Posts in category: Dread Disease

CR361
Dread disease /Exclusion Clause

Claim for dread disease benefit on grounds of cancer – claim not meeting policy criteria – claim settled

Background

1. The policyholder initially consulted her general practitioner who referred her to a Specialist Physician as she was suffering from a chest infection. She was later hospitalised and treated for pneumonia. Thereafter on 30/04/2014 she was re-admitted with a swollen leg and found to have a large pleural effusion. On 12/05/2014 she was diagnosed with Stage 4 pancreatic cancer and subsequently passed away on 16/05/2014.

2. The complainant’s claim for a dread disease benefit was declined by the insurer on the ground that the deceased did not survive the 28 day waiting period after diagnosis.

3. The relevant clauses are as follows:

Cancer

“Cancer shall mean a malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrollable growth of malignant cells and invasion of tissue. The term malignant tumour includes leukaemia, lymphoma and sarcoma.”

Survival Period

“Survival period shall mean the twenty-eight day period commencing at Date of Occurrence.”

Payment of Benefits

“Upon the admission of a dread disease claim before the earlier of the Termination Age and the first day of the month following a Member’s sixty-fifth birthday, the insurer shall pay the Dread Disease Benefit to the Policyholder or as the Policyholder may direct, provided the Member is alive at the expiry of the Survival Period.’’

Date of Occurrence

“Shall mean the date upon which the dread disease event first manifested itself, as determined by the insurer on the basis of objective evidence obtained in Southern Africa.”

Dread Disease Event

‘’Shall mean the onset or diagnosis of any one or more of the events listed in clause 4.’’

Discussion

4. The dread disease benefit is payable if the life assured survives the 28 day waiting period after diagnosis or onset as per the policy terms. The full sum assured for the dread disease benefit is R162 000.00. The life assured did not meet the requirement of surviving for at least 28 days after diagnosis.

5. The complainant submitted that the life assured survived 28 days after the onset of the condition. The life assured’s general practitioner confirmed that it is likely that the cancer was present even though it was not detected and that the other illnesses that she was suffering from could have emanated from the cancer. The specialist physician further confirmed that the medication that the life assured used, would have improved the cancer infiltration.

6. We forwarded the complainant’s arguments to the insurer regarding the survival period and they did not change their stance. We then asked an independent medical specialist for an opinion and he outlined that the deceased was suffering from cancer prior to the existence of the policy. The independent medical specialist confirmed that the results of the life assured’s CT scan “showed pancreatic abnormalities considered to be the site of the primary malignancy”. He noted that there was no evidence to indicate that the life assured or her doctors were aware of the malignant cells until they received the results of the CT scan . He further confirmed that the life assured’s clinical presentation were manifestations of an initially ‘’hidden’’pancreatic cancer.

Result

7. The insurer considered the report from the independent medical specialist and admitted the claim.
JP
April 2016

CR359
Dread Disease
When did Dread Disease claim arise?
The insured suffered from sinus and swelling in his neck and consulted a doctor. He was treated with antibiotics. About one month later the insured turned 65 and the policy’s cover for the benefit expired. The swelling in the neck did not dissipate and the insured again consulted a doctor, who referred him for a biopsy. The pathology report revealed that the insured had mandibular lymph nodes, indicating metastatic carcinoma.
The insured submitted a claim to the insurer under the cancer benefit. The claim was declined on the grounds that the cover had expired about six weeks previously when he had turned 65. The policy states:
“Expiry Date
(The name of the product) will expire on the anniversary of the Commencement Date immediately preceding the Life Assured’s 65th birthday or when contributions cease to be payable, should that be earlier.”
The insured submitted a complaint to our office and the matter was investigated. The insured’s medical attendant confirmed that the nodes in the neck , which had been present at the first consultation, subsequently turned out to be squamous carcinoma.
The insurer’s response was that the policy requires the histological diagnosis of cancer to be evident prior to the expiry of the cover. Cancer is defined as follows in the policy:
“The manifestation of malignant tumour, including leukaemia and Hodgkin’s disease, supported by a histological diagnosis.”
The policy describes three categories into which the various conditions could fall. Under “Benefit”, the policy states that a claim will be admitted if satisfactory proof is submitted to the insurer that the life assured (1) has suffered major burns, a coma etc, (2) or undergone coronary artery disease surgery etc or (3) “is suffering from cancer”, paraplegia etc.

