Underwriting Eye Underwriting Eye Disorders Disorders

Philippine Society of Insurance Philippine Society of Insurance MedicineMedicine

UpdatesUpdates

Eye ExamEye Exam

Eye Exam – valuable information about the client.Eye Exam – valuable information about the client.

Classification:Classification:

1.1. Purely local disorders of the eyes (conjunctivitis Purely local disorders of the eyes (conjunctivitis and other infections, ocular injuries, )and other infections, ocular injuries, )

2.2. Manifestations of systemic disease (Diabetes Manifestations of systemic disease (Diabetes Mellitus, hypertension, SLE, RA, Dermatomyositis, Mellitus, hypertension, SLE, RA, Dermatomyositis, Hyperthyroidism)Hyperthyroidism)

Blindness Blindness

– – Most important ocular medical impairment that merits Most important ocular medical impairment that merits our underwriting attention.our underwriting attention.

– – Most important factor to be considered in risk Most important factor to be considered in risk assessment – its CAUSE. Mortality is increased when assessment – its CAUSE. Mortality is increased when blindness is due to diabetic and hypertensive blindness is due to diabetic and hypertensive retinopathy and other causes where the primary retinopathy and other causes where the primary disease itself is subject to extra mortality, than those disease itself is subject to extra mortality, than those that do not pose hazard to life, e.g. temporary ocular that do not pose hazard to life, e.g. temporary ocular inflammatory conditions.inflammatory conditions.

Blindness (MIRA)Blindness (MIRA)

Total blindnessTotal blindness Life CI TPD WPD ADBLife CI TPD WPD ADBUnilateral 0 Excl Excl Excl 1 Unilateral 0 Excl Excl Excl 1 Bilateral 0 Excl Excl Excl ExclBilateral 0 Excl Excl Excl Excl

Partial blindness – Reduction of Visual AcuityPartial blindness – Reduction of Visual AcuityMild 0 0 1 1 1Mild 0 0 1 1 1Moderate 0 Excl Excl Excl ExclModerate 0 Excl Excl Excl Excl

Visual AcuityVisual Acuity

Reduction of visual acuity is a combination of Reduction of visual acuity is a combination of reduced vision of both eyes.reduced vision of both eyes.

Confirms eye function?Confirms eye function? a) an optometrista) an optometrist b) an opticianb) an optician c) the agentc) the agent d) an ophthalmologistd) an ophthalmologist e) the medical directore) the medical director

OptometristOptometrist

– – is a healthcare professional who performs is a healthcare professional who performs routine eye examinations, administers primary routine eye examinations, administers primary eye care and prescribes eye wear – eyeglasses eye care and prescribes eye wear – eyeglasses or contact lenses to improve vision. or contact lenses to improve vision.

– – is an O.D. (doctor of optometry) is an O.D. (doctor of optometry)

OphthalmologistOphthalmologist

– – a specialist who has trained further or a specialist who has trained further or specialized in the diagnosis and treatment specialized in the diagnosis and treatment (medical or surgical) treatment of eye (medical or surgical) treatment of eye disorders.disorders.

– – is a medical doctor (M.D.)is a medical doctor (M.D.)

Eye ReportEye Report

What should it contain?What should it contain?

a) Nature and cause of the visual impairmenta) Nature and cause of the visual impairment

b) Severity of the conditionb) Severity of the condition

c) Bothc) Both

Hypertensive RetinopathyHypertensive Retinopathy

Poorly controlled hypertension can give rise to Poorly controlled hypertension can give rise to hypertensive retinopathy (fundus hypertensive retinopathy (fundus hypertonicus). hypertonicus).

Grading – based on changes that occur in the Grading – based on changes that occur in the blood vessels at the back of the eye which are blood vessels at the back of the eye which are correlated closely to the changes generally correlated closely to the changes generally observed in blood vessels. observed in blood vessels.

