Posted by James Millar Craig, Partner
When is a heart attack not a heart attack? Why it matters to insurers
James Millar Craig, partner and lead in our denied health insurance claims team, takes a look at a traumatic example of insurers using small print to reject a critical illness policy claim.
To the average lay-person there is not much distinction between a cardiac arrest and a heart attack, but to one family it has meant the difference between being insured and not.
In the case of Steven Huddleston, he was very lucky to survive at all when his heart stopped for 20 minutes. He had suffered a very serious cardiac arrest. After the event, Steven and his family thought that he would not have much trouble in making a claim with Aviva.
Steven was a self-employed floor layer and he had been paying premiums on his critical illness policy for 16 years, as he had a wife and three young children to support and needed to pay his mortgage should the worst happen. Steven was in for a shock, though, when he put in his claim and Aviva denied it, claiming that his cardiac arrest was not the same as a heart attack and denying his claim for a £66,500 payout under the policy.
What is the difference between a heart attack and cardiac arrest?
Apparently, under the insurance policy, Aviva claimed he was not covered for a cardiac arrest.
It appears that the distinction between a heart attack and a cardiac arrest is as follows:
- a heart attack is where the supply of blood to the patient is blocked, normally by a blood clot;
- a cardiac arrest is when the person’s heart stops pumping blood around their body, leading the brain to be starved of oxygen, to stop breathing and the patient fall unconscious.
Both conditions are a medical emergency and potentially fatal unless treated rapidly.
Most people would not understand that distinction at all, particularly when (as in the case of Steven) they have suffered a massive cardiac arrest. It also seemed quite extraordinary for Aviva to reject his claim in these circumstances.
What does this mean for people with a critical illness policy?
Aviva has stated that, since 2013, they have updated their critical illness policy to include cardiac arrest, but as Steven had an older policy it was not covered as distinct from a heart attack (another irony as he had been paying in for 16 years). After being contacted by Money Mail they are making further enquiries and providing some “financial support”.
This dramatic example shows how Aviva and other insurers are fast to rely on the small print with critical illness policy claims in order to avoid a payout, and indeed some of the older policies are defective when compared to the newer ones.
James Millar Craig had this to say about the case:
“We are seeing more and more disputes involving critical illness policies with insurers either refusing to pay out – by seeking to rely on small print exclusions – or embarking on a laborious search through GP records in order to allege some form of non-disclosure of a pre-existing medical condition. Often these conditions are totally unrelated to the illness that causes the claim.
It is best to take early legal advice in the event of a denied health insurance claim, and at the end of the day the Financial Ombudsman Service (FOS) will expect insurers to act in a fair, reasonable and proper manner. It must have been very distressing for Steven Huddleston and his family that after he sustained such a devastating cardiac arrest he then had to battle with the insurers to secure even an interim payout.”
If your health insurance claim has been denied, contact our team to see if they can help
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