Alzheimer's Disease (AD) is one of many causes of dementia. Dementia is an acquired deterioration in cognitive abilities that impairs normal activities of daily living (ADL). Cognitive abilities refer to memory, language, calculation, judgment, problem solving and Visio spatial ability (normal eye-hand coordination like the ability to pick up and move objects, get dressed, point at an object). The most common cognitive functional loss is that of memory loss -10% of people over 70 years of age, and 20-40% of people over 85 years have clinically significant memory loss. In Western countries, the most common cause of dementia (over 50%) is Alzheimer's disease. AD typically presents with memory loss which is followed by language and Visio spatial deficits. These impairments deteriorate progressively over years until it interferes with ADL's such as managing finances, driving, shopping, following instructions. This may be followed by impairment in organizational abilities, word-finding, and so on. The condition progresses until the patient may become lost while walking or driving, language becomes impaired, and they have trouble carrying out sequential tasks. Loss of judgment and reason may follow, and eventually daily supervision is required. The typical duration of AD is 8 to 10 years, but it may last as long as 25 years.

Diagnosis

The diagnosis is made on clinical grounds with the presentation of the symptoms described above. It is usually confirmed by a specialist neurologist or psychiatrist. Brain imaging, i.e. Ct or MRI scan, shows shrinking (atrophy) of the cortex (grey matter) and mid-brain areas (hippocampus) of the brain, and enlargement of the cavities (ventricles) within the brain.

Causes

The most important causes for AD are a positive family history, and old age. Females, even though they tend to live longer than men, seem to be at a bigger risk than men. AD may also occur after previous head injuries and exposure to certain environmental factors like aluminium, mercury and viruses. Certain genetic tests may identify persons at risk for the genetic variant of AD.

Treatment

Medication may control the symptoms to a degree, but will offer no cure. The drugs approved for the treatment of AD are all called cholinesterase inhibitors, some of which are not very popular due to toxic liver side-effects. Some studies have shown that estrogen hormone replacement therapy in post-menopausal women may be protective against the development of AD, however this is controversial. Gingko giloba has been found to improve cognitive function, and some studies found anti-inflammatory drugs (best known one is Voltaren) to be effective. More studies are however indicated. The treatment outcomes are generally not good, as no highly effective drug exists. Medication usually only helps symptomatically and temporarily. Eventually slow progression results in severe impairment.

Contractual requirements for a claim

Most CI benefits require significant reduction in mental and social functioning with continuous supervision as claims criteria. The extent of what is meant by "significant" is usually not clearly defined. In practical terms a successful claim will therefore rely mostly on being able to prove objectively that the claimant requires continuous supervision. This means that claims are paid for end-stage disease. Only one company will admit a claim if there is sufficient evidence of reduction in the executive functions of abstract thinking, judgment and problem solving. Again however, the required extent of reduction in these functions are not defined. The percentage of benefit payable vary from 40% to 100% of insured amount.

Prevalence and Incidence

Statistics for the prevalence and incidence of AD are not reliable, as most of the figures available refer to the number of people with dementia. This includes all causes of dementia like normal old age dementia. According to the Global Burden of Disease estimates for the 2003 World Health Report, dementia contributed 11.2% of years lived with disability in people aged 60 years and older; more than stroke (9.5%), musculoskeletal disorders (8.9%), cardiovascular disease (5.0%), and all forms of cancer (2.4%). One must bear in mind that the above refers to disability over the age of 60 . most of these people can still look after themselves and will as such not qualify for a claim under most CI contracts in our country. The prevalence of AD and other related forms of dementia is a approximately 5.7% in the age group over 65 years

Underwriting

A person with Alzheimer's disease applying for risk cover is unlikely to qualify for any product other than life cover, purely on the basis of his/her age. Life cover will generally be granted with a premium loading as the life expectancy is curtailed. In the rare cases where the disease occurs in a younger person, disability functional impairment, critical illness cover will be declined or at best be accepted with an exclusion.

Claims:

Alzheimer is not a direct cause of death. It can indirectly lead to a shortened life expectancy due to poor health care, insight into medical problems, compliance with medical treatment and associated complications.

The likelihood of a successful disability claim is good, provided that psychometric testing can confirm sufficient impairment in memory, concentration and abstract thinking to render the client unable to do his/her work.

Advanced cases will lead to successful FI claims, when the person is unable to take care of him/herself.

Not all CI products cover Alzheimer's disease. Those that do, rely on impairment of Activities of Daily Living to assess claims. It will therefore also admit claims for advanced stages of the disease.

Arrythmias, also known as dysrhythmias or abnormal heart rhythms, are disorders of the regular rhythmic beating of the heart affecting either the rhythm or the rate of the heartbeat or both. The heart contains an electrical conduction system that causes it to beat in a regular coordinated manner. Problems anywhere along this conduction system can cause an arrhythmia and depending on what part is affected, various types of arrythmias may occur. Arrythmias occur in people who have a history of coronary artery disease, heart valve problems or any other heart disorder. They may also occur in people who have imbalances in their blood chemicals, like too much or too little salt or levels of thyroid hormones that are too high. Some people are also born with an extra part of the electrical conduction system in their hearts and this can lead to a type of short-circuiting which causes the heart to beat too fast. Other causes include drugs like alcohol, caffeine, recreational drugs and certain drugs used for the treatment of heart disease. Arrythmias can be defined as benign (harmless) when they do not cause any problems, or life-threatening as certain types can cause serious heart problems, give rise to strokes or even cause sudden death.

Arrythmias include tachycardias (heartbeat too fast), bradycardias (heartbeat too slow) and true arrythmias (disturbed rhythm) and may have complicated names such as:

• Bradycardia
• Atrial ectopic beats
• Atrial flutter/fibrillation
• Narrow complex tachycardias
• Broad complex tachycardias (including Wolff-Parkinson-White syndrome)
• Ventricular ectopic beats
• Ventricular fibrillation
• Various conduction blocks
• Sick sinus syndrome

• Palpitations (being aware of the heart beating)
• Dizziness
• Shortness of breath
• Feeling faint or light-headed
• Chest pain
• May become aware of an irregular pulse or "missed beats"

For successful diagnosis, the history is very often the most helpful and often gives sufficient information to make a provisional diagnosis. This should be followed by a full clinical examination and certain tests and special investigations listed below:

• Blood tests.

• Standard 12-lead ECG (Electocardiogram).

• 24 or 48hr Holter ECG monitoring. This means wearing the ECG device like a small walkman as it measures and takes tracings of your heartbeat.

• Echocardiogram which is taking a scan of the heart.

• Coronary angiogram which means placing a small tube into the heart through the blood vessels and injecting a dye to show what the arteries of the heart look like.

• More sophisticated testing may also be carried out when more serious arrythmias are suspected. This is called Invasive Electrophysiologic Studies and involves programmed stimulation techniques whereby arrythmias can be initiated and terminated. It is done by placing a small tube into the heart also through the blood vessels.

The prognosis is generally good when it comes to arrythmias and more often it is the underlying disease that affects the prognosis than the arrhythmia itself.

Benefits

Benefits will vary depending on the type of arrhythmia or the complications arising from the condition. They tend to be in the 10% to 25% range but vary from company to company

Underwriting of Arrythmias

Arrythmias will usually lead to a loading for death and disability benefits but in some severecases may these benefits might be declined. Severe illness benefits will usually carry an exclusion for the condition.

Contractual requirements for a claim

Pacemakers

The heart has it's own inherent pacemaker that causes it to contract rhythmically and regularly. However, sometimes something happens to cause this pacemaker to malfunction and then the heart is unable to pump blood around the body like it should.

There are generally two scenarios that develop:

• There is a complete block of the heart's electrical pathway.
• The heart beats very slowly or very irregularly.

• A heart rate that is too slow or too fast.
• Fatigue
• Breathlessness
• Dizziness
• Loss of consciousness

This may require the insertion of a pacemaker to ensure that the heart pumps correctly. There are also less frequent circumstances where a pacemaker might be required. Examples of this is post heart transplantation and in certain cases of cardiomyopathy which is a disease affecting the heart muscle.

An artificial cardiac pacemaker is a small battery operated computer that is connected to the heart via one or more leads. These leads are connected to the inner wall of the heart with either soft plastic hooks or a short metal screw. The system relies on feedback that means that the pacemaker "listens" to the heart and supplements its natural rate. Most modern pacemakers work on a demand basis and only function when they are required to.

There are two major types of cardiac pacemakers:

• Single chamber where only one chamber is used, usually the ventricles.
• Dual chamber where two leads are used for the atrium and ventricle.

The typical hospital stay for pacemaker implantation is one to two days. The procedure is usually done under local anaesthesia and the pacemaker which is very small (the size of a R5 coin) is placed under the skin below the collarbone. The leads are then inserted into the heart through a nearby vein and positioned in the appropriate right-sided heart chamber.

There are also other very sophisticated pacing systems that require more than two leads and involve pacing the left sided heart chambers. These are only used in very special circumstances.

Some of the very rapid and very dangerous heart rhythms are potentially fatal. They may require the insertion of an implantable cardioverter defibrillator. This device can send messages to regulate the heart rate or if that fails can send an electric shock to jolt the heart out of its pattern.

Prognosis is good and generally people with cardiac pacemakers can live a normal life. Most pacemakers last longer than five years but this is evaluated during routine pacemaker checks. Pacemakers can be adjusted by means of external programming devices.

Benefits

Benefits will vary from company to company and what type of pacemaker has been inserted, but they are generally in the 10% to 25% range for severe illness claims. The reason being that pacemaker insertion is an uncomplicated procedure with very successful outcomes for the patient in most cases.

Underwriting

Successful pacemaker insertion will usually lead to a loading for life and disability benefits and an exclusion for severe illness.

Contractual requirements for a claim

A cardiologist's report is necessary for all claims to be assessed

Tumours, or growths, originate from cells that divide in an uncontrolled manner. Tumours are benign (not cancer) or malignant (cancer). Benign brain tumours can usually be removed, and they are not likely to recur. Some of these tumours can be removed without any complications or permanent impairment. The skull cannot stretch and therefore creates a confined space. Any growing mass may press on vital areas or push brain tissue through the openings in the skull. Although they do not invade nearby tissue, benign brain tumours can press on sensitive areas of the brain and interferes with vital functions or increase the pressure inside the skull. (This behaviour of a benign tumour is sometimes referred to as .malignant. behaviour (it behaves as a cancer). Sometimes tumours cannot be removed or can only be removed partially - permanent impairment may result even after successful removal. Brain tumours can occur at any age, studies show that they are most common in two age groups. The first group is children 3 to 12 years old; the second is adults 40 to 70 years old. Many forms of brain tumours can occur. The type of tissue in which they begin classifies primary brain tumours.

The most frequent symptoms of brain tumours include:

• Headaches,
• Drowsiness,
• Seizures (convulsions),
• Nausea or vomiting,
• Paralysis, weakness or loss of feeling in the arms or legs,
• Lack of coordination in walking (ataxic gait),
• Abnormal eye movements or changes in vision
• Changes in personality or memory
• Changes in speech.

Dread disease benefits are paid when benign brain tumours have malignant behaviour (behave like a cancer) and when the resultant impairments cannot be controlled with medication, surgery or radiotherapy. Valid claims will include unrespectable or partially respectable brain tumours with resultant permanent neurological impairment. Small benign brain tumours where the symptoms can be controlled with medication and hormone replacement, do not qualify as a valid claims.

[Benign]: Not cancer. Not malignant. A benign tumour does not invade surrounding tissue or spread to other parts of the body

[Malignant] or [Cancer]: An abnormal growth of cells, which tend to grow in an uncontrolled way and, in some cases, to spread to other organs.

Underwriting

Someone who has had a benign brain tumour must present the clinical reports and brain scan reports to the insurer. Terms on a new policy will be dependant on the location, accurate diagnosis, level of impairment and prognosis. The insurer will want to know if the tumour was completely removed and if there is still a possibility of renewed growth. Terms may include premium loadings and/or exclusion clauses.

