Taken as red

Blood is vital to life. Therefore any disorder of the blood must be recognised by an insurance company assessing an application. The underwriter must evaluate the cause, severity and significance of a blood disorder to establish the risk factors a blood disorder can present. When blood function deteriorates the consequences can vary in severity and the underwriter must therefore know what line of investigation to take.

In order to understand why any such blood disorder will be of concern to the underwriter, we must first understand the role of blood in keeping the body in good working order.

Blood is pumped around the body continuously by the heart. It carries out several functions and is made up of four elements:

• Erythrocytes: These are the red blood cells that give blood its colour and carries oxygen around the body.

• Leucocytes: These are white blood cells that form an essential part of the immune system, protecting the body against infection.

• Platelets: Assist in blood clotting.

• Plasma: This is the fluid in which blood cells are carried around the body.

Any deficiency or problem within these elements may lead to major health problems.

Anaemia

Anaemia can basically be described as a below average number of red cells in the blood. This ultimately results in a reduction in the oxygen flow around the body, often causing tiredness or fatigue. Anaemia is confirmed by laboratory tests, however, its cause is often difficult to confirm. As a result, underwriters assessing applications with any type of anaemia must be aware of the cause of the condition and current haemoglobin levels.

Haemoglobin is a constituent of the red blood cell which gives the blood its colour and is the medium by which oxygen is transported around the body. The haemoglobin level is used to assess the severity of the anaemia.

However, the underwriter does not just have to be concerned by one type of anaemia. There are many different forms of anaemia which hold varying degrees of severity and prognosis.

Iron deficiency anaemia

The most common form of the condition is iron deficiency anaemia. Iron is a core component of the haemoglobin. Therefore if iron is not present in the body a chain reaction can start, which results in a limited production of haemoglobin, which, in turn, reduces the amount of oxygen transported around the body. This can be clinically shown by fatigue, pale skin, headaches and the presence of swollen, cracked and bright red lips.

There are a number of reasons why people may lack iron:

• Major blood loss, for example excess menstruation.

• A person's diet. Certain foods contain higher levels of iron and a well balanced diet would keep iron levels at the recommended level.

• Poor absorption of iron, possibly as a result of surgery, as the body is not storing iron sufficiently.

• Increased demands upon the body can lead to the blood having to work harder, such as during pregnancy or growth spurts.

Once a cause has been established then the correct course of treatment can be prescribed. This can be taken in the form of oral iron tablets and can correct the anaemia and restore iron levels to normal.

Pernicious anaemia

Another type of anaemia, which can be the result of poor diet is pernicious anaemia, otherwise known as vitamin B12 deficiency.

The vitamin is another component of the red blood cell that assists in nerve production. A reduced level of this in the body can lead to certain problems. The body does not produce adequate amounts of vitamin B12 to satisfy needs, so the correct dietary intake of meat, fish, eggs and milk will keep levels high and should result in no problems.

The signs of pernicious anaemia can be of either instant or gradual onset. People can become pale, jaundiced and tired, but should the condition remain for a period of time, then neurological features and a risk of gastric carcinoma may grow.

Pernicious anaemia can be adequately treated with vitamin B12 injections. The injections would normally be given on a monthly basis for life. Other precautionary treatment could be regular gastroscopys to ensure that gastric carcinoma is not present. Any neurological symptoms may improve, but this would depend on the severity of symptoms.

Both iron and perncious anaemia are more common in the elderly, but findings can occur at any age.

Anaemia may attract a premium loading, but this will be based upon certain criteria. The degree of anaemia and whether it has been fully investigated are important factors. If fully investigated and an underlying cause is found, a rating would be applied for the primary cause with a possible increase in premium based upon the degree of anaemia. If no underlying cause is found, ratings can range from standard terms to postpone, depending on the degree of anaemia. For further ratings, see the table opposite.

When assessing applicants with a history of anaemia it is essential for the underwriter to establish that there is no underlying cause and the condition is controlled adequately.

There are many other forms of anaemia varying in severity such as aplastic, macrocytic and sickle cell anaemia.

While discussing blood disorders resulting from a defect in the red blood cells, problems can also occur when other components of the blood are not working correctly.

Leukemia

Leukemia is a cancer of the white blood cells, which is produced in the bone marrow. The bone marrow produces two main types of white blood cells ' lymphocytes and granulocytes which are produced from the myeloid cells in the bone marrow.

Leukemia is categorised in four ways:

• Acute lymphoid leukemia (ALL)

• Acute myeloid leukemia (AML)

• Chronic lymphoid leukemia (CLL)

• Chronic myeloid leukemia (CML)

Acute leukemia occurs rapidly when the bone marrow fails. This will result in a variety of symptoms including tiredness, weakness, shortness of breath on exertion, repeated infections, bruising, bleeding and occasionally lymph node enlargement. The treatment of acute leukemia must be swift because if left untreated it can be fatal.

Acute lymphoid leukemia is most common in childhood and is rare after the age of 15. The condition can be cured and occurs when lymphocytic cells grow rapidly by cell division. Acute myeloid leukemia is more common in adults. This can be cured by bone marrow transplant and can respond to chemotherapy. It occurs when the granulocytes grow rapidly by cell division.

Chronic leukaemias develop progressively over a period of time. Symptoms are similar to that of acute leukaemias but can also include sweating at night, fever and weight loss. Abdominal discomfort can also occur as the results of splenic enlargement. Chronic leukaemias usually occur in adulthood.

Chronic lymphoid leukemia may remain asymptomatic for many years before clinical indication is evident, thus causing minimal life expectancy. The condition is incurable, but with treatment the condition can be kept under control for a number of years.

Chronic myeloid leukemia can be controlled for some time by chemo- therapy, however, it takes an acute form after several years and the outlook becomes poor.

In order to consider clients with a history of leukemia the underwriter has to be aware of several factors. As with all cancers the type and staging of the cancer must be known. This will indicate the likely prognosis. The underwriter must also have information confirming exact date of diagnosis, when and what type of treatment was undertaken and when the treatment finished. Another significant factor is whether there has been a recurrence. As with all cases as full a picture as possible needs to be drawn up so that the underwriter can be in a position to give the application full consideration.

For acute leukemia the rating for life cover will be determined by confirmation of staging, treatment and that there has been no recurrence. Once established, the rating will be applied, based on the years since primary treatment ceased.

For chronic leukemia the underwriter needs to know whether the condition is asymptomatic or not. If this is the case, ratings tend to be moderate to high depending on the age of the applicant and the length of time spent symptom free.

Critical illness plans are generally declined, should a history of leukemia have been indicated.

Blood disorders are generally easy to investigate due to the increased use of laboratory testing. Although we have only covered a proportion of the blood disorders in detail, the importance in recognising and investigating such conditions can only be highlighted by the associated problems.

It is now good underwriting practice to obtain blood tests in certain circumstances to discover if any underlying condition exists. However, if a condition has been followed up adequately then personal medical records should provide all information necessary to correctly assess an application.