First published in ITIJ 100, May 2009
Providing travel insurance for someone suffering from cancer requires an in-depth knowledge of their condition. Krish Shastri shares his knowledge and suggests how high street insurers can do more to help cancer sufferers obtain the travel cover they need
Holidaymakers with a diagnosis of cancer are extremely frustrated to find that the travel insurance industry worldwide is generally unwilling to provide cover for their diagnosis. Given the reluctance of insurers to offer cover and faced with repeated declines, many patients – despite being clinically well – are tragically being forced to give up any hope of ever travelling abroad again.
Aware of these difficulties, UK cancer charities such as Cancer Research and Macmillan have voiced concern that cancer patients are being unfairly excluded from travel insurance. To try and assist patients in their search for cover, many UK cancer charities publish lists of companies that may be able to help. However, for those suffering with active, metastatic or terminal cancer obtaining cover for their diagnosis can be an almost impossible task, with patients in this group often being quoted thousands of pounds. Macmillan has documented the case of a 40-year-old man diagnosed with metastatic colorectal cancer, who was quoted over £40,000 by a major UK insurer for a three-week trip to the US.
These problems are encountered by cancer patients worldwide. Recent surveys in Australia, New Zealand, Ireland, Scandinavia and the US have highlighted that cancer patients in these countries report similar difficulties. The national cancer charities in some of these countries also publish lists and provide advice on how to get cover, while patients denied cover in Australia are able to rely on the cancer charities to assist with the registration of a formal complaint with the regulator and, if necessary, issue writs on the grounds of discrimination.
However, the reluctance of insurers to offer cover is understandable and is driven by the fact that of all the medical conditions, deaths from cancer outnumber deaths caused by heart disease, stroke, circulatory disease and respiratory disease combined. Cancer is the UK’s biggest killer, accounting for over a quarter of all deaths. To put this in perspective, an individual in the UK is fifty times more likely to die of cancer than in a road traffic accident. With over 200 different types of cancer, it is also the most complex group of medical conditions, which is further compounded as over two thirds of all cancers are diagnosed in the over 65s – i.e. those who are also more likely to have other medical complications associated with advancing age.
Given the rapid advances in the treatment of cancer, efforts to underwrite cancer conditions are also complicated by the fact that many therapies are experimental and nearly all cancer treatment strategies have a narrow therapeutic index – i.e. a very close tradeoff between therapeutic benefit and toxicity. This means that patients can very often suffer life-threatening complications due to their therapy rather than the cancer. For example, for those on chemotherapy, over a third of hospital emergency admissions are a direct consequence of the treatment itself. To date, cancer travel insurance has therefore suffered from both a high claims frequency and very high claims costs, not only because of the diagnosis, but also due to complications arising from the treatment.
Keenly aware of these complexities and the disproportionate impact on their books, many insurers will not offer cover for cancer. Even those individuals with annual travel policies who report in midterm a diagnosis of cancer will find that insurers will invoke the ‘health warranty’ clause in their policy and immediately withdraw cover for a newly diagnosed cancer. Some insurers will even terminate the policy completely.
When carrying out screening, the insurer reserves the right to underwrite an individual case declaration at the point of claim.
The few insurers ready to consider cancer cases do so using call centre-based automated ‘screening’ systems, which try to distinguish the ‘survivors’ – those who have had cancer but have been ‘off treatment’ for many months or years – from the ‘sufferers’ – those high-risk individuals who have either recently been diagnosed and are on treatment, or those whose cancer has spread and have a ‘terminal’ diagnosis. A declaration of a terminal prognosis will almost always render an individual uninsurable. This is because a keystone question in the screening process is aimed at identifying whether the applicant has received such a ‘terminal’ prognosis. However, on request, screening companies are unable to provide a definition of ‘terminal’, thus leaving the onus on the cancer patient making the declaration. For instance, you may consider a teenager with the prospect of less than five years of life to have a terminal prognosis but this may not necessarily be the case for an 85 year old, who may also die in the next five years. ‘Terminal’ is clearly open to wide-ranging interpretations and is therefore an elastic term.
