Type 1 Diabetes

Hi everyone, this week Matt Rann is back with me and we are talking about type 1 diabetes.

We are chatting about what diabetes is and how it affects the body, the potential complications that someone can experience and the insurance underwriting terms.

The key takeaways:

  1. Type 1 diabetes can affect all areas of the body and there are specific complications that can occur in the heart, eyes, feet and kidneys.
  2. The key things that underwriters need to know, to give you a potential indication of terms.
  3. A case study of arranging life insurance and income protection, for someone living with type 1 diabetes.

I will be back in a couple of weeks with Alan Knowles. He is back with one of his masterclasses and this time the focus is going to be on critical illness cover.

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

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

Kathryn:       Hi everyone, this is episode 11 of season three and I have Matt Rann back with me.  Hi Matt!

Matt:            Hi Kathryn, hope you’re keeping well?

Kathryn:       I’m very well thank you.  How are you?

Matt:            Excellent, yes, yes, good thank you very much indeed.  Looking forward to some heat at some stage.

Kathryn:       Absolutely, no more rain.  We are focusing today on type one diabetes.  We’re going to be chatting through some statistics, learning about what diabetes is and some of the terms that you might expect when you’re applying for protection insurance.  So this is the Practical Protection podcast.  So Matt, I know you managed to get away for a week’s holiday recently?  I was going to say, is it – do I dare say the banned word of staycation?  You had a staycation.  I think there’s going to be people cringing at me using that word.  It’s one of those people love or hate.

Matt:            It was very much a staycation, thank you, down in the Cotswolds where I was born and where I spent the first 40 years of my life.  So it was nice to get home and see all the family as well so thank you very much.  Definitely a staycation [laughs], perfectly legal.

Kathryn:       Yeah [laughs].  Well I’m really glad that you’ve managed to get that.  We just had a few days off last week just to sort of have a little bit of a chill out – a very, very well deserved chill out and it was just – it felt good.  It felt good to sort of be like a bit relaxed and also I have incredibly exciting news that I’m sure I’ll be sharing lots on social media that people will see which is that we are getting a puppy in a couple of weeks.

Matt:            Oh, goodness gracious.

Kathryn:       I’m so, so excited.  I’ve never had a dog before and I’m very, very excited.  We’re going to go and collect him in a couple of weeks’ time.

Matt:            What type of dog are you going to get, Kathryn?

Kathryn:       We’re getting a cockapoo.

Matt:            Oh yeah, yeah.

Kathryn:       So Alan’s allergic to everything, even me sometimes so we have to go for one that is hypoallergenic and, you know, obviously it’s really hard though.  We tried to rescue a dog and it was so, so hard because obviously the first thing we have to do is make sure that we get a breed that is considered – I know no dogs are actually hypoallergenic but we had to get one that was as hypoallergenic as possible but then the other thing is obviously I’ve got the about the boys who are three, six and nine and the problem is that whenever you’re looking to rescue is that they don’t seem to – I couldn’t find anywhere that’s prepared to say for children under the age of 10 which is obviously as well completely understandable because you just don’t know.  And it was that kind of thing of – well I wouldn’t want to risk getting a dog.  It may be lovely but unless I know for definite that it’s going to be okay with kids, I wouldn’t want to obviously risk bringing it into the home and –

Matt:            Sure, sure.

Kathryn:       It’s a bit of a shame but at the same point, we’re doing what’s best for what we can do and we’re going to give – we’re going to call him Fudge – we’ll give Fudge a lovely home.  Fudge – yeah, absolutely, let’s talk about big sugary treats just before we start talking about type one diabetes and blood glucose and everything.

Matt:            Oh dear.

Kathryn:       So just to sort of set the scene for everybody, so the first thing we’re going to do is just go into a little bit of some statistics and just explain a little bit – kind of like probably a bit of a high level thing about how diabetes is and how it works and then Matt, obviously I know you’ll know far more of the ins and outs of this stuff so I’ll be quizzing you as we go along as well.

Matt:            Excellent.

Kathryn:       So, just to give everybody a bit of a background.  So type one diabetes – so that is an autoimmune condition where essentially the cells in the body start to attack the pancreas.  So essentially you’ve got blood glucose which is the sugar levels in your blood and for people who are type one diabetic the sugar levels are too high and what it means is that the body cannot make the hormone insulin and insulin is essential because what it does is, is breaks down the sugar in the blood so that it can be absorbed within the body and without the insulin the sugar just keeps building up.  It can have some quite long-term implications for the heart, eyes, feet and kidneys so it’s really important that people with type one diabetes are hopefully diagnosed as early as possible and also able to start their treatment quite early.

I actually have a friend of mine who was diagnosed with type one diabetes.  It was in her mid to late 20s actually, it was after we’d been to university together and I was absolutely amazed that in a sense it hadn’t been picked up that early so it’s not just – we do hear about it being diagnosed in people who are young but it is also as well people who are starting to get more into adulthood that are diagnosed.  It is estimated at the moment there’s about 3.8 million people living with diabetes within the UK and there’s possibly about an extra 500,000 people that have diabetes and do not know it so that’s something as well for all the advisers who are listening to just bear in mind that that is a lot of people that you could potentially come across and talk to that would have diabetes.  And in that full amount of people, it’s thought that there’s somewhere between 5-15% of diabetics have type one diabetes so if we go nicely in the middle at 10% then that is roughly 380,000 people in the UK and it’s, you know, it’s something that you’re going to come across probably at some point.

I think it would be very rare for an adviser to advise their entire career and never come across somebody who is diabetic.  It may be type two diabetes and some of the things we’re talking about today will kind of translate over to type two diabetes as well but today we’re just focusing on the type one side of things.  So Matt, I suppose the key thing for me really is to ask you, you know, if I were to come to you and say, “I have a client who has type one diabetes,” what is it that you are wanting to know from an underwriting side of things?

Matt:            Okay, one of the key risk factors that underwriters look for in cases of diabetes, particularly type one, is the control of the condition and it’s actually good to hear and see that the pharmaceutical companies have made life easier for a diabetic to actually control their condition and get early signs if they’re going to have something called a hyperglycaemic attack where the blood sugar is too high in the body or indeed a hypoglycaemic attack where the blood sugar is too low and being able to get an early warning that one of these conditions – sub-conditions – may happen or is starting to happen is absolutely ideal because that gives the diabetic, the person, early warning that they can do something about it.  And that could well be of course taking more insulin, it could well be eating carbohydrate, taking some extra carbohydrate onboard but it allows them some control.

And you’ve touched on – in terms of what underwriters look for; a) control – a key method or a key laboratory test that helps us understand that control is something called an HbA1c test and that stands for glycosylated haemoglobin and what that does is allows the underwriter to have a view of the control of the blood sugars within the body over a period of two to three months.  You will often see blood sugar or blood glucose tests in GP reports but that’s only a snapshot.  It’s only a snapshot of a given time, you know, on the basis that you and I are not diabetic – our blood sugars go up and down all the time and therefore a snapshot of a given time of the day isn’t that useful.  Fasting blood sugars are often seen as well where the person is asked to fast for anything between six and 12 hours before and that gives us – that takes out the – or minimises the risk of a blood glucose being too high because of a recent meal.  But again it’s a snapshot.

The key one for us is the glycosylated haemoglobin so that’s HbA1c and that takes a – ends up with a reading – the blood control of – sorry, the blood sugar control of the period of around two to three months.  So that’s very important and control is a very important predictor of diabetic complications which you have already mentioned a few of.  In terms of the underwriting then yes, those complications and the presence of those complications is very, very important indeed and I always remember one of my late, great and very early mentors, the great Dr Brackenridge, always saying – used this lovely term which I’ve not forgotten in 40 years is that diabetes is an atherosclerotic accelerator.  What a mouthful that is.

Kathryn:       That is, yeah.  I’m glad you said it and not me.

Matt:            [laughs] Effectively, all that means is – and you’ve touched on it yourself earlier on, that diabetes actually hardens the arteries.  It hardens the blood vessels, makes them less stretchy and that type of – it’s often not just in any particular organ in the body although you’ve talked about a number and we’ll go into it a little bit later on but it can be every organ – sorry, blood vessel in the body and obviously the blood vessels in the major organs, if you have a problem with those then you’re going to have a problem full-stop.  And you’ve – the most common one that we see with diabetics is certainly retinopathy which is the vessels in the back of the eye where they become sclerosed, hardened in other words and you’ll often see those come up in medical examinations particularly with diabetics who’ve had the condition for many, many years.  Now the presence –

Kathryn:       Is there two versions –

Matt:            Sorry Kathryn, pardon?

Kathryn:       No, no, is there two versions to retinopathy because there’s background retinopathy and there’s – is it background retinopathy and fore retinopathy?  Is that right?

Matt:            No sorry, there are four different classifications; proliferative retinopathy is the one that is the worst.

Kathryn:       Okay.

