SALLY SORTS IT: The insurance company won’t pay because I just had a heart attack

I’m a fairly decent 60-year-old. But in September 2021 I had a cardiac arrest at home, and then again several times in the ambulance on the way to the hospital. I should have had a pacemaker to keep me alive.

I have a serious illness policy that I took in 1996 with a company called Pegasus when I worked for myself as an IT consultant.

The policy was transferred to Scottish Provident in 2006 and is now run by Royal London.

DISAPPOINTED: A health insurance customer was stunned when he was told he was not covered for heart disease despite being covered for heart attacks

Insurance premiums have risen to about £500 a month, now I’m older, with £244,000 covered if a serious illness is diagnosed.

After my recovery, I asked about filing a claim, but was flabbergasted to find that while my policy covered heart attack, it did not cover cardiac arrest.

My friend who had a similar policy had a heart attack and, after a successful claim, paid off his mortgage and cut his hours.

No one from the insurance company gave me a valid explanation as to why heart attack is excluded, even though the survival rate is lower than the rate for heart attacks.

Immediately.

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

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

Unfortunately, those who suffer from the former and then try to claim the old critical illness policy, as I did, learn the hard way that they are different medical events, as heart attack is usually covered as one of the major critical conditions listed by insurance companies, along with the likes of cancer. A stroke – but not a heart attack.

Cardiac arrest occurs when the heart stops pumping blood around the body, usually due to an irregular heartbeat. A heart attack is essentially the death of part of the heart muscle, usually as a result of a blockage, clot, or narrowing of the arteries.

When you finished your policy 26 years ago, to protect your family’s finances with a lump sum cash payment if you became seriously ill, your chances of surviving cardiac arrest were lower than they are today. Speaking plainly, life insurance will be more important to the victims.

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

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

Cardiac arrest is a fairly recent addition to the critical illness plans, provided by Ageas, says Alan Lucky, founder of CIExpert Protection Insurance Analyst. [which is now AIG] in January 2013.

“All insurance companies require cardiac arrest with implantation of a permanent defibrillator — ICD or CRT-D — which is a type of pacemaker.”

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

Lucky says there are still policies to sell that don’t cover cardiac arrest, including policies from Bagel Street, Virgin Money, Smart Insurance, Budget Life and Foresters. He says that policies purchased directly through comparison sites rather than from an advisor are likely not to include this cover.

Returning to your case, you first contacted me in June, explaining how I initially made a call to the Claims Officers at Royal London. Based on the information you provided, they said you were not covered.

I was infuriated and made a formal complaint to the Royal London on the exclusion of cardiac arrest.

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

I assumed you brought this up earlier, but what the staff said to you on the phone put you off. I asked the insurance company why the staff didn’t suggest you file a formal claim. He said call handlers would not raise expectations or initiate a claims process if there was no evidence to support a successful outcome.

I felt that you were being ridiculed and encouraged you to file a formal claim at once. Without a thorough investigation, how can you be sure that everything about your case has been taken into account?

You duly completed a form in July, with the insurance company confirming that they will go after your GP and consultant to obtain the medical reports. I kept in touch with you to follow up on progress.

Finally, earlier this month I received a decision letter with the disturbing news that the claim had been denied on grounds of exclusion of cardiac arrest.

I contacted Royal London to express our disappointment and request a statement explaining the decision. Two days passed and I repeated the request.

Then came a response I wasn’t expecting: the insurance company has decided to pay your claim – for the full £244,000.

A Royal London spokesperson says: ‘His treating consultant confirmed that he had cardiac arrest as a result of an irregular heartbeat and then insertion of a pacemaker.

Unfortunately, cardiac arrest was not one of the specific events covered by his policy, so his application was denied.

We revised the claim back with more advice from a cardiologist, and then concluded that although the diagnosis was not a heart attack, some features of his complex condition would allow cardiologists to complete the policy definition. As such, we agreed to pay the claim in full.

As well as taking the massive stress out of work, I’ve also used some of that money to donate to the British Heart Foundation and the MPN Research Foundation, a charity that is looking for treatments for rare blood cancers, including polycythemia vera, from which your daughter suffers.

Solve your issues

I’ve taken on dozens of cases since I started as Money Mail Reader’s Champion in April.

These range from sorting out incorrect energy bills to chasing after life insurance companies that are slow to pay money owed to relatives of the deceased.

My gross earnings for 2022 are now over £1.3m. This week’s victory, left, is one of my proudest wins to date, with the decision providing a life-changing sum.

Another case which I had the pleasure of resolving was the payment of a legal course fee of £12,800 to a young woman who had hardly begun her studies when she had to withdraw by a sudden decline in her mental health.

Her father, who works at the hospital, had worked hard and saved up to pay the fees but was refused a refund until she intervened.

He sent me the most beautiful Christmas card saying he will never forget the help you gave his daughter.

It’s not just about winning big amounts. Many people simply want to be treated fairly and have their grievances acknowledged, even if the money involved is modest.

It may not be a case worthy of Sherlock Holmes, but when I was refused payment of £450 for a vet’s fee for his teeth, having paid a total of £2,700 in insurance premiums over the years, I did my best Hound Of Barking Baskervilles in pursuit of the insurance company PetPlan – I agreed to pay.

  • Write to Sally Hamilton at Sally Sorts It, Money Mail, Northcliffe House, 2 Derry Street, London W8 5TT or email sally@dailymail.co.uk – include telephone number, address and a note to the offending organization giving them permission to speak to Sally Hamilton. Please do not send original documents as we cannot be held responsible for them. The Daily Mail cannot accept any liability for the answers provided.

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