Sewing up the definitive heart attack

An alternative to the current ABI definition may be to tie CI to the definition used in clinical practice.

Universal wording

The Third Universal Definition of Myocardial Infarction was published in September 2012 and is shown in Figure 2 (see below right). This expert consensus document is used as a guide by cardiologists for a diagnosis of MI and is refined as clinical practice develops.

With increasingly sensitive troponin assays, the guidance on its use in diagnosis means there is potential for an increase in the number of MI events that are diagnosed clinically. Mills et al. estimates that lowering the diagnostic threshold to the 99th percentile would increase MI diagnosis rates by 47%.

It is difficult to state how many additional valid CI claims would be paid given the differences between the Universal and the ABI standardised definitions. However, there is the chance that, using a wording that ties in with the Universal Definition could significantly increase MI claims costs.

It is possible to tier CI benefits in relation to the level of maximum troponin. This could open arguments about the timing of any sampling but at least allows for claimants to have some benefit when they have been told that they have had a heart attack with lower levels of troponin than the current ABI threshold.

Another alternative is to pay more if there is evidence of more extensive muscle damage with results from echocardiography, or magnetic resonance scanning.

However this will cause problems as many of the claimants will not have had these investigations performed and insurance companies do not want to increase the cost of claims management and investigation.

From the policyholder's viewpoint, there are clear advantages in having a policy where the medical diagnosis ties in so closely with the definition used for determination of a valid critical illness claim.

However, this may come with an associated increase in cost that may be less acceptable. From the insurer's point of view, on products that often have long-term guarantees, the question must arise as to whether the ‘future-proofing' aim, set when the ABI definitions were developed in 2006, can really be regarded as achievable.

The diagnosis of MI based on increasingly smaller levels of troponin suggests that the severity of damage implied by the diagnosis is itself diminishing.

The implication is that along with those who have a severe MI with residual symptoms of breathlessness and heart failure, there are many to whom the diagnosis incurs no lasting disability.

As a consequence, these symptoms therefore no longer represent a ‘critical' illness, as implied by the insurance term (and funded by current levels of CI premium).

However, insurers may be unable to continue to insist on specific elevation of troponin to support an MI diagnosis if these are not measured in clinical practice. Also, it may be unreasonable to deny a claim by imposing a self-set ‘troponin threshold' if there are clear ECG abnormalities and classic symptoms.

The implication of these issues is that either the level of CI premiums will need to increase (making it less affordable) or insurers need to develop a modified approach: one that allows for some level of severity, rather than assessing claims against a single clinical MI definition, thus safeguarding against claims for a condition the insurance industry never intended to cover. 

Joan Coverson is regional chief actuary at Gen Re UK