What are the possible outcomes once an insurer has assessed a pre-existing condition?

Four outcomes are possible once an insurer has assessed your answers. It can offer standard terms, meaning full cover at the standard price. It can apply an exclusion, carving the specific condition — sometimes a related family of conditions — out of the cover in writing. It can apply a premium loading, offering full cover at a higher price to reflect the added risk. Or it can decline to offer terms at all. Which applies depends on the condition, its severity, any treatment and how long ago it occurred.

Why might two insurers reach different decisions on the same medical history?

Underwriting is a judgement, not a fixed formula, so two insurers looking at identical medical records can reasonably reach different conclusions about the level of risk involved. One insurer might view a particular condition as settled and offer standard terms, while another applies an exclusion or a loading for the same history, and a third might decline. This is why more than one written quote matters when you have a relevant history: a decline or loading from one insurer is not necessarily the outcome elsewhere.

What duty do applicants have when answering health questions about past conditions?

Your legal duty, under the Consumer Insurance (Disclosure and Representations) Act 2012, is to take reasonable care not to misrepresent when answering the specific questions the insurer asks — not to volunteer every detail of your medical history unprompted. If a question is ambiguous, ask the insurer to clarify it in writing before you answer, and keep a copy of both the question and your answer with the policy documents. A claim years later can be tested against those original answers.

Critical illness

Critical illness cover and pre-existing conditions

The short answer

Critical illness cover is fully medically underwritten: you answer health questions, and the insurer offers standard terms, excludes the specific condition, loads the premium, or declines. Conditions you already have are not covered. Your legal duty is to take reasonable care to answer the questions asked accurately — nothing more.

Written by Emma Leadbetter. Reviewed by Dior Teshayev.

Published 15 September 2026. Last reviewed 15 September 2026. Next review due 15 December 2026.

What to know about critical illness cover and pre-existing conditions

Underwriting can result in four outcomes: standard terms, an exclusion, a loaded premium, or a decline. Read more
The outcome depends on the condition, its severity, treatment and how long ago it occurred. Read more
Disclosure law requires reasonable care answering the questions asked, not volunteering unprompted information. Read more
Different insurers can reach different conclusions on the same medical history, so compare written offers. Read more

Thinking about critical illness cover and pre-existing conditions

What works well

Underwriting outcomes are given in writing before cover starts.
CIDRA protects honest applicants who take reasonable care.
Different insurers can reach different outcomes on the same history.

What to watch

An exclusion carves out the condition permanently unless reviewed.
A careless answer can void the policy at claim.
A decline from one insurer is not a decline from all.

Your disclosure rights

The Consumer Insurance (Disclosure and Representations) Act 2012 replaced the old duty to volunteer everything with a duty to take reasonable care not to misrepresent when you answer the insurer’s questions. The same Act sets out what an insurer can do if an answer was wrong. If the mistake was careless, the insurer must respond in proportion: where it would have offered cover on different terms it applies those terms, and where it would have charged more it can reduce the claim by the same proportion. Only a deliberate or reckless misrepresentation allows it to cancel the policy and refuse the claim. ^[5] The Ombudsman’s published decisions show these rules applied to real declined critical illness claims — including a claim for multiple sclerosis declined for a careless qualifying misrepresentation under CIDRA, and a prostate-cancer claim on a joint life and critical illness policy where the insurer’s decline was found reasonable. ^[6]^[7] This matters enormously for critical illness cover, because a claim is tested against answers given years earlier.

Alongside the statutes, the FCA’s conduct rules require insurers to give you the product information document and full wording before you buy, and to handle claims and complaints fairly. ^[3] The Consumer Duty sits above all of it: insurers and intermediaries must act to deliver good outcomes for retail customers, covering how products are designed, priced, explained and serviced. ^[4] You can check that any insurer, adviser or broker you deal with is authorised on the Financial Services Register. ^[2]

The four underwriting outcomes

Unlike moratorium-style products, critical illness cover is fully underwritten at application: the insurer asks specific health and lifestyle questions and prices or adjusts the offer against your answers. There are four possible outcomes. Standard terms mean full cover at the standard price. An exclusion means cover with the specific condition — sometimes a family of related conditions — carved out in writing. A premium loading means full cover at a higher price. And a decline means the insurer will not offer terms. Which outcome you get depends on the condition, its severity, treatment and how long ago it was; two insurers can assess the same history differently, which is why written quotes from more than one insurer matter. The Consumer Insurance (Disclosure and Representations) Act 2012 frames your side of the bargain: take reasonable care to answer accurately, and the insurer cannot use an innocent, irrelevant answer against you later — but careless answers can void the policy at claim. The Ombudsman’s published decisions show exactly this being tested in real disputes.

Answer every question as written, ask the insurer to clarify ambiguous questions in writing, and keep a copy of your answers with the policy — that document is your protection at claim. Whatever the specifics of critical illness cover and pre-existing conditions, the discipline that protects you is always the same: get the insurer’s position in writing, keep the documents with the policy, and make sure the people who would help you claim know the policy exists and where the paperwork lives.

Related guides

Common questions

What are the possible outcomes once an insurer has assessed a pre-existing condition?: Four outcomes are possible once an insurer has assessed your answers. It can offer standard terms, meaning full cover at the standard price. It can apply an exclusion, carving the specific condition — sometimes a related family of conditions — out of the cover in writing. It can apply a premium loading, offering full cover at a higher price to reflect the added risk. Or it can decline to offer terms at all. Which applies depends on the condition, its severity, any treatment and how long ago it occurred.
Why might two insurers reach different decisions on the same medical history?: Underwriting is a judgement, not a fixed formula, so two insurers looking at identical medical records can reasonably reach different conclusions about the level of risk involved. One insurer might view a particular condition as settled and offer standard terms, while another applies an exclusion or a loading for the same history, and a third might decline. This is why more than one written quote matters when you have a relevant history: a decline or loading from one insurer is not necessarily the outcome elsewhere.
What duty do applicants have when answering health questions about past conditions?: Your legal duty, under the Consumer Insurance (Disclosure and Representations) Act 2012, is to take reasonable care not to misrepresent when answering the specific questions the insurer asks — not to volunteer every detail of your medical history unprompted.^[5] If a question is ambiguous, ask the insurer to clarify it in writing before you answer, and keep a copy of both the question and your answer with the policy documents. A claim years later can be tested against those original answers.

Sources

Financial Conduct Authority. About the FCA. Accessed 15 September 2026 (primary source)
Financial Conduct Authority. The Financial Services Register. Continuously updated; accessed 15 September 2026 (primary source)
Financial Conduct Authority. ICOBS: Insurance Conduct of Business (FCA Handbook). Accessed 15 September 2026 (primary source)
Financial Conduct Authority. The Consumer Duty. Accessed 15 September 2026 (primary source)
UK Parliament (legislation.gov.uk). Consumer Insurance (Disclosure and Representations) Act 2012. Enacted 8 March 2012 (primary source)
Financial Ombudsman Service. Final decision DRN-6204112 (critical illness claim declined — CIDRA qualifying misrepresentation). Accessed 15 September 2026 (primary source)
Financial Ombudsman Service. Final decision DRN-6459846 (joint life and critical illness claim declined — application accuracy). Accessed 15 September 2026 (primary source)