Claims

Death
All policies should pay death benefits excluding those that only cover death by accident (trauma)

Disability
The outcome of a disability claim will be dependant on the level of functional impairment due to the tumour. The size, location and presence of complications will determine the level of impairment.

Critical illness
This benefit will only pay out if benign brain tumour is a specific benefit of the policy. A claim may also arise if the tumour causes complications that are benefits of such a policy (for example, total paralysis of a limb or blindness). It will not be paid under the cancer benefit.

Functional impairment
Complications of a benign brain tumour may lead to a valid claim in a functional impairment product (for example, hearing loss, blindness, paralysis).

Other
Complications of a brain tumour may lead to valid claims if the complications are benefits of the policy (for example, loss of limb function, confinement to wheelchair).

This is a general definition for inflammation and damage to arteries, especially arteries of the head. Most common forms of arteritis are giant cell arteritis (refer connective tissue diseases), Takayashu's arteritis and temporal arteritis. Takayashu's arteritis is an inflammation of the aorta and temporal arteritis an inflammation of the temporal artery in the side of the head. Endarteritis occurs in the small end arteries and usually results in complete blockage of the tissues supplied with resultant death of that area. The most common endarteritis is endarteritis obliterans which occurs in the leg, often resulting in amputation.

Pathology

Blood flow to various tissues or organs is compromised due to inflammation of the artery supplying that region resulting in necrosis of the tissues/organ. Depending on the type of arteritis, severe complications e.g. renal failure can occur resulting in death, whereas in other types the symptoms can be transient and easily curable.

Incidence

Depends on the artery affected . giant cell arteritis affects about three per 10 000 people

Signs and symptoms

These depend on which artery is affected, but may include:

• pain
• feverjoint pain
• eye paralysis
• hypertension
• pericarditis
• pleuritis
• decreased or no pulses or extreme tenderness on palpation.

Diagnosis

This is normally made after extensive blood investigation and eventual biopsy of an affected area. Occasionally angiography may help.

Treatment

The goal of treatment is to minimize tissue death or damage and therefore it is initially directed at suppressing the auto-immune response that has triggered the arteritis e.g. corticosteroids. Further treatment aims at stabilising the complications e.g. hypertension or preventing complications e.g. blindness. Surgical intervention may help in certain types of endarteritis e.g. vascular bypass.

Underwriting

If the arteritis is an ongoing disorder e.g. giant cell arteritis, then loadings or exclusions will be placed on critical illness benefit. If the arteritis was temporary and fully treated, then standard rates could be applied.

Claims

Evidence with regard to diagnosis of the disease as well as supporting biopsy and blood test results would need to be presented to the insurer

Event relationship to product benefits:

Death
Death claims as a result of arteritis would be covered.

Capital disability
This benefit is only likely to pay our should severe permanent complications occur e.g. blindness.

Critical Illness
Only a few companies cover this condition and as it often is temporary and treatable, it would be paid on a low severity e.g. 10% to 25% of the critical illness benefit. Should severe complications occur like blindness and kidney failure, then nearly all companies would pay out at 100%.

Functional impairment
A percentage of this benefit would pay out only if severe complications occurred, for example blindness at 50% to 100%.

[Cancer] can also be referred to as a malignant tumour or growth, a malignancy, or a non benign tumour or growth. [Leukaemia] and [lymphoma] are cancers in their own right and involve the blood and blood forming organs of the body. They have their own classification system and will be discussed separately. Cancer is a so called dread disease in the true sense of the word. It has therefore always been a core part of the dread disease product since the introduction of this type of risk benefit and remains an important part of this type of insurance cover. Cancer is a condition which involves loss of normal cellular control, resulting in the unregulated and uncontrolled growth of cells. This in turn causes invasion of local and surrounding tissue and allows cancer cells to metastasize. The term metastasis or metastasize refers to the spread of the cancer cells to other parts of the body and represents the severest form of cancer. The invasive quality of cancer cells is a very important concept when it comes to dread disease cover, because it is possible to have uncontrolled growth of cells that do not invade local tissue. The uncontrolled growth of cells that does not invade local tissue is known as a [benign tumour] or growth and does not constitute cancer. Benign tumours do not qualify for payment under cancer definitions unless explicitly mentioned in the policy wording. The same is true for a very early form of cancer where there is no detectable invasion of the surrounding tissue, known as [carcinoma in situ] (CIS). Cancer can occur in anybody, in any organ of the body, and at any age. Cancer is usually the result of a number triggers and events that occur over time. Genetic predisposition and biological as well as environmental factors usually interplay to result in cancer. Thankfully, today there have been great advances in cancer screening and cancer prevention programs. More cancers are being detected at an early stage when cancer treatment is often curable.There are however several well known factors that predispose a person to cancer and these include but are not limited to:

Age

In South Africa, if you were to take 10 000 men aged 25, probably two of them would develop cancer in the next year. Out of 10 000 men aged 45, some18 would be likely to develop cancer over the following year. year and in 10 000 men aged 60, approximately 72 would develop cancer in the following year. Age is a strong determinant of cancer.

Smoking

Smoking is the most avoidable risk factor for cancer. A smoker has a one in three lifetime risk of dying prematurely of a smoking related cancer, or a cardiovascular or pulmonary disease.

Diet

Diets high in fat content and low in fibre are thought to increase the risk of cancer.

Family History

A small but significant portion of cancers are linked to a genetic predisposition and to a family history of cancer. Examples of this type of cancer would include a percentage of breast and bowel cancer.

Environmental factors

Excessive exposure to sun, exposure to radiation, and exposure to asbestos are examples of environmental factors that increase the risk of cancer.

Biological factors.

Certain infections predispose to cancer. The human papilloma virus increases the risk of cervical cancer. The HIV virus increases the risk of Kaposi's sarcoma and lymphomas.

A history of previous cancer.

A previous history of cancer and radiotherapy and /or chemotherapy treatments heighten the risk of a second cancer. As can be seen from the above, the cause of cancer can be complex and it is often an interplay between various factors that leads ultimately to the breakdown of normal control mechanisms and the proliferation and invasion of cancerous cells.

Symptoms and diagnosis

Symptoms of cancer vary tremendously. Weight loss, abnormal swellings, lymph node enlargement, bleeding and anaemia are some of the more common symptoms, to mention a few. The definitive diagnosis of cancer involves removing a portion (a biopsy) of the cancer and examination of the specimen by a pathologist..Microscopic examination, special staining techniques and genetic tests (cytogenetics) are all used to confirm the type of cancer. The above is often called histological testing (histology report) and is required as proof of cancer at the claims stage when submitting an insurance claim.

Staging (severity)

The extent and severity of cancer is described by a taging system. There are four stages. The first stage refers to localised cancer that is confined to the organ of origin. Stage two cancer refers to a larger cancer that has invaded tissue surrounding the organ of origin. Stage three cancer has spread extensively and may involve lymph nodes. Stage four cancer is the severest form of cancer where the cancer has metastasized (spread) to distant sites in the body such as the lungs, bones and brain.. Stage '0' is occasionally referred to and this should be seen to be the equivalent of carcinoma in situ. Stage 0 is excluded from benefit payments. Related to this staging system is a more specific classification system known as the [TNM classification] system. 'T' refers to the tumour size, 'N' refers to lymph node involvement and 'M' refers to any metastases that have occurred. Levels within the TMN classification can be assigned to one of the broader four stages. Prognosis (survival) in cancer is directly linked to the staging of the disease. Prognosis in stage 1 cancer is excellent, where as prognosis in stage 4 cancer is guarded. There are exceptions such as leukaemia and malignant melanoma that use and require a different staging system. Again, prognosis is directly linked the severity levels used in alternative staging systems. It must be noted here that South Africa has one of the highest melanoma rates in the world and advanced melanoma caries a poor prognosis.

Exclusion clauses

Cancer benefits generally exclude pre-malignant conditions and carcinoma-in-situ as they are completely curable and do not impact on lifestyle. Certain specific cancerous skin conditions are also excluded as it has been proven that surgical removal is curative. An example of this would be Basal Cell Carcinoma which is often abbreviated to BCC. A skin cancer known as malignant melanoma is a more serious and aggressive skin cancer. Whilst most companies exclude BCC, the approach to malignant melanoma may vary from company to company. Some policies exclude early malignant melanoma as early removal is mostly curable. A stage 1A melanoma, where the invasion into the skin is less than 0.75 millimetres, caries a 95% cure rate and this very early melanoma may be excluded from cover. A more recent exclusion added to some policies is the exclusion of stage one prostate cancer. It is important to read and understand the exclusion clauses for cancer as it does happen that your doctor advises you that you have an early cancer, but at the claims stage it is declined as it is one of those non life threatening cancers that has been specifically excluded.

Non tiered benefits

This cancer benefit pays 100% of the cover on the diagnosis of cancer as long as the cancer is not specifically excluded (such as Basal Cell Cancer of the skin).This type of cover is available in the market. The definition is simple and does not pay out differing amounts based on the type or severity of the cancer. This type of cancer cover often forms part of a core benefit.

Tiering of Benefits

Recently there has been a movement to link the benefit payment to the degree of severity or staging of the cancer in a tiered benefit. This option pays a portion of the benefit for early stage cancer increasing to 100% benefit for late stages (stage four or in some instances stage three or four) cancer .This product design is more complex, directly linking payment to staging and therefore demands a more medically orientated set of definitions. Tiering allows for a portion of the available insurance cover to be paid for a condition of a lesser severity and allows for there to be reserves available for further dread disease claims whether they be a progression of the initial claim or a totally unrelated event. Tiering is also a method of controlling the cost of cover to the consumer as with tiering 100% of the benefit is not paid with every claim. With cancer however, the financial needs of the client may be paradoxically higher in some early stages of cancer, as it is usually in the first three stages that expensive chemo- and radio-therapy have the best effect, whereas stage four cancers are often treated only symptomatically. As far as possible evidence based medicine is used to determine what cancers are excluded from cover and in the case of tiered benefits what benefit amount is assigned to a certain severity or staging of cancer.

Basal Cell Carcinoma of the skin

This cancer is a common cancer, but almost universally excluded from cover. The rationale for this is that it is almost always curable, although it can cause local tissue destruction and local reoccurrence may occur. It is, however, very unlikely to spread to other parts of the body with the quoted incidence of distant spread at less than 0.1%. For this reason it not considered to be significant enough to warrant a claim.

Prostate Cancer

This is one of the most common cancers in men around the world. The risk of developing prostate cancer increases dramatically with age. Its apparent increased incidence and prevalence in recent years may well be attributed to the increased use of a screening test to detect prostate cancer (known as a PSA test) and the ageing population. The widespread use of PSA testing has seen the incidence of early (stage one prostate cancer) increase by over threefold in recent years. Fortunately, stage one of prostate cancer caries an excellent prognosis with a good life expectancy. Companies have elected to exclude stage one of prostate cancer from cancer cover, because it carries an excellent prognosis and the fact that screening has resulted in a dramatic increase in the diagnosis of early prostate cancer. It would make the insurance cover too expensive to offer a substantial payment for all stage one prostate cancers. Stage two, three and four of prostate cancer is unfortunately associated with a poorer prognosis with stage four prostate cancer having a five year survival rate of only 20% to 30%. Stage two, three and four of prostate cancer can therefore be classified as a dread disease and has the potential to impact on a person's life. For this reason all prostate cancer falling into these stages should receive 100% payment in a non tiered benefit and increasing payments to a maximum of 100% in a tiered benefit. About 65% of all prostate cancer is diagnosed in men over 65. Approximately 70% to 80% of prostate cancer patients are diagnosed at an early stage when there is only localised disease and no spread to other organs.

