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Preventative surgery in case of genetic predisposition : is it a claim?

01 August 2013 Dalene Allen, Altrisk, Sandra Sithole, Norton Rose Fulbright South Africa

While there are many claims for life threatening diseases such as cancer, there is a debate in the industry as to whether preventative surgery can save underwriters money and if patients should be allowed to claim for these procedures.

Dalene Allen, Underwriting Director at Altrisk says genetic testing is a form of early screening and doctors are urging men and women to go for various forms of screening if there is a recognised predisposition to certain cancers. "Early screening could save your life,” says Allen.

Know your status

A paper published by the National Centre for Biotechnology Information (NCBI), an organisation that advances science and health by providing access to biomedical and genomic information, says that between 5% and 10% of breast and ovarian cancers result from the inheritance of mutations in the BRCA1 or BRCA2 gene. Women who carry BRCA1 or BRCA2 genes have a high risk of developing breast and ovarian cancer.
 
Predictive genetic testing for breast and ovarian cancer, as for hereditary non-polyposis colon cancer, can be useful to identify those at increased risk.

Actress Angelina Jolie’s decision to have a prophylactic mastectomy with immediate reconstruction has put the spotlight on this issue.

Now many women want to know if their critical illness policy would respond in such a scenario where, strictly speaking, there is no diagnosis of cancer yet.
 
"We recognise that there is a genetic predisposition to breast cancer and we fully support the brave decision a woman has to make to have an elective mastectomy,” Dalene says.
 
Cover reality

Under Altrisk’s Core and Comprehensive Critical Illness Cover, 25% of the benefit amount applied for would be paid out for a unilateral or bilateral mastectomy for carcinoma in situ, or prophylactic unilateral or bilateral mastectomy performed upon clinical recommendation by the attending specialist.

The following factors apply for a prophylactic mastectomy: breast and/or ovarian cancer in either a mother or sister before the age of 50 years; bilateral breast cancer in either a mother or sister; or confirmed BRCA 1 or 2 carrier status.
 
Reactive development

The availability of screening technology and the growing incidence of early cancer is what led to the development of Altrisk’s Early Cancer Cover benefit.

Reinsurance statistics show that a 30-year-old female is almost six times more likely to have early cancer than a staged cancer. This benefit provides cover for patients with an early cancer diagnosis, which means the cancer hasn’t invaded the surrounding tissue.
 
Thanks to the availability of genetic testing and early screening, people can detect cancer early and avoid the stress, trauma and financial burden associated with cancer, or an early death.
 
Medical advances such as genetic testing have potential for risk assessment and early identification of conditions such as cancer, and could become more relevant in underwriting in the future.

While a significant case can be made for the advantages of covering preventative surgery, Sandra Sithole, Director at Norton Rose Fulbright South Africa explains that depending on the extent of cover, most life policies and health policies including critical illness cover do not cover the type of surgery Jolie had and they need to rethink the issue in the light of scientific advances.
 
The cover debate

Dread disease cover requires a diagnosis of the dread disease itself. Accident and health insurance provides cover for ‘accidental bodily injury, accidental death and sickness or illness.’ Illness is usually defined in the policy as an unforeseen sickness, illness or disease originating, contracted, commencing or first manifesting itself during the period of insurance.
 
"Genetic predisposition is an inherited risk of developing a disease or condition causing illness. Being predisposed to a genetic condition does not mean that individuals will get that disease. It simply means that they are at a higher risk of contracting the disease,” says Sithole.
 
Preventative surgery in the case of genetic predisposition may be performed following genetic testing used to identify people who are genetically predisposed to certain health problems, the most common example being cancer.
 
To have a preventative surgery performed, one can undergo genetic testing to identify the defect and the need for a surgery. Most policies specifically exclude diagnostic procedures performed to diagnose a condition or illness or do not cover these procedures at all.
The trigger for cover is an actual diagnosis of a disease causing the illness.
 
Preventative surgery is a voluntary procedure which is designed to prevent a possible disease from manifesting and is, therefore, also not covered by most health policies.

Additionally, preventative surgery is also considered by many insurance companies as elective surgery. Elective surgery is a procedure that enhances the physical or psychological quality of life as opposed to curing a disease or injury and, therefore, seen by most as not being medically essential.
 
Elective procedures may in some cases reduce the risk of contracting a severe medical condition. However, these are still not covered by many insurance policies.
 
Legally, there is nothing preventing insurance or underwriting companies from developing a niche product designed to cover preventative surgery for insureds who have been identified or diagnosed as being high risk carriers of disease-causing genes.
 
To avoid unfair anti-selection the decision to undergo and disclose the results of genetic testing must be the patient’s decision only.

Preventative steps are clearly insurable. In Truck and General Insurance Co Ltd vs Verulam Fuel Distributors CC 2007 (2) SA 26 (SCA), the court found an insurance company liable to its insured for pollution clean-up costs incurred by the insured following an oil spillage to prevent even greater possible harm. The court found that the insured’s legal obligation to attend to the clean-up costs constituted legal liability covered by the insurance policy.

Insurance companies should consider covering elective genetic testing and preventative surgery of high risk genetically predisposed individuals including reconstructive surgery to keep the insurance industry up to date with scientific developments.

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