Earlier this year Australian life insurers were in the spotlight, allegedly using “out-dated” medical definitions in their Trauma policies. As a consequence, many insurers review(ed) their medical definitions and claims management practices, with particular focus on the definition for heart attack.
The idea of Trauma insurance is simple. Insurers promise financial relief when the insured suffers a familiar medical condition that is dreaded (hence the earlier name of Dread Disease insurance). These conditions were easy to define and grey areas were minimal. This has changed in just a couple of decades. The goal of treating patients as early as possible resulted in ever-improving diagnostics, changing definitions and classifications of medical conditions. The insurer relies on definitions being robust enough to offer sustainable premium rates and objective for claims assessment, but still offer transparency to customers and advisers concerning the level of cover.
Although medical definitions are part of an insurance contract, suggesting an absolute meaning, the insurer’s claims philosophy must address questions such as, “What is intended to be covered?” or “Is the condition covered even if not all claims criteria are fully met?”
In the case of heart attacks, it is tempting to follow the clinical definition. But this still requires interpretation, not only by insurers but also clinicians.
Clinical diagnosis and definition of myocardial infarction
Clinicians are challenged when a patient arrives at an emergency department with typical symptoms of a heart attack that may well turn out to be indigestion only. A quick diagnosis with the aim of providing the best treatment and minimising waste of resources is critical. This is often based on symptoms and more or less abnormal Electrocardiography (ECG) results. To achieve this, clinicians need a reliable test that helps them to quickly rule out a possibly life-threatening condition, and cardiac troponin (cTn) has been recommended as the preferred biomarker for this purpose.
Globally, clinical experts agreed on a universal definition for the diagnosis of a myocardial infarction (MI), also known as heart attack. Its key criterion is the detection of a rise and/or fall of cardiac biomarker values with at least one value above the 99th percentile upper reference limit (URL).
This requirement looks objective on the face of it. However, this seemingly simple requirement has limitations and the level of interpretation that is required before an MI can be finally diagnosed is not insignificant. The most recent (fifth) generation of cTn assays (tests) are known as high sensitive assays (hs-cTn) and detect troponin in more than half of healthy individuals.
Key issues with troponin and the universal definition of heart attack
Clinicians use guidelines to diagnose and utilise the right treatment option. Guidelines include specific algorithms to assist clinicians in predicting with some certainty whether a patient suffers a heart attack or not. These algorithms change with new cTn assays and research findings.
Upper reference limit
The URL depends on the chosen assay and on how the assay manufacturer defined the healthy reference population. Differences by gender and race exist but are often not applied. Also, different studies recommend different URLs for the same assay. In other words, clinicians and insurers depend on the choice of the assay used and which study the laboratory applies at any one time. Simple cut-off levels may thus be difficult to justify in all cases.
(In)significance of a troponin value
In some scenarios (e.g. when a so-called ST-elevation MI (STEMI) is suspected) troponin values are less relevant or even required for a diagnosis. Some algorithms also suggest a single high troponin reading (instead of a rise and/or fall). In these cases where a clinician does not require a rise and/or fall of cTn in order to initiate treatment to prevent an acute MI from further damage, insurers have to consider the overall clinical presentation and treatment provided.
Pattern of rise and fall
Troponin levels increase within a few hours after the onset of heart muscle damage, peak after 24-48 hours and return to normal over a period of several days. Consequently, predictability of cTn levels and changes are influenced by late admission to hospital as well as the use of an earlier generation cTn assay. Insurers using definitions requiring a minimum cTn elevation should include an alternative requirement or otherwise address the fact that cTn rises and falls in a particular pattern.
Every test has a particular sensitivity (identifying a condition amongst diseased people) and a particular specificity (producing a negative test result in a healthy person). The hs-cTn assays are particularly sensitive and thus useful in an uncertain emergency situation where the focus is in ruling out a heart attack swiftly – i.e. achieving a high negative predictability. Insurers, however, want to rely on a test result that has a high positive predictability.
No troponin information
The WHO suggests that whenever there is incomplete information on cardiac biomarkers and other diagnostic criteria needed, the term MI should be used if both a) symptoms of ischaemia and b) development of unequivocal pathological Q-waves (on the ECG) are present.
How to solve this conundrum?
The clinical definition is not the silver bullet answer in terms of objectivity and transparency. The purpose of the universal definition is to make the right decision in an emergency situation. Larger lump sum insurance benefits should be based on the underlying medical condition and damage this has produced. This would be more consistent with other Trauma conditions.
Besides a moderate benefit based upon a clinical diagnosis an additional benefit can be considered when the insured is required to undergo further medical treatment, such as angioplasty or bypass grafting surgery as it approximates the extent of the underlying disease. Furthermore, the benefit level could be tiered depending on the impact the heart attack has had on the heart’s capacity to pump blood using the ejection fraction.
While the idea of Trauma is simple, the underlying benefit trigger is complex. Insurers cannot make simple what is complex in nature. There are individual situations for which a definition may not be perfect and this requires a claims team that can understand the clinical presentation of a heart attack, knows local guidelines and is prepared to go beyond the absolute meaning of a definition and uses all information presented in a holistic approach. Actuaries, too, need to appreciate weaknesses of a clinical definition when pricing and designing an insurance product.
See the original article here.
© Published with the permission of General Reinsurance Life Australia Limited 2016
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