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TUBERCULOSIS IN RELATION TO LIFE ASSURANCE
[FEB. 27, 1937
ADDRESSES AND ORIGINAL ARTICLES year until it is wiped out. For example, in the case of a policy of JE1000, the lien might be 500, reducible each year by, say, 25, until after 20 years, the lien is extin-
TUBERCULOSIS IN RELATION TO LIFE ASSURANCE*
guished. BY OTTO
MAY, M.D. Camb., F.R.C.P. Lond.
PRINCIPAL MEDICAL OFFICER TO THE PRUDENTIAL ASSURANCE
COMPANY,
LONDON
life assurance is a system of pooling group of individuals, in order to pay at death or after a certain period. The annual premiums are calculated on certain mortality tables, which show how many of the group may be expected to die each year. Most of the tables at present in use are " select " ones, based on groups of people specially selected, by careful inspection of a completed proposal form, usually supplemented by a medical examination. The latest table of this type, compiled by the Institute of Actuaries, and known as " A 1924-29 Ult." is based on the mortality between those years of persons accepted by various British companies as first-class risks. It shows, for each age, the mortality-rate for each of the first three years after entry, and subsequently for attained ages regardless of the The Chart shows what this age at entry. latter rate is for lives aged from 30 onwards (dotted line). In the first year it is about 0’0025, and it rises only very gradually, till after 23 years it reaches 0’01 (1 in 100). The continuous black line shows the mortality (males) from the English census returns of 1921 and is slightly higher, though roughly parallel to the former. Types of Impairment IN
essence
by
resources out a sum
a
Suppose now that we have to consider how to deal with a group of proposers in whom there is some definite impairment, some condition likely to upset the mortality curve. Such conditions are of various types, which may be classified as follows :(1) Occupational risks, of which
the most is the retail trade in alcoholic Climatic risks.
life
assurance
important liquors.
in
(2) (3) Family history. (4) History of past illnesses. (5) Impairment in personal condition.
Of course, the same proposer may have impairments in than one of these classes-e.g., a publican with a tuberculous family history, and a bad health record of his own. From the actuarial point of view, the ideal way of assessing the extra risk in a particular case would be to construct, from an experience of a large number of similar cases, the mortality curve, and to calculate from this how best to meet the extra risk thus shown. Unfortunately, for a large proportion of impairments, the necessary data are too scanty to allow of this method, and in such cases the method of dealing with the impairment must be largely empirical. There are various plans in use for accepting impaired lives at special terms, the chief being-
more
.
(1) An addition of years to the age at entry, so that the proposer pays an extra premium equal to the difference between that at his actual age and at the rated-up age. (2) Similarly, a certain extra sum may be added to the premium, either for a limited period or for the duration of the policy, not necessarily corresponding to any special age. (3) A reducing debt or lien is imposed, usually a percentage of the sum assured, which lien is reduced each *
An address to the Tuberculosis Association delivered
Feb. 20th.
5922
As to which is the most suitable from the actuarial point of view, a great deal depends upon the nature of the extra risk. Some are definitely increasing risks, such as the presence of some cardiovascular defect, or excessive weight, or a bad family history of cardiovascular disorders ; some are more or less constant, such as climatic or occupational risks, while others are definitely decreasing, such as a personal history of pulmonary tuberculosis, underweight, &c An increasing or constant risk is best covered by an addition to the premium or rating up of the age, while a decreasing risk is suitably met by a reducing lien, which gradually disappears as the risk diminishes. From the proposer’s point of view, this method makes no appeal when the object of the insurance is primarily protection-i.e., when cover is definitely required in case of early death. When, on the other hand, the investment factor is of importance, such as provision for old age, he would regard the lien as the preferable way, as he pays no extra and, should he survive a certain period, he receives the full face value of the policy.
Impairment from Tuberculosis
Having given this preliminary sketch of life in general, I should now like to indicate how the tuberculosis problem is regarded in presentday life assurance practice. I shall not discuss any of the questions of diagnosis, prognosis, or treatment, but merely indicate how the business of life assurance regards the various aspects of this problem. Our methods may seem grossly empirical and unscientific, but it must be borne in mind (1) that the premiums charged allow only a small margin for medical expenses, and (2) that competition between companies is pretty keen, and tends to prevent a too scrupulous investigation of apparently unimportant points. For these reasons, cases must be assessed on information which is often scrappy as regards both family history and past history, and which is not seldom unreliable even on the question of the personal examination of the proposer. Unless the proposal is for a large amount, it is usually impracticable to have the examination conducted by a specialist, and the questions of expense and competition often prohibit a radiogram of the lungs, or even a sputum examination in cases in which these methods might be regarded In cases in which as indispensable in clinical practice. a past history of pulmonary tuberculosis figures on the proposal, a report from the proposer’s own assurance
doctor often draws a blank, as the proposer may have received institutional treatment, and the practitioner seems unable or unwilling to give any useful information to the company. Of course, it is open to the latter to insist on the proposer giving the name of the institution, with permission to apply to the medical superintendent for a report, but, unless the proposal is for a substantial amount, the cost of the examination and of the doctor’s report, already incurred, together with the further delay involved, may cause the company to assess the case on the information already in their possession, instead of pursuing the matter any further.
