Lupus

Hi everyone, this week I have Matt Rann back with me and we are talking about lupus. This is an autoimmune condition that can potentially have an influence on protection insurance applications. We are talking about Systemic Lupus Erythematosus (SLE), Discoid Lupus (DLE) and Drug-induced lupus (DILE).

Lupus is a condition that usually affects women far more than men, with women nine times more likely to be diagnosed with the condition. Symptoms can involve fatigue, a skin rash, hair loss, and much more including difficulties with the kidneys.

The key takeaways:

  1. Roughly 1 in every 1000 living in the UK have lupus.
  2. Lupus is caused by having too many antibodies within the immune system.
  3. Lupus can be hereditary but it can also be triggered by hormones e.g. puberty, pregnancy, menopause. It can also be triggered by a viral infection, sunlight and some medications.

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

If you want to know more about how to arrange protection insurance, take a look at my Protection Insurance in Practice course here.

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

Matt:            Good morning Kathryn, how are you keeping?

Kathryn:       I’m very good thank you, how are you?

Matt:            Yes, not too bad, not too bad at all.  I’m doing a lot of preparation in between talking to you of course around a long three-day, full-on fishing trip next week.

Kathryn:       Nice.

Matt:            I’m going back to my home county of Gloucestershire with a good friend of mine who’s a bit of a professional –

Kathryn:       Yeah.

Matt:            At his fishing and so much looking forward to that, thank you very much.

Kathryn:       Very, very nice, well I really, really hope that you enjoy that.  I’ve currently – at the moment, I was going to say my – in terms of our getting away and different things like that, Alan has gone to London for the first time since March of 2020 today, so I have the joy of him having obviously this lovely night out – obviously maybe having a couple of glasses of wine or something and I have all three children and Fudge.  So –

Matt:            Ah dear me.

Kathryn:       I expect to be allowed a lie-in on Saturday morning.

Matt:            I should think so too, I should think so too.

Kathryn:       Definitely.  So today everybody we are going to be talking about lupus and how that comes into play with insurance applications.  So this is the Practical Protection Podcast.

Kathryn:       So as we usually do, just a little bit of a general background for everybody in terms of lupus.  There’s a number of different things in terms of the kind of diagnosis that you might hear.  So we have systemic lupus erythematosus – you’re going to have to help me with that one, Matt.

Matt:            That’s absolutely right, erythematosus is what I call it.

Kathryn:       Erythematosus, thank you.

Matt:            We know – yeah.

Kathryn:       You know what I mean and somebody might say to you SLE, so that is – I’ve completely forgotten my phonetics then, so sugar, lima, echo.  I think it’s sugar, is it sugar?  I want to say sierra.

Matt:            I can’t remember, you know.  I can’t remember.  But we know what you mean.

Kathryn:       I want to say sierra.  Everybody knows what I mean, I’ll just make up random ones.  We then also have discoid lupus which would be DLE, so delta, lima, echo and then drug-induced lupus, which is known as DILE.  So delta, indigo, lima, echo.  And Lupus is an auto-immune condition and it is something where women are nine times more likely to be diagnosed with it.  It can be hereditary but it can also be something that is triggered by a certain event such as puberty, being pregnant, the menopause, even a viral infection.  There are some medications and potentially even sunlight might trigger it.  Lupus is actually caused by there being too many antibodies in the system – in the immune system, so basically it means that there’s too much going on there and it can lead to what’s known as inflammatory events.

And it’s one of those things where I think people probably again, as with any of these things that we talk about in this podcast, people think it’s probably not many people, but actually when you look at the numbers it can be quite a lot.  So in terms of the estimates there’s roughly about 50,000 in the UK that are living with lupus and that’s roughly one in every 1,000 people. So I think a good way to start off Matt, seeing as I’ve given a little bit of statistics around there, would be for you to maybe just sort of explain the differences between the different types of SLE – so what are the types of symptoms that we are possibly going to be seeing?

Matt:            Well, thanks for the question Kathryn.  I’ll probably take a step back and say that I’d like to start off with lupus as opposed to a specific type of lupus such as SLE and the other two that you mentioned.  You’re absolutely right, lupus generically is a non-specific inflammatory condition affecting tissue – the connective tissue in the body.  And it sounds absolutely horrible but there are other conditions – big medical conditions, well-known medical conditions which have the same start, if you like.  And it’s a condition whereby the body becomes allergic to its’ own tissue.  Which sounds absolutely horrible.

Kathryn:       That does sound quite intense.  It’s a good explanation of it.

Matt:            It does sound intense, doesn’t it?  But I liked – absolutely, I liked in inverted commas that explanation because it does paint a picture.  And you can see it with other big conditions that are very out there in the marketplace such as diabetes and also multiple sclerosis as well.  So it is – it’s the fact that the body attacks its own tissue is quite frightening.  Now, as we all know, inflammation occurs when your body’s immune system is fighting an infection or an injury.  I would imagine that most, if not everybody, who is listening today has had some form of inflammation, either from playing football on a Sunday morning or having a simple infection.  And of course, this auto-immune picture is right up there with Covid as well.  So – but today we must go back to lupus.  So in terms of systemic lupus erythematosus, this is where the body’s immune system starts to attack or can attack any major organ in the body and it’s pretty serious.  there’s no two ways about that and the areas that are most commonly seen, in terms of those major organs, are the kidneys in particular.  Also it’s known to attack the brain, so the cerebral area of the body and also the heart as well.  So you’ve got some pretty big, if rather important areas of the body there that SLE – systemic – can attack and do damage to.

In terms of the symptoms, it’s quite interesting to note that – and I’ll go onto DLE – discoid lupus erythematosus and drug-induced lupus in a minute – the symptoms for all three types of lupus initially can be very, very similar.  So it’s important that the clinician takes a detailed history of the symptoms themselves and also runs a series of blood tests and also interestingly ask the patient whether there is a history of lupus within the family as well.  Now the symptoms themselves can include extreme fatigue, pain or swelling of the joints, swelling of the hands, feet or around the eyes.  Problems with the skin – the very typical butterfly rash from the cheeks, facial cheeks or nose.  Headaches and low fevers, sensitivity to sunlight or fluorescent light and chest pain when breathing deeply.  Now, I’m sure a lot of the listeners again will have had some of those symptoms at some stage in their lives and that’s –

Kathryn:       It’s hard, isn’t it, because –

Matt:            It’s one of the very difficult areas to get that diagnosis.  Sorry Kathryn, you were going to say?

Kathryn:       I was going to say it is hard because, you know, I think as with so many things isn’t it, you know, the symptoms for almost anything and everything seem to –

Matt:            100% agree.

Kathryn:       It’s kind of like when you go on the NHS website or something, it’s sort of like, “Have you had any of these symptoms?”  Oh sorry, that would be – that would be Fudgie.  Fudgie do you know what, I think he just wants to be on the podcast now every time.

Matt:            I don’t blame him.

Kathryn:       That was my doorbell going and him being my fierce, burly protector obviously.

Matt:            Absolutely.

Kathryn:       I was going to say, he isn’t a protector at all, he would just turn over for a tummy cuddle with anybody at any point.  But no, as I say the NHS website, you’re putting in things about your symptoms and almost every single time it will say, “Oh, you have to go to A&E,” you know, there’s the – what’s the word for it –

Matt:            That’s the crazy thing about it, isn’t it?

Kathryn:       It is.  But it just does cross over with so many things, like the pain and the swelling of the joints and things like that, you know, I think a lot of people have probably had pain in their joints and things like that, so obviously –

Matt:            Absolutely.  The fatigue –

Kathryn:       Yes.

Matt:            Headaches, you know, it’s a difficult one.  And there’s no two ways about it, that as I’ve alluded to, the clinician has to do a very thorough job in terms of analysing those symptoms and looking at the family history and also arranging a series of blood tests.  And the blood tests are often the definitive way, if I can call it that – definitive way of making a diagnosis at the end of the day.  But it’s pretty difficult to do at an early stage with lupus, hence why you’ll find for life cover the underwriting fraternity will often postpone a case for say 12 months until a firm diagnosis has been made and the progression or otherwise of the disease can be calculated.

Kathryn:       Is it – I could be wrong, but I feel like I read somewhere that with lupus it can be quite standard for it to maybe even take five years to actually get an official diagnosis, even once you’re, you know, really engaging and there was even the suspicion of lupus, maybe that’s a certain type, I could be wrong.

Matt:            I think in some circumstances that the five-year term could be right.  I think it very much depends maybe at what stage within the disease that the patient actually seeks medical help.

Kathryn:       I suppose –

Matt:            Or they get investigated properly.

Kathryn:       I was going to say, because I imagine private medical insurance as well, obviously that’s going to probably bring that down.  Because again, it’s one of these things with me, I always think with blood tests, in some ways, I sort of think right, well if they take bloods, they should be able to test everything.  I’m sort of like, “If you’re taking the blood, just test everything and anything.”  But I imagine that they have to do very specific tests to sort of like see if it’s lupus.  It’s not just suddenly going to – it’s not going to pop up on a regular blood screen I imagine.

Matt:            It’s not going to throw out an instant diagnosis.  For all we know, it’s going to be a combination of factors really.

Kathryn:       Yes.

Matt:            Certainly, antibody tests, you know, for the overproduction are very useful in making a diagnosis but at the end of the day it’s a little bit of a wait and see in the context of getting a firm diagnosis.  But that doesn’t necessarily mean that treatment – some form of treatment, can’t be given early doors.  So yeah, it’s not an easy one but it has to be said that the clinicians in this world are generally making the right decisions because the actual mortality involved with the worst of these three – I’ll come onto the other two in a minute – but systemic, i.e. system involvement – the mortality associated with it has come down dramatically in the last 20 years.  And that’s primarily because of the diagnosis and the diagnosis leading to a course of treatment and obviously they can vary the treatment, which is often steroids, or anti-malarials for that matter, accordingly.  And as we’ll come onto a little bit later on, obviously steroids can lead to problems in their own right and therefore have to be very carefully managed by any clinician treating somebody with SLE.

