Heart attacks normally mean huge critical illness ratings, Julie Hopkins looks into new and existing medical research of this condition
Considering Critical Illness and heart attacks together throws up two fundamental questions: Do any heart attack survivors have a sufficiently good risk profile allowing them to be offered critical illness cover? Also if the industry can offer some heart attack survivor's life insurance - then why not critical illness cover?
Why consider Heart Attack at all?
Heart attack is one of the most common causes of claim on critical illness policies and it is also more common than most would expect in the general population. In 2006 the British Heart Foundation estimated there were 1.4 million heart attack survivors aged 35 or over in the UK. As medical treatments advance, this already large number will only increase.
When offering life cover, providers, typically defer until six to 12 months after the attack, with ratings ranging from +100% to +400% extra mortality. The precise rating will depend on an evaluation of medical evidence, functional status, combination risk factors, age at onset, and duration since attack.
Medical evidence: people who have had a heart attack and have not attended for check ups are not an attractive risk compared with those who have.
Functional status: the better risks are those who have returned to work following an event, continued to exercise, and show good ejection fraction (EF) measurements (EF measures the efficiency of the heart).
Controlled risk factors: people in whom combination risk factors such as raised blood pressure, lipids and weight/waist are under control are also likely to be better risks.
Age at onset and duration since attack are other important factors to consider and will influence the final terms offered.
When looking for large-scale studies of heart attack survivors there is very little long-term data published. There are plenty of short-term studies with a follow-up period of 12 months or less, but little beyond that. Indeed, commenting on the supporting evidence base for its Post Myocardial Infarction Guidance 2007, NICE notes a "lack of long-term data on clinical endpoints... with an average follow up of only five years".
A recent Danish population study by Buch et al. however, does contain some excellent short-term data on cumulative mortality during the first year among those admitted to hospital following a heart attack.
Although not a long-term study, this does highlight a number of interesting trends. Looking at calendar-year groups (cohorts), it shows mortality improving over time, with more recent cohorts exhibiting better survival rates during the first year following their heart attack.
The steep initial mortality is particularly evident in the first 14 days (the green line) and the first 30 days (the red line), which tie in with survival periods for standalone critical illness.
Long-term studies covering ten years or more are harder to find. One large population study from Scotland was published in the European Heart Journal in 2000. This looked at mortality at 30 days, one year, and five years, for patients admitted to hospital with heart attack (myocardial infarction) between 1986 and 1995. The main findings were that 70% were alive after one year, and 50% after five.
Improving survival rates
As treatment protocols change, long-term survival rates are improving. Operational treatments such as angioplasty and coronary bypass have been a factor here. Pharmacological treatments have also moved on. By 2007 the number of people treated with thrombolytic (clot-busting) therapy within 60 minutes of calling for help had risen to 70% from just 40% in 2003. In the same year, more than 45 million prescriptions were written for lipid regulating drugs (statins).
The British Medical Journal 2009 detailed a study, the Monica Cohort, which was conducted in Perth, Australia and followed people who survived at least 28 days following a heart attack over 12 years.
Although, at 54, the average age was considered on the young side for such a study, it is significantly older than the typical critical illness (CI) claimant in their 40s. Their results showed survival rates improving. For the most recent group of years studied, only 20% had died within ten years.
Looking at the fully underwritten industry actuarial table (TMN00) for a male non-smoker aged 54, Hannover Life Re UK expect 96.3% to be alive after ten years. This was compared to the 82% who were alive after ten years of the most recent cohort studied in the Perth Monica Study (1991-3). The difference in survival was calculated as approximately +400% extra mortality for life cover, even if terms are deferred for 12 months.
The above rating for mortality is at the top end of the ratings usually offered, so before considering other disclosures, the overall loading for CI could be in excess of +900% extra morbidity - more than four times the maximum loading charged.
Not only is long-term data on survivors in short supply there is also a problem with its consistency. No doubt some heart attack survivors owe their lives to improving treatments and services, but their long-term prognoses remain uncertain.
Some experts suggest that higher proportions are surviving with conditions such as atrial fibrillation.
The investigation concluded that providers could not routinely offer critical illness to heart attack survivors. The risk of suffering one of the named cardio/cerebrovascular conditions is too significant.
However, there is a simple and effective mechanism for enabling cover to be provided to heart attack survivors for both life and critical illness benefits - Cover Reinstatement or Buyback.
Customers can take out an option at the start of their critical illness policy for which they pay a modest increase (typically 12 to 20%) on their premium. If they have made an initial critical illness claim, policyholders can reinstate their cover once a set period of time, usually one year, has elapsed.
Certain criteria are typically imposed to control the risk - for example a maximum age, restricted term or sum assured. Current market practice, it should be noted, is to offer the option only to those accepted at standard rates. Buyback does, however, present a number of basic advantages:
■ Cover can prove invaluable to individuals (CI claimants) who might otherwise be deemed uninsurable.
■ As it is offered to standard rated cases at policy outset, there are no extra underwriting or evidence gathering costs.
■ Offering terms is simple: if you are offered standard rates you are in!
■ Buyback covers not just heart attack survivors but, typically, any survivor of a critical illness claim.
■ Buyback can reinstate coverage for a full range of conditions.
Pooling risk
How can buyback be priced so modestly when earlier in the article it stated that the risk of offering critical illness cover to heart attack sufferers is too great? The answer has two parts. Firstly it is about pooling risk. More importantly, it is about when the policyholder is underwritten.
Buyback is usually only offered to lives accepted at standard rates at the outset of the policy. So for an individual to be able to claim on the buyback option they must first have moved from the healthy state to that of a first claim, before suffering a second event and moving to the second claim state.
In other words, underwriting the policyholder into the healthy pool at outset means the individual must first suffer a critical event before they reach the state of being at risk for a second and subsequent event. This controls the cost as very few individuals will have a first critical event, but for those that have had a first event the likelihood of them as a group having a second event is higher.
Critical illness cover can be offered to heart attack survivors - provided they are covered before they suffer their first heart attack. Buyback is not a panacea - but if included can offer valuable cover to those who would otherwise be denied critical illness. The option would be conditional on the policyholder starting out in the healthy pool.
The take up rate for this valuable optional benefit will depend on how the marketing messages are handled with the customer. The cost of adding buyback to a policy is modest compared to the additional cover obtained.
The fact that cover would not be restricted to heart attack only and other common conditions associated with critical illness claims will also be included, for example stroke and cancer makes this an attractive and valuable addition to any critical illness product offering.
Julie Hopkins is head of underwriting & claims strategy at Hannover Life Re (UK)
