Insuring Ulcerative Colitis

Are people with ulcerative colitis—a chronic inflammatory bowel disease—eligible for life or critical illness insurance? It all depends on the severity of the disease. The trick is to gain a better knowledge of ulcerative colitis (UC), its complications, and how it is underwritten to help make the underwriting process less frustrating for the advisor and the client.

Though a family doctor can provide information on medical impairment, it’s critical advisors obtain the proper information concerning their client’s medical condition. That’s because information that physicians provide isn’t always optimal from an underwriting perspective, and if there is missing or vague data, the underwriter wastes valuable time repeatedly going back to the doctor.

Instead, the advisor should ask right questions, knowing what the underwriter needs. This can speed up the underwriting process and yield the best underwriting decisions.

What is ulcerative colitis?

It is a chronic disease of the colon or large intestine, classified as an inflammatory bowel disease (IBD), and not to be mistaken with irritable bowel syndrome (IBS). Irritable bowel syndrome carries a much lower mortality risk and does not lead to IBD. IBS is also assessed at standard rates for both life and critical illness insurance. Ulcerative colitis is painful; ulcers or open sores form in the colon on the inner lining of the bowel, causing inflammation, ulceration, bleeding and scarring along with a host of other symptoms.

These symptoms can lead to more serious complications down the road. The symptoms of UC, as well as possible complications, will vary depending on the extent of inflammation in the rectum and the colon. The rectum is always involved, but UC can extend a variable distance up to and including the entire colon. The major risk with long-term ulcerative colitis is colorectal cancer; however, regular screening via colonoscopy can help reduce the risk.

According to the Crohn’s and Colitis Foundation of Canada (CCFC), in 2008 there were almost 201,000 Canadians living with IBD, and of these 88,500 had ulcerative colitis. Canada has the highest reported prevalence and incidence of IBD in the world. The age of onset of UC is 15 to 45 years and it isn’t gender-specific. The symptoms of UC are bloody diarrhea (sometimes severe), abdominal cramps, tiredness, loss of appetite and subsequent loss of weight. Anemia may also occur if there has been severe bloody diarrhea.

A diagnosis of ulcerative colitis, especially at a young age, can affect individuals emotionally because the symptoms can make it challenging for people to date, have intimate relationships or plan a family. Symptoms can also complicate travel and work. There is also a stigma around UC because of the embarrassing nature of the symptoms, which means people are not willing to share information about their condition. This can make it difficult for advisors to gather information about the nature and severity of their client’s illness.

That’s why the best approach advisors can take is to arm themselves with as much knowledge about the condition as possible, and to improve communication with the client to ease any embarrassment.

Underwriting ulcerative colitis

The underwriter will require a doctor’s report with full details of the extent of the disease, the number of relapses and details on both medical and surgical treatments, as well as copies of the most recent colonoscopy and biopsy pathology reports. In order to classify the risk, the underwriter must take into consideration the following:

• severity of the disease (mild, moderate or severe);
• age at onset;
• date of last flare-up;
• list of complications, if any;
• treatment (medical or surgery);
• evidence of compliance (with treatment and follow up); and
• type of surveillance (regular screening colonoscopies).

Since the client knows most of this information, it can be conveyed to the underwriter via the advisor if details are lacking.

For life insurance, ratings can range from “mildly substandard” for mild forms of the disease to “highly substandard” for moderately severe disease. If a diagnosis has been made within the past year, and the UC is severe, the case will be postponed.

If the disease is confined to the rectum (proctitis) and there are no complications, UC can be assessed at standard rates for life. If it has been in remission for five years, it can be standard for critical illness insurance as well. For critical illness, a “mild substandard” to a “decline” is the usual outcome for UC. However, if it has been recently diagnosed, it is generally postponed.

In the case of a total proctocolectomy (the surgical removal of the rectum, colon and sigmoid), if no symptoms or complications are present, the result can be standard for both life and critical illness coverage.

It’s important to note that a postponement differs from a de- clinature. A postponement either means that there must be a waiting period before a case can be reconsidered or that further investigation or information is required before a decision can be reached. A declinature most often means the case cannot be reconsidered.

How can underwriting be expedited?

