Global Claims Views: United Kingdom - Interpreting the critical illness definition for heart attack

The definitions for the core critical illness conditions in the U.K. are governed by a Statement of Best Practice for Critical Illness Cover, issued and updated periodically by the Association of British Insurers (ABI). The Statement is mandated for ABI member companies that offer CI cover, and provides a minimum standard definition for any condition present in at least 75% of policies available in the U.K. market. This includes heart attack, one of the main causes of claim under a CI policy in any market.

The current ABI definition is set out below:

Heart attack – of specified severity

Death of heart muscle, due to inadequate blood supply, that has resulted in all of the following evidence of acute myocardial infarction:

• Typical clinical symptoms (for example, characteristic chest pain).
• New characteristic electrocardiographic changes.
• The characteristic rise of cardiac enzymes or Troponins recorded at the following levels or higher:
  - Troponin T > 1.0 ng/ml
  - AccuTnI > 0.5 ng/ml or equivalent threshold with other Troponin I methods.

The evidence must show a definite acute myocardial infarction.For the above definition, the following are not covered:

• Other acute coronary syndromes including but not limited to angina.

This has been the model definition since 2006, and was the first to introduce a severity-based measure in the form of a minimum required value for Troponins. Those familiar with the medical definition of heart attack will notice the insurance definition requires a specific level of Troponins for a valid claim.

This is a talking point for U.K. insurers for two main reasons:

• The advent of high-sensitivity assays for Troponins tests and the variance in reporting units, which means units can be expressed in ng/ml, ug/L or ng/l.
• Difficulties relying upon a dynamic test whose results rise and fall over time.

The effect of these two issues is that U.K. providers of CI insurance are seeing an increasing number of presented claims for heart attack where Troponin levels are below the ABI definition’s required threshold with some uncertainty around when in the diagnostic process the test was done, and a lack of clarity as to the unit measurement the hospital used.

RGA Claims issued a Guidance Note in July 2012 to its U.K. clients that set out clearly how to identify and understand the differences in Troponin unit measurements. If you struggle to understand the difference between ng/ml, ug/L or ng/L please get in touch and we’ll send you a copy.

Most U.K. insurers do not take a strict, literal approach to the interpretation of the ABI definition, and will con- sider claims where Troponin levels are close to the threshold if other mitigating factors about the claim exist. The problem, of course, is: how close is ‘close enough’? And, are insurers consistent as to what the mitigating factors should be? The simple answer is: not enough consistency. The industry through the ABI and the Health Claims Forum (a U.K.-based industry body), are currently working together to help insurers achieve a common understanding.