1. 1 Overview of the Regulation in the Netherlands Robert Kneepkens, MD RGA CMO Interpolis, Eureko

2. 2 Agenda n Medical Examinations Act (Wet op de medische keuringen, WMK). n Focus on articles 3 and 5. n Self Regulation Counsel involved parties (Zelfreguleringsoverleg betrokken partijen, ZRO). n Evaluation of the WMK. n Daily practice and comments from consultant medical officers (CMO’s). n Medical underwriting in the future.

3. 3 Purposes of the WMK n Main purposes: n Protection of privacy and integrity of those who apply for a private life or disability insurance, or for a job. n Guarantee of the access to insurances and jobs of people with chronic medical problems. n Other intentions: n Protection of the right to informational self-determination. n Assurance that participation to population screening programmes remains at a high level, because access to private insurances is granted even after a positive genetic test.

4. 4 Article 3: Genetic testing n No part of a medical examination may constitute a disporportionate invasion of the privacy. n Any investigation to come to the knowledge of the chance of a severe untreatable disease. n Any investigation to come to the knowledge of the presence of a severe untreatable disease, that is not yet manifest. n Restrictions in other articles or mentioned in the Second Chamber. n Article 6 of the WMK makes an exception for the HIV-test under certain conditions, and if the sum insured is above average. n The Minister of Health mentioned only two diseases currently falling under this description: Huntington’s disease and Myotonic Dystrophia.

5. 5 Article 5: Previous genetic tests n Article 5 prohibits questions about (former investigations of) the hereditary disposition to severe untreatable diseases, … n …unless the disease is already manifest. n Article 5 also prohibits these questions if they concern family members. n Information about the hereditary disposition of the client or family members may not be used. n Article 5 is only valid if the sum insured stays below the question limit. n € 159,505 for life insurances; € 31,901 (first year) / € 21,267 (thereafter) for disability insurances. n The question limit is raised by the Minister of Health every 3 years.

6. 6 Self Regulation Counsel (ZRO) n Article 9 of the WMK obliges the involved parties to take counsel together every three year. n The involved parties are: The Dutch Insurers Association, the Platform Insureds & Labour, the Royal Dutch Medical Association n The ZRO is responsible for a more detailed regulation: n Protocol Insurance Medical Examinations, which includes the Moratorium on Genetic Tests (meaning chromosome- and DNA-tests) and the HIV Code of Conduct n Standard health questionnaire (with a family history that is restricted to multifactorial diseases)

7. 7 Main problems in daily practice n The evaluation of the WMK in 2006 was favourable for the insurance industry. Two important conclusions were: n The access to disability insurances in the case of self-employment remains a problem n The WMK uses unclear terms, like: manifest, hereditary, severe, untreatable. n The CMO’s feel that the WMK is outdated already. n The distinction between genetic and non-genetic is felt as unpractical and unethical, becoming more and more untenable. n Daily practice demands a simple distinction between clients that need extra protection and clients that do not.

8. 8 Medical underwriting in the future n Further investigations or questions are allowed for (complications of) voluntary hazards and for manifest diseases. n A hazard is regarded as voluntary, if the client should know that his conduct is very hazardous for his health or longevity. n A disease can be considered being manifest, if any sign or complaint is present or has been present. The simple fact that a test - whether genetic or non-genetic – in the past proved the disease is present, is not enough.

9. 9 Medical underwriting in the future n Extending the protection of clients with a positive hereditary disposition: n No longer just severe untreatable diseases, but all diseases with a genetic basis. n No longer just clients with ‘genetic problems’, but all clients with medical problems that are not yet manifest. n A complete ban on the use of genetic information is no longer needed. n By ending the distinction between origins of diseases, the regulations will be ready for any medical break-through in the future.