Casebook September 2015
September  2015

The cases presented in this issue follow a common theme. Both involve possible “incidental” findings that could evolve into very rare but serious malignancies. As medical imaging and investigations become increasingly available and less invasive, the underwriter is confronted with these situations more frequently.

One could argue that such rare conditions are covered by the underlying expected mortality built into insurance products. But this ignores the fact that the person had symptoms, sought treatment, and – armed with the additional knowledge – applied for insurance.

So, is there a way to estimate mortality associated with these findings?

We start with the medical literature, but always must be aware of referral bias. Simply stated, most medical journal submissions are from academic, tertiary care centers. In our first case study, the two reference studies (Lane, et al and Shields, et al) were conducted at such centers. Of the hundreds of thousands of choroidal nevi seen by optometrists and
ophthalmologists across the USA, these few thousand cases were referred to such centers for their expertise. These are the high-risk cases. However, these high-risk cases are useful for identifying characteristics of the “incidentalomas” that predispose them to potential malignant evolution.

The lesson: be aware of the source of the medical study – is it community-based or from a tertiary referral center? Apply the findings accordingly.

The estimates ultimately will depend on the information provided in the research articles. Ideally mortality outcomes will be based on the findings. Perhaps there are only conversion rates, which then necessitate estimates based on conversion linked to predicted mortality of any future malignancy. Compliance with follow-up and early detection are two factors that would mitigate the mortality risk of any future malignancy.

Cases with multiple variables affecting estimates are challenging, and more than other more straightforward cases rely on the “art of underwriting.” We are interested in your feedback and welcome e-mails on these cases. With your permission we might share
some of your opinions in future issues. ∞​