Endometriosis

Hi everyone, this week we are back to protection insurance underwriting and the focus is upon endometriosis. This is a condition that is far more common than you think and with half of an adviser’s clients being female, one that we feel is good to know about.

In most cases endometriosis will have little impact upon the options available for protection insurance, but there are key questions that you need to ask your clients, to make sure that your research covers everything. It’s also essential to make sure that you approach specific parts of your factfind in a sensitive manner, due to some of the long-term health implications that can be caused by this condition.

The key takeaways:

  1. 1 in 10 women in the UK have endometriosis.
  2. Symptoms and potential treatments for endometriosis.
  3. A case study of arranging life insurance to protect a mortgage, for someone living with endometriosis.

At the end of this episode I also give a few pointers on what to do if you are an employer, so that you can support colleagues that have endometriosis.

On the next podcast Roy McLoughlin is doing his first solo outing as host for the Practical Protection Podcast. Roy will be chatting with Lee Robertson, from Octo Members, about how protection insurance is an essential part of planning a client’s financial future.

Remember, if you are listening to this as part of your work, you can claim a CPD certificate on our website.

Kathryn:       Hi everyone, this is episode five of season three and I have Matt Rann back with me.  Hi Matt!

Matt:            Hi Kathryn, how’s it going?

Kathryn:       Everything is going very well here thank you.  How’s it going for you?

Matt:            Yeah, the sun is shining, the world is a wonderful place today.

Kathryn:       Oh wonderful, wonderful.  It’s wonderful to hear such positivity.  I’m a little bit lockdown fatigued so I’m really glad – I’m going to try and absorb some of the positivity there.  But today we are going to be focusing on endometriosis, the things that underwriters want to know and some good practice tips for advisers and employers when you’re going to be discussing this sensitive topic.  So this is the Practical Protection podcast.  To start things off then, endometriosis is a condition that can affect women and is often quite misunderstood but when I was looking into this, one thing that I found really surprising is that it affects one in 10 women in the UK who are within sort of what we class as the usual reproductive ages which is actually quite – I think quite a significant amount of women and it is the second most prevalent gynaecological condition within the UK and to put things into a bit more of a global perspective, that’s about 176 million women worldwide.

And what happens with endometriosis – so essentially, obviously Matt’s going to go into this a lot more but it’s all to do with the tissue that forms in the lining of the womb and it’s maybe moving about and growing in areas that it’s not meant to.  And what can happen with that is it will – it can cause significant pain at any time really.  It doesn’t necessarily have to be during a period.  It’s doesn’t necessarily need to be just when you’re going to the bathroom but it can be – as I say, it can cause pain at any time but also it can be, you know, specifically when someone is maybe having some problems with intimate contact or potentially going to the toilet.  It can lead to things like heightened feelings of sickness, diarrhoea and constipation during the time that a woman is having her period.  It can also lead to things where somebody can have difficulty in having children which – all of these kind of can lead up to and build into some associated depression and there is a really wide range of treatments for it as well.  It can be treated with painkillers, sometimes hormone medicines and for some people it will also lead to surgery.

So I think that’s sort of a very brief overview there but Matt, can you just do your thing and go into all the medical side of things and also as well teach me more about it because I know bits about it and I know some – I don’t have it myself but I know a couple of people who do and I could really do with actually learning a lot more about it myself.

Matt:            Yeah fine, fine Kathryn.  I hope I can fill in some of those gaps.  Okay, what I thought I would do to start off anyway is just to let everybody listening know or go through again the – what an endometrium is for a start.  When we talk about endometriosis, it’s probably not a – particularly for us men, a term that comes up very often but the endometrium itself is the innermost lining – layer of the uterus and what it does is actually – its function is to actually keep the uterine cavity – the space of the uterine cavity, okay?  So it’s very, very important.  Now, endometriosis itself, as you’ve said, is endometrial tissue that grows outside of the uterus and it often coexists with and grows around, if you like, up the ovaries and fallopian tubes.

Kathryn:       Okay.

Matt:            You’ve covered symptoms as well so pelvic pain, dysmenorrhea –

Kathryn:       What’s dysmenorrhea, if you don’t mind me asking?

Matt:            Dysmenorrhea is absence or infrequent periods.

Kathryn:       Okay.

Matt:            Also it can cause the – when the tissue grows abnormally, it can cause masses within the uterus – a mass and as you’ve already said, infertility as well.  Now, the –

Kathryn:       When it comes to the mass, if you don’t mind me asking, when you say a mass – so is that like a cancerous mass?

Matt:            A growth.

Kathryn:       Or do we just mean like a growth of – like a ball of that tissue in a sense?

Matt:            A ball of that tissue.

Kathryn:       Okay, thank you.

Matt:            Absolutely, yeah.  But obviously it causes an obstruction –

Kathryn:       Yeah.

Matt:            It can cause an obstruction and it can grow large and cause that pain – one of the causes of that pain that we’ve talked about earlier.

Kathryn:       Yeah.

Matt:            In terms of the way that underwriters tend to look at it as well as clinicians, i.e. doctors, you can get – symptoms can be classed as mild, moderate or severe.  Diagnosis is often by laparoscopy.

Kathryn:       Yeah.

Matt:            And the absolute bottom end treatment is, as you said, is a hysterectomy and bilateral oophorectomy, which is the removal of the ovaries.

Kathryn:       Okay.

Matt:            That’s not a term that you come across.  In the severe side of it, we’ve again touched on it, but bowel adhesions – so that’s within the bowel itself remember.

Kathryn:       Okay.

Matt:            Peritonitis, inflammation around the abdominal cavity and urethral and intestinal obstruction.  Urethral – so it’s maybe another term that you haven’t come across maybe but that’s where the mass will cause pressure on the urethra.

Kathryn:       Okay.

Matt:            Okay.

Kathryn:       So like – so obviously very uncomfortable with weeing and –

Matt:            With weeing, absolutely.  Yeah, yeah. Okay, the good news about endometriosis itself is that it’s very rarely fatal.  So from an underwriting perspective for life insurance, unless you have the severe variety with bowel adhesions and so on and so forth, then you would always get standard rates for –

Kathryn:       Okay.

Matt:            For death – cover that pays out on death.  For the disability products, again –

Kathryn:       Oh I just suddenly thought, should I say, just a bit of a disclaimer there, so I know you were saying ‘should always get obviously the standard rates,’ I imagine though if someone is outstanding tests, we should probably be clear, outstanding tests, outstanding surgeries, things like that, then that will probably be more obviously a postponement type area.  So it’s not automatically going to be purely standard rates.  It might – I’m assuming that’s right in saying that.

Matt:            You’re absolutely right, yeah.  I suppose it’s an interesting – a really good question to be honest with you, just shows you how maybe underwriters’ minds work.  This is where there is a definite diagnosis of endometriosis and nothing else.

Kathryn:       Yeah.

Matt:            So, you know, [laughs] that was kind of my definition almost.  But yes –

Kathryn:       Absolutely.

Matt:            You’re absolutely right.  If some of those symptoms are present then the doctors will want to investigate and find out what is causing the issue and yes, if you talk about the adhesions that are caused, say in the bowel or the urethral one, then that needs to be sorted out before any form of insurance will be given.  So you’re absolutely right on that.

Kathryn:       So with the bowel adhesions, just sort of like for my own personal knowledge obviously, so obviously, you know, I appreciate as a woman that the womb and everything is very closely linked to near where the bowel is.  So with the bowel adhesion, is that in a sense – is that forming inside the bowel itself or is that forming more on the womb side towards the bowel area?  That’s just my own personal interest in it.  I don’t know how it works.