Matt:            And you’re at the stage of becoming blind when you get that and it is an indicator that the individual has found it very, very difficult to control their diabetes.  So is that okay?

Kathryn:       Yeah.

Matt:            There’s one, two, three, four.  The first one – the mild retinopathy, one, class one if you like or grade one, you expect to see that particularly in older people and it would not create an additional loading from an underwriter.  When you get to two there’s more of a concern.  When you get to four then there is one heck of a concern because as I said, the proliferative retinopathy is an indicator obviously in the back of the eye but you don’t know where the damage has been done in the rest of the body as well.

Kathryn:       I suppose that’s an indicator isn’t it because we talked about – as you said, the atherosclerosis, I mean as far as I’m concerned that’s a lot to do as well, like you said, with the blood vessels so probably leading towards sort of like potentially increased risks of heart attack is it with plaque build-up?

Matt:            Yes, 100%.  You’re absolutely right.  I mean, unfortunately people with diabetes, and who have got coronary artery disease which as you know can lead to heart attack, are uninsurable currently in the UK market but the underlying issue there being of course that they’re likely to have widespread arterial disease.

Kathryn:       Okay.

Matt:            One of the ones that certainly cropped up in my reinsurance days was problems with the kidneys.

Kathryn:       Yeah.

Matt:            And there again you’ve got the micro vessels that control your kidneys which are so important to everybody and they get damaged and what happens is that the filtration system of the kidneys actually means that protein – or albuminuria – you may have heard of that term, seeping out into the urine and again that can be indicative of diabetic complications and underwriters will again look at that as a sign of possible widespread arterial disease actually caused by diabetes.

Kathryn:       Yeah.

Matt:            Now, I do appreciate as you said, we’re talking type one diabetes today but with type two diabetes, just a couple of sentences, with type two diabetes, it’s often the case where on type one the initial symptoms of having diabetes are pretty obvious – you can become very, very ill and very, very quickly.  With type two diabetes that’s not the case.  Some people can go through – have type two diabetes for many, many years before actually being diagnosed and the challenge with that is that you’ll find that a lot of people with type two – I say a lot, a decent number statistically of people with type two will already have complications because they’ve not known they had diabetes and therefore didn’t control it.

Kathryn:       Yeah, no I can see if they’ve not had that – it’s like with anything obviously as I said before, you know, I’ve got a few health conditions so I know it sounds daft but, you know, if I look at my Mum who didn’t have the health conditions diagnosed and then been diagnosed through me and back through sort of like hereditary to my Mum, she had so many years of just kind of like dealing with things and just carrying on as if, you know, just thinking that she was kind of making things up, you know, as to how she was feeling and how her body felt and so she’s ended up with quite a few knock-on complications whereas the flipside for me, obviously diagnosed at the age of 12, I’ve been able to do a lot of things to hopefully –

Matt:            Mitigate it.

Kathryn:       Yeah, mitigate any issues.  Can I take us back very quickly to the HbA1c thing?  So I think, as an adviser, you know, if I see somebody and they come to me and they say, “I’ve got type one –” sorry, well any diabetes, the first thing I need to say to them is, “What’s your HbA1c?  I really can’t do – I can do research but I can’t give you any kind of clear indication until I have that HbA1c.”  So I’d be saying for that I’d want to know blood pressure readings, cholesterol readings as well just sort of like try and get them all in one go and make sure that we really keep that information and the stuff that the underwriter will see.  With HbA1c’s though, they have changed the readings with them haven’t they?  Maybe it was a couple of years ago now ‘cos it used to be that you’d maybe get, I don’t know, five or 6.2 or something whereas now you’ll maybe get something like 48 or –

Matt:            [laughs] Units you mean [laughs]?

Kathryn:       It’s quite difficult because isn’t it like – when you say like 48 is it something like mmol?

Matt:            Yeah.

Kathryn:       The reading with that.

Matt:            Millimoles per litre in other words.

Kathryn:       Yeah.

Matt:            Again, a bit of a mouthful [laughs].

Kathryn:       Can you just explain to us like the difference in those two reading types please ‘cos that could be something that could really, you know, in some ways if somebody thinks, “Oh well, I know that the insurers are okay if it’s underneath this.”  I don’t know, let’s just say if it’s underneath seven or something, I know there’s not really going to be, you know, too much of an issue but wow this person’s got 48, there’s no way – but then actually it’s because they’re looking at the different reading classifications that are being used now.

Matt:            Yeah.  I have to admit, I can’t actually explain it to you without doing the research myself.  So there you go.

Kathryn:       Sorry to put you on the spot there like that then!

Matt:            No, no, no, absolutely not.  I mean I completely agree with you.  In terms of the underwriting scenarios then when the more unusual – if you see evidence from America, USA for instance, all of their clinical laboratory levels are a different unit than the ones that are used in the UK or generally used in the UK.

Kathryn:       That’s not helpful is it?

Matt:            I think what you do with that is yes, is Google.  I’m sorry, I don’t think I’ve got a better answer for you on that or go to one of say the great Dr Brackenridge’s books who I know – it compares different units together so you can have an idea.  In terms of the – when you ask a client, I think the one that used to be – is standard in the UK is mmol/l so that millimoles per litre and, you know, you talked about readings there and as I say – you’ve mentioned that they’ve changed.  I think that’s really – just rather depends on the laboratory that’s doing the testing and the parameters that they are used to.  In terms of the clinical judgment, then really with HbA1c you’re looking at anything – and this is in millimoles by the way, normal is between four and 5.6.  Pre-diabetes which is something you’ve probably picked up on with clients, 5.7 to 6.4.  That’s particularly common in type two diabetes and then you’ve got an almost definite diagnosis of diabetes at over 6.5.  So –

Kathryn:       I think it’s important as well –

Matt:            Those are the – sorry Kathryn, those are the millimole readings and if they came at me in a different way again I’m afraid I’d have to do a bit of research on that.

Kathryn:       No, no, no that’s fine.  I was going to say something I think is really important to say to advisers as well when they are listening – especially with you mentioning like the pre-diabetes as well which is more of the type two diabetes, if somebody is pre-diabetic then go straight into your usual question set that you would ask of somebody who is diabetic.

Matt:            Absolutely.  I agree.

Kathryn:       With insurers, they will – I don’t want to say this too broadly or to make too blanket a statement but generally, if somebody is pre-diabetic they’re probably going to be assessed very similarly to – or if not the same way as somebody who is diabetic is going to be assessed.  So just make sure that as soon as you hear obviously the word diabetes – and also as well if somebody has obviously had gestational diabetes as well.

Matt:            Yeah.

Kathryn:       You’ll want to know what’s happening with that because some people – I had somebody not long ago where they had gestational diabetes and the doctor had said, “Well you can never recover from diabetes so now you are type two diabetic,” which is a very – that kind of felt quite strange to me actually hearing that because I thought, “Well hang on a minute, I didn’t –”  Maybe I’m wrong Matt?  Maybe you do automatically become a type two diabetic when you’ve had gestational diabetes, I didn’t think that was the case?

Matt:            No I would agree with you.  I don’t believe that is the case.

Kathryn:       No, but then obviously for that person’s medical records it’s difficult because obviously it’s a case of, “Well actually no, that person is – the GP is saying that.”  You know, and as an adviser you’re like, “Well, I don’t think that’s the case but I can’t – if that’s what the GP is saying, they’re sticking to their guns with it.”  That’s a problem.

Matt:            I mean, I think as a general view and what I’m about to say has to be taken in context but I think, you know, GPs are human beings.  They all have different views – not hugely different views but different views on conditions and so on and so forth and I always think it’s right to challenge.

Kathryn:       Yeah.

Matt:            If the GP is sticking by his guns then the underwriter has always got a) his or her own opinion.

Kathryn:       Yeah.

Matt:            And also they will have a bank of chief medical officers who are often consultants either working for the insurer or working for the reinsurer and as long as one of those or several of them say, you know, “Whatever the GP says, this is not technically diabetes,” then you don’t rate as such.  I think just on gestational, there – if you took 1,000 ladies who had gestational diabetes against 1,000 ladies who hadn’t then there is a greater risk of people – the ladies with gestational to go and get diabetes later on.

Kathryn:       Yeah.

Matt:            But I would have to say statistically it’s not a huge difference.

Kathryn:       No, no.

Matt:            So, you know, I kind of maybe see where the doctor – the GP was coming from but, you know, what you do need to do obviously is with gestational diabetes – is in my opinion although again I’ve had a case recently where the insurer disagreed, is that they should be followed up.

Kathryn:       Yes, oh absolutely.

Matt:            Because of that risk sometimes insurers think just because somebody is being followed up then they are at a greater risk which – prevention is better than cure.  Let me put it that way.

Kathryn:       Yeah I was going to say I’m not – personally I would literally – if someone could give me an MRI every year I’d be like, “Do it, just give me the MRI, you know, do the bloods every year thank you.  Let’s just –”  Absolutely, I’m like yeah – prevention absolutely a much better thing.  So I know we’ve talked about the heart, the eyes and kidneys a bit so I know I mentioned as well the feet.  Now I think that falls under potentially the aspect is it of neuropathy a little bit?  Is that right?