Breast Cancer

Breast cancer is one of the top two causes of cancer in females. The lifetime risk of developing breast cancer in the female population in South Africa is one in 36. It is estimated that genetic factors account for 5% of all breast cancers. Unlike prostate cancer, stage one breast cancer should not be excluded from cover. [Breast carcinoma in situ] is however excluded from insurance cover. [TNM classification] is used for breast cancer with the most important prognostic factor being whether the cancer has spread to lymph nodes. Patients without spread to lymph nodes (early disease) have a five year survival rate of 82% and a 10 year survival of 75% where as patients with spread to four or more nodes have a five year survival of 25% and a 10 year survival of 15%. Non tiered benefits would pay 100% of cover for stage one to four breast cancer and tiered benefits would pay increasing percentages to a maximum of 100% for stage four or in some instances stage three or four breast cancer.

The most common Cancers

Approximately 80 000 cancer cases are reported each year to the South African National Cancer Registry. The following table gives the top 5 cancers for males and females and the lifetime risk (age 0 - 74) of developing such a cancer:

[Leukaemia] and [Lymphoma]

Leukaemias and lymhomas are malignancies of the blood and blood forming organs and lymph tissue. They represent a vast array of different diseases with very varying prognoses. It is not possible to stage them with the traditional staging system used for other cancers. Also, the approach to benefit payments is not uniform within the life industry and this may reflect the complexity of these diseases. Some policy wording may well exclude or offer reduced cover for early stage lymphomas and chronic slowly progressive leukaemias as they are associated with more favourable outcomes. In tiered benefits, payments are linked to the overall prognosis of the condition. As these diseases are often associated with relapses or acceleration of the disease there may well need to be a revision of an initial payment. Certain leukaemias are more common in childhood and would be an important portion of cover under a childhood dread disease product.

Cancer Claims

As with all dread disease claims, a multi-disciplined approach will be used in assessing cancer claims. It is a requirement for all cancer claims to be accompanied by reports from a pathologist (histological report) confirming the presence of cancer. The extent and severity of the cancer will also have to be verified as certain low severity cancers are specifically excluded as mentioned above. For this reason a report from the treating specialist (usually an oncologist or haematologist) will also be requested. As there is potential for cancers to progress over time it may well be necessary to review an initial decision in the case of tiered benefits. All insurance companies are usually quite willing to review claims decisions in this respect.

[Carcinoma in situ]

Carcinoma in situ (CIS) is a very early form of cancer where there is no detectable invasion of the surrounding tissue. CIS can be cured through surgical intervention and is therefore not covered under the cancer definition of dread disease policies unless explicitly mentioned in the policy wording. This condition is not life threatening nor should it impact significantly on a person's lifestyle.

Carcinoid Syndrome

This is a group of symptoms that are often associated with a carcinoid tumour, which is a tumour that produces high levels of the hormone serotonin. Serotonin causes blood vessels to dilate as well as stimulating clotting by increasing platelets to aggregate. The symptoms experienced with carcinoid syndrome include flushing, rapid heart rate, facial swelling, low blood pressure, abdominal pain, protein deficiency, diarrhoea and weight loss. Occasional wheezing can also occur. Treatment is by either removing the carcinoid tumour, or by controlling serotonin levels via medication if surgery is not indicated. If not treated, the main complications include stroke and deep vein thromboses from the increased clotting and right sided heart failure. Bowel obstruction and gastrointestinal bleeding from a carcinoid tumour can also occur.

Cardiomyopathy refers to a structural or functional abnormality of the muscle of the heart, causing weakening of the heart muscle. This results in the inability of the heart to pump blood efficiently around the body. While there are many known causes of cardiomyopathy, sometimes there may be no identifiable cause.

Risk Factors

The following is a list of risk factors that could lead to cardiomyopathy.

• Age greater than 60 years
• Obesity
• Smoking
• Alcoholism
• Family history of coronary artery disease or cardiomyopathy
• Certain drug usage as mentioned above
• Diabetes
• Lipid (cholesterol) disorders
• Thyroid disease

Dilated Congestive Cardiomyopathy

In this form the ventricles (lower chambers of the heart) enlarge but are unable to pump sufficient blood to keep up with the body's needs, resulting in heart failure. Causes include:

• Coronary artery disease (most common cause)
• Infections caused by viruses and other organisms
• Endocrine or hormone disorders like diabetes and thyroid disease
• Drugs like alcohol, cocaine and certain anti-depressants
• Pregnancy and rheumatoid arthritis (rare causes)

Hypertrophic Cardiomyopathy

In this form of cardiomyopathy the walls of the ventricles become very thickened. The following are possible causes:

• Birth defect.
• Hormonal disorders like excessive growth hormone or tumours that produce adrenaline.
• Other conditions that increase the work load on the heart such as high blood pressure and heart valve disease.

Restrictive Cardiomyopathy

This is due to the heart muscle in the walls of the ventricles becoming very stiff but not necessarily thickened. This resists the normal filling of the heart with blood between heart beats resulting in there being insufficient blood to pump around the body.

This is the rarest form of cardiomyopathy and its causes are generally unknown. Some known causes include:

• Infiltration of the heart muscle due to sarcoidosis, amyloidosis or haemochromatosis.
• Tumour invading the heart muscle (Wegeners Granulomatosis).

Signs and symptoms

Depending on the severity of the cardiomyopathy it may present with various signs and symptoms

• Easily fatiqued.
• Shortness of breath with exercise or sometimes even at rest.
• Inability to lie flat without becoming short of breath.
• Swelling of the ankles.
• Rapid heartbeat.
• Irregular heartbeat.
• Chest pain.
• Painful swollen liver.

Treatment

Treatment consists of treating underlying causes to prevent complications from developing. The most common complication is heart failure, which is treated by means of certain drugs that reduce fluid volumes, regulate the workload of the heart, or help the heart to pump more efficiently. If the underlying disorder cannot be corrected then cardiomyopathy becomes incurable and leads to heart failure and the prognosis becomes very poor. Often the only treatment then is heart transplant. In rare cases pacemakers are required.

Benefit levels

Severity levels range from mild to very severe but generally companies pay 100% benefits in the severe category provided certain criteria are met. Those companies with tiered benefits will pay lesser percentages for the mild to moderate forms of this disease.

Underwriting of Cardiomyopathy

Depending on the severity, pre-existing cardiomyopathy could lead to all benefits being declined, loaded or excluded. In certain less severe cases severe loadings could be applied.

Contractual requirements for a claim

In all instances a report form a cardiologist will be required. The report will need to contain certain data from special investigations performed to ascertain the severity level and the resultant benefit payment. This differs from company to company.

Coma is a state of prolonged unconsciousness i.e. the lack of appreciation or reaction to stimuli. There is no sleep-awake cycle and the person in a coma cannot be aroused as can one in a deep sleep. Coma is also described as the lack of both reactivity and perceptivity. Reactivity is the response to inborn reflexive actions such as sight, hearing, wakefulness, and orientating to touch, whereas perceptivity is the reaction to conscious learned or acquired responses like communication, language or learned movement responses like flinching. The main cause of coma is due to brain/ head injury . other causes include metabolic or toxic coma (e.g. alcohol, drug abuse), hypoxia, stroke, diabetes mellitus, shock, haemorrhage, central nervous system diseases, infection and iatrogenic (doctor induced for treatment of other diseases or severe injury).

There are two main measures of the depth of coma:

1. Glasgow coma scale . this assesses the ability to open the eyes, verbal responses and motor movements in response to various stimuli. The scale is measured out of 15 with less than 8/15 indicating severe brain damage and coma.


2. Rancho Los Amigos scale . this measures cognitive function and is used in coma patients due to a brain injury. The scale is from one to 10, with one being minimal cognitive response.

It is exceptionally difficult to predict how long a coma will last or how the depth of the coma will progress. A coma will not usually last longer than two to four weeks. After three months, the coma is described as persistent and after one year as permanent. Coma patients can rapidly recover all function and respond to all stimuli or can progress on to a permanent vegetative state, where there are only eye movements and a sleep-wake cycle, but no other response to stimuli. There is a less than 10% recovery rate in patients for have been in a coma for more than three months. Many coma patients can produce sound, have involuntary movement or become agitated, but this is not indicative of recovery. A 'locked in' syndrome can occur where the patient is awake, but cannot respond to environmental stimuli. Prevalence figures from around the world indicate that between two to 10 people per 100 000 are in a vegetative state.

Treatment

Treatment for coma patients includes treating the underlying cause if applicable e.g. stroke and then focusing on preventing any other form of complication or crisis. The mainstay of treatment is to improve and maintain the clinical state of the patient. Initially brain swelling needs to be reduced via use of medication, infection needs to be prevented/treated and seizures need to be prevented. In the long term there needs to be prevention of:

• Contractures due to increased muscle tone . use of ongoing physiotherapy.
• Bladder and renal tract complications . catheterization is mandatory.
• Constipation or diarrhoea.
• Undernutrition . often intravenous feeding is given.
• Respiratory infections.
• Stress ulceration . bed sore prevention by constant movement of position.
• Deep vein thrombosis.
• Complications of medications.
• Disruption of family dynamics.

Underwriting

Clients currently in a coma cannot obviously not be underwritten, but clients who have previously been in a coma and have recovered can be assessed with regard to cause of coma and degree of recovery. Terms can be granted for both life cover and benefits ranging from standard rates for a full recovery to loadings or exclusions should there be any permanent sequelae (condition resulting from a prior disease or injury).

Claims

Claims will be paid out after a period of time in a coma. Medical evidence will need to support the coma diagnosis as well as any specialized tests that have been done. Many companies will exclude iatrogenic coma i.e. coma specifically induced by a doctor.

Event relationship to product benefits:

Death

Death claims following a coma will be covered.

All types of disability products will pay out should a persistent vegetative state be reached. Where there are permanent sequelae following recovery from a coma, an occupational assessment will be done. Some capital disability products will pay for loss of cognitive function or other demonstrable objective sequelae.

Tiered critical illness products will pay out increasing amount based on number of hours or days in a coma as well as permanence of complications. Non-tiered products require a specific amount of hours in a coma prior to paying out 100%. Many of these companies will require that permanent neurological sequelae can be demonstrated.

These products will only pay out once a persistent vegetative state has been reached or there is defined loss of a specific function e.g. loss of use of a limb, in which case a set percentage of the benefit will be paid out.

Usually narrowed coronary arteries are firstly treated with an angioplasty procedure, with or without stenting (refer to section on angioplasty). When this fails, or when the stretched artery gets diseased again, a bypass operation is considered. Some lesions may not be technically possible to stretch with an angioplasty, in which cases a bypass operation may be indicated as first line treatment. The diseased or narrowed section of the artery is bypassed by connecting a healthy vessel before the start of the diseased section, and reconnecting it again beyond this section, thereby creating an easy bypass for blood-flow through the bypass graft.

Two types of vessels are harvested to use as a bypass graft:

• A vein from the lower leg of the patient, or


• A small artery from the chest wall (mammary artery).

The long-term outcomes of artery bypass grafts are better than vein bypass . the explanation continues referring to grafts. Up to seven bypass grafts can be done at the same time. A bypass operation may be repeated if the bypassed section also closes off or gets narrowed, however these are very seldom done on more than two occasions on the same artery.

Benefit payments

Some products pay the full amount if one or more artery is bypassed. Others pay varying percentages of the insured amount according to the number of arteries operated on. These benefits typically pay 25% to 50% for a one-vessel bypass, with increments for more vessels bypassed. Some require three or more vessels to by grafted for a 100% benefit, whereas others require four or more. Bypass operations occur fairly commonly, and a vast proportion of these are done on one or two vessels only. Most of the insurance products providing partial payments, also allow for multiple claims.

Claim statistics

In 2004 in South Africa, approximately 15% of all dread disease claims paid, were for CABG procedures.

This is an enlargement of the right side of the heart due to lung damage.

