Understanding multiple sclerosis

By Hélène Michaud | May 5, 2009 | Last updated on May 5, 2009
9 min read
  • Primary-progressive MS — less common (10 to 15%), people with this type have a nearly continuous worsening of symptoms with no clear relapses or remissions.
  • Secondary-progressive — about half of people with relapsing-remitting MS start to worsen within 10 years of diagnosis, with possibility of increasing levels of disability.
  • Progressive-relapsing — relatively rare, combines attacks with steady worsening from the onset of the disease.
  • Benign MS — few attacks with long periods of remission and little disability after 15 years (about 20% – 25% of people originally diagnosed with Relapsing-Remitting MS have this type.
  • Malignant MS — rapidly progressing disability within five years of diagnosis; rare.

    Diagnostic tests

    The preferred test, which detects plaques or scarring possibly caused by MS, is an MRI because it offers the most sensitive, non-invasive way of imaging the brain. The scanning procedure can often create pictures of lesions, or areas of damage, that would be missed by a CT scan. But an abnormal MRI does not always mean a patient has MS as there are other diseases that can cause similar looking lesions. There are also spots found in healthy individuals, particularly older people, which are not related to any ongoing disease process.

    On the other hand, a normal MRI does not absolutely rule out MS. About 5% of people who are confirmed to have MS on the basis of other criteria, do not show any lesions on the MRI. (Instead, these people may have lesions in the spinal cord or may have lesions that cannot be detected by an MRI.)

    A clear-cut diagnosis might be made based on an evaluation of symptoms, signs, and the results of an MRI, but additional tests may be ordered.

    Evoked potential

    Evoked potential (EP) tests are electrical diagnostic studies that can show if messages are slowed in various parts of the brain. The EP test most widely accepted as an aid to MS diagnosis is the Visual Evoked Potential (VEP). The person sits before a screen on which an alternating checkerboard pattern is displayed. The results are interpreted by a neurologist or neurophysiologist with special training.

    Cerebrospinal fluid

    Cerebrospinal fluid, sampled by a spinal tap or lumbar puncture, is tested for levels of certain immune system proteins and for the presence of a staining pattern of antibodies called oligoclonal bands. These bands indicate an immune response within the central nervous system. Oligoclonal bands are found in the spinal fluid of 90% to 95% of people with MS. However, they are present in other diseases as well — oligoclonal bands alone cannot be relied on as positive proof of MS.

    Blood tests

    While there is no definitive blood test for MS, they can positively rule out other causes for various neurologic symptoms, such as Lyme disease, a group of diseases known as collagen-vascular diseases, certain rare hereditary disorders, and AIDS.

    Separate case studies: Pinpointing onset is critical to MS-related claims

    Applicant: Male, Age 40 with CI coverage of $100,000 on a standard non-smoker basis issued in May 2006. A claim for benefits due to MS was made in February 2008.

    Medical history: The insured saw his family doctor in August 2006 for generalized fatigue and poor sleep. In October 2006 he complained of a five-day headache with blurred vision for three days, which was diagnosed as a migraine.

    He returned in August 2007 after being struck in the right leg and experiencing weakness that persisted for two weeks. In December 2007 the insured again complained of weakness and numbness in his right leg, along with fatigue and two occasions of dizziness over the previous six weeks. An MRI was conducted in January 2008, after routine blood work and other tests failed to pinpoint a reason for the symptoms. The MRI results showed several white lesions, and was interpreted as clinically definite multiple sclerosis. A second MRI in February 2008 also showed several different lesions.

    Claim documentation: The insurance company obtained the complete medical file from the family doctor, the Physician’s Statement form, Claimant’s Statement and MRI results from January 2008. The Physician’s Statement was completed by the neurologist and indicated there were no family members with MS and he could not comment on past medical history as he had only treated the insured for MS.

