2. Lori Boyce, CHS AVP, Underwriting, Risk Management & Research/Development Manulife Financial

3. CI Underwriting Agenda
Risk of anti-selection
Manulife CI Claims experience
Preferred Life clients get cancer too!
Diagnosis is the key to CI
Unique CI Underwriting focus
Routine investigations at age 50: Increased risk of diagnosis: lumps, bumps, lesions…
Points to ponder

4. CI: Risk of anti-selection
Typically….
Beneficiary = insured
Insured is not dead

5. Manulife in 2012
$36,000,000 paid to our clients Average payment: $125,000 per claimant

6. Manulife: 1997 to 2012
$223,000,000 paid 1,900 policies On average, $117,000 per claim

7. Manulife CI Claims

8. Manulife: CI claims

9. Manulife: CI face amounts

10. Critical Illness: diagnosis
NO requirement for:
Premature death
Disability
Proof of incurred expenses
ONLY require the definition be satisfied: typically a diagnosis + survive 30 days from diagnosis

11. Incidence – not mortality
More clients are:
Being diagnosed early
Living longer
Which supports the need for this contract…but offers CI underwriters unique challenges

12. 33 year old female teacher
June 2009: Both she and husband applied for $750,000 Life
Approved on preferred basis
Accepted $25,000 of CI
2nd trimester pregnancy – second child

13. 33 year old female
10/10: she noticed a new lump which felt different from prior clogged duct detected while breast feeding
Ultrasound, mammogram and core biopsy completed:
Invasive ductal carcinoma: T3N2 Mx
( mammogram: general increased density of breast but no lesion noted )

14. November 2009: $25,000 CI benefit paid
33 year old female
November 2009: $25,000 CI benefit paid

15. February 2012: $750,000 Life benefit paid
33 year old female
February 2012: $750,000 Life benefit paid

16. 50 year old male MD 12/08: approved preferred for $750,000 Life
Accepted $187,500 of CI

17. 50 year old male MD
Within two years: symptoms of a urinary tract infection
10/11 Post investigation: bladder cancer
CI Claim paid

18. Canadian Cancer Statistics 2012
2012: Newly diagnosed cancers - 53% will be:
Lung
Colorectal
Prostate
Breast

19. CCS 2012
Every hour, an average of 21 Canadians will be diagnosed with some type of cancer
Men: # 1 PROSTATE CANCER
Women: # 1 BREAST CANCER

20. Breast cancer: moderately high risk factors*
Getting older
First degree relative with breast cancer (especially if prior to menopause)
Genetics: BRCA 1 or BRCA2 carriers
Prior dx of atypical hyperplasia
* WebMD.com

21. Slightly higher risk factors
Distant family history: aunt, grandmother, cousin
Previous abnormal biopsy
No children or first child > age 35
Overweight
Early menstruation < age 12
Late menopause > age 55…

22. NO identifiable risk factors*
BUT…………..
75% of women diagnosed with breast cancer…
NO identifiable risk factors*
*WebMD.com

23. Mammogram challenges
Screening mammograms miss about 20% of breast cancers that are present at time of screening ( high breast density a key factor )
False positives lead to anxiety and additional testing ( ie: ultrasound/biopsy)
Over diagnosis and over treatment

24. Colon cancer 3rd most common cancer in Canada
2nd most common cause of death from a cancer in Canada ( behind lung cancer)

25. Colon cancer risk factors
Age >50
Colon polyp ( adenoma): size and #
Family history ( especially at younger age )
Genetic alterations
HNPCC and FAP
Personal history of cancer (especially ovary, uterus, or breast)
Ulcerative colitis or Crohn’s disease

26. Colonoscopy screening
Tubular adenoma: depending on # and size:
every 3-5 years
Family hx , age 60:
every 5 yrs, starting age 40 or 10 yrs prior to age of diagnosis

27. Thyroid cancer 1998- 2007 for males 2002 -2007 for females
Thyroid cancer incidence rates rose on average almost 7% per year

28. Thyroid cancer risk factors
Increasing age
Female
Exposure to high levels of radiation
Family history of thyroid cancer

29. Points to ponder Know your CI definitions
Identify risk factors for cancer
Be alert to anti-selection risk
Focus on diagnosis/incidence: NOT mortality

30. Dr. Tim Meagher Medical Director Munich Re

31. The Underwriter’s Concern
How do I avoid a claim?
An early claim
An unexpected claim
Any claim at all
How do I accurately assess risk, i.e. be fair to the applicant?

