Must-know Information About Critical Illness Insurance

Workplace Benefits

7 Things Medical Insurance May Not Cover If You Get Sick

3 min read
Oct 25, 2021

We’d all like to think we have the insurance coverage needed to treat a critical illness, like COVID-19i, heart attackii, or stroke.1 But that may not be the case.

That’s because medical insurance may only cover a portion of the costs associated with a serious illness, leaving you to potentially pay thousands out of pocket. According to a report by Salary Finance, about one in three working Americans have medical debt, and more than half of them have defaulted on it.

Fortunately, you can take proactive steps—like signing up for Critical Illness Insurance—to help protect your finances.

What is Critical Illness Insurance, you wonder? In short, it's a voluntary insurance plan that gives you a lump-sum benefit payment upon diagnosis verification of certain covered illnesses. And you can use the money as you see fit, such as for the following expenses, amongst others:

1. Out-of-network care

Some medical plans may offer limited out-of-network coverage, while others may offer none. That means you may end up paying more to see a provider outside of your network.

Critical Illness Insurance pays a lump sum benefit payment directly to you, not the provider, that could be used towards out-of-network care.

2. Your medical insurance deductible

The average deductible (the amount you have to pay out of pocket before your insurance kicks in) is around $1,655, the Kaiser Family Foundation reports.

But what if you haven't met that deductible when you're diagnosed with a serious illness? Luckily, there is no deductible with Critical Illness Insurance. You can file a claim as soon as you are diagnosed with a covered illness and receive a lump-sum benefit payment, which can be used to cover expenses such as your medical insurance deductible.

3. Copays and coinsurance

Known as cost-sharing, copays and coinsurance are fees you may pay healthcare providers, which could come as a shock when you're treating a critical illness. Case in point: The average American family spends up to $5,000 in out-of-pocket medical costs yearly.

Your lump-sum critical illness benefit payment can be used to cover expenses such as co-pays and coinsurance.

4. Alternative medications and treatments

Many medical insurance plans may stipulate which medications or treatments they’ll cover. The list varies by plan and may not include prescriptions your doctor recommends for you, experimental therapies, or other treatments, like acupuncture.

If you choose these services, the costs may be your responsibility. Even if you file an appeal with your medical insurance provider, there’s the possibility that it can be denied, leaving you to foot the bill on your own.

With Critical Illness Insurance, you can use the lump-sum benefit payment to cover expenses such as the costs of alternative treatments and therapies recommended by your doctor.

5. Certain durable medical equipment (DME)

DME is the items you may need as you recover or live with a medical condition. This equipment may include wheelchairs, oxygen tanks, CPAP machines, and blood glucose testing kits, for example.

Some medical insurance plans may cover DME, if it's considered medically necessary to live. However, that may not include things that make your life easier or more comfortable, like handrails in the bathroom.

Fortunately, Critical Illness Insurance pays you a lump-sum benefit payment upon verified diagnosis. And you can use it towards anything you want, such as the purchase of DME medical insurance may not cover.

6. Living expenses

Medical insurance may not pay for rent, utilities, groceries, childcare, transportation—or any of the other living expenses that you may need help with during an illness.

Household expenses could get even more costly when you’re ill. For instance, you may need someone to help you run errands, shop for groceries, and cook, if you’re unable to be as active as usual.

The lump-sum benefit payment you receive from Critical Illness Insurance could give you the ability to hire the help you need and pay for items such as living expenses.

7. Travel expenses

If you need to go out of town to see a doctor or participate in a clinical trial, medical insurance might not cover that—meaning flights, gasoline, food, lodging, and other costs would fall on you.

One solution: Use your lump-sum benefit payment from Critical Illness Insurance to cover travel expenses for yourself and family members. That way, you can focus on recovering, instead of how you'll pay for it.

Interested in learning more about Critical Illness Insurance? Talk to your employer about your plan options. And take our quiz to see what other insurance products might be right for you.

Please review the certificate for specific information about cancer benefits. In most states, not all types of cancer are covered.

Coverage is guaranteed provided (1) the employee is actively at work and (2) dependents to be covered are not subject to medical restrictions as set forth on the enrollment form and in the Certificate. [For CA-sitused cases, coverage is guaranteed provided (1) the employee is performing all of the usual and customary duties of your job at the employer’s place of business or at an alternate place approved by your employer (2) dependents are not subject to medical restrictions as set forth on the enrollment form and in the Certificate.] Some states require the insured to have medical coverage.

Eligibility for portability through the Continuation of Insurance with Premium Payment provision may be subject to certain eligibility requirements and limitations. For more information, contact your MetLife representative.

METLIFE CRITICAL ILLNESS INSURANCE (CII) IS A LIMITED BENEFIT GROUP INSURANCE POLICY. Like most group accident and health insurance policies, MetLife's CII policies contain certain exclusions, limitations and terms for keeping them in force. Product features and availability vary by state. There may be a preexisting condition exclusion. There may be a Benefit Reduction Due to Age provision. There may be a Benefit Suspension Period between recurrences of the same Covered Condition or occurrences of different Covered Conditions. MetLife offers CII on both an Attained Age basis, where rates will increase when a Covered Person reaches a new age band, and an Issue Age basis, where rates will not increase due to age. Rates are subject to change. MetLife reserves the right to raise premium rates for Issue Age CII on a class-wide basis. A more detailed description of the benefits, limitations, and exclusions applicable to MetLife’s CII product can be found in the applicable Disclosure Statement or Outline of Coverage/Disclosure Document available at time of enrollment. For complete details of coverage and availability, please refer to the group policy form GPNP07-CI, GPNP09-CI, GPNP10-CI, GPNP14-CI, GPNP19-CI or contact MetLife for more information. Please contact MetLife for more information. Benefits are underwritten by Metropolitan Life Insurance Company, New York, New York.

MetLife's Critical Illness Insurance is not intended to be a substitute for Medical Coverage providing benefits for medical treatment, including hospital, surgical and medical expenses. MetLife's Critical Illness Insurance does not provide reimbursement for such expenses.


i COVID-19 is covered under the Infectious Disease Category.  For an Infectious Disease Category benefit to be payable, the covered person must have been treated for the disease in a hospital for [5] consecutive days. 

ii The Heart Attack Covered Condition pays a benefit for the occurrence of a myocardial infarction, subject to the terms of the certificate.  A myocardial infarction does not include sudden cardiac arrest.

For information from the MetLife 2021 Open Enrollment Survey click here.