July
14, 2020 | By Tim Eppert | Critical Illness
What is a cancer - and what is not? While the
answer to this question is obvious in many cases, it is not always
straightforward. A disease is deemed as malignant or cancerous when there is an
uncontrolled growth of cells that is invasive, i.e., the cells break through
the natural boundaries of the body to places they do not belong and have the
potential to spread to the lymphatic system and distant places of
the body.
As life is always a continuum, it is not always
clear where to draw the line. How likely is a tumour to spread and how fast
must it grow to be considered cancerous? Next to purely medical questions, the
label that is given to a disease will also change the perception of the person
receiving the diagnosis. Therefore, redefining a disease as cancer is not that
uncommon.
In Critical Illness (CI) insurance, cancer
is the core condition and typically responsible for 50% to 90% of all claims.
All definitions depend either explicitly or implicitly on the medical
definition of cancer, and when the medical classification of a disease changes
from non-cancerous to cancerous (or the other way around), it can change the
decision whether or not a claim for this condition will be paid.
Reclassifications over time can make the
decision of a claim’s validity more challenging - and reduce the policyholder’s
understanding and acceptance as well. If reclassifications only affect rare
conditions, the total effect on the insurance portfolio is limited and other
changes such as in screening programmes or lifestyle behaviours will be more
important for the long-term portfolio experience. But when changes have an
impact on common cancers, insurers must consider how their portfolios might be
affected. This situation can arise as the result of either a complete reclassification
of certain diseases or a reclassification of the severity of a
specific cancer.
The revision of the International Classification
of Diseases (ICD), a medical classification list by the World Health
Organization, is such an event. Currently ICD-10 is
in use, but ICD-11 has
already been published and shall be used for reporting from 2022 onwards.
ICD-10 differentiates between malignant
(C00-C97) and benign (D10-D36) neoplasms, and benign neoplasms are not
considered as cancers. However, there are benign tumours of the brain that are
life-threatening. They do not invade other tissue, but they grow and will
increase pressure on the brain as the skull does not give additional space for
the extra cells. ICD-11 does still differentiate between benign and malignant
neoplasms for most types, but not for the brain and some other areas.
Policies that also cover benign brain tumours -
and sometimes the less common benign spinal tumours - are not significantly
impacted by the ICD revision, but this is different for more basic plans. While
some brain tumours have always been classified as malignant, a significant
number have not. And policies not covering a benign brain tumour also lack
exclusions for less severe conditions of the brain e.g., brain cysts, a common
and often incidental finding.
In CI markets with tiered benefits differentiate
the benefit amount by severity, e.g., by TNM classification, which defines four cancer stages (and
sub-stages) depending on Tumour size, affected Lymph Nodes and distant Metastases (see UICC, AJCC). With increasing understanding of tumour genetics, this
classification may be replaced or at least supplemented by the genetic profile
of the cancer. Breast cancer classification is most advanced in this sense, and
the AJCC cancer classification uses both a staging purely on TNM, called
anatomic staging, and a so-called prognostic staging including new markers,
such as the existence of oestrogen receptors on cancer cells to describe the
disease. Based on US cancer registry data, we analysed how strongly this can
whirl the current classification, as is shown in the following chart. For
anatomic stage II cancers, most will be staged differently when using the
genetic information as well.
A worst-case scenario for an insurer with a
tiered benefit structure would be to pay for the higher of the old and the new
classification. This is not a necessary outcome, but insurers need to be aware
of the risk and think about strategies to cope with changing cancer
definitions. This may be a combination of risk-mitigation measures, such as
limited durations, carefully worded definitions, policy terms and conditions
and others. Talk to us to find out more.
Endnote
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