CR294
Pre-existing conditions
Hypertension and cholesterolaemia as causes of heart failure –proof

Background
The insured’s life policy provided that “No amount shall be payable in the event of your illness, bodily injury, physical defect, ill health, or any other condition which materially contributed to the death claim against the policy, existed (sic) prior to the commencement of the insurance.” The insured died of a heart attack and the insurer rejected the death claim because, prior to the inception of the policy, when the insured life was 55 years old, he had been diagnosed with hypertension as well as cholesterolaemia. The insurer did not submit any blood pressure readings or cholesterol counts to the office, nor did it attempt to prove when these conditions had commenced. One post contractual blood pressure reading of 149/80 was submitted, and as to cholesterol the overall ratio, after conclusion of the contract, was found to be satisfactory. The insured life had no history of any symptoms of heart disease such as angina or shortness of breath. No post mortem was carried out to determine the actual cause of death.

Discussion
The office pointed out that the onus was on the insurer to prove that the pre-existing conditions were the proximate cause of the death, or as the policy put it, that they materially contributed to it.

It is well known that hypertension, even if properly managed, could have a damaging effect on a person’s arteries and heart, especially if it is accompanied by hypercholesterolaemia. Thus if a person had these symptoms before conclusion of the contract and suffers a heart attack resulting in death, insurers usually assume that the pre-existing conditions as such were a cause of the heart attack. It is not in every case, however, that those conditions will necessarily have contributed to the heart attack. In the final analysis the real cause is always a question of fact.

The office asked for expert medical opinion to assist with the assessment of the available evidence. The first expert said he presumed the alleged pre-existing conditions to have been present for some years. In his opinion the two factors are highly significant relating to coronary heart disease. They promote atherosclerotic vascular damage which persists despite adequate control aimed at reducing the progress of such damage. In his opinion the insurer had therefore satisfied the onus resting on it.

The second expert’s opinion was that the post-contractual blood pressure reading had not been bad for a person of the life insured’s age. Considering the evidence and the probabilities he could not conclude that the pre-existing conditions materially contributed to the death.

The office was not persuaded by the views of the first expert. It was of the opinion that speculation is not sufficient, and that the seriousness of the particular conditions and their duration were relevant and should therefore have been proved, which they were not. A person whose blood pressure is only slightly above normal is not as liable to heart failure as a person who has suffered over a prolonged period from blood pressure that is far above normal.

Result

The office ruled that there was insufficient evidence to support a finding, on the probabilities, that either of the alleged risk factors eventually materialised as having contributed to the cause of the insured’s death.

MFBR
October 2009