Each year, approximately 300,000 people in the UK suffer a heart attack. Of these, half will prove f...
Each year, approximately 300,000 people in the UK suffer a heart attack. Of these, half will prove fatal, but the underlying mortality rate from coronary heart disease has been falling over the past 20 years. For adults aged 16-64 it has fallen by 42% in the last 10 years.
Similarly, over the past 10 years the number of angioplasty operations performed has almost doubled and their success rate has also made a significant improvement in mortality rates. The figures for coronary artery bypass graft surgery (CABG) follow a similar trend.
The above statements highlight how important critical illness cover is in today's society. However, the ABI definitions for heart attack, angioplasty and CABG do contain certain exclusions. Policyholders need to understand what these exclusions are and why they are used.
The ABI definitions for heart attack, angioplasty and coronary artery bypass surgery are:
Heart attack
The death of a portion of the heart muscle as a result of inadequate blood supply as evidenced by an episode of typical chest pain, new electrocardiograph (ECG) changes and by the elevation of cardiac enzymes. The evidence must be consistent with the diagnosis of heart attack.
Angioplasty
The undergoing of any interventional technique, on the advice of a consultant cardiologist, involving the use of transluminal coronary catheters to correct significant stenosis (at least 50% diameter narrowing) of two or more arteries. Appropriate angiographic evidence to support the necessity of the above operation will be required.
Coronary artery by-pass surgery
The undergoing of open-heart surgery on the advice of a consultant cardiologist to correct narrowing or blockage of one or more coronary arteries with bypass grafts, but excluding laser relief or any other procedures.
One immediately notices that the most common heart condition, angina, is not covered by any of the previous definitions, or any of the other listed critical illnesses. There are a number of reasons for this.
Approximately 1.4 million people suffer from angina in the UK. Angina is chest pain with varying severity and usually lasts less than 10 minutes. A heart attack however, causes similar pain but the episodes are much more disabling. Whereas a narrowing of the blood vessels to the heart muscle causes angina, a heart attack occurs when one of the vessels becomes completely blocked by a blood clot.
Consequently, angina attacks are generally less disabling and can usually be well-controlled using drug therapy without the individual requiring long periods of time off work. As a result, it is difficult to justify that an individual will suffer significant financial hardship purely as a result of an angina attack.
Definitions explained
In order for a claim to meet the heart attack definitions, three main criteria must be met. It must be, evidenced by an episode of typical chest pain, new electrocardiograph changes and elevation of cardiac enzymes. All need further clarification.
An episode of typical chest pain
When an individual has a heart attack, a typical symptom is sudden severe chest pain, lasting more than a few minutes, which may spread to the arms and throat.
There are also occasions where a heart attack occurs with absolutely no chest pain, or the individual has some chest pain but this was not recognised as of a cardiac origin at the time. This is known as a silent myocardial infarction (MI) and is normally diagnosed from a resting ECG. In fact, the individual will usually be totally unaware that the heart attack has occurred until a resting ECG is performed and this may be months, even years later. This instance is not covered by the definition.
New electrocardiograph changes
The heart attack also needs to be confirmed by ECG changes. The reason for this is due to the fact that a person may experience chest pains and there may be an immediate concern, due to the nature of the pain, that they may have suffered a heart attack. Further investigations including an ECG will then be performed to confirm diagnosis. If the ECG is normal the individual has not suffered a heart attack and the chest pain will usually be diagnosed as musclo-skeletal, for example, or some other benign cause.
Raised liver enzymes
The third requirement to meet the heart attack definition is raised enzymes. Enzymes are released in large quantities into the blood from damaged heart muscle following a MI. Therefore this needs to be evidenced when assessing incidence of heart attack.
The absence of one or more of these criteria could result in a claim not being admitted.
Angioplasty
The angioplasty and coronary artery by-pass surgery critical illness definitions contain a number of terms that need clarification as to why they are included in the definition:
Significant stenosis
The angioplasty definition states there must be significant stenosis - at least 50% narrowing of the arteries. It is usually felt that patients with less than 50% narrowing will not automatically require surgery. In fact, individuals with less than 70% narrowing do not usually experience any symptoms.
Angioplasty surgery is performed based on the extent and severity of an individual's symptoms. In order to prevent 'elective', surgery, life companies have introduced an arbitrary figure to guard against obvious anti-selection. Although 50% is an arbitrary figure, it is highly unlikely surgery would be required at this level of narrowing.
Two or more arteries
There is a lot of discussion surrounding why the definition for angioplasty is restricted to individuals requiring surgery to two or more arteries and those requiring single vessel surgery are excluded.
The reason for this comes down to pricing. Single vessel disease is much more common. Approximately 80% of angioplasty surgery performed is for disease of only one artery. If it were to be included within the definition, it would lead to a considerable increase in the number of claims received. As a consequence, the premiums would need to increase dramatically to account for this, and would result in critical illness cover becoming too expensive for the majority of people.
Appropriate angiographic evidence
This may include various procedures, including angiogram (an x-ray of the blood vessels), thallium scan (a method of studying blood flow through the heart muscle), or an ECG, in order to confirm the extent of the disease.
Laser procedures
The coronary artery bypass surgery definition specifically excludes laser relief or any other procedures. There are two types of laser procedures that can be performed.
The first involves re-boring the blocked artery without the need for open heart surgery. This treatment is in its early, experimental stages and is very rare.
The second involves boring holes into the heart muscle with a laser to try and stimulate new growth of the blood vessels. It is performed purely to relieve symptoms and not to cure them and again, this treatment is in its early stages.
Both of these procedures are usually performed on individuals with angina and as this condition is not covered under critical illness, the associated surgical treatment is also excluded. There are various other procedures that can be performed but due to the fact that the number of these is limited, it would be difficult to substantiate the reliability and success rate of them.
In addition, some of these procedures are less invasive and individuals will require significantly less time off work than those undergoing traditional coronary artery by-pass surgery. In these circumstances individuals will require less time off work and obviously suffer less financial loss, making it difficult to justify a lump sum payout.
After suffering a heart attack, the typical length of time off work can be anything from six weeks. Although this may not seem like a sufficient period of absence to justify a lump sum pay out, under critical illness there are some other considerations to take into account. Individuals whose work is of a physical or stressful nature may have to modify their lifestyle or reduce their workload. This in turn could lead to a reduction in the number of hours they work or a change in the duties they perform in order to adapt their workstyle appropriately. This will lead to a financial loss and the lump sum pay out could be used to subsidise this loss. Individuals who suffer more severe heart attacks may not be able to return to work for some time and may have to give up their current employment. In these cases the benefit paid out could be used as a substitute to their income until they are fit to return to work.
As with other critical illnesses, the industry has had to produce a product which provides cover for those cardiac situations where a financial loss is likely. While there are other cardiac conditions which would be desirable to cover, the need to keep the price of the cover affordable will continue to influence the product design.
Kirsten Jones is individual protection life and disability underwriter at Scottish Equitable