Hypertensive RetinopathyHypertensive Retinopathy

Positive Features: Positive Features: Grade I – IIGrade I – II Well controlled BPWell controlled BP

Negative Features: Negative Features: Grade II – IV Grade II – IV Poorly controlled blood pressure Poorly controlled blood pressure

Impaired visionImpaired vision

Effect of hypertension on the retinaEffect of hypertension on the retina

Retinal changes:Retinal changes:

Grade 1 – mild narrowing or sclerosis of retina arteriesGrade 1 – mild narrowing or sclerosis of retina arteries

Grade 2 – moderate to marked narrowing/sclerosis w/ Grade 2 – moderate to marked narrowing/sclerosis w/

light reflex and A-V crossing changes light reflex and A-V crossing changes

Grade 3 – w/ addtl. hemorrhages or cotton-wool spotsGrade 3 – w/ addtl. hemorrhages or cotton-wool spots

Grade 4 – w/ addtl. swelling of the optic disk or Grade 4 – w/ addtl. swelling of the optic disk or papilledemapapilledema

Hypertensive Retinopathy (MIRA Hypertensive Retinopathy (MIRA Underwriting Guidelines)Underwriting Guidelines)

Life CI TPD WP ADBLife CI TPD WP ADBGrade 1 0 0 1 1 1Grade 1 0 0 1 1 1 Grade 2 25 50 1.25 1 1Grade 2 25 50 1.25 1 1

Grade 3 50 50 + Excl Dec Dec 1Grade 3 50 50 + Excl Dec Dec 1 Grade 4 Dec Dec Dec Dec DecGrade 4 Dec Dec Dec Dec Dec

Hypertensive RetinopathyHypertensive Retinopathy

An asymptomatic 58 yr-old businesswoman, FA 5M, An asymptomatic 58 yr-old businesswoman, FA 5M, hypertensive since 1998, BP = 140/90, w/ incidental finding of hypertensive since 1998, BP = 140/90, w/ incidental finding of mild retinal artery narrowing in the eyegrounds; Past hx = mild retinal artery narrowing in the eyegrounds; Past hx = adequately treated for papillary CA, thyroid, 20 yrs ago; no adequately treated for papillary CA, thyroid, 20 yrs ago; no recurrence of disease; CXR normal, ECG = LVH, 2-D echo recurrence of disease; CXR normal, ECG = LVH, 2-D echo IVS = 11 mm, very minimal MR. Carotid doppler no stenosis; IVS = 11 mm, very minimal MR. Carotid doppler no stenosis; Chol 215 mg/dl, taking felodipine, simvastatin and Aspilet.Chol 215 mg/dl, taking felodipine, simvastatin and Aspilet.

What is your underwriting decision?What is your underwriting decision? a) Accept as substandard riska) Accept as substandard risk b) Postponeb) Postpone c) Declinec) Decline d) Talk to the agent d) Talk to the agent

Prevention of Hypertensive Prevention of Hypertensive RetinopathyRetinopathy

The most important element is the achievement The most important element is the achievement

of satisfactory blood pressure control.of satisfactory blood pressure control.

Diabetic RetinopathyDiabetic Retinopathy

Long-term complications of diabetes – due to Long-term complications of diabetes – due to

accelerated vascular disease. Smaller vessels are accelerated vascular disease. Smaller vessels are affected, most noticeable in the retina, called affected, most noticeable in the retina, called RETINOPATHY – Initially, non-proliferative (small RETINOPATHY – Initially, non-proliferative (small vessels break and leak), and then proliferative (blood vessels break and leak), and then proliferative (blood vessels abnormally grow in the retina producing vessels abnormally grow in the retina producing scarring, leading to retinal detachment and loss of scarring, leading to retinal detachment and loss of vision.) vision.)

Diabetic Retinopathy Diabetic Retinopathy

What do you need:What do you need:

a) FME, MUR a) FME, MUR

b) Diabetes questionnaireb) Diabetes questionnaire

c) BEX (blood exam) – FBS, HbA1c, OGTT c) BEX (blood exam) – FBS, HbA1c, OGTT

where neededwhere needed

Reminder: HbA1c is not recommended for the diagnosis Reminder: HbA1c is not recommended for the diagnosis of diabetes; it is best used to monitor long term of diabetes; it is best used to monitor long term control and prognosis of this disease. control and prognosis of this disease.

