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BLOG: Cardiomyopathy

Posted May 26, 2021

Having a deep understanding of as broad a spectrum of medical conditions as possible is an essential part of any good protection adviser’s toolkit. At Watts Mortgage and Wealth Management it is at the heart of our process when training and recruiting. Finding advisers with a genuine passion and interest in this field is a huge step forwards in ensuring our clients have the best experience we can expect for them.
Over some coming editions of Moneyfacts ILP I will be exploring some more interesting cases to hopefully illustrate the value and impact of this background knowledge.
From a client perspective, when we take a call with an individual with a non-standard medical history, having an adviser on hand who is familiar with their condition is hugely reassuring. Like a visit to a GP, speaking to an individual who is aware of your condition and can ask the right questions, quickly removes any awkwardness or embarrassment from the conversation.
A client with a complex medical history will very often have seen their applications decline previously and have dealt with advisers who had not heard of their condition before and inspired no confidence that they can be found cover. We are all familiar with the idea that you have a limited initial window of time with a client to build trust and confidence. If a client calls and an adviser can quickly reassure them by having knowledge of their condition and how to place cover, this very quickly established the ‘trusted adviser’ status that we are seeking to build.
Training in background medical detail will build client confidence, help ‘normalise’ the conversation and provide speedy reassurance that they are speaking with the right individual. It will hopefully establish long-term relationships that transcend the mere transaction, and gain the very best underwriting result. For myself, and hopefully I am not overly unusual in the industry here, the medical side of things is fascinating and it is a genuine pleasure to be able help people be reassured that their families are now protected should their worst fears be realised.

As example in this edition, I would like to explore a condition that is uncommon enough to not be an everyday conversation, but not unusual enough to be unaware of- cardiomyopathy.

Cardiomyopathy affects around one in five hundred individuals in the UK, totalling around 160,000. It is typically familial in nature and advisers will be aware that most insurers are careful to ask about it as part of their standard family history questionnaires for life insurance applications. Any incidence of cardiomyopathy is always a disclosable event to an insurer, whether that is a personal diagnosis- no matter how far in the client’s past- or a close family member prior to age 65 being diagnosed.
Many clients will have no symptoms that they are aware of, and only know that they have cardiomyopathy due to family history and subsequent testing. This will very often add to their frustration at finding life cover difficult to source- they have no impact to daily living, no or minimal symptoms, and have been told by their cardiologist that they have a good prognosis and just require monitoring. This natural deviation between the reassuring words of a hospital consultant who will be keen to keep a patient relaxed and not dwelling upon any worst-case scenarios, and the blunt realism of an underwriter and the manuals/algorithms they need to follow to assume any risk that is possible, is something that a good adviser will need to become adept at handling. When a client is told by a medical professional that they should expect a long healthy life likely unimpacted by their condition, and then by a professional risk assessor something quite differing- that their premiums are substantially higher than the norm, or that they may be precluded from cover at all, this dissonance can be alarming and needs to be handled delicately and sensitively. Having an understanding here of the condition behind the person is imperative in providing reassurance

Cardiomyopathy is actually a group of conditions affecting the very structure of the heart itself, and its ability to effectively pump blood around the body. Typically, there will be apparent changes to either the shape of the heart or the size/thickness of its muscle walls.
For those that are symptomatic, the impact upon daily life can range from tiredness (due to low oxygen levels), to breathlessness/fluid on the lungs, the swelling of ankles and the abdomen (oedema), palpitations and chest pain all the way through to heart failure. The biggest concern, to both the client and underwriter, will be that of sudden cardiac death

There are differing types of cardiomyopathy, all underwritten in quite distinct manners and some of more concern to underwriters/life insurance providers than others. The most common types you may encounter are:

Dilated/congestive Cardiomyopathy:
This is the most common variant and is caused when the muscles of the heart walls become stretched and thin. It is typically inherited although can be caused by lifestyle. If you have this condition there is a 50% chance your child will inherit the condition.
Symptoms range from shortness of breath to excessive tiredness and palpitations. Whilst most people will live a normal life with treatment and monitoring, there always a risk of sudden cardiac death

Hypertrophic Cardiomyopathy:
In this instance the heart muscle cells are enlarged, with the chambers thickening. This reduces their size, and flexibility, effectively impairing their ability to pump blood around the body. Hypertrophic cardiomyopathy is the most common cause of sudden unexpected death in childhood and young athletes. Perhaps the most famous example to a certain readership would be the case of the Bolton Wanderer’s footballer, Fabrice Muamba in 2012.

