Recently, a news story titled “Claim Denied for Cerebral Vascular Malformation” went viral on social media:
Ms. Chai, a former insurance agent, purchased a policy years ago. When her daughter was recently diagnosed with cerebral vascular malformation, the insurer denied the 700,000 RMB claim, citing congenital exclusion. Ms. Chai disputes this outcome, arguing her daughter was healthy at policy inception and the condition should be considered sudden rather than congenital. How could this happen? Do all insurance policies exclude congenital conditions? Today we examine this case in detail, covering: • Do insurers always reject congenital disease claims? • When might congenital conditions qualify for coverage? • Are congenital disease riders worth purchasing? 1. Do insurers always reject congenital disease claims? Most health insurance policies include this standard exclusion: There are generally two scenarios: • Genetic disorders • Congenital anomalies unrelated to genetics (collectively termed “congenital diseases”) These conditions may not manifest at birth. Genetic disorders like hemophilia or muscular dystrophy often appear during childhood/adolescence, while conditions like cerebral vascular malformation typically emerge in adulthood. If diagnosed conditions fall under these exclusions, insurers may legally deny claims—even if the policyholder was previously unaware. Complications arising from congenital conditions may also be excluded. For example, while craniotomy for cerebral vascular malformation normally qualifies for critical illness coverage, the congenital origin voids eligibility. Diagnostic terminology significantly impacts outcomes. Conditions like choledochal cysts have both congenital (ICD codes beginning with “Q”) and acquired forms. A “congenital” specification in medical records often guarantees claim denial, as demonstrated in our previous case study where three words cost a claimant 300,000 RMB. While legally justified, such denials understandably distress long-term policyholders who purchased coverage precisely to mitigate unforeseen health risks. However, we’ve identified scenarios where congenital disease claims may succeed.2. Under What Circumstances Can Congenital Diseases Be Covered by Insurance?
We consulted professional claims specialists and confirmed the following three scenarios where common critical illness insurance and million-yuan medical insurance may provide coverage, provided the conditions are met: 1. The Policy Explicitly States Coverage Without Exclusions Most health insurance policies cover approximately ten congenital diseases. The policy typically clarifies this in two ways: – Under the specific disease, it states that the condition is not subject to exclusions. – In the exclusions section, it specifies that the listed diseases are not excluded. Therefore, if the policy explicitly covers a congenital disease and the conditions are met, claims are generally approved. For example, a popular critical illness insurance policy covers these 9 congenital diseases: Children’s critical illness insurance often covers more congenital diseases, with some high-quality products offering additional payouts (1-2 times the sum insured) for specified conditions such as osteogenesis imperfecta, spinocerebellar ataxia, and Eisenmenger syndrome. 2. The Condition Was Disclosed During Underwriting and Accepted Without Exclusion For instance, if an applicant with congenital heart disease meets the underwriting requirements after treatment and is accepted without exclusions, subsequent claims related to the covered heart conditions are typically approved. 3. The Claim Results from Other Causes For example, if a policyholder discovers a family history of hereditary deafness after purchasing the policy but loses hearing due to an accident before symptoms appear, the claim should still be approved. Most critical illness and million-yuan medical insurance policies do not cover congenital diseases outside these three scenarios. The primary reasons for excluding most congenital diseases are: – Cost Control: The vast number and complex causes of congenital diseases introduce significant uncertainty. Including them would drastically increase premiums. – Social Impact: Some conditions can be detected prenatally. If high insurance payouts incentivized birthing children with such conditions, it could harm families and society. The “Health Insurance Management Regulations” prohibit insurers from: – Illegally collecting genetic information or test results beyond family medical history. – Using such data for differential pricing or underwriting decisions. As genetic testing advances, potential loopholes may increase. Thus, these exclusions serve both cost control and moral hazard prevention. Proactive measures include: – Pre-pregnancy checkups and preventive care. – Monitoring for abnormalities during pregnancy. – Targeted genetic testing when necessary. Currently, many conditions can be detected prenatally or during pregnancy, such as osteogenesis imperfecta (“brittle bone disease”), spina bifida, and hemophilia.The overall incidence rate of these diseases is relatively low, far less than that of the 28 critical illnesses. However, once encountered, they can be devastating to individuals and families, with treatment costs potentially ranging from hundreds of thousands to millions.
For those who are particularly concerned, some insurance products on the market cover congenital diseases. Interested individuals may explore these options further. 3. Is It Necessary to Purchase Insurance That Covers Congenital Diseases? Currently, certain maternity insurance, mid-to-high-end medical insurance, and inclusive healthcare plans (e.g., Shanghai’s “Hu Hui Bao”) cover congenital diseases. Maternity insurance typically covers 10 to several dozen congenital diseases in newborns, such as congenital myasthenia and spina bifida. However, it only reimburses hospitalization expenses within one year or provides a lump-sum payment of around 100,000 yuan, offering limited coverage. Mid-to-high-end medical insurance plans that cover congenital diseases often impose separate coverage limits, usually ranging from thousands to hundreds of thousands of yuan. Higher reimbursement limits come with higher premiums, costing thousands to tens of thousands annually, which may be unaffordable for average families. Some regional inclusive healthcare plans, like Shanghai’s “Hu Hui Bao,” cover specified genetic diseases (e.g., Fabry disease, mucopolysaccharidosis). Even individuals already diagnosed with these conditions can purchase such plans, alleviating some financial burden. Additionally, certain congenital diseases, such as cleft lip and palate, thalassemia, and hemophilia, are included in national medical insurance, providing partial financial relief. In summary, the coverage and benefits for congenital diseases across various insurance products remain limited. However, congenital diseases represent just one of many health risks, with a relatively low overall incidence rate. There is no need for excessive concern. For most people, comprehensive protection is more important. The 28 most common critical illnesses, including cancer, stroke, and myocardial infarction, account for over 95% of critical illness insurance claims. Accidents, such as falls, fractures, car accidents, and fires, are unpredictable and can disrupt lives. As long as individuals survive and can afford treatment, there is hope. However, in the unfortunate event of death, families may suffer immense grief and financial hardship. Therefore, it is advisable to purchase medical insurance (including NCMS), million-yuan medical insurance, critical illness insurance, accident insurance, and term life insurance. A comprehensive package can cost between 1,000 to 5,000 yuan annually. Note: A pre-purchase medical examination is not required. Simply disclose known health conditions honestly. For assistance in selecting the right insurance, consult a professional advisor. 4. Final Notes Many claim denials are regrettable, often due to inadequate health disclosures, discovering uninsured conditions only at claim time, or exclusions like congenital diseases.We can use our expertise to help you navigate the pre-insurance and claim process effectively.
However, congenital diseases discovered years after purchasing insurance are often beyond our control. We hope the insurance industry will advance further to cover undetected congenital diseases at the time of purchase, providing genuine support to families in need and truly serving as a lifeline.
