Specified serious illness in Ireland — the conditions list, partial payments and what is actually covered

The two questions an SI policy answers

A specified serious illness policy answers two questions, in order. First: is the condition you are diagnosed with on the list of conditions the policy covers? Second: does your specific diagnosis meet the severity definition the policy attaches to that condition? Both questions must produce a “yes” for the claim to pay in full. A “yes” on the first and a “no” on the second — condition covered but severity threshold not met — produces either a partial payment, where partial cover applies, or a declined claim where it does not.

The 2025 mylife.ie whole-of-market claims report puts SI paid rates at 87–93% across the four offices that publish a percentage. The headline number that often appears in marketing — “92% of claims paid” or similar — is the share of claims that reach a payable outcome. The remaining 8–13% are declined predominantly on the second question, not the first. Irish Life publicly states that “definition not met is the biggest cause of declined specified serious illness claims.” New Ireland’s 2024 disclosure broke down 47 declined SI claims as 42 definition-not-met and 5 non-disclosure — nearly nine times as many declines on definition as on disclosure.

The conditions list — how it is built and what is on it

Every Irish SI policy is built around a list of named conditions that the policy will pay on, subject to severity. The list is set in the policy booklet at outset and does not change after the policy is issued. The number of conditions varies by office — Irish offices in 2026 carry lists ranging from roughly 45 to 70+ named conditions, depending on the product tier and the office.

The headline tier of any Irish SI policy will include the conditions below. These are common to all five regulated Irish life offices and account for the great majority of paid SI claims:

• Cancer — invasive malignant disease meeting a defined severity threshold.
• Heart attack — myocardial infarction of specified severity, evidenced by raised cardiac enzymes plus characteristic ECG changes.
• Stroke — cerebrovascular event producing permanent neurological deficit beyond a defined duration.
• Coronary artery bypass surgery — actual undergoing of bypass surgery.
• Multiple sclerosis — well-defined neurological abnormalities persisting for a defined period.
• Major organ transplant — actually undergoing or being on the official waiting list for transplant of heart, lung, liver, kidney, pancreas or bone marrow.
• Kidney failure — end-stage renal failure requiring permanent dialysis or transplantation.
• Benign brain tumour — specified severity, typically requiring surgical removal or producing permanent neurological deficit.
• Total and permanent loss of sight, hearing or speech
• Motor neurone disease, Parkinson’s disease, Alzheimer’s disease — each with diagnostic and severity definitions.

Higher-tier products and recent product launches typically add a further 20–40 conditions — less common cancers in early stages, less common neurological conditions, defined paediatric conditions, and a range of partial-payment categories that do not appear on the headline tier. The headline tier and the higher tier of the same office can produce materially different claim outcomes for the same diagnosis.

Severity — the threshold that decides claim outcomes

Every condition on the list carries a severity definition. The definition is the single most important part of the policy wording for that condition. Two policies that both “cover cancer” can produce a paid claim and a declined claim on identical clinical facts purely because their cancer definitions differ.

Heart attack. The Irish market standard requires evidence of myocardial necrosis (raised troponin or other cardiac enzymes) plus ECG changes characteristic of infarction. A diagnosis of “myocardial infarction” in the discharge letter is not, on its own, sufficient — the underlying clinical evidence is what the underwriter examines. Episodes of unstable angina, troponin rises below the defined threshold and ischaemia without infarction typically do not meet the heart-attack definition.

Stroke. The Irish market standard requires permanent neurological deficit evidenced beyond a specified post-event window — typically four weeks or longer, depending on the office. Transient ischaemic attacks (TIAs) are explicitly excluded from the stroke definition at every Irish office. A stroke that resolves clinically within the defined window does not meet the definition, even though it is medically a stroke.

Coronary artery bypass surgery. Defined by the actual undergoing of the surgical procedure, not by the underlying coronary artery disease. A policyholder whose disease is treated by angioplasty and stenting (rather than bypass) is not paid under the bypass definition at any Irish office, though many offices carry a partial-payment carve-out for angioplasty.

Cancer — the condition that decides most claims

Cancer accounts for 60–68% of paid specified serious illness claims across the four Irish offices that disclose the breakdown. The cancer definition is therefore the single most consequential piece of wording in any Irish SI policy.

Source: each office’s 2025 claims publication, compiled in the mylife.ie 2025 whole-of-market report. Royal London Ireland publishes a combined all-types paid rate and does not separately disclose cancer share.

The Irish market cancer definition typically requires invasive malignant disease— a malignancy that has spread beyond the basement membrane or organ of origin. Pre-malignant disease, in situ carcinoma (cancer that has not invaded), and certain skin cancers are excluded from full payment at every Irish office. They are, however, frequently covered under partial payment carve-outs.