FAMILY HISTORY
Two on
of
large family history
actuarial on
investigations on the influence pulmonary tuberculosis are worth I
494
mentioning, the first by Rusher and Kenchington - (1913) and the second by the American MedicoActuarial Investigation Committee (1914). Without going into details, both these confirmed the fact of the adverse influence on mortality of a family history of one or more cases of pulmonary tuberculosis, especially TABLE I
Effect of Weight
on
young,
proposers
are,
terms
in
America, purposes
a year on medical examination. In contact " is usually regarded for insurance as equivalent to a family history of
"
tuberculosis. PERSONAL HISTORY
of Age
If the young 11 in. and mortality is greater than for Incidentally the American out clearly in this group an
underweight in
and
company it is customary to impose a fairly heavy reducing lien if there has been contact within 12 months of proposal, with an offer to reconsider the
proposers.
addition, tall (5 ft.
upwards), the excess shorter underweights. investigation brought interesting point-namely,
the decreasing proportion of deaths from tuberculosis with increasing weight, and increasing age. This is shown in Table I. In America, where the " numerical rating system" is almost universal, the extra mortality for family history is assessed on the lines shown in Table II, the amount depending on age at entry and the degree of deviation from the average weight for age. In this connexion a further point may be mentioned. To the tuberculosis expert, the interest of family history is principally on the question: how far, if at all, is the disease an hereditary one" To the insurance company, the point of interest is: " Does a tuberculous family history tend to impair the
When, if ever, is it practicable to undertake the insurance of proposers with a personal history of pulmonary tuberculosis?Y I need hardly point out that the mortality in the early years after treatment is high, even in the case of those who came under treatment at a comparatively early stage of the disease. Among those applying for life assurance, with a history of pulmonary tuberculosis, the larger proportion are naturally in this group, though such is the optimism of the sufferer, or perhaps of the agent, that we not very rarely receive proposals from tuberculous patients in an advanced stage of the disease. Two English medico-actuarial investigations of the after-histories of patients who have been under sanatorium treatment are very instructive for the insurance offices, and I should like to refer to them TABLE II
Rating for
Build with or without Tuberculosis
Family History of
"
expectation of life-i.e., to increasethemortalityrisk ? They are not specially interested in the causes of the extra deaths, be they tuberculosis, diabetes, or anything else, but only in the fact of extra deaths in the group in question. CONTACTS
Here we arrive on debatable ground. The problems of marital infection and the analogous risks in family circles have been hotly debated. At present there appears to be a predominating opinion that close contact in insanitary surroundings is a definite risk. A recent paper by Lloyd and MacPherson (1936) confirms this in the case-histories of young adults with pulmonary tuberculosis, although, in the great majority of cases investigated by them, the contact was with tuberculous members of their families, so that the question of contact is complicated by that of heredity or familial susceptibility. This point He was emphasised as long ago as 1908 by Pope. found that the probability of infection between husband and wife was considerably less than between parents and child, or brother and sister, a result suggesting that hereditary " lack of resistance " plays a large part in many of the cases of apparent direct infection. Whatever may be the theoretical truth regarding contact and hereditary predisposition, most insurance companies impose some extra if the proposer has been living in the same house as a patient with open tuberculosis, the amount of the extra depending on the hygienic conditions of the case, and the various other obvious factors, such as proposer’s physique and family history. With my
Plus 50
means a
mortality of 150 instead of the expected 100. R=
rejected.
in this connexion ; they are those from Midhurst and Frimley. The excellent annual reports from Midhurst (1935) contain a statistical record of all the cases discharged from the sanatorium since 1906, arranged in various groups according to the condition on admission, and presence or absence of tubercle bacilli in the sputum during their stay. The total number discharged is 6451, and only 224 (or 3’4 per cent.) cannot be traced.