Pathology

As the right side of the heart has to pump blood to the lungs, if damaged the right ventricle has to work harder to get the blood into the lungs and so, as like any muscle that is over exercised, it enlarges. Cor pulmonale is not the same as congestive heart failure due to valve damage, as by definition, lung damage must be present. Cor pulmonale is normally chronic i.e. occurs over a prolonged period of time, although it can be acute and reversible with temporary lung disorders. The lung damage that normally results in cor pulmonale is chronic bronchitis or chronic obstructive airways disease (more than 50% of cases) from excessive smoking. Other causes are chronic sleep apnoea, airway obstruction e.g. from massively enlarged tonsils, morbid obesity, cystic fibrosis, primary pulmonary hypertension, pneumoconiosis (occupational lung diseases e.g. asbestosis), interstitial lung disease or pulmonary vascular disease.

Incidence

US statistics estimate cor pulmonale to account for 6% to 7% of all adult heart diseases, and propose that international incidence would increase where the smoking rates, pollution and other risk factors for the various lung diseases are increased.

Signs and symptoms

Symptoms in the early stage of the disease would include fatigue, exertional dyspnoea (shortness of breath) and syncope (fainting). Later on chest pain, cough, haemoptysis (coughing up blood) and voice changes may occur. Once there is full blown cor pulmonale, the symptoms would be the same as that for right ventricular heart failure. Signs would be similar to right heart failure as well, but most noticeable would be the signs found in the lung i.e. the cause of the cor pulmonale e.g. wheezing, crackles (water in the lungs), decreased breath sounds and soft heart sounds because the chest wall diameter has increased to try and get more air into the lungs. Other signs would be similar to that described for right ventricular failure.

Diagnosis

As with heart failure, the patient history and physical examination are the most important clues to making a diagnosis. Investigations would be similar to those of right heart failure as well.

Treatment

Initial treatment would be focussed on the cause of the cor pulmonale, especially in acute conditions like pulmonary embolism. Other treatment would include oxygen therapy and medication as for heart failure. If the cardiac damage is not too bad then lung transplantation might be considered, otherwise heart and lung transplantation if the right ventricle is severely compromised.

Underwriting

Both the lung pathology as well as the cardiac compromise would have to be taken into account when considering a client with cor pulmonale for critical illness and generally this would not be granted. Patients with chronic obstructive airways disease and cor pulmonale only have a 30% chance of surviving two years.

Claims

Claims for cor pulmonale are often mixed up with the lung disease that caused it or with heart failure in general, so requirements for claims would be either related to investigations of the lung or heart disease.

Event relationship to product benefits:

Death claims resulting from cor pulmonale would be honoured.

As for heart failure - disability products based on ability to perform an occupation would need an assessment of the severity of the cor pulmonale on the inability to perform the particular work. Other capital disability products would pay out based on the [ejection fraction] level or signs and symptoms of heart failure.

Companies that cover cor pulmonale would generally pay out critical illness at 100% or in the earlier stages at 50% to 75%.

Cor pulmonale payout would be based on the NYHA classification or [ejection fraction] percentage

Crohn's disease is a chronic inflammatory disease involving mainly the small intestine and colon. It is also known as regional enteritis, granulomatous enteritis or colitis, ileitis or terminal ileitis. Together with ulcerative colitis the disease is frequently referred to as inflammatory bowel disease (IBD). There is no cure for Crohn's disease. Once the disease begins, it tends to fluctuate between periods of inactivity (remission) and activity (relapse). The cause of Crohn's disease is unknown. However, it is believed that a compromised immune system appears to play an important role. In the early stages of Crohn's disease small scattered, shallow, crater-like areas (erosions) re formed on the inner surface of the bowel. With time the erosions become deeper and larger, later becoming true ulcers and causing scarring and stiffness of the bowel. As the disease progresses, the bowel becomes increasingly narrowed causing obstruction. Deep ulcers can puncture holes in the wall of the bowel, and bacteria from within the bowel can spread to infect adjacent organs and the surrounding abdominal cavity. These deep punctured holes can create a tunnel between the intestine and adjacent organs. When the ulcer tunnels into an adjacent organ, a channel (fistula) is formed which can drain infected pus.

Symptoms

Common symptoms include abdominal pain, diarrhoea and weight loss. Less common symptoms are poor appetite, fever, night sweats, rectal pain and rectal bleeding. The symptoms are dependant on the location, the extent and the severity of the inflammation.

Complications

These include obstruction and perforation of the small intestine, abscess formation, fistulae and intestinal bleeding. Recent data suggest that there is an increased risk of cancer of the small intestine and colon in patients with longstanding Crohn's disease.

Diagnosis

Once suspected the diagnosis is usually confirmed with a colonoscopy and biopsies (tissue samples) of the affected areas.

Treatment

This includes drugs for suppressing inflammation or the immune system, antibiotics and surgery. Treatment is aimed at keeping the disease in remission. Surgery can significantly improve the quality of life in selected individuals, but recurrence of the disease after surgery is common.

Critical illness benefit cover

Not all the life insurance companies offer cover for Crohn's disease. Companies that do offer cover for this condition will only pay out a partial amount of the total cover if the individual has had a permanent colostomy or is permanently on cortisone or immuno-suppressive therapy.

Heart failure occurs when the inability of the heart to pump blood efficiently results in tissues around the body getting insufficient oxygen causing dysfunction (congestive heart failure). Heart failure can be caused by a problem in the heart muscle of either the right or the left ventricle or both. Normally, heart failure is a long standing, slowly progressive chronic disease, but occasionally the heart can go into sudden failure, known as acute heart failure. Chronic heart failure, although treatable is not normally reversible, whereas acute heart failure is treatable and generally reversible.

Pathology

Heart muscle can be damaged due to various causes including hypertension (the commonest cause of chronic heart failure), coronary artery disease or heart attacks, diseases of the heart valves, cardiomyopathy (enlarged heart muscle due to various causes e.g. alcohol), lung disease, congenital heart problems or heart tumours. Because the heart muscle on either the right or left side or both is damaged, the heart is unable to push blood through to the body (left ventricle dysfunction) or to the lungs (right ventricle dysfunction) or both. This results in inadequate blood getting to either the body or lungs and blood pooling in the lungs (left ventricular dysfunction) or in the liver or gastrointestinal tract and extremities (right ventricular failure) or both. In bilateral heart failure various organs around the body are therefore affected both the lack of blood supply and oxygen, as well as stasis (pooled blood that cannot be sent to the lungs to get more oxygen). Acute heart failure is the sudden onset of congestive heart failure due to extensive heart muscle damage e.g. massive heart attack, overwhelming infection, severe metabolic disorders, or due to an acute exacerbation of previously compensated chronic heart failure. In congestive heart failure many organs slowly go into failure resulting in multi-organ failure and ultimately death.

Incidence

Statistics on heart failure are difficult to gather due to the various levels at which heart failure can clinically diagnosed, but studies that adhere to the European Society of Cardiology guidelines for the definition of heart failure found a crude incidence rate of 140 per 100 000 men and 120 per 100 000 women. These incidence rates increase steeply in the elderly and risk factors include overweight, hypertension, diabetes mellitus, smoking, alcohol abuse or cocaine use.

Signs and symptoms

Most of the signs and symptoms experienced by patients with heart failure are related to the increased fluid either in the periphery due to right ventricular dysfunction or in the lungs due to left sided failure. Symptoms include weight gain (fluid retention), swelling of feet, ankles or abdomen, swollen neck veins, shortness of breath (dyspnoea) either with activity or after lying flat (orthopnoea), difficulty sleeping with waking to get breath (paroxysmal nocturnal dyspnoea), fatigue, palpitations with abnormal heart rhythm, decreased concentration, cough, decreased urine output and loss of appetite, nausea and vomiting. Signs include an irregular and rapid heart beat, increased jugular venous pressure (distended neck veins), enlarged liver, peripheral oedema (swollen legs), lung crackles, an S3 (extra heart sound) and possible pleural or pericardial effusion (water in lining of lung or heart). Generally in most cases of heart failure the heart will be noticeably enlarged.

Diagnosis

This is based on a thorough medical history and examination with special attention focussed on risk factors present. Confirmation is through various investigations, including echocardiogram and the measurement of the [ejection fraction]. [Ejection fraction] is the measurement of the amount of blood pumped out of the ventricle per beat and can be measured in either the right or left ventricle. The left ventricle measurement is the value generally regarded as important as this indicates the amount of blood reaching the body per beat. A normal ejection fraction is about 55% - 65% and in severe heart failure the measurement can be as low as 20%. Other methods used to diagnose heart failure are a chest X-ray, cardiac MRI, MUGA scan (heart nuclear scan) or ECG, which may show enlargement of the heart and arrhythmias. Recently a blood test has been developed called brain natriuretic peptide (BNP) and levels above 500pg/ml are indicative of heart failure. This latter test should make the diagnosis of heart failure more standardised and aid in treatment monitoring.

Treatment

The mainstay of treatment is medication . ACE inhibitors to open up blood vessels and decrease the workload of the heart, diuretics to remove fluid from the body, digitalis to control the rhythm of the heart and other drugs to stabilise the heart and maximise the contractility of the heart muscle fibres. Other treatments include reduction and control of risk factors e.g. decreasing alcohol intake, reducing weight and so on. Severe cases would need admission and stabilisation in an intensive care environment. Acute heart failure is treated more aggressively to prevent any long term cardiac damage.

Underwriting

Although heart failure can be controlled by medication, life expectancy is significantly reduced and therefore most companies would be unable to offer terms to a client who is in heart failure. If the heart failure was acute, then a loading may be applied to the cause e.g. heart attack, providing no other complications have occurred.

Claims

Most insurers will require evidence of ongoing heart failure despite therapy. Many might not specify heart failure, but might cover cardiomyopathy, decreased ejection fraction, severe valve disease or other conditions where the outcome leads to heart failure.

Event relationship to product benefits:

Death claims as a result of heart failure would be covered.

Disability products based on ability to perform an occupation would need an assessment of the effects that the signs and symptoms of the heart failure would be having on the inability to perform the particular work. Other capital disability products would pay out based on the [ejection fraction] level or signs and symptoms of heart failure.

Some companies will not offer specific cover for heart failure in the critical illness benefit, but rather cover the causes of the heart failure e.g. valve damage. Those companies that do cover heart failure will pay the severity based on the [ejection fraction] with a 100% payout being given at a value of about 35% or less. Lower percentage payouts could still be paid out for a slightly suboptimal [ejection fraction] i.e. 40% to 45%. A few companies also cover acute heart failure, but at a lower severity.

If heart failure is covered under these products, the payout would be based on the [ejection fraction] or New York Heart Association (NYHA) classification.

Inflammatory bowel disease includes [Crohn's disease], [ulcerative colitis] and a group of so-called indeterminate diseases where the symptoms make it difficult for placement under either Crohn's or ulcerative colitis. Crohn's and ulcerative colitis are being discussed under the individual topics.

Symptoms/clinical findings

Patients may present with painless bloody diarrhoea usually on an intermittent basis. Rarely is there significant loss of blood. Laboratory findings may include:

• Low iron (Hb)
• Low blood albumin (proteen)

• As for diagnosing [ulcerative colitis] or [Crohn's disease].

• By excluding other causes for inflammation like infectious colitis where organisms/parasites can be found in the stools.

• By direct viewing of the inside of the bowels by means of a scope (colonoscopy); Swelling, redness and ulceration may be seen.

How is it treated?

Medical treatment consists of using fiveamino-salicylic acid products, steroids or drugs that suppresses the immune system. In this regard please refer to individual discussions under Crohn's and ulcerative colitis.

Underwriting

Refer to [ulcerative colitis], [Crohn's disease] and [diverticular disease] individually.

Claims

Cases of complicated inflammatory bowl disease ultimately ending in death benefits.

Inflammatory bowel diseases are largely treatable conditions. Complicated cases resulting in functional impairment to the extent that the life insured is unable to engage in the regular and (if contractually required) a reasonable alternative occupation, taking into account his or her education, training and experience, will qualify for disability benefits. In order to qualify for permanent benefits, however, all reasonable treatment options must have been applied with no chance of further improvement at which stage a specialist physician will do a functional impairment assessment. A decision on total and permanent disability will finally be advised by experts on the medical panel of each company.

