Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
subtle speech pattern changes;
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
altered eye movements and abnormal response of the pupils;
subtle speech pattern changes;
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
altered eye movements and abnormal response of the pupils;
subtle speech pattern changes;
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
altered eye movements and abnormal response of the pupils;
subtle speech pattern changes;
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
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.
In 2008, sales of critical illness insurance increased by 7%, indicating that more advisors are becoming more familiar with the product. Read on to increase your knowledge about the product and some of the covered illnesses.
To help address the knowledge gap challenge faced by advisors, we continue this series with an examination of the concerns and considerations insurance companies take into account when evaluating different diseases and histories.
Multiple Sclerosis (MS) is a disease of the central nervous system — the brain, spinal cord, and optic nerves.
MS attacks the protective covering, called myelin, of the nerves in the brain and spinal cord, which causes inflammation, often damaging the myelin in patches, creating lesions or plaques. When this happens, the usual flow of nerve impulses is interrupted or distorted, resulting in a wide variety of symptoms.
Multiple sclerosis can occur at any age but it is usually diagnosed between the ages of 15 to 40, during a client or patient’s career and family building years. MS is more than twice as likely to occur in women as men, and is seen most commonly in people of northern European background. An estimated 50,000 Canadians have multiple sclerosis — and because MS occurs more often in countries that are further away from the equator, Canada is a high–risk area for the disease. The MS Society estimates that approximately 1,000 new cases of MS are diagnosed each year.
It is not yet known what causes MS. Most researchers believe it to be an autoimmune disease. There is also some evidence that MS may be triggered by a common virus, and that certain people are more susceptible to developing MS because of genetic factors. There is no evidence MS is directly inherited, although a number of genes are probably involved in making some people more susceptible.
MS is not fatal for the vast majority of people affected. In its most common form it has well defined attacks, followed by complete or partial recovery. However, the severity, progression and specific symptoms cannot be predicted at the time of diagnosis. Most people who have MS can expect to live a normal or near normal life span, thanks to improvements in the treatment of symptoms and other therapies.
Underwriting and claims management complexities
No two cases of multiple sclerosis are alike. Symptoms are wide-ranging, sometimes vague, and frequently mimic other conditions. In addition, because symptoms are usually not progressive and persistent, they regularly go unreported.
And, since MS generally emerges at younger ages, physicians may dismiss symptoms due to the otherwise good health of the patient. Each of these factors makes early diagnosis difficult — and create challenges for insurers.
Ask the right questions
Given that MS symptoms are varied and often overlooked by individuals and physicians alike, insurance applicants may inadvertently omit key information, which could in turn, lead to a declined application. Past claims experience leads us to conclude that application questions need to be more specific to better assist underwriters assess an application.
Uncover clues in medical history
At Munich Re, it has been our experience that dizziness and fatigue are the most often ignored symptoms of MS. Dizziness, in particular, is frequently overlooked because it is also attributable to middle ear disorders. However, this is a common symptom of MS, caused by lesions in the complex pathways that coordinate visual, spatial and other input to the brain needed to produce and maintain equilibrium.
Due to the complexities of the disease and the gradual presentation of symptoms leading up to diagnosis, a careful review of the insured’s complete medical history is imperative. As these case studies demonstrate, full medical records are always required to ensure that the onset of symptoms occurred after the policy effective date.
Separate symptoms
The range of symptoms experienced by people with MS varies dramatically and can include reduced or abnormal sensations, weakness, clumsiness, vision disturbances (double or blurred vision), extreme fatigue, loss of balance, muscle stiffness, speech problems, bladder and bowel problems, short-term memory problems, and even partial or complete paralysis.
Often symptoms improve during periods of remission. And symptoms alone don’t indicate MS — as any one or combination of these symptoms might have causes unrelated to MS.
Diagnosis
After taking a careful medical history, including all of a person’s symptoms, past and present, the physician conducts a series of tests to check for signs that can explain the symptoms or point to disease activity. Common signs that can be detected by a doctor include:
altered eye movements and abnormal response of the pupils;
subtle speech pattern changes;
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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)
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.
In 2008, sales of critical illness insurance increased by 7%, indicating that more advisors are becoming more familiar with the product. Read on to increase your knowledge about the product and some of the covered illnesses.
To help address the knowledge gap challenge faced by advisors, we continue this series with an examination of the concerns and considerations insurance companies take into account when evaluating different diseases and histories.
Multiple Sclerosis (MS) is a disease of the central nervous system — the brain, spinal cord, and optic nerves.