Matt:            Absolutely, yeah, that’s really the term where the nerves get damaged through the complications of diabetes and sadly some cases lead to gangrene –

Kathryn:       Yeah.

Matt:            Amputation, but again it’s indicative – if I just go back to – it’s indicative of – there won’t just be damage in the feet, there’ll be damage elsewhere as well.

Kathryn:       I think that’s where –

Matt:            Coexisting issues without any shadow of a doubt but, you know, that’s – again the feet are an area which are very high up in the diabetic clinics, you know, the nurse will always check the feet.  A person who has got diabetes will be always asked to check their feet themselves and that’s why you get a lot of podiatrists – people who look after feet should now, and they have a lot of clients who are diabetics because they’re encouraged to go and, you know, keep the feet in as best health as they possibly can.  The last thing you want to do is obviously get gangrene and yeah, not nice.

Kathryn:       I can’t imagine it.  I was going to say, I think all the complications that we talked about at the moment, none of them sound – obviously we’ve got gangrene, we’ve got blindness, we’ve got heart attacks.

Matt:            Strokes.

Kathryn:       And strokes.

Matt:            Kidney disease, yeah.

Kathryn:       It’s – there seems – obviously there are so many different complications that you can understand in some ways why insurers obviously do want to make sure that they have a really good idea of the potential risk, how that person is monitoring and engaging with their health and taking steps to try and do as much as possible to try and prevent those things.  I think obviously when it comes to life insurance in general, you know, for most people with diabetes there’s probably going to be an offer for a lot of people and especially I think when we’re looking at type one diabetes that’s well controlled – one thing that I was going to ask about and I think we’ve probably answered it already is obviously about critical illness cover.

So critical illness cover on the standard market isn’t available for people with type one diabetes and one of the things that we try to advocate for a bit – we sort of try to say, “Well look, if you can’t cover somebody because of this then why not exclude that and then offer them the rest?”  As an example, obviously I can talk about Parkinson’s, you know, if somebody can’t get critical illness cover because of their Parkinson’s, that doesn’t necessarily mean that they’re at any less risk of getting cancer so why not offer them, you know, a certain – maybe offer them critical illness cover but with the neurological side of things excluded?  Which – I know that for some people would say, “Hmm, I’m not sure,” but for me it’s that kind of situation it’s better for them to have something than nothing and obviously cancer is such a high risk that maybe, you know, sometimes thinking about offering those exclusions could be worthwhile in some situations.  It would be interesting to chat to people – perhaps maybe some people developing products as to whether that could be potentially a choice and not saying though that you have to have an exclusion.

I did arrange – well I was going through a – what was it?  I was advising someone with Parkinson’s a couple of years ago and they’d wanted critical illness cover and it was possible for their situation to get it but with the – just with Parkinson’s excluded so I just want to put it out there – just using that as an example for what I’m saying but there are options so don’t run straight down that route.

Matt:            But Kathryn – sorry – for what it’s worth I have a lot of sympathy with what you say.  I certainly believe, certainly with CICs – critical illness in other words, insurers should do their best to provide some kind of cover rather than nothing at all.  Sometimes it’s pretty difficult.  I think with type one diabetes we’ve probably covered between us all of the complications that you can get so –

Kathryn:       It strips out so much doesn’t it?

Matt:            So much and to be honest I have read that, again statistically-speaking, the people with type one diabetes are at a higher risk of getting cancer.

Kathryn:       Right.

Matt:            Okay?

Kathryn:       That kind of rules out that one as well doesn’t it?

Matt:            You know what I mean?  So diabetes is – type one diabetes, it probably gives an insight to how difficult it is to actually give any form of meaningful cover.  You’ve taken out heart attack, you’ve taken out stroke, you’ve taken out certain cancer and I think that’s where the industry struggles at the moment.  But I think –

Kathryn:       Yeah.

Matt:            In terms of the principle that you talk about, I totally and utterly agree with you.

Kathryn:       Yeah, no I think, you know, thank you.

Matt:            That’s alright.

Kathryn:       I think it’s a difficult one when you’re looking at all those different bits that it could potentially – it’s that whole thing isn’t it?  You know, the body is an interconnected system.

Matt:            Yes, 100%.

Kathryn:       And if you’ve got, you know, higher blood sugar, it doesn’t just go to the heart which is what we’d typically think of, you know, potentially a higher risk of high cholesterol, high blood pressure, heart attacks.  It is affecting everywhere and it’s going into all the organs so it is a very tricky one.  Obviously for people who are part of an employee group insurance –

Matt:            Yeah.

Kathryn:       Not necessarily specifically critical illness but – well for some areas of the critical illness they would be covered for some of the conditions but they would just need to be very clear as to what could potentially lead to an exclusion on the set that’s being offered by the employer.  Something – just before we go onto treatments and different things like that as well ‘cos that will obviously be something that advisers really need to know about.  But in terms of – so something we find quite interesting is that generally we tend to find that the longer somebody has diabetes, the higher the loadings are going to be.  So this is just sort of like an observation, not one that I’m expecting you to sort of like come back with a –

Matt:            No, that’s okay.

Kathryn:       The longer somebody has had it, the more likely they are to get higher ratings.  I think also the fact of I think sort of like the body has been kind of having this kind of battle for so long in terms of the insulin and everything that they’re probably thinking that – as we’ve mentioned with all the different aspects and it affecting all aspects of the body, the body is probably working quite a bit harder than for somebody who isn’t – who doesn’t have diabetes.  But then on some occasions, we’ve found it where there’s maybe been an insurer gone, “Well actually, this person’s had diabetes for 20, 30 years.”  So probably somebody who was diagnosed at a much younger age.  So they’ve had it for 20, 30 years.  All the readings are in a sense perfect for what you’d want them to be.  There’s been, you know, they’ve obviously really engaged with doing the different things they can do in terms of lifestyle and any treatments to make sure that they’re okay.

So actually what we’ll do is we’ll say that if there was going to be anything, any of these kinds of – well I say maybe the kind of red flag complications, we’d have probably already seen them developing by now.  So what we’ll actually do is reduce the loading now.  So I think it’s one of those things – as with anything, probably very unhelpful in many ways but it’s probably that thing of, as an adviser, don’t make an assumption as to what you think might happen because somebody has had it for so long.  Just because you’ve maybe experienced it one way before, it’s not necessarily going to be the case every time and with every insurer.  So it’s always worth having a natter with an underwriter – it’s always good to have a natter [laughs].

Matt:            [laughs] Absolutely.  I agree.  It’s really a function of the way that underwriters relate age to premium.  I think that’s probably why sometimes there are these discrepancies.  The complications are absolutely key.  One of the points I would make is though that certainly I have seen clients or clients’ clients who have had immaculate control throughout their life, have no complications, they’re in – I can’t say 50s and 60s but probably late 40s and the community – the sales community feel, “God, well that guy must be absolutely brilliant – or lady – standard rates.”  Very, very unlikely you will get standard rates even on somebody who has had very good control and is not showing symptoms ‘cos unfortunately to use – I won’t mention Dr Brackenridge’s great comment again because I’m sure it’s too much of a mouthful for everybody, but whatever, there will be some damage.  It might be at a micro level but there will still be some damage to the arterial system.

Kathryn:       Yeah.

Matt:            So they certainly – people will certainly get a decent rating in comparison with other diabetics but please don’t expect standard rates for life insurance.

Kathryn:       Yeah.  Absolutely.  So when it comes to treatments, what would we be expecting for someone with type one diabetes?  What would you be thinking, “Oh yeah, I expect that,” and would there be anything that you’d think, “Hmm, that maybe makes me think it’s possibly stronger, you know, than I was expecting?”

Matt:            Yeah, in terms of – I mean, when we’re talking about type one diabetes we are talking about insulin okay, so the use of pumps etcetera.  There’s two types of insulin really; one that is taken really late on at night to keep your insulin stable while you’re asleep etcetera – long-lasting insulin and there’s also a short-acting insulin which is taken just before you have a meal to help your body control the release of glucose into the body because of eating.  Everybody is different.  Everybody is different and therefore I have not seen underwriting guidelines where they would differentiate between different types or different levels of insulin going into the body.  The absolute key is that control –

Kathryn:       Yeah.

Matt:            And that the client or the diabetic looks after themselves properly and that’s one of the key questions that the GP or the diabetic nurse would be asked and signs that people aren’t looking after themselves properly and taking insulin at the right time would be of course hyperglycaemic attacks and hypoglycaemic attacks.  In terms of underwriting, hyperglycaemic attacks are where there’s too much sugar – it’s the one that starts the red flag if you like.  It’s a bit of a red flag if you have too many of those.  I mean, the challenge again – I think with, you know, if you think of children – little, really tiny children who have got diabetes, how difficult it is for them – they can’t speak for goodness sake.  How are they going to say if they feel ill or anything else like that?  Therefore it’s very much a part of the parenting role to make sure that that blood sugar is controlled and of course when people – again when people get into their teens and 20s and they want to live an unrestricted life in terms of alcohol, in terms of smoking, in terms of eating, in terms of snacking, therefore it’s quite difficult to keep those types of – as a group – an age group, that’s quite often when damage is done ‘cos they don’t really look after themselves.