Diabetic Retinopathy (MIRA)Diabetic Retinopathy (MIRA)

Life CI TPD WP ADBLife CI TPD WP ADB

Visual impairment Dec Dec Dec Dec DecVisual impairment Dec Dec Dec Dec Dec

caused by diabeticcaused by diabetic

retinopathyretinopathy

Diabetic Retinopathy (Brackenridge)Diabetic Retinopathy (Brackenridge)

Basic Ratings for NIDDM:Basic Ratings for NIDDM:

31 – 40 yrs old +10031 – 40 yrs old +100

41 and above +5041 and above +50

Additional Ratings for retinopathyAdditional Ratings for retinopathy

Mild (microaneurysms) 0 Mild (microaneurysms) 0

Moderate (exudative) +50Moderate (exudative) +50

Severe (proliferative) +100Severe (proliferative) +100

Diabetic Retinopathy (Brackenridge)Diabetic Retinopathy (Brackenridge)

Proteinuria Proteinuria

Trace 0Trace 0

+1 +50+1 +50

+2 +100+2 +100

+3 and up Decline +3 and up Decline

Smoker – additional +50Smoker – additional +50

Diabetic RetinopathyDiabetic Retinopathy

60 yr-old male executive, nicotine addict 10 sticks/day 60 yr-old male executive, nicotine addict 10 sticks/day FA 2M, diabetic for the past 10 yrs, has irreg. intake FA 2M, diabetic for the past 10 yrs, has irreg. intake of Euglucon, sees “floaters”, eyegrounds show some of Euglucon, sees “floaters”, eyegrounds show some microaneurysms and exudates; last ff up with his microaneurysms and exudates; last ff up with his endocrinologist 2 yrs ago. HbA1c = 9.4; FBS = 118 endocrinologist 2 yrs ago. HbA1c = 9.4; FBS = 118 mg%. MUR shows +2 proteinuria, ECG – normal mg%. MUR shows +2 proteinuria, ECG – normal

What is your underwriting action?What is your underwriting action? a) accept as highly substandard riska) accept as highly substandard risk b) postponeb) postpone c) declinec) decline d) talk to the agentd) talk to the agent

Prevention of Diabetic RetinopathyPrevention of Diabetic Retinopathy

If the incidence and severity of diabetic If the incidence and severity of diabetic

complications are to be avoided, it is complications are to be avoided, it is

imperative that blood sugar level beimperative that blood sugar level be

maintained within maintained within

normal levels.normal levels.

UveitisUveitis

Life CI TPD WPD ADB Life CI TPD WPD ADB

Present 0 Excl Excl Excl 1Present 0 Excl Excl Excl 1

In history 0 0 1 1 1In history 0 0 1 1 1

GlaucomaGlaucoma

Causes: Uveitis, intraocular trauma, use of Causes: Uveitis, intraocular trauma, use of steroid eye drops, rubeosis in diabetessteroid eye drops, rubeosis in diabetes

MIRA Guidelines MIRA Guidelines W/ visual impairment – Standard, ADBW/ visual impairment – Standard, ADBW/o visual impairment W/o visual impairment stable – standard, w/ CI, ADBstable – standard, w/ CI, ADB unstable – standard, ADB unstable – standard, ADB

CataractCataract

• Lens opacity, usually age-relatedLens opacity, usually age-related• Diabetic causesDiabetic causes• Others: trauma, systemic steroid use, Others: trauma, systemic steroid use,

congenital, occupationalcongenital, occupational

Life CI TPD WPD ADBLife CI TPD WPD ADBOperated 0 Excl Excl Excl 1Operated 0 Excl Excl Excl 1Unoperated 0 Excl Excl Excl 1Unoperated 0 Excl Excl Excl 1

Thank you.Thank you.