Inflammatory bowl disease is not covered under the core benefits. Some companies include [ulcerative colitis] and [diverticulitis] under the comprehensive benefits but only for a small percentage of the insured amount and only if there is objective evidence of severe impairment with regard to the activities of daily living. It is not a common claim event.

Diseases mostly related to the gastro-intestinal tractus rarely cause significant and permanent functional impairment and, although there may be exceptions, are unlikely qualify for benefits.

Ischaemic heart disease (IHD) is also known as coronary artery disease, angina heart and coronary heart disease. It is a progressive disease that affects the coronary arteries that supply the heart muscle with oxygen. Any one or more coronary arteries can become partially or totally obstructed due to one or a combination of a number of processes:

• Cholesterol build-up on the walls of the artery, also known as plaque.
• Inflammation of the smooth lining (endothelium) of the artery wall.
• A blot clot forming on a diseased part of the artery wall, or on a crack in plaque.
• Infection caused by viruses and other organisms.
• Genetic disposition.
• Obesity.
• High cholesterol levels
• Smoking
• Diabetes
• High blood pressure

Total obstruction or blockage of a coronary artery results in a heart attack. This is when a portion of the heart muscle dies due to total lack of oxygen supply. For more detailed descriptions, see [heart attack] or [myocardial infarction]. When one or more arteries become narrowed, the typical symptom is angina. Angina is chest pain, usually experienced when doing physical exercise or work, due to the heart muscle being deprived of oxygen. The chest pain, described as feeling like a tight band being squeezed around the chest usually starts behind the breastbone and may spread up the neck, to the left shoulder or down the left arm. It is often accompanied by dizziness, sweating and/or nausea. Patients with chest pain are normally investigated by doing a stress electrocardiogram (ECG). An ECG recording done after exercising usually shows if certain areas of the heart suffer from lack of oxygen supply during exercise. A positive stress ECG is usually followed up with a coronary angiogram. This is done by injecting a dye into an artery in the groin. The dye then shows up the arteries of the heart on a scan, and narrowings and/or occlusions of arteries can easily be recognised.

Treatment

• Medication that causes the arteries to dilate (open wider) to improve blood flow.
• Addressing the relevant risk factors mentioned.
• Balloon stretching of the narrowed segments (see [angioplasty]).
• Replacing a diseased vessel with a bypass graft (see [coronary artery bypass] or [CABG]).

Benefits

Benefits for ischaemic heart disease under critical illness products are usually defined as benefits for either angioplasty, coronary bypass surgery, or heart attack. Angina per se does not qualify. For more details on the benefits and severity levels, refer to the specific sections on [angioplasty], [CABG] or [myocardial infarction].

The dread disease benefit for liver disease covers advanced liver disease when there is irreversible and progressive liver failure. In order to claim under this condition the liver failure must be advanced. In other words insurance coverage does not pay upon the diagnosis of early liver disease or reversible liver disease. In most instances the disease process is a chronic one but there are instances when the liver failure may happen acutely. Any person undergoing a liver transplant will receive the full benefit by all companies offering this cover. Tiering of benefits does occur within the industry but to a lesser degree than with other conditions. End stage liver failure will receive the same benefit by all life companies. Clinical signs of advanced liver failure include jaundice (a yellowing of the skin and eyes due to the accumulation of breakdown products of the body not processed by the failing liver), ascites which is the accumulation of fluid within the abdominal cavity, a tendency to bleed from the oesophagus due to increased back pressure from the liver (oesophageal varices) and in very severe cases a confusional state caused by the build up of toxic substances with the body ( hepatic encephalopathy). All of these signs occur with significant and advanced liver disease. Some conditions such as an acute viral infection of the liver such a Hepatitis A may cause jaundice but in most instances the liver recovers spontaneously and would not therefore qualify for a benefit as the condition is neither progressive or irreversible. The same can be said for gallstones causing jaundice. Symptoms experienced by patients with advanced liver disease include loss of appetite, weight loss, lethargy, a swollen abdomen from ascites, easy bruising, itching and in very severe cases bleeding from the oesophagus and confusion.

Causes

Cirrhosis of the liver is the main cause of liver failure. Cirrhosis is a term used to describe irreversible chronic injury to the liver that causes alteration to the structure and functioning of the liver (fibrosis and nodule formation).There are numerous causes of cirrhosis of the liver including the following:

• Chronic alcohol abuse
• Infections such as Hepatitis B or Hepatitis C
• Obstruction to the bile tracts (Biliary cirrhosis)
• Drugs and toxins
• Heart Failure
• Rarer genetic conditions such as haemochromotosis or Willson's disease

The most common causes of liver failure in South Africa are alcohol abuse and infections such as Hepatitis B or C. Cancer can obviously also cause liver disease but it is more likely that a claim would fall under the cancer benefit rather than the liver benefit.

Diagnosis

A diagnosis of liver failure can be made clinically from the symptoms and signs present in a patient. Blood tests are used to record the severity of the liver failure and to screen for causes of liver cirrhosis such as Hepatitis B or C. Imaging such as ultrasound, computerised tomography (CT) scanning or magnetic resonance imaging (MRI) scanning are also used as well as gastroscopy to assess for oesophageal varices. In some instances a biopsy of the liver may be necessary but this is not without risk to the patient. Insurance companies will not insist on a biopsy report but would need a report from a specialist physician confirming the presence of the symptoms and signs that would qualify the insured to claim under this benefit.

Treatment

Unfortunately once a person has progressed to the stage of advanced liver failure treatment is mostly supportive. In certain cases liver transplantation is a possibility but a shortage of donor organs, the cost involved, and the lack of resources limits this option. In the case of alcoholic cirrhosis, abstinence from alcohol will be beneficial. In those patients who continue to drink only 50% will live longer than five year. There have been significant advances in the treatment of liver disease due to Hepatitis C by the use of a drug called Interferon. Response to treatment is however more likely in early stages of the disease rather than when they have reached the stage of cirrhosis.

Tiering of benefits

As mentioned tiering of benefits for liver disease is limited. Most, if not all companies will pay 100% of the benefit for end stage liver failure and 100% for liver transplants.. One company has a 75% payment for advanced liver disease and one company pays 75% for surgical intervention for sclerosing cholangitis which is a rare condition. Benefits for partial removal of a liver are also available. The most common reason for this would be to remove a localised tumour. Obviously if the tumour was cancerous then any company would pay out under the cancer benefit in this instance.

Underwriting of liver disease

Pre-existing liver disease at the application/underwriting phase will likely lead to at least a loading for life and/or living benefits, and if severe enough could lead to some benefits being declined altogether.

Contractual requirements for a claim

In all instances a report from a specialist physician will be required to confirm the diagnosis of advanced or end stage liver disease. A report from the attending surgeon will be required in the event of a liver transplant.. It is usually an industry standard that if the cause of end stage liver disease is due to alcohol or drug abuse then the claim will not be paid. As with all cover, it is advisable to read the exclusion clauses relating to the benefit being sold.

Event relationship to Product benefits:

Liver disease that results in the death of an insured will result in the claim being admitted.

Liver disease that has progressed to reach a point where the claimant has functional impairment causing an inability to perform their own (or suited) occupation will have grounds to submit a claim for consideration. The degree of progression of disease and impairment, verse the occupation will determine the success of the disability claim.

If the liver disease fits the required definition for cancer, liver transplant, liver failure or other defined liver disease, then a claim will be paid at the prescribed level

If the liver disease fits the required definition for cancer, liver transplant, liver failure or other defined liver disease, and the level of functional impairment described is met, then a claim will be paid at the prescribed level

This is a group of progressive neurological disorders whereby nerves that supply various muscles are affected causing loss of function in voluntary muscle control like swallowing, speaking, walking or breathing. The motor neuron group of diseases include amyotrophic lateral sclerosis, progressive muscular atrophy, spinal muscular atrophy, primary lateral sclerosis, progressive bulbar palsy and well as others.

Pathology:

Upper motor neurons are nerves that descend from the motor cortex (area in the brain that controls muscle function) to the spinal cord, whilst lower motor neurons are nerves that run from this area in the spinal cord to muscles, thereby initiating action. In motor neuron diseases either both upper and lower motor neurons or either one are affected causing inability of these nerves to act. A cause for this is unknown, although in 5% to10% of cases a genetic link is present. If only lower motor neurons are affected then the muscles atrophy or waste away and become floppy and if only upper motor neurons are affected then the muscles become spastic (stiff) causing twitching and overactive reflexes and abnormal movements. The most common motor neuron disease is amyotrophic lateral sclerosis that affects both groups of motor neurons.

Incidence

Most countries in the world have an incidence of MND of three to five per 100 000 people with a 20% increased incidence in males. Average survival once diagnosed with MND is three to five years with only 10% surviving more than 10 years. Stephen Hawkins, however, has lived with his motor neuron disease since 1963, but this is one of the few documented cases.

Signs and Symptoms

As described above, there is either a muscle weakness or stiffness depending on which motor neuron is affected. The symptoms normally occur gradually and can remain static affecting one specific region only, for example a limb, or can progress throughout all muscle groups eventually leading in death once the muscles of respiration are compromised. Some atrophy does occur in the brain tissue itself and in 33% to 50% of patients, cognitive functioning is affected. Depression occurs in about 5% to 20% and sensation, especially increased sensitivity to touch and heat, affects only 10% of sufferers.

Diagnosis

Diagnosis is difficult and is normally made by clinical suspicious and exclusion of other conditions. Occasionally electromyography can be useful in showing decreased nerve action in certain groups of muscles.

Treatment

There is no cure for MND. A drug called riluzole is used to increase lifespan, but is only effective for 15 to18 months. Treatment is therefore supportive and palliative.

Underwriting

Clients who present to a life insurer with MND will either be offered an exclusion, severe loading or declined depending on the progressive nature of the disease and areas affected. Most would be declined cover.

Claims

To successfully claim for MND, evidence from a neurologist showing the specific diagnosis would need to be given. There would also have to be no evidence of non-disclosure.

Event relationship to product benefits

Initially payout would be dependant on the areas affected and the impact on ability to earn an income. With progression of the disease, nearly all MND sufferers would have a valid capital disability claim

Due to the severe nature and poor prognosis of this condition, nearly all insurers that cover this condition, even those with tiered payouts would pay 100% on diagnosis of MND.

These products would pay out a specific percentage based on complications resulting from the MND, for example 50% to 100% for inability to swallow and 25% to100% for loss of speech.

Paralysis is caused by loss of muscle function in a group of muscles due to damage in either brain or spinal cord control of the muscle function. This results in loss of strength in the affected limb or muscle group. Paralysis can either affect an area supplied by only one nerve (facial nerve paralysis) or a whole section of the body. The following describe paralysis of a whole section of the body:

• Monoplegia . paralysis of one limb.
• Diplegia . paralysis of two limbs on the same side of the body (e.g. left arm and left leg).
• Hemiplegia . paralysis of the whole of one side of the body.
• Paraplegia . paralysis of both legs and the trunk.
• Quadriplegia . paralysis of all four limbs and the trunk.

Periodic paralysis can occur in some inherited disorders where the muscle weakness comes and goes.

