Making Insurance Claims After a Diagnosis in Ireland

People often have more insurance cover than they realise — including policies arranged through an employer or taken out years ago. After a serious diagnosis, checking every possible source of cover is one of the most important practical steps you can take. This guide explains what to look for, how claims work, and what to do if a claim is refused. If you'd rather have a plan built around your situation, answer a few questions and we'll build one around you →

Types of policy to check

Do not cancel or change any policy while you're working out what you hold. Some policies pay out on diagnosis alone, and cancelling now could forfeit an entitlement. Check everything first, then decide.

• Life insurance — pays a lump sum to your beneficiaries on death. Many life policies also include a terminal illness benefit: if a doctor certifies that your life expectancy is less than 12 months, the policy may pay the death benefit to you early, while you are still alive. Check your policy documents or call your insurer to ask whether this clause exists and what the threshold is.
• Specified Illness Cover / Serious Illness Cover — pays a lump sum on diagnosis of a listed condition, regardless of whether you can continue working. This is the Irish product name for what some jurisdictions call critical illness cover. Commonly listed conditions include cancer, heart attack, stroke, coronary artery bypass surgery, kidney failure, and major organ transplant — but the exact list and definitions vary significantly between policies and insurers. The payment is tax-free.
• Income Protection insurance — replaces a portion of your pre-illness income while illness or injury prevents you from working. Also known in Ireland as Permanent Health Insurance (PHI). The amount payable, the waiting period before payments begin, and how long payments last all depend on your specific policy.
• Mortgage Protection insurance — under Irish law, lenders are required to ensure that most mortgage borrowers have life assurance cover in place. Many mortgage protection policies are life-only, but some include a serious illness or disability element. Check your policy documents to see exactly what your cover provides beyond the death benefit.
• Private health insurance — covers the cost of private healthcare including consultations, diagnostics, and treatment. The main providers in Ireland are VHI Healthcare, Laya Healthcare, and Irish Life Health. Private health insurance does not pay a cash sum, but can enable faster access to specialist care and treatment in a private hospital or a private bed in an HSE hospital. Check what your policy covers for your specific diagnosis, including whether it covers outpatient treatment, cancer drugs, and long-term follow-up care. The Health Insurance Authority (HIA) at hia.ie maintains a comparison tool for all available plans.

Group schemes through your employer

Employer-provided group insurance is easily overlooked because the employer arranges and pays for it — it may not appear prominently in your pay documents. Check your employment contract and staff handbook, or ask your HR department, about the following:

• Group life assurance (death in service) — pays a lump sum to your nominated beneficiaries if you die while employed, often two to four times your annual salary. Some schemes include a terminal illness element that pays out early. Check your scheme rules and make sure your nominated beneficiary details are up to date.
• Group income protection — an employer-arranged scheme that pays a portion of your salary if you are off sick long-term, typically after your employer's own sick pay ends. Your HR department can confirm whether you are covered and how to initiate a claim.
• Group serious illness cover — less common than life assurance or income protection but offered by some employers. Pays a lump sum on diagnosis of a qualifying condition, similar to a standalone Specified Illness Cover policy.
• Group private health insurance — many employers provide private health insurance as a benefit. If yours does, your HR team can confirm what the policy covers and how to use it.

If you have left a previous employer in the past few years, ask whether their group scheme offered a continuation option — a right to convert group cover into a personal policy without further medical underwriting when you left employment. If you exercised this option, you may hold a standalone policy you have lost track of.

Finding forgotten or lost policies

Cover from earlier in your life — a policy taken out with a previous employer, a mortgage lender, or a financial broker — can easily be lost track of. Here is where to look:

• Bank and credit-card statements — search for regular direct debit or standing order payments to insurance companies. A small monthly premium may represent cover you have forgotten. Most Irish banks provide several years of statements through online banking.
• Old payslips and employment records — check for deductions labelled as insurance, protection, or benefit contributions. Contact the HR departments of previous employers to ask what group schemes were in place and whether you were a member.
• Your mortgage file — some lenders attach life assurance or mortgage protection as a condition of a mortgage offer, or arrange it alongside the mortgage. Check your original mortgage paperwork or contact your mortgage lender to ask whether a policy was arranged at the time of your mortgage.
• Email and paper files — search for policy documents, annual renewal notices, and correspondence from insurance companies.
• Previous financial brokers or advisers — if you have used a financial broker at any point, they may hold records of policies arranged on your behalf. Contact them directly. Brokers are regulated by the Central Bank of Ireland and are required to keep records of the business they transact.