Kathryn:       Yeah.

Matt:            But I think as I say, from an underwriting perspective, the listeners – please don’t be surprised if somebody appearing with a variety of symptoms with a question mark SLE are not postponed until a firmer diagnosis has been made.

Kathryn:       Yes.

Matt:            It doesn’t have to be an absolute diagnosis but a firmer diagnosis than a variety of symptoms.  And also, it’ll take time probably for the clinician to get the dosage of the steroids or anti-malarials right –

Kathryn:       Yeah.

Matt:            For that person’s particular condition because everybody who suffers from SLE is different and I think that’s pretty important to say.

Kathryn:       Of course.

Matt:            Okay, I did promise to mention the other two types of lupus, which you mentioned and as I’ve already said, with discoid lupus erythematosus and what a mouthful that is, it is actually a separate entity to SLE.  It is classified clinically as a separate entity but unlike systemic – if, again, I always say, remember systemic because it can impact the body’s systems, okay?  That’s why the word is used really.  But with discoid it remains confined to the skin and only the skin.  It doesn’t impact any other major organs.  Generally, for life – but in the great majority of patients, there is a one or two percent that might end of up with SLE but the majority should not have any major problems from a mortality perspective and therefore, once the underwriter – and let’s face it the clinician at the end of the day – are happy that we are looking at DLE and solely DLE, then again once that diagnosis can be firmed up, then you can obviously get standard rates from a mortality perspective –

Kathryn:       Okay.

Matt:            For discoid.  For drug-induced lupus, again the symptoms often overlap with SLE and again it’s very rare that the major organs are affected at all and when people are on treatment on medicines, it can take several months or even years before any of the typical symptoms of lupus actually appear.  But on a little bit of research two drugs do seem to be particularly implicated, if I can call it that, with drug-induced lupus and that’s hydralazine, where 5% of patients develop lupus symptoms and that’s often used for hypertension – for treating high blood pressure.

Kathryn:       Yeah.

Matt:            And also procainamide which is in fact used for – it’s a heart drug used for irregular heart rhythm and 20% of people on that drug can get symptoms.  Other drugs – far less than 1%, often more than – more often less than 0.1%.  So, those are the two types of drugs and indeed – sorry, I’ve just got some – I did find another one to notice, isoniazid which is for tuberculosis – is a little bit higher than 1%.  But here – once those drugs have been stopped or managed – and I think it’s important to say you don’t have to come off them particularly – once they’re managed, symptoms will disappear after six months.  And bear in mind that these – the drug-induced lupus – the clinicians know that the drugs which can cause these types of lupus symptoms, then it’ll be managed very, very well.  And effectively from a life insurance perspective, once those symptoms have disappeared/or stable, then there should be no problems in getting normal terms for life insurance.  Does that help in terms of differentiating the three?

Kathryn:       Yeah, I think it really does.  I mean I think, you know, when we’re talking about lupus and especially as an adviser, who just wants to help somebody, if we’re hearing SLE then we need to be probably more aware that that’s going to be – potentially make some things a bit trickier, we maybe need to know – obviously we always need to know as much as possible but we need to know some extra things as well compared to potentially the others.  So I know we said before about potentially involvement with kidneys and other organs so I know with the kidneys we’re probably going to be looking at what’s known as the GFR readings.

Matt:            Yeah.

Kathryn:       So that is golf, foxtrot, romeo readings.  It’s quite easy if you sort of like do a search online to find in a sense what they should ideally be within and if someone can tell you the number that they have for that then that would be very useful.  Would they be wanting – because obviously I know you said the heart and the brain, I’m not exactly sure what would – you could use in a sense as evidence, or what you would ask somebody about that, but I know obviously typically when I’m looking at things, I would be sort of thinking like kidneys, “Right, I need to know the GFR.”  Are we potentially talking the liver as well?  So we would maybe want to know what the LFTs were as well?

Matt:            I haven’t seen liver specifically mentioned as one of the – if I can use the term common major organs that are used.  With the kidneys, we’re looking at inflammation here and obviously with inflammation when it goes completely haywire, as we’ve seen sadly with Covid, it can stop that organ actually functioning full stop.  So you’re absolutely right with GFR – Glomerular Filtration Rate.

Kathryn:       Yeah.

Matt:            But you’re also looking at other renal kidney function tests such as creatinine as well.

Kathryn:       Yeah.

Matt:            The creatinine clearance.  Now, in terms of the heart and the brain, then you certainly are going to be looking at the bloods that relate to the heart, as we know so well from the diagnosis of heart attack etcetera with bloods.  Troponin is an enzyme which you will know a lot about or will have heard a lot about.  But the brain is an interesting one.  I must admit, I don’t think I’ve ever seen an SLE case where there’s actually been brain involvement apart from during – with my claims experience at post-mortem.  So I’m not ultimately sure whether the blood tests – what blood tests would be needed for that apart from a scan will probably tell you that the tissue in the brain was very inflamed.

Kathryn:       Okay.

Matt:            But I have to say once you get to kidney and cerebral heart involvement, then I’m afraid there is a minimal chance of getting life insurance with those three.  Those – once you get to the major organs, the prognosis is pretty poor, but when it comes to the actuarial underwriting calculations that make up the rating boundaries, the risk boundaries which are applicable in the industry.

Kathryn:       So I think yeah, I see where you’re coming from with that.  I think it’s probably good to clarify that the difficulty would be for life insurance with mainstream insurers.  So there could be some options with some specialist insurers, but obviously, as with anything like that, if somebody was going to be looking at that there’s incredible need to be very, very clear about potentially pricings, potentially exclusions and what that can and can’t involve.  And obviously sometimes there are some product types that we can maybe look at that would maybe be slightly away from what you would imagine, like your personal life insurance space and we can maybe look at some other options that somebody could be covered by.  You never know.  But I think if we talk about – I know you were saying about the medications, so I think that’s another thing that advisers, we generally start to – we have it in our company where we sort of like go, “Right, if it ends in this or it sounds like this then it’s probably going to be one of these and –”

Matt:            Sure, yeah.

Kathryn:       There are certain ones that you know sort of right, okay, then that means that that’s actually, we’ve gone to a new level of maybe sort of like severity of symptoms and needing to have the control but I suppose like you said there’s a thing in terms of some potentially long-term steroid use and I know we all know sort of like that thing and I think we’re told, “Oh, you don’t want to be on steroids for long,” or, “You don’t want to be doing this,” but I suppose I’ve never really sort of like asked the question so what is the problem with long-term steroid use?

Matt:            Well, it –

Kathryn:       It’s not an easy one to answer, sorry.

Matt:            No, no it’s alright.  I mean essentially steroids, although they are counter-inflammatory, in other words reduce the inflammation, they can impact the organs in their own right, i.e. impairing the function of them and therefore getting the actual balance between – say the one that often crops up I think in medical records or when we’re talking to clients is prednisolone, then we have to be careful that the damage caused by prednisolone – well, I say we do, as an underwriter that’s unfair, the clinicians have to be very, very careful that the prednisolone dosage doesn’t cause more damage to the patient as in fact would be the original condition.  And that’s the difficulty of it.  Now, in terms of safe levels and again, I will use that term loosely, of prednisolone, the market still tends to look at 15 – 15, one-five milligrams per day.  And clinicians will vary – will always look for an alternative to the long-term use of prednisolone and look at other ways of treating a given condition.

So 15 milligrams tends to be the kind of cut-off point where insurers start to – a red flag, or maybe an orange flag if I can use that term. And remember we are talking long-term use.  Often the use of prednisolone can be a lot higher but for very short periods.  As soon as the prednisolone starts kicking in and reducing the inflammation then the figure can be reduced.  So an underwriter – just because somebody has had let’s say 45 milligrams for a month, they’re not going to rate them and if they are currently not on 45 milligrams I might add, they’re not going to just rate them out of hand.  It would be the long-term position that they would look at here.  Yeah, it’s a difficult one, but I think short-term bursts of very high dosage of steroids is obviously needed.

Kathryn:       Yeah.

Matt:            And again, we’ve heard of that use of various anti-inflammatory drugs with Covid and an underwriter would only look at the longer-term position.  I think you hit the word on the head, long-term use.

Kathryn:       Yeah.

Matt:            I think the other point here is that some conditions will always require steroids and therefore the base rating – so the number of deaths that the actuaries and the underwriters would see in their statistical analysis – some of those may have died because of the absolutely essential need of high dosages of prednisolone.  So therefore the high doses of prednisolone could already be taken into account in terms of the base loading.  Does that make sense?

Kathryn:       Yeah.  No, I think that makes a lot of sense.

Matt:            Oh good.  Sorry Kathryn –

Kathryn:       That’s alright.

Matt:            So again, the partnership between the actuaries and the underwriters is absolutely key to understand whether it’s the prednisolone that at the end of the day caused the major problem or whether it was the underlying disease.  And where you’ve got both added together, there is absolutely no point in adding another rating for continuing – for prednisolone use.

Kathryn:       Okay.  I think that makes a lot of sense.

Matt:            I hope that makes sense.  It’s a bit of a – it’s one of those more difficult areas within the underwriting piece I think to at least try and explain.

Kathryn:       No absolutely and I’m glad you were the one explaining it and not me!

Matt:            Fair comment!

Kathryn:       There’s also obviously – if we’re talking about the hereditary side of things potentially, there is potentially this thing isn’t there where somebody could be a carrier of the lupus gene and it’s one of those things where – and it can happen with other conditions as well where it can be quite interesting because obviously insurers are not allowed to ask about genetic conditions.  So obviously if it’s a predictive test then they’re not allowed to ask about that.  Obviously if it was a diagnostic test then that’s different in terms of these kinds of tests that are done.  So if somebody had had a predictive test and obviously it says that they are or aren’t a carrier for lupus or potentially, you know, it could develop at some stage then that would be a case of they’re not allowed to bring that up in the questions. However, if somebody does have hereditary sort of like links to lupus, especially just in the very immediate blood relatives – so that’s just parents and siblings, it could well show up in the family medical history because, you know, some insurers will ask a certain set of questions about health conditions and some of them will then say, “Any hereditary condition?”  At which point, you know, it can pop up there.