Pathology

Muscle function is dependant on correct signals reaching the spinal cord from the brain (upper motor neuron) and then signals leaving the spinal cord and innervating the muscle or muscle group (lower motor neuron). If upper motor neuron pathways are interrupted, spastic paralysis occurs with resulting stiffness of muscles affected and if lower motor neurons are affected, flaccid paralysis occurs with weakness of muscle groups. Regrowth and regeneration of nerves can occur resulting in some strength returning to previously paralysed muscles. Peripheral nerve destruction can also cause a muscle to atrophy and become weak. Upper motor neuron interruption occurs with brain damage which is results from . stroke, tumours, trauma, multiple sclerosis, cerebral palsy or metabolic disorders causing death of brain tissue. Lower motor neuron or spinal cord causes include . trauma (the highest case of paraplegia and quadriplegia); tumours, herniated or ruptured discs; spondylosis (stiffness of spinal joints), Rheumatoid arthritis of the spine; neurodegenerative diseases resulting in nerve cell damage; multiple sclerosis. Peripheral nerve damage can be caused by . trauma; compression or entrapment e.g. carpal tunnel syndrome; Guillaine-Barre syndrome (nerve disease following a viral infection); radiation; chronic inflammatory demyelinating polyradiculoneuropathy (pain and swelling in the protective sheath around the nerves); toxins or poisons; or inherited demyelinating diseases (refer motor neuron diseases).

Incidence

Incidence is dependant on the cause - refer to various sections for disease incidence rates. The incidence of spinal cord injury (paraplegia and quadriplegia) in the US is 40 cases per million with the age group most affected between 16 and 30 years.

Signs and symptoms

These will be dependant on whether the brain, spinal cord or peripheral nerves are affected. Brain damage often results in widespread paralysis e.g. hemiplegia or diplegia; whereas paraplegia is often as a result of damage to the lower spinal cord and quadriplegia due to damage to the upper spinal cord (neck). Weakness and paralysis in only the arms and legs may be due to a demyelinating disease and monoplegia due to a peripheral nerve injury. Periodic paralysis can occur with conditions such as multiple sclerosis. Sudden onset paralysis is associated with either an injury or stroke, whereas progressive paralysis is normally due to chronic neurological disorders. Other than either weakness or spascity in a muscle group, paralysis can often also be accompanied by pain, numbness, tingling, and if the brain is affected . changes in vision, speech difficulty, problems with balance. Spinal cord damage may also result in loss of bladder or bowel control and decreased functioning of sexual organs. Quadriplegia can also be associated with breathing difficulties.

Diagnosis

As with all neurological disorders, the patient history and examination are the most important and might indicate the area affected e.g. sudden onset of hemiplegia with headache might indicate a stroke. Investigations done are normally a CT scan, MRI scan, myelography or electromyography . the latter two to assess nerve and muscle function in the spinal cord and locally.

Treatment

Treatment is focussed on the underlying cause, although most conditions causing paralysis are not treatable. The mainstay of therapy is therefore focused on rehabilitation using physical therapy, occupation therapy or more specialised therapies e.g. speech therapy.

Underwriting

This will be determined by the cause of the paralysis and often terms may not be given at all. There is a high risk of complications from paralysis, especially paraplegia or hemiplegia e.g. sepsis or kidney failure. Benefits might be declined and a heavy loading applied to life cover, but these cases will be assessed individually. If the paralysis is due to a nerve injury in a specific muscle, then more favourable terms can be given and possible an exclusion placed on the affected area.

Claims

Confirmatory evidence of the loss of function together with the underlying cause would be required by most companies. Occupational therapy assessments might be requested by companies whose capital disability product is linked to occupation.

Event relationship to product benefits

Death would most commonly be due to the underlying cause of the paralysis. Complications such as septicaemia and renal failure might also result in death. Death claims would be honoured.

Occupationally based capital disability products would require job evaluation to assess whether the particular type of paralysis affects the ability to perform the client's specific occupation. Other disability products might pay out a capital disability claim based on the confirmed diagnosis of a specific area of paralysis.

The majority of companies will pay a 100% benefit for paraplegia, quadriplegia, diplegia or hemiplegia and a lesser percentage for monoplegia or other type of paralysis.

These products would pay out a specific percentage for the area of the body affected and with certain companies, the number of limbs affected e.g. 25% per leg.

Parkinson's Disease (PD) is a degenerative disorder (an accelerated ageing) of the brain characterised by:

• Slowness of movement (bradykinesia)
• Tremor at rest
• Rigidity (stiffness of limbs and back)
• Shuffling gait
• Flexed posture

Causes

The vast majority (about 75%) of PD occurs sporadically and occurs with no identifiable cause. About 25% are inherited and a small percentage may be caused by drugs, strokes or reduced blood supply to the brain. The genetic version typically presents at younger ages (younger than 50), whereas most other cases present in the age group over 60 (range 35 to 85). Risk factors include a positive family history, male gender, head injury and exposure to pesticides.

Diagnosis

The diagnosis is confirmed by a neurologist, usually when two of the following three symptoms are apparent:

• Tremor at rest
• Rigidity
• Bradykinesia (slowness of movement)

The symptoms usually present on one side only and progress slowly. Tremor is present in 85% of patients. Other well-known features include a masked face with very little facial expression, decreased eye blinking, stooped posture and decreased arm movement. The tremor typically starts in one hand with a .pill-rolling. action and spreads up in one arm before starting in the other arm. Eventually the legs, lips and tongue are also affected. The rigidity (stiffness of limbs and back ) and slow movements affect all aspects of daily living including walking, rising from a chair, dressing, and so on. Other features include soft speech, depression, anxiety, memory loss, sleep disturbances, loss of smell, excessive sweating, constipation, and balance difficulties.

Treatment

The condition is incurable; therefore the goal of treatment is to maintain function and quality of life. This is done by medication (dopaminomimetic drugs), physical exercise and stimulating mental activity. The main symptoms (tremor, stiffness, slow movements) respond well to medication, but less success is obtained with the memory and balance difficulties. Over the last decade a number of new operations have proven successful in the treatment of PD. These usually entail a very precise excision or burning under guidance of CT scanning of the problematic areas within the brain. Not all patients are suitable for surgery, and very specific criteria exists for these operations.

Contractual requirements for a claim

In general only the more severe forms of PD will qualify for a claim, i.e. the disease must have progressed to a level where significant impairment in activities of daily living (ADL) is obvious. ADL include food preparation, house maintenance, eating, dressing, bathing, and shopping. Activities of daily living refer to the ability to prepare food, eat, speak, dress, bath, and care for oneself. The length of this list, as well as the number of activities that a claimant should be unable to do vary from one company to another. In general terms the CI benefits are aimed at the person that needs daily assistance, i.e. someone who cannot care for him/herself. Most contracts require the inability of three or more activities of daily living. The percentage of the insured amount payable also varies between different contracts, ranging from 40% to 100%. It is therefore essential that a potential client reads the benefit descriptions prior to purchasing any product to ensure that he/she understands the level of cover provided for PD, and the number of ADL's required for a claim.

Prevalence and Incidence

Comparison of these rates internationally are difficult due to differences in:

• Case definitions
• Diagnostic criteria
• Classification
• Age distributions of the populations
• Environmental risk factors

It is evident that China, Japan and Africa have the lowest prevalence ratios, although experts agree that these figures are generally under reported due to many undetected cases. South African data is unreliable. In Europe the overall prevalence are the following per age group

Prevalence is similar in men and women.

Underwriting

A person with Parkinson's disease applying for risk cover is unlikely to qualify for any product other than life cover, purely on the basis of his/her age. Life cover will generally be granted with a premium loading as the life expectancy is curtailed. In the rare cases where the disease occurs in a younger person, disability functional impairment, critical illness cover will be declined or at best be accepted with exclusion.

Claims

Parkinson's is not a direct cause of death. It can indirectly lead to a shortened life expectancy due to poor mobility and associated complications.

The likelihood of a successful disability claim is good, provided that appropriate treatment cannot control the symptoms sufficiently to render the client able to do his/her work.

The inability to walk, eat, dress and talk in advanced cases will lead to successful FI claims.

Not all CI products cover Parkinson's disease. Those that do, rely on impairment of Activities of Daily Living to assess claims. It will therefore also admit claims for advanced stages of the disease.

Stats on paid CI claims for PD are not available.

Peripheral arterial (vascular) disease includes both coronary artery disease and peripheral arterial disease, which may affect the abdominal aorta and its major branches as well as the arteries of the legs. Most people with peripheral arterial disease have atherosclerosis, where fatty material (plaques) accumulates under the lining of the arterial wall thereby narrowing the artery. Partial or complete occlusion of an artery can result from a blood clot forming on a plague. The part of the body supplied by the occluded artery will not receive enough blood resulting in a decrease in oxygen supplied and even death of the tissue. Risk factors include smoking, obesity, high blood pressure, high cholesterol levels, and diabetes.

Symptoms

The presenting symptom is pain in the calves after walking a short distance, which subsides with a short rest. As the obstruction increases, symptoms become more severe. Pain comes on faster and is more severe when the person walks quickly or uphill. This is called intermittent claudication. As the disease gets worse, the distance the person can walk without pain gets shorter and eventually there will be pain when resting. Severe obstruction can cause tissue death gangrene. Arterial embolism (when a clot is carried by the blood stream and lodges in an artery) may cause sudden occlusion of a blood vessel or an artery.

Diagnosis

When an obstruction is suspected based on the symptoms, clinical examination will detect signs of ischaemia, such as coldness, changes in hair and nails or ulceration. Feeble or absent pulses below the obstruction can be found on examination. The diagnosis may be confirmed with Doppler ultra sound or colour Doppler. Angiography, an X-ray examination of the blood vessels, will show the diameter of the artery and any obstruction.

Treatment

Conservative treatment will include lifestyle changes such as the introduction of an exercise programme and the stopping of smoking, in addition to drug treatment. Angioplasty may be applied whereby a catheter with a balloon on its tip is inserted into the narrowed part of the artery. The balloon is then inflated to clear the obstruction. If the disease is widespread, surgery might be necessary. A bypass graft is performed where synthetic material or a vein from another part of the body is joined to the obstructed artery above and below the obstruction. In the case of worsening gangrene, amputation of the affected part may be necessary.

Insurance cover under critical illness benefit

Various levels of payment are offered depending on the specific treatment required for example angioplasty, stenting, endarterectomy or bypass surgery. Other criteria used are symptoms persisting despite optimal treatment, intermittent claudication (pain in the calf or thigh muscle that occurs after you have walked a certain distance) and/or ulcers, persistent rest pain, gangrene or loss of limbs due to arterial disease. Some products also offer partial payment for symptomatic internal carotid artery narrowing requiring intervention.

Pulmonary embolism is an obstruction in the pulmonary artery or one of its branches, and can be caused by a thrombus (clot), air, fat, malignant material or a foreign body. It is the third leading cause of cardiovascular mortality and predisposing factors include:

• Prolonged bed rest due to illness.
• Prolonged sitting in an airplane.
• Heart failure.
• Immobilisation due to a fracture.
• Coagulation disorders resulting from polycythaemia (too many red blood cells) or oral contraceptives.
• Trauma.
• Post surgery.
• Pregnancy.
• Malignancy.

Causes

A thrombus or clot usually forms in the deep veins as a result of damage to the vessel wall, stasis (the normal flow of blood stops) or increased coagulation (clot formation). A piece of the thrombus breaks off and is now called an embolus. The embolus travels from the deep veins (condition is called deep vein thrombosis), to the heart and then to the lungs where it lodges in the pulmonary artery or in one of its branches. In the lung it can block the flow of blood resulting in one of the following:

• Death of lung tissue (infarction).
• Decreased oxygen to lungs and other organs.
• Death of the individual.

Symptoms

• Sudden, unexplained shortness of breath.
• Sharp chest pain . especially on inhaling or coughing.
• Coughing up blood stained sputum.

• Rapid pulse.
• Rapid breathing.
• Feeling faint.
• Sweatiness.
• Sudden anxiety or feeling of doom.
• Blue colouration of skin (cyanosis).

Persons at risk

• Someone who has experienced previous embolisms.
• People older than 60 years.
• Obese people.
• Pregnant women.
• Smokers.
• People suffering from cancer.
• People with a clotting disorder.

Treatment

Principal treatment consists of intravenous anti-coagulation treatment, followed after four to five days by oral treatment. Patients may also receive a Vena Cava filter, a cone shaped device that is usually implanted in the inferior vena cava, a large vein that drains the lower part of the body. This filter prevents clots from travelling up to the heart and lodging in the lung, while allowing blood to flow freely through it. With the passing of time these clots are broken down by the body and dissolved so that they cannot harm the body. This procedure is said to be very safe, takes about half an hour to be done and is effective. Surgical removal of an embolus can be done in the case of very large emboli, but is associated with a high mortality rate of 30%.

