CRITICAL DECISIONS ON CRITICAL CONDITIONS CLAIMS

BYEmiliano B. Canonigo, Jr., MD., FPCP,

FPCC

Critical Illness

CI claim – Case 1 56 years old, clean medical history CI policy issued 14.01.1999 at standard rate 28.12.2000: severe chest pain admitted to

the CCU(Dr. Q, Cardiologist)

> CI claim for Heart Attack

What do you do?

CI Definition for Heart Attack

> The first occurrence of heart attack or myocardial infarction which means the death of a portion of the heart muscle, as a result of an acute interruption of blood supply to the myocardium.

> The diagnosis must be based on a history of:*Typical chest pain*New ECG changes proving infarction* Diagnostic elevation of cardiac enzymes

> Angina is specially excluded

The Infarcted Heart

Diseased Coronary vessel

CI claim – Case 1 APS of Cardiologist• On and off chest pains for the last two weeks

precipitated by effort relieved by rest• PTA severe chest pain lasting for 30 mins

associated with shortness of breath• On admission – chest pain relieved with nitrate

drip, EKG – ST depression with T wave inversion

• No enzymes done

WHAT WILL YOU DO? DECIDE?

Considerations:

CI claim – Case 1 APS of Interventionist - Cardiologist

• Angiogram performed on the 7th HD revealed 95% stenosis of the LAD, 50% stenosis of the distal RAD

• Angioplasty with stenting of proximal LAD• Troponin levels (done on the day after

angiogram) 1.0 (nv < 0.2)

MD’s diagnosis: Acute Myocardial Infarction

SETTLE OR DENY ?

CI claim – Case 1

DECISION: Settle as Acute MI or Deny Claim?

• No EKG evidence • Enzymes elevate but done only after PTCA

– procedure could raise Trop T• Chest pain typical relieved with nitrate drip

and no recurrence

DECISION?

CI claim – Case 1

POINTS OF ARGUMENT

No EKG evidence non Q MI?Enzymes only after PTCA Trop T - 10

daysChest pain relieved Typical

YOU DECIDE!

CI claim – Case 2 CI policy issued 23.3.1999 at

standard rate 4.2.2000: headache and left side

weakness (Dr. CB, neurologist)

36 years old, clean medical history> CI claim for stroke

CI Definition of Stroke

• A cerebrovascular incident which results in permanent neurological deficit.

• The diagnosis must be supported by new changes on CT or MRI scan.

• The diagnosis must be certified by a neurologist

CI Definition of Stroke

Exclusions:o Infarctions of brain tissue or

intracranial bleeding as a result of bodily injury caused by violent external means or accident, is specifically excluded.

o Transient ischaemic attacks are excluded

CI Claim – Case 2

• APS of Neurologist- December 1998: episode of

headache, but no definitive diagnosis.

- May 1999:headache with left-side weakness.

CI Claim – Case 2

Follow-up:• Headaches resolved• Left limbs recovered after 2-4

weeks with mild residual numbness of the left arm.

CI Claim – Case 2

CONSIDERATIONS:• Doctor states that this is a

permanent condition and it has persisted more than 180 days.

• MRA and Digital subtraction angiography revealed AV malformation

DECISION?

CI claim – Case 2• MR angiogram of brain (5.2.2000)o Strongly suggestive of a venous angioma,

an arteriovenous fistula is also a possibilityo Cigar-shaped lesion (3x1 cm) in the right

posterior parietal region:old hematoma

Digital subtraction angiography (18.2.2000)- Right temporo-parietal arterio-venous malformation.

YOU DECIDE!

CONCLUSION

WARS HAD BEEN WAGED AND KINGDOMS HAVE FALLEN BECAUSE OF POOR OR INADEQUTE

DEFINITION

There is a need to review the definition for CRITICAL CONDITIONS

CONCLUSION CHECK FOR DIAGNOSTIC

ACCURACY CHECK FOR NEGATIVE

PROGNOSTIC INDICATORS ESTIMATE WITHIN SPECIFIC

DIAGNOSTIC CATEGORIES CHECK FOR CO-MORBIDITY

SPECIFIC ISSUES

Little knowledge is a dangerous thing so we attend conferences like this to learn more and live more dangerously

Thank You !