Matt:            Generally, it will be near the womb, yes.

Kathryn:       Okay.

Matt:            Yeah.

Kathryn:       So it would be more like pushing backwards into that, okay.

Matt:            Absolutely, yeah.  Okay, I’ll go on to talk about disability products.  In terms of critical illness then endometriosis is not a condition that is covered specifically.

Kathryn:       Yes.

Matt:            However when you’ve got total and permanent disability then an underwriter would – if everything had been cleared up and in terms of a history of endometriosis and definite endometriosis, then TPD you will get – you should get standard rates as well.

Kathryn:       Okay.

Matt:            No problems at all.  Income protection – again, you would be looking at standard rates but the underwriter would be very much looking at the fact that – whether symptoms were present –

Kathryn:       Yeah.

Matt:            If you like, and what the outcome of that in terms of follow-up on those symptoms were.  If you had current problems with endometriosis, you know, let’s take as an example bowel adhesions, then you would likely – more than likely get a – hopefully an exclusion.

Kathryn:       Yeah.

Matt:            Okay?  Rather than, ‘No, we’re not –’ a declinature or a postponement.  If somebody was about to go into hospital for an operation then you would be postponed but generally endometriosis for life insurance, subject to your comments Kathryn –

Kathryn:       Yes.

Matt:            Should not be a problem.  Critical illness with TPD should not be a problem as long as the symptoms have subsided and everything is clear and the same would go with income protection.  If there are symptoms continuing, then the underwriter would look at that, the severity of them, etcetera, etcetera but of course with income protection, the length of deferred period comes into play there as well.

Kathryn:       Yes.  Yeah, of course.

Matt:            Okay, and to be honest with you, just on a general note, deferred periods are very key to underwriting thinking on income protection.  Perhaps not surprisingly but they certainly are.

Kathryn:       I think that’s probably a good point probably for advisers as well, you know, to sort of say, well, you know, if you’re applying for cover for somebody and there is maybe a no or something, it’s worthwhile saying, “Well is that a no for everything or if we put in a longer deferred period, whilst not ideal, could this potentially be an option?”  Because it may just open a few doors in some places and I think that’s sort of like a good idea to maybe – as an adviser to remember to ask because obviously an underwriter or the person you’re speaking to who’s given you the decision isn’t going to remember necessarily to point all those bits out to you ‘cos they’ve got a million and one things to do, just as we all do.  So I think that’s definitely a technique that advisers can take onboard is to sort of like ask, you know, “Is this a no for every kind of scenario or way that I can build this policy for this person?”

Matt:            Absolutely correct.  Yeah, I would hope, but maybe I’m old fashioned, that underwriters would say, “Sorry we can’t do a deferred for four weeks, but maybe 13 weeks we could do the case and even 26 weeks we could do the case.”  I would hope they would do that and I totally appreciate these days and with systems being the way that they are –

Kathryn:       Yeah.

Matt:            That won’t happen.  So yeah, absolutely always ask the question.  Totally and utterly go for that.  Okay.  One of the things that I wanted to move onto Kathryn, was something called endothelial hyperplasia.

Kathryn:       Okay.

Matt:            Now that’s a mouthful and a half.

Kathryn:       Yes, I’m not going to repeat that back to you [laughs].

Matt:            So [laughs], I do apologise straight away.

Kathryn:       That’s fine.

Matt:            But this particular condition is one that underwriters for life insurance tend to be – it flags – a few red flags come with this particular condition and I’ll go on to explain why.

Kathryn:       Okay.

Matt:            First of all, endothelial.  Really, this is – I will explain that term.  That’s really just simply an excess proliferation of cells within the endometrium –

Kathryn:       Okay.

Matt:            And you remember I’ve already said that the endometrium is the innermost lining – layer of the uterus.  Okay?

Kathryn:       Okay, yeah.

Matt:            And its function is very important for obvious reasons.

Kathryn:       Yeah.

Matt:            Okay?  A hyperplasia is really an abnormal increase in tissue, okay, so it’s a very – an unusual word.  It’s not bandied around a lot but simply just means an abnormal increase in the actual tissue.  With endothelial hyperplasia, it is nearly always caused by excess oestrogen.  The function of oestrogen is it causes the lining of the womb to grow and thicken and to prepare for pregnancy itself. Okay?  Ovulation occurs and then with that, progesterone, another hormone, so oestrogen and progesterone begin to increase and the function of progesterone is to prepare the endometrium to receive and nourish the fertilised egg, okay?

Kathryn:       Okay.

Matt:            If there’s no pregnancy, oestrogen and progesterone fall and that causes the womb to shed its lining, commonly known as menstruation.  Okay?

Kathryn:       Yeah.

Matt:            Okay, once the lining of the womb is completely shed and then a new cycle begins and oestrogen and progesterone come back in its normal cycle.

Kathryn:       Okay.

Matt:            Now, I will go back to my hyperplasia, the condition that I’m talking about and it’s most often caused by excess oestrogen without progesterone, okay?

Kathryn:       Okay.

Matt:            So if you remember that oestrogen is produced by the ovaries.

Kathryn:       Yeah.

Matt:            If ovulation doesn’t occur and progesterone is not made then the lining of the womb – remember that we’re talking about people who are perimenopausal or postmenopausal, then the lining of the womb itself is not shed.

Kathryn:       Oh okay.

Matt:            Okay, so you don’t have menstruation.  What can cause the problem here is that because there is no – the lining of the womb is not shed, the tissue, because it’s not been shed will become thickened and can potentially become abnormal.

Kathryn:       Okay.

Matt:            There can be a problem with that in the case of getting uterine cancer.

Kathryn:       Oh okay, right.

Matt:            So it can become abnormal, it can go – that abnormality can go as far as cancer itself.

Kathryn:       Okay, I had no idea it could lead to cancer.

Matt:            Yeah, yeah.

Kathryn:       I imagine this is more of an unusual circumstance though, that it’s not like a common –

Matt:            Well it is unusual but it is more common than you think.

Kathryn:       Yeah, well I was going to say, endometriosis in itself is a lot more common than I thought anyway.

Matt:            Endometriosis is, yeah.  Remember this is a different scenario than purely endometriosis but obviously we are talking about the uterus.

Kathryn:       Yes.

Matt:            And interestingly, I certainly had to remind myself really about some of the causes here or what can exacerbate the situation and that’s if you take medication which acts like oestrogen, such as tamoxifen –

Kathryn:       Oh!

Matt:            Which we will know an awful lot about –

Kathryn:       Yes.

Matt:            Through cancer, breast cancer in particular.

Kathryn:       Yes.  So for people who – so for people who don’t know that, do you mind just explaining how the tamoxifen – what that is in reference to the things like the breast cancer, please Matt?

Matt:            Yeah, I think it really just keeps the levels of oestrogen up –

Kathryn:       Yeah.  It’s a medicine that somebody will take for – usually it’s about five years or so sometimes after cancer treatment?

Matt:            Post-treatment, yeah, and with the breasts being linked – or a very hormonal part of the body, what they want to reduce is the oestrogen levels so that that doesn’t start stimulating the breasts with an ensuing increase in the chances of cancer.

Kathryn:       Yeah of course.

Matt:            Okay.  Another cause is actually if you use oestrogen for hormone therapy and you don’t take progesterone.

Kathryn:       Right.