I’m talking groups statistically here, I’m not talking about everybody obviously.  So again, rather than the actual levels of insulin, as long as they are being taken regularly and the control is taken seriously, then the type isn’t so much a factor.  That’s really how I would view that from an underwriting perspective.

Kathryn:       Okay.

Matt:            As I say, everybody is different so you’ll get different levels with different people and as long as the control is good, good.  Just good news.

Kathryn:       Fantastic.

Matt:            Does that help Kathryn on that particular question?

Kathryn:       It does help, thank you, because I think sometimes a big thing as well for advisers though is knowing what to ask and like when we’re hearing medications and things, you know, the work that we do and the clients that we have, we’re very used to the names of medications and –

Matt:            Absolutely.

Kathryn:       The conditions.  But even so, sometimes people say them to you and you’re just like, “What now?” [laughs]  You’re kind of just thinking – so at least we know with someone with type one diabetes – is essentially we’re wanting to know what’s happened.  Do they have an insulin pump?  Are they having to use injections?  You know, that’s probably –

Matt:            That’s probably as far as you’ll want to go.

Kathryn:       Yeah, we don’t need to probably go any further.

Matt:            Using your questioning skills – try and – without irritating the client obviously is maybe asking several times how the control is?

Kathryn:       Absolutely.  Well I’ve got a case study now to share and we’re just sort of like coming towards the end.  So the case study to share with everybody was – this was actually a case that was done during lockdown so just to prove that you can still get cover for people with health conditions even while all the restrictions have been in place though I have to say it’s absolutely lovely to see so many insurers that are now starting to remove the restrictions.  I just hope that carries on going and obviously that everything just carries on as it is just generally anyway in society, that we keep moving forward and in a much better place.

Anyway, so we spoke with a male in his early 40s last year and he was diagnosed with type one diabetes almost 30 years prior to that and he used an insulin pump.  So what was quite interesting and from what I can gather is that the insulin pump is something that is usually fitted more sort of like when there’s a specific health need rather than obviously using other methods to get the insulin.  But however for this person, they were very sporty and active so it was decided the insulin pump would work best for them and it worked quite well to be able to explain to the underwriters, “Look, this is why he’s using the insulin pump rather than the other methods,” and it helped the decision.  There was some potential for the mild background retinopathy so that was what, Matt, you were saying the hardening of some of the arteries on the back of the eyes and he had been in hospital for one night when the insulin pump had stopped working.

So in the grand scheme of things, when you’re answering those questions, when you get to the application, this is one of the reasons why it’s so important to do a lot of pre-sales research and speak to the underwriters beforehand and during their assessments of the case.  Like, you know, “We’ve got someone here with diabetes.  They’re on the insulin pump, they’ve got this, you know, starting aspects of the retinopathy.  They’ve been in hospital due to the condition but they’re all kind of – they’re all very light as well in many ways, the things that had happened.”  So whilst they may seem a bit of a standout thing in the application form, it’s really important to provide the context to the underwriters.

The other thing was that this person had Wolf Parkinsons White syndrome which had been identified.  They just needed an ECG at some point and they’d seen an abnormal heart rhythm and that had been corrected through a procedure known as an ablation.  So for this person we were looking at £380,000 of decreasing life insurance over 25 years for the mortgage and that’s ended up being a price of around £65 per month and the income protection – there’s a couple of aspects to that for me to sort of like talk through so for this person, we ended up with the income protection so it’s £3,000 per month that was over 25 years to take them to their retirement age.  It had a 13-week deferred period, a two-year claim period and the price was just under £70 per month.  So what’s interesting – a couple of things to mention with this one is that we did have terms for the full claim period for the client but unfortunately due to affordability the client decided to go – for the time being – for the two-year claim option and I can sort of like feel probably advisers going, “Ooh I don’t know if I’d have done that, I don’t know if I’ve done that,” kind of thing.

So one of the key things for us with this client is that obviously we gave him the options and a big thing for me is that it’s incredibly important to inform people of what’s available but at the same point you also have to be realistic and, you know, there are certain points where the insurance can become too expensive and it’s better to find something that adapts the situation to the client than them walking away with no protection at all for that specific need.  But what was interesting about this one is that we could have got the full claim period at a much cheaper price than what was originally suggested however there would have been an exclusion for any claims relating to the diabetes.

So an interesting thing about this is you may look at it and also it always comes down to the adviser’s kind of – probably their gut feeling but ultimately to me it is important to give the client both options and say, “This one over here will pay all the way to retirement age but it will exclude anything relating to the diabetes and we’ve already said here, that’s probably going to be anything related to the heart, the eyes, the feet, the kidneys, potentially strokes, cancers, you just don’t know depending upon the situation.”  Or you could say to somebody, “For the same price you can have this one.  It will cover any claims relating to your diabetes but it will only pay out for two years.”  And there’s pros and cons to both but ultimately I just think it’s very important to make sure that you are giving the client so they can make that informed decision themselves.  I hope you agree with me Matt?

Matt:            No, I do indeed.  I think it goes back to the principle that we talked about earlier, that something is better than nothing.

Kathryn:       Yeah.

Matt:            And well done you for getting that placed.  That’s I all I can – it’s good.  It’s good.

Kathryn:       It was a really, really good option for the client.

Matt:            Absolutely.

Kathryn:       And they’re obviously very, very happy with it, you know, because obviously I think a lot of the time people would look at things and think automatically and in some places, you know, think diabetes and ‘cos obviously as well there’s not just the diabetes here.  There is the – as I said, there is the background retinopathy starting, there is the fact that he had the Wolf Parkinsons White syndrome so even though that’s been corrected it was still something involving his heart.  There’s lots of things that have been involved in this case for this client and I think a lot of people would probably assume that income protection just would have been a no-go from the start but it just shows that sometimes it is still worth asking.  One of the things that I always train my team to do is sort of, you know, if somebody is wanting a specific insurance, that’s all well and good but do the research for everything and make sure that you give the options in a sense for everything because then at least they can really see what’s in front of them.

And it’s also really good for you because whilst you’re asking an underwriter and chatting to them about one insurance type, you may as well ask them about the others at the same time.  It’s all then done in one go and you increase your knowledge but there we go.  So that’s the podcast for today.  So thank you Matt.  It’s been really lovely chatting to you and I’m really happy to hear that you managed to get that nice break, even though it was a bit rainy.

Matt:            [laughs] No, well thank you for inviting me as always.  It was – just one little thing at the end of the podcast is that I hadn’t realised – but it’s 100 years this year that insulin was discovered in the context of diabetic treatment.

Kathryn:       Oh that’s amazing!

Matt:            So prior to that, really if you had type one diabetes, you wouldn’t live very long.

Kathryn:       Aw that – yeah.

Matt:            Because there was no insulin but it’s 100 years this year since insulin was – as I say, used in the treatment of diabetes.  So I thought I’d mention that.

Kathryn:       Absolutely, no that’s brilliant.  Thank you for mentioning that.  That’s really good.  Actually it’s amazing really to think that 100 years ago – because obviously 100 years ago feels like forever ago but at the same time it’s still relatively quite recent, you know, you sort of think about all of the people that will have not had a chance to access that.  It’s quite –

Matt:            And it was fatal.

Kathryn:       Yeah.

Matt:            You know, there was no middle ground to it.  With type one I’m afraid you’d die very quickly so yeah, it’s – for me anyway [laughs], it was an interesting fact I have to say.

Kathryn:       No absolutely.  Well I’m going to be back in two weeks’ time with Alan and we’re going to be doing a masterclass in critical illness cover.  We’ve done the life insurance, we’ve done IP so now we’re onto critical illness.  So as always, if you’d like a reminder of the next episode, please do drop me a message on social media or visit the website practical-protection.co.uk.  And what I will also say as well is that if you’ve not seen it so far, I’m sure you probably will have done if you’ve seen my social at all, I am launching an adviser training program covering lots of different bits.  The website is adviceforadvisers.co.uk.  I’ve got it on social, have a look and I think this is the first time I’ll be able to say this as well, is that the podcast is now sponsored by Octo Members which is brilliant and they are now doing certified CPD certificates for the episodes.  So – and we’re getting that all up and running and sorted and it just adds an extra bit – to anybody who’s listening obviously who has to do with the insurance world, it will add just a little bit of extra to your training.  So thank you very much for joining me, Matt.

Matt:            Thank you, it’s a pleasure as always.

Kathryn:       Bye.

Matt:            Bye.

