How are liver disorders viewed by insurers? Colette Parkinson gives an underwriter's view
The liver, the largest internal organ of the body, is located in the right upper quadrant of the abdomen, immediately under the diaphragm. It has been estimated to have over 500 functions. Virtually all the blood returning from the intestinal tract to the heart passes through the liver. This means that everything you swallow that is absorbed into the blood stream passes through the liver.
Brief summaries of the liver's functions are:
• Processing digested food from the intestine.
• Controlling levels of fats, amino acids and glucose in the blood.
• Combating infections in the body.
• Clearing the blood of particles and infections including bacteria.
• Neutralising and destroying drugs and toxins.
• Manufacturing bile.
• Storing iron, vitamins and other essential chemicals.
• Breaking down food and turning it in to energy.
• Manufacturing, breaking down and regulation of numerous hormones.
• Making enzymes and proteins, which are responsible for most chemical reactions in the body, for example those involved in blood clotting and repair of damaged tissues.
Despite its complexity, the liver is remarkably resilient. It can keep going even if it loses as much as 80 - 90% of its cells through disease or surgery. However, the human body would not be able to function without it and that is why underwriting liver disorders requires careful consideration.
There are various types of liver disorders which can vary from less serious conditions like gallstones to more serious conditions such as cirrhosis.
Hepatitis
Hepatitis is an inflammation of the liver. Viruses are the most common cause of hepatitis but there are also other causes such as excess consumption of alcohol and the side effects of some drugs. There are several types of hepatitis:
• Hepatitis A. This is spread by eating food or drinking water, which is contaminated with the hepatitis A virus through poor hygiene or sanitation.
• Hepatitis B. This is mainly passed on by blood-to-blood contact but can also be transferred sexually. It is estimated that one million people are infected every year in Europe - in the UK, one in 1,000 people are thought to have the virus. Worldwide this kills between one to two million people annually, yet according to the British Liver Trust there is a vaccine to prevent infection.
• Hepatitis C. This is also passed on through blood. All blood donations have been screened for the virus since 1991 - prior to this some have been infected by blood transfusions. For some the cause of infection is not known, for others, injecting drugs causes this and it can be transmitted by sharing injecting equipment. Most people recover from hepatitis A with no lasting liver damage but B and C can cause long-term liver disease, leading to cirrhosis and even liver cancer.
Cirrhosis
Cirrhosis is a disease that destroys healthy tissue, leaving scar tissue and preventing the liver from functioning properly. It is more common in those over the age of 40 and is also more common in men. It is responsible for around 3,000 deaths per year in the UK and in developed countries is the third most common cause of death for those between the ages of 45 and 65 years old.
There are many causes of cirrhosis, such as chronic hepatitis B and C infection, fatty liver disease and inherited diseases such as haemochromatosis - abnormal processing of iron by the body; Wilson's disease - abnormal processing of copper by the body; and glycogen or lipid storage diseases. By far the most common form of cirrhosis is due to increased alcohol consumption.
The annual report of the chief medical officer for the Department of Health, 2001, stated: "Cirrhosis of the liver is an important cause of illness and death. In 2000 it killed more men than Parkinson's disease and more women than cancer of the cervix."
The rise in deaths from cirrhosis among younger people is of particular concern where binge drinking patterns appear common. According to website www.bbc.co.uk, in 2000, cirrhosis accounted for nearly 500 deaths in men aged 25 - 44 years and nearly 300 deaths in women of this age group.
Other disorders
Fatty liver, as the name suggests, is a build up of fat in the liver cells. This can be caused by a variety of chemicals and drugs, excessive alcohol, marked obesity, raised cholesterol levels and poorly controlled diabetes. There is no known treatment for fatty liver except to eliminate the cause or treat the underlying disorder.
According to the British Liver Trust, approximately one in 10 people will develop gallstones or another gallbladder disease and it is more commonly overweight middle-aged women that are affected. The smaller the stone the more able it is to travel around the bile duct system. Stones can become lodged in the gallbladder outlet and can cause recurrent painful attacks known as biliary colic. Stones that pass from the bile duct into the intestine can also temporarily obstruct the flow of digestive juices from the pancreas resulting in pancreatitis.
There are various ways in which gallstones can be treated. The removal of the gallbladder - cholecystectomy - is the most usual form of treatment for gallstones that cause symptoms. The gallbladder is not essential for life and it ceases to work properly when stones form. Other methods of removing stones are by dissolving them with drugs or breaking them up with shock treatment, called lithotripsy.
Liver cancer
Cancer of the liver is where cells die and are replaced in equal measure. If cells begin to multiply at a faster rate than they should, a growth forms out of all the unwanted cells. Sometimes these cells can become a cancer and could also spread to other organs in the body.
Liver cancer can either start in the liver, primary cancer, or start elsewhere and spread to the liver, secondary cancer. The majority of liver cancers are secondary. In the UK, primary liver cancers are very rare. There are two cell types that tend to form cancers in the liver. The first - hepatocytes - perform the fundamental tasks of the liver, the cancers these form are called hepatomas. The cells lining the bile ducts of the liver can also change into cancers, these are cholangiocarcinomas.
Nearly any cancer in the body can spread to the liver. Cancers that are most likely to have secondary growths in the liver are those from the stomach, pancreas and colon. This is because the blood flows from these organs to the liver. Hence, all cancer cells that break away from the original growth are carried to the liver where they can embed and grow.
Primary liver cancers can be very difficult to cure. But for secondary cancers it is important to try to prevent the original cancer from starting. Stopping smoking, eating a healthy balanced diet and reducing alcohol intake will reduce the chances of liver cirrhosis and hepatomas forming.
Colette Parkinson is a life & disability underwriter with Scottish Equitable Protect
Underwriting implications
The underwriter will obtain a full report from the client's GP and sight of any hospital reports when assessing an application where there is mention of any liver disorder. The underwriter would want to know the results of all investigations available including any liver function tests, liver enzymes and liver biopsy results. Factors such as the level of alcohol consumed, if any underlying cause has been established, the nature of the treatment given and details of any complications need to be considered.
Even if an individual had been diagnosed with hepatitis and has been advised they are clear of the virus, underwriters would still refer to the applicant's GP, as this would ensure that there has been no evidence of long-term liver damage. The evidence received would also indicate the source of infection, such as intravenous drug abuse or alcohol.
For non-specific chronic hepatitis, underwriters would only consider terms for well-documented and stable cases, terms ranging from +100% for applicants over age 45 and +200% if under 45 for life cover. Critical illness (CI) and income protection (IP) applications are most likely to be declined. For alcoholic hepatitis, the applicant would only be considered if they had abstained from alcohol for at least three years, otherwise it is likely the application would be declined. If terms were to be considered for life cover, a rating would possibly be applied - a typical rating would be +100%. CI and IP benefits are unlikely to be considered at all. If all investigations were normal for fatty liver, hepatitis A and hepatitis E, it is possible that terms could be accepted at standard rates for all benefits.
Established cirrhosis is irreversible and the disease tends to be progressive, the outlook without a liver transplant is poor. Any ongoing liver disorders, where the cause is due to increased alcohol intake are likely to be declined for all benefits. Where a liver transplant has taken place it is also highly likely that the applicant would be declined for all benefits.
Financial advisers may wish to discuss the case of any applicant who has disclosed a liver disorder with an underwriting helpline prior to submitting the application.