Matt:            So it’s around this hormone issue so you could take tamoxifen obviously and you can take hormone therapy but doctors need to be aware that those – if I can call it a side effect or a consequence possibly, is that the woman concerned needs to be followed up to ensure that nothing untoward is happening, okay?  Again, I would use another term here which may not be familiar but irregular periods can – especially in the presence of something called polycystic ovarian syndrome.

Kathryn:       Yes.

Matt:            PCOS or infertility and another area that can increase the chances of this condition is obesity –

Kathryn:       Okay.

Matt:            As well, so again, this condition, it needs to be seriously looked at.  The challenge there is that doctors will follow up and look for any signs.  Obviously some of these symptoms are sometimes difficult for ladies to a) talk about or b) even know, you know, some abdominal pain or really the consequences of it.  But talk to your doctor and I’m sure they will be able to sort it out.  In terms of underwriting these conditions then, generally and if the individual is followed up properly and obviously the woman concerned is compliant with what the doctor says in terms of treatment etcetera, then for life insurance, again with follow-ups which are all clear, then there should not be a problem with life insurance.  In terms of critical illness, then you may generate an exclusion for cancer.

Kathryn:       This is for the stronger – this is for the version of this isn’t it that I don’t want to pronounce back to you – is it endometrial hyperplasia?  Is that –

Matt:            That’s the one.  We were talking about this particular one because it’s connected with cancer.

Kathryn:       Yes, of course.

Matt:            Uterine cancer and income protection very much depends on really –

Kathryn:       On the provider.

Matt:            You may get an exclusion.  You may get a small rating but certainly it should be able to be covered as long as obviously you have an absolute diagnosis of it and you’re being followed up for it as well.

Kathryn:       Absolutely.  Sorry, I was going to say what’s good here I think is to maybe talk about, you know, sort of like the key things that insurers want to know and I’ve got a couple of specific questions as well that I think would be really helpful for advisers if I can sort of like put them towards you as well?

Matt:            Yeah, fire away.

Kathryn:       So, you know, from an adviser point of view, what I would say to advisers, as with pretty much any medical condition that you’re going to come across, you’ve got your key things.  You can ask them what the diagnosis is, when they were diagnosed, ideally the month and the year.  You want to know probably what the treatment plan is, you know, have there been any surgeries?  Has there been any medication?  Medications, you want the names and the dosage of it.  You also want – for the surgeries, you know, you want to know when did these happen, again, months and years are very, very useful and how often have they needed to happen if at all?  And I think they’re probably going to give you your main basis if you find out that information and also another one is the impact it possibly has on that person’s ability to work –

Matt:            Absolutely.

Kathryn:       Maybe do some day-to-day tasks, again especially depending upon the type of insurance you’re wanting to look at.  But something again when I was going across this was that when I was looking at it, I came across something about pain management for endometriosis and it can be quite intense I think the pain management side of things.  I saw some of them are long-term needs for anti-inflammatory use and I think one of the things that maybe, you know, a lot of advisers are aware but not all is that, you know, there’s times when you maybe wonder as advisers, “Well why can’t we do this?  It’s actually been managed really well,” but then the actual – the long-term effects of some of the medications can really have a play I think into what the decisions are and the underwriting outcomes and I know with anti-inflammatories, now this could be a misunderstanding on my part.  I don’t think it is but I’m sure you can correct me.  So with anti-inflammatories, I know ‘cos obviously I have hypermobility syndrome.  If I were to take an anti-inflammatory, I have to take certain ones because I’ve been told previously that certain anti-inflammatories can actually have a really adverse effect upon my stomach lining so I have to be very, very careful about that.  So is this, you know, I imagine it’s not just – so if people maybe think endometriosis, you know, well listening to us it should be standard, it should be this, you know, if there was potentially maybe a very, very strong long-term medication in use, I imagine that could have an impact upon some of the underwriting decisions.  Am I correct in thinking that?

Matt:            It’s an interesting question.  I would say possibly but I would only say possibly because generally if there was a – when an actuary and an underwriter get together to come up with a rating, they will look at the type of treatment that the individual is likely to have at a given, you know, whether it’s mild, moderate or severe.  So let’s look at severe.  They will look at the number of deaths or disability events and take into account – or they should take into account any side effects or long-term treatment within it.  So explicitly including a rating for a drug is actually pretty rare –

Kathryn:       Okay.

Matt:            And I would certainly think with – not belittling endometriosis in any way whatsoever –

Kathryn:       Of course.

Matt:            I would say it would be rare for an underwriter to take into account drug use.

Kathryn:       Okay.

Matt:            I would never say never.

Kathryn:       Yes of course.

Matt:            But because doctors themselves have different views on treatments and so on and so forth but I would say it would be pretty rare that that would be a point that the underwriter would be concerned about.

Kathryn:       Yeah of course.  I think another thing in regards to the medication side of things that I just wanted to quickly cover is that obviously endometriosis can have a link potentially to depression but I know that some people are diagnosed some anti-depressants as a form of pain management not necessarily because they are depressed.  I’m just wondering in a sense how is that potentially viewed by underwriters in a sense because I imagine that’s sort of like a bit of a difficult one from an underwriting point of view because kind of like you’re seeing a medication that is both potentially a pain management and also a depression management –

Matt:            Yeah.

Kathryn:       And then you’ve got a condition that is potentially linked closely to depression but obviously if the person is saying that they don’t have depression, I imagine that’s a little bit unusual or maybe it’s a lot more straightforward than I think?

Matt:            Again, it’s a very, very good question.  My take on it would be to ask, as an underwriter, is to ask the right questions.

Kathryn:       Yeah.

Matt:            Okay, so in other words, if they see an anti-depressant being given, in very simple terms ask why.  If there is no history of depression given by the potential client or indeed given by the doctor, GP, on the standard GP report, I would say that an underwriter should realise what the anti-depressant is actually being used for and it shouldn’t be an issue.

Kathryn:       Brilliant.  I think one other area I wanted to – sorry, go on.

Matt:            Oh no it’s alright, Kathryn.  I was just going to say that I think us underwriters generally will ask the question and it’s something where advisers could help if they had that type of relationship with their client by maybe probing a little bit more at outset. That might be a complete red flag to some advisers but I know other advisers who will – who are open about talking with their clients about treatments and so on and so forth.  But it’s asking the right question.  That really is the key and not – for an underwriter not to make an assumption that an anti-depressant equals depression.

Kathryn:       Yeah I think that’s a really good point as well for everybody.  It’s always asking the right questions.  It’s the same as an adviser, we always have to ask the right questions to be able to get things right and I think before we move onto sort of like the case study, there was one last area I wanted to just quickly touch on with you, is that when I was obviously looking into all of this, I came across thoracic endometriosis where the condition develops in the chest cavity and I’ve not heard of this and I suppose it really confuses me because I’m thinking, “Well, is that cells from the lung that are doing it themselves or is it kind of the cells from the womb or endometrium travelling all the way up to the lungs?”  And then I suppose an extra question with that is that because that is kind of obviously a condition that can affect the lung area, is that something that we think that maybe there’s going to be – there will possibly be extra considerations about that at the moment due to obviously the Covid restrictions that are in place?

Matt:            Well you’ve completely stymied me on that one [laughs].  Thank you so much!

Kathryn:       That’s okay! [laughs]

Matt:            I am not aware of thoracic issues linked with the condition that you highlighted however now you’ve highlighted it to me I shall go away and find out.

Kathryn:       Brilliant.

