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Determination
Case number | 12-00-1008694 |
Financial firm | Resolution Life Australasia Limited |
Case number: 12-00-1008694 26 June 2024
The complainant had a heart attack. He made a claim on his trauma insurance policy. The insurer accepted the claim and paid a portion - $50,000 – of the full sum insured. It says the complainant’s heart attack did not meet the policy requirements for payment of the full sum insured.
The complainant disagrees.
No. The complainant was not entitled to the full benefit under the original policy terms. He was entitled to, and was paid, the part benefit under the upgraded policy.
Fairness requires the reasonable expectations of the parties to be met. I am satisfied that in all the circumstances, while the complainant could reasonably expect to be paid a benefit where he suffered a heart attack as diagnosed by his doctors, he has been paid the correct benefit, according to the upgraded terms of the policy.
This determination is in favour of the insurer. The insurer is not required to pay a further benefit or take any other action.
No. The complainant was not entitled to the full benefit under the original policy terms. He was entitled to, and was paid, the part benefit under the upgraded policy.
The original policy terms are recorded in a policy document headed ‘Plan Rules’. The policy pays a benefit if the complainant suffered one of the ‘crisis conditions’ listed and defined in the policy. Among the ‘crisis conditions’ is ‘heart attack – myocardial infarction’.
The policy defines that condition:
Heart attack – myocardial infarction
Description
We will pay if part of an insured person's heart muscle dies as a result of inadequate blood supply to the relevant area. An appropriate consultant medical specialist must certify that a heart attack has occurred and provide confirmatory evidence of this by the following test results:
1. New electrocardiographic changes consistent with myocardial infarction and abnormal biomarkers such as a cardiac enzyme rise above the upper limit of normal
2. a rise of Troponin I above 2.0 ng/ml or Troponin T above 0.6 ng/ml, and evidence of permanent impairment of cardiac function due to the cardiac event, as assessed by reduction of left ventricular ejection fraction to 50% or less where such is confirmed at least 6 weeks after the cardiac event.
We will not pay for other causes of severe non-cardiac chest pain. heart failure or angina.
GLOSSARY OF TERMS
Cardiac enzymes - Damage to heart muscle can raise the level of these enzymes. This is shown in a blood test.
Electrocardiographic changes A graph of electrical activity of the heart showing variation from the normal which is consistent with a heart attack.
Myocardial infarction Heart attack.
The complainant says that the glossary of terms – where myocardial infarction is said to mean heart attack, means that a diagnosis of heart attack or myocardial infarction is enough. I do not agree. The policy needs to be read as a whole. It is clear that there are criteria which must be met (electrocardiographic changes, abnormal biomarkers) before an entitlement arises.
The policy also covers ‘Heart attack - out of hospital cardiac arrest’ but there is no suggestion the complainant suffered that condition.
The insurer says the complainant did not meet requirement for electrocardiographic changes.
The complainant disagrees. He relies on a letter from his GP, Dr EU, dated 6 August 2023, which says:
His ECG findings and troponin levels were consistent with myocardial infarction.
…
For the avoidance of doubts, he had abnormal ECG
The complainant also relies on a referral letter Dr EU wrote to B Hospital on 4 May 2023, which said:
Inverted T waves in V1
I do not accept Dr EU’s opinion. The complainant’s treating cardiologist, Dr DC, wrote ‘normal ECG’ in a medical certificate dated 2 August 2023. That opinion is consistent with an ECG report dated 4 May 2023 which says ‘Conclusion: normal ECG’. Dr DC wrote a further letter dated 22 August 2023, and again in that letter did not say that the complainant had an abnormal ECG. Because he is a cardiologist, Dr DC is better qualified than Dr EU to interpret the complainant’s ECG. I accept his ECG was normal.
There is no evidence showing that the complainant’s ventricular ejection fraction met the requirements of this definition.
The complainant does not meet the definition in the original policy document.