And I think what can be interesting is that – for some people is that we don’t ever want to say to somebody, you know, if they’ve chosen not to have a predictive test at all then obviously, you know, we wouldn’t want to necessarily push anybody towards that at all because there will be very clear reasons as to why they didn’t want to but it’s interesting because if somebody has had a predictive test and then it’s shown that they are sort of like negative for the condition, that can potentially open up opportunities I believe.

Matt:            Yeah, absolutely.  I mean, the negative genetic test result can be a very, very useful tool and in my opinion should always be discussed when advisers talk to their clients and be used accordingly.  Interestingly – and I think this is where the industry falls down a little bit – sometimes you’re going to get underwriters asking, “Well, why?  What’s going on?”  And I suppose you could argue that it’s obvious why they’ve had the test because there is a concern but remember they actually have to get a clinician to agree to doing that test in the first place and if there wasn’t any reason from a clinical perspective – unless they were getting it done privately, then it won’t be done.  But with a clear explanation which really has to come from the client to the whys and wherefores of a particular scenario – then I would hope that all underwriters – the vast majority of underwriters would take it as a positive.  If it’s – as you quite rightly have highlighted, if it’s a positive test –

Kathryn:       Yes.

Matt:            Then there is no need to disclose.

Kathryn:       No, of course.

Matt:            But this is one of the areas – rather like mental illness to be perfectly honest, where the information that can be obtained right at the conversation with the client – and that, as you know so well Kathryn, that is one heck of a skill to have in some of these areas, that the more information that can be obtained from the client the better and the better outcome should be for the client when they go to reinsurers.  But it’s, you know, it is a particular skill.  I know Cura Financial Services are very much into developing those skills within its advisers.

Kathryn:       Absolutely.

Matt:            But the more information the better.

Kathryn:       It’s surprising as well – for a different condition, so we had a – we can sometimes end up in a very awkward position as an adviser as well because we were supporting somebody a while ago and they had the sickle cell trait.  So they came into us, obviously they didn’t have sickle cell, they had the trait – so the genetic – in a sense carrier of the condition and we went through everything and we got the terms back and they weren’t what were expected and so we were sort of saying, “Okay then.”  And so we got a copy of the medical records and everything and had a very, very difficult conversation because the person actually did have sickle cell.

Matt:            Right.

Kathryn:       And they felt that – they believed that they had sickle cell traits and –

Matt:            Right, right.

Kathryn:       And that’s a really, really tricky conversation.  Obviously it’s one of those things as an adviser, you’re kind of sat there thinking – and it’s hard because it’s like, “Well what do I do because, you know, this person’s not had anything – they’ve not had this explained to them?”

Matt:            No, no.

Kathryn:       To the level that they should have maybe had this explained to them.  But ultimately you can’t not tell – it’s very hard because you’re like, “Well I have to tell them but also I’m not a medical professional,” and things like that.

Matt:            Yeah.

Kathryn:       And obviously in this situation we did and again it’s a very, very specific conversation and where you chat to somebody to be able to discuss that and maybe gently suggest that they maybe speak to their medical person just to clarify exactly their health and luckily – obviously once – I mean once we knew that was the case we just in a sense switched insurers and switched approach and it was fine.  But I think it’s important for people to be aware of that as well, you know, somebody might tell you something and, you know, it could be that – there could be a number of things.  They might not realise exactly what the condition is.  They might be confused or they might – sometimes they may have compartmentalised it and they might have just sort of like put it right to the back of their mind and tried to not think about it too much and have made it kind of a lesser thing and that can be something that I always say, you know, what I say in like all of these sessions is, “If you get something back you weren’t expecting terms-wise, get the medical report, double check it and also as well – there are plenty of times the medical reports are wrong.”

I’ve had some very big ones that have been wrong recently with things that you just wouldn’t expect at all to have been done incorrectly but they are sometimes that way and it could just be that it’s not that the person can’t be covered or that you can’t cover them, it could just be that something just needs correcting somewhere or explaining a bit better to someone.

Matt:            I can’t disagree with any of that.  I think it’s extremely well said.  I know – well, having been in the industry for such a long time now, I know that a lot of IFAs feel very, very, very uncomfortable with those types of conversations.

Kathryn:       Yeah.

Matt:            But the reality is that they are so, so important to have.

Kathryn:       Absolutely.

Matt:            So yeah, it’s great that you and the team are prepared to do it.  You’re a rare breed I would say.

Kathryn:       Thank you.  I do like to think of myself as quite rare.  Like you say, quite special, quite quirky.  Before I go onto the case studies, I think probably the last area for us to go on – I know we’d originally said about critical illness cover when we were preparing for this, I imagine it probably flows over to income protection as well I have to say.  But I think a lot of people can get quite confused as well from an advisory point of view because when we’re talking about lupus, you know, and I think what we’ve just talked about here would be very, very helpful because when we’re looking at DLE or DILE, we’re not necessary talking about things going on on the insides whereas with SLE we are thinking that there’s probably going to be at some stage some kind of an organ involvement.  And what we do tend to find is that – so with the discoid lupus and the drug-induced lupus, you can potentially get critical illness cover for them with mainstream providers, obviously very much depending on many things such as the actual symptoms, the treatment schedule, the time since diagnosis – lots of other things.

But with SLE – so the systemic lupus, that would be – I always say with specialist insurers and I just want to clarify what I mean by specialist insurers, so that is what I would term as people who aren’t mainstream insurers.  That’s when I’m having to go much more outside of the usual names that people would think of when they think of an insurance company or potentially, like I mentioned before, potentially a different product type.  And I suppose what’s good to maybe know and I don’t know if there is even an answer to this potentially Matt, is – so like with SLE, we have already said obviously that there is obviously organ involvement so I can understand why there’d be –

Matt:            Kathryn, can I maybe just clarify there is an involvement.  SLE doesn’t necessarily mean that there is.

Kathryn:       Okay.

Matt:            Systemic lupus means that it can –

Kathryn:       Yes.

Matt:            Spread to the organs and those would be the worst case scenarios.

Kathryn:       Yeah.

Matt:            People with SLE that don’t have organ involvement can still get life insurance cover.

Kathryn:       Yes.  Oh no, absolutely.  I was meaning –

Matt:            I just wanted to make sure that – yeah, it’s systemic –

Kathryn:       No ‘cos I’ve moved onto critical illness.  Sorry if I –

Matt:            Oh I’m sorry, I do apologise.

Kathryn:       Not to worry.

Matt:            Shut me up and put me in a box, go on.

Kathryn:       No, no, no not at all.  The thing is I suppose – that’s a really good point though because obviously I’m sort of like thinking, “Organ involvement, right, okay,” so I can understand why there’s a caution about having heart attack cover for a critical illness policy, potentially even a stroke but I don’t know if there’s necessarily an increased risk of cancer?

Matt:            Yeah I think –

Kathryn:       And it comes back to that argument of, you know, “Should we be offering an option that maybe there’s a cancer policy?”  Because that is what a lot of people are scared of.  But then, from what you’ve just said then as well though, not all SLE is necessarily organ involvement.

Matt:            No.

Kathryn:       So for it to be kind of almost a bit of a blanket no is quite hard at the same point as well for that.

Matt:            Yeah, absolutely.  I mean, I think with the – when I say – so systemic lupus erythematosus, it can develop – you can get inflammation and to use your words, in areas of the body.  Now, if you compare that with somebody who has not got SLE or any of the major – say illnesses a critical illness pay-out covers, then the chances that person with SLE getting major organ bond at some stage are far, far higher than somebody else and, you know, we talked about – or you mentioned cancer and people with SLE – the statistics show – and I can’t give you an absolute technical explanation at this moment in time, but they do show higher rates of cancer.

Kathryn:       Right.

Matt:            Okay, so if you take the higher rate, then like all of the medical conditions we’ve talked about, again the underwriters and the actuaries need to get together and say, “Well okay, is that – does that higher rate translate into whether cover can be given or not?”

Kathryn:       Yeah.

Matt:            Is it outside the acceptable limits that insurers want to cover?  And with SLE, certainly then at the moment the risk outweighs the appetite that insurers are happy to take onboard.  Now, logically thinking about it, if somebody has been diagnosed with SLE and they’ve had absolutely no progression for – I’m picking a number slightly off the top of my head here –

Kathryn:       Yeah.

Matt:            Let’s say 10 years, 15 years then with no organ involvement then maybe something can be done for them but in the early stages and when I’m talking about early I’m talking about a very good number of years, then without the knowledge of progression or not –

Kathryn:       Yeah.

Matt:            Because some of them can progress, a doctor – a clinician cannot absolutely say it will or it won’t.

Kathryn:       Yes, of course.

Matt:            Then that risk appetite is just too high.

Kathryn:       Yeah.

Matt:            I think – I mean, critical illness, income protection – we haven’t really touched on both of those areas I don’t think during our year of podcasts and –

Kathryn:       Yeah.

Matt:            I was – unfortunately I was away on holiday – again, before anybody says, during the Income Protection Task Force week.

Kathryn:       Yes.

Matt:            I know Andrew – Andrew Wibberley that is, did a podcast or a session on underwriting and income protection and I’ve yet to see it but it’s a very interesting area whereby you would hope that the insurance market will move forward in the future.  Quite how, I don’t honestly know and I’m wondering if Andrew’s come up with some answers on that.

Kathryn:       Well we absolutely – we love income protection because I mean a big thing for us is –

Matt:            Oh absolutely.

