The insurance industry needs to update its understanding of diabetes, say Nicola Oliver and Scott Reid
What we thought we knew about diabetes has become a little out of date. An extensive literature review conducted by the IFoA’s Diabetes Working Party has shown that the research presently available was largely undertaken before the introduction of current, more effective treatments and lifestyle modifications.
At the moment, the insurance industry underwrites customers with diabetes based on a range of factors, including haemoglobin A1c (HbA1c), body mass index, cholesterol, blood pressure, smoking status, duration since diagnosis, and any related complications. The medical experts within (re)insurance companies then consider how these factors translate into underwriting rules.
For life cover, the rating applied will depend on how well the customer controls their diabetes (if Type 2), but it can be a significant extra cost (+25%–200%). If diabetes has just been diagnosed, it is likely that cover will be postponed until adequate treatment and control is established. Where diabetic control has been poor over time, the ratings will be very high, or the cover postponed or declined. Based on UK and global surveys conducted by the Diabetes Working Party, it is much less likely for a customer with diabetes to be offered critical illness or disability cover than to be offered life-only insurance. (In contrast, Asian insurers are more likely to offer people with diabetes a wider range of morbidity covers.)
How well do we really understand diabetes, though? The past decade has seen significant advances in treatments for both Type 1 and Type 2 diabetes, as well as better understanding of risk factors and overall improved management of the condition, but the current risk estimates are still derived from data that is more than 10 years old. The impact of these improvements on mortality and morbidity has not been fully translated into updates for medical practitioners and the insurance sector. This is one of the key reasons we have commissioned further research. Our aim is to understand the implications of these changes, and to investigate whether, based on the latest evidence, it would be possible to make a wider range of cover accessible to customers with diabetes.
In the meantime, we can share what we already know about diabetes.
What is diabetes?
Diabetes is a disease caused by a lack of insulin (Type 1) or an increased resistance of the body to insulin (Type 2). The resulting chronic high blood glucose levels (hyperglycaemia) are associated with the long-term damage, dysfunction and failure of various organs, especially the eyes, kidneys and heart, as well as blood vessels and nerves.
Type 1 diabetes is a chronic autoimmune disease caused by the pathogenic action of T lymphocytes on insulin-producing beta-cells in the pancreas. It is lethal unless treated with exogenous insulin. Family history is a strong risk factor, and damage to the pancreas due to viral infection is also implicated.
Type 2 diabetes, which accounts for about 90% of cases, is due to insulin resistance or reduced insulin sensitivity, combined with relatively reduced insulin secretion, which in some cases becomes absolute. Insulin resistance is usually well-established by the time of diagnosis, and hyperglycaemia escalates as beta-cell function deteriorates.
The Western lifestyle, involving a high-energy diet and reduced physical activity, is indisputably linked to the obesity and Type 2 diabetes pandemics. This means that less affluent lives are often associated with higher prevalence of diabetes, due to lifestyles that are, on average, poorer.
Risk for developing Type 2 diabetes is also increased for those with hypertension, a family history of diabetes, abnormal cholesterol and triglyceride levels, increasing age, black, Hispanic, American Indian or Asian origin, or those who have previously been diagnosed with gestational diabetes (diabetes of pregnancy).
Why is diabetes a problem?
People with all types of diabetes run a greater risk of developing severe health complications, which can greatly impact their independence and quality of life. The major aim of clinical care for people with diabetes is preventing such complications.
Complications arise because of elevated blood sugar levels. Excess blood sugar decreases blood vessel elasticity and causes them to narrow, impeding blood flow. This can lead to a reduced supply of blood and oxygen, increasing the risk of high blood pressure and damage to blood vessels.
In the UK, diabetes is the leading cause of blindness in working-age people due to retinopathy (damage to the retina), and is a main contributor to kidney failure through nephropathy (deterioration in kidney function). It is also a major cause of lower limb amputations due to blood vessel damage, and of cardiovascular disease, including heart attack and stroke. This is part of the reason that UK insurers are reluctant to offer morbidity cover to people with diabetes.
These complications may take many years to develop, as the damage from chronic elevated blood sugar can be a slow process. With Type 1 diabetes, diagnosis of complications can take between one and 15 years following diabetes diagnosis (bit.ly/Diabetes_Comp). However, with Type 2, even the point of diabetes diagnosis is unlikely to correlate with the point of actual diabetes onset. Symptoms may be absent or non-specific, and the individual may be living in a pre-diabetic state for some years.
During those years, the slow process of vascular damage will have already started. Around 2.1m people in England are estimated to have pre-diabetes or non-diabetic hyperglycaemia, according to the NHS, and are therefore at an increased risk of developing diabetes. Being able to identify those with pre-diabetes would be advantageous not only to the insurer, but also the individual, as it is possible to take steps to prevent progression to a fully diabetic state.
People with Type 2 diabetes are 50% more likely to die prematurely than those without diabetes. However, as previously mentioned, the introduction of improved treatments, and increased understanding of the pathophysiology of diabetes, strengthens the need for an up-to-date analysis of risks and mortality.
In Type 1 diabetes, disease onset is usually rapid, with specific symptoms that can be fatal if untreated. Earlier and tighter glucose control leads to better long-term outcomes. However, complications still exist. Some are specific to Type 1 diabetes and occur in the short term, such as hypoglycaemia (low blood sugar). The vascular complications previously described can also arise if blood sugar control is not well managed. However, the onset of symptoms is likely to be at least 10 years following diagnosis.
How many people have diabetes?
Since 1980 the global prevalence of diabetes has doubled from 4.7% to 8.5% (422m people in 2014). This is largely driven by increases in Type 2 diabetes. According to the World Health Organization, prevalence has been rising more rapidly in low-to-middle income countries. Regions with the highest prevalence of diabetes (over 9%) currently include the Middle East and North Africa, the Western Pacific, South East Asia, and North America and the Caribbean.
In the UK, there are currently around four million people living with diabetes – about 7% of the adult population – with a further estimated 13m who are either at risk or undiagnosed. Prevalence is expected to increase to an estimated 4.6m, or 9.5%, by 2030. Approximately half of this increase is due to the changing age and ethnic group structure of the population, and the other half due to the projected increase in obesity.
Improving insights and access to insurance
Given the complex health implications and changing medical outcomes of diabetes, the research commissioned by the working party will be of interest to (re)insurers who write protection and longevity business.
The project will seek to understand the risks associated with a diabetes diagnosis, the impact of improved treatment, and the increased risk of medical complications, including the impact of behavioural and/or modifiable risk factors and the implications for chronic conditions later in life.
Researchers will produce granular mortality tables for lives with and without diabetes (for all age ranges), as well as granular morbidity tables for inceptions of diabetes. We hope the research will improve the data available to insurers considering diabetic risks, as well as benefit people with diabetes by enabling better access to insurance. Watch this space.
FOOTNOTE: This article is written as a preliminary observation based on our literature review and that further research/investigation needs to be done. We also want to acknowledge that no (re)insurers have been consulted and that this is not a statement of fact/comments made as a result of independent empirical research/raw data analysis rather a view expressed on the basis of limited sources at this stage.”
Nicola Oliver is director of life and health at Medical Intelligence and co-chair of the Diabetes Working Party
Scott Reid is a global protection and data actuary at Zurich and co-chair of the Diabetes Working Party
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