When is a heart attack not a heart attack? When medical technical advances change the nature of trauma and TPD. And insurers and brokers need to keep up.
Heart disease is Australia’s most prevalent long-term disease, with 2004 Australian Institute of Health and Welfare (AIHW) figures showing that about one in five of us lives with a cardiovascular-related condition. This means that, for the average adult, the risk of experiencing trauma from a stroke or heart attack is quite high.
In 2009, heart attack claims to CommInsure were second to cancer in volume, comprising 23% of the 95% of top four traumas. The others were stroke and cardiac bypass surgery – also circulatory-related.But heart attacks – or myocardial infarctions (MIs) as they are medically known – are also getting less deadly. As the AIHW data shows, during an average day in Australia, 135 people will have an MI, but only 50 will die from it.
The odds of surviving are now about 63%; an improvement from 10 years ago when more than half of heart attacks were fatal. Moreover, people are surviving longer with less functional impairment. Naturally, this is changing the face of trauma insurance but also has knock-on effects on occupation and total and permanent disability covers. “Improved treatment optionsare resulting in longer survival periods,” said Dr John Schoonbee, Chief Medical Officer of the RGA Reinsurance Company of South Africa, in recent Australian seminars organised by Macquarie Life.
Shifting goalposts
Advances in emergency medicine, cardiac surgery and medication are partly responsible but, at the same time, the definition of MIs has changed, says Dr Sally Phillips, Head of Underwriting and Claims at Macquarie Life. This can just as much be driven by more technically sophisticated medical tests andmonitoring. “Probably the biggest change has come from both clinicians and insurers now using the cardiac biomarker troponin as confirmation that a heart attack has occurred,” says Dr Phillips, referring to an enzyme released by damaged heart muscle.
“Until around the mid-1990s, you needed to have raised levels of CK-MB (creatine kinase myocardial fractional component), which showed death of myocardial cells; plus certain changes on an ECG; as well as chest pain."
It also raises some three-to-four hours after onset of chest pain, peaks within 24 hours and returns to normal within 72 hours – by which time sufferers could have long been sent home with the “all clear”.
Troponin, on the other hand, is an enzyme more specific to heart muscle and more sensitive, says Dr Bill Monday, CommInsure’s Chief Medical Officer, because its level lifts earlier during the course of an MI and drop down later.
“However, it is such a sensitive marker that you have to find a levels at which you can be certain it is an MI,” cautions Dr Monday.
“In consultation with the various laboratories, the industry has agreed to a certain level, but that has been a challenge,” he continues. “There are different troponins and their levels can also rise after you’ve run a marathon or have an irregular heartbeat, or if you get smacked in the chest with your steering wheel, so we had to fix a type and threshold more specific to an MI.”
This has resulted in about 25% more claims, says Dr Monday, but he says the situation is a vast improvement from before because underwriters, assessors and doctors interpreting pathology reports like anything more specific and sensitive.
Dr Sally Phillips is in agreement. In the early 2000s, the American Heart Association changed its definition of MI and the insurance industry soon followed suit, she says. Before that, people were suffering cardiac damage and, to all intents and purposes having an MI, although CK-MB levels did not reach the (then much higher) cut-off levels, and ECGs were returning false negatives.
Pressure from experts
Changes on ECG were another source of contention: heart attacks can either show an elevated ‘ST segment’ (ie a STEMI) or not (a non-STEMI); a STEMI is more serious but both have the same symptoms, which in about 20% of casesmay be ‘silent’, or not recognised by the patient themselves. The incidence ofSTEMIs have declined over the past decade due to public awareness of warning signs and medication, but non-STEMIs increased before returning to early-2000 levels, Dr Schoonbee said.
Even though non-STEMIs were recognised medically as heart attacks, some would not have elevated CK-MB and no unusual ECG changes. In MLC Ltd vs O’Neill in 2001, the Supreme Court of NSW Court of Appeal ruled that MLC had to pay out a claim for MI after O’Neill’s cardiologist submitted that:
“If doctors were to use their [MLC’s] criteria, we would send home many patients from casualty with small infarcts because they did not fit a textbook description with the nature of their chest pain...it is a pretty unacceptable policy if they are going to use such tight criteria, and ignore the greater accuracy provided by the newer scanning techniques.”
“It made the industry look bad,” recalls Dr Phillips.
Moreover, payments were costed on STEMIs; this could have been changed, she says, but it would affect premiums. Now, some products do give cheaper premiums for non-STEMIs. This may be behind the move to South African-style severity-based claims that Macquarie Life has made, but Dr Phillips says
“Everyone will have to look into this area, and it comes from looking to the clients’ needs. And doctors know these needs too; underwriters regularly get letters from doctors explaining where we should be catching up with clinical practice.”
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