Specified Illness Cover — how definition matching works

Specified Illness Cover is more specific than it appears. Receiving a diagnosis of a condition named in your policy is not automatically enough to trigger a claim — the diagnosis must match the policy's own definition of that condition, including any severity threshold. These definitions are precise, and they vary between insurers and between policy generations.

Common points where definitions matter:

• Cancer — most policies exclude certain early-stage or non-invasive cancers. Definitions commonly exclude carcinoma in situ (cancer that has not yet invaded surrounding tissue), basal cell carcinoma of the skin, and some forms of very early-stage prostate cancer below a defined threshold. Read your policy's cancer definition carefully and ask your oncologist whether your diagnosis falls within or outside it.
• Heart attack — definitions typically require documented evidence of myocardial damage through cardiac biomarkers at a defined threshold, plus either symptoms or ECG changes. A clinical diagnosis alone, without the specific test results in the format the policy requires, can complicate a claim.
• Stroke — most policies require that the stroke produces a neurological deficit lasting longer than 24 hours, distinguishing it from a transient ischaemic attack. Imaging evidence is usually required.
• Partial or lower-severity payments — many modern Specified Illness Cover policies include lower-tier or partial payments for conditions that meet the diagnosis criteria but fall below the severity threshold for a full claim — for example, an early-stage cancer that is listed but at a lower severity level. Check whether your policy includes such provisions and what conditions and thresholds apply.
• Survival period — some older policies contain a survival clause requiring you to survive for a specified period (commonly 14 or 28 days) after the qualifying event before the benefit is payable. Check whether your policy includes this clause.

To give a claim the best chance: read the relevant policy definition before notifying the insurer; ask your specialist to provide a written report that explicitly references the clinical criteria — diagnostic test results, staging, pathology findings — rather than just stating the condition name; and notify the insurer promptly, as most policies include a notification requirement.

Income Protection — understanding the terms

Income Protection policies contain several terms that determine whether and how much you receive. Check each of the following in your policy documents:

• Deferred (waiting) period — the period between becoming unable to work and when benefit payments begin. Common deferred periods in Ireland are 4, 13, 26, or 52 weeks. Your policy will not pay during this period; coordinate with your employer's sick pay and Illness Benefit entitlements to ensure there is no income gap.
• Benefit amount and State illness payment offset — Income Protection policies typically replace around 75% of your pre-illness earnings, but this is usually the maximum including any State illness payments you receive. Most Irish policies contain an offset provision: the insurer deducts the amount of any Illness Benefit or Invalidity Pension you receive from DSP from the policy benefit. The net payment from the insurer is reduced accordingly. Check your policy to confirm whether — and how — State payments are offset.
• Definition of disability — Income Protection policies use different definitions to determine whether you qualify for benefit. The most favourable for policyholders is the "own occupation" definition: you qualify if you are unable to perform the material duties of your specific occupation, taking into account your training and experience. More restrictive definitions — suited occupation, or any occupation — require that you cannot perform any role reasonably suited to your skills, or any paid work at all. Check which definition your policy uses.
• Benefit period — how long payments continue. Some policies pay until you return to work or reach a set retirement age (typically 60 or 65); others pay for a defined maximum period. Check which applies and whether your retirement age has changed since the policy was taken out.
• Index-linking — some policies increase the benefit each year in line with inflation or earnings indices. This matters significantly for long-term claims.

How to make a claim

The process is broadly similar across policy types. Notify the insurer as soon as you decide to claim — do not wait until you have gathered all your documents.