495 The Chart shows the mortality experience (1) of all discharged cases (Curve E) and (2) mild cases only
(Curve D) or Group -cases
1
(Turban-Gerhardt) T.B. positive
in which bacilli have been found-which have
" disease of slight severity, limited to small areas of lobe on either side which, in the case of affection of both apices, does not extend beyond the spine of the scapula or the clavicle, in the case of affection of the apex of one lung, does not extend below the second rib in front."
of a decreasing lien is considered, it will be seen that the situation is more promising. Even two years after discharge, cases of this type might be accepted with a very heavy reducing lien, say 80-90 per cent., especially if proposing for an endowment assurance.
one
The actual figures produce an irregular line, due, of course, to the relatively scanty data. I have had this graduated into a smooth curve which, to the actuary, is an approximation to what might be expected if the data were large enough. A comparison of these with the curves A and B of first-class risks (A 1924-29 and E.L.T. 9) in males from age 30 shows the enormous In the first excess mortality in the early years. year after discharge, Curve E shows a mortality approximately 50 times the expected, and even after 5 years it is still about 25 times that expected from A (A 1924-29) ; after 10 years it is roughly 12 times, after 20 years about 4 times, and only after some 25 years do the two curves show signs of approximation. Curve D, the mild cases, shows, as would be expected, a rather less unfavourable mortality. In the first year it is roughly 17 times the " expected " ; after 5 years about 12 times, after 10 years about 8 times, and after 20 years about 3 times. The Frimley experience deals with the patients admitted between 1905 and 1931, and comprises 8766 patients (Hartley, Wingfield, and Burrows 1935). For comparison with the Midhurst experience, I have taken the group of " Grade B" males. "
All
being T.B. positive
cases
with
slight
showing rate of mortality in-
Chart
A. Inst. of Actuaries table 1924-29 (age 30). B. English Life Table No. 9 (1921 Census), age 30. E. All cases, and D, mild cases of tuberculosis discharged from Midhurst Sanatorium. C. Mild cases of tuberculosis from discharged Frimley Sanatorium 1905-31.
constitutional
disturbances, if
any.... The obvious physical signs should be of very limited extent as follows : Either present in one lobe only and, in the case of an apical lesion of one upper lobe, not extending below the second rib in front and not exceeding an equivalent area in any one lobe ; or where these physical signs are present in more than one lobe, they should be limited to the apices of the upper lobe, and should not extend below the clavicle and the spine of the scapula. No complication (tuberculous or other) of prognostic gravity should be present. A small area of dry pleurisy should not exclude a case from this group."
It will be
seen
that this group is very similar to
Group 1 in the Midhurst classification, and the mortality table here, worked out in Curve C, shows a general resemblance to that already shown for Midhurst (Curve D). We may assume, therefore, that we have a pretty clear view of the mortality of a considerable group of cases having these features (1) all T.B. positive, (2) all having undergone sanatorium treatment, (3) physical signs as defined above-i.e., limited to infiltration
or catarrh of one lobe or small parts of without grave complications. These constitute what one is prone to regard as a favourable type of case, and yet the mortality, compared even with the general population, shows an enormous, though decreasing, excess for at least 20-25 years after discharge.
two-(4)
Effect
Suppose
there
on
were
Insurance a
scheme
of
compulsory
insurance for this group : it is, I think, obvious that the
to cover the risks would have to be to make them fantastic ; it is the early incidence of the risk that makes this inevitablereverse the extra mortality into an increasing risk,
premiums
Naturally the death cover is very small at first, and a policy has little value as protection for dependants, but sufferers from pulmonary tuberculosis can hardly expect it. If they care for a policy that is primarily an investment, this can be achieved by the offer of an endowment with a heavy lien. My company has issued many such policies, usually such
with an offer to reconsider the amount of the lien after the lapse of a few years, and I cannot help thinking that these play a useful part from the psychological point of view. It surely must help a tuberculous patient to a greater confidence in his. future if he finds that a company is willing to offer him an insurance contract, even though the death, benefit is small. Recently my company has investigated theirexperience of a group of entrants 1921-23 (threeyears) who all had a personal history of tuberculosis (nearly half being pulmonary), and who had been accepted under the conditions outlined above. They numbered 894, of whom 353 were pulmonary cases. Of the 894, 79 died in the first 12 years of insurance,
against an expected" 42 ; of the 353 pulmonary 47 died against an "expected" 17. This shows that the selection of cases was reasonably good. The actual claims paid in the group amounted to 11,506; the expected according to A 1924-29 would have been :S11,017—a result indicating that this method strikes "
"
"
fair balance between the proposers and the company.
