How a CriticalGuard Cancer plan worked after a screening mammogram

Dana is 46 and manages the front desk of a busy dental office in Las Vegas. She has health insurance through work. It covers doctor visits, hospital stays and treatment, after a deductible and coinsurance. For most years, that was all she thought about.

Then a friend went through cancer treatment. Her friend’s health plan paid most of the medical bills. What surprised Dana was everything else: the months of reduced hours, the gas and parking for appointments, the meals someone else had to cook. None of that shows up on a medical bill.

So Dana looked at critical illness insurance. Her goal was simple: if something serious happened, she wanted a sum of money she could use for whatever the health plan didn’t touch.

What she chose

CriticalGuard is a critical illness plan underwritten and administered by Golden Rule Insurance Company, a UnitedHealthcare company. It comes in four plans:

• Cancer
• Heart/Stroke
• Cancer + Heart/Stroke
• Critical Illness, the full suite, which adds a set of other critical conditions

Each plan pays a lump sum when a covered person has a First Diagnosis of a Qualifying Event. First Diagnosis means the first occurrence in the covered person’s lifetime, after the waiting period, while the coverage is in force. (The brochure notes that First Diagnosis does not apply in some states.)

Dana chose the Cancer plan. Cancer was the risk on her mind, and she wanted to keep the plan focused.

Next she picked a Benefit Lifetime Maximum Amount. That is the most the plan will pay in a lifetime for one category of Qualifying Events. You choose it in $5,000 steps, and the range depends on your age when the plan is issued. For a Cancer plan at issue ages 18 to 49, the range is $50,000 to $100,000. Dana chose $50,000.

At her age, that amount was not one of the guaranteed issue options. Guaranteed issue means no underwriting. Otherwise, plans are simplified issue, which means the application asks some medical questions. Dana answered them carefully. The brochure is clear that incorrect or incomplete answers can void coverage or lead to denied claims.

The Wellness rider

CriticalGuard offers three optional riders. They cost extra, they apply to everyone on the policy, and they can only be added when you apply. Dana added one: the Wellness rider.

It pays $75 per exam for a covered wellness exam or procedure. The brochure lists examples such as an annual physical, an immunization, a colonoscopy and a mammogram. It pays for one exam per calendar year, and it has the same 30-day waiting period as the main plan. Rider benefits are not counted against the Benefit Lifetime Maximum Amount.

The other two riders, which Dana didn’t take, are:

• Outpatient Prescription Drug: $15 per generic fill and $50 per brand-name fill, up to a combined $600 per calendar year.
• Telemedicine: $0 general physician consultations, unlimited, by app, web or phone at any hour. Behavioral health and dermatology consultations cost extra.

The first year

Dana’s plan took effect on the first of March. Every CriticalGuard plan has a 30-day waiting period after the plan effective date. A diagnosis before the waiting period is over is not covered.

In May, well after the waiting period, Dana had her yearly screening mammogram. It was clear. She printed a claim form from the UHC Member Hub, sent it in with the required information, and the Wellness rider paid her $75. The brochure says benefits are paid directly to you.

That $75 is small. But it was the first time Dana saw the plan work, and she learned the claim process when nothing was at stake.

The second year

The next June, a new calendar year, Dana went back for her screening mammogram. The Wellness rider paid another $75. That is its limit for that calendar year: one exam.

This time the radiologist asked her to come back for more images. A biopsy followed. In July, about 16 months after her plan took effect, a doctor told Dana she had breast cancer.

Her health insurance covered her surgery and treatment the way it always would, after her deductible and coinsurance. CriticalGuard did something different.

How the claim worked

The brochure asks for notice of a claim within 30 days after the First Diagnosis of a Qualifying Event, or as soon as reasonably possible. Dana’s sister helped her print the claim form from the UHC Member Hub the week of the diagnosis. They sent it in with the information the form asked for.

The Cancer plan sorts cancer diagnoses into four Qualifying Events. Each pays a set share of the Benefit Lifetime Maximum Amount:

• Life-threatening cancer: 100%
• Cancer in situ: 25%
• Benign brain tumor: 25%
• Skin cancer: a flat $500

Dana’s diagnosis was reviewed under the policy’s definition of life-threatening cancer. The arithmetic was short:

• Her Benefit Lifetime Maximum Amount: $50,000
• Share for life-threatening cancer: 100%
• $50,000 × 100% = $50,000

The plan paid Dana $50,000 in one lump sum, directly to her. It didn’t matter that her health plan was also paying for her care. CriticalGuard pays regardless of other insurance coverage. And it didn’t matter what her medical bills added up to. The brochure says benefits are a stated amount, regardless of the actual expense.