Arrhythmogenic right ventricular cardiomyopathy (ARVC):
The proteins that hold together heart muscles ordinarily do not develop in people with ARVS, which leads to damage and fatty deposits forming. The right side of the heart is generally impacted mostly.
ARVC can progress though four phases, from the ‘concealed phase’ where only small changes in the right ventricle can be detected, through to both ventricles being impacted and more severe consequences. With ARVC, whilst the risk of sudden cardiac death is normally low, there are ‘hot phases’ when the disease becomes more active and the risk increases. Dizzy spells, palpitations and blackouts can be sign of this issue.

Restrictive Cardiomyopathy
This is a comparatively rare variant, normally diagnosed in children at age 5-6 and is when the muscle cells in the heart become replaced with abnormal scar tissue. This stiffens the ventricles, restricting contraction. Typically genetic in origin, haemochromatosis and amyloidosis can also cause this condition.

As ever with pre-sales medical underwriting, the better quality information an adviser can gain and present to a life company, the more accurate the outcome will be. We are all aware of, at the best of times, the length of time underwriting can take due to the speed of GP report generation- placing a case accurately at the outset is imperative to getting the best client outcomes.
Cardiomyopathy can be a complex and difficult case to place- but extremely rewarding when you are able to find cover for a client who is genuinely concerned about being insured. Putting together a broad case summary to present to a range of insurers will ensure that, when you do submit an application, it will very likely produce the end-terms that have been indicated.
As example of the detail that underwriters will be looking for to provide an indication of terms:

Firstly, and foremost, the single most important piece of information you will need to provide the underwriter is the type of cardiomyopathy- the most common of which have already been detailed above. There are a number of rarer cardiomyopathies with very poor outcomes and survival rates but it is far less common for advisers or insurers to receive application from these groups.

Once you know the type, underwriters would be interested in the following:

– Age of applicant
– Date of diagnosis (approximate)
– Underlying cause – although genetic in many cases, the cause may be relevant for some types such as dilated where alcohol, drugs, pregnancy, myocarditis can all be precipitators
– Current symptoms and/or any restriction on physical activity
– Treatment including whether they have an implantable cardioverter/defibrillator
– Is the condition ‘stable’ or with some dilated cardiomyopathies even resolved altogether?
– Have they had arrhythmias (abnormal heart rhythm) or evidence of heart block or heart failure if known?
– Is there a past history of cardiac arrest?
– Is there a family history of sudden cardiac death?

As ever, you will find some clients fully informed about their condition, and then next time quite the opposite. Copies of consultant’s letters (if the client has them to share) are a great resource as very often cases will progress to re-assurers and chief medical officers’ desks. The latest Echocardiogram report and consultant letters can very much help to establish how well the heart is functioning and overall severity and progression.

Case Study

James came to Watts via a BDM for a large insurer who had been unable to help him. He has a wife, two young children and a mortgage. His father sadly passed away very suddenly at the same age that James is now, 35, from cardiac arrest and had previously been diagnosed with dilated cardiomyopathy. The family history of this condition also extended to James’ paternal grandfather.
James himself was diagnosed with the condition at age 9 and has been regularly monitored since. He is totally asymptomatic and there has been no advancement or structural changes since diagnosis. He takes blood pressure medication and a beta blocker as for purely preventative reasons.
James had previously given up trying to get cover, but had met persistent declines. With him now being the same age that his father passed away, this is something that was worrying to him and a real source of anxiety.
We understood that this would be a difficult case to place, especially with COVID-19 in the background adding an extra layer of complexity. Luckily James could share with us some detail from consultant’s review letters, which helped in getting an accurate reflection from insurers.
The below, whilst not exhaustive, are illustration of the responses we got when we called the case though to various companies to discuss:

Insurer Indication of Terms
Zurich Always decline below age 40. Over 40 a potential +150% rating life only
The Exeter Typically always a decline below age 40- potential term for perfect cases but rating will be above maximum COVID-19 rating at present
Scottish Widows Potential to offer terms, subject to stability and no obvious symptoms. Minimum case size of £250,000. Terms could be around +175%- if they are above this it will be declined due to COVID-19 maximum ratings. Subject to reassurer case review
Aviva Always decline below age 40. Over 40 a potential +150% rating life only
Guardian Likely terms of +200% life only to be offered subject to GPR. Case will be underwritten internally without reassurer review.

This case was subsequently placed with Guardian who offered the most confidence that terms would be issued.
At Watts, as I am sure would be the case with most companies, whilst this case was not of the highest commercial value, it really resonated with our advisers and processing teams as a timely reminder of why we do what we do. Without our reputation for knowing the medical side of things we would not have been introduced to the client, and without our in depth understanding of the condition itself, and persistency in many pre-sales calls, the client may have been left without cover.
As it was, terms were issued within weeks of application, as indicated at the outset, and the client was hugely relieved to not only have his family protected, but to understand that at least some insurers can see past the immediate risk and envisage him having a long and healthy life.

Barry Jones
Protection Specialist
Watts Mortgage & Wealth Management

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