Lori Boyce, CHS AVP, Underwriting, Risk Management & Research/Development Manulife Financial.

Lori Boyce, CHSAVP, Underwriting, Risk Management & Research/DevelopmentManulife Financial

CI Underwriting Agenda

• Risk of anti-selection• Manulife CI Claims experience• Preferred Life clients get cancer too!• Diagnosis is the key to CI• Unique CI Underwriting focus• Routine investigations at age 50: Increased risk

of diagnosis: lumps, bumps, lesions… • Points to ponder

CI: Risk of anti-selection

Typically….

• Beneficiary = insured

• Insured is not dead

Manulife in 2012

$36,000,000 paid to our clients

Average payment: $125,000 per claimant

Manulife: 1997 to 2012

$223,000,000 paid

1,900 policies

On average, $117,000 per claim

Manulife CI Claims

1 4 12 2137 47

79

125142

177189

255247

290311

343

0

50

100

150

200

250

300

350

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12

Manulife: CI claims

13%6%

3% 3%

11%

64%

0%

10%

20%

30%

40%

50%

60%

70%

Cancer Heart Attack Stroke CoronaryBypass

MultipleSclerosis

Other

Manulife: CI face amounts

Under $100K39%

$100-$250K55%

Over $500K1%$251-$500K

5%

Critical Illness: diagnosis

NO requirement for:– Premature death– Disability– Proof of incurred expenses

ONLY require the definition be satisfied: typically a diagnosis + survive 30 days from diagnosis

Incidence – not mortality

More clients are:• Being diagnosed early• Living longer

Which supports the need for this contract…but offers CI underwriters unique challenges

33 year old female teacher

• June 2009: Both she and husband applied for $750,000 Life

• Approved on preferred basis• Accepted $25,000 of CI• 2nd trimester pregnancy – second child

33 year old female

• 10/10: she noticed a new lump which felt different from prior clogged duct detected while breast feeding

• Ultrasound, mammogram and core biopsy completed:

• Invasive ductal carcinoma: T3N2 Mx• ( mammogram: general increased density of

breast but no lesion noted )

33 year old female

November 2009: $25,000 CI benefit paid

33 year old female

February 2012: $750,000 Life benefit paid

50 year old male MD

• 12/08: approved preferred for $750,000 Life

• Accepted $187,500 of CI

50 year old male MD

• Within two years: symptoms of a urinary tract infection

• 10/11 Post investigation: bladder cancer

CI Claim paid

Canadian Cancer Statistics 2012

2012: Newly diagnosed cancers - 53% will be:– Lung– Colorectal– Prostate– Breast

CCS 2012

Every hour, an average of 21 Canadians will be diagnosed with some type of cancer

Men: # 1 PROSTATE CANCERWomen: # 1 BREAST CANCER

Breast cancer: moderately high risk factors*

• Getting older• First degree relative with breast cancer

(especially if prior to menopause)• Genetics: BRCA 1 or BRCA2 carriers• Prior dx of atypical hyperplasia

* WebMD.com

Slightly higher risk factors

• Distant family history: aunt, grandmother, cousin

• Previous abnormal biopsy• No children or first child > age 35• Overweight• Early menstruation < age 12• Late menopause > age 55…

BUT…………..

75% of women diagnosed with breast cancer…

NO identifiable risk factors*

*WebMD.com

Mammogram challenges

• Screening mammograms miss about 20% of breast cancers that are present at time of screening ( high breast density a key factor )

• False positives lead to anxiety and additional testing ( ie: ultrasound/biopsy)

• Over diagnosis and over treatment

Colon cancer

• 3rd most common cancer in Canada

• 2nd most common cause of death from a cancer in Canada ( behind lung cancer)

Colon cancer risk factors

• Age >50• Colon polyp ( adenoma): size and # • Family history ( especially at younger age )• Genetic alterations

– HNPCC and FAP• Personal history of cancer (especially ovary,

uterus, or breast)• Ulcerative colitis or Crohn’s disease

Colonoscopy screening

• Tubular adenoma: depending on # and size: – every 3-5 years

• Family hx , age 60: – every 5 yrs, starting age 40 or 10 yrs prior to age of

diagnosis

Thyroid cancer

• 1998- 2007 for males• 2002 -2007 for females

Thyroid cancer incidence rates rose on average almost 7% per year

Thyroid cancer risk factors

• Increasing age• Female• Exposure to high levels of radiation• Family history of thyroid cancer

Points to ponder

• Know your CI definitions• Identify risk factors for cancer• Be alert to anti-selection risk• Focus on diagnosis/incidence: NOT mortality

Dr. Tim MeagherMedical DirectorMunich Re

The Underwriter’s Concern

• How do I avoid a claim?– An early claim– An unexpected claim– Any claim at all

• How do I accurately assess risk, i.e. be fair to the applicant?