The insurer also assessed the complainant against newer definitions:
Those definitions all refer to ECG changes. Because I do not accept the complainant had ECG changes, he also does not meet those definitions, insofar as they require ECG changes. The other definitions have alternative tests which refer to Q-waves, ventricular ejection fractions, and imaging evidence, but the medical evidence does not show that the complainant met those requirements either.
It follows that the complainant is not entitled to the full benefit for heart attack.
The original policy terms guaranteed to pass on policy upgrades to the complainant:
We review our [policy name] Insurance plans regularly. If we enhance them without increasing the table of rates, reducing existing premium discounts or charging extra premiums, we will automatically offer you enhancements for which you are eligible at no charge.
If we offer this on the plan anniversary, you accept the enhancement when you pay the premium.
The complainant’s policy was upgraded in 2014 and again in 2016 (see section 3 below). The 2016 upgrade provided for payment of 25% of the sum insured, capped at a maximum of $50,000, where a person suffered a heart attack, but did not meet the definition in the policy because of (among other things) the absence of an abnormal ECG. The complainant was in that position. The insurer paid him the $50,000.
Fairness requires the reasonable expectations of the parties to be met. I am satisfied that in all the circumstances, while the complainant could reasonably expect to be paid a benefit where he suffered a heart attack as diagnosed by his doctors, he has been paid the correct benefit, according to the upgraded terms of the policy.
AFCA has made previous determinations about heart attack definitions. In AFCA determination 607118, AFCA considered a trauma policy which paid benefits only for more severe heart attacks. AFCA found:
This case is different. This insurer did respond to the problems identified by ASIC and the Royal Commission. It did upgrade its policy. The result of that upgrade was that heart attacks like the complainant’s, which were not covered under the original policy terms, were covered, and attracted payment of a 25% benefit.
Determination 607118 does not contain a principle that a person should be paid the full trauma benefit for heart attack in all cases where they have a medically diagnosed heart attack.
I note that the outcome in this complaint is consistent with the outcome in an AFCA complaint with similar circumstances – 917163.
AFCA has determined this complaint based on what is fair in all the circumstances, having regard to:
The respective parties have completed a full exchange of the relevant information, and each party has had the opportunity to address any issues raised. I have reviewed and considered all of the information the parties have provided.
While the parties have raised a number of issues in their submissions, I have restricted this determination to the issues that are relevant to the outcome.
On page 17,the following is added to the second column of the table of listed conditions and medical procedures for Trauma cover Standard:
– Heart Attack – partial payment
On page 17,the following is added to the second column of the table of listed conditions and medical procedures for Trauma cover Optimum:
– Heart Attack – partial payment
On page 17,the following paragraph is added under the table of listed conditions and medical procedures for Trauma cover Standard, and under the table of listed conditions and medical procedures for Trauma cover Optimum:
Specific rules for Heart Attack – partial payment
For Heart Attack – partial payment, a limited benefit payment amount applies. The amount we pay for Heart Attack – partial payment is 25% of the Trauma cover 'insured amount' up to a maximum of $50,000.
We will not pay more than once for a claim under this trauma condition.
If a benefit is payable for Heart attack – partial payment:
– the Trauma cover ‘insured amount’ for the ‘insured person’, and
– the ‘insured amount(s)’ under any linked Death cover and/or TPD cover,
will be reduced by the benefit payable, and your premium will be reduced having regard to the reduced ‘insured amount(s)’.
We will not pay a claim under this trauma condition where the insured amount reduces to less than $40,000.
…
Heart attack – partial payment
The ‘insured person’ suffers a heart attack resulting in the death of an area of the heart muscle due to a lack of adequate blood supply where, together with symptoms of ischaemia there are diagnostic changes in the relevant cardiac enzymes or biomarkers in the days following the heart attack.
A heart attack must be confirmed by diagnostic changes in relevant cardiac enzymes or biomarkers and there will be no need for typical new ischaemic changes (new ST-T) or new left bundle branch block (LBBB) in the electrocardiograph (ECG)
We won’t pay for:
– non heart attack related causes of elevated cardiac enzymes or biomarkers, and
– other acute coronary syndromes including, but not limited to, angina pectoris.
