Policy Coverage
A claimant submits a hospital indemnity claim for a 3-day stay after a routine childbirth. Does this qualify for coverage?
Yes, if childbirth is covered under the hospital indemnity policy.
A claimant submits a hospital claim for an elective procedure. Is this covered under most voluntary benefits policies?
No, elective procedures are typically excluded
What documents are required to prove a hospital stay when filing a hospital indemnity claim
A hospital bill or discharge summary
A claimant submits a claim for a broken arm sustained in a fall while hiking. The policy provides coverage for accidental injuries
Accident
A claimant is seeking benefits for a broken arm sustained during a car accident. They have accident coverage. Is this covered?
Yes, accident insurance would cover this type of injury.
A claimant files a claim after sustaining an injury during an illegal activity. The policy has an exclusion for illegal acts. Is this covered?
No, injuries resulting from illegal acts are typically excluded
A claimant files a critical illness claim for a cancer diagnosis. What documentation is necessary to support the claim?
A pathology report or physician’s diagnosis of cancer
A claimant was admitted to the hospital for 3 days due to severe pneumonia and is seeking benefits for their hospital stay.
Hospital Indemnity
A claimant submits a claim after being diagnosed with early-stage melanoma. They have critical illness insurance. Is this covered?
Yes, critical illness insurance typically covers melanoma
A claimant is hospitalized due to a drug overdose. The policy excludes substance abuse-related incidents. Is this claim covered
No, substance abuse is usually excluded
A claimant submits a disability claim. What document must be included to confirm their inability to work?
A physician’s statement certifying the disability
A claimant submits a claim after being diagnosed with stage 3 breast cancer. Their policy offers a lump sum payout for life-threatening diseases.
Critical Illness
A claimant submits a claim after being diagnosed with Type 2 diabetes. The policy covers critical illnesses but excludes non-life-threatening conditions. Is this claim covered?
No, diabetes is usually not covered under critical illness policies unless specifically stated.
A claimant submits a critical illness claim for a heart condition that was diagnosed two months before their coverage began. Their policy has a pre-existing condition exclusion. Is this covered?
No, because it is a pre-existing condition
A claimant submits an accident claim for a fractured leg. What documentation could verify the details of the accident
An incident report, medical report, or X-rays
A claimant files a claim for a severe concussion sustained while playing football.
Accident and Organized Sport Benefit if applicable
A claimant files a hospital indemnity claim after being admitted for a sleep study related to sleep apnea. Is this covered under most hospital indemnity policies
It depends on the policy, but sleep studies are often excluded unless hospitalization is medically necessary.
A claimant submits a short-term disability claim for a condition resulting from self-harm. The policy excludes intentional self-inflicted injuries. Is this covered?
No, self-inflicted injuries are typically excluded
A claimant appeals a denied claim due to insufficient proof of their illness. What additional documentation could help?
Updated medical records or a specialist’s report
A claimant submits a claim after undergoing a surgical procedure to remove a tumor, requiring a 5-day hospital stay. They are seeking benefits for both the stay and the life-threatening diagnosis
Critical Illness and Hospital