Matt:            In terms of any lung condition with Covid, then at this moment in time then yes it would be a concern amongst – but I would wonder how much Covid itself would exacerbate the situation.

Kathryn:       Okay.

Matt:            So from the Covid scenario, it wouldn’t add any particular additional concern than I would have apart from, “What is this condition and what are the consequences of this condition?”

Kathryn:       Okay, thank you.  Well I think it’s probably time now to start going towards the case study and I’ll just also give a little bit of input in regards, as an employer myself, as to what you can do to help people if you have somebody who’s working with you who maybe shares that they have this condition.  So from a case study point of view, I’ve already mentioned what the insurers are going to want to know.  They’re going to want to know when the diagnosis was made, what it was, the medications in use, the treatment surgeries – if they’ve been done or if they’re planned.  What’s really important as well from an adviser’s point of view is to be really sensitive when approaching the questions.  It’s quite easy to kind of go into a bit of an auto-mode as an adviser in the sense of, you know, saying, “Right, you know, do you have any dependents, you know, any kind of children?  Do you have this?  Do you have that?”

And what’s really important, especially if you already know – for whatever reason, if you already know that this person has endometriosis before you do speak to them, it’s just to be really conscious that this person may have struggled to have had children or have been unable to have children at all.  It could be that they’ve even had to have, you know, the full hysterectomy.  So it can be quite a sensitive topic and even if someone is in that situation, you can never assume that it’s something that they’re going to find hard to talk about or easy to talk about.  It’s always about being very reactive to what that individual person needs and it’s also very important, as with anything like this, to be very understanding of the fact that they’ve potentially experienced a lot of pain from this condition.  It’s not just having heavy periods or very uncomfortable periods, it is a completely separate condition to that and, you know, as with anything, I always think there’s a fine balance between being sort of like empathising with somebody and then crossing that line.

So, you know, we don’t want to get into kind of any scenarios of like, “Ooh yeah, when I get my period pain, I always have a hot water bottle and it helps.  Do you find it helps?”  Which, depending upon the rapport that you have with your client and if they’re a close friend, you know, maybe that would work okay but it’s probably better to just sort of be much more – sort of remove yourself a little bit from that a little bit and probably be along the lines of sort of like, you know, obviously, it’s always, you know, “I’m really sorry to hear that.  I can’t imagine what that must feel like.”  And I spoke to somebody myself the other day about it and I said, you know, “I really have quite uncomfortable periods.”  I say it feels like I’ve been kicked in the places that you can imagine but even so, that makes me feel like a complete wimp actually compared to what they must be going through when they’re experiencing this.

As well, when you’re writing your documents – obviously when we’re doing these compliance reports for people as an adviser, you know, we will sometimes say, you know, “This is your situation.”  Again, if you know that somebody has maybe not been able to have children due to the condition or they’ve had to have a hysterectomy or something along those lines, it may be that you speak with a compliance officer and just ask if you can maybe, you know, obviously subtly take out the reference to that in the report that goes to the client just so that it’s not staring them in the face that you’re saying, “Well you have no children.”

When it comes to the case study side of things, just an example to people – so obviously we helped a couple that were in their thirties. They were non-smokers.  Everything in regards to the medical side of things was what we classed as we would say in the industry as ‘straight through’ except for the female life had endometriosis and she’s had two laparoscopic surgeries to remove some tissue in the past and the last time had been about a year or so before the application.  So to just give an idea of what was sort of like achieved insurance-wise, we got decreasing life insurance for both of them of around £112,000 over 33 years and it was just under £14 per month.

As an employer, there are some things that you can potentially do as well to support people.  I know this can be very, very difficult for a man or a woman to speak to somebody about but if somebody is really struggling significantly on a monthly basis and you sort of like start to wonder if they’re being a bit of a hypochondriac because of bad periods or anything like that, the important thing to do is listen to that person because also as well, even if they are having horrendous periods, to listen to them and try and be comforting, you know, try and be considerate and accommodating without drawing attention to the person.  So, you know, if they are somebody who maybe needs to, you know, if they are in significant pain every month when they are having their period, you know, maybe give them the option to be able to work from home for a few days, you know.  It doesn’t have to be obvious to everybody.  It could just be something that that person needs.

There are so many things you can do, you know, if somebody is having to go to the bathroom quite often, you know, maybe there’s a way that you can subtly change where they are positioned within the building or the office so that if they are going to the toilet on a regular basis, that it’s maybe not obvious to everybody that they are having to get up and walk to the bathroom and I think, yeah, just having that openness for somebody to be able to talk to you and to make sure that people – and say to people, you know, maybe, you know, every now and then say to people, “Look, if you are experiencing anything, any kind of medical conditions or anything like that, you don’t have to tell us but we would love to be able to support you.  Please, you know, obviously privately let me know,” or also say if you’re big enough to have HR departments like that say, you know, “There’s also people in HR who are obviously very much designed to be able to have these conversations and to go through things with you.”

And probably the last thing from an employer point of view is to make sure that if you have something like the group cover, whether or not somebody speaks to you directly or not, make sure that you are making your team aware and signposting them to the support services and with some of the group insurances, as an employer you can access some support services yourself in regards to being able to get some guidance on how to better support employees in different situations.  So there’s lots of things that we can do.  The way that I like to see it as well and to leave it is that, you know, women – they’re half of your client bank – to all the advisers, so it’s a really good idea not to ignore these things and to make sure that even if you yourself don’t feel comfortable talking about it, that you have some kind of process in place where you can have somebody talk to that person and support them through it.  Anything that you would like to add Matt, as we’re coming towards the end of this?

Matt:            No I don’t think so.  Very interesting session.  You always raise such great points Kathryn, so well done you.  I think probably the only – the last thing I would say is a good friend of mine died a couple of weeks ago.  A lady –

Kathryn:       Oh I’m sorry to hear that.

Matt:            Thank you.  The lady will be very well known to Johnny Timpson.  The lady concerned was a lady called Frances Heggie who used to be the chief underwriter of Scottish Widows and she was a good friend, fantastic sense of humour and she’ll be sorely missed.  So I’d just like to maybe dedicate this one – this podcast to Frances –

Kathryn:       Absolutely.

Matt:            And may she enjoy the great underwriting department in the sky.  Okay, that’s me, thank you.

Kathryn:       I think that’s lovely Matt, thank you and thank you obviously for complimenting the things that I’ve brought up.  I think it’s been really, really useful hearing your knowledge on this.  Obviously it’s extremely extensive and thank you for going through that and I think that’s lovely.  I did see some posts – I wasn’t fortunate enough to meet Frances but I did see some posts, I think it was on LinkedIn and you could see that there was a significant outpouring of love towards her and she obviously meant a great deal to a lot of people so I think that’s a wonderful thing to do with this episode.  So obviously thank you very much to everybody for listening to this underwriting episode with Matt.  Next time, Roy McLoughlin is going to be having his first solo outing as a host on the podcast and he’s going to be interviewing Lee Robertson from Octo Members about protection and how it’s an essential part of planning a client’s financial future.

As we always say, if you would like a reminder of the next episode, please drop us a message and we will get you added to our reminders list and you can see us on the social media and visit the website of practical-protection.co.uk and I think for many underwriters and advisers listening, there is definitely a key element of CPD understanding on this so please do remember to get your certificate on the website as well.  So thank you very much for joining me, Matt.

Matt:            Thank you.  Speak to you again soon.

Kathryn:       Speak to you soon, bye.

Matt:            Bye.

