Critical Illness Insurance

Critical health insurance provides financial support for severe illnesses like cancer, heart attack, or stroke. It covers treatment costs, hospital stays, and post-recovery expenses, ensuring financial stability during health crises.
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19-March-2025

The changing lifestyle has significantly impacted on human health, resulting in critical illnesses among all age groups. A critical illness insurance policy can save you from the financial burden that may occur due to such illnesses.

Coupled with increasing healthcare expenses, tackling critical illness and its treatment has become challenging. Precisely why, having a critical illness insurance policy becomes more crucial. Critical health insurance policies not only give you financial security but also helps you focus on your treatment and recovery.

What is a critical illness insurance policy?

The policy offers comprehensive coverage against life-threatening conditions. When you opt for a critical illness policy amidst the rising medical costs, you safeguard your savings from being drained due to high treatment charges.

Most health insurance plans offer critical illness as an add-on cover with an additional premium.

A critical illness insurance policy provides financial protection against severe and life-threatening diseases such as cancer, heart attack, and stroke. It offers a lump sum payout upon diagnosis, helping you cover medical expenses, hospital stays, and even loss of income. With rising healthcare costs, this policy ensures your savings remain intact while accessing quality treatment. Many health plans offer it as an add-on cover.

Difference between critical illness insurance plans vs health insurance plans

A critical illness insurance plan provides a lump-sum payout upon the diagnosis of severe diseases like cancer, stroke, or heart attack, helping cover medical costs and income loss. In contrast, a health insurance plan covers a wide range of medical expenses, including hospitalisation and treatments, through reimbursements or cashless claims. While critical illness insurance offers financial security for life-threatening conditions, health insurance ensures ongoing medical expense coverage. Below is a comparison of critical illness insurance plans and health insurance plans:

Aspects

Critical illness insurance

Health insurance

Purpose

Provides a lump-sum payout upon diagnosis of specific critical illnesses, such as cancer or heart disease.

Covers a broader range of medical expenses, including hospitalisation, doctor visits, and preventive care.

Coverage

Covers a limited number of critical illnesses specified in the policy, offering financial support during severe health crises.

Offers comprehensive coverage for a wide range of medical expenses, including routine and emergency healthcare.

Premium

Lower in comparison to health insurance policies.

Higher as it offers extensive coverage for healthcare needs.

Pay-out

One-time lump sum payment upon diagnosis of a covered critical illness.

Reimburses actual medical expenses up to policy limits.

Policy termination

Terminates after a successful claim.

Continues to provide coverage for other illnesses and medical expenses even after a claim is made

 

What are the features of critical illness insurance plans?

Key features of critical health insurance plans include coverage for life-threatening illnesses, a lump-sum payout upon diagnosis, access to specialized medical care, and flexibility in using funds for treatment or recovery expenses.Here are some key features of critical illness insurance policy.

High coverage amount

Critical illness policy provides coverage of up to Rs. 50 lakh to give you access to the required medical treatment without worrying about expenses.

Lump sum payout

Critical illness policies usually offer a lump sum payout to the policyholder when the illness is diagnosed so that treatment charges can be taken care of.

Tax exemptions

Claim tax deductions on the premium paid for a critical illness covered under Section 80D of the Income Tax Act of 1961. Those below the age of 60 years can claim up to Rs. 25,000. Additionally, senior citizens over 60 years old can claim up to Rs. 50,000 under this section. The amounts may vary depending on the prevalent tax regime.

Easy claim processing

Critical illness insurance plans typically offer straightforward and hassle-free claim processing, allowing policyholders to access funds quickly and efficiently when diagnosed with a covered condition, ensuring timely financial support.

Waiting period

Most critical illness insurance policies include a waiting period in health insurance, typically ranging from 30 to 90 days from the policy start date. During this period, claims cannot be made. Understanding this waiting period is crucial for effective financial planning.

Loss of income

Critical illness insurance can provide financial relief for loss of income due to serious health issues. This coverage helps policyholders manage living expenses while recovering from illnesses that prevent them from working.

What are the benefits of a critical illness insurance plan?

