The breast cancer claim process

Do you sometimes wonder why underwriters make certain decisions? Need insight into the different claims processes or help explaining things to clients? This mini-series from Munich Re will provide some answers. A family history of cancer does not automatically lead to a declined critical illness insurance application. A number of factors must be taken into […]

By Hélène Michaud | June 19, 2009 | Last updated on June 19, 2009
4 min read
  • the number of family members diagnosed with cancer (increased risk with increased number)
  • the type of cancer diagnosed (breast/ovarian cancer poses a higher risk)
  • the age of diagnosis (increased risk if diagnosed before age 50)

However, family history should not be the sole determinant in the underwriter’s decision to apply a rating or exclusion or to decline the application. The applicant’s medical course of action should also be a key consideration. It is recommended that all female applicants with a family history of breast or ovarian cancer undergo yearly surveillance, including breast examination and mammography. This should begin at either age 50 or 10 years earlier than the earliest age of occurrence of breast or ovarian cancer in the family, whichever comes first.

If the applicant has followed the appropriate surveillance, ratings will apply based on the level of family history risk. However, female applicants not under surveillance will likely be postponed for coverage or offered coverage with a rating and an exclusion for breast and ovarian cancer. The exclusion may be reconsidered once the applicant begins routine surveillance.

It is essential that all pertinent information be disclosed during the application process to ensure smooth adjudication process.

Let’s look at some examples.

Applicant: Female, age 46, with CI coverage on a standard non-smoker basis issued in July 2006. A claim for benefits due to breast cancer was made in July 2007.

Medical History: In March 2004, the insured saw her family doctor for a lump in her breast that had been there for two weeks. She indicated no family history of breast or other types of cancer. A mammogram revealed two large cysts. A fine needle aspiration (FNA) was conducted, and the cysts were deemed benign. The insured was diagnosed with fibrocystic disease and instructed to have repeat mammograms at six-month intervals. After another normal mammogram in September 2005, the patient was instructed to undergo annual surveillance.

The client was considered a standard risk for critical illness as the FNA had proven the cysts to be benign and she had received the appropriate follow-up mammogram, which was negative. In April 2007, the patient returned to her doctor after finding a new breast lump. A mammogram indicated a large palpable mass, and an excisional biopsy was performed, which led to a diagnosis of infiltrating ductal breast cancer.

Result: The claim was paid because the symptoms, consultations, tests and diagnosis of cancer occurred after the 90-day cancer moratorium period, the cancer was covered by the contract and no exclusions applied, and her medical file and APS information confirmed no misrepresentations of health history, smoking or family history on the application.

Applicant: Female, age 54, with CI coverage on a standard non-smoker basis issued in October 2005. A claim for benefits due to breast cancer was made in June 2007.

Medical History: In April 2007, the insured went to her attending physician for a lump in her right breast. She underwent a general physical examination, and a suspicious mass was noted with exterior signs of skin dimpling. On questioning, the patient revealed that her sister and mother were diagnosed with breast cancer at ages 49 and 52, respectively. She had never mentioned her family history to her doctor and therefore had not undergone regular breast mammograms. The doctor noted the family history information on the Physician’s Statement form submitted to make a claim for CI benefits. An investigation confirmed that the insured was aware of her family history of breast cancer but had not indicated any family history of cancer on the insurance application.

Result: Had the insurer known the family history at time of underwriting, the policy would have been rated at 225% (an extra rating of +125). In addition, there would have been an exclusion for breast and ovarian cancer as the client was not having annual breast exams and mammograms, which are required when this type of family history exists. The insured’s failure to disclose a family history of cancer on the application, which was material to the risk, voided the contract from inception, and the claim was therefore not payable.

Hélène Michaud is assistant vice-president, marketing, at Munich Re.

(06/19/09)

Hélène Michaud

Do you sometimes wonder why underwriters make certain decisions? Need insight into the different claims processes or help explaining things to clients? This mini-series from Munich Re will provide some answers.

A family history of cancer does not automatically lead to a declined critical illness insurance application. A number of factors must be taken into account to make an appropriate decision, particularly when the applicant is female.

In the case of a female applicant with a family history of cancer, the underwriter must look at:

  • the number of family members diagnosed with cancer (increased risk with increased number)
  • the type of cancer diagnosed (breast/ovarian cancer poses a higher risk)
  • the age of diagnosis (increased risk if diagnosed before age 50)

However, family history should not be the sole determinant in the underwriter’s decision to apply a rating or exclusion or to decline the application. The applicant’s medical course of action should also be a key consideration. It is recommended that all female applicants with a family history of breast or ovarian cancer undergo yearly surveillance, including breast examination and mammography. This should begin at either age 50 or 10 years earlier than the earliest age of occurrence of breast or ovarian cancer in the family, whichever comes first.

If the applicant has followed the appropriate surveillance, ratings will apply based on the level of family history risk. However, female applicants not under surveillance will likely be postponed for coverage or offered coverage with a rating and an exclusion for breast and ovarian cancer. The exclusion may be reconsidered once the applicant begins routine surveillance.

It is essential that all pertinent information be disclosed during the application process to ensure smooth adjudication process.

Let’s look at some examples.

Applicant: Female, age 46, with CI coverage on a standard non-smoker basis issued in July 2006. A claim for benefits due to breast cancer was made in July 2007.

Medical History: In March 2004, the insured saw her family doctor for a lump in her breast that had been there for two weeks. She indicated no family history of breast or other types of cancer. A mammogram revealed two large cysts. A fine needle aspiration (FNA) was conducted, and the cysts were deemed benign. The insured was diagnosed with fibrocystic disease and instructed to have repeat mammograms at six-month intervals. After another normal mammogram in September 2005, the patient was instructed to undergo annual surveillance.