What the 25% would have meant

Dana’s result could have been different. Suppose the biopsy had shown cancer in situ instead. Here is how that would have worked:

• $50,000 × 25% = $12,500 paid
• $50,000 − $12,500 = $37,500 still available in the Cancer category

The brochure says that when a benefit in a category is less than 100%, the rest stays available. It can be paid for a later Qualifying Event, according to the policy’s terms, but the total never goes above the maximum. So if a later diagnosis qualified as life-threatening cancer, the plan could pay up to the $37,500 left. It would not pay a fresh $50,000.

Cancer in situ, benign brain tumor and skin cancer are each limited to one benefit per person, per lifetime.

Where the money went

The $50,000 was Dana’s to use however she wanted. The brochure is direct about this: bills, living expenses, out-of-pocket medical costs and more. Here is how she split it:

• $6,000 for her share of medical costs under her health plan. Her plan’s out-of-pocket maximum for the year was $6,000, and she reached it by fall.
• $9,600 to replace pay. She cut back to part-time for 12 weeks during treatment, about $800 a week less than usual.
• $1,800 for two trips for a second opinion: travel, a hotel and meals.
• $2,400 for help at home: rides to appointments on days her sister worked, and a cleaner every other week.
• $30,200 into savings, for the year after treatment.

That adds up to $50,000. The point wasn’t any single line. It was that Dana didn’t have to choose between her treatment and her mortgage.

The cancer support service

The Cancer plan includes the Optum Cancer Resource Service at no added cost. The brochure is careful to say these Optum programs are not insurance, and they may require a diagnosis to qualify.

After her diagnosis, Dana used it. According to the brochure, the service offers:

• An oncology nurse who can answer questions and connect you with cancer-related services
• Guidance to providers for treatment or a second opinion, based on the diagnosis
• Help finding a network provider at a Centers of Excellence facility
• Information on clinical trials and links to community resources

The nurse helped Dana find where to get her second opinion. That is where the $1,800 for travel went.

The plan also includes Optum Perks, a prescription discount card. It is a discount program, not insurance, and it is available to the general public.

What the plan didn’t do

Dana’s plan worked the way it was built to. It’s just as important to see where it stops.

It has a 30-day waiting period. A diagnosis that occurs before the waiting period is satisfied is excluded. If Dana’s diagnosis had come in her first 30 days, the plan would not have paid.

It has a preexisting conditions limitation. The policy won’t pay for a Qualifying Event caused by, or contributed to by, a Preexisting Condition. That includes a condition you had care, treatment or medical advice for in the 12 months before your effective date. It also includes a screening or test recommended or done in those 12 months that leads to care after the effective date. This limitation stops 12 months after your effective date. Dana’s diagnosis came about 16 months in, so it no longer applied. If her diagnosis had come sooner and traced back to something from before she bought the plan, the answer could have been different. Some states define this differently.

It only pays for cancer. The Cancer plan pays benefits for cancer Qualifying Events only. It would not pay for a heart attack, a stroke or any other illness. The policy also excludes loss from any other disease, even one complicated by or caused by a Qualifying Event or its treatment.

It pays once per category. Dana’s $50,000 is her lifetime Cancer maximum, and it has now been paid in full. The plan won’t pay another cancer benefit for her, even if her cancer comes back.

It doesn’t replace health insurance. CriticalGuard is a supplement. It is not major medical coverage, and it is not Minimum Essential Coverage under the Affordable Care Act. Dana’s treatment was paid by her health plan. CriticalGuard paid her.

The brochure lists other exclusions too. Among them: a diagnosis made outside the United States, and a diagnosis made by you or a member of your immediate family or household.

Is a plan like this right for you?

A Cancer plan may suit you if:

• You have health insurance, but a high deductible or a long stretch of reduced pay would strain your budget.
• You want money that is yours to spend, not money paid to a hospital.
• Cancer is the specific risk you want to plan for, and you’d rather keep the plan focused.

If heart attack and stroke matter to you as much, compare the Cancer + Heart/Stroke plan. It gives each category its own maximum. If you want the widest list of conditions, compare the full-suite Critical Illness plan.

Questions worth asking before you apply:

1. What Benefit Lifetime Maximum Amount fits my budget, and what range is open to me at my age?
2. Is the amount I want guaranteed issue, or will there be medical questions?
3. Do any doctor visits, tests or treatment in the last 12 months count as a Preexisting Condition?
4. Is a rider worth its extra premium for me? Remember, riders can only be added when you apply.
5. What does my health plan leave me to pay in a bad year?

A few things about the policy itself are good to know. CriticalGuard is available for issue ages 18 through 90, and it is guaranteed renewable for life, as outlined in the policy. It stays renewable until the maximum benefits are paid, premiums go unpaid, you ask to end it, or there is fraud. Premium rates can change. The brochure says they won’t change solely because you made a claim or your health changed, and Nevada policyholders get at least 60 days’ notice of any change.

Once your policy arrives, you have a 10-day free look in most cases (longer in some states). If you decide it isn’t right, you can return it within that window for a refund of the premium you paid.

This is a fictional illustration. Actual policy benefits, underwriting rules, and availability depend on carrier guidelines and state regulations.