In life insurance, critical illness insurance is a kind of insurance that people are most concerned about. The insurance period and insurance payment period are long, and the premium is not cheap, at least several thousand a year, often decades. Everyone will be more cautious about the insurance of critical illness insurance.
This also makes consumers' goodwill for critical illness insurance plummet in the case of suspected "no compensation for serious illness", and there are remarks such as "no compensation for this, no compensation for that" and "no guarantee for life". In Wu's view, when you encounter a dispute over critical illness insurance claims, don't rush to scold the insurance company, because this is really not necessarily the pot of the insurance company!
Today, I will talk about the claims of critical illness insurance, hoping to help you.
1. Let's look at a real case first.
Small, engaged in sales work. He usually goes out for drinks and business with clients. As a result, he suddenly fainted in the wine bureau and was sent to the hospital for rescue. He was diagnosed with acute myocardial infarction. Knowing that he had critical illness insurance, his family immediately reported the case to the insurance company to apply for compensation.
However, the insurance company rejected their claim.
The reason is that the critical illness insurance purchased by Xiao, for the claim of "acute myocardial infarction", at least three conditions must be met:
Xiao did not meet the terms agreed in the contract, which made it impossible to pay for the accident.
1. critical illness insurance claims standard classification
In fact, the claim for critical illness insurance is not as simple as "compensation after diagnosis". Wu Qian also wrote that taking the 25 major diseases defined by the CBRC as an example, the compensation standards for critical illness insurance can be roughly divided into three categories:
Pay immediately after diagnosis.
12 all kinds of diseases, including malignant tumors, are settled immediately after diagnosis. In other words, if the hospital diagnosis is this disease, then the insurance company will pay directly. The diagnosis certificate mentioned here refers to specialized hospitals and doctors recognized by insurance companies. After a series of scientific examinations, the examination results can be called "diagnosis certificate" by insurance companies.
An agreed payment for performing an operation
This requires that the diagnosed disease should not only meet the serious diseases agreed in the contract, but also undergo corresponding surgical treatment, both of which are indispensable.
For example, benign brain tumors can only be solved by craniotomy and radiotherapy; In other words, if it is other minimally invasive surgery, such as no craniotomy, it will not be settled; There are also major organ transplantation and hematopoietic stem cell transplantation, coronary artery bypass grafting, heart valve surgery and aortic surgery. It is necessary to meet the requirements of taking corresponding treatment in order to meet the claim conditions of the disease.
Pay only when you reach a certain state.
Eight diseases, such as "acute myocardial infarction" and "sequela of stroke", need a certain state to settle claims. Taking "sequela of cerebral apoplexy" as an example, the following criteria must be met: it is not only bleeding and embolism caused by cerebrovascular diseases, but also permanent sexual dysfunction of the nervous system. How to define this permanent nervous system dysfunction? The requirement is that 180 days after diagnosis, there is still complete loss of limb function or language, and refusal to swallow.
Another example is Xiao A in the last article, because the three conditions are not met, the change of electrogram indicates acute myocardial infarction; The insurance company refuses to pay for the increase of myocardial enzymes or other symptoms that can be "acute myocardial infarction".
1. Is it really difficult to claim for critical illness insurance?
Wu wrote 20 18 overall claims data of major insurance companies. Whether it is a big company like China Renshou Ping An or a small company that everyone has never heard of (such as Fosun and Jixiang), the odds are basically above 97%, and the time limit for claims is mostly within 2 days. The highest amount of claims is 40 billion, and the lowest is close to 1 100 million.
Some friends will say that you can't look at the overall data, and critical illness insurance is the most difficult to claim, so let's take out the critical illness insurance policy and have a look:
Sometimes consumers will worry that it is difficult to claim compensation, but it is not necessary. As long as it meets the terms, the insurance company has no reason to refuse to pay compensation.
1. What shall we do?
Tell the truth.
Before we buy insurance, there will be a health notice asking about past medical history and health status. If it meets the requirements, we can buy it directly. If it doesn't meet the requirements, we can't buy it directly We need to notify the insurance company to underwrite. If you buy after underwriting, you can get normal claims later.
If we say that we don't meet the health notice and buy directly, the insurance company will investigate our past medical records and refuse to pay for it in the future.
1. Read the insurance clauses carefully to confirm which ones are guaranteed and which ones are not.
The coverage of critical illness insurance is very clear, subject to the definition of disease in the clause. What is serious and how much compensation can be made will be written clearly. At present, 99% of the critical illness insurance on the market contains 25 kinds of legal critical illness, and the compensation standards of various companies are basically the same, and these diseases can account for 95% of the critical illness insurance compensation. If you buy a product with mild liability, I suggest you pay attention to whether it includes a high incidence of mild illness.
Besides knowing what to insure and what not to insure, it is also important. In order to avoid risks, insurance companies will definitely rule out some situations.
Usually the insured's illegal behavior, intentional crime or resisting arrest, intentional self-injury, drunkenness, fighting, taking, smoking or injecting drugs, driving without a license, drunk driving and driving without a license motor vehicles, war riots, etc. , which will be listed under "Excluded Liability".
In fact, the terms of each policy are clearly written, which has nothing to do with the brand of the insurance company, whether the price is expensive or not, and whether there are acquaintances. Wu wrote an article "What does the insurance clause say? It is no longer difficult to explain relevant terms and understand insurance clauses in vernacular! You can read the article and learn to understand the insurance clauses yourself. Don't panic.
1. Once you are in danger, report the case in time and prepare the claim materials.
Reporting the case is to let the insurance company verify the insurance accident as soon as possible, and it is also convenient for everyone to get the claim money faster. When reporting a case, it is best to prepare the insurance contract, the identity information of the insured, the cause and result of the accident and other related materials in advance to improve the reporting efficiency.
In addition to general insurance contracts, claims applications, identity documents and bank card account information, the main claims materials of different types of insurance have different requirements. For example, because medical insurance is reimbursement payment, it needs medical expense invoices and expense list details. For critical illness insurance, it is mainly the disease diagnosis certificate.
Write it at the end
In fact, as long as the health status is truthfully informed before insurance, and the disease meets the definition of the clause after insurance, the insurance company will not agree to no compensation. After all, every contract is a contract clause with legal effect and rigid payment. There are also the strictest regulatory agencies and laws in the world.
However, we can still take some measures to reduce the occurrence of claims disputes: First, we can enhance our understanding of insurance knowledge and be aware of it. Everyone usually pays more attention to Wutongjun's articles, and I believe you will soon become a small expert in insurance knowledge. Second, we can find reliable professionals or platforms to help us choose insurance, make plans and assist in claims settlement. Wutongshu Insurance Brokerage Co., Ltd. is a formal insurance brokerage institution approved by China Banking Regulatory Commission, which plans scientific insurance allocation for every family and solves worries.