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Type 1 Diabetes

Hi everyone, this week Matt Rann is back with me and we are talking about type 1 diabetes.

We are chatting about what diabetes is and how it affects the body, the potential complications that someone can experience and the insurance underwriting terms.

The key takeaways:

  1. Type 1 diabetes can affect all areas of the body and there are specific complications that can occur in the heart, eyes, feet and kidneys.
  2. The key things that underwriters need to know, to give you a potential indication of terms.
  3. A case study of arranging life insurance and income protection, for someone living with type 1 diabetes.

I will be back in a couple of weeks with Alan Knowles. He is back with one of his masterclasses and this time the focus is going to be on critical illness cover.

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

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

Kathryn:       Hi everyone, this is episode 11 of season three and I have Matt Rann back with me.  Hi Matt!

Matt:            Hi Kathryn, hope you’re keeping well?

Kathryn:       I’m very well thank you.  How are you?

Matt:            Excellent, yes, yes, good thank you very much indeed.  Looking forward to some heat at some stage.

Kathryn:       Absolutely, no more rain.  We are focusing today on type one diabetes.  We’re going to be chatting through some statistics, learning about what diabetes is and some of the terms that you might expect when you’re applying for protection insurance.  So this is the Practical Protection podcast.  So Matt, I know you managed to get away for a week’s holiday recently?  I was going to say, is it – do I dare say the banned word of staycation?  You had a staycation.  I think there’s going to be people cringing at me using that word.  It’s one of those people love or hate.

Matt:            It was very much a staycation, thank you, down in the Cotswolds where I was born and where I spent the first 40 years of my life.  So it was nice to get home and see all the family as well so thank you very much.  Definitely a staycation [laughs], perfectly legal.

Kathryn:       Yeah [laughs].  Well I’m really glad that you’ve managed to get that.  We just had a few days off last week just to sort of have a little bit of a chill out – a very, very well deserved chill out and it was just – it felt good.  It felt good to sort of be like a bit relaxed and also I have incredibly exciting news that I’m sure I’ll be sharing lots on social media that people will see which is that we are getting a puppy in a couple of weeks.

Matt:            Oh, goodness gracious.

Kathryn:       I’m so, so excited.  I’ve never had a dog before and I’m very, very excited.  We’re going to go and collect him in a couple of weeks’ time.

Matt:            What type of dog are you going to get, Kathryn?

Kathryn:       We’re getting a cockapoo.

Matt:            Oh yeah, yeah.

Kathryn:       So Alan’s allergic to everything, even me sometimes so we have to go for one that is hypoallergenic and, you know, obviously it’s really hard though.  We tried to rescue a dog and it was so, so hard because obviously the first thing we have to do is make sure that we get a breed that is considered – I know no dogs are actually hypoallergenic but we had to get one that was as hypoallergenic as possible but then the other thing is obviously I’ve got the about the boys who are three, six and nine and the problem is that whenever you’re looking to rescue is that they don’t seem to – I couldn’t find anywhere that’s prepared to say for children under the age of 10 which is obviously as well completely understandable because you just don’t know.  And it was that kind of thing of – well I wouldn’t want to risk getting a dog.  It may be lovely but unless I know for definite that it’s going to be okay with kids, I wouldn’t want to obviously risk bringing it into the home and –

Matt:            Sure, sure.

Kathryn:       It’s a bit of a shame but at the same point, we’re doing what’s best for what we can do and we’re going to give – we’re going to call him Fudge – we’ll give Fudge a lovely home.  Fudge – yeah, absolutely, let’s talk about big sugary treats just before we start talking about type one diabetes and blood glucose and everything.

Matt:            Oh dear.

Kathryn:       So just to sort of set the scene for everybody, so the first thing we’re going to do is just go into a little bit of some statistics and just explain a little bit – kind of like probably a bit of a high level thing about how diabetes is and how it works and then Matt, obviously I know you’ll know far more of the ins and outs of this stuff so I’ll be quizzing you as we go along as well.

Matt:            Excellent.

Kathryn:       So, just to give everybody a bit of a background.  So type one diabetes – so that is an autoimmune condition where essentially the cells in the body start to attack the pancreas.  So essentially you’ve got blood glucose which is the sugar levels in your blood and for people who are type one diabetic the sugar levels are too high and what it means is that the body cannot make the hormone insulin and insulin is essential because what it does is, is breaks down the sugar in the blood so that it can be absorbed within the body and without the insulin the sugar just keeps building up.  It can have some quite long-term implications for the heart, eyes, feet and kidneys so it’s really important that people with type one diabetes are hopefully diagnosed as early as possible and also able to start their treatment quite early.

I actually have a friend of mine who was diagnosed with type one diabetes.  It was in her mid to late 20s actually, it was after we’d been to university together and I was absolutely amazed that in a sense it hadn’t been picked up that early so it’s not just – we do hear about it being diagnosed in people who are young but it is also as well people who are starting to get more into adulthood that are diagnosed.  It is estimated at the moment there’s about 3.8 million people living with diabetes within the UK and there’s possibly about an extra 500,000 people that have diabetes and do not know it so that’s something as well for all the advisers who are listening to just bear in mind that that is a lot of people that you could potentially come across and talk to that would have diabetes.  And in that full amount of people, it’s thought that there’s somewhere between 5-15% of diabetics have type one diabetes so if we go nicely in the middle at 10% then that is roughly 380,000 people in the UK and it’s, you know, it’s something that you’re going to come across probably at some point.

I think it would be very rare for an adviser to advise their entire career and never come across somebody who is diabetic.  It may be type two diabetes and some of the things we’re talking about today will kind of translate over to type two diabetes as well but today we’re just focusing on the type one side of things.  So Matt, I suppose the key thing for me really is to ask you, you know, if I were to come to you and say, “I have a client who has type one diabetes,” what is it that you are wanting to know from an underwriting side of things?

Matt:            Okay, one of the key risk factors that underwriters look for in cases of diabetes, particularly type one, is the control of the condition and it’s actually good to hear and see that the pharmaceutical companies have made life easier for a diabetic to actually control their condition and get early signs if they’re going to have something called a hyperglycaemic attack where the blood sugar is too high in the body or indeed a hypoglycaemic attack where the blood sugar is too low and being able to get an early warning that one of these conditions – sub-conditions – may happen or is starting to happen is absolutely ideal because that gives the diabetic, the person, early warning that they can do something about it.  And that could well be of course taking more insulin, it could well be eating carbohydrate, taking some extra carbohydrate onboard but it allows them some control.

And you’ve touched on – in terms of what underwriters look for; a) control – a key method or a key laboratory test that helps us understand that control is something called an HbA1c test and that stands for glycosylated haemoglobin and what that does is allows the underwriter to have a view of the control of the blood sugars within the body over a period of two to three months.  You will often see blood sugar or blood glucose tests in GP reports but that’s only a snapshot.  It’s only a snapshot of a given time, you know, on the basis that you and I are not diabetic – our blood sugars go up and down all the time and therefore a snapshot of a given time of the day isn’t that useful.  Fasting blood sugars are often seen as well where the person is asked to fast for anything between six and 12 hours before and that gives us – that takes out the – or minimises the risk of a blood glucose being too high because of a recent meal.  But again it’s a snapshot.

The key one for us is the glycosylated haemoglobin so that’s HbA1c and that takes a – ends up with a reading – the blood control of – sorry, the blood sugar control of the period of around two to three months.  So that’s very important and control is a very important predictor of diabetic complications which you have already mentioned a few of.  In terms of the underwriting then yes, those complications and the presence of those complications is very, very important indeed and I always remember one of my late, great and very early mentors, the great Dr Brackenridge, always saying – used this lovely term which I’ve not forgotten in 40 years is that diabetes is an atherosclerotic accelerator.  What a mouthful that is.

Kathryn:       That is, yeah.  I’m glad you said it and not me.

Matt:            [laughs] Effectively, all that means is – and you’ve touched on it yourself earlier on, that diabetes actually hardens the arteries.  It hardens the blood vessels, makes them less stretchy and that type of – it’s often not just in any particular organ in the body although you’ve talked about a number and we’ll go into it a little bit later on but it can be every organ – sorry, blood vessel in the body and obviously the blood vessels in the major organs, if you have a problem with those then you’re going to have a problem full-stop.  And you’ve – the most common one that we see with diabetics is certainly retinopathy which is the vessels in the back of the eye where they become sclerosed, hardened in other words and you’ll often see those come up in medical examinations particularly with diabetics who’ve had the condition for many, many years.  Now the presence –

Kathryn:       Is there two versions –

Matt:            Sorry Kathryn, pardon?

Kathryn:       No, no, is there two versions to retinopathy because there’s background retinopathy and there’s – is it background retinopathy and fore retinopathy?  Is that right?

Matt:            No sorry, there are four different classifications; proliferative retinopathy is the one that is the worst.

Kathryn:       Okay.

