Critical Illness Insurance: Does It Cover Congenital Diseases?

According to the World Health Organization’s definition , congenital conditions refer to structural or functional abnormalities that exist before or at the time of an infant’s birth, such as congenital heart disease, congenital metabolic disorders, congenital hearing or vision defects, cleft lip and palate, Down syndrome, incomplete organ development, abnormalities, or deformities .

Depending on the type and severity of the congenital condition, it can be discovered and diagnosed before the infant’s birth, at birth, or even a few days to several months after birth.

Known causes of congenital conditions

Genetics, chromosomal abnormalities, genetic mutations, viral infections, radiation exposure, environmental pollution, maternal illness, or malnutrition.

Many want to know whether CI insurance can cover congenital conditions.

How Do I Know If Congenital Condition is a Critical Illness?

Critical illness insurance is specifically designed for serious diseases, and its compensation conditions require the insured to be diagnosed with the specified serious diseases or medical conditions listed in the policy for the insurance company to provide compensation.

Therefore, the primary condition is whether the relevant congenital condition is one of the specified critical illnesses covered in the policy.

If a critical illness policy states that compensation is available for heart failure or severe heart disease, but the insured’s congenital condition discovered after purchasing the policy is an arrhythmia that has not led to serious heart problems, then the insured would not be eligible for CI insurance compensation.

What Factors Cause Unsuccessful Claims for CI Insurance?

Conditions or medical situations known before the policy takes effect are generally excluded from coverage. This is to maintain fairness among all policyholders and prevent abuse of insurance compensation by those with pre-existing conditions.

However, if the insured’s congenital condition showed no signs or symptoms before purchasing CI insurance, and they were unaware and reasonably should not have been aware of it, the insurance company will generally provide compensation.

What is Waiting Period / Survival Period ?

Waiting period

Generally 30 days to 1 year after the policy takes effect. Compensation claims are only considered by the insurance company after the waiting period has passed, regardless of whether the diagnosed condition is a congenital one.

Survival Period

Generally 14 to 45 days after diagnosis, requiring the insured to survive for the specified period after being diagnosed with the critical illness to be eligible for compensation.

For example, in Bowtie’s term CI insurance series, the “waiting period” is 90 days after the policy takes effect, and there is no “survival period” clause in the policy.

Conclusion

Whether the compensation claim is ultimately approved depends on the policy terms of the underwriting insurance company.

You are advised to read through the policy before signing and should inquire in detail with the insurance company or intermediary.

Traditional medical insurance or voluntary medical insurance generally do not provide targeted coverage for congenital diseases diagnosed in children before the age of 8.

Bowtie has launched Bowtie Children’s Growth Term CI (BBCI) , providing Hong Kong’s first coverage for congenital genetic diseases, filling the gap in existing medical insurance.

This product covers 76 genetic, congenital, and childhood diseases diagnosed in Hong Kong:

• Covered genetic diseases include: severe maple syrup urine disease, severe classic congenital adrenal hyperplasia, and Angelman syndrome , among others
• Covered congenital and childhood diseases include: severe hemophilia, cancer, benign brain tumors, Kawasaki disease with heart complications, rheumatic heart valve disease, severe autism # , and severe attention deficit hyperactivity disorder # , among others
• Coverage includes pregnant mother complications and newborn medical conditions , such as various pregnancy complications (like amniotic fluid embolism and preeclampsia ), as well as phototherapy for severe newborn jaundice *

Patients with congenital diseases can generally apply for CI insurance, but depending on the type and severity of the condition, the insurance company may make the following arrangements:

• List the congenital disease and its complications as Exclusions in the policy
• Charge the applicant additional premiums (commonly known as Loading )
• List the congenital disease and its complications as Exclusions in the policy and charge additional premiums
• Decline coverage (for more severe congenital diseases or conditions)

Patients should adhere to the principle of utmost good faith by accurately and thoroughly reporting their medical history and health status to the insurance company. This helps avoid disputes during future claims.