• Notify the insurer promptly. Contact your insurer by phone or in writing to register your intention to claim. Note the date, the name of the person you spoke to, and any reference number given. Most policies include a notification time limit — late notification can complicate your claim even if the underlying claim is valid.
• Request a claim form. The insurer will provide a claims pack with a form and a list of required documents. Read the requirements carefully before gathering anything.
• Obtain medical evidence — typically an Attending Physician's Report. The insurer will usually ask your GP or treating specialist to complete a detailed medical report (sometimes called an Attending Physician's Statement or APS). The report should include the diagnosis using clinical terminology, the date of diagnosis, relevant diagnostic test results, current treatment, and prognosis. A vague letter confirming only a condition name will usually not be sufficient.
• Gather supporting documentation. Depending on the policy type, this may include the completed claim form, medical reports, test results or pathology reports, proof of pre-illness income (for Income Protection), and copies of employment documentation if a group scheme is involved.
• Submit and keep copies of everything. Record the date you submitted the claim and obtain written confirmation of receipt. Keep a copy of every document you send.
• The insurer may contact your doctor directly. You will typically be asked to sign an authority allowing the insurer to contact your GP or specialist. This is standard practice.
• Independent Medical Examination. For significant claims, particularly Income Protection and Specified Illness Cover, the insurer may ask you to attend an examination by a doctor of their choosing. You are generally required to cooperate with a reasonable request; you are also entitled to request a report of the findings.

Under the Consumer Insurance Contracts Act 2019, insurers in Ireland are required to handle claims promptly and fairly, and to act with utmost good faith towards the policyholder during the claims process. If you feel a claim is being delayed without good reason, or handled unfairly, this can be raised in a formal complaint.

Disclosure and why claims get declined

One common reason for a declined claim is an allegation of non-disclosure or misrepresentation at the time the policy was taken out — the insurer argues that had they known about a pre-existing condition or other information, they would not have issued the policy, or would have issued it on different terms.

The Consumer Insurance Contracts Act 2019 significantly changed the rules on pre-contractual disclosure in Ireland. Under the old law, policyholders owed a duty of "utmost good faith" to volunteer all material information, even if not asked. The 2019 Act replaced this with a more proportionate framework:

• Your pre-contract duty is now limited to answering the insurer's questions honestly and with reasonable care. You are not required to volunteer information the insurer has not asked for.
• Innocent misrepresentation — where you gave an incorrect answer in good faith and without negligence — cannot be used to void the policy or decline a claim. The insurer is entitled to no remedy for a purely innocent misrepresentation.
• Negligent misrepresentation — where you answered carelessly — entitles the insurer to a proportionate remedy rather than an automatic right to void the policy. The insurer can reduce the claim payment in proportion to what their terms would have been had the correct answer been given. They cannot simply refuse the entire claim unless they can show they would not have issued the policy at all on any terms.
• Fraudulent misrepresentation — where you deliberately gave false information — entitles the insurer to void the contract from the outset and retain premiums paid.

If your claim has been declined on disclosure grounds, the proportionality provisions of the 2019 Act are likely to be relevant. Seek advice from Citizens Information or a solicitor before accepting the insurer's decision as final.

How insurance is regulated in Ireland

Insurance in Ireland is regulated by the Central Bank of Ireland. The Central Bank's Consumer Protection Code requires all regulated financial service providers — including insurers — to act honestly, fairly, and professionally in the best interests of consumers. The Code sets out specific obligations on how claims must be handled: insurers must acknowledge claims promptly, keep consumers informed of progress, and not seek unnecessary information or use delay as a tactic.

You can verify that an insurer or broker is authorised by the Central Bank at registers.centralbank.ie. Doing business with an authorised firm ensures you have access to the formal complaints and redress system described below.

Private health insurance is also overseen by the Health Insurance Authority (HIA), which enforces the community rating and open enrolment rules that apply to the Irish private health insurance market. The HIA's comparison tool at hia.ie allows you to compare all available private health insurance plans. If you have a complaint about a private health insurer, you can also contact the HIA — though disputes about specific claim decisions are ultimately handled by the FSPO.

If your claim is declined

A declined claim is not final. You have a clear, free escalation path — and the Financial Services and Pensions Ombudsman frequently upholds complaints against insurers.

Step 1 — Internal complaints procedure

Before going elsewhere, you must first make a formal complaint through the insurer's internal complaints process. Write to the insurer setting out clearly why you believe the decision was wrong, referencing the relevant policy definition and the medical evidence. Ask for all documents and information the insurer relied upon in reaching their decision — they are required to provide this under the Consumer Protection Code.

