Hepatitis C Underwriting Update

The underwriting of Hepatitis C for life insurance is changing based on new diagnostic tools and new treatment options. This month we review these important changes.

New Diagnostic Tools

While the liver biopsy has always been the "gold standard" test in the work up for Hepatitis C, the tissue samples from this procedure are yielding even more information. One aspect of this new information is the unique "genotype" of the Hepatitis C virus.

Genotype is the "internally coded, inheritable information" carried by all living organisms. This stored information is used as a "blueprint" or set of instructions for building and maintaining a living creature. The Hepatitis C virus has its own unique genotypes.

Hepatitis C has at least 6 distinct genotypes. Types 1, 2 and 3 are found most often in the United States with genotype 1 being the most common. Genotype 4 is largely confined to the Middle East and northern Africa. Genotype 5 is found in South Africa while genotype 6 is found in Asia.

Knowing the specific genotype of a person’s Hepatitis C is the most important predictor of response to therapy.

Example: While genotype 1 is the most common in the United States, its response to treatment (i.e. how long the treatment lasts) is half of type 2 and 3.

In addition to genotypes, there has also been an improvement in how the tissue from the liver biopsy is "graded" and "staged."

Grading and staging (commonly used in cancer cases) refer in Hepatitis C to how the liver tissue samples look under the microscope. While Hepatitis C is not itself a malignancy, you can use these principles to measure the degree of the disease’s activity (grade) and the damage it has already caused (stage).

The grading of Hepatitis C simply refers to degree of inflammation of liver cells. Rosenburg has classified the grading on a scale from 0 to 4 with 0 being no inflammation and 4 being severe inflammation and tissue damage (Rosenburg PM. Hepatitis C: a hepatologist’s approach to an infectious disease. Clin Infect Dis. 2001;33:1728-1732.).

Knowing the grade of the Hepatitis C provides important information about the risk of lethal changes in the liver called cirrhosis. It also helps determine who should receive treatment.

Example: Cirrhosis develops within 10 years of nearly all patients with severe inflammation (grade 4). Cancer of the liver develops also exclusively in patients with cirrhosis. See this link for an overview of cirrhosis of the liver: http://www.gastro.org/public/cirrhosis.html

The staging of Hepatitis C simply refers to the degree of fibrosis (i.e. how much normal liver tissue has been replaced by scar or fibrotic tissue). Rosenburg has classified this on a scale from 0 to 4 with 0 being no fibrosis and 4 being cirrhosis (Rosenburg PM. Hepatitis C: a hepatologist’s approach to an infectious disease. Clin Infect Dis. 2001;33:1728-1732.).

Knowing the stage of the Hepatitis C provides important information about the risk of lethal changes in the liver called cirrhosis. It also helps determine who should receive treatment.

Example: On average, Hepatitis C progresses one stage every 4 years (i.e. moving from stage 2 to a stage 3). This means that a patient who is stage 3 (extensive scarring but no cirrhosis) would move into stage 4 (cirrhosis) within four years.

Treatment for Hepatitis C is recommended for all patients with a grade 2 inflammation and stage 1 tissue damage (fibrosis).

New Treatment Options

Combination therapy is the treatment standard for patients with Hepatitis C using the medications interferon and ribavirin How long a patient is treated is determined by their genotype.

Patients with genotype 2 and 3 can be treated successfully with 24 weeks of combination therapy. Patients with genotype 1, assuming they respond to the first 24 weeks, are treated for 48 weeks.

While the treatment sounds straight forward, there are significant side effects that are serious enough for 15% of patients to withdraw from therapy (see this link for an overview of side effects http://www.va.gov/hepatitisc/pted/side_effects.htm).

What is considered a treatment success?

The "viral load" is measured after 24 weeks of treatment. A detectable load at 24 weeks is a reliable predictor of lack of response to a longer treatment course and allows for cessation of therapy. The absence of a viral load indicates a response to treatment.

A "sustained response" is defined as normal liver function tests (LFTs) and no viral load at the end of therapy and for at least 6 months thereafter.

Field Underwriting Questions

Below are the key field underwriting questions from RiskTutor for screening life insurance applicants with a history of Hepatitis C:

1) When was the client diagnosed with Hepatitis C?

Underwriting Comment: The majority of client’s with Hepatitis C (75%) are asymptomatic (without symptoms) and the diagnosis is usually "discovered" during an investigation of abnormal liver enzymes.

REMEMBER: The most common means of transmission of Hepatitis C is contaminated blood products (before 1992) and intravenous use of drugs. Sexual transmission, though possible, is rare. Approximately 4,000,000 Americans have been infected with Hepatitis C. In 40% of reported of cases of Hepatitis C the exact cause is classified as "unknown" (i.e. the client is unwilling to disclose the source of the infection).

2) Did the client have a liver biopsy? If yes, when and where?

Underwriting Comment: A liver biopsy is a critical piece of underwriting information that helps determines both the severity of the Hepatitis C as well as treatment options.

REMEMBER: While clients with Hepatitis C may be asymptomatic, the disease is anything but benign. Chronic liver disease develops in 70% of infected individuals leading to cancer of the liver as well as liver failure. The number one cause of liver transplantation in the United States is Hepatitis C.

3) Has the client been treated for Hepatitis C?

Underwriting Comment: The majority of clients with Hepatitis C will be monitored without any treatment. Other clients will be treated with medications (interferon and ribavirin) in an attempt to eradicate the Hepatitis C virus.

REMEMBER: Even with the new "combination approach" to treating Hepatitis C (interferon and ribavirin), there can be problems with side effects and treatment failures. There is no known cure for Hepatitis C and most cases eventually progress to liver dysfunction.

4) Are the client’s liver enzymes stable, increasing or decreasing?

Underwriting Comment: Clients with Hepatitis C are usually aware of the status of their liver enzymes. They may not know the exact readings but they do know if their condition is stable, improving or deteriorating.


5) What medications is the client currently taking?

Underwriting Comment: The client’s current medications are an important "underwriting clue" to possible complications of Hepatitis C or other medical problems (you can find out any medication’s color code in Pharmacy Tutor).


6) How much alcohol does the client consume on a daily basis?

Underwriting Comment: Clients with known liver disease are usually advised to curtail or quite their alcohol consumption. With liver disease, even modest amounts of alcohol can increase the severity and complications of the problem.