Trends in Critical Illness - Multiple Sclerosis & TPD

1. The Actuarial Profession making financial sense of the future Trends in Critical Illness - Multiple Sclerosis & TPD 1 October 2002 Sue Elliott Hamish Galloway Daniel Ryan

2. MultipleSclerosis(MS) • Prevalence • Age & sex profile • Epidemiology • Clinical vs insurance definition • Symptoms • Drugs and treatment • Areas of future research • Data sources: • UK - population • UK - insured ("A Critical Review") • Overseas - population • Improved underwriting practices

3. Watsone Wyatt Employee:DR to complete ? Prevalence • Estimated 85,000 sufferers in UK • Varieties of MS • Relapsing remitting - 35-45% of total, 85% of initial presentation • Benign - 10-20% of total • Primary progressive - 10% of total • Progressive relapsing - 5% of total • Secondary progressive - 30% of total

4. Watson Wyatt Employee: DR to complete ? Variety by Disability/Time Graphs RRMS PPMS PRMS SPMS

5. Age & sex profile • Age at onset 10 - 59 years, with peak between mid 20's and early 30's • Ratio of women to men: • 2:1 across all MS sufferers • 1:1 for Primary Progressive

6. Watson Wyatt Employee: DR to insert age chart Age & sex profile From Mumford and Compston (1995) Prevalence from south Cambridgeshire district

7. Epidemiology • Geographic location: Distance from equator • Ethnicity: Caucasian vs African/Asian • Environmental factors • Seasonality • Infective agent • Susceptibility genes • Familial aggregation, twin studies • Complex multifactorial incl. DR2 gene

8. Clinical vs insurance definition • Clinical Definition • Poser criteria (1983) - 2 symptomatic attacks at 2 separate sites in central nervous system including optic nerves • Laboratory anomalies at 2nd site can replace requirement for symptoms • Insurance Definition is diagnosis by a neurologist meeting all of the following criteria: • Current impairment of motor or sensory function, which must have persisted for a continuous period of at least six months • Diagnosis must be confirmed by diagnostic techniques current at the time of the claim • Actual application in the industry

9. Symptoms • Symptoms in order of perceived importance to MS sufferer • Cognitive impairment • Depression • Spasticity & weakness • Ataxia & tremor • Bladder & bowel dysfunction • Fatigue • Sexual dysfunction • Pain

10. Drugs & treatment • Acute relapses • Corticosteroids affect duration, severity and probability of recovery from relapses • Disease modifying treatment • Primarily affect number and severity of attacks • Inconclusive as to impact on transition to progressive • Interferon beta, Glatiramer acetate

11. Areas of future research • Primary prophylaxis of at risk individuals • Relapse prevention & limiting • Neuroprotective & restorative • Remyelination • Protein growth factors • Better prospects than ever - hence question for insurance industry is will MS remain both permanent and critical?

12. Watson Wyatt Employee: 1991 date subject to change (DR) UK data sources (population) • HES data - 1993 to 2001

13. Watson Wyatt Employee: DR to insert graph HES data trends

14. UK data sources (population) • HES data - 1993 to 2001 • MSGP - 1981/82, 1991/92, 2001/02(not available yet; discussions are continuing within DoH about the possibility of another study)

15. UK data sources (population) • HES data - 1993 to 2001 • MSGP - 1981/82, 1991/92, 2001/02(not available yet) • MS Society (letter sent 24 July 2002 under Mike Urmston's signature; initial feedback is positive) • McAlpine - summary of different studies

16. Watson Wyatt Employee: DR to insert UK regional slide UK regional statistics From Robertson & Compston (1995) - Surveying multiple sclerosis in United Kingdom

17. UK data sources (insured) • "A Critical Review" - covers 1991-97 • 1998, 1999 - imminent (due at Health Conference 2002)

18. CIBT93 construction - MS • HES data 1994/95 • MSGP data 1991/92 • OPCS - Mortality Statistics by Cause, England & Wales 1993 • "Multiple Sclerosis" by Bernie O'Brien, Office of Health Economics (1987)

19. UK insured experience - MS

20. Overseas data sources (population) • Australia • longitudinal study commenced in May 2002; first release of results scheduled for May 2004 • US • SLIFKA - cohort study produced by National MS Society • International Federation of MS

21. Watson Wyatt Employee: DR to insert global stats Global statistics From McAlpine's Multiple Sclerosis 3rd Edition (1998)

22. Watson Wyatt Employee: HG to find out what the current questions are and what could be done if cost and public perception were not an issue. Improved underwriting practices • Ease of anti-selection • More probing questions required • Family history • Laboratory tests

23. Total & Permanent Disability (TPD) • CIBT93 • UK insured experience • Alternative approaches • Alternative definitions • Current issues

24. CIBT93 construction - TPD • No published data available in the UK • Condition invented by the insurance industry • Safety net for CI policies • IIP data (CMIR7 & CMIR15) • Cause of claim data (CMIR8)

25. UK insured experience - TPD

26. Alternative approaches • Long-term income protection claims by cause, ie D26+ • Severe Disability Allowance (government statistics)

27. Alternative definitions • Own occupation • Any occupation • Activities of daily working (ADWs) • Functional assessment tests (FATs)

28. Current issues • High level of declinatures (> 50%) • potential mis-selling? • Subjective definition (ie occupationally based)

29. The Actuarial Profession making financial sense of the future Trends in Critical Illness - Multiple Sclerosis & TPD 1 October 2002 Sue Elliott Hamish Galloway Daniel Ryan