Intensive care in critical illness cover

What we mean by intensive care

In medicine, intensive care is not just any hospital stay. It refers to a specialist unit looking after people who are critically ill and need organ support. For CI purposes the focus is almost always on one thing. Being kept alive on a breathing machine. That means:

• Tracheal intubation- a tube placed into the windpipe through the mouth or nose or via a tracheostomy
• the tube connected to a mechanical ventilator that pushes air in and out of the lungs
• usually in an intensive care or high dependency unit setting.

This is what doctors call invasive mechanical ventilation. It is used for people who are too sick to breathe for themselves or who need a protected airway while they are unconscious or sedated.

Non-invasive ventilation such as a tight-fitting mask for a bad COPD flare does not count for most policies. The wording is usually very clear that the ventilation has to be via tracheal intubation. So, when a client asks whether intensive care is covered, what the policy is really talking about is a spell on full life support.

How common is this level of illness

Plenty of people pass through ICU for a day or two after big surgery or a severe infection and then recover well. The group the policies are aimed at is smaller. Those who are so unwell that they need prolonged ventilation.

Studies of critically ill adults show that patients who stay on a ventilator for many days fall into a small but very high-risk group. They make up perhaps 5 to 20 percent of ICU admissions but account for a disproportionate share of deaths and long-term disability.

For children we have better UK data. Paediatric intensive care units admit around 150 children per 100,000 under 16 each year. Of those, roughly 1 in 13 needs invasive ventilation and about a quarter of those ventilated children are still on the ventilator seven days later. Put together, that works out to around 11 to 12 children per 100,000 per year on prolonged ventilation in PICU.

So, the level of illness that triggers a typical intensive care benefit is rarer but extremely serious.

The typical adult intensive care definition

Most modern UK CI plans now include intensive care as a named condition in the main list of full payment illnesses. Although the wording varies a little, the core shape is very similar. Adult definitions usually read along the lines of any sickness or injury that leaves the person needing:

• continuous mechanical ventilation by means of tracheal intubation
• for 10 consecutive days
• 24 hours per day
• in an intensive care unit in a UK hospital.

There are additional points to consider with regard to policy wordings:

• It can be any cause; pneumonia, sepsis, trauma, complications of surgery and so on. The trigger is how sick they became, not why.
• The ventilation has to be a breathing tube or tracheostomy on a ventilator. Masks and other non invasive support are not enough.
• It has to be continuous. Typically, the person is on the ventilator day and night for at least ten days in a row. Short breaks for an attempted wean do not usually cause problems if the ICU team still regard it as continuous support, but a clear gap of a day off the ventilator would.
• There is often a UK hospital requirement. Some definitions specify a UK intensive care unit. Others will accept equivalent units abroad, but it is worth checking the policy for incidents that happen on holidays away.  
• Certain causes are excluded. Many policies do not pay if the intensive care stay is due to alcohol or drug misuse or other self inflicted injury.

On top of that, the ordinary survival period for the policy still applies. So even after ten days of ventilation, the person normally has to survive another 10 to 14 days for a claim to be valid, depending on the insurer.

Child intensive care benefits

Children’s cover tends to treat intensive care slightly differently. Rather than a full sum assured, it is often an additional lump sum paid on top of the parent’s cover.

Again, the wording is quite consistent across the market, and similar to adult wordings. There are a couple of important points with children’s cover. In short, there are additional stipulations. For example, some wordings do not pay if the child is under a certain number of days old at admission. Others exclude ventilation where it is related to prematurity, such as for babies born before 37 weeks.

Given how long paediatric ICU stays can be, this benefit can make a real difference for families who suddenly face weeks in hospital, travel costs and time off work.

Why the bar is set so high

From the outside you might expect that any ICU stay would be covered. In truth, insurers are deliberately targeting the extreme end of risk. Mechanical ventilation for ten days or more is a strong marker that someone has been through a life threatening event. Studies looking at people with prolonged ventilation show high one year mortality and a big burden of long-term disability among survivors.

If policies paid for any ICU admission, they would start to pick up large numbers of short, routine planned post operative stays where the person is expected to make a full recovery. By tying the wording to prolonged ventilation, insurers are trying to focus on genuinely catastrophic episodes.

It is also relatively easy to verify. ICU charts and discharge summaries make it very clear when a patient was intubated, when they were extubated and how long mechanical ventilation lasted. That helps avoid arguments at claim stage.

Differences between insurers that matter in practice

Across the main individual CI providers the broad approach is similar, but there are details that are worth watching.

• First, the number of days. For adults, most mainstream policies use 10 consecutive days on a ventilator, although this can vary. For children, seven days is more common as a threshold for an additional child benefit.
• Second, some definitions exclude cases where the underlying cause is drug or alcohol misuse or other self-inflicted harm. That may be relevant in overdose or self-harm scenarios, especially in teenagers and young adults.

Overall though, the market is fairly aligned. If someone has been on a ventilator for ten days in ICU due to an illness or accident, you would expect most modern policies with an intensive care definition to at process a claim.

Underwriting when a client has a past intensive care stay

Intensive care is not a condition in its own right, it is a clue to how serious an underlying event was. Underwriters therefore focus less on the fact of ICU admission and more on what sat behind it and what the long-term outcome has been.

Useful information you can gather up front

• What actually happened; date of admission, length of stay, whether they were ventilated and for how long, and the main diagnosis such as sepsis from pneumonia, major trauma, complicated surgery, heart failure and so on.
• Any long term damage; for example chronic lung problems, heart damage, kidney failure, or neurological issues after long ventilation and sedation.
• Whether they have been back; repeat ICU admissions or frequent hospitalisations since the event will worry underwriters much more than a one off episode five years ago in an otherwise healthy person.
• Current day to day life; are they working full time, exercising, living independently, or have they had to step back because of breathlessness, fatigue or cognitive problems.

In practice a young client ventilated after trauma with a good recovery may eventually be offered standard terms after a defer period. Someone with a history of prolonged ventilation for advanced lung disease or heart failure, with ongoing symptoms, is much more likely to see loadings or exclusions for related conditions.

What helps if a client needs to claim under intensive care

If a client has been in ICU and you think the intensive care benefit might apply, gathering together the right paperwork can help with the speed of the claim.

For both adults and children, the claims team will want to see

• Confirmation from the hospital of the dates the person was ventilated and whether that was invasive mechanical ventilation. In many cases a simple ICU discharge summary will spell out intubation and extubation dates (when ventilation was started and stopped).
• A clear count of consecutive days. Some insurers will do this from the raw notes, others may ask the treating consultant or ICU team to confirm that the client met the 7 or 10 day threshold.
• The diagnosis and cause of admission. For example septic shock, severe asthma, meningitis, traumatic brain injury. This matters for any exclusions around self-inflicted injury or substance misuse and for overlapping definitions such as coma or brain injury.
• Age and prematurity information for child claims. Especially where the baby was in neonatal or paediatric intensive care soon after birth. Gestation at delivery and the reason for ventilation are key here because of the prematurity exclusions mentioned earlier.

It can help to warn families early that hospital records and letters can often be slow to arrive. Encouraging clients to keep copies of key letters and discharge summaries as they go along can make a later claim much smoother.

Also remember that an ICU stay may open more than one route to a claim. A client might not qualify for an intensive care payment based on 10 days of ventilation, but could later qualify under a separate brain injury or heart failure definition if they are left with permanent problems.