The insurer must acknowledge your complaint promptly and provide a final response within a regulated timeframe. Keep the final response letter — it is the starting point for the next step.

Step 2 — Financial Services and Pensions Ombudsman (FSPO)

If the insurer's internal process does not resolve your complaint, you can escalate to the Financial Services and Pensions Ombudsman (FSPO) — a free, independent statutory body with the power to make binding decisions on insurers and other regulated financial service providers.

The FSPO covers all Central Bank-regulated insurance, including life insurance, Specified Illness Cover, Income Protection, Mortgage Protection, and private health insurance. FSPO investigators review the insurer's decision impartially and can direct the insurer to pay a claim, pay compensation, or take other remedial action. A decision by the FSPO is binding on the insurer if you accept it; if you do not accept it, you remain free to pursue the matter through the courts.

• Website: fspo.ie
• Phone: 01 567 7000
• Do not delay — time limits apply to bringing a complaint to the FSPO. Check the current limits at fspo.ie before submitting your complaint.

For large or complex disputed claims, it is also worth consulting a solicitor who specialises in insurance law. A specialist can advise on whether your case is better suited to the FSPO process or to the courts, and can help frame the legal arguments. Many work on a conditional fee basis for insurance disputes.

Work-caused illness

Ireland does not have a no-fault compensation scheme covering all injuries and illnesses regardless of cause. If your illness is not connected to your work, the main protections are personal insurance, HSE treatment, and the DSP benefit system covered in the other guides in this cluster.

Two routes exist specifically for work-related illness:

• Occupational Injuries Benefit Scheme (DSP) — this scheme provides payments for injuries or illnesses arising from work. Injury Benefit is a weekly DSP payment (paid for up to 26 weeks) for employees who cannot work due to a workplace accident or a prescribed occupational disease. Disablement Benefit is a longer-term payment (or in some cases a lump sum) for people with a permanent disability resulting from a prescribed occupational disease — including conditions such as pneumoconiosis, asbestosis, mesothelioma, occupational deafness, and vibration white finger. You do not need to prove employer negligence for these DSP payments — they are paid on the basis of the prescribed disease or workplace injury alone. Apply through DSP at gov.ie.
• Personal injury claim via the Injuries Resolution Board and the courts — if your illness was caused or significantly worsened by your employer's negligence — for example, exposure to asbestos, hazardous chemicals, or other workplace conditions — you may have a personal injury claim against your employer. In Ireland, before bringing a court action for most personal injury claims, you must first apply to the Injuries Resolution Board (IRB) at injuriesboard.ie. The IRB can assess your claim and make an award; if the respondent does not consent to assessment, or if you do not accept the award, the case can proceed to court. Employers are required by law to hold employers' liability insurance. This is a civil route; a solicitor specialising in occupational disease or personal injury claims can advise on prospects and the process. Many work on a no-win, no-fee basis.

Getting help with a claim

Insurance policy wording is technical, definitions are applied strictly, and the medical evidence requirements can be exacting. If you are unsure whether your diagnosis meets a policy definition, are dealing with a complex claim, or have had a claim declined, consider getting professional help before accepting the insurer's decision.

• Irish Cancer Society Support Line — 1800 200 700 (free, Monday to Friday, 9am–5pm). Information and support for people affected by cancer, including guidance on navigating insurance and financial questions.
• Citizens Information — 0818 07 4000 or citizensinformation.ie. Free information on insurance rights, how to complain, and the FSPO process. Can help you understand your options and draft a complaint.
• Financial Services and Pensions Ombudsman (FSPO) — fspo.ie or 01 567 7000. The FSPO can provide guidance on whether a complaint falls within its remit before you submit formally.
• A regulated financial adviser or insurance broker — an adviser who specialises in protection products can help interpret policy definitions, prepare evidence for a claim, and correspond with the insurer on your behalf. Verify any adviser or broker is authorised by the Central Bank at registers.centralbank.ie before engaging them.
• A solicitor specialising in insurance disputes — for declined claims involving significant sums, a specialist solicitor can advise on the legal merits and represent you at the FSPO or in court. The Law Society of Ireland at lawsociety.ie can help you find a solicitor with relevant expertise. Many work on a conditional fee basis for insurance matters.