Kathryn:       Yeah absolutely.  I mean, we’re sort of like of the opinion like for – pretty much if you’re earning money, then income protection should be very, very high up on that priority list but one of the reasons that we love it as well is because it can be so much more flexible than critical illness cover.  Whereas you can find with critical illness cover, it’s, you know, you can either get – it’s kind of a yes or a no, there’s some that you might be able to get some exclusions but it is much more – I always feel like critical illness cover is a bit more black and white in the sense of you’re getting it or you’re not.  There’s not really any movement whereas with income protection, there is quite a lot of the time so much movement and if you sometimes put in a slightly longer deferred period, there’s so many different things that can maybe just make it okay.

So if somebody is trying to look at options, I do think that probably someone that’s obviously living with SLE will find it difficult to get income protection with a mainstream insurer and for people with other forms of lupus, if you’re going to have income protection it’s obviously – it’s quite likely that there’d be an exclusion on the claim set to anything related to their version of the lupus and again it’s one of those strange things where sometimes you might get an exclusion that says sort of like, “Exclusion for lupus,” but then you’d maybe get another person like trying to say, “Well exclusion for all autoimmune conditions.”  You know, and you’d have to be very, very careful as to where you’re looking to make sure you get that right.  Another very, very – I was going to say – not underrated but I think something that’s just not necessarily promoted anywhere near as much as it should be is obviously the options that can come with group income protection.  So, you know, especially group income protection.  If you’ve got somebody and they’re in a company and, you know, they’re obviously – the company is going to get cover for all of its employees, then they’re going to be covered and there’ll be a certain amount where there won’t be any exclusion relating to the SLE.

Matt:            Absolutely, yeah.

Kathryn:       So it’s – and I think that’s pretty much – we can say to listeners, you know, going back to almost I think probably every condition that we’ve covered, you know, if you have somebody in that situation and there’s the option for group insurance or group life insurance, group income protection, that is a huge, huge thing to have in your power bank as an adviser, to be able to offer that.  There are definitely some technicalities so I always say to people, “Please don’t just rush straight into group cover, there are certain things that you really, really do need to know.”  But it is somewhere where the ability to – actually access to insurance has such incredible potential.

Matt:            Yeah, I totally and utterly agree.  There’s no two ways about it and just one thing around income protection that I’d like to share is that income protection was the first protection type policy that I ever bought at the age of 21.  It wasn’t life insurance and critical illness – shows you how old I am, but critical illness was in its relative infancy in those days.  But income protection was the one absolute stand-out protection policy even 40 years ago so there you go.  For me.

Kathryn:       Yeah, absolutely brilliant.  I’m glad that it was there.  I was going to say I have to be – ‘cos I’m – obviously with my kids I’m, you know, obviously I’ve got them pensions set up.  My youngest had a pension from about nine months, you know, so I’m like doing loads of stuff and I’ve even been thinking now – and it could sound – it seems so daft but I’m thinking, “Right, as soon as they’re able to get life insurance I might just get it for them.”  Before anything happens to them health-wise or anything like that, just get it for them, get a nice amount and I’ll just pay it and just make sure that they’ve got life insurance in place that they can eventually take over and have when they’re working and then as soon as they’re working I’ll pay for them to probably have the income protection just so that I know that they’ll be alright.  And I imagine there’s some people going, “No, let them do it themselves.”  And I’m thinking, “Yeah I really want them to but at the same point, you know, young kids –”  I say young kids, oh my God I’m at that age where I’m 36 – and young kids – and I’m thinking of 21-year olds as young kids.  That’s just soul destroying.

Matt:            I mean – no absolutely.  I mean, it’s an interesting example because I had a client I suppose you’d call it – not in a broking sense by the way, where her Dad actually bought her critical illness when she was 18.

Kathryn:       Right.

Matt:            But subsequently had a cardiovascular – sorry, a cerebrovascular problem when she was only in her late 20s –

Kathryn:       Right.

Matt:            Which wasn’t covered by critical illness but actually made it impossible for her to get critical illness ever again and that policy that was taken out at 18 was expiring at the age of 30.

Kathryn:       Right.

Matt:            So what you said back there, you know, it does make a lot of sense.  Get the cover in when they’re young if you’re a parent or otherwise.

Kathryn:       Absolutely.  I mean, I do think though – I just constantly think – I don’t constantly think but when I do think about it – I think of my kids – I think oh bless them when it gets to their family medical history and they’re going to have to put me in there and I’m thinking, “Oh, has your Mum been diagnosed with anything before the age of 65?”  And it’s going to be a case of, “How much paper do you have?”

Matt:            I love the question, anything, absolutely.  I’m of course bearing the – I don’t know what you call it absolutely but unfortunately my daughter will bear the brunt of me having been diagnosed with colon cancer.

Kathryn:       Yeah.

Matt:            And her critical illness will be rated at automatically plus 50.

Kathryn:       Yeah.

Matt:            So, you know, it’s an interesting debate when people should first start getting protection cover.  But certainly, you know, there are a couple of examples there.

Kathryn:       Absolutely and a very good example.

Matt:            Very early would have been very useful.

Kathryn:       Absolutely.  But I was going say – and a very, very good example as to getting a conversation in with your daughter’s employers some critical illness cover.

Matt:            Yes.  Yes, absolutely.  Yeah, no I agree.

Kathryn:       Good option there.  Okay, so we’ve got a case study for us to wrap up with.  So we had spoken to somebody obviously a little while ago now and they had been diagnosed with a discoid lupus in their early 20s and then a few years later it was actually a further diagnosis of the systemic lupus.  They had things like – they experienced pain.  They’d had to take some time off work at one stage but it was – the time off work had been very, very much in the past.  The diagnosis had been, you know, this was – we were talking a good 15 years or so since the initial diagnoses and this time off work.  They did need to take painkillers when they needed and also had the hydroxychloroquine and mepoquine I think it is?

Matt:            Yeah.

Kathryn:       But they took that sort of like on an as and when basis.  So we’re talking some of the higher medications there and then as well as having the SLE they also had developed as a kind of secondary condition to the lupus – they developed antiphospholipid syndrome and some people may know that a bit more as the acronym APS and what they needed to do with that was they were having to have warfarin quite regularly because they had previously experienced deep vein thrombosis or DVT.  They had a young family, a very young child and they wanted to obviously make sure that there was going to be financial security in place and obviously as most people expect, they came to us because of the fact that we are specialists in this area for people with health conditions.  And what was brilliant was being able to arrange them the insurance.

So based upon obviously a number of factors, we came up with the option for £136,000 of level life insurance over 27 years and the premium came out at around £28 per month.  So I do like to use that as obviously a really good example because we have – straight away people would maybe be looking at this situation and thinking, “Oh systemic lupus, well that’s the stronger one,” and then we also then have a progression to another condition.  We’ve got the higher medications and, you know, we’re talking – obviously we’re not talking standard terms.  We are talking ratings on the premiums but I always think it’s really interesting to sort of like highlight this, you know, obviously rating on a premium it becomes £28 per month and whilst obviously I know that’s not – that doesn’t look great if you look at the original amount of life insurance – the premium.  It does however show that just because you might get a higher rating with life insurance, it doesn’t mean that it’s going to be going into silly money.  It’s still within the realms of what a lot of people would find comfortable as a payment each month.

Matt:            Absolutely.  Yeah, yeah, it’s a great example Kathryn.  A great example again.

Kathryn:       Brilliant.  Well I’m glad we’ve been able to have a chat and we’ve gone off on a few little tangents.

Matt:            Oh well, never mind.

Kathryn:       But no, no it’s me, I think I’ve took us off a few places today but I’ve enjoyed it.  It’s been good to have a good natter.

Matt:            It’s great to hear Fudge joining in as well.

Kathryn:       Oh I know.  He’s –

Matt:            He obviously wants to get involved.  I think you might need to have a word with him.

Kathryn:       Absolutely.

Matt:            Maybe he wants to be a trainee underwriter.

Kathryn:       He does.  Well I don’t know if anybody will have noticed but he is up on our website now.

Matt:            Oh yes.

Kathryn:       Lindsay was quite adamant the other day that we would have Fudge on as the third director and Chief Cuteness Operative for Cura and he’s got his own little bio and everything so yes, he’s absolutely sort of like a Cura dog.  Everybody absolutely adores him and he does – he came in and we did some job interviews the other day, last week even, and he was there and we were just kind of like, “Ignore the dog, it’s fine.”  And I think they just enjoyed it because they were having a job interview and also getting to pet a dog.

Matt:            Yeah absolutely.

Kathryn:       Which a lot of people seemed to enjoy.  But thank you.

Matt:            Who had the last word Kathryn, that’s what I’d like to see?  Was it one woof for yes and two woofs for no or something?

Kathryn:       Ah absolutely.

Matt:            I’m pulling your leg, I’m sorry.

Kathryn:       No of course.  I was going to say, he definitely has the last word which is a really big achievement when somebody is chatting to me.  So, good on him.

Matt:            Excellent.

Kathryn:       But thank you so much for coming in obviously and sharing your insights again as to all these different things.  We are going to be back next time and I’ll have Roy McLoughlin back with me and we’re going to have Jeff Woods as well from Legal & General.  And we’re going to be talking about some of the things from their State of the Nation report and it’s going to be talking a lot about protection, especially in the SME space and I’ve seen it, I’ve been going through it and it’s really interesting – some of the statistics.  So I’m hoping everyone is going to tune in for that.  If anybody would like a reminder of the next episode, as always just drop us a message on social media or visit the website practical-protection.co.uk and also don’t forget if you are listening to this as part of your work, you can claim a CPD certificate on the website too and that is thanks to our sponsors, OctoMembers.  So again, thank you very, very much Matt.

Matt:            My pleasure as always, Kathryn.  Lovely to speak to you – and Fudge!

Kathryn:       Lovely to speak to you too.  Bye!

Matt:            Bye!

