Consumer is unsatisfied about rejected claim for critical illness cover

Critical Illness

Jorge came to us when his insurer refused to pay his claim after suffering a heart attack.

What happened

Jorge had a heart attack and had to give up work. He contacted his insurer to make a claim under his critical illness policy. After investigating his claim, Jorge's insurer wouldn't pay out. They said that Jorge's heart attack didn't meet the policy's definition, which is why they wouldn't pay out.

Jorge was unhappy with his insurer's decision, so he made a complaint to us. He said he thought the critical illness cover policy would cover him if he was critically ill. He said that his heart attack had left him critically ill.

What we said

We asked Jorge's insurer to send us a copy of the terms of Jorge's policy. It showed that it was designed to cover heart attacks of "specified severity". The definition of this, along with other factors, was that the attack caused cardiac enzymes to rise above a certain level.

This definition was in line with guidelines set by the Association of British Insurers (ABI) that apply to all critical illness policies.

We looked at medical evidence from Jorge's consultant. It showed that Jorge's cardiac enzymes had been significantly lower than the levels set out in the policy. An echocardiogram test also suggested that the heart attack wasn't "severe" as defined by the policy.

Even though it was clear that Jorge had suffered from a heart attack, the evidence didn't show that Jorge met the policy's definition of a heart attack. Because of this, we decided not to uphold Jorge's complaint.