Endometriosis

Hi everyone, this week we are back to protection insurance underwriting and the focus is upon endometriosis. This is a condition that is far more common than you think and with half of an adviser’s clients being female, one that we feel is good to know about.

In most cases endometriosis will have little impact upon the options available for protection insurance, but there are key questions that you need to ask your clients, to make sure that your research covers everything. It’s also essential to make sure that you approach specific parts of your factfind in a sensitive manner, due to some of the long-term health implications that can be caused by this condition.

The key takeaways:

  1. 1 in 10 women in the UK have endometriosis.
  2. Symptoms and potential treatments for endometriosis.
  3. A case study of arranging life insurance to protect a mortgage, for someone living with endometriosis.

At the end of this episode I also give a few pointers on what to do if you are an employer, so that you can support colleagues that have endometriosis.

On the next podcast Roy McLoughlin is doing his first solo outing as host for the Practical Protection Podcast. Roy will be chatting with Lee Robertson, from Octo Members, about how protection insurance is an essential part of planning a client’s financial future.

Remember, if you are listening to this as part of your work, you can claim a CPD certificate on our website.

Kathryn:       Hi everyone, this is episode five of season three and I have Matt Rann back with me.  Hi Matt!

Matt:            Hi Kathryn, how’s it going?

Kathryn:       Everything is going very well here thank you.  How’s it going for you?

Matt:            Yeah, the sun is shining, the world is a wonderful place today.

Kathryn:       Oh wonderful, wonderful.  It’s wonderful to hear such positivity.  I’m a little bit lockdown fatigued so I’m really glad – I’m going to try and absorb some of the positivity there.  But today we are going to be focusing on endometriosis, the things that underwriters want to know and some good practice tips for advisers and employers when you’re going to be discussing this sensitive topic.  So this is the Practical Protection podcast.  To start things off then, endometriosis is a condition that can affect women and is often quite misunderstood but when I was looking into this, one thing that I found really surprising is that it affects one in 10 women in the UK who are within sort of what we class as the usual reproductive ages which is actually quite – I think quite a significant amount of women and it is the second most prevalent gynaecological condition within the UK and to put things into a bit more of a global perspective, that’s about 176 million women worldwide.

And what happens with endometriosis – so essentially, obviously Matt’s going to go into this a lot more but it’s all to do with the tissue that forms in the lining of the womb and it’s maybe moving about and growing in areas that it’s not meant to.  And what can happen with that is it will – it can cause significant pain at any time really.  It doesn’t necessarily have to be during a period.  It’s doesn’t necessarily need to be just when you’re going to the bathroom but it can be – as I say, it can cause pain at any time but also it can be, you know, specifically when someone is maybe having some problems with intimate contact or potentially going to the toilet.  It can lead to things like heightened feelings of sickness, diarrhoea and constipation during the time that a woman is having her period.  It can also lead to things where somebody can have difficulty in having children which – all of these kind of can lead up to and build into some associated depression and there is a really wide range of treatments for it as well.  It can be treated with painkillers, sometimes hormone medicines and for some people it will also lead to surgery.

So I think that’s sort of a very brief overview there but Matt, can you just do your thing and go into all the medical side of things and also as well teach me more about it because I know bits about it and I know some – I don’t have it myself but I know a couple of people who do and I could really do with actually learning a lot more about it myself.

Matt:            Yeah fine, fine Kathryn.  I hope I can fill in some of those gaps.  Okay, what I thought I would do to start off anyway is just to let everybody listening know or go through again the – what an endometrium is for a start.  When we talk about endometriosis, it’s probably not a – particularly for us men, a term that comes up very often but the endometrium itself is the innermost lining – layer of the uterus and what it does is actually – its function is to actually keep the uterine cavity – the space of the uterine cavity, okay?  So it’s very, very important.  Now, endometriosis itself, as you’ve said, is endometrial tissue that grows outside of the uterus and it often coexists with and grows around, if you like, up the ovaries and fallopian tubes.

Kathryn:       Okay.

Matt:            You’ve covered symptoms as well so pelvic pain, dysmenorrhea –

Kathryn:       What’s dysmenorrhea, if you don’t mind me asking?

Matt:            Dysmenorrhea is absence or infrequent periods.

Kathryn:       Okay.

Matt:            Also it can cause the – when the tissue grows abnormally, it can cause masses within the uterus – a mass and as you’ve already said, infertility as well.  Now, the –

Kathryn:       When it comes to the mass, if you don’t mind me asking, when you say a mass – so is that like a cancerous mass?

Matt:            A growth.

Kathryn:       Or do we just mean like a growth of – like a ball of that tissue in a sense?

Matt:            A ball of that tissue.

Kathryn:       Okay, thank you.

Matt:            Absolutely, yeah.  But obviously it causes an obstruction –

Kathryn:       Yeah.

Matt:            It can cause an obstruction and it can grow large and cause that pain – one of the causes of that pain that we’ve talked about earlier.

Kathryn:       Yeah.

Matt:            In terms of the way that underwriters tend to look at it as well as clinicians, i.e. doctors, you can get – symptoms can be classed as mild, moderate or severe.  Diagnosis is often by laparoscopy.

Kathryn:       Yeah.

Matt:            And the absolute bottom end treatment is, as you said, is a hysterectomy and bilateral oophorectomy, which is the removal of the ovaries.

Kathryn:       Okay.

Matt:            That’s not a term that you come across.  In the severe side of it, we’ve again touched on it, but bowel adhesions – so that’s within the bowel itself remember.

Kathryn:       Okay.

Matt:            Peritonitis, inflammation around the abdominal cavity and urethral and intestinal obstruction.  Urethral – so it’s maybe another term that you haven’t come across maybe but that’s where the mass will cause pressure on the urethra.

Kathryn:       Okay.

Matt:            Okay.

Kathryn:       So like – so obviously very uncomfortable with weeing and –

Matt:            With weeing, absolutely.  Yeah, yeah. Okay, the good news about endometriosis itself is that it’s very rarely fatal.  So from an underwriting perspective for life insurance, unless you have the severe variety with bowel adhesions and so on and so forth, then you would always get standard rates for –

Kathryn:       Okay.

Matt:            For death – cover that pays out on death.  For the disability products, again –

Kathryn:       Oh I just suddenly thought, should I say, just a bit of a disclaimer there, so I know you were saying ‘should always get obviously the standard rates,’ I imagine though if someone is outstanding tests, we should probably be clear, outstanding tests, outstanding surgeries, things like that, then that will probably be more obviously a postponement type area.  So it’s not automatically going to be purely standard rates.  It might – I’m assuming that’s right in saying that.

Matt:            You’re absolutely right, yeah.  I suppose it’s an interesting – a really good question to be honest with you, just shows you how maybe underwriters’ minds work.  This is where there is a definite diagnosis of endometriosis and nothing else.

Kathryn:       Yeah.

Matt:            So, you know, [laughs] that was kind of my definition almost.  But yes –

Kathryn:       Absolutely.

Matt:            You’re absolutely right.  If some of those symptoms are present then the doctors will want to investigate and find out what is causing the issue and yes, if you talk about the adhesions that are caused, say in the bowel or the urethral one, then that needs to be sorted out before any form of insurance will be given.  So you’re absolutely right on that.

Kathryn:       So with the bowel adhesions, just sort of like for my own personal knowledge obviously, so obviously, you know, I appreciate as a woman that the womb and everything is very closely linked to near where the bowel is.  So with the bowel adhesion, is that in a sense – is that forming inside the bowel itself or is that forming more on the womb side towards the bowel area?  That’s just my own personal interest in it.  I don’t know how it works.

