CR79 Dread disease claim rejected. Catheterisation and angioplasty cannot be regarded as open-heart surgery

See too: CR, Dread Disease [NEW],

CR79

Dread disease claim rejected. Catheterisation and angioplasty cannot be regarded as open-heart surgery.

Background

The policy which was issued some years ago featured a dread disease benefit, one of the events covered being heart surgery, which was defined as ‘open surgical correction of structural abnormalities of the heart or coronary arteries.’ The policyholder submitted a claim for benefit following angiography and the insertion of stents utilising a catheter. The complainant argued that “in order to correct the defect the physicians had to insert the stents via my thigh which had to be “opened up” in order to locate the defected arteries.

The Ombudsman’s initial reaction was that the complaint was barely serious, bordering on the frivolous. However, on reflection it was appreciated that layman’s knowledge of medical technical procedures were probably limited.

Assessment

The fact that the skin had to be transgressed (opened up) to obtain access to an artery in order to advance a catheter into coronary arteries does not qualify the process to be labelled as an open surgical procedure. Medical procedures have changed and now it is unusual for an incision to be made in the groin. The usual procedure is to insert a needle through which the catheter is passed into the artery without any incision. If a small incision has to be made it would certainly not change the procedure to an “open surgical” event.

This is not a matter of semantics – there is a vast difference between open surgical access to the heart and the percutaneous transvascular approach. To further exemplify this difference, stent insertion is performed by a cardiologist, considered to be a physician specialised in invasive cardiology, whereas open heart surgery is performed by a cardiac surgeon.

Result

The complaint was not upheld.

DM

October 2005

Subscribe to our Newsletter