Casper was hospitalised due to ischemic chest pain and submitted a hospitalisation claim for the expenses incurred. The insurer rejected the claim on the grounds that the condition was classified as a congenital anomaly and therefore excluded under the Policy.

Exclusions

The Company will not pay the Insured Benefits as stated in Clause 5.1 under this Policy, any of the following, whether directly or indirectly:
Any treatment or surgical operation for Congenital Conditions or deformities, including hereditary conditions.

‘Congenital Conditions’ means any medical or physical abnormalities that existed at the time of birth or neonatal physical abnormalities developing within six (6) months from the time of birth. This will include all types of hernias and epilepsy except when caused by a trauma which occurred after the Effective Date.

FINDINGS

Casper’s coronary angiogram revealed a diagnosis of ‘myocardial bridge’, a coronary anomaly. It occurs in about 5% of individuals and is a known cause of ischemic chest pain.

ICD‑11 (Code BA60.0) classifies myocardial bridging under coronary artery anomalies, which are medically recognised as congenital in nature.

Although Casper’s condition was diagnosed in adulthood, congenital anomalies can manifest symptoms later in life. The definition in the Policy relates to existence at birth, not the timing of diagnosis.

OUTCOME

The Ombudsman acknowledged the seriousness of Casper’s condition but found that medical evidence confirmed ‘myocardial bridge’ to be a congenital coronary anomaly.

As the Policy expressly excludes congenital conditions regardless of when symptoms arise, the insurer’s decision to reject the claim was consistent with the Policy terms. The adjudication was in favour of the insurer.