Matt:            Generally, it will be near the womb, yes.

Kathryn:       Okay.

Matt:            Yeah.

Kathryn:       So it would be more like pushing backwards into that, okay.

Matt:            Absolutely, yeah.  Okay, I’ll go on to talk about disability products.  In terms of critical illness then endometriosis is not a condition that is covered specifically.

Kathryn:       Yes.

Matt:            However when you’ve got total and permanent disability then an underwriter would – if everything had been cleared up and in terms of a history of endometriosis and definite endometriosis, then TPD you will get – you should get standard rates as well.

Kathryn:       Okay.

Matt:            No problems at all.  Income protection – again, you would be looking at standard rates but the underwriter would be very much looking at the fact that – whether symptoms were present –

Kathryn:       Yeah.

Matt:            If you like, and what the outcome of that in terms of follow-up on those symptoms were.  If you had current problems with endometriosis, you know, let’s take as an example bowel adhesions, then you would likely – more than likely get a – hopefully an exclusion.

Kathryn:       Yeah.

Matt:            Okay?  Rather than, ‘No, we’re not –’ a declinature or a postponement.  If somebody was about to go into hospital for an operation then you would be postponed but generally endometriosis for life insurance, subject to your comments Kathryn –

Kathryn:       Yes.

Matt:            Should not be a problem.  Critical illness with TPD should not be a problem as long as the symptoms have subsided and everything is clear and the same would go with income protection.  If there are symptoms continuing, then the underwriter would look at that, the severity of them, etcetera, etcetera but of course with income protection, the length of deferred period comes into play there as well.

Kathryn:       Yes.  Yeah, of course.

Matt:            Okay, and to be honest with you, just on a general note, deferred periods are very key to underwriting thinking on income protection.  Perhaps not surprisingly but they certainly are.

Kathryn:       I think that’s probably a good point probably for advisers as well, you know, to sort of say, well, you know, if you’re applying for cover for somebody and there is maybe a no or something, it’s worthwhile saying, “Well is that a no for everything or if we put in a longer deferred period, whilst not ideal, could this potentially be an option?”  Because it may just open a few doors in some places and I think that’s sort of like a good idea to maybe – as an adviser to remember to ask because obviously an underwriter or the person you’re speaking to who’s given you the decision isn’t going to remember necessarily to point all those bits out to you ‘cos they’ve got a million and one things to do, just as we all do.  So I think that’s definitely a technique that advisers can take onboard is to sort of like ask, you know, “Is this a no for every kind of scenario or way that I can build this policy for this person?”

Matt:            Absolutely correct.  Yeah, I would hope, but maybe I’m old fashioned, that underwriters would say, “Sorry we can’t do a deferred for four weeks, but maybe 13 weeks we could do the case and even 26 weeks we could do the case.”  I would hope they would do that and I totally appreciate these days and with systems being the way that they are –

Kathryn:       Yeah.

Matt:            That won’t happen.  So yeah, absolutely always ask the question.  Totally and utterly go for that.  Okay.  One of the things that I wanted to move onto Kathryn, was something called endothelial hyperplasia.

Kathryn:       Okay.

Matt:            Now that’s a mouthful and a half.

Kathryn:       Yes, I’m not going to repeat that back to you [laughs].

Matt:            So [laughs], I do apologise straight away.

Kathryn:       That’s fine.

Matt:            But this particular condition is one that underwriters for life insurance tend to be – it flags – a few red flags come with this particular condition and I’ll go on to explain why.

Kathryn:       Okay.

Matt:            First of all, endothelial.  Really, this is – I will explain that term.  That’s really just simply an excess proliferation of cells within the endometrium –

Kathryn:       Okay.

Matt:            And you remember I’ve already said that the endometrium is the innermost lining – layer of the uterus.  Okay?

Kathryn:       Okay, yeah.

Matt:            And its function is very important for obvious reasons.

Kathryn:       Yeah.

Matt:            Okay?  A hyperplasia is really an abnormal increase in tissue, okay, so it’s a very – an unusual word.  It’s not bandied around a lot but simply just means an abnormal increase in the actual tissue.  With endothelial hyperplasia, it is nearly always caused by excess oestrogen.  The function of oestrogen is it causes the lining of the womb to grow and thicken and to prepare for pregnancy itself. Okay?  Ovulation occurs and then with that, progesterone, another hormone, so oestrogen and progesterone begin to increase and the function of progesterone is to prepare the endometrium to receive and nourish the fertilised egg, okay?

Kathryn:       Okay.

Matt:            If there’s no pregnancy, oestrogen and progesterone fall and that causes the womb to shed its lining, commonly known as menstruation.  Okay?

Kathryn:       Yeah.

Matt:            Okay, once the lining of the womb is completely shed and then a new cycle begins and oestrogen and progesterone come back in its normal cycle.

Kathryn:       Okay.

Matt:            Now, I will go back to my hyperplasia, the condition that I’m talking about and it’s most often caused by excess oestrogen without progesterone, okay?

Kathryn:       Okay.

Matt:            So if you remember that oestrogen is produced by the ovaries.

Kathryn:       Yeah.

Matt:            If ovulation doesn’t occur and progesterone is not made then the lining of the womb – remember that we’re talking about people who are perimenopausal or postmenopausal, then the lining of the womb itself is not shed.

Kathryn:       Oh okay.

Matt:            Okay, so you don’t have menstruation.  What can cause the problem here is that because there is no – the lining of the womb is not shed, the tissue, because it’s not been shed will become thickened and can potentially become abnormal.

Kathryn:       Okay.

Matt:            There can be a problem with that in the case of getting uterine cancer.

Kathryn:       Oh okay, right.

Matt:            So it can become abnormal, it can go – that abnormality can go as far as cancer itself.

Kathryn:       Okay, I had no idea it could lead to cancer.

Matt:            Yeah, yeah.

Kathryn:       I imagine this is more of an unusual circumstance though, that it’s not like a common –

Matt:            Well it is unusual but it is more common than you think.

Kathryn:       Yeah, well I was going to say, endometriosis in itself is a lot more common than I thought anyway.

Matt:            Endometriosis is, yeah.  Remember this is a different scenario than purely endometriosis but obviously we are talking about the uterus.

Kathryn:       Yes.

Matt:            And interestingly, I certainly had to remind myself really about some of the causes here or what can exacerbate the situation and that’s if you take medication which acts like oestrogen, such as tamoxifen –

Kathryn:       Oh!

Matt:            Which we will know an awful lot about –

Kathryn:       Yes.

Matt:            Through cancer, breast cancer in particular.

Kathryn:       Yes.  So for people who – so for people who don’t know that, do you mind just explaining how the tamoxifen – what that is in reference to the things like the breast cancer, please Matt?

Matt:            Yeah, I think it really just keeps the levels of oestrogen up –

Kathryn:       Yeah.  It’s a medicine that somebody will take for – usually it’s about five years or so sometimes after cancer treatment?

Matt:            Post-treatment, yeah, and with the breasts being linked – or a very hormonal part of the body, what they want to reduce is the oestrogen levels so that that doesn’t start stimulating the breasts with an ensuing increase in the chances of cancer.

Kathryn:       Yeah of course.

Matt:            Okay.  Another cause is actually if you use oestrogen for hormone therapy and you don’t take progesterone.

Kathryn:       Right.