It was the office’s view that the histological proof was not required prior to the expiry of the benefit, provided the condition had manifested itself prior to expiry and was subsequently medically confirmed. The insured, therefore, had to show that he was suffering from cancer from a date prior to expiry. The condition had manifested itself prior to the expiry date and the nodes were proven to contain malignant tumours when tested a few weeks after the cover had expired. These nodes did not appear over night when he was referred for a biopsy and they were probably present before cover had expired.

The insurer was asked to re-consider the claim, which was subsequently admitted.
NvC
September 2014

CR349
Dread disease / Equity

Claim for impairment and/or dread disease benefit on grounds of dysfunctional colon disease – claim not meeting policy criteria – claim settled for 50% of sum assured on basis of equity

Background

1. The complainant had a dysfunctional colon, and had several surgical procedures over about five years. A nerve stimulator was inserted and this led to improvement in her symptoms but left her with severe pain and discomfort. Her surgeons were reluctant to remove it because of the possibility of spinal cord injury. Eventually she had a colectomy and colostomy which severely limited her lifestyle. She also developed a hernia around the stoma. She had not worked for the last five years.

2. The complainant’s claim for an impairment benefit and/or a dread disease benefit was repudiated by the insurer, on the grounds that her condition did not fall within the ambit of any of the covered conditions on her policy. She lodged a complaint with our office.

Discussion

3. The impairment benefit was payable if the life assured was permanently impaired “as defined in one of the benefit categories” in the policy. The full sum assured for the impairment benefit was R2 million.

4. The condition under the Digestive System which was relevant was the “Lower Gastrointestinal Tract”. The definitions and criteria for this benefit included persistent fever, inappropriate fatigue, sustained weight loss and signs due to inflammation. 50% of the sum assured was payable for moderate to severe exacerbations with severe pain and being more than 15% below desirable body weight (BMI of 19), and 75% was payable for unremitting severe symptoms uncontrolled by medical treatment and being more than 20% below desirable body weight.

5. The complainant did not meet all the criteria necessary, in particular the criterion of being more than 15% below desirable weight; her weight had actually increased over recent years and she had a BMI of 31.

6. The dread disease benefit “provides cover for people who are concerned about the financial burden of an illness or injury”. The benefit was payable for certain stipulated conditions under the specified bodily systems. The full sum assured was R1 million. The contract made it clear that “it is essential that the condition diagnosed fully complies with the applicable definition”.

7. Under “Gastrointestinal System” the conditions covered were Crohn’s Disease, Ulcerative Colitis and Pancreatic Disorders. The complainant’s condition was not any of these. There was no other bodily system under which her condition fell.

8. The policy did, however, make provision for a “Catch-All” dread disease benefit category. This was payable if:

“The Life Assured is assessed as suffering from a serious physical condition that is considered to be of equivalent severity to a condition that would qualify for a 100% payout under another benefit category. The degree of impairment must result in a Whole Person Impairment of at least 35% and meets the Class 4 impairment criteria specified for the relevant system(s) in the AMA Guide, in order to qualify for a payment under this benefit category”.

9. The policy specifically referred to the Whole Person Impairment (WPI) concept, “as published from time to time in the American Medical Association’s (AMA) ‘Guidelines to the Evaluation of Permanent Impairment’”. This incorporates a complex scoring system for different conditions and allows for objective standards to be applied.

10. The insurer calculated the WPI as 23%, thus below the 35% required for a benefit.

11. We asked the insurer to provide us with the worked calculation, and then provided this to the complainant’s doctor. On his calculation, including the hernia problem, the WPI was 29%. The insurer stood by its decision, as this was still below the required 35%.

12. We accepted that the complainant’s condition did not meet the criteria under any of the impairment benefit or specified dread disease categories. However we requested that the insurer reconsider the case on equitable grounds.

13. We noted that one of the criteria for the dread disease Catch-All benefit was that the life assured be suffering from a serious physical condition considered to be of equivalent severity to a condition that would qualify for a 100% payout (R1 million in the complainant’s case) under another benefit category. We pointed out that 100% was payable for Crohn’s Disease or Ulcerative Colitis “requiring permanent colostomy or ileostomy”. While the complainant did not have these diseases, she had a permanent colostomy, and this was certainly a marker of severity of the burden of her illness. We noted further that the insurer had not disputed that the addition of the hernia would place the WPI at 29%, which was not far from the Catch-All requirement of a 35% WPI.

