Is the heart attack serious enough?

This case study looks at a complaint about disability insurance and the interpretation of medical evidence and policy provisions when a client has a heart attack. This is from the Insurance and Savings Ombudsman (ISO) annual report.

Thursday, February 10th 2011, 6:00AM 1 Comment

Background

In 2003, C arranged critical illness insurance with P.

In April 2008, C made a claim to P because he had suffered a heart attack.

P declined the claim, because although C had suffered from a heart attack, it did not believe he met the policy definition of a "Heart attack". It advised that based on his Troponin T levels, he had had "an insufficient rise in his cardiac enzymes".

Assessment

In terms of the policy, for P to be liable for the claim, C's heart attack had to meet the criteria in the policy definition, based on the following:

 

  1. "clinical features" consistent with a heart attack;
  2. "confirmatory new electrocardiogram (ECG) changes" consistent with a heart attack; and
  3. "diagnostic elevation of cardiac enzyme CK-MB" consistent with a heart attack; or
  4. "evidence that the event produced a permanent reduction in the Cardiac Ejection Fraction to 50% or less".

 

C's hospital discharge stated he had "intermittent chest pain" and was diagnosed with a "Non-ST elevation MI".

As such, C had "clinical features" consistent with a heart attack.

C's ECG showed a "T-wave inversion", which P accepted as "confirmatory new electrocardiogram (ECG) changes" consistent with a heart attack.

C's "cardiac enzyme CK-MB" was not tested for elevation (in New Zealand, these tests have largely been superseded by measurements of the cardiac markers Troponin T ("TnT") and Troponin I ("TnI")).

C's "ejection fraction was 74%".

C's heart attack could not be measured against the third element required by the policy for a "Heart attack", because his "cardiac enzyme CK-MB" was not measured when he had his heart attack.

Moreover, C's heart attack did not meet the alternative requirement that the "Cardiac Ejection Fraction" be permanently reduced to 50% or less.

Therefore, C did not meet the definition of a "Heart attack" under the policy.

 

• P's declinature

P declined the claim, because C did not have an elevation of TnT to above 0.6 ug/L. It said that he did not meet the criteria of a "diagnostic elevation of cardiac enzyme CK-MB" consistent with a heart attack, "due to an insufficient rise in his cardiac enzymes".

Because P declined the claim on this basis, to determine whether C's heart attack met the policy definition for a "Heart attack", the Case Manager believed it needed to be established what level of TnT equated to a "[d]iagnostic elevation of cardiac enzyme CK-MB" consistent with a heart attack.

 

• The research

The Case Manager reviewed the available medical research on cardiac enzymes and TnT and, in particular, any comparative studies carried out.

This proved to be a difficult process to undertake, as there has been little or no medical research done to date that specifically addresses this matter.

Advice from specialists was that "Troponin levels are not directly comparable to previously used enzymatic markers including Creatine Kinase (CK) and its cardiospecifi c MB fraction (CKMB)".

An independent cardiologist advised, "it is difficult to def ne a precise threshold of Troponin T levels where a rise in CKMB might not be expected to be detected but my view would be that this would be around 0.1 mcg/L".

The Case Manager also found a document from the Diagnostic Medlab, New Zealand, which referred to a TnT level of 0.1 ug/L as being comparable to the "Old M.I. Threshold (by comparing with CKMB cut off)".

 

• The medical information

The highest recorded TnT level was 0.19 ug/L.

 

• The analysis

The Case Manager did not believe there was any way to determine a TnT value that absolutely and definitively equated to a "diagnostic elevation of cardiac enzyme CK-MB". However, because of the way P declined the claim, it was important to find an approximate TnT value, based on the best information available.

According to the information from the Diagnostic Medlab and supported by the statements made by the cardiologist, a TnT reading of 0.1 ug/L would equate approximately to the "Old M.I. Threshold (by comparing with CKMB cut off)".

The Case Manager believed, therefore, that for the purposes of this Assessment, a TnT level of 0.1 ug/L or above should be considered to equate to a "diagnostic elevation of cardiac enzyme CK-MB."

Therefore, because C had a TnT reading of 0.19 ug/L he met the policy definition of a "Heart attack", given P's reliance on TnT levels in its consideration of his cardiac enzyme levels and application of the policy wording to the claim.

 

Result Complaint upheld

 

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Comments from our readers

On 24 June 2011 at 1:18 pm Robert Oddy said:
TIME FOR INSURERS TO CHANGE THE DESIGN OF POLICY BENEFIT CRITERIA?
I have just read this article which reinforces for me the challenge that the insurance industry has in respect of low percentage of the population that is insured and the generally low levels of cover for certain types of policies. As a consumer of medical and trauma/serious illness insurance, I would prefer my insurer pays a claim when cover is provided for a heart attack should I be told by a registered doctor/cardiologist in a public hospital that I have suffered one: irrespective of its severity. I suggest there is dismay amongst potential NZ consumers at the perceived adversarial attitude of insurers at the time when calamity strikes. Owners of this type of policy are likely to consider they are covered when they have a heart attack and unlikely to understand the medical criteria being used by claim managers. The reaction in TV interviews from earthquake shattered Christchurch policy owners suggests to me that there is a disconnect between what consumers expect and want from their insurer and what they receive. While it could be argued that they may not have received adequate information about the policy terms and conditions at the time of purchase, there is no disguising the fact that many consider 'let down'. While I have no statistical evidence to support my impression that this is one of the reasons for dissuading many from wanting to buy insurance, anecdotal information does tend to support this view. I note recent comments from other contributors about the need for insurers to focus on consumers if the poor level of insurance is to have any chance of being corrected. I concur and suggest it is time for insurers to consider providing policies that provide the benefits to be paid when an expected event arises without the subsequent further stress caused by having to 'fight' for what the claimant feels is not a 'fair go' - but of course, at actuarialy-calculated sensible premiums. Reducing the opportunity for conflict will likely lead to greater confidence that insurance is not only a necessity but that the insurers will be there to stand alongside when needed - without claimants having to fight to receive what they perceive as being a justified, honest claim. A final note: the cheapest premium does not necessarily provide the optimum solution for any consumer
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