SERVICE: Mortgage/Loan/Credit Card Protection
OUTCOME: Settled
Issues: Policy Exclusion
Summary: Mrs N’s* complaint was settled, because the insurer agreed it had not proven the exclusions.
Mr N arranged payment protection insurance for his loan. Within the term of the policy, Mr N died. Mrs N made a claim.
The insurer declined the claim, relying on policy exclusions for claims attributable to drug addiction or being under the influence of drugs, and for pre-existing conditions. The insurer referred to amphetamine use on Mr N’s death certificate and references in his medical notes to hyperlipidaemia and cardiovascular disease risk. It also referred to a medical note which said Mr N’s cardiac arrest was attributable to myocardial infarction.
The case manager’s assessment
The case manager discussed with the insurer that the policy exclusions did not apply. Specifically, there was no evidence that Mr N’s death was attributable to drug addiction, or to Mr N being under the influence of drugs.
While the death certificate noted “Amphetamine Use Unknown” as a cause of death, the word “Unknown” referred to an unknown length of time between drug use and death. This did not prove Mr N had been under the influence of drugs when he died.
In terms of the pre-existing condition exclusion, Mr N’s cholesterol was well treated and his most recent cholesterol level was much better than most of the population. In addition, as there was no autopsy, there was no way of knowing if Mr N had artheroma in his coronary arteries. Therefore, there was insufficient evidence that Mr N’s death was attributable (wholly or in part) to his pre-existing hyperlipidaemia or pure hypercholesterolemia.
The insurer reconsidered its decision and agreed to pay the claim.
*Name has been changed.
Complaint No: 00234704