1. Core Clauses: What’s Covered vs. What’s Not?
1.1 Coverage Scope: What Does the Policy Cover?
Different insurance types focus on distinct protections:
| Policy Type | Primary Coverage | Typical Claim Scenario |
|---|---|---|
| Critical Illness | Specified major illnesses (e.g., cancer, heart attack) | Lump-sum payout upon diagnosis |
| Medical Insurance | Hospitalization/outpatient costs (reimbursement-based) | Surgery/medication expense reimbursement |
| Accident Insurance | Accidental death/disability + medical expenses | Payout for car crash injuries or fatalities |
| Life Insurance | Death/total disability (regardless of cause) | Financial support for families after loss |
Key Points:
Critical Illness: Not all severe diseases are covered—only those meeting policy definitions (e.g., cancer requires pathological confirmation).
Medical Insurance: Only reimburses "reasonable and necessary" costs (e.g., ICU fees covered, but nutritional supplements excluded).
1.2 Exclusions: What’s Not Covered?
All policies have exclusions. Common exclusions include:
Critical Illness/Medical Insurance:
Pre-existing conditions (if undisclosed).
Congenital diseases (e.g., congenital heart disease).
Illnesses/injuries from drug use, drunk driving, or suicide.
Accident Insurance:
Sudden death (unless added via rider).
High-risk activities (e.g., skydiving, unless specified).
Life Insurance:
Suicide within 2 years of purchase (standard exclusion).
Case Example:
A claim for "herniated disc hospitalization" was denied because the policy excluded "degenerative spinal conditions."
How to Avoid Issues:
✅ Scrutinize the "Exclusions" section before purchasing.
✅ Consult professionals to confirm coverage aligns with your needs.
2. Critical Details That Impact Claims
2.1 Disease Definitions (Critical Illness Policies)
28 Standard Major Illnesses: All critical illness policies must cover these with identical definitions (e.g., cancer, post-stroke conditions).
Mild/Moderate Conditions: Vary significantly by insurer. Pay attention to:
High-frequency conditions (e.g., coronary stents, mild strokes).
Claim criteria: Some require "surgery performed," others only "diagnosis."
Example Comparison:
| Condition | Insurer A | Insurer B |
|---|---|---|
| Mild Stroke | Symptoms persist for 180 days | Symptoms persist for 90 days |
| → Insurer B’s terms are more lenient. |
2.2 Deductibles (Medical Insurance Thresholds)
Standard Plans: Often have ¥10K deductibles (only amounts above ¥10K post-social insurance are reimbursed).
Premium Plans: May offer ¥0 deductibles (higher premiums).
Choosing Wisely:
Healthy young adults: Opt for higher deductibles (lower premiums).
Elderly/frail individuals: Consider ¥0 deductible or supplemental plans.
2.3 Reimbursement Ratios (Actual Payout Amounts)
Medical Insurance:
100% reimbursement after social insurance (may drop to 60% without it).
Accident Insurance:
Medical expense ratios (80%–100%); check if limited to social insurance drugs.
Example:
An accident policy covering "100% of social insurance costs, 50% of out-of-network drugs" would only pay ¥10K for ¥20K in imported medications.
2.4 Waiting Periods (Coverage Gaps)
Critical Illness/Life Insurance: 90–180 days (no claims allowed during this time).
Medical Insurance: 30 days (accident policies usually have none).
Advice:
Avoid medical exams during waiting periods to prevent claim denials.
Overlap old and new policies when switching to avoid lapses.
3. How to Avoid Buying the Wrong Insurance?
3.1 Four-Step Verification
Before purchasing, confirm:
What’s covered → 2. What’s excluded → 3. Claim criteria → 4. Payout amounts.
3.2 Prioritize Health Disclosures
Honesty is crucial: Hiding conditions (e.g., nodules, hypertension) risks denial.
Use "smart underwriting": Some products offer non-recorded pre-approval checks.
3.3 Compare Policies Across Insurers
For similar products, prefer those with:
Looser disease definitions (easier mild/moderate condition claims).
Fewer exclusions (e.g., some cover "high-altitude falls" while others exclude them).
4. Summary: Insurance Is About the Fine Print
Claims depend solely on policy clauses—not brand reputation or agent promises. Remember:
Exclusions > Coverage (What’s not covered matters most).
Disease definitions dictate claim ease (especially for mild/moderate conditions).
Renewability > Coverage limits (20-year guaranteed renewal policies are safer).
Final Tip: Save a digital copy of your policy, highlighting key clauses (e.g., definitions, exclusions). Only by understanding the terms can insurance truly safeguard you!
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