Most food that we eat is converted to glucose by the body's alimentary tract. During and after eatin...
Most food that we eat is converted to glucose by the body's alimentary tract. During and after eating, insulin is released into the blood stream, which helps to control the level of
blood glucose. Between meals, when blood glucose levels fall, insulin production decreases, preventing further absorption of glucose for storage and causing the release of stored glucose as necessary. In this way, blood glucose levels are largely maintained within a particular range.
In someone who is diabetic, reduced insulin production means that the storage of glucose for later use is impaired in varying degrees. This results in abnormally high blood glucose levels. The kidneys filter glucose from the blood and excrete it in the urine once the blood glucose concentration exceeds a certain threshold level (glycosuria). If glycosuria is present this could indicate the presence of diabetes. In a recognised diabetic the absence or presence of glycosuria is an indicator as to how well the diabetes is being controlled.
If left untreated, or if the condition is poorly controlled, a condition called ketoacidosis can occur (vomiting, dehydration and coma); this can be fatal if not treated quickly. Those who are unable to maintain a good control of their condition are also more likely to develop long-term complications.
Long-term complications
l Hyperlipidaemia an abnormally high concentration of fats in the blood which can accelerate the development of fatty plaques on the inner walls of the arteries leading to ischaemic heart disease, strokes and complications of peripheral vascular disease.
l Diabetic retinopathy a disorder of the retina where small red dotted spots are present leading to a possible impairment of vision. In more advanced cases haemorrhage can occur which can cause blindness.
l Cataracts which can lead to blindness.
l Diabetic nephropathy disease of the kidney usually indicated by the continuous presence of protein in the urine. In advanced cases renal failure may occur.
l Diabetic neuropathy disease of the peripheral nerves, usually affecting the legs and feet; it can also lead to impairment of bowel and bladder function. Symptoms are usually weakness and numbness in the affected area, sometimes accompanied by nocturnal pain. In advanced cases infection, ulceration or gangrene can occur.
Types of diabetes mellitus
l Type 1 diabetes insulin dependent diabetes mellitus (IDDM) usually, but not always, occurs below the age of 40 and requires daily insulin injections to maintain control. Initial symptoms usually consist of lethargy, excessive thirst, loss of weight and excessive secretion of urine.
l Type 2 diabetes non-insulin dependent diabetes mellitus (NIDDM). This is generally the milder of the two conditions and usually occurs in the middle-aged or elderly. The diagnosis is often made by chance during a routine medical examination. Control can normally be maintained by a low carbohydrate diet or oral drugs. The progression of this is slower than IDDM, but complications may eventually occur.
The long-term course of diabetes mellitus is difficult to predict. It will depend on the degree of control, the presence or absence of any complications, and any adverse family history.
Good control is achieved through a full understanding of the condition and strict adherence to diet and treatment. If good control is achieved and maintained any serious complications can be delayed until many years after the original diagnosis. Those having poor control of their condition are likely to develop complications at an earlier stage.
How does the presence of diabetes mellitus affect an applicant's ability to obtain life assurance or critical
illness protection? In order to assess the suitability of an applicant, the underwriter will typically request the following information:
l Completion of a diabetes questionnaire by the client this gives the underwriter an insight into the individual's understanding and control of their condition.
l Completion of a report by the client's own GP this will normally provide the underwriter with information regarding the patient's attitude to and control of their condition and will also indicate any associated complications.
l A medical examination may be required if up to date information from the GP is unavailable or where the client's weight or blood pressure needs to be verified.
l A glycated haemoglobin test may be requested if no recent results are available. (This indicates the level of control over a longer period of time rather than daily blood glucose levels which can vary greatly from day to day).
Underwriting considerations
The main factors that the underwriter will consider are:
l Whether the client is suffering from type 1 or type 2 diabetes.
l The age of the client at the time of application older lives who have only recently been diagnosed as diabetic can be treated with more lenience. This is because there will usually be less likelihood of any diabetic complications occurring.
l For type 1 diabetes the age of the client when the condition was diagnosed should be considered studies have shown that mortality rates are significantly higher in those under age 30 at the age of diagnosis. The age at onset also has an important bearing on the incidence of complications.
Control of the disease if the following criteria are met the condition can be classed as well controlled:
l Client has a good understanding of the condition.
l Under close medical supervision and co-operation with the doctor or diabetic clinic.
l No need for frequent variation of treatment type or dose.
l Occasional glycosuria only.
l No recent history of coma.
l Fasting blood glucose below 6.1 mmol/1.
l Level of glycated haemoglobin (HbA1c) is normal or near normal.
There are also a number of other factors to be considered:
l Albuminuria/microalbuminuria (albumin in the urine, which could indicate an abnormality of the kidneys or urinary tract, this could in turn lead to renal failure).
l Build.
l Alcohol consumption.
l Family history.
l Hyperlipidaemia.
l Hypertension (raised blood pressure).
l Neuropathy.
l Retinopathy.
l Smoking (a combination of smoking and diabetes increases the risk of developing vascular disease).
l Vascular conditions (for example, stroke, heart attack or intermittent claudication).
Life cover
The majority of applications will be acceptable, although with an increased plan payment, (the amount depending on the above features). In some instances, where the diabetes was diagnosed at a young age and a long plan term has been requested, the underwriter may limit the term of the plan. However, where there is evidence of poor control or where associated complications are already present, it may be necessary to either delay offering terms or decline the protection.
Critical illness protection
Due to the possible complications of diabetes, (heart disease, stroke, kidney problems, blindness, and so on), most of which are included in the main core illnesses of a critical illness policy, the majority of type 1 diabetics will be declined for this type of protection.
Terms may be available, with an increased plan payment, for some type 2 diabetics who display optimum control and have no complications and who are shown to co-operate fully with their doctor/diabetic clinic.
Underwriting helplines
Where an adviser has a potential applicant with a known history of diabetes mellitus it is recommended that they take advantage of any underwriting helpline made available by the life office.
These lines are normally manned by experienced underwriters who will be able to give an indication of whether terms are likely to be available and possibly indicate a level of loading. It should be noted that the underwriters can only give an indication to the likely terms based on the evidence presented and will only be able to confirm terms once an application and medical evidence have been received and assessed.
Julie Dorsman is a life and disability underwriter at Guardian Financial Services