Matt:            And you’re at the stage of becoming blind when you get that and it is an indicator that the individual has found it very, very difficult to control their diabetes.  So is that okay?

Kathryn:       Yeah.

Matt:            There’s one, two, three, four.  The first one – the mild retinopathy, one, class one if you like or grade one, you expect to see that particularly in older people and it would not create an additional loading from an underwriter.  When you get to two there’s more of a concern.  When you get to four then there is one heck of a concern because as I said, the proliferative retinopathy is an indicator obviously in the back of the eye but you don’t know where the damage has been done in the rest of the body as well.

Kathryn:       I suppose that’s an indicator isn’t it because we talked about – as you said, the atherosclerosis, I mean as far as I’m concerned that’s a lot to do as well, like you said, with the blood vessels so probably leading towards sort of like potentially increased risks of heart attack is it with plaque build-up?

Matt:            Yes, 100%.  You’re absolutely right.  I mean, unfortunately people with diabetes, and who have got coronary artery disease which as you know can lead to heart attack, are uninsurable currently in the UK market but the underlying issue there being of course that they’re likely to have widespread arterial disease.

Kathryn:       Okay.

Matt:            One of the ones that certainly cropped up in my reinsurance days was problems with the kidneys.

Kathryn:       Yeah.

Matt:            And there again you’ve got the micro vessels that control your kidneys which are so important to everybody and they get damaged and what happens is that the filtration system of the kidneys actually means that protein – or albuminuria – you may have heard of that term, seeping out into the urine and again that can be indicative of diabetic complications and underwriters will again look at that as a sign of possible widespread arterial disease actually caused by diabetes.

Kathryn:       Yeah.

Matt:            Now, I do appreciate as you said, we’re talking type one diabetes today but with type two diabetes, just a couple of sentences, with type two diabetes, it’s often the case where on type one the initial symptoms of having diabetes are pretty obvious – you can become very, very ill and very, very quickly.  With type two diabetes that’s not the case.  Some people can go through – have type two diabetes for many, many years before actually being diagnosed and the challenge with that is that you’ll find that a lot of people with type two – I say a lot, a decent number statistically of people with type two will already have complications because they’ve not known they had diabetes and therefore didn’t control it.

Kathryn:       Yeah, no I can see if they’ve not had that – it’s like with anything obviously as I said before, you know, I’ve got a few health conditions so I know it sounds daft but, you know, if I look at my Mum who didn’t have the health conditions diagnosed and then been diagnosed through me and back through sort of like hereditary to my Mum, she had so many years of just kind of like dealing with things and just carrying on as if, you know, just thinking that she was kind of making things up, you know, as to how she was feeling and how her body felt and so she’s ended up with quite a few knock-on complications whereas the flipside for me, obviously diagnosed at the age of 12, I’ve been able to do a lot of things to hopefully –

Matt:            Mitigate it.

Kathryn:       Yeah, mitigate any issues.  Can I take us back very quickly to the HbA1c thing?  So I think, as an adviser, you know, if I see somebody and they come to me and they say, “I’ve got type one –” sorry, well any diabetes, the first thing I need to say to them is, “What’s your HbA1c?  I really can’t do – I can do research but I can’t give you any kind of clear indication until I have that HbA1c.”  So I’d be saying for that I’d want to know blood pressure readings, cholesterol readings as well just sort of like try and get them all in one go and make sure that we really keep that information and the stuff that the underwriter will see.  With HbA1c’s though, they have changed the readings with them haven’t they?  Maybe it was a couple of years ago now ‘cos it used to be that you’d maybe get, I don’t know, five or 6.2 or something whereas now you’ll maybe get something like 48 or –

Matt:            [laughs] Units you mean [laughs]?

Kathryn:       It’s quite difficult because isn’t it like – when you say like 48 is it something like mmol?

Matt:            Yeah.

Kathryn:       The reading with that.

Matt:            Millimoles per litre in other words.

Kathryn:       Yeah.

Matt:            Again, a bit of a mouthful [laughs].

Kathryn:       Can you just explain to us like the difference in those two reading types please ‘cos that could be something that could really, you know, in some ways if somebody thinks, “Oh well, I know that the insurers are okay if it’s underneath this.”  I don’t know, let’s just say if it’s underneath seven or something, I know there’s not really going to be, you know, too much of an issue but wow this person’s got 48, there’s no way – but then actually it’s because they’re looking at the different reading classifications that are being used now.

Matt:            Yeah.  I have to admit, I can’t actually explain it to you without doing the research myself.  So there you go.

Kathryn:       Sorry to put you on the spot there like that then!

Matt:            No, no, no, absolutely not.  I mean I completely agree with you.  In terms of the underwriting scenarios then when the more unusual – if you see evidence from America, USA for instance, all of their clinical laboratory levels are a different unit than the ones that are used in the UK or generally used in the UK.

Kathryn:       That’s not helpful is it?

Matt:            I think what you do with that is yes, is Google.  I’m sorry, I don’t think I’ve got a better answer for you on that or go to one of say the great Dr Brackenridge’s books who I know – it compares different units together so you can have an idea.  In terms of the – when you ask a client, I think the one that used to be – is standard in the UK is mmol/l so that millimoles per litre and, you know, you talked about readings there and as I say – you’ve mentioned that they’ve changed.  I think that’s really – just rather depends on the laboratory that’s doing the testing and the parameters that they are used to.  In terms of the clinical judgment, then really with HbA1c you’re looking at anything – and this is in millimoles by the way, normal is between four and 5.6.  Pre-diabetes which is something you’ve probably picked up on with clients, 5.7 to 6.4.  That’s particularly common in type two diabetes and then you’ve got an almost definite diagnosis of diabetes at over 6.5.  So –

Kathryn:       I think it’s important as well –

Matt:            Those are the – sorry Kathryn, those are the millimole readings and if they came at me in a different way again I’m afraid I’d have to do a bit of research on that.

Kathryn:       No, no, no that’s fine.  I was going to say something I think is really important to say to advisers as well when they are listening – especially with you mentioning like the pre-diabetes as well which is more of the type two diabetes, if somebody is pre-diabetic then go straight into your usual question set that you would ask of somebody who is diabetic.

Matt:            Absolutely.  I agree.

Kathryn:       With insurers, they will – I don’t want to say this too broadly or to make too blanket a statement but generally, if somebody is pre-diabetic they’re probably going to be assessed very similarly to – or if not the same way as somebody who is diabetic is going to be assessed.  So just make sure that as soon as you hear obviously the word diabetes – and also as well if somebody has obviously had gestational diabetes as well.

Matt:            Yeah.

Kathryn:       You’ll want to know what’s happening with that because some people – I had somebody not long ago where they had gestational diabetes and the doctor had said, “Well you can never recover from diabetes so now you are type two diabetic,” which is a very – that kind of felt quite strange to me actually hearing that because I thought, “Well hang on a minute, I didn’t –”  Maybe I’m wrong Matt?  Maybe you do automatically become a type two diabetic when you’ve had gestational diabetes, I didn’t think that was the case?

Matt:            No I would agree with you.  I don’t believe that is the case.

Kathryn:       No, but then obviously for that person’s medical records it’s difficult because obviously it’s a case of, “Well actually no, that person is – the GP is saying that.”  You know, and as an adviser you’re like, “Well, I don’t think that’s the case but I can’t – if that’s what the GP is saying, they’re sticking to their guns with it.”  That’s a problem.

Matt:            I mean, I think as a general view and what I’m about to say has to be taken in context but I think, you know, GPs are human beings.  They all have different views – not hugely different views but different views on conditions and so on and so forth and I always think it’s right to challenge.

Kathryn:       Yeah.

Matt:            If the GP is sticking by his guns then the underwriter has always got a) his or her own opinion.

Kathryn:       Yeah.

Matt:            And also they will have a bank of chief medical officers who are often consultants either working for the insurer or working for the reinsurer and as long as one of those or several of them say, you know, “Whatever the GP says, this is not technically diabetes,” then you don’t rate as such.  I think just on gestational, there – if you took 1,000 ladies who had gestational diabetes against 1,000 ladies who hadn’t then there is a greater risk of people – the ladies with gestational to go and get diabetes later on.

Kathryn:       Yeah.

Matt:            But I would have to say statistically it’s not a huge difference.

Kathryn:       No, no.

Matt:            So, you know, I kind of maybe see where the doctor – the GP was coming from but, you know, what you do need to do obviously is with gestational diabetes – is in my opinion although again I’ve had a case recently where the insurer disagreed, is that they should be followed up.

Kathryn:       Yes, oh absolutely.

Matt:            Because of that risk sometimes insurers think just because somebody is being followed up then they are at a greater risk which – prevention is better than cure.  Let me put it that way.

Kathryn:       Yeah I was going to say I’m not – personally I would literally – if someone could give me an MRI every year I’d be like, “Do it, just give me the MRI, you know, do the bloods every year thank you.  Let’s just –”  Absolutely, I’m like yeah – prevention absolutely a much better thing.  So I know we’ve talked about the heart, the eyes and kidneys a bit so I know I mentioned as well the feet.  Now I think that falls under potentially the aspect is it of neuropathy a little bit?  Is that right?

