and Alberta it is two years from when you knew or ought to have known of the illness, which can be well before any denial; and in Quebec it is generally three years. Other provinces have their own limits. A complaint does not automatically stop that clock, so get legal advice before it runs out.

Frequently asked questions

How do I make a critical illness insurance claim?

Contact your insurer or advisor to start the claim, then complete the claimant statement, have your doctor or specialist complete the attending physician statement, and sign an authorization so the insurer can collect your medical records. For cancer, the insurer will want the pathology report.

How long do I have to file a critical illness claim?

Under provincial insurance law for individual policies, you must give written notice within 30 days and proof of claim within 90 days. If that was not reasonably possible, act as soon as you can, and no later than one year. Group and creditor coverage follow their own terms, which can be shorter, so check your policy and act early.

How long does a critical illness claim take?

It depends mostly on how quickly doctors and hospitals provide records. Any survival period must pass first, and claims within the first two years of the policy can take longer because the insurer reviews the application against your medical records.

Do I keep paying premiums while my claim is reviewed?

Yes, keep paying them so the policy stays in force. Some insurers refund the premiums paid while the claim was being reviewed if it is approved.

What can I do if my critical illness claim is denied?

Ask for the reasons in writing, send any new medical information, and use the insurer’s appeal or complaint process. If you are still not satisfied, the OmbudService for Life and Health Insurance reviews complaints for free, and in Quebec you can also ask for your file to go to the Autorité des marchés financiers. Watch the legal time limit for going to court, because a complaint does not automatically pause it.

What to do next

If you bought your coverage through an advisor, contact them before you start: an advisor can help you gather the right documents and follow up with the insurer. If you are shopping for coverage, the claim rules are worth reading before you buy.