Critical illness insurer wouldn’t pay because I ONLY had cardiac arrest

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Critical illness insurer wouldn’t pay because I ONLY had cardiac arrest

I am a fairly fit 60-year-old. But in September 2021 I suffered a cardiac arrest at home, and then again a few more times in the ambulance on the way

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I am a fairly fit 60-year-old. But in September 2021 I suffered a cardiac arrest at home, and then again a few more times in the ambulance on the way to hospital. I had to have a pacemaker fitted to keep me alive.

I have a critical illness policy that I took out in 1996 with a company called Pegasus when I went self-employed as an IT consultant. 

The policy transferred to Scottish Provident in 2006 and it is now managed by Royal London.

Denied: A health insurance customer was left stunned when he was told he was not covered for cardiac arrests despite being covered for heart attacks

Denied: A health insurance customer was left stunned when he was told he was not covered for cardiac arrests despite being covered for heart attacks

Denied: A health insurance customer was left stunned when he was told he was not covered for cardiac arrests despite being covered for heart attacks

Premiums have risen to about £500 a month now I’m older, with cover of £244,000 if a critical illness is diagnosed.

After my recovery, I asked about making a claim but was flabbergasted to discover that while my policy does cover a heart attack, it does not cover cardiac arrest.

My friend who had a similar policy had a heart attack and, following a successful claim, paid off his mortgage and reduced his working hours.

Nobody from the insurance company has given me a valid explanation as to why cardiac arrest is excluded, even though the survival rate is lower than for heart attacks. Anon.

Sally Hamilton replies: I wonder how many people know the difference between a cardiac arrest and a heart attack.

Not many, I suspect, unless they are in the medical profession.

Unfortunately, those who suffer the former and then try to claim on an old‑style critical illness policy, as you did, learn the hard way that they are different medical events, with heart attack usually covered as one of the key critical conditions listed by insurers, alongside the likes of cancer and stroke — but not cardiac arrest.

Cardiac arrest is when the heart stops pumping blood around the body, normally due to an irregular heart rhythm. Heart attack is essentially the death of a portion of the heart muscle, usually as a result of a blockage, a clot or narrowing of the arteries.

When you took out your policy 26 years ago, to protect your family finances with a cash lump sum payout if you were struck down by serious illness, the chances of surviving cardiac arrest were lower than today. Speaking plainly, life insurance would be more relevant to victims.

With medical progress, more people are now likely to survive and live with the health consequences of cardiac arrest.

For this reason, some providers now include the condition in their cover, so long as certain types of implant are used to treat the condition.

Alan Lakey, founder of protection insurance analyst CIExpert, says: ‘Cardiac arrest is a fairly recent addition to critical illness plans, being introduced by Ageas [which is now AIG] in January 2013.

‘All insurers require cardiac arrest together with implantation of a permanent defibrillator — ICD or CRT-D — a type of pacemaker.’

Cardiac arrest is included by Royal London, Aegon, AIG, Aviva, Guardian, HSBC, Legal & General, Scottish Widows, Vitality and Zurich.

Mr Lakey says there are still policies sold that don’t incorporate cardiac arrest, including those from Beagle Street, Virgin Money, Smart Insurance, Budget Life and Foresters. He says policies bought direct through comparison sites rather than an adviser are more likely to not include this cover.

Returning to your case, you first contacted me in June, explaining how you had initially made a call to Royal London’s claims staff. On the basis of the information you gave, they said you were not covered.

You were furious and made a formal complaint to Royal London about cardiac arrest being excluded.

By this point you had already paid a total of £40,000 in premiums. When I contacted Royal London to request it revisit your case, I was told it could not consider this without a formal claim form.

I had assumed you had submitted this previously, but you had been deterred by what claims staff had told you over the phone. I asked the insurer why staff had not suggested you make a formal claim. It said that call handlers will not raise expectations or initiate a claims process if there’s no evidence to support a successful outcome.

I felt you’d been fobbed off and encouraged you to make a formal claim at once. Without a thorough investigation, how could you be sure everything about your condition had been taken into account?

You duly completed a form in July, with the insurer confirming it would chase your GP and consultant for medical reports. I kept in touch with you to monitor progress.

Finally, earlier this month you received a decision letter with the upsetting news that the claim had been rejected on the basis of the cardiac arrest exclusion.

I contacted Royal London expressing both our disappointment and asking for a statement explaining the decision. A couple of days passed and I repeated the request.

Then a response came back that I was not expecting: the insurer had decided to pay your claim after all — for the full £244,000.

A Royal London spokesman says: ‘His treating consultant confirmed that he had a cardiac arrest as a result of an arrhythmia followed by insertion of a pacemaker.

‘Unfortunately, cardiac arrest is not one of the defined events covered by his policy so his claim was declined.

‘We reviewed the claim again with further specialist cardiologist advice, after which we concluded that despite the diagnosis not being one of heart attack, some features of his complex condition would allow cardiologists to conclude the policy definition has been satisfied. As such, we have agreed to pay the claim in full.’

As well as taking huge pressure off you work-wise, you’ve also used some of this money to make donations to the British Heart Foundation and to MPN Research Foundation, a charity looking for cures for rare blood cancers, including polycythemia vera, from which your daughter suffers.

Resolving your cases 

I have taken on scores of cases since I started as Money Mail’s Readers’ Champion in April.

These range from sorting out incorrect energy bills to chasing life insurance companies dragging their heels over paying money due to the relatives of the deceased.

The value of my total wins for 2022 now exceeds £1.3 million. This week’s triumph, left, is one of my proudest to date, as the resolution provides a life-changing sum.

Another case that gave me pleasure resolving was the £12,800 reimbursement of fees for a legal training course for a young woman who had barely started her studies when she had to pull out due to a sudden decline in her mental health.

Her hospital worker father had scrimped and saved to pay the fees but was refused a refund until I got involved.

He sent me the loveliest Christmas card saying he would never forget the help I’d given his daughter.

It is not only about winning big sums. Many people simply want to be treated fairly and have their complaints recognised, even if the money involved is modest.

It may not be a case worthy of Sherlock Holmes, but when a reader was refused reimbursement of £450 dental vet fees for his beloved Staffordshire bull terrier, after paying a total of £2,700 in premiums over the years, I did my best Hound Of The Baskervilles bark in pursuit of the insurer PetPlan — and it agreed to pay up.

  • Write to Sally Hamilton at Sally Sorts It, Money Mail, Northcliffe House, 2 Derry Street, London W8 5TT or email [email protected] — include phone number, address and a note addressed to the offending organisation giving them permission to talk to Sally Hamilton. Please do not send original documents as we cannot take responsibility for them. No legal responsibility can be accepted by the Daily Mail for answers given. 
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