Critical illness insurance provides financial protection by paying a lump sum upon diagnosis of serious conditions like cancer, heart attack, or stroke. This coverage helps cover medical expenses, rehabilitation costs, and loss of income during recovery, offering peace of mind and financial stability during challenging times.

  • Coverage beyond hospitalisation: Standard mediclaim policies typically cover critical illnesses only for expenses incurred during hospitalisation.. Reimbursement is limited to the costs associated with in-patient treatment. Conversely, critical illness insurance plans offer a lump-sum payment upon diagnosis of a covered critical illness. This benefit can be utilised for healthcare expenses, regardless of whether hospitalization is required.
  • Secures financial future: A critical illness diagnosis often impacts a patient's ability to maintain their previous income level due to potential physical limitations. Simultaneously, the financial burden of medical treatment increases significantly. Critical illness insurance provides a financial safeguard for families. The lump-sum payout can be used to cover medical expenses, as well as everyday living costs, ensuring financial stability during a challenging time.
  • Rising medical inflation: Advancements in medical technology, including substantial investments in specialised equipment by hospitals, have improved treatment outcomes. However, this progress, coupled with general medical inflation, has driven up the cost of healthcare, particularly for hospitalisations.

For instance, the cost of Herceptin, a medication used in breast cancer treatment, ranges from Rs. 15,000 to Rs. 54,000 per vial. Treatment often requires approximately 16 vials. Consequently, patients may incur medication expenses between Rs. 2.5 lakh and Rs. 8.6 lakh during their course of treatment.

Inclusions of critical illness insurance policy

Here are the standard inclusions under the critical illness policy:

Critical illness health insurance provides coverage for up to 50 major critical illnesses, including coronary artery bypass surgery, stroke, kidney failure, major heart conditions, and organ transplants. The sum insured varies based on the insurer and policy terms. After 30 days of diagnosis (depending on the insurer), the insured receives a lump-sum payout for medical and lifestyle expenses. Additionally, many plans also cover annual health check-ups for preventive care.

Here is the list of critical illness disease which is covered under critical insurance policy.

  • Cancer (up to a specified stage) – Covers specific stages of cancer where abnormal cell growth spreads uncontrollably, affecting tissues and organs. Coverage varies by insurer.
  • First-time heart attack – Provides financial support for the first occurrence of a heart attack caused by reduced blood supply, leading to heart muscle damage.
  • Open-heart coronary artery bypass graft – Covers surgery that improves blood flow to the heart by bypassing blocked arteries using grafts from other body parts.
  • Open-heart heart valve replacement or repair – Provides coverage for surgical procedures to replace or repair damaged heart valves, ensuring proper blood flow regulation.
  • Coma of specified severity – Covers cases of prolonged unconsciousness due to brain injury or disease, requiring life support and long-term medical care.
  • Kidney failure requiring regular dialysis – Covers end-stage kidney disease where both kidneys lose function, requiring dialysis or a kidney transplant for survival.
  • Stroke – Provides financial aid for strokes caused by blocked or ruptured blood vessels in the brain, leading to long-term disability or impairment.
  • Major organ transplant – Covers expenses related to transplants of critical organs such as the heart, liver, lungs, or kidneys due to severe organ failure.
  • Bone marrow transplant – Covers the costs of a bone marrow transplant, which is essential for treating blood-related diseases like leukemia and lymphoma.
  • Permanent limb paralysis – Provides coverage for cases where injury or illness results in irreversible loss of movement in one or more limbs.
  • Motor neuron disease (ALS) – Covers degenerative conditions affecting nerve cells in the brain and spinal cord, leading to progressive muscle weakness and loss of function.
  • Multiple sclerosis – Provides financial support for this chronic autoimmune disease that affects the central nervous system, causing mobility issues and neurological impairments.
  • Aplastic anemia – Covers bone marrow failure that leads to a shortage of blood cells, increasing the risk of infections, bleeding, and severe fatigue.
  • Bacterial meningitis – Provides coverage for life-threatening inflammation of the brain and spinal cord membranes, which can cause severe complications if untreated.
  • Loss of speech – Covers permanent loss of speech due to illness or injury affecting the vocal cords or related nerves and muscles.
  • End-stage liver disease – Provides financial assistance for irreversible liver failure, often caused by chronic liver conditions, requiring a transplant or extensive medical care.
  • Deafness – Covers complete and irreversible hearing loss in both ears, which significantly impacts communication and daily life activities.
  • End-stage lung disease – Provides coverage for severe and irreversible lung conditions that impair breathing and require oxygen therapy or a lung transplant.
  • Fulminant viral hepatitis – Covers acute and severe liver failure caused by viral hepatitis, leading to rapid deterioration and the need for urgent medical care.
  • Major burns – Provides financial support for third-degree burns covering a significant portion of the body, requiring intensive medical treatment and skin grafting.
  • Muscular dystrophy – Covers progressive muscle-wasting diseases that lead to loss of mobility and severe physical disabilities over time.