so enormous as
a
and the
You will have noticed, of course, that I have discussed the insurance of these cases in bulk, and
problem would be less insoluble. If, however, instead of extra premium, the method
Special Cases
496 said nothing about methods of individual selection. As I have indicated above, unless the proposals are for fairly large sums, it may be impracticable to investigate them as thoroughly as one would like to do, though personally I should never accept any proposal with a T.B. plus history, during the first five years without a heavy rating, however free from symptoms or physical signs he may appear to be.
that
period varies according to whether the attack dry or with effusion, and according to the duration of the attack (dry), whether less than or more than two weeks, and according to the period that has elapsed, the age of the proposal, and the weight/height ratio.
was
TABLE III
Dry Pleurisy.
glad to hear medical opinion on how by artificial pneumothorax is to be regarded as a favourable prognostic feature. Judging by the Frimley report, this method is used hardly at all in mild (Group Bl) cases. It was performed chiefly (in over 80 per cent.) in Group B3 : " Cases with profound systemic disturbance or constitutional deterioration, with marked impairment of function, either local or general, and with little or no prospect of recovery." These cases, when compared with I should be far treatment
same
of less than 2
weeks)
Deviation from average weight2nd and 3rd years.
ARTIFICIAL PNEUMOTHORAX
other groups of the
(Attacks
sex, age-group, and medical
grade on admission, showed a more favourable mortality, suggesting that in these comparatively advanced cases it improved the period of survival. We receive proposals from quite a considerable number of patients either with a history of, artificial pneumothorax treatment, or even still having periodical refills, but I can give no figures of comparison with other cases. We seldom find it practicable to consider these
favourable terms, as the evidence of better definitely prognosis is still rather scanty. As regards other methods of treatment, such as phrenicotomy, thoracoplasty, and oleothorax, the number of proposals is small, and of course the cases are usually those in which the disease has been severe, so that it could hardly be expected that the terms of acceptance would be more favourable. on more
a
NON-PULMONARY TUBERCULOSIS
I have discussed the acceptance of pulmonary cases in some detail, and what has been said in that connexion applies, more or less closely, to urogenital tuberculosis. No case would be accepted within five years of the disease, except with a maximum lien, and from five to ten years the lien should be a substantial one. In tuberculous joint or bone disease and adenitis we do not, as a rule, take such a grave view as in genito-urinary and pulmonary disease; each case is treated on its merits, with regard to family history, age, physique, occupation and, of course, the extent of the original infection, and the time elapsing since then. PLEURISY
primary pleurisy, whether dry or with assurance purposes always regarded It is my usual as probably of tuberculous origin. practice to impose some lien in every case with this history till at least seven years have elapsed: the amount of the lien varies according to the time, family history, physique, and so on. It may be as little as 20 per cent. (our minimum). In our investigation of 2040 cases accepted in 1921-23, the actual deaths numbered 209, against the " expected" (A 1924-29) of 159 : as regards the amount of claims, the " net " actual was :E37,400 against the " expected " of U6,475, a fairly substantial surplus, which is largely distributed as bonus to the survivors. In the " Medical impairment mortality ratings," A
history
of
effusion, is for
are used in America for their numerical method of assessment, no case is considered until at least The " extra " imposed after a year after the attack.
which
It should be noted that the ratings here given are independent of and in addition to those which normally apply on account of the build of the applicant.
Table III is
an
example
of their method for
assess-
ment of an attack of dry pleurisy lasting less than two weeks. It will be seen that the extra mortality rating varies from + 70 for young underweights in the second or third year after attack, to 0 in elderly people
of normal (over two + 140.
weight or over. For a longer attack weeks) the corresponding maximum is Conclusion
In conclusion I should like to emphasise once more that the life assurance attitude towards tuberculosis is inevitably one of grouping cases into classes for which some sort of mortality table has been calculated, or can be presumed, rather than of considering them as clinical individuals. It is probable, nay certain, that some cases are dealt with too harshly, and others too leniently, but I If anysee no way of avoiding this state of affairs. one can point out any simple means of more exact prognosis in individual cases, I for one will welcome the information, and use it so far as is practicable for a more equitable assessment of the terms of acceptance in these cases. REFERENCES Amer. Med.-Actuarian Invest. Comm. (1914). Hartley, P. H.-S., Wingfield, R. C., and Burrows, V. A. (1935) Brompton Hosp. Rep. 4, 1. Lloyd, W. E., and MacPherson, M. (1936) Brit. med. J. 2, 1130. Midhurst Sanatorium (1935) Ann. Rep. Pope, E. G. (1908) A Second Study of the Statistics of Pulmonary Tuberculosis : Marital Infection. Edited by Karl Pearson. London. Rusher, E. A., and Kenchington, C. W. (1913) J. Inst. Acht.
