Ischaemic heart disease

Nigel Kirkpatrick assesses life and health insurance implications for sufferers of ischaemic heart disease

Ischaemic heart diseas

Ischaemic Heart disease (IHD) is the largest cause of death in the developed world and is responsible for a significant number of premature deaths. It is also responsible for a considerable proportion of morbidity (sickness) experienced and disabling symptoms resulting in absence from work.

Where IHD occurs the coronary arteries are unable to supply adequate quantities of oxygenated blood to the heart muscle due to the narrowing or occlusion of the coronary artery. This may result from a build-up of fatty plaques or scar tissue, and may or may not be associated by a thrombosis. Whatever the cause, the blood circulation is severely disrupted. The ischaemia inadequate flow of blood may result in pain and/or dyspnoea (shortness of breath), present in varying degrees, or may be so severe as to cause a myocardial infarction a heart attack in layman's terms which results in the death of an area of heart muscle.

Who is at risk from IHD?

In general, men of all ages may be affected by IHD, but the level of incidence increases with age. IHD is less common in women, particularly at younger ages, but again the level of incidence rises steadily after middle age. Studies have also identified a strong link with cigarette smoking, existing hypertension (raised blood pressure), obesity, diabetes, and a raised serum cholesterol level.

Furthermore, family history may be of relevance. Where a client has a strong family history of IHD this may be indicative of the presence of an inherited lipid disorder, and as a result, they are at an increased risk of developing IHD. Stress can also play a part in IHD either as a precipitator of an attack or as a long-term contributor to the cause.

Forms of IHD

The first form of IHD is angina pectoris (stable angina) which strictly means 'pain in the chest'. This condition tends to develop gradually and is normally brought on by physical effort, emotion or extremes in temperature, in particular the cold. The pain is usually in the form of a heaviness or tightness in the chest which may also radiate down one or both arms, or up into the throat.

A second form of IHD is acute coronary insufficiency, also known as unstable or crescendo angina. This differs in that the pain is of a sudden onset, often with similar symptoms to stable angina, but these tend to be more severe or prolonged. Attacks may occur through exertion, emotion or in the cold but they sometimes occur when at rest and without warning.

The third form is the actual occurrence of a myocardial infarction (heart attack) where permanent damage to the heart muscle occurs because of an inadequate blood flow due to a blockage or partial blockage of a coronary artery. A heart attack is sometimes preceded by anginal pain possibly over several years, but the occurrence of a heart attack is the first indication of IHD for many. The symptoms of a heart attack are similar to those for angina, but the retrosternal pain often lasts in excess of an hour. Again there will be tightness and heaviness which may radiate down the arms or up into the throat. In addition there is often sweating and nausea.

The final form of IHD is asymptomatic coronary disease, which is frequently found purely by chance following a routine ECG. Here the ECG will contain changes which suggest either a past occurrence of a heart attack or the presence of ischaemia. Consequently, a review will be made of the client's personal medical notes for any past episode of chest pain which perhaps was not thought to have been of cardiac origin at the time.

Obtaining cover

How does the presence of IHD affect an applicant's ability to obtain life assurance or critical illness protection? In order to assess the suitability of an applicant a life office will, in all cases, obtain a PMAR (private medical attendant's report) from the applicant's GP, often accompanied by a specific questionnaire designed to obtain detailed information of the condition. This evidence will provide the underwriter with important information such as: what was the exact diagnosis and when was it made; what was the applicant's age at diagnosis; has the applicant returned to normal activities or have they been forced to give up work; does the applicant still experience episodes of chest pain or are they symptom-free? Other factors such as any raised cholesterol levels, raised blood pressure, obesity or smoking, will also be identified. Underwriters frequently obtain copies of any hospital reports or letters concerning admission to hospital, the results of any ECGs performed at the time and treatment received.

The underwriter may request the applicant attend an insurance medical examination which may be accompanied by a blood test to obtain up-to-date serum cholesterol levels.

Life assurance

When assessing an application for life assurance, an underwriter will typically not offer terms in the six-month period after an incidence of IHD. For applicants with a history of unstable angina or who have recently suffered from a myocardial infarction, it is normal to wait until the applicant has returned to normal activities for six months. The delay period is required due to the high incidence of further attacks which make the life uninsurable during this time.

Once the initial six-month period has passed, terms should be available to most applicants. The risk presented decreases over time and the longer one waits after the initial incident, the lower the loading. After the high risk of the initial years the presented risk flattens out, but an applicant with a history of IHD will be unlikely to return to a standard terms risk.

To reflect this an underwriter may apply a temporary loading (normally charged over a restricted number of years at the start of the plan) and/or permanent loading (in other words, charged throughout the term of the plan).

Surgical treatment

An increasing number of IHD patients have undergone surgical treatment for their condition. The two types of surgery often encountered are CABG (coronary artery bypass graft) and PTCA (percutaneous transluminal coronary angioplasty).

Applicants who have undergone surgery again will typically have to wait a six-month period after returning to normal duties. Once past the six-month waiting period, the underwriter will base their assessment on the number of coronary vessels involved.

Typically, the higher the number of vessels involved, the more severe the terms. Other factors such as age, raised cholesterol levels, raised blood pressure, obesity and smoking will again be taken into consideration. Where an applicant is below age 35 and known to have IHD, it is unlikely that any terms for life protection will be granted.

Critical illness/permanent total disability

The majority of critical illness plans cover named illnesses related to the heart, such as heart attack, coronary artery disease requiring surgery, heart valve and structural surgery and major organ transplant among others.

Where an applicant already has a history of IHD, normal practice will be to decline the whole critical illness cover, because the applicant may have already suffered from the named illness or their current condition means there is a high chance of them having a named illness.

Underwriting helplines

Where an adviser has a potential applicant with a known history of IHD it is recommended that they take advantage of any underwriting helpline made available by a life office. These lines are normally manned by experienced underwriters who will be able to give an indication of whether terms are likely to be available and possibly indicate a level of loading. It should be noted that the underwriters can only give an indication of the likely terms based on the evidence presented and will only be able to confirm terms once an application and medical evidence have been received and assessed.

Nigel Kirkpatrick is underwriting manager at Guardian Financial Services