Why critical illness claims get declined

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How often critical illness claims are declined

Insurers publish declines as well as payments, and the difference between products is large.

Royal London shows the same pattern from a different book of business. It paid 98.4 per cent of all protection claims in 2025 and 89.3 per cent of critical illness claims.

So a critical illness claim is more than six times more likely to be refused than a life claim at the same insurer.

That is not a reason to avoid the product. It is a reason to buy it on the wording rather than the price.

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Three reasons critical illness claims are declined

1. The definition was not met

This is the largest cause and the least understood. The illness was real and the diagnosis was correct, but the policy set a severity the diagnosis did not reach.

Cancer is the clearest example. Most policies exclude some early stage and non invasive cancers, or pay a reduced percentage for them.

Stroke is the other. A transient ischaemic attack, often called a mini stroke, is usually excluded because the policy requires permanent symptoms.

Heart attack definitions normally require specific troponin readings or evidence of heart muscle damage. A cardiac event without those markers may not qualify.

2. Non-disclosure on the application

The insurer asked a medical question and the answer was incomplete. Most cases are honest forgetfulness rather than fraud.

The consequence depends on what was missed. The insurer may reduce the payment, apply the terms it would have offered, or void it entirely.

3. The claim fell outside the policy terms

A condition specifically excluded at underwriting, a policy that had lapsed, or a claim inside a waiting period.

None of these three are decided at claim stage. All of them were fixed in place when the policy started.

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Three policy definitions to check before you buy

Cancer, heart attack and stroke cause the large majority of critical illness claims. Cancer alone was 65 per cent of all critical illness claims paid across the market in 2025.

So the length of the condition list matters far less than how those three are written.

• Cancer. Check which early stage cancers are covered in full, which pay a reduced percentage, and which are excluded outright. Prostate and skin cancer wordings often vary between insurers.
• Heart attack. Check whether the definition requires a troponin level, and what level. Some insurers set a lower bar than others.
• Stroke. Check whether permanent symptoms are required, and how long after the event permanence is measured.
• Partial payments. Check whether a reduced payment leaves the rest of your cover in force. Many policies do, and it matters a great deal.
• Children's cover. Check the age range, the amount, and whether it continues through full time education.

A policy with 40 well written conditions can be worth more than one with 100 poorly written ones.

This is the part of the job an adviser actually earns. Comparison sites rank by premium, and the premium does not tell you where the line was drawn.

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How to avoid a declined critical illness claim

• Declare everything the application asks about, including investigations that came back clear.
• If you cannot remember dates, say so on the form rather than guessing or leaving it blank.
• Ask your GP surgery for a copy of your records before you apply if your history is complicated.
• Keep the completed application. It is your evidence if a claim is ever queried.
• Read the cancer, heart attack and stroke definitions and ask what happens at the edges.
• Check whether the policy pays again after a partial payment, and whether cover continues.

Nearly nine in ten critical illness claims are paid. The failures cluster in predictable places, and every one of those places is visible before you buy.

If you already hold a policy, dig out the key features document and read those three definitions. It takes ten minutes and it tells you what you actually own.

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Frequently asked questions

What percentage of critical illness claims are declined?

Aviva declined 8.7 per cent of critical illness, children's benefit and total permanent disability claims in 2025. Royal London paid 89.3 per cent of its critical illness claims in the same year, so roughly one in ten did not pay.

Why are critical illness claims refused more than life claims?

Because a critical illness claim turns on a written medical definition and a life claim turns on a death. Aviva declined 1.3 per cent of life claims in 2025 against 8.7 per cent of critical illness claims.

Does critical illness cover pay out for all cancers?

No. Most policies exclude some early stage and non invasive cancers, or pay a reduced percentage for them. The wording differs between insurers, so the cancer definition is worth reading before you buy.

Will a mini stroke be covered?

Usually not. A transient ischaemic attack normally falls outside the stroke definition because most policies require permanent symptoms. The detail varies between insurers, so check the wording.

What happens if I forgot to declare something?

It depends on what was missed and whether it was relevant. The insurer may pay in full, reduce the payment, apply the terms it would have offered, or decline. Tell your adviser as soon as you realise, because it is easier to correct before a claim than during one.

Is a policy with more conditions better?

Not automatically. Cancer, heart attack and stroke cause most claims, so how those three are defined matters more than whether the list runs to 40 conditions or 100.

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Where these figures come from

• Aviva, paying out when you need it, 2025 claims data
• Royal London, record £821m paid in protection claims, 2025
• ABI, protection insurers pay out £7.84bn, 2025 claims data

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Related reading

• Can you get cover with a health condition?
• Do life insurance companies actually pay out?
• What people actually claim for
• Critical illness cover explained
• What critical illness cover actually covers
• Income protection versus critical illness