Prognosis

In survivors, the prognosis depends on predisposing risk factors such as malignancy, obstructive airways disease, poor mobility and so on. Untreated cases have a mortality rate of 30%, while treated cases may have a mortality rate as high as 10% due to recurrent emboli or associated disease. Secondary pulmonary hypertension reduces life expectancy.

Benefits

Most companies cover pulmonary embolus under their severe illness benefits. Severity levels range from 25% to 30% of the cover amount.

Underwriting of Pulmonary Embolus

A past history of pulmonary embolism will in most cases have a minimal bearing on the resultant benefits applied for except for severe illness where an exclusion is likely to be applied. In certain instances there are pre-disposing factors that will have lead to the pulmonary embolus. In these cases benefits are likely to be declined or loaded depending on the cause and any resultant complications. Recurrent pulmonary embolus will lead to most benefits being declined altogether.

Contractual requirements for a claim

A report from a specialist physician or consultant pulmonologist is a prerequisite in all cases together with radiological or ventilation/perfusion scan evidence of the event.

Chronic renal failure (also known as end stage renal disease, kidney failure, chronic renal failure, or uraemia) is the end process by which the damage caused by disease to the structure of both kidneys is no longer reversible and leads to progressive destruction of the internal renal structures (nephrons). Glomerulonephritis, caused by infection, was for many years the leading cause of renal failure, but since the early 1980's with better treatment of this disease, [diabetes] and hypertension have taken over as the two leading causes. Expressed as a percentage the causes are as follows:

• Diabetes 34%
• Hypertension 25%
• Glomerulonephritis 16%

In terms of risk factors these would be as per those for diabetes and hypertension.

Symptoms

The symptoms, which can be multiple and vary greatly, ultimately affect every organ of the body. The onset is slow with a gradual increase in fatigue (tiredness) which is a common main symptom. The main cause of the symptoms is a rise in blood urea (waste product chemical produced by the body) as a consequence of the urea not being excreted via the kidneys. This is accompanied by a rise in another chemical usually excreted by the kidney, creatinine.

Diagnosis

The diagnosis is based on the following criteria:

• History and clinical examination
• Blood tests, crucially measuring urea and creatinine
• Urine tests for protein
• Glomerular filtration rate (GFR) . measure of the rate of excretion of renal chemicals
• Pyelogram . XR dye test to visualise the kidneys and renal system
• Renal biopsy

Treatment

Treatment for renal failure is either by dialysis or kidney transplant. Two main types of dialysis are used, either haemodialysis or peritoneal dialysis. Haemodialysis is the process whereby unwanted substances are removed from the body and replaced with desirable substances using the blood system. Blood is diverted from an artery in the arm, run through a filter machine and the desirable cleansed blood is then returned to the body via a vein in the arm. On average patients require six to nine hours of dialysis per week. Peritoneal dialysis is in essence the same concept of filtering the unwanted substances out, but the peritoneal fluid (fluid in the abdominal cavity) is used. Here a catheter is inserted into the abdomen and this is the fluid transfer medium.

Prognosis

The prognosis of renal failure is very variable and is dependent on multiple factors. These relate to how well controlled the underlying condition is, access to dialysis and the response and compatibility of the kidney transplant, should this option be used.

Severity levels

Renal failure is a severe illness with a very significant impact on the lifestyle of the patient. The very fact that to qualify for this benefit the insured must have attained the point at which dialysis is necessary, implies the severest level has been reached. For this reason, this benefit always pays 100% of the contractual insured amount no matter what policy type is applicable.

The inclusion of respiratory disorders in critical illness products varies considerably amongst different products as well as different product options. Generally chronic respiratory failure due to a lung or respiratory disease is covered under most products and results in a 100% payment. Some, but not all, products also require that the respiratory failure should lead to a lung transplant.

[Chronic respiratory failure]

Respiratory failure is a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide becomes dangerously high. Respiratory failure results from an inadequate exchange of oxygen and carbon dioxide between the lungs and the blood or from inadequate ventilation of the lungs.

Causes:

• Chronic airway obstruction like chronic bronchitis (airflow obstruction due to inflammation of the small airways)

• Emphysema (destruction of the alveoli)

• Bronchiectasis (chronic dilation of the airways due to inflammatory disease)

• Cystic fibrosis (an inherited disease resulting in the production of abnormal secretions of glands, which in the lungs leads to clogging of the airways and infections)

• Chronic uncontrolled asthma

• Muscle weakness for example muscular dystrophy (a group of congenital muscle diseases leading to muscle weakness)

• Stroke

• Spinal cord injury

• Abnormality of lung tissue for example pulmonary fibrosis (inflammation of the lung tissue resulting in extensive scarring of the lungs)

• Widespread tumours, radiation, and sarcoidosis (a disease where abnormal collections of inflammatory cells form in the lungs and other tissues)

• Abnormality of the chest wall for example severe kyphoscoliosis (a deformity of the spine that reduces the space left in the chest cavity for the lungs)

Severity levels

Usually a 100% payment is granted for chronic respiratory failure or a lung transplant. Respiratory disorders are not covered under dread disease products offering only core benefits.

Prevalence

One thousand four hundred to one thousand five hundred lung transplants are performed worldwide each year. Compared to the other major critical illnesses, lung transplants are therefore not very prevalent. The majority (78%) are performed for chronic obstructive pulmonary disease and pulmonary fibrosis. Comprehensive dread disease policies pay a potion of the sum assured for removal of a lobe of a lung (a portion of one lung) or removal of one lung.

[Pulmonary Embolism]

Pulmonary embolism is the sudden blocking of an artery in the lung by an embolus, usually a blood clot originating from a blood clot in the deep veins of the legs. Some dread disease policies pay a smaller percentage for an uncomplicated single episode of pulmonary embolism and a bigger percentage for recurrent pulmonary embolism where a filter is inserted into the vein draining blood to the heart. Pulmonary embolism is normally confirmed with a ventilation-perfusion scan. This test involves the administration of a radioactive marker intravenously (in the veins) and through inhalation. The lungs are then viewed through a gamma camera. Areas where the blood supply has been interrupted can be identified and is diagnostic of pulmonary embolism.

[Lung Abscess]

Some Dread Disease policies pay a small percentage of the sum assured in the event of a lung abscess (a pus-filled cavity in the lung, caused by an infection and treated by draining it surgically).

[Empyema with Drainage]

Pus in the space between the two layers of the membranes (pleurae) around the lung is called empyema. Some Dread Disease policies pay a small percentage of the sum assured in the event of empyema needing drainage.

[Irreversible Cor Pulmonale]

Cor pulmonale is defined as the enlargement of the right lower heart chamber and subsequent heart failure due to abnormalities of the lung, thorax, ventilation of the lungs or blood circulation of the lungs. Heart failure means that the heart can no longer pump efficiently and leads to poor circulation, shortness of breath and swelling of the feet. Causes of chronic cor pulmonale include recurrent pulmonary embolism, chronic inflammation of the lung's blood vessels and primary pulmonary hypertension (raised blood pressure in the arteries of the lung). The development of heart failure due to lung disease reflects the seriousness of the underlying lung disease and has a poor prognosis. Some policies pay 100% of the sum assured for irreversible cor pulmonale.

[Pulmonary Venous Occlusive Disease]

[Status Asthmaticus]

Status asthmaticus is a severe form of asthma where severe airway obstruction lasts for days and does not respond to optimal therapy.

[Fibrosing Alveolitis]

This is scarring of the tiny air sacs of the lung due to inflammation. Comprehensive dread disease policies pay a small percentage for this condition.

[Near Drowning]

Near drowning requiring ventilation in an intensive care unit for longer than 24 hours results in a partial payment under comprehensive dread disease policies.

[Broncho-pleural Fistula]

This condition normally occurs after chest surgery where there is communication between a bronchus (air way) and the pleural cavity (the space between the two layers of the membrane surrounding the lung). This may lead to blood stained sputum being coughed up and to collapse of the lung. Fistulas are repaired surgically. Comprehensive dread disease policies pay a portion of the sum assured.

[Pneumoconiosis]

This is an occupational lung disease where a person inhales harmful particles such as asbestos, coal dust, silica or other particles causing lung damage and scarring. Comprehensive dread disease policies pay a portion of the sum assured for these conditions.

Sarcoidosis, also known as sarcoid or Boeck's disease, is a multi-system, auto-immune disease in which abnormal collections of inflammatory cells (non-caseating granolomas) form in many organs of the body. It is a systemic granulomatous disease especially involving the lungs but can also affect skin, liver, spleen, eyes, bones, brain, parotid glands and other soft tissue organs. Sarcoidosis is not contagious and the onset may appear without any symptoms. This condition develops predominantly between the ages of 20 and 40 and is most common among Swedes and American blacks, although it can occur in anyone.

Causes

The cause of sarcoidosis is unknown. It may result from infections or from an abnormal response of the immune system. Inherited factors may be important.

Description

Sarcoidosis is characterized by the presence of collections of inflammatory cells (granulomas) mainly in the lungs. It usually affects young adults. About 10 to 20% of patients with sarcoidosis go on to develop progressive fibrosis with damage to the lungs, eyes, heart or nervous system. In over 50% of cases, the disease has a mild onset and develops slowly over a two to three year period. Spontaneous improvement and clearing is common, but in some patients there is high risk of progressive lung disease and gradual development of right heart failure ([cor pulmonale]). Hypercalcaemia (too much calcium in the blood) is a rare finding in sarcoidosis, but if left untreated is associated with progressive renal failure.

Extrathoracic (outside the chest) involvement occurs in the following organs:

• Liver: in up to 50% of cases of sarcoid, granulomata are seen on liver biopsy.

• Skin: rashes on the face or on the lower legs occur in 25% of patients.

• Nervous system: about 5% of patients may have neurological involvement with facial nerve palsy being the most common. Virtually any part of the nervous system may be affected though causing a variety of symptoms.

• Eyes: ocular involvement occurs in about 20% of patients, usually as a uveitis (inflammation of the middle layer of the eye), which may progress to blindness. Conjunctivitis may occur.

• Cardiac: there may be involvement of the heart in 10% of cases.

• Endocrine: hypercalcuria (high levels of calcium in the urine) occurs in many cases, although hypercalcaemia is present in only about 10% of cases.

• Musculoskeletal system: arthralgias and/or arthritis occur in between a quarter and half of patients often of a migratory nature affecting large joints.

• Bone cysts may be noted on X-ray.

• Lymphatic system: in addition to hilar lymphadenopathy (enlarged lymph glands in the chest), extra-thoracic lymphadenopathy may occur.

• Kidney: renal involvement is usually asymptomatic, but renal stones may develop.

Symptoms

Patients with asymptomatic sarcoidosis are usually diagnosed incidentally after a chest X-ray demonstrates disease in the lymph glands or lungs. However, most people with sarcoidosis present to their doctors with non-specific, generalised symptoms, including fatigue, malaise, loss of appetite, weight loss and fever. Most develop minor symptoms that do not progress. Serious symptoms are rare. Other symptoms relate to the organs that are affected by the granulomas, with over 50% of patients presenting with ongoing respiratory symptoms. These depend upon the organs affected and can include muscle and joint pain, arthritis, breathlessness, eye inflammation, enlarged lymph nodes in the neck and elsewhere, a bruise-like rash on the lower legs, a purplish rash on the face, and areas of numbness.

• An acute (quick onset) disorder with skin rashes and/or an abnormal chest x-ray in a young adult.

• An insidious presentation (spreading in a subtle manner) with chronic cough, progressive dyspnoea (shortness of breath) and signs of extra-pulmonary disease.

