Case study 1 An insurance company refused to cover the cost of a coronary bypass operation, despite the patient being unaware she had a cardiac condition when she took out medical expenses insurance.

The complainant had attended a consultant with chest pains weeks before joining the scheme but had been assured the pains were not cardiac.

Some time after taking out the policy, she had had to undergo a coronary bypass. The insurance company used a clause in the policy stating that the date of onset of a medical condition was "determined on the basis of medical advice".

A consultant cardiologist consulted by the ombudsman expressed the opinion after the event that the complainant would have been suffering from the condition at the time she applied for membership of the scheme, making it a pre-existing condition and therefore not covered.

However, it was clear that the complainant and her expert medical advisers, including a consultant cardiologist, were unaware prior to her application that she had a cardiac condition.

Given the condition was undetected and untreated, the ombudsman felt it "wholly unjust" that no contribution be made to the cost of her emergency treatment. She arranged an ex gratia payment towards the costs of the operation.