Matt:            Absolutely, yeah, that’s really the term where the nerves get damaged through the complications of diabetes and sadly some cases lead to gangrene –

Kathryn:       Yeah.

Matt:            Amputation, but again it’s indicative – if I just go back to – it’s indicative of – there won’t just be damage in the feet, there’ll be damage elsewhere as well.

Kathryn:       I think that’s where –

Matt:            Coexisting issues without any shadow of a doubt but, you know, that’s – again the feet are an area which are very high up in the diabetic clinics, you know, the nurse will always check the feet.  A person who has got diabetes will be always asked to check their feet themselves and that’s why you get a lot of podiatrists – people who look after feet should now, and they have a lot of clients who are diabetics because they’re encouraged to go and, you know, keep the feet in as best health as they possibly can.  The last thing you want to do is obviously get gangrene and yeah, not nice.

Kathryn:       I can’t imagine it.  I was going to say, I think all the complications that we talked about at the moment, none of them sound – obviously we’ve got gangrene, we’ve got blindness, we’ve got heart attacks.

Matt:            Strokes.

Kathryn:       And strokes.

Matt:            Kidney disease, yeah.

Kathryn:       It’s – there seems – obviously there are so many different complications that you can understand in some ways why insurers obviously do want to make sure that they have a really good idea of the potential risk, how that person is monitoring and engaging with their health and taking steps to try and do as much as possible to try and prevent those things.  I think obviously when it comes to life insurance in general, you know, for most people with diabetes there’s probably going to be an offer for a lot of people and especially I think when we’re looking at type one diabetes that’s well controlled – one thing that I was going to ask about and I think we’ve probably answered it already is obviously about critical illness cover.

So critical illness cover on the standard market isn’t available for people with type one diabetes and one of the things that we try to advocate for a bit – we sort of try to say, “Well look, if you can’t cover somebody because of this then why not exclude that and then offer them the rest?”  As an example, obviously I can talk about Parkinson’s, you know, if somebody can’t get critical illness cover because of their Parkinson’s, that doesn’t necessarily mean that they’re at any less risk of getting cancer so why not offer them, you know, a certain – maybe offer them critical illness cover but with the neurological side of things excluded?  Which – I know that for some people would say, “Hmm, I’m not sure,” but for me it’s that kind of situation it’s better for them to have something than nothing and obviously cancer is such a high risk that maybe, you know, sometimes thinking about offering those exclusions could be worthwhile in some situations.  It would be interesting to chat to people – perhaps maybe some people developing products as to whether that could be potentially a choice and not saying though that you have to have an exclusion.

I did arrange – well I was going through a – what was it?  I was advising someone with Parkinson’s a couple of years ago and they’d wanted critical illness cover and it was possible for their situation to get it but with the – just with Parkinson’s excluded so I just want to put it out there – just using that as an example for what I’m saying but there are options so don’t run straight down that route.

Matt:            But Kathryn – sorry – for what it’s worth I have a lot of sympathy with what you say.  I certainly believe, certainly with CICs – critical illness in other words, insurers should do their best to provide some kind of cover rather than nothing at all.  Sometimes it’s pretty difficult.  I think with type one diabetes we’ve probably covered between us all of the complications that you can get so –

Kathryn:       It strips out so much doesn’t it?

Matt:            So much and to be honest I have read that, again statistically-speaking, the people with type one diabetes are at a higher risk of getting cancer.

Kathryn:       Right.

Matt:            Okay?

Kathryn:       That kind of rules out that one as well doesn’t it?

Matt:            You know what I mean?  So diabetes is – type one diabetes, it probably gives an insight to how difficult it is to actually give any form of meaningful cover.  You’ve taken out heart attack, you’ve taken out stroke, you’ve taken out certain cancer and I think that’s where the industry struggles at the moment.  But I think –

Kathryn:       Yeah.

Matt:            In terms of the principle that you talk about, I totally and utterly agree with you.

Kathryn:       Yeah, no I think, you know, thank you.

Matt:            That’s alright.

Kathryn:       I think it’s a difficult one when you’re looking at all those different bits that it could potentially – it’s that whole thing isn’t it?  You know, the body is an interconnected system.

Matt:            Yes, 100%.

Kathryn:       And if you’ve got, you know, higher blood sugar, it doesn’t just go to the heart which is what we’d typically think of, you know, potentially a higher risk of high cholesterol, high blood pressure, heart attacks.  It is affecting everywhere and it’s going into all the organs so it is a very tricky one.  Obviously for people who are part of an employee group insurance –

Matt:            Yeah.

Kathryn:       Not necessarily specifically critical illness but – well for some areas of the critical illness they would be covered for some of the conditions but they would just need to be very clear as to what could potentially lead to an exclusion on the set that’s being offered by the employer.  Something – just before we go onto treatments and different things like that as well ‘cos that will obviously be something that advisers really need to know about.  But in terms of – so something we find quite interesting is that generally we tend to find that the longer somebody has diabetes, the higher the loadings are going to be.  So this is just sort of like an observation, not one that I’m expecting you to sort of like come back with a –

Matt:            No, that’s okay.

Kathryn:       The longer somebody has had it, the more likely they are to get higher ratings.  I think also the fact of I think sort of like the body has been kind of having this kind of battle for so long in terms of the insulin and everything that they’re probably thinking that – as we’ve mentioned with all the different aspects and it affecting all aspects of the body, the body is probably working quite a bit harder than for somebody who isn’t – who doesn’t have diabetes.  But then on some occasions, we’ve found it where there’s maybe been an insurer gone, “Well actually, this person’s had diabetes for 20, 30 years.”  So probably somebody who was diagnosed at a much younger age.  So they’ve had it for 20, 30 years.  All the readings are in a sense perfect for what you’d want them to be.  There’s been, you know, they’ve obviously really engaged with doing the different things they can do in terms of lifestyle and any treatments to make sure that they’re okay.

So actually what we’ll do is we’ll say that if there was going to be anything, any of these kinds of – well I say maybe the kind of red flag complications, we’d have probably already seen them developing by now.  So what we’ll actually do is reduce the loading now.  So I think it’s one of those things – as with anything, probably very unhelpful in many ways but it’s probably that thing of, as an adviser, don’t make an assumption as to what you think might happen because somebody has had it for so long.  Just because you’ve maybe experienced it one way before, it’s not necessarily going to be the case every time and with every insurer.  So it’s always worth having a natter with an underwriter – it’s always good to have a natter [laughs].

Matt:            [laughs] Absolutely.  I agree.  It’s really a function of the way that underwriters relate age to premium.  I think that’s probably why sometimes there are these discrepancies.  The complications are absolutely key.  One of the points I would make is though that certainly I have seen clients or clients’ clients who have had immaculate control throughout their life, have no complications, they’re in – I can’t say 50s and 60s but probably late 40s and the community – the sales community feel, “God, well that guy must be absolutely brilliant – or lady – standard rates.”  Very, very unlikely you will get standard rates even on somebody who has had very good control and is not showing symptoms ‘cos unfortunately to use – I won’t mention Dr Brackenridge’s great comment again because I’m sure it’s too much of a mouthful for everybody, but whatever, there will be some damage.  It might be at a micro level but there will still be some damage to the arterial system.

Kathryn:       Yeah.

Matt:            So they certainly – people will certainly get a decent rating in comparison with other diabetics but please don’t expect standard rates for life insurance.

Kathryn:       Yeah.  Absolutely.  So when it comes to treatments, what would we be expecting for someone with type one diabetes?  What would you be thinking, “Oh yeah, I expect that,” and would there be anything that you’d think, “Hmm, that maybe makes me think it’s possibly stronger, you know, than I was expecting?”

Matt:            Yeah, in terms of – I mean, when we’re talking about type one diabetes we are talking about insulin okay, so the use of pumps etcetera.  There’s two types of insulin really; one that is taken really late on at night to keep your insulin stable while you’re asleep etcetera – long-lasting insulin and there’s also a short-acting insulin which is taken just before you have a meal to help your body control the release of glucose into the body because of eating.  Everybody is different.  Everybody is different and therefore I have not seen underwriting guidelines where they would differentiate between different types or different levels of insulin going into the body.  The absolute key is that control –

Kathryn:       Yeah.

Matt:            And that the client or the diabetic looks after themselves properly and that’s one of the key questions that the GP or the diabetic nurse would be asked and signs that people aren’t looking after themselves properly and taking insulin at the right time would be of course hyperglycaemic attacks and hypoglycaemic attacks.  In terms of underwriting, hyperglycaemic attacks are where there’s too much sugar – it’s the one that starts the red flag if you like.  It’s a bit of a red flag if you have too many of those.  I mean, the challenge again – I think with, you know, if you think of children – little, really tiny children who have got diabetes, how difficult it is for them – they can’t speak for goodness sake.  How are they going to say if they feel ill or anything else like that?  Therefore it’s very much a part of the parenting role to make sure that that blood sugar is controlled and of course when people – again when people get into their teens and 20s and they want to live an unrestricted life in terms of alcohol, in terms of smoking, in terms of eating, in terms of snacking, therefore it’s quite difficult to keep those types of – as a group – an age group, that’s quite often when damage is done ‘cos they don’t really look after themselves.

