This month Nigel Kirkpatrick looks at the importance of a person's family history when trying to sec...
This month Nigel Kirkpatrick looks at the importance of a person's family history when trying to secure health or life cover
In the insurance market the relevance of an applicant's family history has increased in importance over the last few years, particularly with the development of critical illness protection.
With regard to life protection, the main familial conditions of interest are Huntington's disease and polycystic kidney disease. Successive studies have pointed to the relevance of a number of other familial conditions when assessing applications for life and critical illness protection. A Society of Actuaries Medical Impairment Study (1962-1977) showed that where an applicant had two or more first degree relatives with cardiovascular disease diagnosed before aged 60, the risk of the person being diagnosed with cardiovascular disease was almost double that of the general population for a male, and one and a quarter times greater for a female.
An inherited factor is also recognised in studies of families who have a strong tendency to cancer, especially breast and colorectal cancer. The study also indicated that where an applicant had two or more first degree relatives with cancer prior to age 60, the risk of the applicant contracting cancer was almost double that of the general population for a female, and one and a half times greater for a male.
Certain neurological disorders including motor neurone disease, Parkinson's disease, and Alzheimer's disease may have a genetic component, particularly where there is a familial tendency to their early development.
Breast cancer
It is estimated that approximately 5%-10% of all breast cancer cases are hereditary with the patients having a strong family history of the disease. The remaining cases are classed as sporadic. Inherited breast cancer has several distinctive clinical features:
l The age at onset is younger than in sporadic cases.
l The prevalence of bilateral breast cancer is higher.
l The presence of associated tumours which may include ovarian, colon, and prostate cancer in affected individuals.
A typical medical loading for a female applicant under age 45 who has a first degree relative diagnosed with breast cancer under age 50 is:
l Life protection at one and a half times standard rates.
l Critical illness cover at two times standard rates, or breast cancer can be excluded.
If the first degree relative was diagnosed with breast cancer between the ages of 50 to 64, the terms will be standard rates for life and critical illness protection.
Where there is a family history of breast cancer, terms can usually be quoted on the proposal disclosure. If the applicant has a history of a breast cyst or lump, a private medical attendant's report will be requested to confirm the histology.
Colorectal cancer
About 0.4% of the population has two first degree relatives affected by colorectal cancer - representing 105,900 people aged 30-70 in the UK. It is estimated that approximately 10% of patients with one or more first degree relatives affected by colorectal cancer, have an increased risk of developing the disease themselves, particularly if a relative was affected at an early age (before 45). The risk is even greater if the unaffected person has a family history when aged less than 45 themselves.
People with a family history are twice as likely as the general population to develop colorectal cancer themselves, but there is a considerable variation in the risk to each person.
The likely medical loading for an applicant aged under 45 who has first degree relative diagnosed with colorectal cancer under age 60 is:
l Life protection at one and a half times standard rates.
l Critical illness cover at two times standard rates, or colorectal cancer can be excluded.
As with breast cancer, it will usually be possible to offer terms based on the client's disclosure on the application form.
Huntington's disease
Huntington's disease is an autosomal dominant disorder in which half the children of an affected parent can be expected to develop the disease. The disease is characterised by the degeneration of cells in certain parts of the brain causing progressive dementia between the ages of 30 and 50. The condition is normally fatal between 10 and 15 years after the onset of symptoms. Where the disease is present, terms will not be available for life protection or critical illness protection.
If the applicant is between the ages of 20 and 50 and has a positive family history in either parent, but they have no symptoms themselves, critical illness protection will be declined. However, it will be possible to offer terms of life protection with a temporary loading payable for 10 years.
If the applicant is over age 55 and has no symptoms, then both life and critical illness protection will be accepted at standard rates.
Where there is a positive family history of Huntington's disease, a private medical attendant's report will always be requested to check if the applicant has any symptoms of the disease.
Familial adenomatous polyposis (FAP)
This is similar to Huntington's disease in that it is an autosomal dominant disorder, which means it will occur in half the children of an affected parent. Familial adenomatous polyposis affects one in 8,000 individuals.
It is characterised by the appearance of, usually in the third decade, hundreds of polyps throughout the colon and rectum, with malignancy usually ensuing around age 40. Screening via colonoscopy of all families at risk usually starts in teenage years and continues until age 35-40, by which time the risk of developing the disease is negligible. If the applicant has a family history of FAP and is under age 40, critical illness protection will be declined, but life protection can be accepted with a temporary medical extra usually payable after five years. If the applicant is over age 40 and has regular follow-up checks with no signs of the disease, then both life and critical illness protection will be accepted at standard terms. A private medical attendant's report will always be requested to check that the applicant is having regular follow-up checks and is also symptom free.
Familial hypercholesterolaemia
This is also an autosomal dominant disorder. The prevalence in the general population is thought to be approximately one in 500 with an estimated 10 million sufferers worldwide.
There is an increased premature risk of coronary artery disease, with early age diagnosis in approximately 3%-5% of cases being related to the familial condition. An indication of this is highlighted through the risk associated with suffering a myocardial infarction (heart attack). The risk of a male with familial hypercholesterolaemia suffering this is:
l 5% below the age of 30.
l 50% by the age of 50.
l 85% by the age of 60.
A private medical attendant's report is requested to obtain details of any cholesterol readings. A fasting cholesterol test may also be arranged in order that an up to date result is obtained.
Any medical loading will depend on all cholesterol levels and also additional factors such as smoking, blood pressure and obesity.
Alzheimer's disease
Alzheimer's disease is the degeneration of the cerebral cortex, which results in loss of memory, aphasia (loss of speech), and paralysis. There is evidence to suggest that a relatively small percentage (10%) of cases are inherited as an autosomal dominant trait.
However, in view of the relative late onset of the condition both in the patient and the previous generations affected, the possible genetic associations of the condition may have been underestimated.
Families that have the genetic form of the disease have special characteristics. The age at onset is relatively low, usually between ages 35 and 60 and the onset is fairly consistent with the family. If a family member suffers from the non-genetic form of the disease, the risk to a close relative is three times higher than the risk for a person of a similar age who has no family history of the disease.
If there is any family history of Alzheimer's disease, any loading will depend on the age at which the family member was diagnosed, the age of the applicant, duration of the plan and type of benefits required, in other words, life or critical illness protection.
Outlook
There are a large number of medical conditions that are affected by family history and a few have been outlined here. The whole area of family history within the insurance market is still in its embryonic stage.
However, a number of studies are producing information which is pointing at the significance of family history when assessing applications for life protection, critical illness protection, and disability insurance.
Where an adviser has a potential applicant with a known family history of any of the above illnesses, it is recommended that they take advantage of any underwriting helpline made available by a life office.
These helplines are normally staffed by experienced underwriters. They will be able to give an indication of the terms likely to be offered based on the given evidence. They will only be able to confirm terms once an application and medical evidence have been received.
Nigel Kirkpatrick is underwriting manager at Guardian Financial Services
Source of statistical information, Swiss Re Life and Health Intermediate Underwriting Course 1999.
