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