    Conclusion: Both the neurologist and family doctor agreed the symptoms began in October 2006. The insured had several episodes of neurological abnormalities and the two MRIs confirmed the presence of lesions consistent with MS. The claim was paid because no misrepresentations were noted on the application, no policy exclusions applied, and the insured met all aspects of the contract definition, as follows: “a diagnosis by a neurologist of definite multiple sclerosis, characterized by well defined neurological abnormalities persisting for a continuous period of at least six months or with evidence of two separate clinically documented episodes. Multiple areas of demyelination must be confirmed by MRI scanning or imaging techniques generally used to diagnose multiple sclerosis.”

    Applicant:

    Female, age 36 with CI coverage of $150,000 on a standard non-smoker basis issued in March 2007.

    A claim for benefits due to MS was made in October 2007.

    Medical history: In November 2004, the insured complained of numbness and tingling in her hands that existed since giving birth in July of the same year. This was diagnosed as carpal tunnel syndrome and treated with an anti-inflammatory. In May 2005 she was diagnosed with labyrinthitis (inner ear disturbance). A complaint of dizziness and nausea in June 2005 was diagnosed as vertigo. Two hospital visits in 2005 and 2006 for ongoing dizziness were again treated as labyrinthitis. In July 2007 she complained of vertigo, nausea and double/blurred vision. The insured visited an optometrist in September 2007 after experiencing persistent double vision. Shortly after the optometrist visit, an MRI indicated definite multiple sclerosis.

    Claim documentation: The insurance company obtained the complete medical file from the family doctor, the Physician’s Statement form, claimant’s Statement and MRI results from August 2007. The insured had not admitted the various consultations for numbness and tingling in 2004 and dizziness in 2005 and 2006 on the application for insurance. There was a remote family history of MS in a cousin.

    Conclusion: The date of the first signs of MS are unclear but likely began with the November 2004 complaint of tingling in the hands since July. Remote family history was not asked on the application, but this was an informed applicant who was knowledgeable about MS. The application asked a number of questions that should have been answered “yes” by the insured. Had the correct answers been given, the application would not have been issued as applied for, but would instead have had an exclusion for MS. This claim was declined and the policy rescinded.

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

    (05/05/09)

    Hélène Michaud

  • Relapsing-remitting MS — characterized by clearly defined attacks (relapses) followed by complete or partial recovery (remissions). This is the most common form representing 75% at the time of diagnosis.
  • Primary-progressive MS — less common (10 to 15%), people with this type have a nearly continuous worsening of symptoms with no clear relapses or remissions.
  • Secondary-progressive — about half of people with relapsing-remitting MS start to worsen within 10 years of diagnosis, with possibility of increasing levels of disability.
  • Progressive-relapsing — relatively rare, combines attacks with steady worsening from the onset of the disease.
  • Benign MS — few attacks with long periods of remission and little disability after 15 years (about 20% – 25% of people originally diagnosed with Relapsing-Remitting MS have this type.
  • Malignant MS — rapidly progressing disability within five years of diagnosis; rare.

    Diagnostic tests

    The preferred test, which detects plaques or scarring possibly caused by MS, is an MRI because it offers the most sensitive, non-invasive way of imaging the brain. The scanning procedure can often create pictures of lesions, or areas of damage, that would be missed by a CT scan. But an abnormal MRI does not always mean a patient has MS as there are other diseases that can cause similar looking lesions. There are also spots found in healthy individuals, particularly older people, which are not related to any ongoing disease process.

    On the other hand, a normal MRI does not absolutely rule out MS. About 5% of people who are confirmed to have MS on the basis of other criteria, do not show any lesions on the MRI. (Instead, these people may have lesions in the spinal cord or may have lesions that cannot be detected by an MRI.)

    A clear-cut diagnosis might be made based on an evaluation of symptoms, signs, and the results of an MRI, but additional tests may be ordered.

    Evoked potential

    Evoked potential (EP) tests are electrical diagnostic studies that can show if messages are slowed in various parts of the brain. The EP test most widely accepted as an aid to MS diagnosis is the Visual Evoked Potential (VEP). The person sits before a screen on which an alternating checkerboard pattern is displayed. The results are interpreted by a neurologist or neurophysiologist with special training.