ADDRESSES AND ORIGINAL ARTICLES year until it is wiped out. For example, in the case of a policy of JE1000, the lien might be 500, reducible each year by, say, 25, until after 20 years, the lien is extin-
TUBERCULOSIS IN RELATION TO LIFE ASSURANCE*
guished. BY OTTO
MAY, M.D. Camb., F.R.C.P. Lond.
PRINCIPAL MEDICAL OFFICER TO THE PRUDENTIAL ASSURANCE
COMPANY,
LONDON
life assurance is a system of pooling group of individuals, in order to pay at death or after a certain period. The annual premiums are calculated on certain mortality tables, which show how many of the group may be expected to die each year. Most of the tables at present in use are " select " ones, based on groups of people specially selected, by careful inspection of a completed proposal form, usually supplemented by a medical examination. The latest table of this type, compiled by the Institute of Actuaries, and known as " A 1924-29 Ult." is based on the mortality between those years of persons accepted by various British companies as first-class risks. It shows, for each age, the mortality-rate for each of the first three years after entry, and subsequently for attained ages regardless of the The Chart shows what this age at entry. latter rate is for lives aged from 30 onwards (dotted line). In the first year it is about 0’0025, and it rises only very gradually, till after 23 years it reaches 0’01 (1 in 100). The continuous black line shows the mortality (males) from the English census returns of 1921 and is slightly higher, though roughly parallel to the former. Types of Impairment IN
essence
by
resources out a sum
a
Suppose now that we have to consider how to deal with a group of proposers in whom there is some definite impairment, some condition likely to upset the mortality curve. Such conditions are of various types, which may be classified as follows :(1) Occupational risks, of which
the most is the retail trade in alcoholic Climatic risks.
life
assurance
important liquors.
in
(2) (3) Family history. (4) History of past illnesses. (5) Impairment in personal condition.
Of course, the same proposer may have impairments in than one of these classes-e.g., a publican with a tuberculous family history, and a bad health record of his own. From the actuarial point of view, the ideal way of assessing the extra risk in a particular case would be to construct, from an experience of a large number of similar cases, the mortality curve, and to calculate from this how best to meet the extra risk thus shown. Unfortunately, for a large proportion of impairments, the necessary data are too scanty to allow of this method, and in such cases the method of dealing with the impairment must be largely empirical. There are various plans in use for accepting impaired lives at special terms, the chief being-
more
.
(1) An addition of years to the age at entry, so that the proposer pays an extra premium equal to the difference between that at his actual age and at the rated-up age. (2) Similarly, a certain extra sum may be added to the premium, either for a limited period or for the duration of the policy, not necessarily corresponding to any special age. (3) A reducing debt or lien is imposed, usually a percentage of the sum assured, which lien is reduced each *
An address to the Tuberculosis Association delivered
Feb. 20th.
5922
As to which is the most suitable from the actuarial point of view, a great deal depends upon the nature of the extra risk. Some are definitely increasing risks, such as the presence of some cardiovascular defect, or excessive weight, or a bad family history of cardiovascular disorders ; some are more or less constant, such as climatic or occupational risks, while others are definitely decreasing, such as a personal history of pulmonary tuberculosis, underweight, &c An increasing or constant risk is best covered by an addition to the premium or rating up of the age, while a decreasing risk is suitably met by a reducing lien, which gradually disappears as the risk diminishes. From the proposer’s point of view, this method makes no appeal when the object of the insurance is primarily protection-i.e., when cover is definitely required in case of early death. When, on the other hand, the investment factor is of importance, such as provision for old age, he would regard the lien as the preferable way, as he pays no extra and, should he survive a certain period, he receives the full face value of the policy.
Impairment from Tuberculosis
Having given this preliminary sketch of life in general, I should now like to indicate how the tuberculosis problem is regarded in presentday life assurance practice. I shall not discuss any of the questions of diagnosis, prognosis, or treatment, but merely indicate how the business of life assurance regards the various aspects of this problem. Our methods may seem grossly empirical and unscientific, but it must be borne in mind (1) that the premiums charged allow only a small margin for medical expenses, and (2) that competition between companies is pretty keen, and tends to prevent a too scrupulous investigation of apparently unimportant points. For these reasons, cases must be assessed on information which is often scrappy as regards both family history and past history, and which is not seldom unreliable even on the question of the personal examination of the proposer. Unless the proposal is for a large amount, it is usually impracticable to have the examination conducted by a specialist, and the questions of expense and competition often prohibit a radiogram of the lungs, or even a sputum examination in cases in which these methods might be regarded In cases in which as indispensable in clinical practice. a past history of pulmonary tuberculosis figures on the proposal, a report from the proposer’s own assurance
doctor often draws a blank, as the proposer may have received institutional treatment, and the practitioner seems unable or unwilling to give any useful information to the company. Of course, it is open to the latter to insist on the proposer giving the name of the institution, with permission to apply to the medical superintendent for a report, but, unless the proposal is for a substantial amount, the cost of the examination and of the doctor’s report, already incurred, together with the further delay involved, may cause the company to assess the case on the information already in their possession, instead of pursuing the matter any further.
