A stroke is the clinical end product of cerebrovascular disease and is the term used to describe loc...
A stroke is the clinical end product of cerebrovascular disease and is the term used to describe localised damage to brain tissue due to reduction or cessation of blood flow in, or haemorrhage from, an artery supplying part of the brain.
Mortality from cerebrovascular disease continues to decline, although it is still the third leading cause of death. In 1974 it was responsible for approximately 11% of all deaths, but by 1979 this figure had dropped to 8.8%*. This decline in mortality is reported through-out the West and is probably due to more effective drug therapy in the control of hypertension (raised blood pressure).
Prognosis
To define the prognosis of cerebrovascular disease is almost impossible. It is a generic term and covers various conditions, differing in origin, pathology and site of lesion. In theory, it should be possible to sub-divide the various causes, but this is not feasible in practice without the use of modern imaging techniques.
However, determining the specific cause of a stroke is important in gauging prognosis and it is agreed that certain causes of stroke should be excluded. For example, the outlook following a sub-arachnoid haemorrhage is generally more favourable than that following cerebral thrombosis.
Morbidity prognosis will also be influenced by the nature and severity of symptoms and any complications. The cause of stroke is a significant factor and those that result from atheroma (degeneration of the walls of the arteries), tumour or trauma all carry differences in mortality and morbidity. Where atheroma has been identified, this may imply more widespread disease with associated complications. The oral contraceptive pill has been implicated as a cause in certain cases of stroke, and in these instances where a full recovery has been made and the pill is no longer taken, the outlook is generally favourable.
Transient ischaemic attacks
A transient ischaemic attack (TIA) is a brief neurological deficit that is a result of temporary interruption of the arterial blood supply to a part of the brain. The after-effects of this will depend on the area of the supply affected. The attack usually lasts from a few minutes to several hours but, by definition, must be shorter than 24 hours. If symptoms continue for more than a day, regardless of how minor they are, the individual should be considered to have suffered a complete stroke.
One of the symptoms of a TIA is 'amaurosis fugax'. This is a sudden monocular visual loss on the same side as the affected artery. The attack is usually brief, lasting about five minutes. Sometimes bright yellow cholesterol crystals will also appear on the eye. Other symptoms include heaviness of an arm or leg, sometimes accompanied by facial weakness. Sensory symptoms include tingling and numbness in the side of the face.
Transient ischaemia in the dominant hemisphere (the left hand side of the brain), may also cause dysphasia (speech problems), usually expressive but sometimes receptive. Vertigo and hemiparesis may also be experienced.
l Life protection: When underwriting an application for life cover, where an individual has suffered a TIA, the case would usually be delayed for the first six months following the episode. After this period - assuming there is no raised blood pressure and no residual neurological deficit - it is usually possible to quote. Individuals under 50 will carry the higher ratings, while for those over 60 only a small permanent extra is usually imposed. After five years have elapsed since the TIA, insurers may be in a position to consider standard terms or a slight extra premium for individuals aged under 59, whereas for those aged over 60 standard rates may be applied after the third year.
l Critical illness: As a stroke is an insured condition under critical illness, all cases with a history of any type of cerebrovascular disease will be declined.
l Total and permanent disability and waiver of premium: Terms for these benefits, whatever the type of stroke, are usually dependent on the decision for life cover. If the life rating is under 100%, terms may be quotable at an extra premium. If the life rating is over 100%, the disability benefit will usually be declined. If terms can be quoted, these will usually be on an any occupation or activities of daily living (ADL) as opposed to own occupation.
Minor ischaemic stroke
This category is sometimes used for minor strokes that do not fulfil the criteria for a TIA, in other words the initial symptoms last for more than 24 hours but resolve completely after a few weeks. However, in cases where the neurological signs persist for longer than three months, although eventually disappearing, the case should be assessed as a cerebral infarction (embolism).
l Life protection: For cases of minor ischaemic stroke, the application would usually be postponed for 12 months following the episode and after this period rated terms would usually be quoted.
Individuals under 50 will carry the greater ratings, although whatever the age these ratings do decrease the longer the time that has elapsed since the initial episode. However, where an individual has suffered a completed stroke the decision will be different again. Although the initial delay period is usually the same - 12 months, after this period the loadings imposed for younger ages can be severe and all age groups will carry a significant permanent extra weighting regardless of the time elapsed since the episode.
If the proposer has suffered from more than one attack, terms will only be possible for selected cases.
l Critical illness protection: See details for TIA.
l Total and permanent disability and waiver of premium: See details for TIA.
Sub-arachnoid haemorrhage
Spontaneous rupture of a congenital aneurysm is the most common cause of sub-arachnoid haemorrhages, but the presence of one would only be suspected if it either bleeds or grows enough to cause pressure on surrounding structures. Therefore, unless it has been found by chance, it will only become relevant from an underwriting point of view once symptoms have occurred.
The incidence of sub-arachnoid haemorrhage increases with age and although a haemorrhage may occur in someone who does not suffer from hypertension, the fact that blood pressure increases as we get older may be responsible.
The mortality associated with a sub-arachnoid haemorrhage is high - almost one in three* - and due to the fact that individuals who survive a first bleed are susceptible to a further episode, surgical treatment will be carried out wherever possible. This will either take the form of four-vessel angiography or 'clipping' the neck of the aneurysm. Clipping offers an excellent chance of completely eliminating the aneurysm but may not always be an option, depending on the positioning of the aneurysm.
l Life protection: Sub-arachnoid haemorrhages still often go unrecognised, especially if the aneurysm has only leaked. Symptoms include recurrent and severe headaches associated with nausea or vomiting, and these may be present for months before the haemorrhage. Consequently, when underwriting an individual that has been experiencing these symptoms, it may be necessary to postpone an application until the cause has been ascertained.
When underwriting an application where the individual has suffered from a sub-arachnoid haemorrhage, the decision will firstly be dependent on whether surgery has been performed or not. If treatment has been of a purely medical nature or surgery other than clipping has been performed, it would be usual to postpone the application within the first 12 months. After that time, terms would be quoted on the basis of one attack.
Again, the person's current age will be a factor, with individuals under 50 carrying the higher permanent extras, while those over 60, after the initial 12 month delay period, would only incur a minimal extra premium. For all ages, this is assuming that there had been no problems since the initial attack and that their blood pressure was not raised. From the sixth year onwards, it may even be possible to consider standard rates for ages up to 59, while for those aged 60 or over this may be the case after the fourth year. Applications from claimants that have suffered from more than one attack will be considered on an individual basis.
If, however, the applicant has undergone four-vessel angiography or surgery comprising of clipping, age is not as relevant. For the first six months following the angiography or the surgery, it would be usual to postpone. After this a rating will usually be imposed for the two years following, but then if there have been no problems, it may be possible to offer standard rates.
l Critical illness protection: See details for TIA.
l Total and permanent disability and waiver of premium: If surgery has not taken place the ratings will be as above for TIA. However, if surgery has been performed, it may be possible to offer standard rates based on any occupation TPD six months after the surgery has taken place, providing there have been no post-operative problems.
Additional factors
The two additional factors that can have a significant impact on the final decision are smoking and hypertension. A current history of smoking will carry a minimum of an extra 25% on the final loading for light smokers. However, if the individual is considered to be a heavier smoker, this extra could rise to 50% upwards.
If the proposer is currently suffering from hypertension - with or without treatment - the extra imposed for this factor will depend on their current control, with a minimum imposed of 50/75%. If the control is not acceptable, then the individual may be declined.
* Medical Selection of Life Risks: RDC Brackenridge
Kirsten Jones is life and disability underwriter at Guardian Financial Services
