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CR244 Exceptions Exclusions – where death results from heart disease



Exclusions – where death results from heart disease – whether heart attack necessarily results from heart disease.


The policy featured an initial two year waiting period in which claims would not be paid in the event of death as a result inter alia of heart disease. The policyholder died within the two year period. The only information presented in support of the claim was a death certificate which described death as due to natural causes, and a form which stated that the cause of death was heart failure. On the basis thereof the insurer denied liability. The issue was whether heart failure was the result of heart disease.


The Ombudsman took the view that heart failure is a clinical concept consisting of phenomena caused by inadequate cardiac function, the important point being that one can suffer from heart failure without the underlying cause being heart disease. The way the contract was framed placed the onus on the insurer to produce satisfactory medical evidence in support of its contention that death had resulted from heart disease.


As the insurer could produce no such medical evidence it admitted liability.

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