Exclusions of critical illness insurance policy

Here are the standard exclusions under the critical illness policy:

  • There is no compensation if a person dies within 30 days of diagnosis of critical illness or surgery.
  • Any critical illness developed due to smoking, tobacco, alcohol, or drug intake is not included in the policy.
  • The critical illness developed due to internal or external congenital disorder is not included in critical illness insurance.
  • Pregnancy or childbirth-related critical conditions are not covered under critical illness insurance.
  • Adventure sports injuries, self-harm, and war injuries are not included in the critical illness policy.
  • Critical illness diagnosed during the waiting period
  • Death occurring within 30 days of critical illness diagnosis or surgery
  • Illness arising from smoking, alcohol, tobacco, or drug use
  • Critical illness caused by congenital internal or external disorders
  • Conditions related to pregnancy or childbirth complications
  • HIV/AIDS-related illnesses
  • Dental care, cosmetic surgery, infertility, or hormone replacement treatments, and treatments conducted outside India

Who should buy a critical illness insurance policy?

The need for a critical illness policy

A critical illness policy is essential to protect against the financial burden of serious medical conditions like cancer, heart attack, or stroke. Such illnesses often require costly treatments and extended recovery time, during which income may be lost. A critical illness policy provides a lump-sum payout, helping cover medical expenses, daily living costs, and other financial commitments.

Who can benefit from critical illness insurance plan?

A critical illness insurance plan benefits anyone concerned about financial stability during serious health crises. It's particularly advantageous for individuals without sufficient savings or those seeking additional coverage beyond standard health insurance. This coverage ensures financial support for medical treatments, daily expenses, and other costs associated with critical illnesses, offering peace of mind during challenging times.

What documents are required for critical illness insurance?

The specific documents required for a critical illness insurance application can vary depending on the insurer and the individual's circumstances. However, some common documents typically requested include:

  • Application form: A completed and signed application form provided by the insurance company.
  • Identity proof: Documents to verify the applicant's identity, such as a passport, driver's license, Aadhaar card, or PAN card.
  • Age proof: Documents to verify the applicant's age, such as a birth certificate, school leaving certificate, or passport.
  • Address proof: Documents to verify the applicant's residential address, such as utility bills (electricity, water, gas), bank statements, or a ration card.
  • Medical history: Details of the applicant's past and current medical conditions, including any pre-existing illnesses, surgeries, hospitalizations, and medications. This may involve completing a medical questionnaire.
  • Medical reports: Copies of medical reports, diagnostic tests, and prescriptions related to any existing health conditions or recent medical evaluations. This could include reports from specialists.
  • Financial information: In some cases, insurers may request financial information to assess the applicant's ability to pay premiums. This could include income statements, tax returns, or bank statements.
  • Occupation details: Information about the applicant's occupation and nature of work, as some occupations may be considered higher risk.

