Jorge was disappointed to discover that his heart attack wasn’t severe enough for his critical illness policy.
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 declined it. It said that his heart attack didn't meet the policy's “severity” definition, which is why it wouldn't pay out.
Jorge was unhappy with his insurer's decision. He thought his critical illness policy would cover him because his heart attack had left him critically ill. He brought his complaint to us.
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 a particular level of 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. A medical test called an echocardiogram also suggested that the heart attack wasn't “severe” as defined in the policy.
Even though Jorge had suffered from a heart attack, the evidence didn't show that Jorge met the policy's definition of a severe heart attack. Because of this, we didn’t uphold Jorge's complaint.