Critical Illness Heart Attack Payout

In this article we will take a more in-depth look at claiming on your Critical Illness policy when someone has suffered from a heart attack (called myocardial infarction, or MI for short)

Firstly, if you think you’re experiencing a heart attack please seek medical attention immediately. You can visit the NHS guidance if you think you might be experiencing a heart attack here.

In the simplest terms, "MI" typically refers to "Myocardial Infarction," which is commonly known as a heart attack. It occurs when the blood supply to a part of the heart muscle is blocked, usually by a blood clot, leading to damage or death of the heart tissue. This can result in chest pain or discomfort and requires prompt medical attention.

Generally speaking there are two main types of heart attack:

ST-segment elevation myocardial infarction (STEMI):

This type is characterized by a specific pattern on an electrocardiogram (ECG or EKG), where the ST segment is elevated. It indicates a complete blockage of a coronary artery, requiring urgent medical intervention, often with procedures like angioplasty or stent placement.

Non-ST-segment elevation myocardial infarction (NSTEMI):

In this type, there may be changes on the ECG, but the ST segment is not elevated. It suggests a partial blockage of a coronary artery. While serious, it may not require immediate invasive procedures, but still demands medical attention and management.

Often a STEMI is considered more serious than an NSTEMI as there is often more blockage of the artery involved. You can claim on your Critical Illness for both these conditions, although you may find it harder for an NSTEMI, as we’ll discuss below.

 

Will my Critical Illness pay in the event of a heart attack?

This can be a tricky question and can depend on a few things (we’ll address each point).

  • When the policy was taken out can define what is meant by a “heart attack” and to which severity.
  • The type of policy you have, for example is the policy one provided by your employer or taken privately.
  • They type of “heart attack” and severity.

Claiming for Heart Attack on Critical Illness

In relation to the first point the ABI (Association of British Insurers) provide minimum standards for all Critical Illness policies. These standard provide standard wording and ensures companies provide a “minimum standard” of cover when it comes to definitions. As of September 2022, the “minimum definition” of MI is as follows:

A definite diagnosis of acute myocardial infarction with death of heart muscle as evidenced by all of the following:

  • Typical clinical symptoms (for example, characteristic chest pain).
  • New characteristic electrocardiographic changes or new diagnostic imaging changes.
  • The characteristic rise of cardiac enzymes or Troponins recorded at the following levels or higher:
    • Troponin T > 200 ng/L (0.2 ng/ml or 0.2 ug/L)
    • Troponin I > 500 ng/L (0.5 ng/ml or 0.5 ug/L)

The evidence must show a definite acute myocardial infarction. For the above definition, the following are not covered:

  • Myocardial injury
  • Angina without myocardial infarction

This can be somewhat confusing, as there’s quite a bit of medical jargon involved, and these claims can be quite complex. Additionally, older policies have slightly different minimum standards so it can be difficult to realise if you have a claim or not.

Generally, to receive a pay-out you would need to have clinical symptoms, new EKG or diagnostic imaging changes, and a certain characteristic rise in Troponin levels (to the specified levels).

Troponin is a protein that plays a crucial role in muscle contraction, particularly in the heart muscle. When heart muscle cells are damaged, troponin is released into the bloodstream. Therefore, measuring troponin levels in the blood is a common and sensitive test for detecting heart muscle injury.

The timing of peak troponin levels can vary depending on the individual and the specific circumstances of heart muscle injury. However, in the context of a heart attack (myocardial infarction), troponin levels typically begin to rise within a few hours of the onset of symptoms, and they usually peak within 24 to 48 hours.

The rate at which troponin levels increase and the duration of elevated levels depend on factors such as the extent of heart muscle damage and the effectiveness of medical interventions.

This can cause issues when claiming as often people don’t go to the hospital when they first experience symptoms of an MI, often putting symptoms down to stress, indigestion or other conditions. We have seen cases where someone has suffered from an MI, when to the hospital 3 or 4 days later and their troponin levels were marginally below the levels needed, and their claims were “wrongly” declined.

