Calculating the risk

the two major inflammatory disorders are systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD). These conditions belong to the group of more than 80 auto-immune disorders, in this instance, affecting the connective tissues.

The immune system normally functions to protect the body and helps to fight invading infections and cancers, turning itself on when the infection is detected and shutting down when it resolves.

However, in the case of SLE and MCTD this finely-tuned regulatory process fails. For reasons which are unknown, the body's immune system, in effect, attacks organs in the body. Over-activity of the immune system produces increased amounts of abnormal antibodies and damage results from the reaction of certain organs to the excessive deposits of immune complexes within them.

The exact cause of these conditions is unknown which, along with the many different symptoms that are individually non-specific, makes diagnosis and treatment difficult, with treatment aimed at managing and suppressing symptoms when the disease is active.

Most sufferers have symptoms many years before the condition is diagnosed. These can include finger swelling, joint pain, Raynaud's symptoms ('white finger' when cold) and commonly overwhelming fatigue. Frequent throat, gum or respiratory infections are common. As these symptoms cannot be individually diagnosed, a formal diagnosis is often not made until the illness has progressed to a point where there is damage to the internal organs.

The conditions can also affect the skin, kidneys, lungs, heart, liver, endocrine, digestive and nervous systems which are all made up of connective tissue. The over-production of collagen causes severe tissue damage and creates fibrosis in the internal organs impairing their efficiency. There can even be dysfunction of the oesophagus which makes swallowing difficult.

It has already been noted that diagnosis is difficult and in the early stages it is often difficult to differentiate from other connective tissue disorders such as rheumatoid arthritis. Once symptoms have become highly suggestive of SLE there are 11 criteria laid down by the American College of Rheumatologythat are used to make a definite diagnosis. Four must be present to make a diagnosis. The anti-nuclear antibody test (ANA) is almost always positive in SLE.

It is unlikely there will be a cure until the cause of the disease is identified. Treatment, therefore, is given to control the various symptoms and can also be given to suppress or modify the immune system in an attempt to try and change the course of the illness. A combination of different treatments is often used.

Medication

In mild cases, non-steroidal anti-inflammatories can be used to control the symptoms of joint pain. Anti-malarial medication such as hydroxychloroquine reduces SLE activity and can help ease joint and skin trouble. In more aggressive cases, steroids such as prednisolone and other powerful medications are used to reduce the inflammation that can lead to fibrosis. There are, however, risks in the long term from this medication and by suppressing the immune system there is a risk that infections and cancer can occur.

As there can be kidney involvement with SLE, kidney function and blood pressure are monitored closely and can be treated to prevent kidney damage. The exact treatment will depend on the individual's symptoms and will be a combination or 'cocktail' approach.

The course of the disease is most commonly chronic and relapsing, although in some cases it does burn itself out completely. There are often long periods of remission and the outlook depends on which organs are involved and severity of the disease.

The majority of the extra mortality and sickness risk occurs when the heart, lungs, kidneys and central nervous system are involved. Regular monitoring of the condition with appropriate preventative treatment where necessary is essential especially where the kidneys are involved. Most sufferers will be closely monitored by their specialist, usually a rheumatologist.

Where there is no major organ involvement with only the skin and joints affected, the prognosis is far more favourable. The 10-year survival rates have improved considerably.

As with most relapsing and remitting conditions the longer a history there is, the better an assessment can be made of the likely future prognosis based on the course of the disease since diagnosis.

Most proposers affected are followed up closely by their GP and specialists, and hospital reports, when available, provide a useful history of the course of the disease.This allows the underwriter to make a calculated assessment of the extra risk associated with each application.

Applications will only be considered where the diagnosis was made a full 12 months ago and any proposals in the first year will be postponed.

Calculating the premium

From the first year onwards the ratings reduce as each year passes, provided the condition is well controlled, the individual is on less than 7.5 mgs of steroids per day and the major organs such as kidneys and the central nervous system are not involved. Life cover ratings are as follows:

If the disease is in full remission and the proposer has been off treatment for two to four years then +75% could be considered reducing to +50% after four to five years, and if greater than five years, ordinary rates could be considered.

The risk of kidney, heart and cerebral involvement as well as the general unpredictable and widespread nature of the condition presents an extra risk for critical illness cover. Within three years of onset, the application would be postponed and in the fourth year, a 200% loading would apply falling to 150% thereafter.

Sickness-related benefits

The extra morbidity risk associated with the condition is considerable due to the widespread nature of the symptoms, particularly the joint involvement and also the complications of long-term treatment with steroids and other powerful toxic medication.

Permanent and total disability benefit, waiver of premium benefit and income protection are unlikely to be offered unless there have been no symptoms or treatment for at least five years.

As with any auto-immune and chronic relapsing and remitting condition the course of the disease will vary widely and each proposal must be assessed on an individual basis depending on length of time since diagnosis, the severity of the symptoms and any major organ involvement. Terms will vary widely according to these factors ranging from ordinary rates in the best scenario to declinature where the condition is in its most severe and aggressive form.