Critical illness heart attack definitions are under scrutiny as medical advances redefine the condition, as Joan Coverson explains the main conditions covered under CI policies in the UK have been subject to standardised definitions, determined by the Association of British Insurers (ABI), since 1999.
To add to this issue, the current troponin level stated in the ABI definition of MI is regarded by many as too high to tie in with current clinical practice.
From the policyholder’s point of view, it is a reasonable expectation that their CI policy should pay out if their cardiologist confirms to them that they have suffered an MI or that they receive treatment as having had a heart attack.
It is not unusual for companies to pay claims for MI when troponin levels are below those strictly stated in the definition, because the claims assessor believes that the claim is valid from the evidence available.
The current ABI levels were set in 2006, and since then troponin assays have become significantly more sensitive , with some now measuring as little as a few picograms (a picogram being 1/1000th of a nanogram [ng]).
Current clinical guidelines recommend a troponin T level of 0.1ng/ml or less as the criteria for diagnosis of a probable MI, well below the current ABI level of 1ng/ml.
It is now common for companies to remove the criteria for there to be typical clinical symptoms (as stated in the ABI standard wording), thus creating a so-called ‘ABI plus’ definition. Taking this into consideration leaves a wording that could be regarded as unfit for purpose.
One of the key issues addressed when definitions were derived in 2006 was to make them future proof, particularly as CI policies can have many years duration. Clearly, this difficult to achieve even when only taking account of medical advances in the past few years. Adding to the debate are the questions of when it is ‘right’ for a CI claim to be paid and how severe an illness has to be to justify a 100% payout.
As troponin assays increase in sensitivity, it becomes possible for cardiologists to diagnose ever smaller amounts of heart damage. If CI definitions follow clinical practice, could the pool of potential claimants become much wider?
There is no doubt that the level of troponin representative of the amount of damage to heart tissue does have an impact on future prognosis.
Mills et al. (2012) tracked probability of death or MI recurrence within 12 months of the original event. Death or recurrence rates for troponin I levels of over 0.05 micrograms per litre were found to be over five times that for a reading of below 0.012 micrograms per litre.
To put this into some context a level of 0.05 micrograms per litre is just one-tenth of the level in the current ABI definition.
There remains significant probability of death or recurrence at or below this level, which perhaps demonstrates some of the difficulties with the current definition. This is emphasised by the fact that in current clinical practice a probable MI would be diagnosed where a patient has a troponin I level of at least 0.05 micrograms per litre.