MS attacks the protective covering, called myelin, of the nerves in the brain and spinal cord, which causes inflammation, often damaging the myelin in patches, creating lesions or plaques. When this happens, the usual flow of nerve impulses is interrupted or distorted, resulting in a wide variety of symptoms.
Multiple sclerosis can occur at any age but it is usually diagnosed between the ages of 15 to 40, during a client or patient’s career and family building years. MS is more than twice as likely to occur in women as men, and is seen most commonly in people of northern European background. An estimated 50,000 Canadians have multiple sclerosis — and because MS occurs more often in countries that are further away from the equator, Canada is a high–risk area for the disease. The MS Society estimates that approximately 1,000 new cases of MS are diagnosed each year.
It is not yet known what causes MS. Most researchers believe it to be an autoimmune disease. There is also some evidence that MS may be triggered by a common virus, and that certain people are more susceptible to developing MS because of genetic factors. There is no evidence MS is directly inherited, although a number of genes are probably involved in making some people more susceptible.
MS is not fatal for the vast majority of people affected. In its most common form it has well defined attacks, followed by complete or partial recovery. However, the severity, progression and specific symptoms cannot be predicted at the time of diagnosis. Most people who have MS can expect to live a normal or near normal life span, thanks to improvements in the treatment of symptoms and other therapies.
Underwriting and claims management complexities
No two cases of multiple sclerosis are alike. Symptoms are wide-ranging, sometimes vague, and frequently mimic other conditions. In addition, because symptoms are usually not progressive and persistent, they regularly go unreported.
And, since MS generally emerges at younger ages, physicians may dismiss symptoms due to the otherwise good health of the patient. Each of these factors makes early diagnosis difficult — and create challenges for insurers.
Ask the right questions
Given that MS symptoms are varied and often overlooked by individuals and physicians alike, insurance applicants may inadvertently omit key information, which could in turn, lead to a declined application. Past claims experience leads us to conclude that application questions need to be more specific to better assist underwriters assess an application.
Uncover clues in medical history
At Munich Re, it has been our experience that dizziness and fatigue are the most often ignored symptoms of MS. Dizziness, in particular, is frequently overlooked because it is also attributable to middle ear disorders. However, this is a common symptom of MS, caused by lesions in the complex pathways that coordinate visual, spatial and other input to the brain needed to produce and maintain equilibrium.
Due to the complexities of the disease and the gradual presentation of symptoms leading up to diagnosis, a careful review of the insured’s complete medical history is imperative. As these case studies demonstrate, full medical records are always required to ensure that the onset of symptoms occurred after the policy effective date.
Separate symptoms
The range of symptoms experienced by people with MS varies dramatically and can include reduced or abnormal sensations, weakness, clumsiness, vision disturbances (double or blurred vision), extreme fatigue, loss of balance, muscle stiffness, speech problems, bladder and bowel problems, short-term memory problems, and even partial or complete paralysis.
Often symptoms improve during periods of remission. And symptoms alone don’t indicate MS — as any one or combination of these symptoms might have causes unrelated to MS.
Diagnosis
After taking a careful medical history, including all of a person’s symptoms, past and present, the physician conducts a series of tests to check for signs that can explain the symptoms or point to disease activity. Common signs that can be detected by a doctor include:
altered eye movements and abnormal response of the pupils;
subtle speech pattern changes;
altered reflex response;
impaired coordination;
sensory disturbances; and
evidence of spasticity or weakness in the arms or legs.
Physical examinations may include:
an eye exam, which may reveal presence of damage to the optic nerve;
a check of muscle strength;
measuring coordination, usually with a finger–to-nose test;
an examination of body surface sensation;
a test of vibratory sense; and
a test of reflexes.
Because there is no single test that can be used to confirm MS, diagnosis can be very difficult. The process typically involves:
evidence from the person’s history;
a clinical examination; and
one or more laboratory tests.
A physician often requires all three in order to rule out other possible causes for symptoms. The basic rule for diagnosing MS requires both of the following:
Objective evidence of at least two areas of myelin loss, or lesions, and there must be evidence the lesions have occurred in different places within the brain, spinal cord, or optic nerve, at different points in time.
All other diseases that can cause similar neurological symptoms have been objectively ruled out.
Until both of the above criteria have been satisfied, a physician is not able to make a definite diagnosis. Depending on the clinical problems present when a person sees a physician, one or more of the diagnostic tests described here might be performed. Sometimes tests are done several times over a period of months, to help gather the needed information.
definite MS diagnosis satisfies what doctors call the McDonald criteria, named for neurologist W. Ian McDonald, who sparked a recent effort to make the diagnostic process for MS faster and more precise.
Types of MS
Multiple sclerosis has been grouped into several main types. These include:
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.
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