Earlier this year researchers at Heidelberg University Hospital announced the development of a blood test that can detect breast cancer cells in patients - with higher accuracy than mammography. Around the same time it was reported that a second and third HIV-positive person had been cured of the disease. Then in March 2019 the development of a new Ebola vaccine, created from antibodies taken from a survivor, was announced.

Medical progress happens all the time - with unprecedented speed in the 21st century. New approaches in the fields of prevention, diagnostics and therapy suggest that the extinction of serious diseases could become a reality. In any case, they offer the prospect of earlier discovery or of a more precisely tailored therapy, and they give hope for an improved chance of survival even in the case of hitherto lethal diseases.

But how are these developments reflected in medical underwriting? Does this rapid development mean that underwriting guidelines can be updated frequently to reflect improved outcomes, resulting in more and more cases of standard (medical) risk assessments?

First Priority - A Fundamentally Sound Basis in Medical Research

Underwriting guidelines follow the principle of evidence-based underwriting (EBU). EBU is inspired by (and builds on) the concept of evidence-based medicine (EBM).

EBM has the goal of systematically evaluating the published medical literature and thereby communicating scientifically verified findings. It is important to emphasize that the hierarchical classification by evidence type only reflects the structure of a medical study and says nothing about its content.

The content or the research question of a study can still be of only limited value, even if the study is ranked high according to the grid. The subject-specific evaluation of scientific findings and their consequences for diagnosis, therapy and prognosis requires a great deal of clinical experience and broad coordination. A detailed knowledge of internal and external validity is required to assess whether a clinical trial is “good”.

Big questions have to be answered to evaluate the value and usefulness of a clinical study, including:

• Is the number of subjects large enough?
• Is the observation period long enough?
• How many subjects dropped out?
• Were the methods suitable and targeted?

From Medical Research to Underwriting - Taking Great Care to Get It Right

EBU developed on the basis of EBM in order to ensure the best possible assessment, i.e., a non-discriminatory offer to the customer, with a risk-adequate premium rate. It does so while taking advantage of the latest valid findings on risk from the clinical field.

Basically, the same types of evidence are used for EBU as in EBM. High demands are placed on the selection of suitable information and the transfer of findings from the clinical context to the context of insurance medicine.

Multiple factors include:

• The population studied and whether the findings are transferable to the target group of insurance products
• The reputation of the researcher and the journal the study is published in
• The main purpose of the research and whether the study design is transferable to the insurance medicine sector
• The funder of the research and whether the study was conducted with a specific objective that is inconsistent with the objectives of the underwriting guideline

The interpretation of these (and other) factors - as well as the transfer of clinical findings to the insurance context - is the responsibility of relevant experts, most typically medical doctors. Their expertise is also required when it comes to the completion of guidelines in areas where clinical information is not available (e.g., rare diseases, certain age ranges, combinations of diseases, etc.).

Danger of Skipping the Validity Check - Too Quick on the Draw

It’s clear all these steps are important when you look at the reality of medical progress.

• Only days after the recent announcement of the revolutionary breast cancer blood test by the University of Heidelberg, the school apologized for the premature and misleading marketing of its research results and the hopes that had been prematurely raised.
• Meanwhile, the apparently cured HIV patients really do exist, but their cure came about in a very specific and not easily replicable way.
• As for Ebola, things still look grim. Since the summer of 2018 the virus has been raging in the Congo. As of March 2019, more than 1,000 people have been infected and over 600 fatalities confirmed.

Medical progress observed these days (and reflected almost daily in the headlines) is extraordinary. But, for the reasons outlined above, it requires patience for spectacular advances to be reflected in insurance underwriting guidelines that will stand the test of time.