{"id":82348,"date":"2026-05-12T09:40:53","date_gmt":"2026-05-11T23:40:53","guid":{"rendered":"https:\/\/riskinfo.com.au\/news\/?p=82348"},"modified":"2026-05-19T09:47:21","modified_gmt":"2026-05-18T23:47:21","slug":"ruling-highlights-power-of-older-policy-definitions","status":"publish","type":"post","link":"https:\/\/riskinfo.com.au\/news\/2026\/05\/12\/ruling-highlights-power-of-older-policy-definitions\/","title":{"rendered":"Ruling Highlights Importance of Older Policy Definitions"},"content":{"rendered":"
\n
\n

An AFCA ruling overturning an insurer\u2019s decision to deny a heart attack claim using an updated policy term attracted strong reader interest this week\u2026<\/h3>\n<\/div>\n<\/div>\n

An AFCA ruling<\/a>\u00a0against Nippon Life Insurance has highlighted how older policy definitions can determine the outcome of modern critical illness claims, in a decision likely to interest advisers managing legacy IP and trauma portfolios.<\/p>\n

Members of the authority found the insurer wrongly rejected a claim from a policyholder who suffered a cardiac event in October 2022 and later sought payment under a critical condition benefit attached to his IP policy.<\/p>\n

The policy, originally issued in 2003, provided a six-month IP payment if the insured suffered certain defined medical conditions, including \u201cheart attack\u201d.<\/p>\n

The insurer declined the claim in May 2023, arguing the medical evidence did not satisfy the policy definition. AFCA overturned the decision, finding the complainant met a more favourable 2008 wording that applied to the contract following policy upgrades over time.<\/p>\n

The ombudsman said the claimant had demonstrated \u201cmyocardial infarction, new changes on electrocardiogram and raised troponins (heart attack biomarkers)\u201d consistent with the applicable definition of heart attack.<\/p>\n

…the insurer had relied in part on a stricter 2021 definition…That did not apply to the complainant\u2019s cover…<\/p><\/blockquote>\n

Central to the dispute was whether the claimant\u2019s condition amounted to myocardial infarction or merely myocardial injury. The insurer relied heavily on the absence of obstructive coronary artery disease and later recovery of heart function, arguing there was insufficient evidence of severe heart muscle damage.<\/p>\n

AFCA rejected that position, saying the insurer had relied in part on a stricter 2021 definition requiring \u201csevere heart muscle damage\u201d, wording that did not apply to the complainant\u2019s cover.<\/p>\n

the determination points to the importance of reviewing historic policy definitions…<\/p><\/blockquote>\n

The authority instead accepted later evidence from the treating cardiologist, who clarified that ECG testing performed during the hospital admission showed lateral T-wave inversion consistent with myocardial ischaemia (reduced blood flow to the heart).<\/p>\n

The determination points to the importance of reviewing historic policy definitions when assessing declined claims, particularly where contracts have been upgraded or reissued over many years.<\/p>\n

In addition to paying the claim, AFCA ordered the insurer to pay interest under section 57 of the Insurance Contracts Act, finding it became unreasonable to withhold payment after additional ECG tracings and clinical material were supplied in January 2026.<\/p>\n

Click here<\/a> for the full ruling.<\/p>\n","protected":false},"excerpt":{"rendered":"

An AFCA ruling overturning an insurer\u2019s decision to deny a heart attack claim using an updated policy term attracted strong reader interest this week\u2026 An AFCA ruling\u00a0against Nippon Life Insurance has highlighted how older policy definitions can determine the outcome of modern critical illness claims, in a decision likely to interest advisers managing legacy IP […]<\/p>\n","protected":false},"author":23,"featured_media":82351,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8,8281,8291],"tags":[],"class_list":["post-82348","post","type-post","status-publish","format-standard","has-post-thumbnail","category-compliance-regulation","category-health-wellness","category-story-of-the-week"],"_links":{"self":[{"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/posts\/82348","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/users\/23"}],"replies":[{"embeddable":true,"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/comments?post=82348"}],"version-history":[{"count":0,"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/posts\/82348\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/media\/82351"}],"wp:attachment":[{"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/media?parent=82348"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/categories?post=82348"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/riskinfo.com.au\/news\/wp-json\/wp\/v2\/tags?post=82348"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}