Neurological Disorders

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Neurological Disorders
Handling claims
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Agenda

• Introduction - claims and underwriting
• Epilepsy
• Multiple Sclerosis
• Stroke
• Head Injury
• Parkinsons Disease

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Introduction

• Why are neurological claims so important
• Out of approximately 2000 claims seen in a 12
  month period by Swiss Re
• 6.5 were attributable to Multiple Sclerosis
• 5.9 were attributable to CVA

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Claims Report 2000 Swiss Re Life Health
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Claims Report 2000 Swiss Re Life Health
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Statutory benefits increasingly expensive

• DLA 1.1m people in 1992 2.1m in 2000
• Cost of DLA 2 billion in 1992 6 billion in
  2000
• Claimants awarded attendance allowance increased
  by 45, and cost doubled 1992-2000
• Too much avoidable physical and psychological
  disablement from lack of rehabilitation services,
  and delayed or ineffective management of
  treatable disease (DLAAB 1998)

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Factors governing benefits

• Offer of rehabilitation to those with DLA is a
  threat to their income
• The money rewards failed function, but does not
  reward functional gains made through
  rehabilitation
• A change of culture is needed benefits should be
  structured to encourage a return to normality, or
  at least to useful function in society.

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Epilepsy - 1st seizure

• Variables Age lt50, nocturnal sz, FH of Ep or
  febrile sz
• no variables 18 recurrence
• one variable 31
• two variables 42
• three variables 60
• At one year after presenting seizure
• Hopkins et al 1988 Lancet

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Multiple Sclerosis
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Diagnosis of Multiple Sclerosis

• A definite diagnosis of Multiple Sclerosis can be
  made if the disease process fits either of the
  following criteria
• (i) Two attacks and clinical evidence of two
  separate lesions OR
• (ii) Two attacks clinical evidence of one lesion
  and paraclinical evidence of another separate
  lesion.
• The two attacks must involve different parts of
  the central nervous system, must be separated by
  a period of at least one month and must each last
  a minimum of 24 hours.
• However, certain historical information may be
  substituted for clinical evidence of one of the
  two lesions.

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Multiple Sclerosis - difficulties in diagnosis

• Fatigue
• Visual disturbances
• Neuralgia
• Neuritis
• Post-viral syndrome
• Transverse myelitis
• Vertigo
• Positive Family History
• Two episodes of neurological symptoms

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Prognostic indicators

• Lesion load on MRI scanning
• Symptoms at onset
• Number of attacks
• Recovery
• Age
• Sex

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Clinical Progression of Multiple Sclerosis
Compston A, Coles A. Multiple Sclerosis. Lancet
April 2002 359 1221-1231
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Multiple Sclerosis
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MRI scan showing typical cerebral multiple
sclerosis
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MRI Scan of spinal cordshows areas of
demyelination
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Multiple Sclerosis -
Claim criteria

• A definite diagnosis by a Consultant Neurologist
  of Multiple Sclerosis which satisfies all of the
  following criteria
• There must be current impairment of neurological
  function, which must have persisted for a
  continuous period of at least six months
• The diagnosis must be confirmed by diagnostic
  techniques current at the time of the claim

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New Diagnostic Criteria for Multiple Sclerosis -
what are the implications for insurers ?
Compston A, Coles A. Multiple Sclerosis. Lancet
April 2002 359 1221-1231
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Daily Mail Wednesday April 17 2002
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New therapies and diagnosis

• Diagnosis is now made earlier
• Beta-interferons modify course and disability
• New therapies are coming
• Diagnosis will be made even earlier in future

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MS risk - familial

• brother 2
• sister 4
• child of conjugal pair 6
• identical twin 25
• non identical twin 3
• sister of MS female 6
• child of MS parent 3

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Risk of MS in Northern Europe

• overall risk 1 600
• child of one affected parent 1 200
• affected sibling 1 40
• child of two affected parents 1 17
• affected identical twin 1 3(age-adjusted
  risks are greater)

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prognosis

• disease less active after 1st year
• early relapsing-progressive course has worse
  prognosis
• generally 2nd year less relapses than first
• patients generally underestimate their disability
• more frequent relapses incur greater lesion load

• relapses more frequent in cases seen at onset
• early progressive course also bad prognosis
• men more active disease than women
• DSS 3 reached in 1.4 yrs
• DSS 6 in 4.5 yrs
• DSS 8 in 24 yrs

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Definition of stroke

• Stroke is defined as an insult to the central
  nervous system on a primary vascular basis.

