ASK A LAWYER: Critical Illness Insurance Coverage Disputes

If an individual with Alzheimer’s is denied their critical illness insurance benefits by their insurance company, how can they fight for their rights given that one of the major symptoms of the disease is memory loss?

They should turn to a trusted friend or family member to assist them in finding expert legal assistance to determine whether they have any grounds to pursue the claim against the insurance company.

My husband, who has been diagnosed with Multiple Sclerosis, made a claim to his critical illness insurance and they denied it. The insurance policy does cover MS but they say that because he is over 60, he is no longer eligible. What gives?

A thorough review of the policy wording would be required to determine whether coverage ends at age 60. If that is the case it should be clearly set out in the policy. In the absence of such a clause, the decision should be questioned and a full explanation should be requested. If the basis of the denial still does not appear to have a contractual basis, you should consult a lawyer to review this further.

Can an insurance company deny a claim based on “material misrepresentation” if the health issue being contested is not related to the illness or injury that has prompted the claim for benefits?

Yes. People often believe that if, for example, they have been diagnosed with a form of cancer, but the alleged misrepresentation is regarding high blood pressure, that those two items seem to be unrelated and the misrepresentation appears to be irrelevant.

Claims denied based on material misrepresentation turn on the question of, firstly, whether the answer to the question was inaccurate, and secondly, whether the disclosure of the prior medical condition would have been “material” to the insurance company’s decision to issue the policy. If in doubt, contact an experienced insurance lawyer for further guidance and advice. SP


When an employee on long-term disability insurance benefits tries to return to work but fails due to the same or a related disability, they may go back on claim without having to satisfy another waiting or “elimination” period. This is called the recurrent disability provision, and its purpose is to protect employees who wish to return to work on a trial basis without having to worry about losing their benefits.

Recurrent disability provisions have time limits, and these time limits vary from policy to policy. If the disability recurs after the time limit, the claimant must file a new claim and will once again be subject to a waiting period.

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“A hero is no braver than an ordinary man, but he is braver five minutes longer.”

- Ralph Waldo Emerson