FAMILY HISTORY
Two on
of
large family history
actuarial on
investigations on the influence pulmonary tuberculosis are worth I
494
mentioning, the first by Rusher and Kenchington - (1913) and the second by the American MedicoActuarial Investigation Committee (1914). Without going into details, both these confirmed the fact of the adverse influence on mortality of a family history of one or more cases of pulmonary tuberculosis, especially TABLE I
Effect of Weight
on
young,
proposers
are,
terms
in
America, purposes
a year on medical examination. In contact " is usually regarded for insurance as equivalent to a family history of
"
tuberculosis. PERSONAL HISTORY
of Age
If the young 11 in. and mortality is greater than for Incidentally the American out clearly in this group an
underweight in
and
company it is customary to impose a fairly heavy reducing lien if there has been contact within 12 months of proposal, with an offer to reconsider the
proposers.
addition, tall (5 ft.
upwards), the excess shorter underweights. investigation brought interesting point-namely,
the decreasing proportion of deaths from tuberculosis with increasing weight, and increasing age. This is shown in Table I. In America, where the " numerical rating system" is almost universal, the extra mortality for family history is assessed on the lines shown in Table II, the amount depending on age at entry and the degree of deviation from the average weight for age. In this connexion a further point may be mentioned. To the tuberculosis expert, the interest of family history is principally on the question: how far, if at all, is the disease an hereditary one" To the insurance company, the point of interest is: " Does a tuberculous family history tend to impair the
When, if ever, is it practicable to undertake the insurance of proposers with a personal history of pulmonary tuberculosis?Y I need hardly point out that the mortality in the early years after treatment is high, even in the case of those who came under treatment at a comparatively early stage of the disease. Among those applying for life assurance, with a history of pulmonary tuberculosis, the larger proportion are naturally in this group, though such is the optimism of the sufferer, or perhaps of the agent, that we not very rarely receive proposals from tuberculous patients in an advanced stage of the disease. Two English medico-actuarial investigations of the after-histories of patients who have been under sanatorium treatment are very instructive for the insurance offices, and I should like to refer to them TABLE II
Rating for
Build with or without Tuberculosis
Family History of
"
expectation of life-i.e., to increasethemortalityrisk ? They are not specially interested in the causes of the extra deaths, be they tuberculosis, diabetes, or anything else, but only in the fact of extra deaths in the group in question. CONTACTS
Here we arrive on debatable ground. The problems of marital infection and the analogous risks in family circles have been hotly debated. At present there appears to be a predominating opinion that close contact in insanitary surroundings is a definite risk. A recent paper by Lloyd and MacPherson (1936) confirms this in the case-histories of young adults with pulmonary tuberculosis, although, in the great majority of cases investigated by them, the contact was with tuberculous members of their families, so that the question of contact is complicated by that of heredity or familial susceptibility. This point He was emphasised as long ago as 1908 by Pope. found that the probability of infection between husband and wife was considerably less than between parents and child, or brother and sister, a result suggesting that hereditary " lack of resistance " plays a large part in many of the cases of apparent direct infection. Whatever may be the theoretical truth regarding contact and hereditary predisposition, most insurance companies impose some extra if the proposer has been living in the same house as a patient with open tuberculosis, the amount of the extra depending on the hygienic conditions of the case, and the various other obvious factors, such as proposer’s physique and family history. With my
Plus 50
means a
mortality of 150 instead of the expected 100. R=
rejected.
in this connexion ; they are those from Midhurst and Frimley. The excellent annual reports from Midhurst (1935) contain a statistical record of all the cases discharged from the sanatorium since 1906, arranged in various groups according to the condition on admission, and presence or absence of tubercle bacilli in the sputum during their stay. The total number discharged is 6451, and only 224 (or 3’4 per cent.) cannot be traced.