Underwriters reading this article and contemplating their own understanding of ‘terminal’ may be interested to review a survey of doctors published in the Journal of Palliative and Supportive Care. This survey showed that in Norway, doctors expect a terminal patient to have 3.6 weeks (25 days!) of life. The younger doctors (27 to 39 years old) held shorter perspectives of ‘terminal’ than doctors from the older age groups. Not only did the understanding of ‘terminal’ vary by age, but the research showed that doctors of internal medicine and surgeons held significantly shorter estimations of ‘terminal’ than did clinicians in general practice, public health, and psychiatry. Clearly, even amongst doctors the definition of ‘terminal’ is dependent on the varying perspectives of the individual.
The problem with screening
Given the wide ranging complexity of cancer, the general public cannot be expected to understand all aspects of their diagnosis, the significance of past events or what an insurer may consider to be ‘relevant facts’. Screening approaches are therefore severely handicapped by being reliant on self declaration. For instance, it is understandable that Mrs Brown with a recent diagnosis of liver cancer may not in her mind link it to her breast cancer 15 years earlier. In addition, those individuals who quite reasonably choose to adopt the coping strategy of ‘do not want to know’ are disadvantaged and put at serious risk of making an incomplete disclosure.
Looking at it another way, it should be noted that from an insurer’s point of view, self declaration helpfully transfers the responsibility for the declaration of the details of a complex medical condition to the applicant, allowing ample scope for a discussion on the interpretation of terms (e.g. ‘terminal’) to the point of claim.
However, by far the biggest shortcoming of ‘screening’ is that it is often confused with case ‘underwriting’. Most individuals, having submitted to medical screening, will assume that their case has been underwritten and that they therefore have ‘certainty of cover’. This is not the case. In carrying out screening, the insurer is simply performing an automated and generalised sifting process to help distinguish between categories of applicants rather than individuals. So for instance, ‘lung cancer’ is simply a broad categorisation of individuals with the same disease site, and not a specific cancer such as adenocarcinoma or squamous cell carcinoma of the lung. Each of the many different cancers affecting the lung has its own treatment strategy and disease trajectory.
When carrying out screening, the insurer reserves the right to underwrite an individual case declaration at the point of claim. This approach delivers substantial cost savings to the insurer, as only a small number of cases need to be actually underwritten. But in so doing, the cancer patient is being denied certainty of cover as it is leaving him vulnerable to misunderstandings and inadvertent errors that may not emerge until the point of claim – well after the opportunity for clarification has been lost. For example, Mrs Brown, in making a declaration of liver cancer, and not realising that it is metastatic disease from her diagnosis of breast cancer 15 years earlier, would not be made aware of her mistake until she makes a claim – only to see the policy voided on the grounds of an inaccurate screening declaration. From the patient’s point of view, ‘certainty of cover’ is therefore a fundamental requirement in this high risk sector where medical complications whilst on a trip can be financially crippling.
In recognition of the systemic limitations of screening, insurers have almost exclusively focused on sifting out the lower end of the spectrum of complexity i.e. the longer term survivors. This is because as cases move up the spectrum from survivors to sufferers, there is a near exponential increase in risk.
However, the reluctance of insurers to offer cover is understandable and is driven by the fact that of all the medical conditions, deaths from cancer outnumber deaths caused by heart disease, stroke, circulatory disease and respiratory disease combined.
Screening therefore isolates and excludes a large group of individuals, who as sufferers are enduring the rigors of active, metastatic or terminal cancer. As mentioned earlier, there are over 200 different types of cancer and each has the potential to spread (metastasise) to any other part of the body. With these disease permutations, the development of cancer underwriting mechanisms and algorithms is a fiendishly complex exercise. The process is further complicated by the wide spectrum of treatment options, each with a myriad of toxicity complications. For instance, in actuarial terms is it better to have a solitary metastatic lesion in two different organs or multiple small lesions in the same organ? Does it make a difference if the lesion is on a major blood vessel? Is it better to have radiotherapy or surgery? Amongst other factors this actuarial calculation is affected by the site of the primary disease, age, treatment protocol and the individual’s toxicity response.
