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Material Facts

Material facts are the pieces of information that are essential for an insurer to accurately assess risk and decide whether to approve an application, determine premiums, or apply exclusions. These facts include any details that could influence the insurer’s decision to issue coverage or the terms of that coverage. Examples include medical conditions, medications, family health history, lifestyle habits, and participation in hazardous activities.

When applying for health, life, or disability insurance, applicants are legally required to disclose all material facts truthfully and completely. Failure to disclose or misrepresent a material fact can result in the insurer denying a claim, canceling the policy, or declaring it void from inception. The obligation to disclose material facts applies both during the initial application and when making changes to existing coverage.

Example:

If you apply for life insurance and do not disclose that you were recently diagnosed with high blood pressure, that omission is considered a failure to disclose a material fact. If you die from a related condition within the contestability period, the insurer may deny the death benefit.

What to Watch For:

Be honest and thorough when answering all questions on insurance applications. If you are uncertain whether something is relevant, disclose it and let the insurer decide. Keep copies of your completed application and correspondence. Once a policy is issued, review the information carefully to confirm that all material facts were recorded accurately.

Related Terms

Major Restorative

Major restorative coverage includes complex dental procedures designed to restore the function and appearance of teeth. Examples include crowns, bridges, onlays, dentures, and sometimes implants. These treatments are more extensive and expensive than basic restorative services such as fillings.

Medical Condition

A medical condition refers to any illness, injury, disease, disorder, or ongoing health issue that affects a person’s physical or mental well-being. In the context of insurance, the term includes both acute and chronic conditions, whether diagnosed, treated, or undiagnosed at the time of application or claim. Examples include high blood pressure, diabetes, asthma, depression, or past surgeries.

Medical Emergency

A medical emergency is a sudden and unforeseen illness, injury, or medical condition that requires immediate medical attention to prevent serious harm, disability, or death. In the context of health and travel insurance, it refers to an unexpected situation where urgent care is needed while away from home or outside your province or territory of residence.

Medically Necessary

Medically necessary describes any service, treatment, or supply required to diagnose, treat, or manage a health condition, rather than for convenience, appearance, or personal preference. Insurers use this term to determine whether a claim qualifies for payment under your policy.

Medically Underwritten (MU)

Medically underwritten (MU) refers to the process used by insurers to evaluate an applicant’s health history before approving coverage and determining eligibility, premiums, and benefit limits. In a medically underwritten plan, you must answer health questions, disclose pre-existing conditions, and often complete a medical questionnaire or provide additional documentation

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