There remains much debate about Coronavirus and the many ways in which it has affected, is affecting and will affect societies: for example, the death tolls so far and in future, ways to suppress its activity, the value of testing, tracing and monitoring, the economic impact of ‘lockdowns’ and whether governments have responded appropriately in a timely manner.
It is interesting to compare how countries around the world are doing in their battle to beat the virus. Joseph Lu, working on behalf of the COVID-19 Actuaries Response Group1, has published an analysis and concluded2 that many small countries from Albania to Vietnam (but also including Australia) have largely won the battle by getting the number of new infections almost down to zero. In contrast, a variety of other countries, including Brazil, Canada, India, Pakistan, Sweden, the UK and the US, still need to take urgent action. In between are countries that are “nearly there” including most of those in western and southern Europe.
As we all knew, the impact of the virus on individual nations has been variable, but how much can a comparison such as this be trusted? Reported infection rates and rates of deaths directly and indirectly due to COVID-19 depend on the extent of testing (numbers and who gets tested and when) and the way that data is recorded, in terms of consistency, accuracy and definitions; these factors naturally vary from country to country. Lu addresses this by arguing that these are likely to be irrelevant in the context of which actions need to be taken, and that using a rolling 10-day average helps reduce potentially misleading ‘spikes’ in the data.
Data for England and Wales from the UK’s Office for National Statistics enable some pretty reliable conclusions as to how Coronavirus has affected the mortality of particular groups. According to the Continuous Mortality Investigation’s Mortality Monitor – COVID-19 update3, at the end of week 18 on 1 May, cumulative standardised mortality rates overall for 2020 were 5.7% above the 2010-19 average. Before the massive upswing that occurred in April the trend was closely following that of 2019 which had shown very favourable mortality.
In that week, mortality was up 58% overall compared with the same week in 2019 (55% up for men and 61% up for women). By age group, mortality ratios were as follows:
|Ages 45-64||Ages 65-74||Ages 75-84||Ages 85 up|
The overall mortality ratio for ages 15-44, males and females combined, was around 115%, showing the sharp correlation between age and excess mortality in this disease.
That the pandemic is hopefully coming under control is demonstrated by the figures for the week ending 23 April, which were far higher:
|Ages 45-64||Ages 65-74||Ages 75-84||Ages 85 up|
The corresponding overall figure for ages 15-44 was approximately 140%.
Note that the mortality ratios for men and women are very similar, which casts some doubt (but see later) on the assertion that COVID-19 hits men harder than it does women. There is, however, good evidence that the virus discriminates by racial group and socio-economic deprivation. Consider these hazard ratios for in-hospital COVID deaths gleaned from analysis of 17 million UK National Health Service records4:
|Ethnicity||Adjusted for age and sex||Fully adjusted||Deprivation quintile||Adjusted for age and sex||Fully adjusted|
|Hazard ratio||Hazard ratio|
|White||1.00 (ref)||1.00 (ref)||1 (least)||1.00 (ref)||1.00 (ref)|
From the same analysis, a spotlight on co-morbidities:
|Co-morbidity||Adjusted for age and sex||Fully adjusted|
|BMI 40 up||2.97||2.27|
|Respiratory disease exc asthma||2.35||1.78|
|Asthma (no recent oral steroids)||1.23||1.11|
|Asthma (recent oral steroids)||1.70||1.25|
|Chronic heart disease||2.01||1.27|
|Controlled diabetes (HbA1c <58 mmol/mol)||2.02||1.60|
|Uncontrolled diabetes (HbA1c >58 mmol/mol)||3.61||2.36|
|No recent HbA1c||2.35||1.87|
|Cancer diagnosed <1 year ago||1.83||1.56|
|Cancer diagnosed 1-4.9 years ago||1.39||1.19|
|Cancer diagnosed 5+ years ago||1.03||0.97|
And in respect of these in-hospital deaths related to COVID-19, men did fare much worse than did women: taking women as the benchmark, the hazard ratio for men was 1.99 fully adjusted.
All very interesting. But what are the implications for insurers?
In the UK they will have taken a mortality hit but in the long run it will not be as great as the mortality ratios in tables 1 and 2 on the face of it imply. Those figures represent just a short period in the year. Even if there is a second (or even a third) ‘wave’ of infection it is unlikely, given the greater level of preparedness and much better understanding of how the virus behaves, to give rise to such high mortality rates.
A factor that might mitigate the impact is that the great majority of deaths have been at ages 65 up, in which many insurers have a relatively low exposure. And those that have been fortunate – or smart – enough to have a companion longevity portfolio will be seeing some mortality ‘losses’ offset by longevity ‘gains’.
Disability insurers too will have been affected, especially those writing covers with very short deferred periods (a few specialists pay benefit from day one of disability). Although the acute phase of the illness is relatively short, after-effects such as fatigue and shortness of breath can linger on for a few weeks. Even insurers writing business with deferred periods of one month upwards may see new or extended claims as a result of COVID aggravating existing medical conditions.
Given that Coronavirus-related deaths have been predominantly among the frail and those with co-morbidities, might residual insured populations be healthier and thus exhibit improved mortality in the years to come? Possibly, although COVID-19 won’t be going away, and an effective vaccine might become available rather later than some have been suggesting. Also, the pandemic has deterred those with new symptoms of serious illness from seeking medical attention, so there is likely to be a backlog of diagnoses; it may be the that the delays in treating these patients will push up future mortality a little.
Day-to-day underwriting has inevitably needed to respond to the pandemic. Underwriters’ key challenges are prevention of anti-selection, decision-making on applicants who have been infected but have made a recovery, and considering the outlook of those individuals who are acceptable for insurance but who have significant co-morbidities – and who thus are more likely to succumb should they contract the virus in future. There has also been the matter of medical evidence: physical contact restrictions have prohibited traditional (para-) medical exams and insurers have been reluctant to obtain attending physician reports to avoid further burdening their exceptionally busy offices and surgeries. The situation is steadily evolving but there have been alterations to application forms, welcome new guidance in underwriting manuals and some innovative approaches to medical screening.
The world has seen in the recent past South Asian and Middle East respiratory syndromes and various strains of ‘bird flu’, but COVID-19 has been the first true pandemic since ‘Spanish flu’ killed millions of people in 1918-19. And the thing is, it won’t be the last. The risk environment is changing all the time. Hopefully the challenge of and response to Coronavirus will leave countries – and their insurance industries – better prepared for the future.
- Institute and Faculty of Actuaries. https://www.actuaries.org.uk/learn-and-develop/continuous-mortality-investigation/other-cmi-outputs/mortality-monitor
- Williamson E, Walker AJ, Bhaskaran KJ, Bacon S et al. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1