Does that Make Me Crazy? A Decade in Mental Health Karen Hunt, BA (Psychology) Hons, MSC (Health Psych) Claims Medical Specialist Kate Ramsay, Research Audit & Development Underwriter Rob Rosa, GP, Swiss Re CMO
Common Mental Health conditions Mild to moderate depression Anxiety/Stress Generalised Anxiety Disorder (GAD) Generally considered different to Bipolar disorder Schizophrenia Psychosis that affect more like 1% of the population 2
Mental Health in the UK 1 in 5 people have a mental health condition at any one time Estimated social and economic cost of 105 billion a year Mental illness accounts for 23% of burden but only 13% NHS spend (Centre for Mental Health, 2012) Mental health problems account for 30 % of GP consultations Depression is on the increase (World Health Organisation, 2003) 3
Mental Health in the UK 1 in 4 people will experience some kind of mental health problem in the course of a year Mixed anxiety and depression is the most common mental disorder in Britain Women are more likely to have been treated for a mental health problem than men Suicide rates show that British men are three times as likely to die by suicide than British women Self-harm statistics for the UK show one of the highest rates in Europe: 400 per 100,000 population Depression affects 1 in 5 older people (Mental Health Foundation) 4
UK prevalence of common mental health 1993 to 2007 (Mental Health Foundation) 5
How would you answer 'Have you experienced stress, anxiety, depression in last 5 years? ' W No symptoms Moderate symptoms 6 Severe symptoms & diagnosis
How does the patient present? Typically / hidden agenda Overt requests for time off work Evolution of treatments LIFT talking therapies self help (bibliotherapy) Books on prescription Computerised CBT Triggers for PHQ9 7
PHQ9 8
Defining mental illness how? (or WHO) ICD10 WHO International Statistical Classification of Diseases and related health problems. Latest version 2010 next due 2015. Chapter V covers mental and behavioural disorders (F00 F99). Over 450 definitions, including F93.3 Sibling rivalry disorder F65.0 Fetishism F51.3 Sleepwalking F44.3 Trance and possession disorders F60.5 Anankastic personality disorder "Personality disorder characterized by feelings of doubt, perfectionism, excessive conscientiousness, checking and preoccupation with details, stubbornness, caution, and rigidity." F19.F1x0.00 acute alcohol intoxication uncomplicated / 'drunkenness NOS' 9
Application form questions 10 years ago Now Have you, or have you ever had nervous, mental or neurological complaint, eg fits, epilepsy, blackouts, persistent headaches, paralysis, anxiety/depression? Do you currently have or have you ever had mental illness that has required hospital treatment or referral to a psychiatrist? In the last 5 years have you had anxiety, depression, stress, fatigue, or any form of nervous or mental disorder, including work related stress? (IP) During the last 5 years have you been off work or unable to carry out your normal duties due to sickness, accident or injury for more than 5 days at any one time? 10
How we collect info at underwriting stage 10 years ago Paper application forms Client questionnaires GPRs Now Online application forms either via IFA or D2C with reflexive questioning Telephone applications with nurse or underwriter Less GPRs 11
Mental illness straight through processing Magnum data ranges between 4 11 % disclosure 'mental health' An average of 7% of all disclosure Outcome Rule = 'minor' Rule = 'severe' Standard 60% 2.5% Loaded 27% 0% Decline 2.5% 23% Postpone 1.5% 7.5% Evidence 9% 67% Refer UW 1% 0% 12
Has our underwriting philosophy changed over 10 years? More consistent but less individual? We rate less for life cover Other risk factors such as IBS and migraine recognised as contributing towards mental health disability claims, and underwritten accordingly Exclusions for IP & TPD own have increased in view of claims experience Source: Claims Watch 2012 13
Disability exclusion wording Exclude mental or functional nervous disorder Chronic fatigue syndrome was added in the late 90s No benefit will be payable under this policy for any illness or disability consisting of or arising directly or indirectly from any mental or behavioural disorder (as defined by the World Health Organisation using the International Classification of Diseases (ICD10 or subsequent revision(s) therof)) including (but not exhaustively) anxiety, depression, bipolar disorder, stress, schizophrenia and schizoaffective disorders, or mental or behavioural disorder due to alcohol or substance use or misuse or any functional somatic symptoms (also known as medically unexplained symptoms) including (but not exhaustively) chronic fatigue, chronic pain, or irritable bowel syndromes or myalgic encephalo-myelitis/-pathy (ME) 14
Case study 1 what would you do? A Forensic Psychologist who works within the prison system, treating murderers, sex offenders and other criminal types No history of mental health condition or current symptoms Discloses that they have their own psychologist who they see on a monthly basis in view of the distressing nature of their job A professional requirement 'supervision' for clinical therapists and seen as best practice. Many talking therapists would/should have this set up A mental ill health prevention strategy 15
Case study 2 what would you do? A policyholder claims for depression At application he disclosed a back problem and that he smoked cannabis occasionally He was accepted standard rates with a back exclusion Was this a claim waiting to happen? 16
Swiss Re non-disclosure survey: life cover Significant non-disclosure recorded in approximately 10% of cases. Of which, mental illness on post-issue GPR sampling : UK market average 18% Mental illness is most commonly non-disclosed risk factor Overlap with lifestyle, eg excessive alcohol A little maths 20% people reported mental health problems at any one time. 8.8% applicants disclose mental illness (7% + post-issue NDL1.8%) = 11.2%??? 17
18 I Had a Black Dog, Matthew Johnstone, (2007)
Suicide early death claims analysis Do we get it right at underwriting? Early death claims analysis of 90 death claims within 2 years from inception 13% of all causes was suicide; 25% of which avoided due to early suicide exclusions 50% of NDL was mental health or lifestyle related Value of suicide exclusion? 19
Suicide some statistics It s estimated that approximately 5% of people attempt suicide at least once in their life. Between 10% and 14% of the general population have suicidal thinking throughout their lifetime. Suicide is estimated to be under-reported for reasons of stigma, religion and social attitudes. Many suicides are hidden among other causes of death, such as road traffic accidents and drowning. Source: International Association for Suicide Prevention 20
Number of suicides in English population, by sex 21
Trends in the numbers of suicides and unemployed claimants in England 2000-2010 - Women (Barr et al., BMJ, 2012) 22
Trends in the numbers of suicides and unemployed claimants in England 2000-2010 - Men (Barr et al., BMJ, 2012) 23
Psychosocial factors Fears Motivation Confidence Anxieties Problem solving Support Expectations Coping 2010 The Actuarial Profession www.actuaries.org.uk 24
Biopsychosocial model in Claims? Research Methods and Procedure Prospective cohort study UK Bank Claims notification (T0) FU at 6 months (T1) 100 Emplo yees (80% females Mean age 41) Illness NO RTW RTW
What does this mean to claims management? The results suggest that low mood and expectations determine not returning to work This is consistent with previous studies in the non insured Psychosocial factors probably do determine RTW in insurance claims If these results are confirmed, we next need to test early intervention to target mood and expectations
Global mental health impacts UK (Source: Kessler, Harvard) Recent discrimination challenge to insurers in Australia could this happen in the UK? 27
What about the next decade in mental health? Mental health likely to continue to have a significant impact at both UW and claims Use of biopsychosocial model will hopefully assist with management of these claims as well as being brought into underwriting We should get better at predicting those who claim and those who recover and return to work once on claim Will we see rates of common mental health conditions increase?
Any questions? Where are you on the fifty shades of grey today? 29
Thank you
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