Attempt to get away from standard Critical Illness (CI) benchmark definitions when trying to underwrite a better product, and there are going to be delays.Still, Megacorp Insurance Agencies president, Dick Gilbert says the benchmark definitions in place today have holes, and those holes get larger with every passing day – allowing more denied claims along the way – as medical advances improve diagnosis and treatment options.

His effort to launch a new group CI product with several unique features, and a stronger commitment to paying claims when they arise, took more than 19 months to develop and underwrite.

Today though, Total Living Care (TLC) is being sold to employers who want to add a CI component to their employee benefits.

“This is just a standalone, CI product,” Gilbert says. “We’re not bundled (with other benefits). The benefit is not conditional on employers buying something else, as well.”

The features include full coverage until age 70, entry into the program up to age 69, and the ability to name contingent beneficiaries, in the rare event the insured person dies before a claim is paid.

“Everyone else I’m aware of, pays it to the estate, which means fees, taxes, delays. Everything. We will let you name a contingent beneficiary.”

Features of the product also include guaranteed coverage, including coverage for those with pre-existing conditions, in groups of 50 or more. Groups of 10-49 lives have a 12-month pre-existing condition period, increased to 24-months for less than 10 members. If the plan is replacing an existing group CI plan, conditions and amounts under the previous plan can be grandfathered.

Another relatively unique element, is the addition of traumatic brain injury (TBI) to the list of covered conditions. “We did that because we have a lot of interest in supporting organisations,” Gilbert says.

Diagnosis or treatment

By comparison, Gilbert says companies are routinely denying otherwise legitimate claims, because their diagnosis or treatment is being done in a way which isn’t outlined in contract definitions.

Coronary bypass surgery, or heart valve replacement surgery, for example, today can be done using a “keyhole” technique, where surgeons repair the damage using a much smaller incision and a scope. Claims have been denied, however, because companies say the claim isn’t valid, unless open heart surgery is involved.

Similarly, suffering a heart attack in a setting more rural could conceivably result in a denied claim. “The policy stipulated that only biochemical markers would be accepted to satisfy the definition.” In the case he refers to, the patient suffered “a bona fide heart attack,” Gilbert says. “They used elevated cardiac enzyme testing to prove it – and this was in a fairly good-sized city.” Although biochemical markers might be used for testing in larger centres, he points out they’re not used universally.

“If your cottage is in Parry Sound and you’re having a heart attack, are you really going to drive all the way back to Toronto to qualify for your policy?”

Interestingly, he points out the benchmark definitions used today, are based on older European market examples – where legislators have since required companies to clean things up.

“Advances in medical technology, and medical breakthroughs will always be coming. You can’t keep updating the policy every six or 10 months,” he says. “Anytime you have a claim for one of our covered conditions, even if there is some new diagnostic testing, we’ll accept that.”