Hypertension, or high blood pressure, is a common medical problem. It can be caused by a number of other medical conditions such as chronic kidney disease, thyroid disorders and other hormonal upsets, and a rare adrenal gland tumour called phaeochromocytoma. But most of the time hypertension has no obvious cause, although sometimes it is associated with overweight or a diet with an overly high salt content, and people of Afro-Caribbean heritage seem to be more susceptible to it.
If left unchecked, high blood pressure can damage kidney function, enlarge the heart and accelerate the process of arterial degeneration; thus hypertension is an important risk factor for coronary heart disease and stroke.
Way, way back, hypertension was difficult to treat. The drugs were not that effective and their side effects put people off taking them. Control of blood pressure levels, therefore, was poor and erratic. Nowadays, a variety of anti-hypertensive drugs are available that work in different ways and the unpleasant side-effects are far fewer. Thus good control is much easier to achieve.
And it has been recognised that cardiovascular risk is directly associated with blood pressure level. Even though BP tends to rise with age, it still makes sense to try and keep levels around the ‘ideal’ 120/80 mark, which is why many of those aged in their late 50s and upwards are on anti-hypertensive medication. In some countries, the UK included, family doctors are under some pressure to monitor BP as a matter of routine in the interests of health maintenance: it is more cost-effective to prevent BP-related illnesses than to wait and then treat them when they arise.
Compared with hitherto, significantly lower levels of blood pressure are now regarded as indicators for prescribing anti-hypertensive therapy. Also, people are generally much more health-conscious than they were and are more likely to get advice if they don’t ‘feel quite right’. Thus today underwriters see plenty of cases of (usually successfully) treated hypertension and very few with substantial elevation that so far have not been treated. And the days of stumbling across ‘ticking time-bomb’ cases featuring grossly elevated BP levels are pretty much gone.
Nevertheless, it is not impossible for an underwriter to encounter significantly elevated BP readings on an insurance medical exam arising from either untreated or poorly controlled hypertension. How to deal with this eventuality? Rate it on the basis of what is known? Or some other course of action? BP rating calculators in the underwriting manuals will usually show a rating and, depending on the BP level, maybe that will be quite a high rating, signifying maybe three times the normal risk or more.
But would that offer be acceptable to the customer? Just as importantly, would it be fair given that how the hypertension will be managed and the outcome for the individual – and thus the risk – cannot be predicted with anything like accuracy? It is quite possible that that high BP can quickly be brought down to normal levels.
In these situations hypertension ratings are designed to cover the risk associated with any unknown cause of high blood pressure, together with the cardiovascular impact of the BP itself. But in modern societies in which healthcare is available and affordable, and in which (probably) people are health-conscious, how likely is that that hypertension will go uninvestigated and untreated?
It is generally accepted that uncomplicated treated hypertension is a standard or borderline standard risk in most cases. Newly diagnosed or what appears to be treated hypertension that needs to be brought under control again needs a more cautious approach, but maybe just entering BP levels into a calculator doesn’t get the right answer. Most likely, that +200 risk will shortly be a +50 one or even qualify for standard rates.
The fair thing to do, certainly in markets where good healthcare is available and affordable, would be to offer to re-underwrite the case in a few months’ time after either a postponement or applying a rating; ideally the latter would take into account the health-consciousness of the individual – provided if there is evidence for it.
There will of course be those cases that are genuinely urgent such as those covering a loan or mortgage and cover may have to go into force straightaway. But underwriters need to think carefully about the principle of treating the customer fairly. Charging a high permanent extra premium to cover a risk that may only be high for a matter of a few weeks is rather at odds with it.