I’m talking groups statistically here, I’m not talking about everybody obviously.  So again, rather than the actual levels of insulin, as long as they are being taken regularly and the control is taken seriously, then the type isn’t so much a factor.  That’s really how I would view that from an underwriting perspective.

Kathryn:       Okay.

Matt:            As I say, everybody is different so you’ll get different levels with different people and as long as the control is good, good.  Just good news.

Kathryn:       Fantastic.

Matt:            Does that help Kathryn on that particular question?

Kathryn:       It does help, thank you, because I think sometimes a big thing as well for advisers though is knowing what to ask and like when we’re hearing medications and things, you know, the work that we do and the clients that we have, we’re very used to the names of medications and –

Matt:            Absolutely.

Kathryn:       The conditions.  But even so, sometimes people say them to you and you’re just like, “What now?” [laughs]  You’re kind of just thinking – so at least we know with someone with type one diabetes – is essentially we’re wanting to know what’s happened.  Do they have an insulin pump?  Are they having to use injections?  You know, that’s probably –

Matt:            That’s probably as far as you’ll want to go.

Kathryn:       Yeah, we don’t need to probably go any further.

Matt:            Using your questioning skills – try and – without irritating the client obviously is maybe asking several times how the control is?

Kathryn:       Absolutely.  Well I’ve got a case study now to share and we’re just sort of like coming towards the end.  So the case study to share with everybody was – this was actually a case that was done during lockdown so just to prove that you can still get cover for people with health conditions even while all the restrictions have been in place though I have to say it’s absolutely lovely to see so many insurers that are now starting to remove the restrictions.  I just hope that carries on going and obviously that everything just carries on as it is just generally anyway in society, that we keep moving forward and in a much better place.

Anyway, so we spoke with a male in his early 40s last year and he was diagnosed with type one diabetes almost 30 years prior to that and he used an insulin pump.  So what was quite interesting and from what I can gather is that the insulin pump is something that is usually fitted more sort of like when there’s a specific health need rather than obviously using other methods to get the insulin.  But however for this person, they were very sporty and active so it was decided the insulin pump would work best for them and it worked quite well to be able to explain to the underwriters, “Look, this is why he’s using the insulin pump rather than the other methods,” and it helped the decision.  There was some potential for the mild background retinopathy so that was what, Matt, you were saying the hardening of some of the arteries on the back of the eyes and he had been in hospital for one night when the insulin pump had stopped working.

So in the grand scheme of things, when you’re answering those questions, when you get to the application, this is one of the reasons why it’s so important to do a lot of pre-sales research and speak to the underwriters beforehand and during their assessments of the case.  Like, you know, “We’ve got someone here with diabetes.  They’re on the insulin pump, they’ve got this, you know, starting aspects of the retinopathy.  They’ve been in hospital due to the condition but they’re all kind of – they’re all very light as well in many ways, the things that had happened.”  So whilst they may seem a bit of a standout thing in the application form, it’s really important to provide the context to the underwriters.

The other thing was that this person had Wolf Parkinsons White syndrome which had been identified.  They just needed an ECG at some point and they’d seen an abnormal heart rhythm and that had been corrected through a procedure known as an ablation.  So for this person we were looking at £380,000 of decreasing life insurance over 25 years for the mortgage and that’s ended up being a price of around £65 per month and the income protection – there’s a couple of aspects to that for me to sort of like talk through so for this person, we ended up with the income protection so it’s £3,000 per month that was over 25 years to take them to their retirement age.  It had a 13-week deferred period, a two-year claim period and the price was just under £70 per month.  So what’s interesting – a couple of things to mention with this one is that we did have terms for the full claim period for the client but unfortunately due to affordability the client decided to go – for the time being – for the two-year claim option and I can sort of like feel probably advisers going, “Ooh I don’t know if I’d have done that, I don’t know if I’ve done that,” kind of thing.

So one of the key things for us with this client is that obviously we gave him the options and a big thing for me is that it’s incredibly important to inform people of what’s available but at the same point you also have to be realistic and, you know, there are certain points where the insurance can become too expensive and it’s better to find something that adapts the situation to the client than them walking away with no protection at all for that specific need.  But what was interesting about this one is that we could have got the full claim period at a much cheaper price than what was originally suggested however there would have been an exclusion for any claims relating to the diabetes.

So an interesting thing about this is you may look at it and also it always comes down to the adviser’s kind of – probably their gut feeling but ultimately to me it is important to give the client both options and say, “This one over here will pay all the way to retirement age but it will exclude anything relating to the diabetes and we’ve already said here, that’s probably going to be anything related to the heart, the eyes, the feet, the kidneys, potentially strokes, cancers, you just don’t know depending upon the situation.”  Or you could say to somebody, “For the same price you can have this one.  It will cover any claims relating to your diabetes but it will only pay out for two years.”  And there’s pros and cons to both but ultimately I just think it’s very important to make sure that you are giving the client so they can make that informed decision themselves.  I hope you agree with me Matt?

Matt:            No, I do indeed.  I think it goes back to the principle that we talked about earlier, that something is better than nothing.

Kathryn:       Yeah.

Matt:            And well done you for getting that placed.  That’s I all I can – it’s good.  It’s good.

Kathryn:       It was a really, really good option for the client.

Matt:            Absolutely.

Kathryn:       And they’re obviously very, very happy with it, you know, because obviously I think a lot of the time people would look at things and think automatically and in some places, you know, think diabetes and ‘cos obviously as well there’s not just the diabetes here.  There is the – as I said, there is the background retinopathy starting, there is the fact that he had the Wolf Parkinsons White syndrome so even though that’s been corrected it was still something involving his heart.  There’s lots of things that have been involved in this case for this client and I think a lot of people would probably assume that income protection just would have been a no-go from the start but it just shows that sometimes it is still worth asking.  One of the things that I always train my team to do is sort of, you know, if somebody is wanting a specific insurance, that’s all well and good but do the research for everything and make sure that you give the options in a sense for everything because then at least they can really see what’s in front of them.

And it’s also really good for you because whilst you’re asking an underwriter and chatting to them about one insurance type, you may as well ask them about the others at the same time.  It’s all then done in one go and you increase your knowledge but there we go.  So that’s the podcast for today.  So thank you Matt.  It’s been really lovely chatting to you and I’m really happy to hear that you managed to get that nice break, even though it was a bit rainy.

Matt:            [laughs] No, well thank you for inviting me as always.  It was – just one little thing at the end of the podcast is that I hadn’t realised – but it’s 100 years this year that insulin was discovered in the context of diabetic treatment.

Kathryn:       Oh that’s amazing!

Matt:            So prior to that, really if you had type one diabetes, you wouldn’t live very long.

Kathryn:       Aw that – yeah.

Matt:            Because there was no insulin but it’s 100 years this year since insulin was – as I say, used in the treatment of diabetes.  So I thought I’d mention that.

Kathryn:       Absolutely, no that’s brilliant.  Thank you for mentioning that.  That’s really good.  Actually it’s amazing really to think that 100 years ago – because obviously 100 years ago feels like forever ago but at the same time it’s still relatively quite recent, you know, you sort of think about all of the people that will have not had a chance to access that.  It’s quite –

Matt:            And it was fatal.

Kathryn:       Yeah.

Matt:            You know, there was no middle ground to it.  With type one I’m afraid you’d die very quickly so yeah, it’s – for me anyway [laughs], it was an interesting fact I have to say.

Kathryn:       No absolutely.  Well I’m going to be back in two weeks’ time with Alan and we’re going to be doing a masterclass in critical illness cover.  We’ve done the life insurance, we’ve done IP so now we’re onto critical illness.  So as always, if you’d like a reminder of the next episode, please do drop me a message on social media or visit the website practical-protection.co.uk.  And what I will also say as well is that if you’ve not seen it so far, I’m sure you probably will have done if you’ve seen my social at all, I am launching an adviser training program covering lots of different bits.  The website is adviceforadvisers.co.uk.  I’ve got it on social, have a look and I think this is the first time I’ll be able to say this as well, is that the podcast is now sponsored by Octo Members which is brilliant and they are now doing certified CPD certificates for the episodes.  So – and we’re getting that all up and running and sorted and it just adds an extra bit – to anybody who’s listening obviously who has to do with the insurance world, it will add just a little bit of extra to your training.  So thank you very much for joining me, Matt.

Matt:            Thank you, it’s a pleasure as always.

Kathryn:       Bye.

Matt:            Bye.

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