14. According to her doctors, the complainant had severe dysfunctional colon disease with an end stage colostomy. As she was unable to
work she had obviously suffered a financial burden from her illness, against which the policy was, according to its terms, designed to provide cover. We accepted that the Catch-All benefit did not provide for any graded levels of severity, but stated that in our view the criteria for this category indicated a degree of discretion/flexibility in the assessment. We asked the insurer to consider making an ex gratia payment, of all or part of the sum assured.

Result

15. The insurer responded that, while it still did not believe there was any claim as it did not meet the dread disease criteria stipulated in the policy, “in terms of equity” it was prepared to offer a concession payment of 50% of the sum assured to the complainant as a full and final settlement.

16. The complainant accepted the offer, and was paid R500 000.

SM
September 2014

CR346
Underwriting

Alleged unreasonable delay in processing application for dread disease cover – in the interim complainant diagnosed with breast cancer and cover not granted.

During August 2010 the complainant, who already had other risk policies with insurer A, obtained a quote for dread disease cover from insurer B, and then approached insurer A to find out if they could give her better terms. As insurer A wanted to retain her as a client they engaged in negotiations with her financial adviser, who was insurer A’s agent, to persuade her not to move the complainant’s portfolio from insurer A. During the negotiations, which took some time, the complainant accepted insurer B’s quote and was granted dread disease cover the commencement date of which was to be 1 October 2010. Having in the meanwhile been persuaded by insurer A that they could offer better terms, the complainant cancelled her policy with insurer B on 1 September 2010 and on the following day applied for dread disease cover to be added to one of her existing policies with insurer A.

Although she had given her application for the policy alteration to her financial adviser on 2 September 2010, the latter only submitted it to the insurer on 7 September 2010, and informed her that the processing of the alteration would take no more than seven days. Insurer A explained that in terms of its service level agreement, policy alterations that do not require underwriting have to be processed within four days, while those that do require it, as in the case of the complainant, have to be processed within 30 to 45 days. The letter requiring the complainant to undergo certain blood tests was uploaded on 17 September 2010.

The complainant claimed that she was in good health when she applied for the policy alteration. However, on 21 September she discovered a lump on her breast which was initially thought to be benign, but after its excision on 27 September 2010 was found to be cancerous. At that stage the complainant had not yet complied with the underwriting requirements, and when she did so on 30 September 2010 cover was not granted due to the cancer diagnosis.

The complainant contended that the delay in processing her application was unreasonable and that it had caused her to suffer loss for which insurer A was liable. She explained that had there been no delay the intervening cancer diagnosis would not have affected her application as cover would probably have commenced by then. She further contended that as a result of being persuaded by insurer A not to take the dread disease policy from insurer B, she had cancelled said policy and could no longer qualify for cover due to the cancer diagnosis.

We found that the insurer’s delay was not unreasonable in that it complied with the insurer’s service level agreement. We also found that there was a delay on the complainant’s part in complying with the underwriting requirements, and that since according to the insurer policy alterations take effect on the first day of the month following the date of acceptance of risk, insurer A’s policy would not have commenced before the 1 October 2010. With regard to the complainant’s contention that she had suffered loss as a result of being persuaded to cancel the policy with insurer B, we found that as the commencement date of that policy was 1 October 2010, and in keeping with the common law requirement to notify the insurer of any changes in health occurring between the date of acceptance of the application for cover and the date of commencement of cover, she would have been required to disclose the cancer diagnosis to insurer B and would doubtless not have been granted cover.

CNN
February 2013

CR334
Dread disease

Medical evidence not meeting criteria for claim on basis of stroke – claim repudiated – insurer asked to consider whether the evidence supported any other condition listed under “Nervous System” – insurer requesting neurologist report – complainant undergoing neurology assessment resulting in diagnosis of motor neuron disease – claim paid

Background

1. The complainant had a policy covering him for death, disability and dread disease, commencing on 1 February 2011. In May 2011 he fell and hurt his face. Subsequently he noticed that he had no feeling in his left index finger, his speech was slurred and his left leg dragged as he walked. He went to Addington Hospital and was put on daily aspirin treatment. An appointment was made for a scan, the earliest time available being three months later. When he had the scan in August 2011 there was no sign of a clot, but there were “features of age inappropriate cerebral atrophy”, as reported by the radiologist. He was under the impression that he had had a stroke, but that the clot had dissolved by the time he had the scan.

2. The complainant lodged a claim for a critical illness (dread disease) benefit, stroke being one of the conditions listed in the policy as covered under “Nervous System”. The insurer however repudiated the claim as the medical reports did not confirm the diagnosis of a stroke, and the condition of age inappropriate cerebral atrophy was not an insured event. The complainant lodged a complaint with our office.