32. CI is all about Incidence
Is a covered condition likely to develop in this applicant?
Cancer
Myocardial Infarction
Stroke
What are the tip-offs that I can detect at time of application?
“Predictors” of future events
The big 3

33. Predictors Family History Medical History Traditional predictors
Particularly important in CI underwriting
Medical History
Increased use of APS
Lower threshold for laboratory testing
Traditional predictors
Build

34. Family History- Breast Cancer
Risk varies with
Number of first degree relatives affected
One affected: RR 1.8
Two affected: RR 2.93
Age at diagnosis of relative
RR 2.9 if relative < 30
RR 1.5 if relative > 60

35. Family History- Breast Cancer
Risk increased if
Breast and/or ovarian cancer in at least 2 first degree relatives
or 1 first and at least 1 second degree relative , especially if:
family history of bilateral breast cancer
history of male breast cancer
history of both breast and ovarian cancer
history of early onset breast or ovarian cancer (before age 50)

36. Underwriting Challenges in CI
The challenge of benign lesions
The challenge of changing incidence
The challenge of non-specific symptoms

37. Underwriting Challenges in CI
The challenge of benign lesions
The challenge of changing incidence
The challenge of non-specific symptoms

38. Risk factors for Breast Cancer
Age
Gender
Race
Ethnicity
Family history
Genetic factors
Benign breast disease
Personal history of cancer
Lifestyle, dietary factors
Reproductive history
Hormonal factors
Radiation exposure
Environmental factors

39. F45, $100,000 CI – Underwritten March 2003
Family Hx: Mother diagnosed with breast 67
Para: Did not disclose breast lump.
APS:
June 02 Lump noted on BSE. Smooth mass L breast. Mammogram: “moderate amount dense glandular tissue which decreases exam sensitivity.”
U/S: “several simple cysts bilaterally. Largest cyst on R measures 1.5 cm. Largest cyst on L measures 1.5cm. No solid lesions but one cyst has a septation and some echogenic debris within it.”
Dx: simple bilateral breast cysts.(U/S report did not recommend f/up)
CPX Feb 03 – on exam notes no new masses or cysts.

40. F 45, $100,000 CI – Underwritten March 2003
Case approved STD March 20, 2003
Claimed for breast cancer in 2004
June 2004 noted swelling in her L axilla.
Mammogram showed a “spiculated mass at 12 o’clock L breast and multiple pathologic appearing nodes in the axilla”
Bx: 3.5cm well differentiated tumour with negative resection margins. Positive lymph node involvement.
Dr states: “This patient has no prior history of breast cancer, although in retrospect it is felt that this may have been present on a mammogram of that was read as benign breast disease.”

41. Underwriting Challenges in CI
The challenge of benign lesions
The challenge of changing incidence
The challenge of non-specific symptoms

42. The Challenge of Changing Incidence: Thyroid Cancer
F34 CI $100,000
Healthy
Policy issued at standard rates 2009
Carotid bruit detected Jan 2010
Ultrasound of carotid: 1 cm thyroid nodule
Thyroid biopsy
papillary cancer of thyroid

43. The Challenge of Changing Incidence: Thyroid Cancer
Incidence increasing
1973: 3.6/100,000
2002: 8.7/100,000
Majority are very small papillary cancers
Mortality has not changed!
Parallel with prostate cancer with PSA

44. Underwriting Challenges in CI
The challenge of benign lesions
The challenge of changing incidence
The challenge of non-specific symptoms

45. The Challenge of “Non-Specific” Symptoms
F35 $150K CI 2008
MS in maternal GF
?MS maternal aunt
Since 2000:
Intermittent pains x 2-3d in different areas of body
Decreased concentration
MRI 2002 N
2010:
Constant pain; worsening fatigue

46. The Challenge of “Non-Specific” Symptoms
PX: decreased sensation in both feet
MRI 2 focal areas of demyelination C2 and C4 suggestive of MS or transverse myelitis
CSF: + oligoclonal bands
Diagnosis: MS

47. Underwriting Challenges in CI
The challenge of benign lesions
The challenge of changing incidence
The challenge of non-specific symptoms
The challenge of anti-selection

48. CI: Risk Selection Approach is more conservative than with life
APS more frequently requested
Blood profiles more frequently requested

49. Judy Beamish, MD, FRCPC VP & Chief Medical Director Sun Life Financial
Critical Illness Claims Challenges
Judy Beamish, MD, FRCPC VP & Chief Medical Director Sun Life Financial

50. Cancer moratorium wording
No benefit will be payable for cancer and the Insured Person's coverage for cancer will terminate if within the first 90 days following the later of:
the effective date of the policy (coverage), or
the effective date of last reinstatement of the policy (coverage),
the insured person has any of the following:
signs, symptoms or investigations, that lead to a diagnosis of cancer (covered or excluded under the policy), regardless of when the diagnosis is made,
a diagnosis of cancer (covered or excluded under the policy).
While the Insured Person's insurance for cancer terminates, insurance for all other covered conditions remains inforce.