Apart from the more obvious clinical, statistical and risk rating issues, the development of an underwriting methodology is affected by:
a) the presence of other pre-existing medical conditions (co-morbidity)
b) choice of destination and,
c) in an industry driven by legislation, compliance.
It may be worthwhile to briefly review these to see how they may impact on the underwriting process:
- Co- morbidity or the presence of other pre-existing medical conditions:
Statistically, cancer predominantly affects those over the age of 65 years, and insurers are keenly aware of the adverse impact of this age group on their loss ratios. A cancer underwriter must therefore first be reconciled to offering cover to the over-65s and be able to quote for the usual range of over 65s’ complications, including cardiac, respiratory, circulatory diseaes, and so forth, before contemplating extending cover to those with cancer.
In addition, apart from being at risk of recurrence or metastatic disease, individuals diagnosed with cancer have a higher statistical predisposition to the diagnosis of a second, but unrelated cancer. Any underwriting process must therefore be responsive not only to other medical conditions but also to the possibility of more than one primary cancer. In 2008, InsureCancer reviewed the case of a 66-year-old woman who was diagnosed with four successive primary cancers; colon cancer in 1980, endometrial cancer in 2000, duodenal cancer in 2004 and then in 2008, she was diagnosed with a lung cancer and metastatic liver disease. This lady planned to travel whilst in the midst of her chemotherapy. We granted cover, and I am happy to report that this trip was completely event-free.
Given the seriousness of the disease and the gravity of the potential complications, cancer underwriting must be responsive to the choice of destination. For instance, although Greece may be a fairly benign destination, in the event of an emergency, a small remote Greek island may not be helpful in speedily accessing life-saving oncology resources. I am also concerned that emerging tourist destinations like the Cape Verde islands may not have the medical infrastructure to deal with serious cancer related medical complications.
For the same reason, is it sensible for an individual with advanced cancer to be insured for a trip to the Antarctic? And, does it make sense for a man with advanced disease and metastatic spinal involvement to go on an active sailing holiday in the Caribbean?
In developing underwriting mechanisms, therefore, cases need to be evaluated not only in the context of the country, but also the specific destination and the nature of the trip. To be of any assistance to cancer patients, conventional travel insurance screening approaches need to evolve rapidly as they generally still only see the world in four zones.
- Compliance and legislation:
In the UK, apart from ensuring compliance in the Financial Services Authority’s (FSA) new ‘outcomes focused’ rather than ‘principles-based’ regulatory regime, compliance officers may reflect on the fact that the Disability Discrimination Act 1995 was amended in December 2005 to specifically include cancer. The Act prohibits insurers from making generalised assumptions about groups of individuals with a disability – including cancer. Any cancer insurer would therefore have to tread carefully and must be able to show that screening is not based on process generalisations or categorisations of broad groups of individuals. The assumption that anyone with metastatic disease is always a ‘bigger’ risk may yet be challenged in court.
An emerging concern for compliance officers in the UK is that the practice of withdrawing cover for newly diagnosed medical conditions has been challenged by the Ombudsman. He has expressed concern that insurers are effectively unilaterally varying policy terms after purchase by relying on the ‘health warranty’ clause discussed earlier. The Ombudsman has stated: “We do not necessarily consider the terms of such policies to be fair and reasonable – these firms are seeking to exclude from cover not only any medical conditions that the customer suffered from before they took out the policy, but also any medical conditions arising between the start of the policy and the start of the trip.” Given the Ombudsman’s stance, it is unlikely that this practice will pass the ‘Watchdog’ test. Compliant mainstream insurers, in seeking to protect their books from a midterm diagnosis of cancer, will now need to speedily identify a cancer underwriter able and ready to accept a transfer of these cancer risks.
In an increasingly politically correct world, cancer is unhelpfully ageist, sexist and racist. Understanding these statistical differences is actuarially very helpful but building an underwriting mechanism to account for these differences may be sensitive to legal challenge. In practice, it would not be possible for instance, to establish the ethnicity of an applicant even though in underwriting terms this might be helpful. For instance, the incidence of primary liver cancer is highest in developing countries and almost unknown in the developed world, and men are four times more likely to develop liver cancer than women.