Discussion

3. We accepted that there were no signs of stroke, but we mentioned to the insurer that various conditions were covered under “Nervous System” as well as stroke, including Altzheimer’s disease, dementia, benign brain tumour, Guillain Barré syndrome, Creutzfeld-Jacob disease, motor neuron disease, multiple sclerosis, muscular dystrophy and accidental brain damage amongst others. We asked the insurer whether the signs of age inappropriate cerebral atrophy would not fall within any of the other conditions listed under this category.

4. The insurer’s medical officer responded that the brain scan report indicated widespread signs of a shrinking brain, and involvement of the ventricular system, sulci and basal cisterns. He stated that this was typical of a chronic brain condition like senile dementia, Alzheimer’s disease, alcoholism or early age related atrophy. He proposed a neurologist assessment.

5. We pointed out to the complainant that while he might have one of the listed conditions, no such condition had actually been diagnosed and verified. The insurer was not prepared to pay for a neurologist assessment, correctly pointing out that the onus of proving his claim lay with the complainant.

6. The complainant then obtained a referral to Albert Luthuli Hospital where he was admitted for eight days for neurophysiological tests, MRI brain and spine scan, blood tests and lumbar puncture. Motor neuron disease was diagnosed.

Result

7. We sent the test results to the insurer. A claim for motor neuron disease was admitted and paid, in the amount of R715 000.

SM
February 2013

CR251

Dread disease claim – interpretation of contract – complainant making second claim in respect of dread disease benefit – insurer refusing to pay claim on ground that benefit cancelled after first claim – policy wording did not support this interpretation – if any ambiguity in policy, wording to be construed contra proferentem

Background

The insured had had a life policy for 17 years. There was a dread disease benefit attached, covering heart attack, heart surgery, cancer, stroke, kidney failure, and paralysis. In 2005 he underwent heart surgery, submitted a claim and was paid R53 322. He thereafter paid full premiums, escalating each year, and continued to receive updated annual schedules, the latest of which indicated a dread disease benefit in 2007 of R63 500 (and a death benefit of R318 000).

In May 2007 the insured was diagnosed with cancer of the colon. The insurer refused to pay his claim, contending that the policy provided that any payment of a claim on the dread disease benefit would cancel this benefit, and reduce the life cover and disability benefits by the amount paid out. The insurer stated that they had neglected to adjust the policy after the claim payment in 2005, and the benefits had mistakenly remained in force so that he could not submit a second claim. The insurer adjusted the policy and applied the surplus premiums of R3 425 to investment; alternatively the insurer was prepared to refund the premiums plus interest if the insured preferred.

The insured was unhappy about these suggestions, stating that if he had known in 2005 that the benefit was cancelled, he could have made arrangements for alternative savings or dread disease cover. He now had huge medical bills which he could not pay, as he had relied on his insurance for such eventualities.

Discussion

In our view it was not at all clear that the relevant policy clauses could be interpreted to mean that the dread disease cover would be cancelled after a payment of the benefit.

The policy stated that any dread disease benefit accruing shall

“(a) be payable in lieu of the benefit(s) or such amount of the benefits (as stated in the schedule) which would otherwise have been payable had death occurred at the date on which the event giving rise to the claim took place, and

(b) have the effect of terminating the benefit(s) or such amount of the benefit in lieu of which the [dread disease] benefit is payable”.

In our view clause (a) meant that payment of the dread disease benefit is in place of payment of the death benefit, or that proportion of the death benefit which is stipulated in the schedule as being the amount of the dread disease benefit. Clause (b) appeared to refer to the same benefits as clause (a) (ie the death benefit) and apparently stipulated that payment (of the dread disease benefit) shall have the effect of terminating the death benefit or such amount of the death benefit in lieu of which the dread disease benefit was payable. On this reading of the clauses the death benefit would either be cancelled (only if it was equivalent to the amount of the dread disease benefit) or reduced by the amount paid in respect of the dread disease benefit (as set out in the schedule).

The wording in the clauses could be compared with a clause under the accidental death and injury benefit, which stated that

“Payment of any benefit accruing in terms of this provision shall have the effect of terminating the Accidental Death and Injury Benefit and no further premiums or benefit can or will become payable thereunder”.

There was no mention under the dread disease benefit that no further premiums or benefit can or will become payable after a claim has been paid.

When we pointed this out, the insurer took the view that the wording was ambiguous, but that the insured was not entitled to be paid the dread disease benefit again. They were prepared to grant an amount of R6590, however, being the upgrades that had taken place between the first and second claim dates, less the premiums they had already refunded. R3165 was paid into his bank account.