A step-by-Step guide: How to choose critical health insurance

Buying any health insurance policy requires you to carefully analyse the policy details to ensure that there are no hidden fees and chargers, and you get maximum coverage at reasonable premium. Given below are the key things to remember when opting for a critical care insurance policy:

  • Inclusions and exclusions: You must go through the inclusions and exclusions of the critical illness insurance policy. There can be instances where a policy may not cover the expenses for an illness that you consider a critical health condition.
  • Calculate premium rates: When choosing a critical illness insurance plan, start by calculating premium rates based on your age, health status, and coverage amount. Compare quotes from multiple insurers to find a plan that fits your budget while providing adequate coverage.
  • Find out the covered illnesses: Review the list of covered illnesses in each plan. Ensure that the policy includes major conditions like cancer, heart attack, and stroke. Understanding what is covered helps you select a plan tailored to your specific health concerns and risks.
  • Sum insured: Consider the sum insured while checking different policy options. As the cost of treatment varies for different critical illnesses, checking the coverage amount becomes imperative before applying.
  • Claim settlement ratio: Check the claim settlement ratio in health insurance of the insurer. The ratio indicates the number of claims the insurer has settled in a year.
  • Waiting period: The waiting period is the stipulated time after which a policyholder can avail of the benefits of the insurance policy insurance policy. Check all the waiting periods mentioned in the document to be sure about when claims can be raised and will be accepted.

Tax benefits under a critical illness insurance policy

The fact that critical illness insurance offers tax benefits is an additional advantage, and you can claim tax deductions against the premium paid under the relevant sections of the prevalent tax laws.Tax benefits under a critical illness insurance policy allow you to claim deductions on premiums paid under Section 80D of the Income Tax Act, reducing your taxable income and providing financial relief while securing your health.

The deduction amount varies based on the age of the insured individual and their parents. Below is a breakdown of the maximum deduction you can avail under Section 80D:

Category

Self, spouse and dependent children

Parents

Maximum deduction U/S 80d

All insured individuals are below 60 years

Rs.25,000

Rs.25,000

Rs.50,000

Parents are 60 years or older

Rs.25,000

Rs.50,000 (including medical expenses)

Rs.75,000

Both insured individual and parents are 60+

Rs.25,000

Rs.50,000 (including medical expenses)

Rs.1,00,000

 

Importance of critical illness insurance in India

One of the most important benefits of this health insurance plan is the enhanced coverage. It covers a wide range of critical illnesses and helps the insured manage all associated healthcare expenses besides hospitalisation costs. critical illness health policy also offers a lump-sum amount that helps individuals manage healthcare costs in a better way.

How does critical illness insurance work?

Critical illness insurance, often referred to as critical illness cover, functions as a policy where the policyholder pays regular premiums to an insurance provider. In the unfortunate event that the insured individual is diagnosed with a predefined critical illness, a waiting period typically applies.

After this waiting period, the policy offers a tax-free lump-sum payout. This financial support can be utilised to cover medical expenses, debts, or any other financial obligations. The extent of critical illness policy coverage varies based on the specific critical illnesses listed in the policy.

Typically, once a successful claim is processed, the policy terminates, offering crucial financial protection alongside traditional health insurance.

Pro Tip

A comprehensive health plan not only covers hospitalization but also pre & post-treatment expenses, ensuring complete financial protection against rising medical costs.

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How to file a claim for critical illness policy?

Here is the complete process for the Claim Process for Critical Illness Health Insurance Policy:

Cashless claim

You get cashless treatment facility at the insurer’s network hospitals. Here you do not have to deal with any paperwork. The network hospital will take care of the entire claim process. You simply have to follow the below procedure.

  • Approach the network hospital with your policy details.
  • The hospital will verify your details and send a pre-authorisation form to the insurer.
  • The insurer will verify the pre-authorisation request and convey the policy coverage and other details to the hospital.

Planned hospitalisation

  • Insured members should be intimate about admission at least 72 hours before.
  • In the case of emergency hospitalisation, the insured member or his representative should report such admission within 24 hours.
  • The insurer will send you or the network hospital a pre-authorisation letter. The pre-authorisation letter, ID card issued to you along with this policy, and any other information or documentation that the insurer has specified must be produced to the network hospital identified in the pre-authorisation letter at the time of your admission to the same.
  • If the procedure above is followed, you will not be required to pay for the medical expenses above the aggregate deductible in the network hospital.
  • Original bills and evidence of treatment in respect of the same shall be left with the network hospital.