Diagnosis

Treatment

There is no treatment that appears to alter the natural history of sarcoidosis. Corticosteroids suppress inflammation and disease activity in the short term, but may need to be used long-term if the disease is of the chronic type. At least 50% of patients do not require steroids. The use of corticosteroids suggests more severe disease. Indications include uveitis, hypercalcaemia, nervous system involvement, cardiac disease, progressive pulmonary disease and disfiguring skin lesions. People who have no symptoms should not take corticosteroids. Although corticosteroids control symptoms well, they do not prevent lung scarring over the years. About 10% of those who need treatment fail to respond to corticosteroids and are switched to chlorambucil or methotrexate which may be very effective. Hydroxychloroquine is sometimes helpful in eliminating disfiguring skin lesions. The success of treatment can be monitored with chest x-rays, CT, pulmonary function tests, and certain blood tests like measurements of calcium or angiotensin-converting enzyme levels. These tests are repeated regularly to detect relapses after treatment stops.

Prognosis

About half of all patients do not require corticosteroids and the disease eventually remits. Sarcoidosis improves or clears up spontaneously in nearly two thirds of people with lung sarcoidosis. The course can be chronic or progressive in 10% to 30% of people. Serious involvement outside of the chest (for example, of the heart, nervous system, eyes, or liver) occurs in 4% to 7% of people at the beginning of their illness; the chance of involvement outside of the chest increases if lung disease persists. People who have sarcoidosis that has not spread beyond the chest do better than those who also have sarcoidosis elsewhere in the body. People with enlarged lymph nodes in the chest but no sign of lung disease have a very good prognosis. Those whose disease began with erythema nodosum (skin rash on legs) have the best prognosis. About 10% of people with sarcoidosis develop a serious disability from damage to the eyes, respiratory system, or elsewhere.

Benefits

Benefit payment depends on the severity and complications of the disease and may range from 5% to 100%. Many of the benefit conditions will be described under different headings depending on what part of the body is involved in Sarcoidosis.

Underwriting of Sarcoidosis

Pre-existing sarcoidosis and its complications will lead to a range of underwriting decisions from standard rates to decline. The final decision will depend on the stage of the disease as well as the outcome of treatment.

Contractual requirements for a claim

A report from the treating specialist will be necessary to assess all claims.

This is an opening surgically created through the neck into the trachea (windpipe). A tube (tracheostomy tube) is placed into the opening to maintain an airway and also to allow a passage to clear secretions from the lungs./

Procedure

The procedure is normally done under a general anaesthetic under controlled conditions, or after a patient is sedated in the emergency situation. The neck is cleaned and a surgical cut made into the space between the cartilage rings in the trachea or in the emergency setting, in the cricothyroid membrane. A tracheostomy tube is then inserted and sutured in place.

Indications

Tracheostomies are performed because there is insufficient air getting to the lungs through the upper airway system due to various causes which include: an inherited abnormality of the larynx or trachea; severe neck or mouth injuries; inhalation of corrosive material, smoke or steam; large object blocking the airway above the tracheostomy cut; paralysis of the muscles that affect swallowing due to disease or coma.

Complications

The main complication from having a tracheostomy, especially a long term one, is tracheal scarring or erosion. The latter often then constricts the trachea further, resulting in a long term tracheostomy being inserted.

Underwriting

A short term tracheostomy insertion that has healed with no complications would result in standard rates for critical care. Long term tracheostomy insertion would be rated for the cause of the tracheostomy insertion.

Claims

Proof of tracheostomy would need to be provided by the specialist who performed the procedure. Reason for tracheostomy would also be requested as this might result in a higher payout under another system like cancer.

Event relationship to product benefits:

An unsuccessful tracheostomy could result in death . these claims would be honoured.

The tracheostomy procedure in itself is unlikely to result in a disability claim. The underlying disorder that warranted the procedure might result in disability, however.

As the tracheostomy is generally a low complication procedure, the severity rating for this is low (10% to 25%) in the companies that cover this for critical illness. Causes for the tracheostomy like cancer of the larynx would be covered under the cancer benefit at the severity rating appropriate to that cancer.

Tracheostomies are generally not covered under this benefit

Ulcerative colitis is characterized by episodes of cramping, abdominal pains and diarrhoea which is often bloody. A small percentage of patients complain of bleeding or diarrhoea alone. Fever and weight loss are present in approximately one-third of patients and 15% to 25% may also have signs of the disease in their eyes (inflammation), joints (arthritis) and/or skin (erythema nodosum). An initial attack of ulcerative colitis typically has a longer period of active disease than acute infectious diarrhoea. The disease is usually restricted to the large bowel (colon). The inflammation always begins in the lower part of the colon and gradually spreads upward. In mild disease there is redness and swelling of the inner lining (mucosa) of the colon. In moderate to severe disease there is varying degrees of ulceration of the mucosa of the colon from which bleeding may occur. In patients with longstanding ulcerative colitis the colon loses the normal folds and has a flaccid, featureless appearance. Complications may include:

• Toxic enlargement of the large bowel (mega-colon). This is a rare but life-threatening form of ulcerative colitis and manifests with a high fewer, high pulse rate, abdominal distension. A blood sample will show a high white cell count and X-rays of the abdomen will show a severely distended bowel. This occurs in less than 2% of patients.

• Perforation of the large bowel which leads to a high probability of dying.

• Scarring with restriction of the bowel, an uncommon complication rarely seen.

• Massive bleeding. This is a rare complication but usually requires emergency removal of the large bowel.

• Cancer. Patients with ulcerative colitis are at increased risk of developing cancer of the large bowel. The duration the disease is strongly correlated with the cancer risk; The longer the disease is presence therefore, the bigger the risk for developing cancer which is reported in 13% of patients after 20 years and 34% after 30 years of ulcerative colitis.

Causes, risk factors, diagnosis

No specific cause has been identified. It seems however that there is a genetic sensitivity for developing the disease. In a person with a genetic sensitivity, other factors like infections and the smoking habit may activate the condition. Stressful situations may also bring on an attack of the disease. The diagnosis is made by a history of an extended period of painful diarrhoea with/without bleeding and by excluding other causes of diarrhoea (particularly infections) and the typical findings when doing an instrumental examination of the large bowel (sigmoidoscopy or colonoscopy). Simultaneously a small piece of the bowel lining is removed (biopsy) for further examination of the inflamed tissue. Supportive evidence of the diagnosis will also be the absence of small bowel involvement.

Treatment and outcome

• 5-Aminosalicylic acid. Treatment with this drug results in symptomatic improvement in 50% to 75% of patients in four to eight weeks and remains the drug of choice. Patients with an allergy to sulpha's cannot use this drug.

• Corticosteroids. These drugs can be used as enemas for limited disease or in the oral form in more severe cases. Steroids clear up active disease in 75% to 90% of cases but should not be used long-term. Complications than may arise with the long-term use of steroids include Cushing Syndrome and osteoporosis. Immunosuppressive drugs. These drugs are indicated when a patient is resistant to or dependant form steroids. These drugs cause suppression of the immune system that may lead to a susceptibility to infections. Taking into account that ulcerative colitis is a surgically treatable condition, it should therefore not be administered for lengthy periods of time.

• Surgical treatment. The indications for removal of the large bowel will be poor response on medical therapy, perforation of the colon or the development of cancer of the colon.

Total remission of disease on treatment is being accomplished in 50% of all cases. Some 24% of patients will end up with a colectomy at 10 years and 30% at 25 years. Some 93% of patients will still have the functional capacity to work after 10 years of disease.

Contractual requirements for a claim

The inflammatory bowel conditions are usually managed quite well with medication for many years (20 years and more). Only in very severe cases do patients become impaired in function affecting their ability to work or to cope with activities of daily living. CI contractual requirements for a claim differ in terms of the severity descriptors and the percentage of sum assured payable. In general terms claims will only be considered for cases where optimal treatment has failed. This usually means that the patient should have significant weight loss (25% or more below desirable weight), evidence of nutritional deficiency and ongoing symptoms despite treatment.

Prevelance of disease/incidence

The incidence varies between different geological areas. Northern countries such as the United States, United Kingdom, Norway and Sweden have the highest rates. A higher prevalence is found in affluent people. Ulcerative colitis also runs in families. If a parent has ulcerative colitis, the risk of a child getting the disease will be 10%. Additional factors that may increase the risk for ulcerative colitis is the use of oral contraceptives. Smoking causes a two-fold increase in the risk of developing the disease.

Underwriting

Life ratings

Factors that may influence the terms offered include:

• Years since diagnosis
• The area of the large bowl involved. (Only left sided disease of the whole colon.)
• Severity of the disease.
• Surgical treatment applied.
• Months since surgery.
• Complications not restricted to the large bowl only.

Terms offered may vary from standard terms to a small loading, or a decline of life cover in severe complicated cases. (Life threatening episodes and/or cancer may emerge with time.)

Disability

Depending on the severity of disease, ratings may vary from a small loading to a decline of benefits in the more severe and complicated cases.

Critical illness

Terms offered may vary form standard terms to a significant premium loading. In the more severe cases a cancer clause will apply.

Claims

Cases of complicated ulcerative colitis ultimately ending in death will qualify for death benefits.

Cases of failed medical and/or surgical treatment may result in functional impairment to the extent that the insured life is unable to engage in the regular and (if contractually required) a reasonable alternative occupation, taking into account his or her education, training and experience, and will qualify for benefits. In order to qualify for permanent benefits, however, all reasonable treatment options must have been applied with no chance of further improvement at which stage a specialist physician will do a functional impairment assessment. A decision on disability will finally be advised by experts on the medical panel of the specific company.

Ulcerative colitis is not covered under the core benefits. Some companies include ulcerative colitis under the comprehensive benefits but only for a small percentage of the insured amount and only if there is objective evidence of severe impairment with regard to the activities of daily living.

Diseases mostly related to the gastro-intestinal tractus rarely cause significant and permanent functional impairment and, although there may exceptions in this regard, are unlikely to qualify for benefits.

Dementia is significant loss of intellectual or cognitive abilities such as memory capacity, severe enough to interfere with social or occupational functioning. Dementia is not temporary confusion or forgetfulness that might result from a self-limited infection, underlying illness, or side effects of medications. Dementia worsens over time. Criteria for the diagnosis of dementia include impairment consciousness and awareness, intelligence, attention, orientation, memory and recall, judgment, problem solving, language, movement skills, and function. Dementia is by definition not secondary to serious mental illness like depression or schizophrenia. Patients with dementia may however have secondary personality, emotional and behaviour problems. The diagnosis is made on the symptoms and absence of other diseases. Psychiatric evaluation and brain scans will be part of the diagnostic process. The ability to perform activities of daily living (ADL), and the level of supervision needed are used to determine the severity level of dementia. Dementia is reported in as many as 1% of adults 60 years of age. It has been estimated that the frequency of dementia doubles every five years after 60 years of age. There are a number of causes of dementia. Alzheimer's disease is the most common form of dementia. Among other causes are medical conditions (thyroid disease, drug toxicity, thiamine deficiency with alcoholism, and others), brain injury, strokes, multiple sclerosis, infection of the brain (such as meningitis), HIV infection, hydrocephalus, drug abuse, brain injuries and brain tumours. Dementia treatment is directed toward the particular underlying cause. Other measures are directed to control the symptoms and prevent progression. It is mostly not curable.

Underwriting

Most cases will be declined, as a contract cannot take place with an individual with limited or no insight into the contract. Rare exceptions will be when recovery took place in cases of dementia with a treatable cause (e.g. exposure to toxins).

Claims:

Death due to complications of dementia will constitute a valid claim. Accidental death policies are excluded.

The level of impairment due to the dementia, will determine if it is a valid claim.

This policy will only pay if dementia is a specific benefit.

Only if dementia is listed as a benefit and the criteria are met, will someone with dementia have a valid claim. Some of these policies may specifically exclude dementia as a benefit.

Complications of dementia might be listed as benefits under policies like physical impairment (for example, confinement to bed or wheelchair).