CI is all about Incidence

• Is a covered condition likely to develop in this applicant?– Cancer– Myocardial Infarction– Stroke

• What are the tip-offs that I can detect at time of application?– “Predictors” of future events

The big 3

Predictors

• Family History– Particularly important in CI underwriting

• Medical History– Increased use of APS– Lower threshold for laboratory testing

• Traditional predictors– Build

Family History- Breast Cancer

• Risk varies with – Number of first degree relatives affected

• One affected: RR 1.8• Two affected: RR 2.93

– Age at diagnosis of relative• RR 2.9 if relative < 30• RR 1.5 if relative > 60

• Risk increased if– Breast and/or ovarian cancer in at least 2 first degree

relatives – or 1 first and at least 1 second degree relative ,

especially if:• family history of bilateral breast cancer• history of male breast cancer• history of both breast and ovarian cancer• history of early onset breast or ovarian cancer

(before age 50)

Family History- Breast Cancer

Underwriting Challenges in CI

• The challenge of benign lesions• The challenge of changing incidence• The challenge of non-specific symptoms

Risk factors for Breast Cancer

• Age• Gender• Race • Ethnicity• Family history• Genetic factors• Benign breast disease

• Personal history of cancer• Lifestyle, dietary factors• Reproductive history• Hormonal factors• Radiation exposure• Environmental factors

F45, $100,000 CI – Underwritten March 2003

• Family Hx: Mother diagnosed with breast cancer @ 67

• Para: Did not disclose breast lump.

• APS:

• June 02 Lump noted on BSE. Smooth mass L breast. Mammogram: “moderate amount dense glandular tissue which decreases exam sensitivity.”

• U/S: “several simple cysts bilaterally. Largest cyst on R measures 1.5 cm. Largest cyst on L measures 1.5cm. No solid lesions but one cyst has a septation and some echogenic debris within it.”

• Dx: simple bilateral breast cysts.(U/S report did not recommend f/up)

• CPX Feb 03 – on exam notes no new masses or cysts.

F 45, $100,000 CI – Underwritten March 2003

• Case approved STD March 20, 2003

• Claimed for breast cancer in 2004

• June 2004 noted swelling in her L axilla.

• Mammogram showed a “spiculated mass at 12 o’clock L breast and multiple

pathologic appearing nodes in the axilla”

• Bx: 3.5cm well differentiated tumour with negative resection margins.

Positive lymph node involvement.

• Dr states: “This patient has no prior history of breast cancer, although in

retrospect it is felt that this may have been present on a mammogram of

2002 that was read as benign breast disease.”

The Challenge of Changing Incidence: Thyroid Cancer

• F34 CI $100,000• Healthy• Policy issued at standard rates 2009• Carotid bruit detected Jan 2010

– Ultrasound of carotid: 1 cm thyroid nodule• Thyroid biopsy

papillary cancer of thyroid

The Challenge of Changing Incidence: Thyroid Cancer

• Thyroid Cancer• Incidence increasing

– 1973: 3.6/100,000– 2002: 8.7/100,000

• Majority are very small papillary cancers

• Mortality has not changed!

The Challenge of

“Non-Specific” Symptoms

• F35 $150K CI 2008– MS in maternal GF– ?MS maternal aunt

• Since 2000:– Intermittent pains x 2-3d in different areas of body– Decreased concentration– MRI 2002 N

• 2010: – Constant pain; worsening fatigue

The Challenge of

“Non-Specific” Symptoms

• PX: decreased sensation in both feet• MRI 2 focal areas of demyelination C2 and C4

suggestive of MS or transverse myelitis• CSF: + oligoclonal bands• Diagnosis: MS


• The challenge of benign lesions• The challenge of changing incidence• The challenge of non-specific symptoms• The challenge of anti-selection

CI: Risk Selection

• Approach is more conservative than with life

• APS more frequently requested

• Blood profiles more frequently requested

Judy Beamish, MD, FRCPCVP & Chief Medical Director

Sun Life Financial

Critical Illness Claims Challenges

Cancer moratorium wording

• No benefit will be payable for cancer and the Insured Person's coverage for cancer will terminate if within the first 90 days following the later of:

• the effective date of the policy (coverage), or • the effective date of last reinstatement of the policy (coverage),

• the insured person has any of the following:• signs, symptoms or investigations, that lead to a diagnosis of cancer

(covered or excluded under the policy), regardless of when the diagnosis is made,

• a diagnosis of cancer (covered or excluded under the policy).• While the Insured Person's insurance for cancer terminates, insurance for

all other covered conditions remains inforce.

