The majority of critical illness plans now cover Alzheimer's disease, but the definition can be conf...
The majority of critical illness plans now cover Alzheimer's disease, but the definition can be confusing. While the critical illness definition for Alzheimer's disease relates directly to the named condition, there are a number of organic brain conditions that are also covered under the definition.
According to the ABI critical illness definition Alzheimer's disease is: "Deterioration or loss of intellectual capacity or abnormal behaviour (as proven by the clinical state and accepted standardised questionnaires or tests), arising from Alzheimer's disease or irreversible organic degenerative disorders, excluding neurosis and psychiatric illnesses, and resulting in significant reduction in mental or social functioning requiring continuous supervision. The diagnosis must be made by a consultant neurologist, holding an appointment at a major hospital in the UK."
A closer look
It is worthwhile looking at Alzheimer's disease in a little more detail in order to gain an understanding of the condition. Alzheimer's disease is caused by a degenerative process with a loss of cells from the basal forebrain, cerebral cortex and other brain areas. There is severe loss of intellectual function and the dementia is progressive and insidious. Prevalence increases with age, particularly after the age of 75. Early onset Alzheimer's disease is more likely to be hereditary.
Seizures occur in approximately 10% of individuals and the average duration of the illness from onset of symptoms to death is eight to 10 years. There is no specific treatment but a wide variety of drugs are now being developed which appear to improve cognition but without altering the progressive nature of the condition.
Treatment is also symptomatic, but ultimately all patients require institutionalisation and 24-hour care.
There are a number of different parts to the CI definition and it is worthwhile looking at them individually to explain why they have been included and exactly what is and what is not covered by the definition.
The loss of intellectual capacity or abnormal behaviour must be proven by the clinical state and accepted standardised questionnaires or tests. Formal cognitive testing is a mandatory part of the diagnostic process. The screenings should test for: changes in abstract thinking; initiative; judgement; language skills; memory; misplacing items; behaviour; mood; orientation of time and place; personality and task performance.
The tests distinguish between cognitive changes that occur with normal ageing and cognitive decline consistent with dementing disorders such as Alzheimer's disease.
Other investigations are a CT brain scan or MRI scan, which provide information that may help to distinguish between vascular dementia and Alzheimer's disease.
Wider scope
We have already looked at Alzheimer's in detail, but irreversible organic degenerative disorders are also covered within the definition. These will include the following:
l Creutzfeldt-Jakob Disease: CJD is characterised by involuntary movements and abnormal electroencephalogram (EEG) activity. Symptoms generally develop between the ages of 40 and 60, it is invariably fatal, usually within one year.
l Lewy body dementia: Lewy bodies are characteristic of Parkinson's disease and are found in the brainstem and cortex in up to 20% of patients with dementia. There are clinical differences in presentation of the dementia but there is still a considerable overlap with Alzheimer's disease.
There are similarities between all these conditions and Alzheimer's disease, and the risk profile is also similar. Again, it can be seen that there is an immediate financial need for the client if they are diagnosed with irreversible organic degenerative disorders. The key word is 'irreversible'. At the present time there is no cure for these conditions and the quality of life for the patient is dramatically reduced, as is their life expectancy.
These conditions, which include Alzheimer's disease, cause considerable suffering to those affected by it, and also to family and carers. The demands on those caring for someone with dementia are enormous, particularly when there is behavioural disturbance.
Neurosis and psychiatric illness are not covered under the definition for a number of reasons:
l The diagnosis can sometimes be ambiguous whereas the diagnosis of Alzheimer's disease is made by a number of definitive investigations.
l Neurosis and psychiatric illness may have little affect on an individual's lifestyle and they can usually be treated by simple drugs.
l They are not irreversible conditions.
l In the majority of cases there will not be a significant reduction in mental or social functioning.
l There will not be severe disabling episodes resulting in institutional care and continuous supervision.
l Any severe episodes will not last for a significant length of time.
l The prevalence of neurosis and psychiatric illness in the UK is on the increase. If they were to be included within the critical illness definitions there would obviously be a significant impact on the cost of critical illness and as a result it would become less affordable for the majority of clients.
Consultant referral
If a patient was suspected of having Alzheimer's disease or any of the other major irreversible organic brain diseases outlined above, they would automatically be referred to a consultant neurologist who would initiate all the relevant investigations and would confirm or make a diagnosis. Even though the GP may suspect Alzheimer's disease it will be the consultant neurologist alone who will be able to make the exact diagnosis based on all the findings.
The main aim of critical illness protection is to provide as comprehensive cover as possible at an affordable price and the exclusions relating to neurosis or psychiatric illness contained within the definition ensure that cover is still affordable for the majority of the insured population.
It is also fair to say that insurance companies in association with the ABI are continually monitoring their definitions to ensure a consistent and fair approach is adopted throughout the industry.
The other main aim is to ensure that the definitions are easy to understand and are not full of medical or legal jargon which creates an uncertainty with clients as to when a claim will be payable.
Mark Preston is life and disability underwriter at Scottish Equitable Protect