Often, and especially with older policies, insurance companies insisted on EKG changes. This would effectively rule out any NSTEMI someone has suffered from. This has thankfully now been changed and reflected in the minimum standards and we’ve had some great success in overturning decisions where an insurance company has rejected claims on this basis.

 
 

Employer Critical Illness policies

In relation to the second point, employers’ policies sometimes have more lax rules around definitions of MI but can reject claims for “pre-existing conditions”. Because employer policies aren’t medically underwritten, they often come with a wide range of exclusions. This can be as trivial as having a single raised cholesterol reading (insurance companies may link this to your MI) to more serious illnesses such as diabetes.

We have encountered several cases where a person’s minor medical conditions have been used as an “associated” medical condition when it comes to claiming on the group or employer Critical Illness policy.

Heart attacks and severity

You may read on the terms of the policy ““Heart attack – of specified severity”. Insurance companies often use the “specified severity” to avoid paying claims. Before getting into what this looks like, it’s worth looking at the different types of MI and how they can differentiate and how this impacts your policy.

As previously discussed, there’s two main types of MI. A STEMI and NSTEMI. The main differences are:

ECG Characteristics:
STEMI: The ECG in STEMI shows a specific pattern with elevated ST segments, indicating a complete blockage of a coronary artery.
NSTEMI: The ECG in NSTEMI may show changes, but the ST segments are not elevated to the extent seen in STEMI. There may be ST-segment depression, T-wave inversion, or other non-specific changes.

Extent of Coronary Artery Blockage:
STEMI: Typically, there is a complete blockage of a coronary artery, leading to a more severe and immediate threat to the heart muscle.
NSTEMI: There may be a partial blockage of a coronary artery, and the degree of blockage is usually less than in STEMI.

Treatment Approach:
STEMI: Requires urgent and immediate intervention to restore blood flow to the blocked artery. This is often done through procedures such as angioplasty and stent placement or, in some cases, thrombolytic therapy.
NSTEMI: Treatment may involve medications to manage symptoms, stabilize the condition, and prevent further clot formation. Invasive procedures like angioplasty may be performed later based on clinical assessment.

Risk and Prognosis:
STEMI: Generally considered a more severe form of heart attack with a higher risk of complications. Immediate intervention is crucial to minimize damage.
NSTEMI: While still serious, the risk may be somewhat lower compared to STEMI. However, appropriate management is essential to prevent further complications.

Timing of Troponin Levels:
STEMI: Troponin levels rise early and peak relatively quickly after the onset of symptoms.
NSTEMI: Troponin levels also rise but may peak later than in STEMI, and the increase might be more gradual.

Both NSTEMI and STEMI require prompt medical attention, and the treatment approach is determined based on the specific circumstances of the individual case.

People who have suffered a STEMI heart attack often experience less resistance to receiving a Critical Illness pay-out. This is because the symptoms are much more severe and often require hospital treatment right away, which means tests are much more prompt. There’s also clear changes to a person’s EKG which makes the diagnosis and meeting the terms of the policy easier.

Someone who suffers from a NSTEMI heart attack might have a different experience altogether. NSTEMI’s are generally considered not as “severe” but the impact can be wide ranging. From “small” MI’s to larger infarcts of 1 of more arteries.

Often insurance companies may point to troponin levels not breaching the threshold or no changes in the EKG being seen. Often, when someone goes to hospital with an MI troponin level may be measured over a period of 24 hours. There are several reasons for this, but he levels of troponin rise over time after the onset of symptoms. Measuring troponin levels serially allows healthcare providers to observe the pattern of release and understand the timing of the heart muscle injury.

The issue arises if someone attends hospital some days after the event. Their troponin T levels may be 150ng/l, 120ng/l a few hours later, then 80ng/l a few hours after that. These levels are generally considered out with the normal reference range (this does depend in the laboratory the results were taken in) but wouldn’t breach the insurance policies required references.

We often see a lot of these cases and we have considerable experience in overturning these decisions. You can find more of these cases in our “Case Studies” section of our website.

If you’re worried about claiming on your Critical Illness policy or had a claim rejected. You can speak to Resolute Claims confidentially and free of charge on 0333 050 8792 or book an appointment.