Caution: critical illness policies

Critical illness policies are popular with self-

employed people, people with responsible occupa-

tions and those concerned about their families

should they develop an illness which might shorten

their lives or reduce their income. They are sold by

agents who are often not medically trained to indi-

viduals who may not understand the small print or

conditions related to the payout. Invariably doctors

are unaware of the existence of a policy when treat-

ing individual patients and of course should not be

influenced by a policy’s conditions. With regard to

coronary artery disease, however, policies are not

logical.

For a claim to be successful regarding angioplasty

there must be significant stenoses of greater than

50% in each of ‘two’ or more coronary arteries and

these must be operated on at the same time. In con-

trast, coronary artery bypass surgery is covered if

‘one’ or more arteries are operated on. Patients I

have seen with these policies have no idea of the sig-

nificance of these conditions nor at any time had

anyone explained their significance, even though pol-

icies are quite clear on this difference. Of course the

difference between allowable angioplasty and surgery

lacks any sense, so it is understandable that lay peo-

ple may feel that they are covered when the opposite

is true. Furthermore, most doctors are unaware of

the policy limitations.

Some time ago a 46-year-old self-employed man

presented with a new onset angina and a very

strongly positive exercise test. A drug eluting stent

was inserted in his culprit 99% stenosed right coro-

nary lesion and the 70% obtuse marginal lesion was

not attempted. He made an excellent recovery. His

critical illness claim was denied but would have

been successful if the obtuse marginal had been

stented or coronary artery surgery performed. In

spite of evidence-based aggressive medical therapy,

his angina returned and a year later he underwent

coronary intervention to the obtuse marginal coro-

nary artery and two further lesions in the right cor-

onary artery. He then successfully claimed. Did the

stress of the first unsuccessful claim and his loss of

income due to the illness have an adverse effect?

A 36-year-old man presented with angina sec-

ondary to hypercholesterolaemia and a single severe

right coronary artery lesion was identified and

judged to be too long and complex for stenting.

He underwent a successful internal mammary

bypass graft. Unbeknown to him and ourselves, his

firm had taken out critical illness policies on their

staff and he was able to claim £250,000 – if stent-

ed he would have received nothing in spite of the

lesion technically being the same, i.e. single vessel

disease.

Whilst I am sure insurance companies pay out

appropriately most of the time, there is a clear need

to explain to policy holders at the time they take

out the policy exactly what the limitations mean,

even if that entails getting medically qualified peo-

ple to go through the document with them. A

recent report in the Daily Mail of a woman with

‘the wrong kind of breast cancer’ on two occasions

leading to her claim being denied highlights the

need for better understanding. Incidentally, I really

do not accept that there is a ‘wrong’ kind of any

cancer.

Finally, to redress the balance, one of my patients

claimed from two companies one million pounds

from each after undergoing a single internal mam-

mary graft for unstable angina. The problem was in

my care he had had within 6 months a normal cor-

onary angiogram and his main pathology was

hypertension with significant ECG changes. After

being asked for my verification of the need for sur-

gery I was naturally perplexed. I reviewed the film

and confirmed its normality. I then began a series

of investigations and discovered from two other

centres an additional two normal coronary angio-

grams. On reviewing the operative note, he was

operated on urgently for unstable angina with

severely limited exercise ability. This apparently

began the day before I watched him walk briskly

through Schipol airport, where by chance we were

on the same plane to London. His claim was not

successful – was the surgeon a victim of switched

films?

Critical illness policies serve a purpose but are not

straightforward and a better understanding of their

content is needed – approach with caution.

Disclosures

None.

Graham JacksonEditor

Email: gjcardiol@talk21.com

doi: 10.1111/j.1742-1241.2011.02722.x

Approach with

caution

EDITORIAL

ª 2011 Blackwell Publishing Ltd Int J Clin Pract, July 2011, 65, 7, 717–721 717