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The weight of morbidity data suggest coronary artery disease (CAD) will be the Number One covered risk encountered in the exciting new product we call critical illness insurance.

This disease manifests most ominously as a myocardial infarction (abbreviated MI). Most of us simply call it a “heart attack.”

Why is it important to know this? Because growing evidence suggests that critical illness insurance will be an increasingly important product in the insurance marketplace. Therefore, producers need to know about recent developments in coronary disease that will impact placement of CI coverage. This article will address this need.

For most of the 20th century, experts held that elevated cholesterol levels were mainly responsible for inciting CAD. Today, we know that inflammation plays an equivalent role in inducing acute coronary events such as heart attacks.

In some ways, inflammation may the more urgent consideration, as it is associated with what cardiologists call unstable plaque lesions. Stable lesions can cause chest pain when provoked by exertion. Unstable lesions, on the other hand, are prone to rupture, inducing formation of a thrombus, or blood clot, that is the known culprit in most heart attacks.

Researchers have discovered a new marker, performed as a simple blood test, that helps to pinpoint persons having, or at risk of having, an unstable disease. This test is called high sensitivity C-reactive protein, or hs-CRP for short.

Individuals with elevated hs-CRP levels are greatly at increased risk, not only a first event but also for later events, if the person manages to survive the first heart attack.

It is likely that insurers will make use of this inexpensive test in screening applicants thought to be at increased risk for CAD, based on longtime smoking, elevated cholesterol, high blood pressure and diabetes.

There also is intriguing evidence that hs-CRP may be measured using an oral fluid (saliva) test. If this is true, we may be able to assess risk using this client-friendly alternative to blood collection.

A new test has now been anointed by American and European cardiologists as the Number One marker for a heart attack. It is known as a troponin assay. There are such tests and they are designated Troponin T and Troponin L. Both have identical implications.

In the past, when a person came to the emergency room complaining of “suspicious” chest pain and/or related symptoms, doctors used three criteria to decide if there was an evolving heart attack. These were: 1) the nature of the chest pain; 2) whether there were certain types of ECG changes; and 3) the blood levels of certain older markers for heart damage.

The markers previously used lacked the reliability of troponin. As a result, some persons with actual heart attack were sent home, while many others with noncardiac chest pain were hospitalized despite not having an MI.

The new official “rules” for diagnosing a heart attack make it mandatory that there be rise in one of the troponin tests. Other evidence still plays a role, but the final diagnosis depends on results of troponin tests.

CI underwriters will now focus on troponin test findings as reported on attending physician and hospital records.

There is another aspect to the troponin test that could make life very interesting for the CI underwriter.

When someone undergoes angioplasty in a blocked artery, the level of the troponin will sometimes rise modestly. The same may happen when a patient has major noncardiac surgery. Cardiologists have even come up with a novel term for this event. They call it an “infarctlet” (that is, a tiny infarction of a small bit of the heart muscle).

This event raises several CI underwriting questions. Does it mean a silent heart attack has occurred? Does such an event constitute a “critical illness,” as typically defined in a CI policy contract? And, what is the line that separates silent heart injury from overt damage that can have immediate implications for accruing major medical expense and influence ones short-term well-being?

These are issues with which underwriters will grapple when they give input on wording of CI contract impairment definitions. CI underwriters will grapple with these issues even more as they confront these scenarios in a case underwriting context. The same is true for CI claims analysts, who are charged with determining whether or not a claim in this setting is valid.

These realities will, on occasion, make CI underwriting a complicated undertaking. On the other hand, the vast majority of healthy individuals need not be concerned about such intricacies. They should expect to see their coverage approved promptly, on a favorable basis.

, FALU, FLMI, CLU, is president of Inc., Greendale, Wisc. His e-mail address is hankgeorge@aol.com.


Reproduced from National Underwriter Life & Health/Financial Services Edition, October 31, 2003. Copyright 2003 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.