The financial services ombudsman has told an insurer to pay income protection benefits after finding a man suffered a heart attack.

The claimant had held critical illness cover with Nippon Life since 2003, during which time there were a series of upgrades and changes to the policy’s definition of heart attack.

The man’s cardiologist said myocardial infarction – or a heart attack – had occurred in October 2022, but the insurer’s chief medical officer said there was no definitive evidence of this and the policy definition was not satisfied.

The insurer said the definition required evidence of “severe heart muscle damage”.

Nippon used a 2021 policy wording, under which the requirement was “heart attack – with evidence of severe heart muscle damage”.

However, the Australian Financial Complaints Authority says the man is entitled to the policy wording most favourable to him, and it uses a 2008 definition.

“He does not need to separately establish or confirm the severity of damage to his heart muscle,” AFCA said.

In ruling the claim should be paid with interest, AFCA says the medical evidence supports the heart attack diagnosis.

See the ruling here.