495 The Chart shows the mortality experience (1) of all discharged cases (Curve E) and (2) mild cases only
(Curve D) or Group -cases
1
(Turban-Gerhardt) T.B. positive
in which bacilli have been found-which have
" disease of slight severity, limited to small areas of lobe on either side which, in the case of affection of both apices, does not extend beyond the spine of the scapula or the clavicle, in the case of affection of the apex of one lung, does not extend below the second rib in front."
of a decreasing lien is considered, it will be seen that the situation is more promising. Even two years after discharge, cases of this type might be accepted with a very heavy reducing lien, say 80-90 per cent., especially if proposing for an endowment assurance.
one
The actual figures produce an irregular line, due, of course, to the relatively scanty data. I have had this graduated into a smooth curve which, to the actuary, is an approximation to what might be expected if the data were large enough. A comparison of these with the curves A and B of first-class risks (A 1924-29 and E.L.T. 9) in males from age 30 shows the enormous In the first excess mortality in the early years. year after discharge, Curve E shows a mortality approximately 50 times the expected, and even after 5 years it is still about 25 times that expected from A (A 1924-29) ; after 10 years it is roughly 12 times, after 20 years about 4 times, and only after some 25 years do the two curves show signs of approximation. Curve D, the mild cases, shows, as would be expected, a rather less unfavourable mortality. In the first year it is roughly 17 times the " expected " ; after 5 years about 12 times, after 10 years about 8 times, and after 20 years about 3 times. The Frimley experience deals with the patients admitted between 1905 and 1931, and comprises 8766 patients (Hartley, Wingfield, and Burrows 1935). For comparison with the Midhurst experience, I have taken the group of " Grade B" males. "
All
being T.B. positive
cases
with
slight
showing rate of mortality in-
Chart
A. Inst. of Actuaries table 1924-29 (age 30). B. English Life Table No. 9 (1921 Census), age 30. E. All cases, and D, mild cases of tuberculosis discharged from Midhurst Sanatorium. C. Mild cases of tuberculosis from discharged Frimley Sanatorium 1905-31.
constitutional
disturbances, if
any.... The obvious physical signs should be of very limited extent as follows : Either present in one lobe only and, in the case of an apical lesion of one upper lobe, not extending below the second rib in front and not exceeding an equivalent area in any one lobe ; or where these physical signs are present in more than one lobe, they should be limited to the apices of the upper lobe, and should not extend below the clavicle and the spine of the scapula. No complication (tuberculous or other) of prognostic gravity should be present. A small area of dry pleurisy should not exclude a case from this group."
It will be
seen
that this group is very similar to
Group 1 in the Midhurst classification, and the mortality table here, worked out in Curve C, shows a general resemblance to that already shown for Midhurst (Curve D). We may assume, therefore, that we have a pretty clear view of the mortality of a considerable group of cases having these features (1) all T.B. positive, (2) all having undergone sanatorium treatment, (3) physical signs as defined above-i.e., limited to infiltration
or catarrh of one lobe or small parts of without grave complications. These constitute what one is prone to regard as a favourable type of case, and yet the mortality, compared even with the general population, shows an enormous, though decreasing, excess for at least 20-25 years after discharge.
two-(4)
Effect
Suppose
there
on
were
Insurance a
scheme
of
compulsory
insurance for this group : it is, I think, obvious that the
to cover the risks would have to be to make them fantastic ; it is the early incidence of the risk that makes this inevitablereverse the extra mortality into an increasing risk,
premiums
Naturally the death cover is very small at first, and a policy has little value as protection for dependants, but sufferers from pulmonary tuberculosis can hardly expect it. If they care for a policy that is primarily an investment, this can be achieved by the offer of an endowment with a heavy lien. My company has issued many such policies, usually such
with an offer to reconsider the amount of the lien after the lapse of a few years, and I cannot help thinking that these play a useful part from the psychological point of view. It surely must help a tuberculous patient to a greater confidence in his. future if he finds that a company is willing to offer him an insurance contract, even though the death, benefit is small. Recently my company has investigated theirexperience of a group of entrants 1921-23 (threeyears) who all had a personal history of tuberculosis (nearly half being pulmonary), and who had been accepted under the conditions outlined above. They numbered 894, of whom 353 were pulmonary cases. Of the 894, 79 died in the first 12 years of insurance,
against an expected" 42 ; of the 353 pulmonary 47 died against an "expected" 17. This shows that the selection of cases was reasonably good. The actual claims paid in the group amounted to 11,506; the expected according to A 1924-29 would have been :S11,017—a result indicating that this method strikes "
"
"
fair balance between the proposers and the company.