Lupus

Hi everyone, this week I have Matt Rann back with me and we are talking about lupus. This is an autoimmune condition that can potentially have an influence on protection insurance applications. We are talking about Systemic Lupus Erythematosus (SLE), Discoid Lupus (DLE) and Drug-induced lupus (DILE).

Lupus is a condition that usually affects women far more than men, with women nine times more likely to be diagnosed with the condition. Symptoms can involve fatigue, a skin rash, hair loss, and much more including difficulties with the kidneys.

The key takeaways:

  1. Roughly 1 in every 1000 living in the UK have lupus.
  2. Lupus is caused by having too many antibodies within the immune system.
  3. Lupus can be hereditary but it can also be triggered by hormones e.g. puberty, pregnancy, menopause. It can also be triggered by a viral infection, sunlight and some medications.

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

If you want to know more about how to arrange protection insurance, take a look at my Protection Insurance in Practice course here.

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

Matt:            Good morning Kathryn, how are you keeping?

Kathryn:       I’m very good thank you, how are you?

Matt:            Yes, not too bad, not too bad at all.  I’m doing a lot of preparation in between talking to you of course around a long three-day, full-on fishing trip next week.

Kathryn:       Nice.

Matt:            I’m going back to my home county of Gloucestershire with a good friend of mine who’s a bit of a professional –

Kathryn:       Yeah.

Matt:            At his fishing and so much looking forward to that, thank you very much.

Kathryn:       Very, very nice, well I really, really hope that you enjoy that.  I’ve currently – at the moment, I was going to say my – in terms of our getting away and different things like that, Alan has gone to London for the first time since March of 2020 today, so I have the joy of him having obviously this lovely night out – obviously maybe having a couple of glasses of wine or something and I have all three children and Fudge.  So –

Matt:            Ah dear me.

Kathryn:       I expect to be allowed a lie-in on Saturday morning.

Matt:            I should think so too, I should think so too.

Kathryn:       Definitely.  So today everybody we are going to be talking about lupus and how that comes into play with insurance applications.  So this is the Practical Protection Podcast.

Kathryn:       So as we usually do, just a little bit of a general background for everybody in terms of lupus.  There’s a number of different things in terms of the kind of diagnosis that you might hear.  So we have systemic lupus erythematosus – you’re going to have to help me with that one, Matt.

Matt:            That’s absolutely right, erythematosus is what I call it.

Kathryn:       Erythematosus, thank you.

Matt:            We know – yeah.

Kathryn:       You know what I mean and somebody might say to you SLE, so that is – I’ve completely forgotten my phonetics then, so sugar, lima, echo.  I think it’s sugar, is it sugar?  I want to say sierra.

Matt:            I can’t remember, you know.  I can’t remember.  But we know what you mean.

Kathryn:       I want to say sierra.  Everybody knows what I mean, I’ll just make up random ones.  We then also have discoid lupus which would be DLE, so delta, lima, echo and then drug-induced lupus, which is known as DILE.  So delta, indigo, lima, echo.  And Lupus is an auto-immune condition and it is something where women are nine times more likely to be diagnosed with it.  It can be hereditary but it can also be something that is triggered by a certain event such as puberty, being pregnant, the menopause, even a viral infection.  There are some medications and potentially even sunlight might trigger it.  Lupus is actually caused by there being too many antibodies in the system – in the immune system, so basically it means that there’s too much going on there and it can lead to what’s known as inflammatory events.

And it’s one of those things where I think people probably again, as with any of these things that we talk about in this podcast, people think it’s probably not many people, but actually when you look at the numbers it can be quite a lot.  So in terms of the estimates there’s roughly about 50,000 in the UK that are living with lupus and that’s roughly one in every 1,000 people. So I think a good way to start off Matt, seeing as I’ve given a little bit of statistics around there, would be for you to maybe just sort of explain the differences between the different types of SLE – so what are the types of symptoms that we are possibly going to be seeing?

Matt:            Well, thanks for the question Kathryn.  I’ll probably take a step back and say that I’d like to start off with lupus as opposed to a specific type of lupus such as SLE and the other two that you mentioned.  You’re absolutely right, lupus generically is a non-specific inflammatory condition affecting tissue – the connective tissue in the body.  And it sounds absolutely horrible but there are other conditions – big medical conditions, well-known medical conditions which have the same start, if you like.  And it’s a condition whereby the body becomes allergic to its’ own tissue.  Which sounds absolutely horrible.

Kathryn:       That does sound quite intense.  It’s a good explanation of it.

Matt:            It does sound intense, doesn’t it?  But I liked – absolutely, I liked in inverted commas that explanation because it does paint a picture.  And you can see it with other big conditions that are very out there in the marketplace such as diabetes and also multiple sclerosis as well.  So it is – it’s the fact that the body attacks its own tissue is quite frightening.  Now, as we all know, inflammation occurs when your body’s immune system is fighting an infection or an injury.  I would imagine that most, if not everybody, who is listening today has had some form of inflammation, either from playing football on a Sunday morning or having a simple infection.  And of course, this auto-immune picture is right up there with Covid as well.  So – but today we must go back to lupus.  So in terms of systemic lupus erythematosus, this is where the body’s immune system starts to attack or can attack any major organ in the body and it’s pretty serious.  there’s no two ways about that and the areas that are most commonly seen, in terms of those major organs, are the kidneys in particular.  Also it’s known to attack the brain, so the cerebral area of the body and also the heart as well.  So you’ve got some pretty big, if rather important areas of the body there that SLE – systemic – can attack and do damage to.

In terms of the symptoms, it’s quite interesting to note that – and I’ll go onto DLE – discoid lupus erythematosus and drug-induced lupus in a minute – the symptoms for all three types of lupus initially can be very, very similar.  So it’s important that the clinician takes a detailed history of the symptoms themselves and also runs a series of blood tests and also interestingly ask the patient whether there is a history of lupus within the family as well.  Now the symptoms themselves can include extreme fatigue, pain or swelling of the joints, swelling of the hands, feet or around the eyes.  Problems with the skin – the very typical butterfly rash from the cheeks, facial cheeks or nose.  Headaches and low fevers, sensitivity to sunlight or fluorescent light and chest pain when breathing deeply.  Now, I’m sure a lot of the listeners again will have had some of those symptoms at some stage in their lives and that’s –

Kathryn:       It’s hard, isn’t it, because –

Matt:            It’s one of the very difficult areas to get that diagnosis.  Sorry Kathryn, you were going to say?

Kathryn:       I was going to say it is hard because, you know, I think as with so many things isn’t it, you know, the symptoms for almost anything and everything seem to –

Matt:            100% agree.

Kathryn:       It’s kind of like when you go on the NHS website or something, it’s sort of like, “Have you had any of these symptoms?”  Oh sorry, that would be – that would be Fudgie.  Fudgie do you know what, I think he just wants to be on the podcast now every time.

Matt:            I don’t blame him.

Kathryn:       That was my doorbell going and him being my fierce, burly protector obviously.

Matt:            Absolutely.

Kathryn:       I was going to say, he isn’t a protector at all, he would just turn over for a tummy cuddle with anybody at any point.  But no, as I say the NHS website, you’re putting in things about your symptoms and almost every single time it will say, “Oh, you have to go to A&E,” you know, there’s the – what’s the word for it –

Matt:            That’s the crazy thing about it, isn’t it?

Kathryn:       It is.  But it just does cross over with so many things, like the pain and the swelling of the joints and things like that, you know, I think a lot of people have probably had pain in their joints and things like that, so obviously –

Matt:            Absolutely.  The fatigue –

Kathryn:       Yes.

Matt:            Headaches, you know, it’s a difficult one.  And there’s no two ways about it, that as I’ve alluded to, the clinician has to do a very thorough job in terms of analysing those symptoms and looking at the family history and also arranging a series of blood tests.  And the blood tests are often the definitive way, if I can call it that – definitive way of making a diagnosis at the end of the day.  But it’s pretty difficult to do at an early stage with lupus, hence why you’ll find for life cover the underwriting fraternity will often postpone a case for say 12 months until a firm diagnosis has been made and the progression or otherwise of the disease can be calculated.

Kathryn:       Is it – I could be wrong, but I feel like I read somewhere that with lupus it can be quite standard for it to maybe even take five years to actually get an official diagnosis, even once you’re, you know, really engaging and there was even the suspicion of lupus, maybe that’s a certain type, I could be wrong.

Matt:            I think in some circumstances that the five-year term could be right.  I think it very much depends maybe at what stage within the disease that the patient actually seeks medical help.

Kathryn:       I suppose –

Matt:            Or they get investigated properly.

Kathryn:       I was going to say, because I imagine private medical insurance as well, obviously that’s going to probably bring that down.  Because again, it’s one of these things with me, I always think with blood tests, in some ways, I sort of think right, well if they take bloods, they should be able to test everything.  I’m sort of like, “If you’re taking the blood, just test everything and anything.”  But I imagine that they have to do very specific tests to sort of like see if it’s lupus.  It’s not just suddenly going to – it’s not going to pop up on a regular blood screen I imagine.

Matt:            It’s not going to throw out an instant diagnosis.  For all we know, it’s going to be a combination of factors really.

Kathryn:       Yes.

Matt:            Certainly, antibody tests, you know, for the overproduction are very useful in making a diagnosis but at the end of the day it’s a little bit of a wait and see in the context of getting a firm diagnosis.  But that doesn’t necessarily mean that treatment – some form of treatment, can’t be given early doors.  So yeah, it’s not an easy one but it has to be said that the clinicians in this world are generally making the right decisions because the actual mortality involved with the worst of these three – I’ll come onto the other two in a minute – but systemic, i.e. system involvement – the mortality associated with it has come down dramatically in the last 20 years.  And that’s primarily because of the diagnosis and the diagnosis leading to a course of treatment and obviously they can vary the treatment, which is often steroids, or anti-malarials for that matter, accordingly.  And as we’ll come onto a little bit later on, obviously steroids can lead to problems in their own right and therefore have to be very carefully managed by any clinician treating somebody with SLE.

