2008 General Meeting Assemblée générale 2008 Toronto, Ontario
34
2008 General Meeting Assemblée générale 2008 Toronto, Ontario Canadian Institute of Actuaries L’Institut canadien des actuaires
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Canadian Institute of Actuaries. L’Institut canadien des actuaires. 2008 General Meeting Assemblée générale 2008 Toronto, Ontario. Group Living Benefits. Critical Illness Role of Medical Director. Howard Minuk Chief Medical Officer Swiss Re Life & Health. - PowerPoint PPT Presentation
Transcript of 2008 General Meeting Assemblée générale 2008 Toronto, Ontario
2008 General MeetingAssemblée générale 2008
Toronto, Ontario
2008 General MeetingAssemblée générale 2008
Toronto, Ontario
Canadian Institute
of Actuaries
Canadian Institute
of Actuaries
L’Institut canadien desactuaires
L’Institut canadien desactuaires
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Group Living BenefitsGroup Living Benefits
Critical Illness
Role of Medical Director
Howard MinukChief Medical OfficerSwiss Re Life & Health
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Group Living BenefitsGroup Living Benefits
• team player working with actuarial, underwriting, sales, claims
Medical Director
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Medical Director and Pricing Actuary
• provide reliable incidence information for covered CI
• speculate what factors might affect population CI incidence trends
• help determine what impact underwriting will have on insured CI incidence
• determine detailed knowledge about how the product is priced and understand the impact that changing risk factors for CI will have on premium rate
• speculate what impact changes in medical technology, medical definitions, and legislation, may have on the CI risk classification process and the bottom line
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Distribution of the “Big Four”
United States
Cancer44.6%
1,258,000
MI23.7%
670,000
CABG13.9%
392,000
CVA17.7%
500,000
Canada
Cancer49.4%
129,000MI
26.1%68,000
CVA19.1%50,000
CABG5.4%
14,000
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Coronary Artery Mortality Trends
Ford ES et al. CAD Mortality Among Young Adults in USA 1980-2002. (J Am Coll Cardiol 2007;50:2128–32)
Among both men & women age > 35 years, the age-adjusted mortality rates from coronary heart disease have decreased steadily from 1980 through 2002.
49%
52%
About 50% of the decrease in mortality is related to a reduction in CV risk factors and the remainder is related to improvements in medical technology
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Ford ES et al. CAD Mortality Among Young Adults in USA 1980-2002. (J Am Coll Cardiol 2007;50:2128–32)
Among both men & women age 35-54 years, the age-adjusted mortality rates from coronary heart disease have already plateaued
Coronary Artery Mortality Trends
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Storm Clouds on the Horizon •Obesity •‘Metabolic Syndrome’ - Clustered heart attack risks (diabetes, prediabetes, lipids hypertension) associated with central obesity threaten to reduce or even reverse the declining trend in population cardiovascular mortality.
Are CI insurers protected from these epidemics?
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2003 Health Canada’s Wt Guidelines
Underweight < 18.5
Normal 18.5–24.9
Overweight 25.0–29.9
Obese, class I 30.0–34.9
Obese, class II 35.0–39.9
Obese, class III 40.0+
Lemieux S et al. CMAJ, Nov 23,2004
BMI (kg/m2)
Body Shape indicators of increased risk Waist circumference Male: > 40 inches (102m)
Female: > 35 inches (88cm)
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Canada Obesity Prevalence 1979 vs 2004
96
13
20
11
20
17
11
21 20
30 30
25 24
0
5
10
15
20
25
30
35
18-24 25-34 35-44 45-54 55-64 65-74 75+
1979 2004P
erc
en
t O
bese B
MI
> 3
0
Tjepkema. Adult Obesity in Canada. Statistics Canada-Cat. No.82-620-MWE Canadian Adult Age Bands
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Obesity & CV Risk Clustering
0 30 45 60Age
CVDPVD
Retinopathy
Nephropathy
Type 2DM
PreDM
Geneticsusceptibility
plus
Childhoodobesity
& inactivity
BP
Fats
&
Insulin resistance
Metabolic Syndrome
Excess CV Morbidity
NGT
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Epidemic of MS in USA/CDA by Age
25
34
4441
21
43
9.0
13
44
15
7.0
33
0
5
10
15
20
25
30
35
40
45
50
20-29 30-39 40-49 50-59 60-69 70+
MS
Prev
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ce (%
of p
op) Men
Women
Ford ES et al. Prevalence of the Metabolic Syndrome in US Adults.JAMA.2002;287:356-359
This data on the prevalence of the MS comes from an analysis of information obtained from 8814 US men & women age > 20 who participated in the Third National Examination survey from 1998-1994. This is a cross sectional survey of a nationally representative sample of the US population. Up to the time of this report, there was little available information on the US prevalence of the metabolic syndrome. This study indicates a very high prevalence of the MS increasing with age.