Partial payments — the carve-outs that matter most

A partial payment is a defined fraction of the sum assured — typically 10%, 20% or 25%, capped at a maximum cash amount — paid where a condition meets a less severe threshold than the full-payment definition. Partial payments matter most on cancer, cardiac and neurological conditions where early-stage diagnoses are common and modern treatment outcomes are good but financially costly.

The most consequential Irish partial-payment carve-outs in 2026:

• Early-stage prostate cancer. Diagnosed at low Gleason score (commonly Gleason 6) and at early T-stage (commonly T1 or T2a-c). Different offices draw the line at different stage-and-grade combinations.
• Carcinoma in situ of breast. Pre-invasive breast cancer (DCIS, LCIS). Universally excluded from full payment, near-universally included in partial payment at varying percentages.
• Ductal carcinoma in situ. Specific subtype of in-situ breast cancer; partial payment standard.
• Early-stage thyroid cancer. Sub-T2N0M0 thyroid cancer is partial-payment at most offices, full-payment at none.
• Early-stage bladder cancer. Below T2N0M0 (non-muscle-invasive) is typically partial-payment.
• Pre-Binet-A chronic lymphocytic leukaemia (CLL). Asymptomatic CLL meeting only early diagnostic criteria.
• Angioplasty and stenting. Coronary artery disease treated by percutaneous intervention rather than bypass surgery; partial-payment carve-out at most offices.
• Less advanced strokes. Some offices carry a separate partial-payment definition for strokes that produce neurological deficit shorter than the full-payment threshold.

The partial-payment list is where the five Irish offices diverge most materially on like-for-like cover. A policy with a longer, more inclusive partial-payment list is meaningfully more valuable than the headline sum assured alone suggests, and the price difference between offices on partial coverage is often a fraction of the price difference on full coverage.

Exclusions — conditions and circumstances that do not pay

Every Irish SI policy carries a defined exclusion list in addition to the severity thresholds. Standard market exclusions include:

• Self-inflicted conditions — deliberate self-injury, including suicide attempts.
• Conditions caused by alcohol or drug misuse — typically defined to require a direct causal link.
• HIV / AIDS — outside defined exceptions (e.g. occupational acquisition by a healthcare worker, or transfusion-acquired infection, where these carve-outs are included).
• Conditions arising from war, civil war, terrorism where the policyholder was an active participant.
• Pre-existing conditions specifically excluded at underwriting — these appear in the policy schedule, not the standard exclusion list.

The standard exclusion list is short. The far more consequential restriction on payment is the severity definition on each named condition — the exclusion list catches a small number of edge cases; the severity threshold is what decides the typical declined SI claim.

Children’s serious illness benefit

Most Irish SI policies include, either as standard or as an optional rider, a children’s serious illness benefit. The benefit covers diagnoses in the policyholder’s children up to a defined age (commonly 18 or 21) against a defined list of paediatric conditions — often a subset of the adult list, plus a small number of conditions specific to childhood.

The payment under the children’s benefit is typically a defined fraction of the parent’s sum assured, capped at a cash maximum — commonly 50% of sum assured to a maximum of €25,000 to €30,000, depending on the office. The benefit is paid to the policyholder, not the child, and claims are administered alongside the parent’s policy. The children’s benefit does not reduce the parent’s sum assured.

Why two policies on the same life can pay differently

The headline architecture of Irish SI cover is the same across the five regulated life offices. The detail — severity thresholds, partial-payment lists, exclusions, children’s benefit definitions — differs in material ways. The 2025 mylife.ie whole-of-market claims report shows the SI paid-rate spread (87–93%) as the largest paid-rate spread of any protection product class in the Irish market. The spread is structural and wording-driven, not behavioural.

Two policies sold to the same person, by two different offices, in the same year, can pay and not pay on identical clinical facts purely because the wording differs. The lower paid rate on a specific office is not, on its own, a signal that the office is behaving badly. It is a signal that the contract is written to a tighter set of severity thresholds. The cheapest SI premium in the market is rarely the most claimant-friendly contract, and is sometimes the least.

How mylife.ie compares SI wording across the market

mylife.ie is a whole-of-market intermediary regulated by the Central Bank of Ireland (C42382). On any specified serious illness enquiry, a QFA-qualified adviser compares the five regulated Irish life offices — Aviva, Irish Life, New Ireland, Royal London Ireland and Zurich Life — on the specific conditions and severity thresholds most relevant to the case. Where the consumer has a relevant family history or a specific concern, the comparison can be weighted toward the offices whose wording responds best to that exposure.

We do not claim to be the cheapest in every case — we claim to compare every case. Every case reviewed by a QFA.

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