22/02/2015. Possible causes. Decisions decisions decisions. Challenging eye and ear conditions at underwriting and claim stage Dr Maritha van der Walt

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Dwight Harrington
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Challenges Underwriting symptoms rather than conditions- tinnitus, vertigo, blurred vision Requests for narrower rather than broad exclusions and consequences Pre existing condition and unrelated

1 Challenges Underwriting symptoms rather than conditions- tinnitus, vertigo, blurred vision Requests for narrower rather than broad exclusions and consequences Pre existing condition and unrelated claims Rapid expansion of knowledge, super specialisation Problems at claim stage Excluding the symptom or impairment, the condition or the organ? One or both? Balance between offering the best terms to the client and protecting the company Challenging eye and ear conditions at underwriting and claim stage Dr Maritha van der Walt 2 Decisions decisions decisions A typical day in the office 3 4 Possible causes Gradual hearing loss, tinnitus, chronic diarrhoea, abdominal pain Lead poisoning causing sensorineural deafness, irritability, stomach cramps. Beethoven s hair by Russell Martin Distended inner ear found at autopsy 5 6 1

Balance between offering the best terms to the client and protecting the company Challenging eye and ear conditions at underwriting and claim stage Dr Maritha van der Walt 2 Decisions decisions

2 Anatomy Practical audiogram 7 8 Hearing loss severity Audiogram left ear Conductive hearing loss Air bone gap Sensorineural Hearing loss No Air bone gap 9 10 Mixed hearing loss Shape Left ear Air bone gap Both graphs fall in the hearing impairment part of the audiogram Conductive and sensorineural hearing loss Example otitismedia and presbycusis

loss Shape Left ear Air bone gap Both graphs fall in the hearing impairment part of the

3 Ménière s Disease Drop attacks Dr Prosper Ménière French physician 1861 Idiopathic endolymphatic hydrops Fluctuating hearing loss, Vertigo Tinnitus, feeling of fullness in the ear Otolitic crisis of Tumarkin Severe cases of Ménière's disease No loss of consciousness Thoughts on lesions of the internal ear presenting as symptoms of seizures of sudden cerebral origin Pathology Ménière's disease: Assessing the risk Incurable disease Symptoms managed by lifestyle changes and medical treatment Surgery reserved for medical treatment failure Most often bilateral over time Profound hearing loss Burnt out vertigo stops but hearing loss is permanent

symptoms of seizures of sudden cerebral origin 13 14 Pathology 15 16 Ménière's disease: Assessing the risk Incurable disease Symptoms managed by lifestyle changes and

4 Vestibular conditions Principles of assessing ear related claims (I) Benign paroxysmal positional vertigo Vestibular neuronitis Labyrinthitis Loss of hearing or balance or both? Loss of hearing Pure tone Audiogram Confirms conductive, sensorineuralor mixed hearing loss Can fluctuate in Ménière's disease Speech discrimination, other tests must be consistent, full audiologist report Principles of assessing ear related claims (II) Vincent van Gogh Is there an exclusion clause relating to ear conditions on the policy Is this an progressive disorder or A new, unrelated event? Example: Previous conduction hearing loss, now presenting with an acoustic neuroma. Apply the but for test Numerous psychiatric diagnoses Self inflicted injuries Asylum for Epileptics and Lunatics at St Remy Letters to his brother Theo detailed description of attacks Suicide in Starry night Wheatfield with cypresses Van Gogh Had Ménière's Disease and Not Epilepsy I.K. Arenberg, L.F. Countryman, L.H. Bernstein, G.E. Shambaug JAMA July 25, 1990, Vol264, No

5 Conditions of the eye 26 Anatomy of the eye

6 Measurement Testing Steepness of greatest Curvature Mild Diopters Moderate Diopters Advanced Diopters Severe Above 60 Diopters Thickness of the Cornea Mild above 525 micron Moderate micron Advanced micron Severe Less than 400 micron Progression : highest risk during puberty, stabilises by age 40 Most often bilateral Treatment Hard contact lenses Cross linking Does not prevent progression,optical correction only Preserves vision, does not improve the condition May still need corneal transplant later Corneal transplant Life span 15 years, rejection is always a risk Improves vision, corrects the condition Cannot be regarded as a reasonable requirement for maximum medical improvement Cataracts Causes Lifestyle factors: smoking, alcohol Diabetes Use of oral or high dose inhalation steroids Older age Sun damage Congenital Trauma

linking Does not prevent progression,optical correction only Preserves vision, does not improve the condition May still need corneal transplant later Corneal transplant Life span 15 years, rejection

7 Vision through cataract Assessing the risk Phacoemulsification and intraocular lens replacement Very low risk procedure, 98% success rate Very good long term prognosis Underwrite the underlying cause Often bilateral Increased intra ocular pressure Asymptomatic in early stages Damages the optic nerve Peripheral field vision loss initially

Underwrite the underlying cause Often bilateral 39 40 Increased intra ocular pressure

8 43 44 : Assessing the risk Identify the benefit, exact definition total loss of vision/ visual field Access to medical care, level of care Compliance Track record and consequences exclusion

9 Retinal detachment Medical emergency Laser treatment Good outcome unless macular damage Complications manifest early Long track record Macular dystrophy and degeneration Macular pathology Dystrophy Genetic Younger ages Underwriting Exclude on all benefits Degeneration Multi factorial Older ages Claims Pay the claim

degeneration 51 52 Macular pathology Dystrophy Genetic Younger ages Underwriting

10 Vascular conditions of the retina Vascular conditions of the retina Retinal artery occlusion Retinal vein thrombosis Retinal artery occlusions Atherosclerosis Emboli Think vascular system Retinal vein thrombosis Increased viscosity Platelets, smoking Think vascular system Optic neuritis High risk of developing multiple sclerosis Apply correct exclusion Claim probably under the neurological system Summary: Underwriting Summary: Claims Definite diagnosis, better information > better underwriting decision Identify the system Ear, eye, nervous system, vascular? Nature of disease process Progressive and likely to involve both organs or One event and fully recovered or stable? Exclude the condition if possible, excluding symptoms can cause problems at claim stage. Remember that the claimant can be disabled before reaching levels of functional or physical impairment. Do occupational underwriting. We cannot rely on surgery when assessing maximal medical improvement Definite diagnosis, better information > better underwriting decision> easier claims assessment Remember that the claimant can be disabled before reaching levels of functional or physical impairment. Do occupational assessment We cannot rely on surgery when assessing permanence or maximal medical improvement Existing exclusion clause relating to the claim can be very difficult to apply Full information But for test

neurological system 57 58 Summary: Underwriting Summary: Claims Definite diagnosis, better information > better underwriting decision Identify the system Ear, eye, nervous system, vascular?

11 Questions? Thank you for watching! Thank you for listening! Enjoy the walk!

CRISIS COVER CLAIM FORM (DEAFNESS/ PARTIAL LOSS OF HEARING OR CAVERNOUS SINUS THROMBOSIS SURGERY/ COCHLEAR IMPLANT SURGERY) SECTION

Reg. No 199002477Z CRISIS COVER CLAIM FORM (DEAFNESS/ PARTIAL LOSS OF HEARING OR CAVERNOUS SINUS THROMBOSIS SURGERY/ COCHLEAR IMPLANT SURGERY) SECTION 1 This section is to be completed by the Life Assured