Matt:            So it’s around this hormone issue so you could take tamoxifen obviously and you can take hormone therapy but doctors need to be aware that those – if I can call it a side effect or a consequence possibly, is that the woman concerned needs to be followed up to ensure that nothing untoward is happening, okay?  Again, I would use another term here which may not be familiar but irregular periods can – especially in the presence of something called polycystic ovarian syndrome.

Kathryn:       Yes.

Matt:            PCOS or infertility and another area that can increase the chances of this condition is obesity –

Kathryn:       Okay.

Matt:            As well, so again, this condition, it needs to be seriously looked at.  The challenge there is that doctors will follow up and look for any signs.  Obviously some of these symptoms are sometimes difficult for ladies to a) talk about or b) even know, you know, some abdominal pain or really the consequences of it.  But talk to your doctor and I’m sure they will be able to sort it out.  In terms of underwriting these conditions then, generally and if the individual is followed up properly and obviously the woman concerned is compliant with what the doctor says in terms of treatment etcetera, then for life insurance, again with follow-ups which are all clear, then there should not be a problem with life insurance.  In terms of critical illness, then you may generate an exclusion for cancer.

Kathryn:       This is for the stronger – this is for the version of this isn’t it that I don’t want to pronounce back to you – is it endometrial hyperplasia?  Is that –

Matt:            That’s the one.  We were talking about this particular one because it’s connected with cancer.

Kathryn:       Yes, of course.

Matt:            Uterine cancer and income protection very much depends on really –

Kathryn:       On the provider.

Matt:            You may get an exclusion.  You may get a small rating but certainly it should be able to be covered as long as obviously you have an absolute diagnosis of it and you’re being followed up for it as well.

Kathryn:       Absolutely.  Sorry, I was going to say what’s good here I think is to maybe talk about, you know, sort of like the key things that insurers want to know and I’ve got a couple of specific questions as well that I think would be really helpful for advisers if I can sort of like put them towards you as well?

Matt:            Yeah, fire away.

Kathryn:       So, you know, from an adviser point of view, what I would say to advisers, as with pretty much any medical condition that you’re going to come across, you’ve got your key things.  You can ask them what the diagnosis is, when they were diagnosed, ideally the month and the year.  You want to know probably what the treatment plan is, you know, have there been any surgeries?  Has there been any medication?  Medications, you want the names and the dosage of it.  You also want – for the surgeries, you know, you want to know when did these happen, again, months and years are very, very useful and how often have they needed to happen if at all?  And I think they’re probably going to give you your main basis if you find out that information and also another one is the impact it possibly has on that person’s ability to work –

Matt:            Absolutely.

Kathryn:       Maybe do some day-to-day tasks, again especially depending upon the type of insurance you’re wanting to look at.  But something again when I was going across this was that when I was looking at it, I came across something about pain management for endometriosis and it can be quite intense I think the pain management side of things.  I saw some of them are long-term needs for anti-inflammatory use and I think one of the things that maybe, you know, a lot of advisers are aware but not all is that, you know, there’s times when you maybe wonder as advisers, “Well why can’t we do this?  It’s actually been managed really well,” but then the actual – the long-term effects of some of the medications can really have a play I think into what the decisions are and the underwriting outcomes and I know with anti-inflammatories, now this could be a misunderstanding on my part.  I don’t think it is but I’m sure you can correct me.  So with anti-inflammatories, I know ‘cos obviously I have hypermobility syndrome.  If I were to take an anti-inflammatory, I have to take certain ones because I’ve been told previously that certain anti-inflammatories can actually have a really adverse effect upon my stomach lining so I have to be very, very careful about that.  So is this, you know, I imagine it’s not just – so if people maybe think endometriosis, you know, well listening to us it should be standard, it should be this, you know, if there was potentially maybe a very, very strong long-term medication in use, I imagine that could have an impact upon some of the underwriting decisions.  Am I correct in thinking that?

Matt:            It’s an interesting question.  I would say possibly but I would only say possibly because generally if there was a – when an actuary and an underwriter get together to come up with a rating, they will look at the type of treatment that the individual is likely to have at a given, you know, whether it’s mild, moderate or severe.  So let’s look at severe.  They will look at the number of deaths or disability events and take into account – or they should take into account any side effects or long-term treatment within it.  So explicitly including a rating for a drug is actually pretty rare –

Kathryn:       Okay.

Matt:            And I would certainly think with – not belittling endometriosis in any way whatsoever –

Kathryn:       Of course.

Matt:            I would say it would be rare for an underwriter to take into account drug use.

Kathryn:       Okay.

Matt:            I would never say never.

Kathryn:       Yes of course.

Matt:            But because doctors themselves have different views on treatments and so on and so forth but I would say it would be pretty rare that that would be a point that the underwriter would be concerned about.

Kathryn:       Yeah of course.  I think another thing in regards to the medication side of things that I just wanted to quickly cover is that obviously endometriosis can have a link potentially to depression but I know that some people are diagnosed some anti-depressants as a form of pain management not necessarily because they are depressed.  I’m just wondering in a sense how is that potentially viewed by underwriters in a sense because I imagine that’s sort of like a bit of a difficult one from an underwriting point of view because kind of like you’re seeing a medication that is both potentially a pain management and also a depression management –

Matt:            Yeah.

Kathryn:       And then you’ve got a condition that is potentially linked closely to depression but obviously if the person is saying that they don’t have depression, I imagine that’s a little bit unusual or maybe it’s a lot more straightforward than I think?

Matt:            Again, it’s a very, very good question.  My take on it would be to ask, as an underwriter, is to ask the right questions.

Kathryn:       Yeah.

Matt:            Okay, so in other words, if they see an anti-depressant being given, in very simple terms ask why.  If there is no history of depression given by the potential client or indeed given by the doctor, GP, on the standard GP report, I would say that an underwriter should realise what the anti-depressant is actually being used for and it shouldn’t be an issue.

Kathryn:       Brilliant.  I think one other area I wanted to – sorry, go on.

Matt:            Oh no it’s alright, Kathryn.  I was just going to say that I think us underwriters generally will ask the question and it’s something where advisers could help if they had that type of relationship with their client by maybe probing a little bit more at outset. That might be a complete red flag to some advisers but I know other advisers who will – who are open about talking with their clients about treatments and so on and so forth.  But it’s asking the right question.  That really is the key and not – for an underwriter not to make an assumption that an anti-depressant equals depression.

Kathryn:       Yeah I think that’s a really good point as well for everybody.  It’s always asking the right questions.  It’s the same as an adviser, we always have to ask the right questions to be able to get things right and I think before we move onto sort of like the case study, there was one last area I wanted to just quickly touch on with you, is that when I was obviously looking into all of this, I came across thoracic endometriosis where the condition develops in the chest cavity and I’ve not heard of this and I suppose it really confuses me because I’m thinking, “Well, is that cells from the lung that are doing it themselves or is it kind of the cells from the womb or endometrium travelling all the way up to the lungs?”  And then I suppose an extra question with that is that because that is kind of obviously a condition that can affect the lung area, is that something that we think that maybe there’s going to be – there will possibly be extra considerations about that at the moment due to obviously the Covid restrictions that are in place?

Matt:            Well you’ve completely stymied me on that one [laughs].  Thank you so much!

Kathryn:       That’s okay! [laughs]

Matt:            I am not aware of thoracic issues linked with the condition that you highlighted however now you’ve highlighted it to me I shall go away and find out.

Kathryn:       Brilliant.