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Swiss Re Canadian Group Claims
CancerStrok
e
MI
MS Other
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Distribution of Denied Swiss Re Claims
Does not meet contractual definition
90 day waiting periodPreviously
diagnosedOther
Pre-ex
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Age-specific cancer incidence rates
Incid
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1000
05
1015202530354045
15-19
25-29
35-39
45-49
55-59
65-69
75-79
85+
Age at diagnosis
MaleFemale
1.21.6
2.74.2
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SEER Incidence and U.S. MortalityAll Cancers, Female (per 1000)
Year of Cancer Diagnosis and U.S. Female Mortality
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
‘74
‘76
‘78
‘80
‘82 ‘84 ‘86 ‘88 ‘90 ‘92 ‘94
In
cid
en
ce p
er
10
00
3.11 3.08 3.03 3.07 3.14 3.273.36 3.43 3.47 3.48 3.424.0 1999-2005 Annual % change (APC) = -0.7%
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4.82
'74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94
3.72 3.89 3.95 4.09 4.13 4.25 4.36 4.51 4.78
5.34
1.0
2.0
3.0
4.0
5.0
6.0
SEER Cancer Incidence rate and U.S. MortalityAll Cancers, Male (per 1000)
Inci
den
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000
Year of Cancer Diagnosis and U.S. Male Mortality
1995-2005 APC = -0.6%
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Prostate Cancer Incidence Rates USA by Year
2.38
1.85
1.16
0
0.5
1
1.5
2
2.5
YEAR
Inci
denc
e/1000
http://seer.cancer.gov/faststats/sites.php?site=Prostate+Cancer&stat=Incidence#trend
Lung
Prostate
Colon
White Males
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Incidence Common Male Cancers(2000-USA, All Ages - Seer)
0
50
100
150
200
250
Prostate Lung Colorectal Urinary
Inci
den
ce in
Th
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san
ds
Total 2000 661,200
2002 637,500 2008 745,180
31%(of all male cancers)
15%
10%9%
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Incidence Common Female Cancers (2000-USA, All Ages - Seer)
0
20
40
60
80
100
120
140
160
180
Breast Colorectal Lung
Inci
den
ce in
Th
ou
san
ds
30%
12%13%
Total 2000 596,000 2002 647,400 2008 692,000
(of all female cancers)
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CA Incidence Trends(1973-94, Seer, US Female, All Ages)
0
20
40
60
80
100
120
140
% in
crea
se
Lung MelanomaNon-Hodgkin’s
Kidney ThyroidLiver
BreastAll Cancers
122%
82%
67%53%
35% 34%23%
13%
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% in
crea
se
0
20
40
60
80
100
120
140
160
ProstateMelanoma
Non-Hodgkin’sLiver Testis
KidneyAll Cancers
141% 142%
90%75%
50%36%
27%
CA Incidence Trends (1973-94, Seer, US Male, All Ages)
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0
20
40
60
80
100
Whole Life < 85 < 75 < 65
% o
f C
ance
rs D
iagn
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Age
100%93%
71%
41%
Impact of Contract Duration on Cancer Diagnosis (Seer 1987 - 1991)
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CI pays a lump sum benefit
on the diagnosis of one of the
pre selected critical illnesses.
Product
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Risks in CI definitions
Increasingincidence
rates
Client perceptions about cover& exclusions
Evolvinglegislation
Scientificmedical
advances
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Myocardial infarct: definition flexibility?
2008
Benchmark MI Definition
1999
New myocardial infarction
tests
Troponin –T
Current myocardial infarction definition
CP, EKG changesenzyme rise & fall
Changing sensitivity and specificity of tests
Risks in CI definitions
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CI Individual
• concern about behaviour pattern of applicants• epidemic of informed applicants who have been
over represented in claims • possibly poor mix of applicants because of reduced
sales
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CI Individual
Applicant
UnderwriterActuary
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Incomplete Underwriting information
InformedApplicant
Underwriter
Actuary
CI Individual
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Pre-Existing Condition• A Critical Illness that is directly or indirectly related to a
condition for which the employee obtained medical care, or for which a reasonably prudent person would have sought medical attention within 24 months before he became insured.
• Medical care is considered to be obtained when he consults a doctor or other health care practitioner, uses medication on the advice of a doctor, or receives other medical services or supplies, advice or treatment, whether or not a specific diagnosis is made.
• This exclusion does not apply if the illness is diagnosed after he has been continuously insured for 24 months.
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CI Individual
•Can informed applicants hurt us?
Yes!
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Materially Important Nondisclosure • not commonly involved in contestable life insurance claims
• may be one important unrecognized factor responsible for adverse mortality experience especially in preferred lines of business
• more commonly recognized in other lines of business, such as DI and CI
• Recent increasing sales of CI insurance have really been an eye opener in understanding the behavior pattern of insurance applicants
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2008Group CI
• law of large numbers
• we hang our hat on pre-existing unless excess
• 8 out of 10 Group CI claims are paid
• CV claims seen are sometimes seen at young ages-late 30’s early 40’s
• potential worsening experience with increases in population risk factor clustering
• partnering with experienced reinsurer
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CI Benchmark DefinitionsAlzheimer’sAortic surgeryAplastic anemiaBacterial meningitisBenign brain tumourBlindnessCancerComaCoronary angioplastyCABGDeafnessMIHeart valve replacement
Kidney failureLoss of independent existenceLoss of limbsLoss of speechMajor organ failureMajor organ transplantMotor neuron diseaseMultiple sclerosisOccupational HIVParalysisParkinson’s diseaseSevere burnsStroke
