Insurability after Severe Traumatic
Brain Injury
The tragic skiing accident of Formula 1 racing champion
Michael Schumacher increased the awareness of severe
traumatic brain injury, which is a leading cause of death
and disability worldwide.
Traumatic Brain Injury (TBI) is defined as an injury
resulting from a significant trauma to the brain. The
most common causes are motor vehicle accidents,
followed by falls (especially in older adults), sports
accidents and assault. TBI has also become a relatively
common injury among the combat military personnel
deployed in areas where improvised explosive devices
(IEDs) are employed as weapons.
TBI can be distinguished from non-traumatic brain
injuries, such as stroke, because it is the result of a
sudden event with a specific cause. Whereas strokerelated brain injury is typically the result of a more
complex and often chronic underlying disease process.
TBI can be caused by a focal impact upon the head
(e.g., being hit by a baseball), by a sudden acceleration
and deceleration of the head (e.g., whiplash) or by
a combination of both movement and impact (e.g.,
acceleration and deceleration associated with striking
the windshield in a high speed auto accident).
In addition to the damage caused at the moment of
impact, secondary injury to the brain can be caused by
alterations in cerebral blood flow and increased pressure
within the skull related to bleeding within the skull
and/or swelling of the brain. These secondary effects
take place in the first hours or days after the initial injury,
and contribute substantially to the resulting damage of
the brain.
TBI can be associated with a number of neurological,
cognitive, social and behavioral effects, and outcome can
range from complete recovery to permanent disability
or death.
TBI may be mild, moderate or severe. A mild injury
is generally not serious and a full recovery, in a short
order and without complications, is expected. A
moderate injury may, more likely, result in more obvious
impairment of, or brief loss of, consciousness and require
a couple of weeks for full recovery. A severe injury may
result in significantly altered mental activity, including
coma, and may take weeks to months, or longer, for
maximal recovery. Of note, repetitive mild or moderate
brain injuries can have a cumulative effect in boxers, for
example, with history of repetitive head trauma.
For the purposes of this article we will focus on
severe TBI.
A severe TBI – like that suffered by Michael Schumacher
– is a life threatening event, and studies have found
mortality rates of 30-35 percent during the first six
months. However, advances in neurosurgery and modern
intensive care medicine have increased the chances to
survive even severe TBI, and the improved probability of
long-term survival is relevant for insurers.
Over the last 20 years, the evidence on survival after
moderate to severe TBI has grown with long-term
follow-up studies of large groups. These studies are
consistent in the identification of (a) age and (b) severity
of ongoing functional disability as the most important
clinical predictors of long-term survival.
One of the most recent studies addressing the question
of long-time survival after TBI comes from Brooks et al.,
and was published in 2013 in the Archives of Physical
Medicine and Rehabilitation1. In this study, more than
7,000 patients admitted to hospitals with a TBI, and
who survived for longer than one year post injury, were
enrolled and followed for up to 20 years. The mean age
at injury was 39 years and 73 percent were male. For
the group, survival was poorer than that of the general
population, with a standardized mortality ratio of 2.1
(an extra mortality of 110 percent). The major prognostic
risk factors for survival was age and remaining
functional disability.
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Insurability after Severe Traumatic Brain Injury
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The survivors who were largely independent from any
assistance (with ADLs, IADLs, etc.) had a significantly
better survival compared to those requiring mechanical
aids or personal assistance. For those with minimal
disability and being mainly independent, the estimated
survival curve was slightly worse than that of typical
40-year-old man in the general population.
The same may apply to disability covers. However, long
term complications, especially sensory, behavioral and
cognitive problems, may develop slowly years after
the injury. Fully recovered survivors of severe TBI may
often be accepted for disability products. However, a
rated and/or limited benefit period policy might be
appropriate to cover the risk for morbidity associated
with long-term complications.
For those at the severe end of the spectrum, who
required 24-hour care, the estimated median survival
time for a 40-year-old male was 13.4 additional years,
that is, until age 53.4.
In an Australian study2 from 2012, including 2,545
working-age adults with severe TBI being discharged
from a rehabilitation center, mortality remained higher
than the general population for many years. Again,
functional disability was one of the main prognostic
parameters, as discharge from rehabilitation to long
term care facilities doubled the risk of mortality after
TBI compared to those being discharged to home.
The main causes of death in survivors of severe TBI are
diseases of the respiratory and nervous system as well
as mental and behavioral disorders.
In underwriting individuals with history of TBI, it is
important to take into account the current functional
status of the applicant as this is a primary prognostic
indicator. This would include any cognitive or neuro­
logical deficit, any remaining functional disability,
history of respiratory problems, psychiatric disorders,
substance abuse, etc. Applicants with minimal or no
complications three years after a severe TBI can likely be
accepted at low substandard to standard rates in highly
favorable cases.
For the assessment of sports and avocation risks, the
tragic accident of Michael Schumacher reminds us
that no active participant is immune from the risks of
(extreme) sports or avocations, or, for that matter, the
risks of daily living. It is assuring to know that, with
modern emergency and intensive medical care and the
growing use of protective gear (helmets, etc.), more
and more people will likely survive severe TBIs. But the
flip-side of this success is that, at the same time, more
people will leave the hospital with long-term functional
disabilities. It is important that underwriters understand
the risks associated with severe TBI to properly assess
the long-term mortality and morbidity risks associated
with this injury.
References
1
Brooks JC, Strauss DJ, Shavelle RM, Paculdo DR, Hammond FM,
Harrison-Felix CL (2013). Long-term disability and survival in traumatic
brain injury: Results from the National Institute on Disability and
Rehabilitation Research Model Systems. Archives of Physical Medicine
and Rehabilitation, 94:2203-2209.
Baguley IJ, Nott MT, Howle AA, Simpson GK, Browne S, King AC,
Cotter RE, Hodgkinson A (2012). Late mortality after severe traumatic
brain injury in New South Wales: A multicentre study. Med J Aust.
2012 Jan 16;196(1):40-5.
2
Mark Skillan
Vice President & Medical Director
Munich American Reassurance Company
Not if, but how
© 2014 Munich American Reassurance Company, Atlanta, Georgia