Kathryn:       Yeah.

Matt:            But I think as I say, from an underwriting perspective, the listeners – please don’t be surprised if somebody appearing with a variety of symptoms with a question mark SLE are not postponed until a firmer diagnosis has been made.

Kathryn:       Yes.

Matt:            It doesn’t have to be an absolute diagnosis but a firmer diagnosis than a variety of symptoms.  And also, it’ll take time probably for the clinician to get the dosage of the steroids or anti-malarials right –

Kathryn:       Yeah.

Matt:            For that person’s particular condition because everybody who suffers from SLE is different and I think that’s pretty important to say.

Kathryn:       Of course.

Matt:            Okay, I did promise to mention the other two types of lupus, which you mentioned and as I’ve already said, with discoid lupus erythematosus and what a mouthful that is, it is actually a separate entity to SLE.  It is classified clinically as a separate entity but unlike systemic – if, again, I always say, remember systemic because it can impact the body’s systems, okay?  That’s why the word is used really.  But with discoid it remains confined to the skin and only the skin.  It doesn’t impact any other major organs.  Generally, for life – but in the great majority of patients, there is a one or two percent that might end of up with SLE but the majority should not have any major problems from a mortality perspective and therefore, once the underwriter – and let’s face it the clinician at the end of the day – are happy that we are looking at DLE and solely DLE, then again once that diagnosis can be firmed up, then you can obviously get standard rates from a mortality perspective –

Kathryn:       Okay.

Matt:            For discoid.  For drug-induced lupus, again the symptoms often overlap with SLE and again it’s very rare that the major organs are affected at all and when people are on treatment on medicines, it can take several months or even years before any of the typical symptoms of lupus actually appear.  But on a little bit of research two drugs do seem to be particularly implicated, if I can call it that, with drug-induced lupus and that’s hydralazine, where 5% of patients develop lupus symptoms and that’s often used for hypertension – for treating high blood pressure.

Kathryn:       Yeah.

Matt:            And also procainamide which is in fact used for – it’s a heart drug used for irregular heart rhythm and 20% of people on that drug can get symptoms.  Other drugs – far less than 1%, often more than – more often less than 0.1%.  So, those are the two types of drugs and indeed – sorry, I’ve just got some – I did find another one to notice, isoniazid which is for tuberculosis – is a little bit higher than 1%.  But here – once those drugs have been stopped or managed – and I think it’s important to say you don’t have to come off them particularly – once they’re managed, symptoms will disappear after six months.  And bear in mind that these – the drug-induced lupus – the clinicians know that the drugs which can cause these types of lupus symptoms, then it’ll be managed very, very well.  And effectively from a life insurance perspective, once those symptoms have disappeared/or stable, then there should be no problems in getting normal terms for life insurance.  Does that help in terms of differentiating the three?

Kathryn:       Yeah, I think it really does.  I mean I think, you know, when we’re talking about lupus and especially as an adviser, who just wants to help somebody, if we’re hearing SLE then we need to be probably more aware that that’s going to be – potentially make some things a bit trickier, we maybe need to know – obviously we always need to know as much as possible but we need to know some extra things as well compared to potentially the others.  So I know we said before about potentially involvement with kidneys and other organs so I know with the kidneys we’re probably going to be looking at what’s known as the GFR readings.

Matt:            Yeah.

Kathryn:       So that is golf, foxtrot, romeo readings.  It’s quite easy if you sort of like do a search online to find in a sense what they should ideally be within and if someone can tell you the number that they have for that then that would be very useful.  Would they be wanting – because obviously I know you said the heart and the brain, I’m not exactly sure what would – you could use in a sense as evidence, or what you would ask somebody about that, but I know obviously typically when I’m looking at things, I would be sort of thinking like kidneys, “Right, I need to know the GFR.”  Are we potentially talking the liver as well?  So we would maybe want to know what the LFTs were as well?

Matt:            I haven’t seen liver specifically mentioned as one of the – if I can use the term common major organs that are used.  With the kidneys, we’re looking at inflammation here and obviously with inflammation when it goes completely haywire, as we’ve seen sadly with Covid, it can stop that organ actually functioning full stop.  So you’re absolutely right with GFR – Glomerular Filtration Rate.

Kathryn:       Yeah.

Matt:            But you’re also looking at other renal kidney function tests such as creatinine as well.

Kathryn:       Yeah.

Matt:            The creatinine clearance.  Now, in terms of the heart and the brain, then you certainly are going to be looking at the bloods that relate to the heart, as we know so well from the diagnosis of heart attack etcetera with bloods.  Troponin is an enzyme which you will know a lot about or will have heard a lot about.  But the brain is an interesting one.  I must admit, I don’t think I’ve ever seen an SLE case where there’s actually been brain involvement apart from during – with my claims experience at post-mortem.  So I’m not ultimately sure whether the blood tests – what blood tests would be needed for that apart from a scan will probably tell you that the tissue in the brain was very inflamed.

Kathryn:       Okay.

Matt:            But I have to say once you get to kidney and cerebral heart involvement, then I’m afraid there is a minimal chance of getting life insurance with those three.  Those – once you get to the major organs, the prognosis is pretty poor, but when it comes to the actuarial underwriting calculations that make up the rating boundaries, the risk boundaries which are applicable in the industry.

Kathryn:       So I think yeah, I see where you’re coming from with that.  I think it’s probably good to clarify that the difficulty would be for life insurance with mainstream insurers.  So there could be some options with some specialist insurers, but obviously, as with anything like that, if somebody was going to be looking at that there’s incredible need to be very, very clear about potentially pricings, potentially exclusions and what that can and can’t involve.  And obviously sometimes there are some product types that we can maybe look at that would maybe be slightly away from what you would imagine, like your personal life insurance space and we can maybe look at some other options that somebody could be covered by.  You never know.  But I think if we talk about – I know you were saying about the medications, so I think that’s another thing that advisers, we generally start to – we have it in our company where we sort of like go, “Right, if it ends in this or it sounds like this then it’s probably going to be one of these and –”

Matt:            Sure, yeah.

Kathryn:       There are certain ones that you know sort of right, okay, then that means that that’s actually, we’ve gone to a new level of maybe sort of like severity of symptoms and needing to have the control but I suppose like you said there’s a thing in terms of some potentially long-term steroid use and I know we all know sort of like that thing and I think we’re told, “Oh, you don’t want to be on steroids for long,” or, “You don’t want to be doing this,” but I suppose I’ve never really sort of like asked the question so what is the problem with long-term steroid use?

Matt:            Well, it –

Kathryn:       It’s not an easy one to answer, sorry.

Matt:            No, no it’s alright.  I mean essentially steroids, although they are counter-inflammatory, in other words reduce the inflammation, they can impact the organs in their own right, i.e. impairing the function of them and therefore getting the actual balance between – say the one that often crops up I think in medical records or when we’re talking to clients is prednisolone, then we have to be careful that the damage caused by prednisolone – well, I say we do, as an underwriter that’s unfair, the clinicians have to be very, very careful that the prednisolone dosage doesn’t cause more damage to the patient as in fact would be the original condition.  And that’s the difficulty of it.  Now, in terms of safe levels and again, I will use that term loosely, of prednisolone, the market still tends to look at 15 – 15, one-five milligrams per day.  And clinicians will vary – will always look for an alternative to the long-term use of prednisolone and look at other ways of treating a given condition.

So 15 milligrams tends to be the kind of cut-off point where insurers start to – a red flag, or maybe an orange flag if I can use that term. And remember we are talking long-term use.  Often the use of prednisolone can be a lot higher but for very short periods.  As soon as the prednisolone starts kicking in and reducing the inflammation then the figure can be reduced.  So an underwriter – just because somebody has had let’s say 45 milligrams for a month, they’re not going to rate them and if they are currently not on 45 milligrams I might add, they’re not going to just rate them out of hand.  It would be the long-term position that they would look at here.  Yeah, it’s a difficult one, but I think short-term bursts of very high dosage of steroids is obviously needed.

Kathryn:       Yeah.

Matt:            And again, we’ve heard of that use of various anti-inflammatory drugs with Covid and an underwriter would only look at the longer-term position.  I think you hit the word on the head, long-term use.

Kathryn:       Yeah.

Matt:            I think the other point here is that some conditions will always require steroids and therefore the base rating – so the number of deaths that the actuaries and the underwriters would see in their statistical analysis – some of those may have died because of the absolutely essential need of high dosages of prednisolone.  So therefore the high doses of prednisolone could already be taken into account in terms of the base loading.  Does that make sense?

Kathryn:       Yeah.  No, I think that makes a lot of sense.

Matt:            Oh good.  Sorry Kathryn –

Kathryn:       That’s alright.

Matt:            So again, the partnership between the actuaries and the underwriters is absolutely key to understand whether it’s the prednisolone that at the end of the day caused the major problem or whether it was the underlying disease.  And where you’ve got both added together, there is absolutely no point in adding another rating for continuing – for prednisolone use.

Kathryn:       Okay.  I think that makes a lot of sense.

Matt:            I hope that makes sense.  It’s a bit of a – it’s one of those more difficult areas within the underwriting piece I think to at least try and explain.

Kathryn:       No absolutely and I’m glad you were the one explaining it and not me!

Matt:            Fair comment!

Kathryn:       There’s also obviously – if we’re talking about the hereditary side of things potentially, there is potentially this thing isn’t there where somebody could be a carrier of the lupus gene and it’s one of those things where – and it can happen with other conditions as well where it can be quite interesting because obviously insurers are not allowed to ask about genetic conditions.  So obviously if it’s a predictive test then they’re not allowed to ask about that.  Obviously if it was a diagnostic test then that’s different in terms of these kinds of tests that are done.  So if somebody had had a predictive test and obviously it says that they are or aren’t a carrier for lupus or potentially, you know, it could develop at some stage then that would be a case of they’re not allowed to bring that up in the questions. However, if somebody does have hereditary sort of like links to lupus, especially just in the very immediate blood relatives – so that’s just parents and siblings, it could well show up in the family medical history because, you know, some insurers will ask a certain set of questions about health conditions and some of them will then say, “Any hereditary condition?”  At which point, you know, it can pop up there.

