In the December 2022 edition of SCORacle, we included an article that detailed the revised Association of British Insurer’s (ABI) Guide to Minimum Standards for Critical Illness Cover document (the Guide), that was released on 15th September 2022.

Soon after the release of the updated Guide, the ABI were alerted to some areas where suggested improvements could be made. This was despite a wide consultation of the draft version of the Guide to many stakeholders, leading up to the release of the final document.

As a result, the ABI have further discussed with the ABI Critical Illness Working Group and have decided to make some further changes to ensure the document is as contemporary as it can be and meets the main objective of bringing additional clarity to the ABI recommended wordings. Therefore, there are some minor changes which have now been made to the Guide relating to the cancer and heart attack definitions. 
Details of the updated Guide were released by ABI on 14th April 2023 and can be found here.

Changes to the ABI recommended wording for Cancer

The most significant changes to the Guide relate to the new exclusion for borderline malignancy/low malignant potential neuroendocrine tumours (NETs) and gastrointestinal stromal tumours (GISTs), which was originally as follows:

• Gastrointestinal stromal tumours and neuroendocrine tumours without lymph node involvement or distant metastases unless they are WHO Grade 2 or above.

Since the Guide was released, there was a challenge made as to whether the WHO grading is applicable for GISTs, although there is no question that it is appropriate for NETs.

Upon further investigation, it appears that whilst many gastrointestinal tumours are categorised using WHO grading, GISTs are not, and for risk stratification purposes there are different classification systems used across the globe.

After consulting with the Royal College of Pathologists, it was confirmed that GISTs are classified in the UK using the Air Forces Institute of Pathology (AFIP), Miettenen and Lasota system, the names of which detail the research referenced in the development of the classification system.

The discussions also mentioned that pathology reports are encouraged to apply a staging system taken from the Union for International Cancer Control (UICC) and TNM, that is globally recognised for classifying cancers, and is entirely consistent with the AFIP system. Therefore, it is quite possible that pathology reports for GISTs requested by claims assessors, could include details relating to either system.

It was felt that because NETs and GISTs use different classification systems for risk stratification purposes, it was necessary to have separate exclusions for each, rather than have a joint exclusion, as suggested in the original Guide released in September 2022.

The revised exclusion wordings for NETs and GISTs

Taking all this information into account, the revised exclusion wordings for borderline malignancy/low malignant potential NETs and GISTs, are now as follows:

• Neuroendocrine tumours without lymph node involvement or distant metastases, unless classified as WHO Grade 2 or above.
• Gastrointestinal stromal tumours without lymph node involvement or distant metastases unless classified by either AFIP/Miettinen and Lasota as having a moderate or high risk of progression, or as UICC/TNM8 stage II or above.”

More information on NETs and GISTs

As explained in our December 2022 edition of SCORacle, there has been much industry discussion as to whether it is reasonable to exclude “low graded” NETS and GISTs. Historically, these were medically considered as “benign” as many of them do not impact upon mortality and once treated, quality of life is usually excellent. However, even though they are low graded tumours, they are now considered to have at least some malignant potential and are no longer referred to as being benign.

Previously, these tumours relied upon the exclusions in the cancer wording of “borderline malignancy”; or having “low malignant potential”. However, this occasionally attracted criticism from some physicians that this terminology should also not be applied for low graded NETs or GISTs. Therefore, a specific exclusion for NETs and GISTs to bring additional clarity to the wording, seems a sensible change.

Incidence of NETs and GISTs

NETs are relatively rare types of tumours that occur in various parts of the body, including the lungs, pancreas, and gastrointestinal tract. The prognosis of these tumours is variable, and the “grading” is an extremely significant factor. Low graded tumours having, an excellent prognosis, whereas the higher graded tumours act very differently, and carry a much worse prognosis.

The incidence of NETs in the UK is estimated to be around 5,000 and in Ireland around 220 new cases per year. Despite their rarity, they have caused increasing problems for insurers in more recent years, with the main concern being related to the exclusion wordings.

GISTs can occur anywhere in the gastrointestinal tract, with the most common sites being the stomach and small intestine. As with NETs, the grading of GISTs is an important prognostic factor, together with size, site and spread of the tumour. GISTs are even rarer than NETs, with the estimated incidence in the UK of around 900, and in Ireland around 80 new cases per year.

Although both NETs and GISTs are comparatively rare types of cancer, there is no doubt that the new exclusions will help to reduce potential claims issues in the future.

For more information on both NETs and GISTS, follow the link to SCOR’s Expert Views publication “Borderline Malignancy /Low Malignant Potential Cancers".

Slight change to prostate cancer exclusion

It was also noticed that the prostate cancer exclusion appeared to be missing reference to when tumours apply a “clinical” staging using the TNM staging system (by using the letter “c”) as per the draft document that was circulated. This was an oversight, and the correct wording has now been confirmed as follows with the change shown in red text:

• All tumours of the prostate unless histologically classified as having a Gleason score of 7 or above or having progressed to at least TNM classification cT2bN0M0 or pT2N0M0 following prostatectomy (removal of the prostate).

Changes to the heart attack wording

With the release of the Guide in September 2022, there were various media articles that were critical of the new exclusion contained within the heart attack wording relating to “myocardial injury”, which is a condition that can occur with or without myocardial infarction (heart attack).

The main criticism being that the wording did not make it clear that myocardial injury can occur without myocardial infarction (MI), and because myocardial injury is a pre-requisite for MI, the new exclusion wording could be misinterpreted that all MI’s would effectively be excluded. This, despite there being several very clear references in the wording that all the medical evidence must be consistent with MI for a claim to be met.

In view of other changes being made to the Guide, it was felt there was an opportunity to apply a very slight change to the exclusion wording that would accommodate all views. The revised heart attack wording in full, with the changes in red text, is as follows.

Heart attack – of specified severity

A definite diagnosis of acute myocardial infarction with death of heart muscle as evidenced by all of the following:  

• Typical clinical symptoms (for example, characteristic chest pain).
• New characteristic electrocardiographic changes or new diagnostic imaging changes.
• The characteristic rise of cardiac enzymes or Troponins recorded at the following levels or higher:
  • Troponin T 200 ng/L (0.2 ng/ml or 0.2 ug/L)
  • Troponin I 500 ng/L (0.5 ng/ml or 0.5 ug/L)&

The evidence must show a definite acute myocardial infarction. For the above definition, the following are not covered:

• Myocardial injury without myocardial infarction.
• Angina without myocardial infarction.

Actions to be taken

In view of the revised wordings, it is important that offices adopt the changes as soon as possible, in order to take advantage of the benefits and clarity they bring. The ABI Guide is maintaining these changes should be implemented by 31^st January 2024.

Other changes to the Guide

In addition to the changes to the CI wordings, there has been appropriate updates made to the Generic Terms section, by adding in some explanation relating to the different classification systems that have now been added with regards to GISTs.

Conclusion

This article aims to provide details for the additional changes made to the Guide and also includes explanations of the reasons why it was felt necessary to make changes so soon after the release of the Guide in September 2022.

These changes are relatively minor. However, they all help towards improving the existing wordings and reducing future claims issues.