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Category: Insurance / Health Insurance / Heart Disease

CommInsure denying heart attack claims due to outdated definition

Friday, 4 Mar 2016 21:57:18

The Commonwealth's insurance arm is rejecting claims by using an outdated definition to determine the severity of a heart attack. (ABC News: Margaret Burin)

The Commonwealth Bank is facing fresh allegations of unethical and unscrupulous behaviour in its life insurance business CommInsure, as it tries to rebuild its reputation after a damaging scandal in its financial planning division.

Key points:

  • CommInsure uses outdated definition to deny heart attack claims
  • Victim's heart stopped but he was still denied a payout
  • Leading cardiologist says heart attack definition is wrong

The Bank's insurance arm is denying legitimate heart attack claims by continuing to use an outdated definition that is buried in the fine print of its policy documents.

Leading cardiologists say CommInsure's policy definition is years out of date and should not be used in isolation to determine the severity of a heart attack.

The joint investigation by Four Corners and Fairfax can reveal that CommInsure's senior staff had been told the heart attack definition was problematic.

Heart attacks are one of the largest and most expensive claim areas in the life insurance industry. They are also the biggest killers in Australia, with 55,000 people having a heart attack each year.

Do you know more about this story? Email christodoulou.mario@abc.net.au

'Have another heart attack, better luck next time'

James Kessel, 46, had his $1.1 million life insurance claim refused after he had a major heart attack in September 2014.

The heart attack was so severe his heart stopped and he had to be revived by nurses using a defibrillator.

The bank denied his claim because he did not have enough of a protein called Troponin in his blood.

"I couldn't believe it ... It just simply states that your Troponin levels were not at the right level so you don't get it, goodbye, have another heart attack, better luck next time."

CommInsure's policy requires precise measurements of Troponin in a person's blood stream to prove their heart attack is severe enough to qualify for a claim.

But the definition is out of step with current medical practice.

President of the Cardiology Society of Australia and New Zealand Professor Andrew MacIsaac said it was not possible to diagnose the severity of a heart attack based on Troponin levels alone.

"You can't consider Troponin in isolation ... The diagnosis of a heart attack does involve looking at the Troponin level and that's a very important factor, but the whole situation has to be taken into account including how the patient presented to hospital, what symptoms did they have and then in addition other tests," he said.

Inside CommInsure a survey of 40 random heart attack cases in June 2014 concluded that more than half of critical illness heart attack claims could have been declined based on Troponin levels alone.

CommInsure knew it was not acting in utmost good faith

In Mr Kessel's case, Comminsure was aware he had suffered a severe heart attack, but rejected his claim anyway.

The Four Corners-Fairfax investigation has obtained an email which says inside CommInsure there was no dispute that Mr Kessel had suffered a severe heart attack. The email reveals by rejecting the claim on Troponin levels alone, the bank would not be acting in "utmost good faith".

The policy needs to be updated and is being updated and that work has been ongoing now for a number of months.

Commonwealth Bank chief executive Ian Narev

"The sole reason [Kessel] does not satisfy the policy terms is due to him not reaching the Troponin threshold which is not in line with current medical practice," it said.

"We believe that by declining this claim based on a now unobtainable threshold, CommInsure would not be acting in utmost good faith."

Acting in "utmost good faith" is a legal requirement for insurers in assessing claims.

The CommInsure document warned that if the decision was disputed it would attract negative attention by the Financial Ombudsman Service.

In an interview with Four Corners, Commonwealth Bank chief executive Ian Narev acknowledged the heart attack definition may be out of date and also promised to have a look at Mr Kessel's case.

"The policy needs to be updated and is being updated and that work has been ongoing now for a number of months and we're going to make sure we accelerate it now to update the definition," he said.

"We pay approximately 22,000 claims a year in CommInsure, so it's a business with about 4 million customers, and we make 22,000 claims. The vast majority of those claims are well handled cases."

CommInsure's policy includes a clause which allows for "any other medical evidence" to be presented which suggests the heart attack occurred to the same severity as that indicated by the Troponin levels.

But cardiologists say the trouble with this is that Troponin is not a consistent measure of severity.

"The more severe the heart attack the higher the Troponin level is likely to be, but it is possible to have serious heart attacks with lower Troponin levels that could be quite threatening to the patient," Dr MacIsaac said.

AustraliaPlus


 

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