The matter was discussed at an adjudicators’ meeting. The unanimous view was that to the extent that there was any ambiguity, which we did not perceive, the wording should in any event be interpreted contra proferentem i.e. against the drafter of the policy, the insurer. In effect the policy provided for an acceleration of a part of the death benefit, being the part stipulated in the schedule as being the amount of the dread disease benefit. There was no restriction in the policy to payment of only one claim under the dread disease benefit, nor was there any provision for the benefit to be cancelled; the death benefit was however reduced by the amount paid in respect of the dread disease benefit (as set out in the schedule).

Result

We made a provisional ruling that the insured be paid the benefit in respect of his second dread disease claim, for cancer, less any amounts already paid, together with interest as from the date of the second claim. The insurer accepted the ruling and the benefit was paid.

SM
May 2008

CR241

Dread disease

Complainant claiming for dread disease benefit on grounds of cancer – policy excluding “(a) all skin cancers, and (b) cancer–in-situ, including all melanomas-in-situ”- established that, while complainant’s was not a cancer-in-situ or a melanoma-in-situ, the tumour had not spread beyond the skin and therefore remained a skin cancer; insurer’s liability excluded

Background

The complainant’s policy provided for the payment of benefits in the case of so-called “personal catastrophes”, of which cancer was one. It was described as follows:

“Cancer – a disease manifested by the presence of a malignant tumour characterised by the uncontrolled growth and spread of malignant cells, and the invasion of tissue. The term “cancer” also includes leukaemia and Hodgkin’s Disease but excludes:
(a) all skin cancers
(b) cancer-in-situ, including melanoma-in-situ”.

Medical reports indicated that the complainant had a “changing mole” on his right leg. A biopsy showed that it was “an infiltrating superficial spreading melanoma”, measured as “Clark’s Level III Breslow 0,32mm”. The tumour was excised. The doctor reported that there was no residual tumour, and the area healed without complications.

The insurer repudiated the complainant’s claim for a benefit on the grounds that such cancer, a skin cancer, was an excluded type in terms of the policy provision.

Discussion

We agreed with the insurer that, as the cancer was a skin cancer, it was an excluded condition, and the insurer was not liable to pay the claim. We furthermore advised the complainant that his melanoma also appeared still to be in-situ. We referred to clinical descriptions of the stages of melanoma published by the Skin Cancer Foundation, which indicated that his melanoma was at Stage 1a – the tumour was less than 1.0mm (regarded as a very thin tumour) and had not spread to any other part of the body beyond the skin.

The complainant took issue with this. He claimed that, because his was one that was described as an infiltrating superficial spreading melanoma, his cancer was not one in-situ and that it was therefore not excluded. He backed his assertion with a letter from a dermatologist to the effect that, as the melanoma had infiltrated the skin, rather than remaining on the outer layer (epidermis), it was not a melanoma-in-situ. Based thereon the complainant maintained that the express addition to the definition in clause (b) of a melanoma-in-situ as part of the exclusion could only mean that a melanoma that is not in-situ was not intended to be excluded. He also argued that melanomas are not normal skin cancers, and that this was apparently why they were mentioned as a separate case in the policy.

At that stage we sought the advice of an independent medical expert, who agreed that the melanoma was not in-situ, as it had spread from its site of origin into neighbouring epidermal tissue. He added, however, that as it had not spread beyond the basement layer of the dermis, it was confined to the skin and was therefore still a skin cancer.

We therefore stood by our initial ruling that the cancer, being a skin cancer, was excluded. We accepted that because all skin cancers were excluded in terms of clause (a), it was unnecessary for the policy also to have mentioned a melanoma-in-situ as an exclusion in clause (b). While it was certainly a tautologous addition, however, it made no difference and would not mean that the exclusion in (a) did not apply to the complainant’s melanoma.

Result

The insurer’s repudiation of the claim was upheld.

CR182

Dread disease benefit claim – insurer refused claim, as condition did not qualify, but was only prepared to offer more life cover at substantially higher rates

Background

The complainant, Mrs M, took out an insurance policy in 2001. In 2004 she was diagnosed with breast cancer. A mastectomy was performed and she submitted a claim under her policy. Cancer is defined in her policy as follows: “The manifestation of a malignant tumour, characterized by the uncontrolled growth and spread of malignant cells and the invasion of normal tissue, and which requires major surgery and/or chemotherapy and/or radiotherapy.”

