Multiple sclerosis affects 85,000 sufferers in the UK and is a major cause of disability in young adults. Simon Taylor looks at its implications for life and CI cover
One of the most common major nervous system diseases an IFA is likely to encounter is multiple sclerosis (MS). It is the most common cause of chronic neurological disability in young adults. While it can be diagnosed from the age of 10 to 59, the disease generally begins in the 20 to 40 age group, with the mean age of onset of 29 to 33.
MS affects 85,000 people in the UK, with 2,500 new cases diagnosed each year.
There is a 50% greater incidence in women than men, so for every two men diagnosed there are three women with the condition, it accounts for between 250 and 280 deaths a year.
What is MS?
MS is an inflammatory demyelinating condition where white blood cells are activated to enter the brain, in turn activating other elements of the immune system in a way that makes them attack and destroy myelin ' the fatty sheath that surrounds nerve fibres in the brain and spinal cord.
This damage means that the nervous system's normal signals are interrupted and blocked and movement becomes difficult and sensations impaired.
This damage can manifest itself in many ways to varying degrees. Symptoms include numbness, weakness and co-ordination problems which affect balance and motor skills, such as walking. It can affect bladder and bowel and control and cause fatigue, pain and mood swings.
One of the most common initial presentations is an eye condition known as optic neuritis, which causes painful blurred vision and even temporary blindness. This is because the optic nerve is vulnerable to myelin damage being rich in myelin antigens and, although optic neuritis can be a condition in itself, 20% to 50% of cases will eventually progress to MS. This progression can take as long as 15 years. As with many auto-immune conditions there is no clear answer to what causes MS and it is a difficult condition to research.
The two main causes are thought to be genetics and environment, with 'other' factors the third element. There can also be an element of chance, with traumatic damage to the brain or spinal cord being implicated in some cases.
There is no simple genetic link, although there is a greater risk in siblings of those affected ' especially sisters. There is a one in three risk for an identical twin if the other twin is diagnosed with MS, so the risk is not purely genetic. The link on the female side is stronger than the male ' if a mother has MS, the son has no increased risk, but a daughter's risk increases to 4.96%.
There is an increased risk according to environment. Around the equator people are likely to be immune ' the further away from the equator, north or south, the higher the risk, with the highest incidences in Scandinavia and North America. One theory here is temperature-related viral factors. There is also a theory that common viruses, such as measles, herpes or chlamydia, may trigger the auto-immune process that activates MS, but there is no solid proof for this. Population risk in the UK is one in every 1,000. However, in Scotland, this rises to one in 700. In Canada, the risk increases two-fold to one in 500.
Making a diagnosis
A GP who suspects that a patient may have MS will refer them to a neurologist. There are 280 consultants in the UK for 60 million people and this can lead to a nine-month waiting list for an appointment. The new advice is that all cases of optic neuritis should be investigated with an magnetic resonance imaging (MRI) scan.
This can show the presence of white plaques or lesions, which indicate areas of damage. If there are five or more of these plaques, MS will be diagnosed. Lumbar punctures to test cerebro-spinal fluid are also used; these identify oligoclonal bands which are indicative of MS. There is, however, no specific genetic test to confirm or rule out MS
One key recent development is that the consultant neurologist should now make a diagnosis to the patient as to whether they have MS. Often in the past when there was a suspicion that it may be MS the patient was not made aware until a further episode or relapse had taken place or 'tentative' diagnosis was made.
There are eight types of MS, but the most common are as follows:
• Benign disease: this accounts for 10% of cases and there would be no or very minimal symptoms after 10-15 years.
• Relapsing and remitting: this accounts for the majority of cases and would involve a number of relapses, followed by periods of complete remission.
• Secondary progressive MS: this follows the same course as relapsing/remitting but later in the disease more progressive disability results, as there is incomplete recovery from the relapses.
• Primary progressive MS: this is of slow onset but has a more steadily worsening progression.
The rate of progression can vary enormously with MS. In its most aggressive form, it only takes four years from diagnosis to leave the sufferer wheelchair dependent. Acute episodes are usually treated with oral steroids such as prednisolone or intravenous steroids, which aim to shorten the attack.
The relapsing remitting form can be treated with beta-interferon which reduces the number of relapses by one third and therefore slows down the rate of progression, but this is an expensive treatment and not widely available. Other drugs can be given to treat the symptoms of MS such as bowel and bladder problems.
More recently, there has been a public debate as to whether the use of cannabis is beneficial and should be allowed in MS treatment. Clinical trials are taking place before a legal ruling is made.
The final decision
The underwriter's decision will depend on the date of diagnosis, the course and type of the disease and the current level of symptoms. If the condition was diagnosed within the last year and there has been a good recovery from the initial episode it is too early to predict the course of the disease and a more cautious view would need to be taken with a likely rating of at least +100% for life cover. For those where the condition was diagnosed over a year ago, the following advice would apply for l ife cover:
• If the condition follows the benign course, with no signs or symptoms for five years, then a small loading of +50/75% may be applied. In the best cases, standard rates may be possible.
• If the applicant displays more moderate disability, with more evident symptoms but where they are fully self-sufficient, it would lead to a loading of about +100/150%.
• The more severe forms of MS would require careful underwriting. If the client needs mobility aids, such as walking sticks, terms may be possible with a loading of +200% for a shorter term policy, but where the use of a wheelchair is required and bowel or bladder problems are involved the cover would almost certainly be declined.
Given the unpredictable nature of the disease and the complications involved critical illness (CI) cover would rarely be considered, except in the most benign cases where a rating and exclusions would also be imposed. For similar reasons, providers would not be able to consider any sickness-related benefits such as income protection, total and permanent disability or waiver of premium benefits. There is a genetic link and a family history of MS needs to be taken into consideration when considering CI cover. Terms will depend on which family member was affected and the sex and age of the applicant.
A female applicant aged under 50 with any first degree relative ' mother, father or sibling ' diagnosed with MS before the age of 50 would have MS excluded from the CI cover. A male applicant would similarly have MS excluded if his father or a sibling had been diagnosed but if it were his mother only, no exclusion would be necessary.
Simon Taylor is senior life and diasbility underwriter at Scottish Equitable