Case A: PSA and cancer moratorium

• Effective date of coverage January 1, 2011• PSA ordered January 31: 4.97 (0-4)• Result repeated, still abnormal and free/total

PSA 11% (intermediate risk of cancer)• Referred to urologist on March 10 due to high

PSA with low free/total PSA• July 16, 2011 – biopsy diagnosis of prostate

cancer

Case B: PSA and cancer moratorium

• Effective date of coverage January 1, 2009• PSA March 1, 2009: 5.2 (0-4)• Previous PSA’s had been elevated at this level or

higher for 3-4 years• Seen by a urologist in 2006 with PSA of 5.4 – normal

biopsy in 2007• October 2012 – PSA 9.1 -> referred back to urologist• December 16, 2012 – biopsy diagnosis of prostate

cancer

Is case A different from case B ?

• In case A there was a new finding during the moratorium period which led directly to referral and diagnosis of cancer

• In case B there was nothing new about the elevated PSA during the moratorium period and this did not trigger an investigation leading to a diagnosis of cancerIt was the bump in PSA in 2012 that led to the diagnosis

Case C

• Male 40• $50,000. Group CI policy (Guaranteed Issue)

effective 2005 and 2009 • Advanced Polycystic Kidney Disease

Definition major organ failure

• Major organ failure on waiting list which is: major organ failure on waiting list-means a definite Diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under major organ failure on waiting list, the Insured must become enrolled as the recipient in a recognized transplant centre in Canada or the United States that performs the required form of transplant Surgery. The date of Diagnosis is the date of the Insured's enrollment in the transplant centre. The Diagnosis of the major organ failure must be made by a Specialist Physician.

Case C APS

In view of the continued deterioration, I thought it was appropriate for Mr. __________ to plan, along with his sister for a transplant during the

summer. It seems that this will suit both him and his sister well.

He was not placed on a waiting list becausehis sister is going to be the donor

Case C

In view of the continued deterioration, I thought it was appropriate for Mr. __________ to plan, along with his sister for a transplant during the summer. It seems that this will suit both him and his sister well.

Kidney failure is defined as chronic kidney disease stage 5, with the GFR below 15. He reached this point in March 2011 and at that visit his nephrologist recommended that he and his sister plan for renal transplantation during the summer.

• Does he meet the definition ?

Case D heart attack

• Claimant submitted claim for heart attack

Case D APS

Medical Consultant’s Review

Hospital Discharge Report

Definition of heart attack• Heart Attack is defined as “a definite diagnosis of the death of heart muscle due to obstruction of

blood flow, that results in: • Rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial

infarction, with at least one of the following:• heart attack symptoms• new electrocardiogram (ECG) changes consistent with a heart attack• development of new Q waves during or immediately following an intra-arterial cardiac procedure

including, but not limited to, coronary angiography and coronary angioplasty.• The diagnosis of Heart Attack must be made by a Specialist. • Exclusion: No benefit will be payable under this condition for:• elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including,

but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or

• ECG changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition as described above.”

Case E

• ECG – classic findings of acute inferior wall MI

Presented with chest pain and bradycardia

Case E Hospital #1

Treated with thrombolysis at hospital #1, then transferred to hospital #2

Hospital #2

• Admitted with diagnosis of acute inferior MI, post-thrombolysis

• Taken to cath lab for angioplasty• No troponin done

Is this claim payable ?

Timing of Release of Various Biomarkers After Acute Myocardial Infarction.

Anderson J L et al. Circulation 2011;123:e426-e579

Copyright © American Heart Association

Case F - hospital records

• STEMI • Smoker• Took cocaine 03/01/2011

What does the contract say ?

• No benefit is payable if the covered condition is caused directly or indirectly by……voluntary or involuntary consumption of drugs or participation in any criminal act

Triggers for Acute MI

Lancet 2011;377:732-40

What can we conclude ?

• Claims come in for a variety of events many of which don’t fit the letter of the definition

• Hospital records are essential• Medical expertise required for cases that

don’t quite fit• What is the intent of the definition ?

Questions?

Lori Boyce, CHS AVP, Underwriting, Risk Management & Research/Development Manulife Financial.

Documents

Transcript of Lori Boyce, CHS AVP, Underwriting, Risk Management & Research/Development Manulife Financial.