The heated debate over whether chronic fatigue syndrome (CFS) is a genuine illness rather than a gateway to an easy life cooled in January this year. Chief medical officer Sir Liam Donaldson publicly backed an inquiry that endorsed the existence of the syndrome.
But official recognition has not brought clarity for insurers. The inquiry was unable to point to any virus or other agent responsible for the syndrome. Loose definitions remain and different attitudes prevail among doctors.
Insurers see the devil in the long-term repetitive nature of CFS. Take for instance a 30-year-old City high flyer who succumbed aged 30 when earning £75,000 a year. The policyholder might be in line to get two-thirds salary – £50,000. Over 35 years, if the condition never resolved, the insurer would be paying out £1.75m.
Dale Tranter, the senior researcher at intermediary network Misys, himself suffered a four-month chronic fatigue episode 11 years ago. He says the condition is “amazingly difficult to put your finger on”. The trouble revolves round the absence of any physiological or psychological diagnostic tests.
Renaming the condition CFS and discarding earlier labels, including the pejorative yuppie flu and ME (myalgic encephalomyelitis) was helpful. “Syndrome” implies a range of causes and symptoms, rather than a specific reaction to an organism. This helps explain the wide apparent variations in claim rates across the industry.
Sun Life Financial of Canada managing director Paul Davies thinks the condition could account for as much as ten per cent of claims by value. But he speaks from the group perspective.
The individual market appears to be less vulnerable. This may be due to the potentially high number of stressed-out executives in group schemes.
Yet the individual market is far from unaffected. Norwich Union’s Louise Zucchi says this “greyest of grey areas” accounts for a considerable part of the gamut of mental illnesses which make up a third of all IP claims.
On the other hand, Friends Provident technical claims manager Andy Parkinson says: “Mental health and chronic fatigue claims comprise round about a quarter of all the claims we have. But I would suggest that chronic fatigue claims do not approach the ten per cent figure. A lot of claims come through from people suffering from very similar symptoms but they may be given different labels. One might come through as stress or anxiety. One might be called chronic fatigue syndrome, another post-viral fatigue or nervous debility.”
Scottish Provident, the country’s third-biggest provider of individual IP, has seen “no dramatic rise in CFS”. Head of marketing and product development Nick Kirwan says: “We know that stress, mental conditions and back problems are the big ones.” But with a condition as ill-defined as CFS, could not some stress claims fall in to the CFS basket? Kirwan responds: “It’s a tantalising condition and there are conflicting medical views.”
Totals from Unum, which claims top spot in IP, are low. In 1992, chronic fatigue cases accounted for 3.2 per cent of claims. This proportion wavered over the following years (in 1993, 1.3 per cent of the total but in 1996, 3.5 per cent). In 2000, cases accounted for 1.5 per cent of the caseload but increased last year to two per cent.
According to Unum benefits operations manager James Vallender, some claims that formerly might have been classified as chronic fatigue are today examined more thoroughly.
The doctor might now make a more specific diagnosis, such as thyroid malfunction or a depressive illness.
He says: “We experienced a big rise in the 1990s but in the last 18 months or so it’s got quieter. In some cases the label chronic fatigue covered other underlying illnesses and these are now being better diagnosed.
“But when you are settling a claim, the diagnosis is one of the least important things. What matters is what people can and cannot do physically and mentally.”
To this end, it is becoming standard practice for insurers to pay for medical interventions, such as cognitive behaviour therapy, in CFS cases.
Norwich Union, for instance, uses neurologists, psychiatrists and rheumatologists, the latter because joint problems are common in CFS sufferers. Zucchi recalls: “We had our first claim 12 years ago and they have since continued to grow. We are active in helping policyholders.
“We send trained people to their homes to find what needs they have and whether we can help with recovery. It gives an insight into how people can get over it. We have put more and more emphasis on home visits and rehabilitation over the past five or six years.”
A typical rehabilitation programme could be designed to:
|•||Tackle a financial problem caused by the individual, or an underlying problem in the workplace; the employer might be asked to adjust workplace routine.|
|•||Redeploy the employee in a different department; if that entailed a salary cut, the insurer would consider how to make good the difference.|
|•||Regain fitness and entail exercise in the gym: all this might be paid by the insurer.|
A commonly reported problem is lack of medical services. As Parkinson puts it: “Many doctors would say there’s a shortage of rehabilitation facilities for all sorts of illnesses, and chronic fatigue is no exception.”
Sun Life Financial of Canada has co-opted German occupational health company Prisma Health to help. At the insurer’s Basingstoke offices, Davies says insurers need just such a specialist company because of the diverse nature of the syndrome.
He says: “In nearly all cases there’s a whole range of contributory factors, not all of which are represented by fatigue. It could be financial, family, business, managerial or promotion prospects. Usually it occurs when one of these reaches breaking point.”
Many claimants have been working 12-hour days, five days a week. Says Davies: “It is surprising the number of people who through email and other means feel they are permanently on call.”
The company’s exposure to chronic fatigue claims has pushed it into a very proactive approach. Davies explains: “We are probably a little more expensive but we have put a lot greater effort in to getting people back to work. We’ve been looking at cases that have been on the books a couple of years. We are getting them the medical attention that perhaps the National Health Service has not been giving them for 18 months.
“The crux is that if you did not apply rigorous medical attention and ‘rehab’ programmes you really would have very long term claims. We recognise this quite early in the process and apply resources much earlier. If a company notifies us before the end of the deferred period and we get to the individual after, say, four weeks, the condition probably never reaches chronic fatigue syndrome.”
Pinpointing the trigger for the syndrome is the first goal. “It could be something to do with the family. So we’d get Prisma to talk to the individual and also the partner. The problem is seldom totally medical and Prisma will work out a programme to get that person’s life back.”
Prisma’s assessment costs a “significant sum”, says Davies. IP providers in the individual market are wary about pushing the lifeboat out to the same degree. The group insurer could spend £50,000 on one rehabilitation. “You’re talking about people on big salaries in very high-powered jobs that themselves give rise to stress. So if you want to get the person back to work, you should look at it in the round and the employer has to play his part too,” says Davies.
Until recently, the role of IP providers stopped at paying claims. Now they are initiating intervention in a way that seems to help all parties. Davies adds a postscript: “We’ve had a few letters from people saying ‘Thank you for giving me my life back.’”