In the example earlier, Mrs Brown’s declaration of a primary liver cancer would therefore immediately interest an expert interviewer who would be aware that statistically in the UK, this is unlikely to be a primary cancer. He would therefore be able to explore with Mrs Brown the possibility of metastatic disease – i.e. her previous history of cancer. The few examples of primary liver cancer in the UK are often connected to historic liver disease such as cirrhosis, which could also be easily overlooked in the process of making a cancer declaration. The expertise of the interviewer is therefore the key to minimising inadvertent errors at the point of declaration.
Understanding is key
Given these wide-ranging complications it is not surprising that insurers worldwide have had great difficulty in developing responsive and effective underwriting mechanisms able to offer cover to cancer patients. However, InsureCancer has evolved, piloted and implemented a cancer underwriting methodology that has successfully resolved the above issues.
The underwriting methodology is based on a keen understanding of the specific cancer’s disease trajectory and an integrated, fully correlated approach to the clinical, statistical and risk indicators. In every case, the patient is able to have a conversation with a specialist interviewer and outline their cancer experience in their own words. With a deep understanding of the management and treatment of cancer, it is possible for the interviewer to clarify key aspects of the declaration during the course of the conversation, eliminating the possibility of any misunderstanding. The patient’s attending clinicians are also given the opportunity of offering their perspectives on the patient’s treatment and stability. Every case is then individually underwritten using InsureCancer’s methodology. As the focus of the methodology is on clinical fitness to travel, a terminal prognosis is irrelevant and plays no part in our underwriting process. From a patient’s point of view, a major advantage of the approach is that the underwriting is carried out at the point of application, and therefore our cancer patients have the benefit of certainty of cover before embarking on perhaps the last trip of a lifetime.
Uniquely able to offer cover to patients at any stage of their cancer journey, our underwriting methodology is also responsive to those patients in the midst of their treatment, such as chemo or radiotherapy. The methodology has been shown to accurately identify those cases most likely to have complications. By markedly reducing the frequency of claims and therefore eliminating the consequent adverse impact on loss ratios, premiums are very realistic and affordable. In the event of a claim, the wealth of case data makes it possible to track claims experience by case, diagnosis, treatment protocol and the extent of metastatic disease – correlating these factors to the actual disease trajectory thus further refining the underwriting process.
In a sector with very high average cost of claims, it is imperative to be able to confidently identify those unwise risks most likely to trigger a claim. However, reliant on broad categorisations and unable to make process changes, insurers with screening systems can only make spreadsheet driven rate adjustments in response to claims experience. It is this repeated rate adjustment to meet spiralling claims experience that has resulted in the very substantial premiums being charged for cancer patients.
it must … be possible for insurers to respond to the concerns of our national cancer charities and give them an undertaking to moderate our premium expectations.
The emergence of a case-responsive cancer underwriting methodology has made it possible to successfully offer cover at realistic cost to patients at any stage of their cancer journey. However, too many patients faced with repeated screening declines conclude that they are uninsurable and therefore never travel abroad again. We are ready to work with mainstream travel insurers who at the point of decline can simply alert cancer patients to the possibility of contacting a specialist cancer insurer. As an industry, it is therefore possible for all of us to make a direct contribution to the lives of cancer patients.
For those of us committed to this sector, we should strive to achieve the following objectives:
- Engage cancer patients with compassion and understanding
- Eliminate the ‘terminal’ question from operating routines
- Ensure ‘certainty of cover’
- Moderate premium expectations
It is cancer patients who are paying the cost of our industry’s underwriting mistakes. As a specialist in providing cover at the ‘terminal’ end of the high-risk cancer spectrum, InsureCancer routinely offers cover for around £200 for trips in the EU and perhaps twice that for a trip to the US. As an industry, it must therefore be possible for insurers to respond to the concerns of our national cancer charities and give them an undertaking to moderate our premium expectations. An industry maximum of, say, £500 for the EU and £1,000 for the US must be realistic and more than adequate for all insurers in this sector. As an industry we must accept the ethical and moral responsibility to engage our skills and make a meaningful contribution to this very deserving but hitherto neglected sector of our community.