so enormous as
a
and the
You will have noticed, of course, that I have discussed the insurance of these cases in bulk, and
problem would be less insoluble. If, however, instead of extra premium, the method
Special Cases
496 said nothing about methods of individual selection. As I have indicated above, unless the proposals are for fairly large sums, it may be impracticable to investigate them as thoroughly as one would like to do, though personally I should never accept any proposal with a T.B. plus history, during the first five years without a heavy rating, however free from symptoms or physical signs he may appear to be.
that
period varies according to whether the attack dry or with effusion, and according to the duration of the attack (dry), whether less than or more than two weeks, and according to the period that has elapsed, the age of the proposal, and the weight/height ratio.
was
TABLE III
Dry Pleurisy.
glad to hear medical opinion on how by artificial pneumothorax is to be regarded as a favourable prognostic feature. Judging by the Frimley report, this method is used hardly at all in mild (Group Bl) cases. It was performed chiefly (in over 80 per cent.) in Group B3 : " Cases with profound systemic disturbance or constitutional deterioration, with marked impairment of function, either local or general, and with little or no prospect of recovery." These cases, when compared with I should be far treatment
same
of less than 2
weeks)
Deviation from average weight2nd and 3rd years.
ARTIFICIAL PNEUMOTHORAX
other groups of the
(Attacks
sex, age-group, and medical
grade on admission, showed a more favourable mortality, suggesting that in these comparatively advanced cases it improved the period of survival. We receive proposals from quite a considerable number of patients either with a history of, artificial pneumothorax treatment, or even still having periodical refills, but I can give no figures of comparison with other cases. We seldom find it practicable to consider these
favourable terms, as the evidence of better definitely prognosis is still rather scanty. As regards other methods of treatment, such as phrenicotomy, thoracoplasty, and oleothorax, the number of proposals is small, and of course the cases are usually those in which the disease has been severe, so that it could hardly be expected that the terms of acceptance would be more favourable. on more
a
NON-PULMONARY TUBERCULOSIS
I have discussed the acceptance of pulmonary cases in some detail, and what has been said in that connexion applies, more or less closely, to urogenital tuberculosis. No case would be accepted within five years of the disease, except with a maximum lien, and from five to ten years the lien should be a substantial one. In tuberculous joint or bone disease and adenitis we do not, as a rule, take such a grave view as in genito-urinary and pulmonary disease; each case is treated on its merits, with regard to family history, age, physique, occupation and, of course, the extent of the original infection, and the time elapsing since then. PLEURISY
primary pleurisy, whether dry or with assurance purposes always regarded It is my usual as probably of tuberculous origin. practice to impose some lien in every case with this history till at least seven years have elapsed: the amount of the lien varies according to the time, family history, physique, and so on. It may be as little as 20 per cent. (our minimum). In our investigation of 2040 cases accepted in 1921-23, the actual deaths numbered 209, against the " expected" (A 1924-29) of 159 : as regards the amount of claims, the " net " actual was :E37,400 against the " expected " of U6,475, a fairly substantial surplus, which is largely distributed as bonus to the survivors. In the " Medical impairment mortality ratings," A
history
of
effusion, is for
are used in America for their numerical method of assessment, no case is considered until at least The " extra " imposed after a year after the attack.
which
It should be noted that the ratings here given are independent of and in addition to those which normally apply on account of the build of the applicant.
Table III is
an
example
of their method for
assess-
ment of an attack of dry pleurisy lasting less than two weeks. It will be seen that the extra mortality rating varies from + 70 for young underweights in the second or third year after attack, to 0 in elderly people
of normal (over two + 140.
weight or over. For a longer attack weeks) the corresponding maximum is Conclusion
In conclusion I should like to emphasise once more that the life assurance attitude towards tuberculosis is inevitably one of grouping cases into classes for which some sort of mortality table has been calculated, or can be presumed, rather than of considering them as clinical individuals. It is probable, nay certain, that some cases are dealt with too harshly, and others too leniently, but I If anysee no way of avoiding this state of affairs. one can point out any simple means of more exact prognosis in individual cases, I for one will welcome the information, and use it so far as is practicable for a more equitable assessment of the terms of acceptance in these cases. REFERENCES Amer. Med.-Actuarian Invest. Comm. (1914). Hartley, P. H.-S., Wingfield, R. C., and Burrows, V. A. (1935) Brompton Hosp. Rep. 4, 1. Lloyd, W. E., and MacPherson, M. (1936) Brit. med. J. 2, 1130. Midhurst Sanatorium (1935) Ann. Rep. Pope, E. G. (1908) A Second Study of the Statistics of Pulmonary Tuberculosis : Marital Infection. Edited by Karl Pearson. London. Rusher, E. A., and Kenchington, C. W. (1913) J. Inst. Acht.