The insurer took the view that “the crux of the matter is that the breast cancer was in situ, had not spread and was not characterized by the uncontrolled growth of malignant cells and the invasion of tissue.” Based on this view, the insurer declined the claim.

The complainant then applied for more life cover and terms were offered at substantially higher rates, as “there is a history of illness, namely breast cancer… The client has been placed in a high-risk category and will be loaded accordingly.”

The complainant referred the matter to our office for assistance, as she was unhappy with the conclusion that her condition did not qualify her for the dread disease benefit but that life cover would only be offered to her at substantially higher premium rates.

Discussion

We referred the matter to an independent medical consultant for an opinion and he stated the following in his report:

“I would therefore not contradict the insurer’s rejection of the claim, as the contractual criteria defining cancer have not been fulfilled. However, this case is somewhat unusual, in that the extent of cancerous ductal cellular change was scattered and widely spaced, and that in addition, a second focus of lobular carcinoma in-situ, with a worse prognosis was found, causing the surgeon to proceed to a mastectomy operation.

Possibly also worthy of consideration, is Mrs M’s allegation that she had been offered four-fold premium-loading by [the insurer] at her recent application for more life cover. This would support her impression that the insurer, while trivializing her claim for cancer, considers the event to be of major prognostic significance when offering further insurance.”

A copy of the report was provided to the insurer.

Result

The insurer made an offer of 50% of the dread disease benefit to the complainant, which she duly accepted.

HE
November 2006

CR160

Dread disease claim – heart attack definition not met

Background

The definition of heart attack in dread disease polices has been a recurring problem for the Ombudsman’s office and is a problem which goes back many years. Dread disease contracts usually define heart attacks as “… the death of a portion of heart muscle as a result of inadequate blood supply…” and stipulate the three criteria needed to substantiate the diagnosis. These are:-

1. Cardiac related discomfort;
2. Electrocardiographic changes;
3. Elevation of cardiac enzymes above standard laboratory level

Assessment

In this particular case the complainant’s doctor had informed him unequivocally that he had suffered from a heart attack but the claim was declined as the three criteria mentioned above were not met. It was clear from the medical evidence that the complainant had suffered an episode of chest pain consistent with cardiac pain. The ECG changes supported a diagnosis of heart attack but the cardiac enzyme levels were not in fact increased.

The three criteria mentioned above is the established diagnostic criteria accepted by the European Society of Cardiology and the American College of Cardiology and clearly one is dealing with a diagnostic directive applicable to academic and epidemiological cardiology. This will not necessarily apply in clinical practice where doctors would not be so confined when making a diagnosis of heart attack and quite clearly doctors may state that a patient had suffered a heart attack when only two of the above criteria are present. One can understand the policyholder’s strongly felt grievance when he is informed unequivocally by his own doctor that he suffered a heart attack, to have his claim repudiated by the insurer. However, so far as our office is concerned we have to give effect to the contractual definition and not to clinical practice and consequently, in this particular case, because raised enzymes did not feature, the insurer’s decision to deny liability was upheld.

Result

The complaint was not upheld.

DM
April 2006

CR79

Dread disease claim rejected. Catheterisation and angioplasty cannot be regarded as open-heart surgery.

Background

The policy which was issued some years ago featured a dread disease benefit, one of the events covered being heart surgery, which was defined as ‘open surgical correction of structural abnormalities of the heart or coronary arteries.’ The policyholder submitted a claim for benefit following angiography and the insertion of stents utilising a catheter. The complainant argued that “in order to correct the defect the physicians had to insert the stents via my thigh which had to be “opened up” in order to locate the defected arteries.

The Ombudsman’s initial reaction was that the complaint was barely serious, bordering on the frivolous. However, on reflection it was appreciated that layman’s knowledge of medical technical procedures were probably limited.

Assessment

The fact that the skin had to be transgressed (opened up) to obtain access to an artery in order to advance a catheter into coronary arteries does not qualify the process to be labelled as an open surgical procedure. Medical procedures have changed and now it is unusual for an incision to be made in the groin. The usual procedure is to insert a needle through which the catheter is passed into the artery without any incision. If a small incision has to be made it would certainly not change the procedure to an “open surgical” event.

This is not a matter of semantics – there is a vast difference between open surgical access to the heart and the percutaneous transvascular approach. To further exemplify this difference, stent insertion is performed by a cardiologist, considered to be a physician specialised in invasive cardiology, whereas open heart surgery is performed by a cardiac surgeon.

Result

The complaint was not upheld.

DM

October 2005