An insured has lost a claim dispute after seeking a bigger payout than the $50,000 he received from his insurer, insisting he met his trauma policy’s definition of a heart attack.

Resolution Life had accepted the man’s claim and provided the payment in line with updates it made to the policy in 2016.

The 2016 change provided for payment of 25% of the sum insured, capped at $50,000, when a person suffered a heart attack but did not meet the policy definition due to, among other things, the absence of an abnormal electrocardiograph result.

“The complainant was in that position,” the Australian Financial Complaints Authority says in its ruling on the dispute. “The insurer paid him the $50,000 ... he has been paid the correct benefit, according to the upgraded terms of the policy.”

AFCA says the dispute is different from previous complaints because the insurer has responded to problems around heart attack coverage in trauma policies that were identified by the Hayne royal commission and the Australian Securities and Investments Commission.

Resolution Life did “upgrade its policy” and the result is that heart attacks like the complainant’s, which were not covered under the original policy terms, triggered a payment, AFCA says.

The insurer also assessed the complainant against newer definitions, according to the dispute ruling.

“Those definitions all refer to [electrocardiograph] changes. Because I do not accept the complainant had [electrocardiograph] changes, he also does not meet those definitions, insofar as they require [electrocardiograph] changes.”

The complainant had argued he met the requirement for electrocardiographic changes. He provided a letter from his GP dated August 6 last year that stated he had an “abnormal” electrocardiograph result.

But AFCA did not accept the GP’s opinion, saying the complainant’s treating cardiologist was “better qualified” to interpret electrocardiograph readings.

The cardiologist wrote “normal” for the electrocardiograph result in his medical certificate dated August 2 last year, and a further letter dated August 22 did not say the complainant had an abnormal reading.

“I accept his [electrocardiograph reading] was normal,” an AFCA ombudsman said.

Click here for the ruling.