Patients with melanoma are avoiding follow-up to get insuranceBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7803 (Published 03 December 2012) Cite this as: BMJ 2012;345:e7803
- Ciarstan McArdle, plastic surgery trainee, Department of Plastic Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, UK
Malignant melanoma is the fifth most commonly diagnosed cancer in the United Kingdom.1 Incidence has risen fourfold in the past four decades, to 17 cases per 100 000 in 2010, with 85% of patients presenting with localised stage I and II disease.2 Although the predicted survival rates for these patients at five years is 97% and 81%, the impact of melanoma can be life changing for patients, both personally and financially.3
Guidelines on melanoma revised by the British Association of Dermatologists in 2010 recommended up to five years of follow-up after initial diagnosis to examine for evidence of new lesions, recurrence, and potential spread of disease. 4 However, lately in my plastic surgery unit we have seen an alarming rise in the number of patients electing to withdraw from regular review because of difficulties in trying to secure insurance. Patients who do not attend follow-up or fail to self examine risk missing something new or suspicious, especially patients who have had melanomas removed in areas that are difficult to self examine.
Some insurers class follow-up as ongoing care or treatment and can refuse to provide cover to applicants who are receiving such so called ongoing treatment. Even though the predicted risk of recurrence after a localised primary stage I or II melanoma is low, at 2.8% at five years and 3.6% at 10 years,3 patients either struggle to get medical insurance to cover them or the premium can be as much as four times more expensive.
The Association of British Insurers issues no guidelines for companies to refer to when considering providing insurance for patients with malignant melanoma. Each company determines the risk-benefit ratio for insuring patients. When asked by telephone, seven of the 10 leading British companies that provide medical insurance in the UK told me that they would decline applications from anyone with a pre-existing medical condition, including melanoma, that had been diagnosed within five years of application. They considered the grade and staging of melanoma irrelevant.
Two of the three remaining companies were unwilling to provide insurance for any pre-existing medical condition diagnosed, treated, or receiving ongoing treatment within five years before the application for insurance. These companies considered outpatient follow-up review for people diagnosed with melanoma to be “ongoing treatment.” Insurance would be provided only if applicants remained disease-free for the first two years of the policy. One company did not provide information on its policies on providing insurance, citing data protection rules.
An independent online insurance company with a special interest in coverage for people with pre-existing medical conditions would expect patients with low grade stage I disease to pay three to five times more for insurance than someone without pre-existing medical conditions. Patients diagnosed as having melanoma with stage IB or II disease would initially be refused insurance for up to two years and could then expect to pay as much as twice the annual rate for insurance for a period of five to seven years. Thereafter, patients can again expect to pay above the expected annual price for insurance. Patients with stage IIB or IIC disease diagnosed within the past year would not be provided with cover for two to four years.
The British health insurance industry generated revenue of £3.6bn (€4.47bn; $5.7bn) in 2010.5 Statistics from the Association of British Insurers show that 3.3 million people bought private medical insurance covering 5.8 million people in the UK in 2010. But a diagnosis of melanoma can have huge financial implications for patients trying to secure medical insurance or life assurance for the future.
Patients with stage I and II disease have similar life expectancy to the average fit and well patient and should pay a similar price for insurance premiums. The insurance industry needs an overhaul, and companies should engage more with clinicians to provide medical advice on conditions such as melanoma.
Cite this as: BMJ 2012;345:e7803
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
I thank Keith Allison, consultant plastic surgeon, who supervised this work, and the James Cook University Hospital, Middlesbrough.
Provenance and peer review: Not commissioned; not externally peer reviewed.