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News
ABI STATEMENT ON THE CRITICAL ILLNESS INSURANCE CANCER DEFINITION
ABI STATEMENT ON THE CRITICAL ILLNESS INSURANCE CANCER DEFINITION
Summary
1. The ABI are issuing this Statement to explain what will happen if a consumer is diagnosed with either essential thrombocythaemia and polycythaemia rubra vera (see Annex 1 for more information) and they make a claim for it under a critical illness (CI) insurance policy. Both conditions are rare and affect the blood. Both are mentioned as examples of pre-malignant conditions in the 2006 ABI definition but new medical evidence submitted since the last review indicates that opinion is divided and that there is a substantial view that considers that these conditions can indeed be malignant. Unlike prostate cancer, for example, there is no severity scale for either condition at present.
2. This Statement means that consumers will be covered if they are diagnosed with either of these conditions under the new definition, or post-definition amendment. The issue will be reconsidered if appropriate, along with any other potential changes, at the next full three yearly review.
3. It is important to note that, while the ABI Statement of Best Practice sets out categories of conditions that are, and are not, covered by CI insurance, it is entirely down to individual member companies to evaluate individual claims and decide whether or not they should be paid. Given the latest medical evidence, our recommendation is that companies should amend their claims philosophy and also treat as valid any claims for these conditions under policies bought before the new 2006 definition was launched.
Background
4. During the consultations on the review of the CI Statement of Best Practice, the consensus was that these were pre-malignant conditions rather than malignancies and it seemed that the best way to avoid any doubt on the matter was to include them as examples of pre-malignant conditions.
Conclusion
5. In producing the 2006 definition, it was never the ABI’s intention to make new malignant cancer exclusions. The effect of the new evidence about their malignancy is as follows:
a. Assuming member companies follow our recommendation, consumers with policies that cover cancer that include pre-2006 wording will be covered if they are diagnosed with either condition.
b. Consumers who have policies with the 2006 cancer definition wording will also be covered because the exclusion in their policies fails as they are not examples of pre-malignant conditions.
c. For the avoidance of doubt, we are advising insurers who have yet to implement the new cancer definition to delete reference to these conditions as pre-malignant examples (see Annex 2 for amended definition). Accordingly, future buyers will also continue to be covered.
Annex 1
General description of the conditions and malignancy
1. Myeloproliferative disorders (MPD) are clonal proliferative disorders of multipotent haematological progenitor cells. They include polycythaemia rubra vera (PRV), essential thrombocythaemia (ET), chronic idiopathic myelofibrosis (IMT or IMF), chronic myeloproliferative disease (unclassifiable), and chronic myeloid leukaemia (CML). ET and PRV are the only conditions where there was any doubt about malignancy.
Essential thrombocythaemia (ET) - prognosis and treatment
2. Current medical opinion received is that, for the most part, the disease is relatively benign. Most patients survive many for many years following diagnosis. There is a low risk of transformation to acute leukaemia or myelodysplasia or to marrow fibrosis. There is also an increased risk of thrombosis and haemorrhage due to the increased number of often functionally defective platelets.
3. The majority of people with ET will require some form of treatment. Low dose aspirin which interferes with the way blood platelets work may be used for those considered to be at risk of developing thrombosis and those with a more significant risk may be treated with hydroxyurea. Whilst this drug is usually well tolerated, it may increase the risk of transformation into acute leukaemia in later life.
4. ET is often an indolent condition, with a long median survival of 12 to 15 years. As ET normally occurs in later years, life expectancy is nearly normal at diagnosis. Transition to myelofibrosis and/or acute leukaemia occurs in 3 to 10% of cases.
Polycythaemia rubra vera – prognosis and treatment
5. Current medical opinion received is that for the most part, the disease is relatively benign. Most patients survive many for many years following diagnosis. There is a risk of transformation to acute leukaemia or myelodysplasia. There is also an increased risk of thrombosis. PV may therefore shorten life.
6. Treatments vary for PRV depending on a number of factors including the duration and severity of the condition and the age of the person affected. The most effective method of treatment is to reduce the number of red blood cells in the circulation by blood-letting, also known as phlebotomy or venesection. This procedure involves removing a unit (a pint) of blood via a needle in the arm identical to the procedure used in connection with blood donation. When the condition is first diagnosed, this may mean regular venesection perhaps as often as once per week. Intervals become longer as the blood profile improves and eventually the procedure may only be required infrequently with months in-between. The main benefit from this treatment is that there are virtually no side-effects.
7. The limitation of phlebotomy is that is does not reduce platelet count and therefore hydroxyurea may also be used as adjunctive therapy. Interferon can be used for those where hydroxyurea is unsuitable. However, it often has unpleasant side effects. Small doses of aspirin may also be used to reduce the risk of thrombosis and paracetamol may be used if analgesia is required.
8. If left untreated most patients with PRV will die of thrombosis at an average of less than 2 years from the first sign of the disease. However with the development of effective therapies, life expectancy has increased to over 10 years although there is always a risk of conversion to acute myeloid leukaemia at any stage. The mode of treatment affects this risk. The PRV study group found that in those treated with phlebotomy the risk of transformation was 1.5%. Gastro-intestinal and skin cancers are also more common in the condition and are affected by mode of treatment.
Incidence rates
9. The incidence of ET is not as well documented. However, there is UK research that suggests that 1 per 100,000 -150,000 are diagnosed each year but there may well be a pool of undiagnosed cases. Higher incidence of 1.5 to 2.5 per 100,000 has been reported in the Scandinavia and the USA. The average age is 50-60 but increasing numbers of younger people being diagnosed, possibly due to increased testing using more sensitive methods.
10. The incidence of PRV in the general population is about 2 per 100,000 in the UK with an equal sex ratio. It occurs most commonly between 50 and 70 years of age.
Annex 2 – Revised ABI Cancer definition 2006 – showing deletion of conditions
Cancer – excluding less advanced cases
Any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue.
The term malignant tumour includes leukaemia, lymphoma and sarcoma.
For the above definition, the following are not covered:
· All cancers which are histologically classified as any of the following:
o pre-malignant, for example essential thrombocythaemia and polycythaemia rubra vera ;
o non-invasive;
o cancer in situ;
o having either borderline malignancy; or
o having low malignant potential.
· All tumours of the prostate unless histologically classified as having a
Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0.
· Chronic lymphocytic leukaemia unless histologically classified as having progressed to at least Binet Stage A.
· Any skin cancer other than malignant melanoma that has been histologically classified as having caused invasion beyond the epidermis (outer layer of skin).
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