To speed up the underwriting process, advisors should include the following information, along with an application to expedite the underwriting process:

• What is the diagnosis? (example: proctitis, ulcerative colitis)
• At what age was the diagnosis made?
• Explain the treatment (whether it was surgery or medical).
• If surgery was done, when and what type was it?
• Have symptoms resolved?
• If medication, provide the name(s) of the medication being taken?
• When was the date of last attack?
• How long has your client been symptom-free, i.e. when was the last flare-up?
• Is the client receiving regular colonoscopies?
• Date of last colonoscopy?
• Is time off work required during attacks?
• Are any of the complications listed above present?

Is reconsideration possible for a client assessed substandard?

An underwriter should always clarify whether a rating can be reconsidered or not and if so, at what point in time and what evidence will be required at reconsideration time. If you have not been provided with this information, ask your underwriter.

ating for critical illness is not usually reconsidered for UC unless the disease has been in remission for a minimum of five years, but it is always worthwhile to ask the underwriter if there is a possibility. Reconsideration for life coverage can be obtained if your client has been in remission for one or two years.

Although reconsideration may be possible for life and critical illness, it is also dependent on whether there has been a change in insurability.

Understanding ulcerative colitis

UC does not run the same course with all people. The disease is generally classified as mild, moderate or severe, and patterns vary.

Mild

Mild symptoms with less than four bowel movements per day, no bleeding, no weight loss, infrequent attacks and symptoms easily controlled with anti-inflammatory drugs, long periods of remission; No hospitalizations; Extent of the disease is confined to the rectum; Patient is compliant with treatment and follow-up with doctors; Patient has good insight into the disease.

Moderate

Symptoms include more than four bowel movements per day with blood, abdominal pain, and other complications (weight loss and anemia); Flare-ups require corticosteroids for relief; Disease involves one-third to one-half of colon.

Severe

Continuous symptoms are present, such as frequent bowel movements with blood, weight loss, fatigue, and fever, that require ongoing corticosteroids or immunosuppressants; Need for hospitalizations; Presence of extensive disease that involves the entire colon.

Complications

Ulcerative colitis can lead to complications such as arthritis, uveitis (inflammation of the eye), liver disease, clubbing (a deformity of the ends of the fingers) in addition to weight loss, anemia and colon cancer. If an individual has had ulcerative colitis for eight years or more with frequent flare-ups affecting the whole of the large intestine, then the risk of cancer is much greater.

About one in 10 people who have had ulcerative colitis for more than 20 years will develop cancer. Therefore, regular colonoscopy is advised after ulcerative colitis has been present for more than eight years. This regular review can identify a cancer much earlier and lead to a much better prognosis.

Treatment

Treatment of UC can involve medication and/or surgery. Corticosteroids are used for acute flare-ups and 5-aminosalicylate (5-ASA) drugs can be taken continuously to reduce inflammation.

The medical treatment is based on the severity of the disease—and the type of medication prescribed can let the underwriter know how bad things are. A 5-ASA compound is generally used for mild to borderline moderate disease and is used to maintain remission. Corticosteroids are used along with 5-ASA for acute flare-ups. They are not taken on a long-term basis because of possible side effects. A severe case of UC involves frequent hospitalizations, a failure to control the disease with corticosteroids, and treatment with an immunosuppressant. If medical treatment does not bring UC under control, the option is surgery.

This involves the removal of the whole colon, including the rectum (proctocolectomy) with the creation of a permanent ileostomy (the ileum or small intestine is brought out of the body to allow wastes to pass). Historically, surgeons tried to leave the rectum and remove the colon only and create an ileo-rectal anastomosis (attaching the ileus to the rectum), as this avoided the need for an ileostomy. However, as the significant risk of cancer developing in the rectum still remains, this procedure is very rarely performed these days.

It is important to note that individuals who have had a proctocolectomy with ileostomy are cured of the disease.

An option for younger patients as an alternative to an ileostomy is the ileo-anal pouch. This pouch is created internally using the ileum (small intestine), which is connected to the anus, after the colon and rectum are removed. This surgery may involve up to three surgeries by the time it’s complete. The latter is the best option for young adults as it eliminates the need for an ileostomy.

Finally, surgical removal of the entire colon is a curative approach for UC and eliminates the risk of colon cancer. Surgery has come a long way and has provided dignity to these individuals by eliminating the need to wear an external bag for the elimination of wastes.

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Carmela Tedesco is VP of Underwriting Services at LOGiQ3 Inc., which is located in Toronto and provides audit, consulting, outsourcing, and underwriting solutions to the North American insurance and reinsurance industry.

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