    Cerebrospinal fluid

    Cerebrospinal fluid, sampled by a spinal tap or lumbar puncture, is tested for levels of certain immune system proteins and for the presence of a staining pattern of antibodies called oligoclonal bands. These bands indicate an immune response within the central nervous system. Oligoclonal bands are found in the spinal fluid of 90% to 95% of people with MS. However, they are present in other diseases as well — oligoclonal bands alone cannot be relied on as positive proof of MS.

    Blood tests

    While there is no definitive blood test for MS, they can positively rule out other causes for various neurologic symptoms, such as Lyme disease, a group of diseases known as collagen-vascular diseases, certain rare hereditary disorders, and AIDS.

    Separate case studies: Pinpointing onset is critical to MS-related claims

    Applicant: Male, Age 40 with CI coverage of $100,000 on a standard non-smoker basis issued in May 2006. A claim for benefits due to MS was made in February 2008.

    Medical history: The insured saw his family doctor in August 2006 for generalized fatigue and poor sleep. In October 2006 he complained of a five-day headache with blurred vision for three days, which was diagnosed as a migraine.

    He returned in August 2007 after being struck in the right leg and experiencing weakness that persisted for two weeks. In December 2007 the insured again complained of weakness and numbness in his right leg, along with fatigue and two occasions of dizziness over the previous six weeks. An MRI was conducted in January 2008, after routine blood work and other tests failed to pinpoint a reason for the symptoms. The MRI results showed several white lesions, and was interpreted as clinically definite multiple sclerosis. A second MRI in February 2008 also showed several different lesions.

    Claim documentation: The insurance company obtained the complete medical file from the family doctor, the Physician’s Statement form, Claimant’s Statement and MRI results from January 2008. The Physician’s Statement was completed by the neurologist and indicated there were no family members with MS and he could not comment on past medical history as he had only treated the insured for MS.

    Conclusion: Both the neurologist and family doctor agreed the symptoms began in October 2006. The insured had several episodes of neurological abnormalities and the two MRIs confirmed the presence of lesions consistent with MS. The claim was paid because no misrepresentations were noted on the application, no policy exclusions applied, and the insured met all aspects of the contract definition, as follows: “a diagnosis by a neurologist of definite multiple sclerosis, characterized by well defined neurological abnormalities persisting for a continuous period of at least six months or with evidence of two separate clinically documented episodes. Multiple areas of demyelination must be confirmed by MRI scanning or imaging techniques generally used to diagnose multiple sclerosis.”

    Applicant:

    Female, age 36 with CI coverage of $150,000 on a standard non-smoker basis issued in March 2007.

    A claim for benefits due to MS was made in October 2007.

    Medical history: In November 2004, the insured complained of numbness and tingling in her hands that existed since giving birth in July of the same year. This was diagnosed as carpal tunnel syndrome and treated with an anti-inflammatory. In May 2005 she was diagnosed with labyrinthitis (inner ear disturbance). A complaint of dizziness and nausea in June 2005 was diagnosed as vertigo. Two hospital visits in 2005 and 2006 for ongoing dizziness were again treated as labyrinthitis. In July 2007 she complained of vertigo, nausea and double/blurred vision. The insured visited an optometrist in September 2007 after experiencing persistent double vision. Shortly after the optometrist visit, an MRI indicated definite multiple sclerosis.

    Claim documentation: The insurance company obtained the complete medical file from the family doctor, the Physician’s Statement form, claimant’s Statement and MRI results from August 2007. The insured had not admitted the various consultations for numbness and tingling in 2004 and dizziness in 2005 and 2006 on the application for insurance. There was a remote family history of MS in a cousin.

    Conclusion: The date of the first signs of MS are unclear but likely began with the November 2004 complaint of tingling in the hands since July. Remote family history was not asked on the application, but this was an informed applicant who was knowledgeable about MS. The application asked a number of questions that should have been answered “yes” by the insured. Had the correct answers been given, the application would not have been issued as applied for, but would instead have had an exclusion for MS. This claim was declined and the policy rescinded.

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

    (05/05/09)