Will Critical Illness insurance keep pace with medical science?

The rate of technological advancement has increased and medical science in particular has been experiencing a breadth of new diagnostic tools and surgical methods as a result. Inevitably, this has an effect on Critical Illness (CI) insurance where protection against heart disease, heart conditions, stroke, cancer and loss of independent existence play an integral part.

The medical criteria in policy conditions are often vulnerable to changes in medical practice, but today’s consumers also have access to an unprecedented wealth of information on their health via websites, smartphone apps, and even home diagnostic products sold online or in supermarkets and pharmacies. As a result, the rate of CI claims may increase and continual monitoring of medical developments as well as consumer trends is integral to managing CI products in the modern world.

Here are some of the medical advances which Munich Re has seen impacting CI business and which insurers should keep on their radar:

1. New diagnostic tests – Enhanced methods of diagnostic testing, more sensitive imaging techniques and screening programmes, plus improved consumer awareness and self-testing
2. Surgical advancement – The move toward minimally invasive surgery

In addition, medical advances in tailored treatment and new pharmacological treatments mean potentially more precise individual solutions resulting in fewer side effects, better prognostic outcomes and the benefit of prolonging activities of daily living and independence.

Current MRI, CT and ultrasound scanning are valuable as diagnostic tools - helping to find or confirm health issues sooner when they should be easier to treat. An example of this has already happened in Korea. Their Living Benefits market suffered large losses following the introduction of a new screening service for thyroid cancer. Incidence rates materially increased due to detection of early stage disease, resulting in unexpected claims. Survival in early stage thyroid cancer is 100%. The Canadian Life and Health Insurance Association (CLHIA) addressed this in the 2013 CI Benchmark Definitions by recognizing and removing early thyroid cancer as a full benefit covered condition.

With ultrasound technology becoming inexpensive and a more routine early diagnostic tool, ultrasound scanning companies may take advantage of this new opportunity to perform private thyroid ultrasounds. Munich Re has already seen evidence of this, for example, a diagnosis of thyroid cancer by ultrasound being made in China and subsequently, a claim for cancer being filed in Canada.

Scientists have been working on a 10-minute cancer test which can detect circulating tumour RNA with just a specimen of saliva. This non-invasive test, called a liquid biopsy, is reported to be simple, convenient, private, and inexpensive and 100% accurate, leading to its widespread coverage in the news last year.

Liquid biopsy is still in its infancy, and it is unclear whether they will be sufficiently accurate or sensitive, or specific to the types of cancer they will be able to detect. The idea is to eventually develop tests not only for oropharyngeal and lung cancers, but also for gastric, breast, ovarian and pancreatic cancers.

For now, there is no direct impact to our industry as it is unclear if these or similar tests will be helpful to screen for cancer, whether from a medical or an underwriting perspective. This will need to be proven by scientific studies which are not yet available.

However, this is a test to keep an eye on. While it is at the beginning of clinical trials, insurers must be aware of the potential for an imbalance of information at the application stage between applicants and life insurance companies.

Stroke remains a major healthcare challenge worldwide and is now considered to be the second leading cause of death and disability in Western countries. In Canada, there are around 50,000 new stroke cases each year, and it is one of the core covered critical illness conditions as included in the industry’s 2008 and 2013 CI Benchmark Definitions.

Following a number of international randomized trials, doctors are now able to remove potentially debilitating and lethal blood clots with the use of a new mechanical clot retrieval technology also known as thrombectomy, which may significantly improve the outcome and reduce the impact of any neurological deficit. It is now possible even to remove clots within an hour of hospital admission. In some instances this can be the difference between the patient being transferred to a nursing home or being sent home. For younger patients, it may mean a relatively quick return to work.

Two medical studies reported in 2015, MR CLEAN (Multicenter Randomised CLinical trial of Endovascular treatment for Acute ischaemic stroke in the Netherlands) and ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times), have both shown that brain tissue can now be saved via thrombectomy procedures by directly removing blood clots which block major blood vessels to the brain.

Under current treatment methodology, one in five stroke patients who received standard drug therapy such as tissue plasminogen activators (tPA), were able to return to independent living. The results improved to one in three with direct clot removal under the MR CLEAN trial, and one in four people for those in the ESCAPE study.

The Benchmark Definition for Stroke requires neurological deficit persisting for more than 30 days following diagnosis. With the early promising outcomes suggested by these trials, could we see an impact on stroke claims, with a possible increase in the numbers of claims declined due to non-fulfilment of the severity-based element of the definition?

A debate could also begin as to whether stroke would be considered life threatening. Further, would there be a decrease in stroke claims as defined by the current Stroke definition, perhaps resulting in an impact on pricing and/or inclusion of a partial payment definition for Stroke?

Currently tPA therapy is the standard treatment for acute ischaemic stroke, however new trials have shown that tPA therapy in combination with thrombectomy may help to improve clinical outcomes further in the future. Overall, it is too early to estimate future outcomes following any endovascular treatment.

Another surgical technique to be aware of is Transcatheter Aortic Valve Implantation (TAVI). This is the insertion of an aortic valve replacement device via a catheter in the femoral artery. The technique began as a method of treating patients who had too many risk factors for open heart surgery or were inoperable, often in the case of older patients. Newer TAVI devices have reduced mortality and result in fewer complications compared with open surgery, even in patients with lower risk scores.

TAVI may become the standard procedure in younger and healthier patients, however, it will likely replace open surgery without an increase in numbers requiring aortic valve replacement, meaning there will be little to no change in the overall number of procedures being performed.

In the future, it may be reasonable to include TAVI as a partial payment under the Benchmark Definition for Heart Valve Replacement or Repair which currently excludes percutaneous trans-catheter procedures.

Endovascular Aneurysm Repair (EVAR), a catheter based procedure for aortic disease, is one example of a new procedure which has not been previously covered but may effect claims. It is currently excluded from the Benchmark Definition for Aortic Surgery, despite a significant increase in EVAR utilization per capita when compared with open surgical repair. As a result, rejecting an EVAR claim could pose a reputational risk for the following reasons:

• EVAR utilization is shown to have increased 29% between 2005 (11.5%) and 2011 (41%) in Canada
• Mortality and morbidity are comparable between EVAR and open surgery
• There is no significant cost benefit of EVAR compared to open surgery

The number of individuals who require aortic aneurysm repair each year is stable and as EVAR replaces open aneurysm surgery, now could be the time to consider including EVAR as a claims trigger.

The speed of advancement in medical treatments is a reminder that outcomes of medical events, even significant ones such as stroke, may change in years to come. Regular review of CI definitions should focus on diagnostic thresholds and evidentiary criteria, and claims trends should be monitored carefully for opportunities for product development.

It is important now more than ever that we monitor new medical tests and procedures as they arise. There could be implications for application questions, definitions, product design and pricing as the industry strives to maintain fair outcomes for consumers and insurers.