Reimbursement claim

If the insurer denies pre-authorisation under the cashless claim procedure in a critical illness insurance policy, or if the treatment is taken at a non-network hospital, or if you choose not to avail of the cashless facility, you can opt for a medical reimbursement. In such cases, you must submit the required documents, including medical bills and reports, to the insurer for reimbursement.

  • You or someone claiming on your behalf must inform the insurer in writing immediately within 48 hours of hospitalisation and gather all the hospital documents.
  • In the event of the iCritical illness insurance plan vs health insurance plan Below is a comparison of critical illness insurance plans and health insurance plans: AspectsCritical illness insuranceHealth insurancePurposeProvides a lump-sum payout upon diagnosis of specific critical illnesses, such as cancer or heart disease.Covers a broader range of medical expenses, including hospitalisation, doctor visits, and preventive care.Coverage it Covers a limited number of critical illnesses specified in the policy, offering financial support during severe health crises.Offers comprehensive coverage for a wide range of medical expenses, including routine and emergency healthcare.PremiumLower in comparison to health insurance policies.Higher as it offers extensive coverage for healthcare needs. Pay-outOne-time lump sum payment upon diagnosis of a covered critical illness. Reimburses actual medical expenses up to policy limits. Policy terminationTerminates after a successful claim. Continues to provide coverage for other illnesses and medical expenses even after a claim is madensured person’s death, someone claiming on their behalf must inform the insurer (in writing) immediately and send a copy of the post-mortem report (if any) within 30 days.
  • The insurer shall not indemnify you for any period of hospitalisation of fewer than 24 hours, except for day-care procedures.

Conclusion

Critical illness insurance offers crucial financial protection during difficult times, particularly in the event of unforeseen medical crises. It complements senior citizen health insurance plans effectively, providing comprehensive coverage for illnesses that necessitate substantial medical expenditures. Given the escalating costs of healthcare, securing appropriate insurance coverage is essential for safeguarding savings and ensuring access to quality medical care. When selecting a critical illness policy, careful consideration of the specific needs of senior citizens is paramount to guarantee adequate financial and medical support.

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Frequently asked questions

What does critical illness insurance do?

Critical illness insurance provides financial protection to individuals diagnosed with a serious illness. It pays out a lump sum to the policyholder to cover medical expenses, lost income, or any other costs related to their illness.

What are examples of critical illness cover?

Common examples of critical illness cover include cancer, heart attack, stroke, organ failure, and other life-threatening conditions. The specific illnesses covered may vary depending on the insurance provider.

What is the best critical illness insurance for you?

The best critical illness insurance policies are those that offer comprehensive coverage for a wide range of medical conditions, with reasonable premiums and flexible payment options. It is important to compare policies and providers to find the best fit for your needs.

Should we buy critical illness cover?

Critical illness cover can provide valuable financial security for individuals and families facing a serious medical diagnosis. It is worth considering for anyone with dependent family members, significant financial obligations, or concerns about covering medical expenses and lost income.

How do I buy a critical illness policy?

To buy a critical illness policy, you will need to research insurance providers and policies, compare prices and coverage options, and apply for coverage. You can typically apply directly through the insurance company or choose a policy from online insurance marketplaces. Be sure to read and understand the policy terms and conditions before purchasing.

Which is better life insurance or critical illness?

Critical illness and life insurance are two different types of insurance policies that serve different purposes. Life insurance is intended to provide financial support to your beneficiaries after your death, while critical illness insurance protects you in the event of a serious illness diagnosis. Both types of insurance can be valuable as part of a comprehensive financial plan.

What are the eligibility criteria for purchasing critical illness insurance?

To purchase critical illness insurance, individuals typically need to meet certain eligibility criteria, including being within a specified age range, generally between 18 and 65 years old, and in good health without pre-existing critical illnesses.

Do I need to undergo medical tests to avail critical illness cover?

Whether medical tests are required to avail critical illness cover depends on various factors, including your age, health condition, and the sum assured. In some cases, insurers may require medical tests to assess your health status and determine eligibility.