And I think what can be interesting is that – for some people is that we don’t ever want to say to somebody, you know, if they’ve chosen not to have a predictive test at all then obviously, you know, we wouldn’t want to necessarily push anybody towards that at all because there will be very clear reasons as to why they didn’t want to but it’s interesting because if somebody has had a predictive test and then it’s shown that they are sort of like negative for the condition, that can potentially open up opportunities I believe.

Matt:            Yeah, absolutely.  I mean, the negative genetic test result can be a very, very useful tool and in my opinion should always be discussed when advisers talk to their clients and be used accordingly.  Interestingly – and I think this is where the industry falls down a little bit – sometimes you’re going to get underwriters asking, “Well, why?  What’s going on?”  And I suppose you could argue that it’s obvious why they’ve had the test because there is a concern but remember they actually have to get a clinician to agree to doing that test in the first place and if there wasn’t any reason from a clinical perspective – unless they were getting it done privately, then it won’t be done.  But with a clear explanation which really has to come from the client to the whys and wherefores of a particular scenario – then I would hope that all underwriters – the vast majority of underwriters would take it as a positive.  If it’s – as you quite rightly have highlighted, if it’s a positive test –

Kathryn:       Yes.

Matt:            Then there is no need to disclose.

Kathryn:       No, of course.

Matt:            But this is one of the areas – rather like mental illness to be perfectly honest, where the information that can be obtained right at the conversation with the client – and that, as you know so well Kathryn, that is one heck of a skill to have in some of these areas, that the more information that can be obtained from the client the better and the better outcome should be for the client when they go to reinsurers.  But it’s, you know, it is a particular skill.  I know Cura Financial Services are very much into developing those skills within its advisers.

Kathryn:       Absolutely.

Matt:            But the more information the better.

Kathryn:       It’s surprising as well – for a different condition, so we had a – we can sometimes end up in a very awkward position as an adviser as well because we were supporting somebody a while ago and they had the sickle cell trait.  So they came into us, obviously they didn’t have sickle cell, they had the trait – so the genetic – in a sense carrier of the condition and we went through everything and we got the terms back and they weren’t what were expected and so we were sort of saying, “Okay then.”  And so we got a copy of the medical records and everything and had a very, very difficult conversation because the person actually did have sickle cell.

Matt:            Right.

Kathryn:       And they felt that – they believed that they had sickle cell traits and –

Matt:            Right, right.

Kathryn:       And that’s a really, really tricky conversation.  Obviously it’s one of those things as an adviser, you’re kind of sat there thinking – and it’s hard because it’s like, “Well what do I do because, you know, this person’s not had anything – they’ve not had this explained to them?”

Matt:            No, no.

Kathryn:       To the level that they should have maybe had this explained to them.  But ultimately you can’t not tell – it’s very hard because you’re like, “Well I have to tell them but also I’m not a medical professional,” and things like that.

Matt:            Yeah.

Kathryn:       And obviously in this situation we did and again it’s a very, very specific conversation and where you chat to somebody to be able to discuss that and maybe gently suggest that they maybe speak to their medical person just to clarify exactly their health and luckily – obviously once – I mean once we knew that was the case we just in a sense switched insurers and switched approach and it was fine.  But I think it’s important for people to be aware of that as well, you know, somebody might tell you something and, you know, it could be that – there could be a number of things.  They might not realise exactly what the condition is.  They might be confused or they might – sometimes they may have compartmentalised it and they might have just sort of like put it right to the back of their mind and tried to not think about it too much and have made it kind of a lesser thing and that can be something that I always say, you know, what I say in like all of these sessions is, “If you get something back you weren’t expecting terms-wise, get the medical report, double check it and also as well – there are plenty of times the medical reports are wrong.”

I’ve had some very big ones that have been wrong recently with things that you just wouldn’t expect at all to have been done incorrectly but they are sometimes that way and it could just be that it’s not that the person can’t be covered or that you can’t cover them, it could just be that something just needs correcting somewhere or explaining a bit better to someone.

Matt:            I can’t disagree with any of that.  I think it’s extremely well said.  I know – well, having been in the industry for such a long time now, I know that a lot of IFAs feel very, very, very uncomfortable with those types of conversations.

Kathryn:       Yeah.

Matt:            But the reality is that they are so, so important to have.

Kathryn:       Absolutely.

Matt:            So yeah, it’s great that you and the team are prepared to do it.  You’re a rare breed I would say.

Kathryn:       Thank you.  I do like to think of myself as quite rare.  Like you say, quite special, quite quirky.  Before I go onto the case studies, I think probably the last area for us to go on – I know we’d originally said about critical illness cover when we were preparing for this, I imagine it probably flows over to income protection as well I have to say.  But I think a lot of people can get quite confused as well from an advisory point of view because when we’re talking about lupus, you know, and I think what we’ve just talked about here would be very, very helpful because when we’re looking at DLE or DILE, we’re not necessary talking about things going on on the insides whereas with SLE we are thinking that there’s probably going to be at some stage some kind of an organ involvement.  And what we do tend to find is that – so with the discoid lupus and the drug-induced lupus, you can potentially get critical illness cover for them with mainstream providers, obviously very much depending on many things such as the actual symptoms, the treatment schedule, the time since diagnosis – lots of other things.

But with SLE – so the systemic lupus, that would be – I always say with specialist insurers and I just want to clarify what I mean by specialist insurers, so that is what I would term as people who aren’t mainstream insurers.  That’s when I’m having to go much more outside of the usual names that people would think of when they think of an insurance company or potentially, like I mentioned before, potentially a different product type.  And I suppose what’s good to maybe know and I don’t know if there is even an answer to this potentially Matt, is – so like with SLE, we have already said obviously that there is obviously organ involvement so I can understand why there’d be –

Matt:            Kathryn, can I maybe just clarify there is an involvement.  SLE doesn’t necessarily mean that there is.

Kathryn:       Okay.

Matt:            Systemic lupus means that it can –

Kathryn:       Yes.

Matt:            Spread to the organs and those would be the worst case scenarios.

Kathryn:       Yeah.

Matt:            People with SLE that don’t have organ involvement can still get life insurance cover.

Kathryn:       Yes.  Oh no, absolutely.  I was meaning –

Matt:            I just wanted to make sure that – yeah, it’s systemic –

Kathryn:       No ‘cos I’ve moved onto critical illness.  Sorry if I –

Matt:            Oh I’m sorry, I do apologise.

Kathryn:       Not to worry.

Matt:            Shut me up and put me in a box, go on.

Kathryn:       No, no, no not at all.  The thing is I suppose – that’s a really good point though because obviously I’m sort of like thinking, “Organ involvement, right, okay,” so I can understand why there’s a caution about having heart attack cover for a critical illness policy, potentially even a stroke but I don’t know if there’s necessarily an increased risk of cancer?

Matt:            Yeah I think –

Kathryn:       And it comes back to that argument of, you know, “Should we be offering an option that maybe there’s a cancer policy?”  Because that is what a lot of people are scared of.  But then, from what you’ve just said then as well though, not all SLE is necessarily organ involvement.

Matt:            No.

Kathryn:       So for it to be kind of almost a bit of a blanket no is quite hard at the same point as well for that.

Matt:            Yeah, absolutely.  I mean, I think with the – when I say – so systemic lupus erythematosus, it can develop – you can get inflammation and to use your words, in areas of the body.  Now, if you compare that with somebody who has not got SLE or any of the major – say illnesses a critical illness pay-out covers, then the chances that person with SLE getting major organ bond at some stage are far, far higher than somebody else and, you know, we talked about – or you mentioned cancer and people with SLE – the statistics show – and I can’t give you an absolute technical explanation at this moment in time, but they do show higher rates of cancer.

Kathryn:       Right.

Matt:            Okay, so if you take the higher rate, then like all of the medical conditions we’ve talked about, again the underwriters and the actuaries need to get together and say, “Well okay, is that – does that higher rate translate into whether cover can be given or not?”

Kathryn:       Yeah.

Matt:            Is it outside the acceptable limits that insurers want to cover?  And with SLE, certainly then at the moment the risk outweighs the appetite that insurers are happy to take onboard.  Now, logically thinking about it, if somebody has been diagnosed with SLE and they’ve had absolutely no progression for – I’m picking a number slightly off the top of my head here –

Kathryn:       Yeah.

Matt:            Let’s say 10 years, 15 years then with no organ involvement then maybe something can be done for them but in the early stages and when I’m talking about early I’m talking about a very good number of years, then without the knowledge of progression or not –

Kathryn:       Yeah.

Matt:            Because some of them can progress, a doctor – a clinician cannot absolutely say it will or it won’t.

Kathryn:       Yes, of course.

Matt:            Then that risk appetite is just too high.

Kathryn:       Yeah.

Matt:            I think – I mean, critical illness, income protection – we haven’t really touched on both of those areas I don’t think during our year of podcasts and –

Kathryn:       Yeah.

Matt:            I was – unfortunately I was away on holiday – again, before anybody says, during the Income Protection Task Force week.

Kathryn:       Yes.

Matt:            I know Andrew – Andrew Wibberley that is, did a podcast or a session on underwriting and income protection and I’ve yet to see it but it’s a very interesting area whereby you would hope that the insurance market will move forward in the future.  Quite how, I don’t honestly know and I’m wondering if Andrew’s come up with some answers on that.

Kathryn:       Well we absolutely – we love income protection because I mean a big thing for us is –

Matt:            Oh absolutely.