Matt:            In terms of any lung condition with Covid, then at this moment in time then yes it would be a concern amongst – but I would wonder how much Covid itself would exacerbate the situation.

Kathryn:       Okay.

Matt:            So from the Covid scenario, it wouldn’t add any particular additional concern than I would have apart from, “What is this condition and what are the consequences of this condition?”

Kathryn:       Okay, thank you.  Well I think it’s probably time now to start going towards the case study and I’ll just also give a little bit of input in regards, as an employer myself, as to what you can do to help people if you have somebody who’s working with you who maybe shares that they have this condition.  So from a case study point of view, I’ve already mentioned what the insurers are going to want to know.  They’re going to want to know when the diagnosis was made, what it was, the medications in use, the treatment surgeries – if they’ve been done or if they’re planned.  What’s really important as well from an adviser’s point of view is to be really sensitive when approaching the questions.  It’s quite easy to kind of go into a bit of an auto-mode as an adviser in the sense of, you know, saying, “Right, you know, do you have any dependents, you know, any kind of children?  Do you have this?  Do you have that?”

And what’s really important, especially if you already know – for whatever reason, if you already know that this person has endometriosis before you do speak to them, it’s just to be really conscious that this person may have struggled to have had children or have been unable to have children at all.  It could be that they’ve even had to have, you know, the full hysterectomy.  So it can be quite a sensitive topic and even if someone is in that situation, you can never assume that it’s something that they’re going to find hard to talk about or easy to talk about.  It’s always about being very reactive to what that individual person needs and it’s also very important, as with anything like this, to be very understanding of the fact that they’ve potentially experienced a lot of pain from this condition.  It’s not just having heavy periods or very uncomfortable periods, it is a completely separate condition to that and, you know, as with anything, I always think there’s a fine balance between being sort of like empathising with somebody and then crossing that line.

So, you know, we don’t want to get into kind of any scenarios of like, “Ooh yeah, when I get my period pain, I always have a hot water bottle and it helps.  Do you find it helps?”  Which, depending upon the rapport that you have with your client and if they’re a close friend, you know, maybe that would work okay but it’s probably better to just sort of be much more – sort of remove yourself a little bit from that a little bit and probably be along the lines of sort of like, you know, obviously, it’s always, you know, “I’m really sorry to hear that.  I can’t imagine what that must feel like.”  And I spoke to somebody myself the other day about it and I said, you know, “I really have quite uncomfortable periods.”  I say it feels like I’ve been kicked in the places that you can imagine but even so, that makes me feel like a complete wimp actually compared to what they must be going through when they’re experiencing this.

As well, when you’re writing your documents – obviously when we’re doing these compliance reports for people as an adviser, you know, we will sometimes say, you know, “This is your situation.”  Again, if you know that somebody has maybe not been able to have children due to the condition or they’ve had to have a hysterectomy or something along those lines, it may be that you speak with a compliance officer and just ask if you can maybe, you know, obviously subtly take out the reference to that in the report that goes to the client just so that it’s not staring them in the face that you’re saying, “Well you have no children.”

When it comes to the case study side of things, just an example to people – so obviously we helped a couple that were in their thirties. They were non-smokers.  Everything in regards to the medical side of things was what we classed as we would say in the industry as ‘straight through’ except for the female life had endometriosis and she’s had two laparoscopic surgeries to remove some tissue in the past and the last time had been about a year or so before the application.  So to just give an idea of what was sort of like achieved insurance-wise, we got decreasing life insurance for both of them of around £112,000 over 33 years and it was just under £14 per month.

As an employer, there are some things that you can potentially do as well to support people.  I know this can be very, very difficult for a man or a woman to speak to somebody about but if somebody is really struggling significantly on a monthly basis and you sort of like start to wonder if they’re being a bit of a hypochondriac because of bad periods or anything like that, the important thing to do is listen to that person because also as well, even if they are having horrendous periods, to listen to them and try and be comforting, you know, try and be considerate and accommodating without drawing attention to the person.  So, you know, if they are somebody who maybe needs to, you know, if they are in significant pain every month when they are having their period, you know, maybe give them the option to be able to work from home for a few days, you know.  It doesn’t have to be obvious to everybody.  It could just be something that that person needs.

There are so many things you can do, you know, if somebody is having to go to the bathroom quite often, you know, maybe there’s a way that you can subtly change where they are positioned within the building or the office so that if they are going to the toilet on a regular basis, that it’s maybe not obvious to everybody that they are having to get up and walk to the bathroom and I think, yeah, just having that openness for somebody to be able to talk to you and to make sure that people – and say to people, you know, maybe, you know, every now and then say to people, “Look, if you are experiencing anything, any kind of medical conditions or anything like that, you don’t have to tell us but we would love to be able to support you.  Please, you know, obviously privately let me know,” or also say if you’re big enough to have HR departments like that say, you know, “There’s also people in HR who are obviously very much designed to be able to have these conversations and to go through things with you.”

And probably the last thing from an employer point of view is to make sure that if you have something like the group cover, whether or not somebody speaks to you directly or not, make sure that you are making your team aware and signposting them to the support services and with some of the group insurances, as an employer you can access some support services yourself in regards to being able to get some guidance on how to better support employees in different situations.  So there’s lots of things that we can do.  The way that I like to see it as well and to leave it is that, you know, women – they’re half of your client bank – to all the advisers, so it’s a really good idea not to ignore these things and to make sure that even if you yourself don’t feel comfortable talking about it, that you have some kind of process in place where you can have somebody talk to that person and support them through it.  Anything that you would like to add Matt, as we’re coming towards the end of this?

Matt:            No I don’t think so.  Very interesting session.  You always raise such great points Kathryn, so well done you.  I think probably the only – the last thing I would say is a good friend of mine died a couple of weeks ago.  A lady –

Kathryn:       Oh I’m sorry to hear that.

Matt:            Thank you.  The lady will be very well known to Johnny Timpson.  The lady concerned was a lady called Frances Heggie who used to be the chief underwriter of Scottish Widows and she was a good friend, fantastic sense of humour and she’ll be sorely missed.  So I’d just like to maybe dedicate this one – this podcast to Frances –

Kathryn:       Absolutely.

Matt:            And may she enjoy the great underwriting department in the sky.  Okay, that’s me, thank you.

Kathryn:       I think that’s lovely Matt, thank you and thank you obviously for complimenting the things that I’ve brought up.  I think it’s been really, really useful hearing your knowledge on this.  Obviously it’s extremely extensive and thank you for going through that and I think that’s lovely.  I did see some posts – I wasn’t fortunate enough to meet Frances but I did see some posts, I think it was on LinkedIn and you could see that there was a significant outpouring of love towards her and she obviously meant a great deal to a lot of people so I think that’s a wonderful thing to do with this episode.  So obviously thank you very much to everybody for listening to this underwriting episode with Matt.  Next time, Roy McLoughlin is going to be having his first solo outing as a host on the podcast and he’s going to be interviewing Lee Robertson from Octo Members about protection and how it’s an essential part of planning a client’s financial future.

As we always say, if you would like a reminder of the next episode, please drop us a message and we will get you added to our reminders list and you can see us on the social media and visit the website of practical-protection.co.uk and I think for many underwriters and advisers listening, there is definitely a key element of CPD understanding on this so please do remember to get your certificate on the website as well.  So thank you very much for joining me, Matt.

Matt:            Thank you.  Speak to you again soon.

Kathryn:       Speak to you soon, bye.

Matt:            Bye.

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