51. Case A: PSA and cancer moratorium
Effective date of coverage January 1, 2011
PSA ordered January 31: (0-4)
Result repeated, still abnormal and free/total PSA 11% (intermediate risk of cancer)
Referred to urologist on March 10 due to high PSA with low free/total PSA
July 16, 2011 – biopsy diagnosis of prostate cancer

52. Case B: PSA and cancer moratorium
Effective date of coverage January 1, 2009
PSA March 1, 2009: 5.2 (0-4)
Previous PSA’s had been elevated at this level or higher for 3-4 years
Seen by a urologist in 2006 with PSA of 5.4 – normal biopsy in 2007
October 2012 – PSA 9.1 -> referred back to urologist
December 16, 2012 – biopsy diagnosis of prostate cancer

53. Is case A different from case B ?
In case A there was a new finding during the moratorium period which led directly to referral and diagnosis of cancer
In case B there was nothing new about the elevated PSA during the moratorium period and this did not trigger an investigation leading to a diagnosis of cancer
It was the bump in PSA in 2012 that led to the diagnosis

54. Case C
Male 40
$50,000. Group CI policy (Guaranteed Issue) effective 2005 and 2009
Advanced Polycystic Kidney Disease

55. Definition major organ failure
Major organ failure on waiting list which is: major organ failure on waiting list-means a definite Diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under major organ failure on waiting list, the Insured must become enrolled as the recipient in a recognized transplant centre in Canada or the United States that performs the required form of transplant Surgery. The date of Diagnosis is the date of the Insured's enrollment in the transplant centre. The Diagnosis of the major organ failure must be made by a Specialist Physician.

56. Case C APS He was not placed on a waiting list because
In view of the continued deterioration, I thought it was appropriate for Mr. __________ to plan, along with his sister for a transplant during the summer. It seems that this will suit both him and his sister well.
He was not placed on a waiting list because
his sister is going to be the donor

57. Case C
In view of the continued deterioration, I thought it was appropriate for Mr. __________ to plan, along with his sister for a transplant during the summer. It seems that this will suit both him and his sister well.
Kidney failure is defined as chronic kidney disease stage 5, with the GFR below 15.
He reached this point in March 2011 and at that visit his nephrologist recommended that he and his sister plan for renal transplantation during the summer.

58. Does he meet the definition ?

59. Case D heart attack
Claimant submitted claim for heart attack

60. Case D APS

61. Medical Consultant’s Review

62. Hospital Discharge Report

63. Definition of heart attack
Heart Attack is defined as “a definite diagnosis of the death of heart muscle due to obstruction of blood flow, that results in:
Rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:
heart attack symptoms
new electrocardiogram (ECG) changes consistent with a heart attack
development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.
The diagnosis of Heart Attack must be made by a Specialist.
Exclusion: No benefit will be payable under this condition for:
elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or
ECG changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition as described above.”
Canada benchmark

64. Case E ECG – classic findings of acute inferior wall MI
Presented with chest pain and bradycardia

65. Case E Hospital #1
Treated with thrombolysis at hospital #1, then transferred to hospital #2

66. Hospital #2
Admitted with diagnosis of acute inferior MI, post-thrombolysis
Taken to cath lab for angioplasty
No troponin done
Is this claim payable ?

67. Timing of Release of Various Biomarkers After Acute Myocardial Infarction.
Timing of Release of Various Biomarkers After Acute Myocardial Infarction. The biomarkers are plotted showing the multiples of the cutoff for acute myocardial infarction (AMI) over time. The dashed horizontal line shows the upper limit of normal (ULN; defined as the 99th percentile from a normal reference population without myocardial necrosis; the coefficient of variation of the assay should be 10% or less) The earliest rising biomarkers are myoglobin and CK isoforms (leftmost curve). CKMB (dashed curve) rises to a peak of 2 to 5 times the ULN and typically returns to the normal range within 2 to 3 d after AMI. The cardiac-specific troponins show small elevations above the ULN in small infarctions (e.g., as is often the case with NSTEMI) but rise to 20 to 50 times the ULN in the setting of large infarctions (e.g., as is typically the case in STEMI). The troponin levels may stay elevated above the ULN for 7 d or more after AMI. Modified from Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3rd ed. Rochester, MN: Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007: 773–80.70 Used with permission of Mayo Foundation for Medical Education and Research. CK = creatine kinase; CKMB = MB fraction of creatine kinase; CV = coefficient of variation; MI = myocardial infarction; NSTEMI = non–ST-elevation myocardial infarction; UA/NSTEMI = unstable angina/non–ST-elevation myocardial infarction.
Anderson J L et al. Circulation 2011;123:e426-e579
Copyright © American Heart Association

68. Case F - hospital records
STEMI
Smoker
Took cocaine 03/01/2011

69. What does the contract say ?
No benefit is payable if the covered condition is caused directly or indirectly by……voluntary or involuntary consumption of drugs or participation in any criminal act

70. Triggers for Acute MI Lancet 2011;377:732-40
Cocaine is the most powerful known trigger for MI
Lancet 2011;377:732-40

71. What can we conclude ?
Claims come in for a variety of events many of which don’t fit the letter of the definition
Hospital records are essential
Medical expertise required for cases that don’t quite fit
What is the intent of the definition ?

72. Questions?