Kathryn:       Yeah absolutely.  I mean, we’re sort of like of the opinion like for – pretty much if you’re earning money, then income protection should be very, very high up on that priority list but one of the reasons that we love it as well is because it can be so much more flexible than critical illness cover.  Whereas you can find with critical illness cover, it’s, you know, you can either get – it’s kind of a yes or a no, there’s some that you might be able to get some exclusions but it is much more – I always feel like critical illness cover is a bit more black and white in the sense of you’re getting it or you’re not.  There’s not really any movement whereas with income protection, there is quite a lot of the time so much movement and if you sometimes put in a slightly longer deferred period, there’s so many different things that can maybe just make it okay.

So if somebody is trying to look at options, I do think that probably someone that’s obviously living with SLE will find it difficult to get income protection with a mainstream insurer and for people with other forms of lupus, if you’re going to have income protection it’s obviously – it’s quite likely that there’d be an exclusion on the claim set to anything related to their version of the lupus and again it’s one of those strange things where sometimes you might get an exclusion that says sort of like, “Exclusion for lupus,” but then you’d maybe get another person like trying to say, “Well exclusion for all autoimmune conditions.”  You know, and you’d have to be very, very careful as to where you’re looking to make sure you get that right.  Another very, very – I was going to say – not underrated but I think something that’s just not necessarily promoted anywhere near as much as it should be is obviously the options that can come with group income protection.  So, you know, especially group income protection.  If you’ve got somebody and they’re in a company and, you know, they’re obviously – the company is going to get cover for all of its employees, then they’re going to be covered and there’ll be a certain amount where there won’t be any exclusion relating to the SLE.

Matt:            Absolutely, yeah.

Kathryn:       So it’s – and I think that’s pretty much – we can say to listeners, you know, going back to almost I think probably every condition that we’ve covered, you know, if you have somebody in that situation and there’s the option for group insurance or group life insurance, group income protection, that is a huge, huge thing to have in your power bank as an adviser, to be able to offer that.  There are definitely some technicalities so I always say to people, “Please don’t just rush straight into group cover, there are certain things that you really, really do need to know.”  But it is somewhere where the ability to – actually access to insurance has such incredible potential.

Matt:            Yeah, I totally and utterly agree.  There’s no two ways about it and just one thing around income protection that I’d like to share is that income protection was the first protection type policy that I ever bought at the age of 21.  It wasn’t life insurance and critical illness – shows you how old I am, but critical illness was in its relative infancy in those days.  But income protection was the one absolute stand-out protection policy even 40 years ago so there you go.  For me.

Kathryn:       Yeah, absolutely brilliant.  I’m glad that it was there.  I was going to say I have to be – ‘cos I’m – obviously with my kids I’m, you know, obviously I’ve got them pensions set up.  My youngest had a pension from about nine months, you know, so I’m like doing loads of stuff and I’ve even been thinking now – and it could sound – it seems so daft but I’m thinking, “Right, as soon as they’re able to get life insurance I might just get it for them.”  Before anything happens to them health-wise or anything like that, just get it for them, get a nice amount and I’ll just pay it and just make sure that they’ve got life insurance in place that they can eventually take over and have when they’re working and then as soon as they’re working I’ll pay for them to probably have the income protection just so that I know that they’ll be alright.  And I imagine there’s some people going, “No, let them do it themselves.”  And I’m thinking, “Yeah I really want them to but at the same point, you know, young kids –”  I say young kids, oh my God I’m at that age where I’m 36 – and young kids – and I’m thinking of 21-year olds as young kids.  That’s just soul destroying.

Matt:            I mean – no absolutely.  I mean, it’s an interesting example because I had a client I suppose you’d call it – not in a broking sense by the way, where her Dad actually bought her critical illness when she was 18.

Kathryn:       Right.

Matt:            But subsequently had a cardiovascular – sorry, a cerebrovascular problem when she was only in her late 20s –

Kathryn:       Right.

Matt:            Which wasn’t covered by critical illness but actually made it impossible for her to get critical illness ever again and that policy that was taken out at 18 was expiring at the age of 30.

Kathryn:       Right.

Matt:            So what you said back there, you know, it does make a lot of sense.  Get the cover in when they’re young if you’re a parent or otherwise.

Kathryn:       Absolutely.  I mean, I do think though – I just constantly think – I don’t constantly think but when I do think about it – I think of my kids – I think oh bless them when it gets to their family medical history and they’re going to have to put me in there and I’m thinking, “Oh, has your Mum been diagnosed with anything before the age of 65?”  And it’s going to be a case of, “How much paper do you have?”

Matt:            I love the question, anything, absolutely.  I’m of course bearing the – I don’t know what you call it absolutely but unfortunately my daughter will bear the brunt of me having been diagnosed with colon cancer.

Kathryn:       Yeah.

Matt:            And her critical illness will be rated at automatically plus 50.

Kathryn:       Yeah.

Matt:            So, you know, it’s an interesting debate when people should first start getting protection cover.  But certainly, you know, there are a couple of examples there.

Kathryn:       Absolutely and a very good example.

Matt:            Very early would have been very useful.

Kathryn:       Absolutely.  But I was going say – and a very, very good example as to getting a conversation in with your daughter’s employers some critical illness cover.

Matt:            Yes.  Yes, absolutely.  Yeah, no I agree.

Kathryn:       Good option there.  Okay, so we’ve got a case study for us to wrap up with.  So we had spoken to somebody obviously a little while ago now and they had been diagnosed with a discoid lupus in their early 20s and then a few years later it was actually a further diagnosis of the systemic lupus.  They had things like – they experienced pain.  They’d had to take some time off work at one stage but it was – the time off work had been very, very much in the past.  The diagnosis had been, you know, this was – we were talking a good 15 years or so since the initial diagnoses and this time off work.  They did need to take painkillers when they needed and also had the hydroxychloroquine and mepoquine I think it is?

Matt:            Yeah.

Kathryn:       But they took that sort of like on an as and when basis.  So we’re talking some of the higher medications there and then as well as having the SLE they also had developed as a kind of secondary condition to the lupus – they developed antiphospholipid syndrome and some people may know that a bit more as the acronym APS and what they needed to do with that was they were having to have warfarin quite regularly because they had previously experienced deep vein thrombosis or DVT.  They had a young family, a very young child and they wanted to obviously make sure that there was going to be financial security in place and obviously as most people expect, they came to us because of the fact that we are specialists in this area for people with health conditions.  And what was brilliant was being able to arrange them the insurance.

So based upon obviously a number of factors, we came up with the option for £136,000 of level life insurance over 27 years and the premium came out at around £28 per month.  So I do like to use that as obviously a really good example because we have – straight away people would maybe be looking at this situation and thinking, “Oh systemic lupus, well that’s the stronger one,” and then we also then have a progression to another condition.  We’ve got the higher medications and, you know, we’re talking – obviously we’re not talking standard terms.  We are talking ratings on the premiums but I always think it’s really interesting to sort of like highlight this, you know, obviously rating on a premium it becomes £28 per month and whilst obviously I know that’s not – that doesn’t look great if you look at the original amount of life insurance – the premium.  It does however show that just because you might get a higher rating with life insurance, it doesn’t mean that it’s going to be going into silly money.  It’s still within the realms of what a lot of people would find comfortable as a payment each month.

Matt:            Absolutely.  Yeah, yeah, it’s a great example Kathryn.  A great example again.

Kathryn:       Brilliant.  Well I’m glad we’ve been able to have a chat and we’ve gone off on a few little tangents.

Matt:            Oh well, never mind.

Kathryn:       But no, no it’s me, I think I’ve took us off a few places today but I’ve enjoyed it.  It’s been good to have a good natter.

Matt:            It’s great to hear Fudge joining in as well.

Kathryn:       Oh I know.  He’s –

Matt:            He obviously wants to get involved.  I think you might need to have a word with him.

Kathryn:       Absolutely.

Matt:            Maybe he wants to be a trainee underwriter.

Kathryn:       He does.  Well I don’t know if anybody will have noticed but he is up on our website now.

Matt:            Oh yes.

Kathryn:       Lindsay was quite adamant the other day that we would have Fudge on as the third director and Chief Cuteness Operative for Cura and he’s got his own little bio and everything so yes, he’s absolutely sort of like a Cura dog.  Everybody absolutely adores him and he does – he came in and we did some job interviews the other day, last week even, and he was there and we were just kind of like, “Ignore the dog, it’s fine.”  And I think they just enjoyed it because they were having a job interview and also getting to pet a dog.

Matt:            Yeah absolutely.

Kathryn:       Which a lot of people seemed to enjoy.  But thank you.

Matt:            Who had the last word Kathryn, that’s what I’d like to see?  Was it one woof for yes and two woofs for no or something?

Kathryn:       Ah absolutely.

Matt:            I’m pulling your leg, I’m sorry.

Kathryn:       No of course.  I was going to say, he definitely has the last word which is a really big achievement when somebody is chatting to me.  So, good on him.

Matt:            Excellent.

Kathryn:       But thank you so much for coming in obviously and sharing your insights again as to all these different things.  We are going to be back next time and I’ll have Roy McLoughlin back with me and we’re going to have Jeff Woods as well from Legal & General.  And we’re going to be talking about some of the things from their State of the Nation report and it’s going to be talking a lot about protection, especially in the SME space and I’ve seen it, I’ve been going through it and it’s really interesting – some of the statistics.  So I’m hoping everyone is going to tune in for that.  If anybody would like a reminder of the next episode, as always just drop us a message on social media or visit the website practical-protection.co.uk and also don’t forget if you are listening to this as part of your work, you can claim a CPD certificate on the website too and that is thanks to our sponsors, OctoMembers.  So again, thank you very, very much Matt.

Matt:            My pleasure as always, Kathryn.  Lovely to speak to you – and Fudge!

Kathryn:       Lovely to speak to you too.  Bye!

Matt:            Bye!

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