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Major Blood Vessels of the brain
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Classifying Stroke

• TIA less than 24 hrs deficit
• Lacunar infarction may be small and subclinical
  pontine and capsular lacunes cause symptoms
• Major arterial occlusion
• Intra-cerebral haemorrhage

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Lacunar infarct
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Carotid disease
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Causes of Stroke
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Stroke - relative risk

• Hypertension 4 - 5
• Smoking 1.5 - 3
• Atrial fibrillation 5 - 7
• Diabetes 1.5 - 2
• Alcohol abuse 1 - 4

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Stroke risks (/year)

• Aged gt70y 0.6
• Asymptomatic carotid bruit 1.5
• Asymptomatic carotid stenosis 2
• Atrial fibrillation 5
• AF after minor stroke 12
• Isolated TIA 6
• (12 1st year and 30 at 5 years)
• TIA with carotid stenosis 13
• Previous ischaemic stroke 9

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Aspirin in stroke

• Reduces stroke rate from 10.2/y to 8.2/y (23
  odds reduction)
• Not so effective in absence of risk factors for
  stroke
• AF stroke risk reduced by 70 with warfarin - but
  risky if gt75y
• Carotid endarterectomy - an evolving story

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Increased stroke risk

• Smoking (double)
• Associated with myocardial ischaemia, and cardiac
  arrhythmias (AF)
• Family history of vascular disease
• Hypercholesterolaemia (screen lt45yrs) - MI risk
• Migraine
• Diabetes mellitus (2x)
• Hypertension (linear 4x if diastolic gt 100mmHg)

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Cellular Injury during Ischaemia
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Overall Stroke outcome

• 45 independent
• 25 dependent on others
• 30 dead
• Better outcomes with small strokes, posterior
  circulation strokes, lacunar strokes

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Stroke - rehabilitation

• Can improve disability and handicap, but not
  neurological deficit
• Manage and prevent depression
• Actual benefit of rehabilitation programmes is
  difficult to quantify, because the interventions
  are multifactorial

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Stroke - avoidable disabilities

• Frozen shoulder
• Contractures
• Falls causing injury
• Corneal abrasion
• Pulmonary emboli

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Stroke recovery - better if

• Rapid immediate phase of recovery
• Pure motor stroke
• No speech involvement
• No incontinence
• Younger age
• No cerebellar features
• Never unconscious

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Stroke - claim criteria

• A cerebrovascular accident resulting in permanent
  neurological damage. Transient Ischaemic Attacks
  are specifically excluded.

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Permanent Neurological Damage?

• Confusing term..
• Do we mean permanent neurological disability
• whats the difference
• MRI scanning evidence
• Remember we are insuring the person not the brain
  scan
• Silent infarcts?

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Vermeer et al Prevalence Risk Factors of
Silent Brain Infarcts in the Population Based
Rotterdam Scan Study. Stroke January 2002,
21-25.
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(No Transcript)
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Permanent Neurological Damage?

• Confusing term..
• Do we mean permanent neurological disability
• whats the difference
• MRI scanning evidence
• Remember we are insuring the person not the brain
  scan
• Silent infarct - do not meet claim criteria

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Stroke definitions - problems

• Should SAH be separately insured?
• Is TIA with a small MRI lesion a stroke?
• How long and by what criteria should deficit
  persist?
• The issue of age-related silent infarcts
  resembles silent myocardial ischaemia and should
  be handled similarly
• Brain infarction after brain compression is not
  stroke

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Head Injury

• Implications for TPD and stroke claim
• Outcome after head injury?
• GCS/AIS Score
• Subarachnoid haemorrhage
• Minor head injuries/post concussional syndrome
• Post traumatic stress disorder

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Head Injury Scoring

• GCS (Glasgow Coma Score)

• AIS (Abbreviated Injury Scale)
• AIS 1-2 short period of unconsciousness or
  linear skull fracture
• AIS 3 complex skull fracture or cerebral
  contusion
• AIS 4 prolonged unconsciousness or intracranial
  haemorrhage
• AIS 5 unconsciousness gt 24 hours, diffuse brain
  lesions, or severe mass effect

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Outcome after Head Injury
Masson F et al. Disability and handicap 5 years
after head injury a population-based study.
Journal of Clinical Epidemiology 1997 50 595-601

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Disability rates in patientswith AIS Scores 4
and 5
Masson F et al. Disability and handicap 5 years
after head injury a population-based study.
Journal of Clinical Epidemiology 1997 50
595-601
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5 year death rate followinghead injury
Masson F et al. Disability and handicap 5 years
after head injury a population-based study.
Journal of Clinical Epidemiology 1997 50
595-601
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Epidural Haematoma
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Brain Haemorrhage after backwards fall
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Parkinsons Disease
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Parkinsons Disease

• No test available
• Diagnosis is made on the basis of clinical
  evaluation
• Claim criteria
• Confirmation by a Consultant Neurologist of a
  definite diagnosis of Parkinsons Disease (before
  age ?).
  
  
  Parkinsons Disease secondary to alcohol or drug
  misuse is not covered.
• Implications for TPD - what is occupation?

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Common additional problems in PD

• Loss of manual dexterity
• Depression, hallucinations and dementia
• Falls
• Autonomic Nervous System dysfunction
• Dyskinesias

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The Times Wednesday 17 April
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Related conditions

• Lewy body dementia
• Progressive pseudobulbar palsy
• Cortico-basal degeneration
• Apractic syndromes
• Picks disease
• Other dementias with extrapyramidal signs

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Things to be sure of

• History of the illness
• When was it suspected, and when diagnosed?
• What is the evidence?
• How bad is it? (for TPD, IP)
• Who is giving the information?
• Is there a conflict of interest?

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Implications

• Seek clarity
• Confirm the diagnosis, against the insured
  definition
• Consider non-disclosure as an issue
• Consider the quality of the evidence
• Be fair and consistent

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Neurological Disorders
Michael Swash Royal London Hospital