What is the sum insured of critical illness insurance cover?

The sum insured of critical illness insurance cover typically varies based on individual preferences and insurance providers. It can range from a few lakhs to several crores, depending on factors such as age, health status, and financial requirements.

What is critical illness cover in health insurance?

Critical illness cover in health insurance provides a lump-sum payout upon diagnosis of severe illnesses listed in the policy. It helps cover expenses beyond regular health insurance, such as treatment costs, loss of income, and lifestyle adjustments during recovery.

What are the 13 critical illnesses?

The 13 critical illnesses typically include cancer, heart attack, stroke, major organ transplant, kidney failure, coronary artery bypass surgery, paralysis, and others depending on the insurer. Each illness must meet specific criteria outlined in the policy for the claim to be valid.

What are 36 critical illnesses?

The 36 critical illnesses typically covered include conditions like cancer, heart attack, stroke, major organ transplants, kidney failure, and paralysis. The exact list may vary by insurer but usually includes severe, life-threatening diseases requiring extensive treatment and care.

Is diabetes a critical illness?

Diabetes is not usually classified as a critical illness itself, but complications arising from diabetes, such as kidney failure or heart disease, can be considered critical illnesses under some insurance policies. Always check the specific conditions covered in your policy.

Is kidney failure a critical illness?

Yes, kidney failure is classified as a critical illness. It requires life-saving treatments such as dialysis or a kidney transplant, which are often expensive. Critical illness insurance can provide financial support for managing the costs of kidney failure treatments.

How long does critical illness cover last?

Health insurance with critical illness cover provides comprehensive protection, offering a lump-sum payout for specific severe conditions like cancer or heart disease. Critical illness cover typically lasts for the duration of the policy, which can range from 10 to 30 years, depending on the insurer. It may also be part of a term insurance plan that lasts until a certain age or policy maturity.

What are the disadvantages of critical illness insurance?

The disadvantages of critical illness insurance include high premiums, limited coverage to specific conditions, and a strict claim process. Additionally, some policies may have long waiting periods and exclusions, such as pre-existing conditions or illnesses related to lifestyle habits.

How much critical illness benefit is required for an individual?

The required benefit amount varies based on individual circumstances. Consider factors like medical costs, living expenses, and income replacement needs. Aim for coverage that adequately addresses potential financial burdens during treatment and recovery.

Is it worth buying a critical illness benefit?

Yes, a critical illness benefit offers financial security against life-threatening diseases. It provides a lump-sum payout upon diagnosis, helping cover treatment costs, lost income, and other related expenses. This can alleviate financial strain during a challenging time.

Is there any medical test required before purchasing a critical illness rider?

Yes, medical tests are typically required before purchasing a critical illness rider. Insurers use these tests to assess your health and determine eligibility. The specific tests vary depending on your age, medical history, and the coverage amount.

What are the big 5 critical illnesses?

While the exact list can vary, the "big 5" often include cancer, heart attack, stroke, kidney failure, and coronary artery bypass surgery. These conditions are prevalent and often require extensive medical care, making them common inclusions in critical illness plans.

What is the waiting period for critical illness insurance?

The waiting period is the time after policy purchase before you can claim benefits. It typically ranges from 30 to 90 days. Some illnesses may have longer waiting periods. Understanding this period is crucial before relying on the policy.

Can I take multiple claims under critical illness coverage for the same disease?

No, most critical illness insurance policies provide a one-time lump sum payout upon diagnosis. Once a claim is made, the policy usually terminates unless specified otherwise in the terms.

How important is critical illness insurance?

Critical illness insurance is essential as it provides financial security against life-threatening diseases by covering medical expenses, income loss, and treatment costs, ensuring peace of mind during health crises.

Is a critical illness insurance payout taxable?

No, the payout received under a critical illness insurance policy is tax-free under Section 10(10D) of the Income Tax Act, provided the premium is paid by the insured individual.

Does critical illness insurance cover pre-existing conditions?

Most critical illness insurance policies do not cover pre-existing conditions. Insurers may exclude illnesses diagnosed before purchasing the policy or impose waiting periods before coverage begins.

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