The client was considered a standard risk for critical illness as the FNA had proven the cysts to be benign and she had received the appropriate follow-up mammogram, which was negative. In April 2007, the patient returned to her doctor after finding a new breast lump. A mammogram indicated a large palpable mass, and an excisional biopsy was performed, which led to a diagnosis of infiltrating ductal breast cancer.

Result: The claim was paid because the symptoms, consultations, tests and diagnosis of cancer occurred after the 90-day cancer moratorium period, the cancer was covered by the contract and no exclusions applied, and her medical file and APS information confirmed no misrepresentations of health history, smoking or family history on the application.

Applicant: Female, age 54, with CI coverage on a standard non-smoker basis issued in October 2005. A claim for benefits due to breast cancer was made in June 2007.

Medical History: In April 2007, the insured went to her attending physician for a lump in her right breast. She underwent a general physical examination, and a suspicious mass was noted with exterior signs of skin dimpling. On questioning, the patient revealed that her sister and mother were diagnosed with breast cancer at ages 49 and 52, respectively. She had never mentioned her family history to her doctor and therefore had not undergone regular breast mammograms. The doctor noted the family history information on the Physician’s Statement form submitted to make a claim for CI benefits. An investigation confirmed that the insured was aware of her family history of breast cancer but had not indicated any family history of cancer on the insurance application.

Result: Had the insurer known the family history at time of underwriting, the policy would have been rated at 225% (an extra rating of +125). In addition, there would have been an exclusion for breast and ovarian cancer as the client was not having annual breast exams and mammograms, which are required when this type of family history exists. The insured’s failure to disclose a family history of cancer on the application, which was material to the risk, voided the contract from inception, and the claim was therefore not payable.

Hélène Michaud is assistant vice-president, marketing, at Munich Re.

(06/19/09)

Do you sometimes wonder why underwriters make certain decisions? Need insight into the different claims processes or help explaining things to clients? This mini-series from Munich Re will provide some answers.

A family history of cancer does not automatically lead to a declined critical illness insurance application. A number of factors must be taken into account to make an appropriate decision, particularly when the applicant is female.

In the case of a female applicant with a family history of cancer, the underwriter must look at:

  • the number of family members diagnosed with cancer (increased risk with increased number)
  • the type of cancer diagnosed (breast/ovarian cancer poses a higher risk)
  • the age of diagnosis (increased risk if diagnosed before age 50)

However, family history should not be the sole determinant in the underwriter’s decision to apply a rating or exclusion or to decline the application. The applicant’s medical course of action should also be a key consideration. It is recommended that all female applicants with a family history of breast or ovarian cancer undergo yearly surveillance, including breast examination and mammography. This should begin at either age 50 or 10 years earlier than the earliest age of occurrence of breast or ovarian cancer in the family, whichever comes first.

If the applicant has followed the appropriate surveillance, ratings will apply based on the level of family history risk. However, female applicants not under surveillance will likely be postponed for coverage or offered coverage with a rating and an exclusion for breast and ovarian cancer. The exclusion may be reconsidered once the applicant begins routine surveillance.

It is essential that all pertinent information be disclosed during the application process to ensure smooth adjudication process.

Let’s look at some examples.

Applicant: Female, age 46, with CI coverage on a standard non-smoker basis issued in July 2006. A claim for benefits due to breast cancer was made in July 2007.

Medical History: In March 2004, the insured saw her family doctor for a lump in her breast that had been there for two weeks. She indicated no family history of breast or other types of cancer. A mammogram revealed two large cysts. A fine needle aspiration (FNA) was conducted, and the cysts were deemed benign. The insured was diagnosed with fibrocystic disease and instructed to have repeat mammograms at six-month intervals. After another normal mammogram in September 2005, the patient was instructed to undergo annual surveillance.

The client was considered a standard risk for critical illness as the FNA had proven the cysts to be benign and she had received the appropriate follow-up mammogram, which was negative. In April 2007, the patient returned to her doctor after finding a new breast lump. A mammogram indicated a large palpable mass, and an excisional biopsy was performed, which led to a diagnosis of infiltrating ductal breast cancer.

Result: The claim was paid because the symptoms, consultations, tests and diagnosis of cancer occurred after the 90-day cancer moratorium period, the cancer was covered by the contract and no exclusions applied, and her medical file and APS information confirmed no misrepresentations of health history, smoking or family history on the application.

Applicant: Female, age 54, with CI coverage on a standard non-smoker basis issued in October 2005. A claim for benefits due to breast cancer was made in June 2007.

Medical History: In April 2007, the insured went to her attending physician for a lump in her right breast. She underwent a general physical examination, and a suspicious mass was noted with exterior signs of skin dimpling. On questioning, the patient revealed that her sister and mother were diagnosed with breast cancer at ages 49 and 52, respectively. She had never mentioned her family history to her doctor and therefore had not undergone regular breast mammograms. The doctor noted the family history information on the Physician’s Statement form submitted to make a claim for CI benefits. An investigation confirmed that the insured was aware of her family history of breast cancer but had not indicated any family history of cancer on the insurance application.

Result: Had the insurer known the family history at time of underwriting, the policy would have been rated at 225% (an extra rating of +125). In addition, there would have been an exclusion for breast and ovarian cancer as the client was not having annual breast exams and mammograms, which are required when this type of family history exists. The insured’s failure to disclose a family history of cancer on the application, which was material to the risk, voided the contract from inception, and the claim was therefore not payable.

Hélène Michaud is assistant vice-president, marketing, at Munich Re.

(06/19/09)