Between 1960 and 2015, the average life expectancy of an American has increasedfrom 69.77 years to 78.74 years, according to World Bank. That’snearly a 10-year increase in the past 55 years! Consider themedical advancements across all kinds of conditions and treatmentsthis represents. Further, consider that there are billions andbillions of dollars poured into medical research annually. Clearly,the ways we treat patients and the way we view illness areconstantly changing, but the question is: Are insurance policieskeeping up with this rapid pace of change?

The insurance industry, by its nature, requires very specificguidelines for when and how carriers are able to pay benefits topolicyholders. And industry professionals depend on feedback frommedical practitioners to determine when and if a policyholder iseligible for benefits. But, if the language used for the policydoesn’t match the way the doctor treats the patient, it’sultimately the policyholder who suffers — and often at an alreadydifficult time.

How we treat critical illness

Critical illness insurance is, perhaps, the most relevant areato examine and determine whether policy language matches medicalpractices. With other insurance policies, such as accident,disability or life, there is a bit more of a definitive diagnosisto be made, whereas critical illness encompasses more of a grayarea.

While working on a new critical illness policy, we discovered that 63percent of critical illness claim denials are due to conditions notbeing covered or definitions not being met, according to Gen Re’sU.S. Critical Illness Insurance Market Survey. This suggests thatthere is a fairly large gulf between how a policy describes illnessand how a doctor diagnoses that illness. As we dug in and lookedcloser at this issue, our concerns were confirmed and we realizedthere were all kinds of disconnects between how policies look atillness and how doctors treat illness in the field. We choose toaddress the issues head on and help change the way the industrytakes care of customers. Here are a few examples:

Heart attack – To receive a benefit for a heartattack, many critical illness policies require that the heartattack be confirmed by the presence of enzymes in a lab test.Doctors, however, are more focused on preserving muscle tissue inthe heart and treating the condition as soon as possible. As such,lab tests are not always performed to confirm what a doctor mayalready know: that the patient has had a heart attack. This,however is a major disconnect between the medical world and theinsurance world, because a policyholder could be denied benefitswithout the lab test. So, in addition to updatingdefinitions, providing a benefit for an earlier stage of coronarydisease, such as angina, may go a long way in preventing a heartattack from ever happening.

Stroke – Medical professionals, as in the caseof heart attacks, are focused more on preserving brain tissue andreturning to pre-stroke function than simply supportive care forthe stroke patient. Thus, policies which use the presence oflong-term neurologic deficits as a basis for providing benefitsplace the policyholder who undergoes modern clot busting treatmentwith a successful outcome at a financial disadvantage. By medicalstandards, that person may have had a stroke, but because thepolicy language doesn’t match the way the doctor diagnoses andtreats the condition, the claim could be denied. Policies thatprovide a benefit for TIA, a precursor of actual stroke, may helpthe policyholder avoid the more devastating financial, emotionaland physical impact of a stroke.

Cancer – There is no such thing as a goodcancer, but some are considered worse thanothers. All types of cancers, including benign tumors and skincancers, can require treatment and pose a threat to patients.Doctors consider the cancer from the standpoint of the treatabilityof the cancer, the type of cancer and the level of danger it posesto a patient. Typical critical illness insurance, however, has muchmore rigid guidelines and the financial support a policyholderreceives may not correspond to the severity of the situation asdetermined by a doctor and experienced by the insured.Additionally, a policy which provides benefits for early and laterstages of the same cancer may help stop or slow the advancement ofthe cancer and will be there for the policyholder if and whenneeded.

How we can do better

It’s unfortunate that an insurance company can’t pay benefitsfor every illness, injury or condition. But, the insurance industrycan do a better job of ensuring that we are as closely aligned aspossible to the latest in medicine to help pay more claims. We canapply this way of thinking across the board in insurance. In sodoing, we can ensure that we are providing relevant support and notgetting too focused on technicalities based on outdated policylanguage or looking to cover outdated approaches to medicine.Taking a closer look at the way we approach policy language canhelp bridge this gap and provide better support for policyholders.Because at the end of the day, caring about them is what we’re allabout.