Helen came to us when her insurer wouldn't pay out on her claim because her heart condition didn't exactly match their definition.

What happened

Helen took out life assurance to cover her £150,000 mortgage. The policy benefit was payable if she died or was diagnosed with a critical illness.

A few weeks after taking out the policy, Helen was diagnosed with atherosclerosis. Her consultant recommended that she have a balloon angioplasty to correct her narrowed arteries.

Helen contacted her insurer to make a claim for the policy benefit. They then contacted her consultant to ask whether the blockage was ‘at least 70% in two or more coronary arteries’. This was their policy definition of ‘angioplasty’.

Her consultant confirmed that one artery was 95-99% blocked and another was 50% blocked. The consultant said that this was a particularly serious and life-threatening condition. They also said that if it was left untreated, it would’ve been fatal.

Helen was very upset that her insurer wouldn't pay the claim, as they said that her condition didn't meet the terms of the policy.

What we said

We listened to both sides of the story. Insurers are entitled to decide what conditions they wish to cover. But they must make the terms of their policies clear to customers.

Helen had taken out a policy to cover her for critical illness. She’d experienced a critical illness that required urgent treatment. If her doctor hadn’t performed balloon angioplasty, Helen would’ve required bypass surgery. This would also have entitled her to claim under the policy.

We noted that assessing the extent of a blocked artery isn’t an exact science. We felt that insurers shouldn't just base their decision on a formulaic basis. They also need to think about the seriousness of the condition as a whole.

We felt that Helen's insurer's decision to only pay out to patients with a specific blockage percentage constituted an ‘onerous’ policy condition. We thought that the insurer should’ve made this very clear in the information they gave out to customers.

We decided that Helen's condition was so serious that the insurer couldn't just rely on a formulaic approach to her claim. We decided to uphold her complaint, and told the insurer to pay out the claim given the increases in our award limits.

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