Scientific evidence on the effect of COVID-19 on health in the long term may still be limited, but there are already clear signs that this is more than ‘only’ a respiratory disease, with the virus affecting various organ systems. Considering evidence from previous coronavirus infections such as SARS and MERS provides valuable insights on what these future implications may be. Most of the impairments discussed below are features from these infections.
From a claims management point of view, specifically with regard to disability insurance, it is important to be aware of COVID-19’s potential longer-term effects on the health of policyholders as possible future claimants.
This article focuses on the main impairments that are currently thought to be most likely to present as a claim cause. We will also discuss clinical presentation and functional limitations as well as claims management strategies.
Vice President, Global Head of Claims
RGA South Africa
Severe respiratory disease in COVID-19 includes acute respiratory distress syndrome (ARDS) that may require ICU admission and mechanical ventilation. As a result, individuals may present with ongoing symptoms and complaints including reduced endurance and mobility, shortness of breath, and coughing.1
Radiological investigations may be of limited value as part of claims evidence, as studies have shown that high-resolution computed tomography (HRCT) may only reveal minor fibrotic changes, and it is thought that functional impairment is likely neuromuscular in nature, rather than due to structural lung changes.2
The 6-minute walk test (6MWT) is a good measure of exercise tolerance, particularly when determining the longer-term effects of ARDS. At the end of the 6MWT, the patient’s oxygen saturation percentage, heart rate, and dyspnea rating are recorded, and the total distance covered during the 6 minutes calculated. Predicted normal values consider gender, age, height, and weight.3 It is found to be more indicative of impairment when spirometry results are within normal limits and HRCT reveals few or no abnormal findings.4
Improvement in respiratory function can occur over a lengthy period, up to five years post-ARDS; however, the most noticeable improvement can be expected in the first year following hospital admission.
Individuals may present with ongoing symptoms and complaints including reduced endurance and mobility, shortness of breath, and coughing.1
The U.S. Centers for Disease Control and Prevention (CDC) states that several cognitive and mental health symptoms may be associated with long-term effects of COVID-19.5 To better understand the potential impairments, it is again relevant to consider evidence from non-COVID-19 ARDS patients as an indication of neuropsychiatric disability. Studies mention reduced attention and memory, as well as impaired general mental processing capabilities, especially high executive cognitive functioning. From a functional point of view and through the claims investigation process, the following may be reported by claimants or their family and caregivers:
Additional mental health symptoms such as anxiety, depression, and posttraumatic stress disorder (PTSD) are also widely reported in ARDS survivors. While PTSD is most prevalent upon ICU or hospital discharge, depression remains present for much longer.6
A study published in Lancet Psychiatry reported a doubling of risk in adults of being newly diagnosed with a psychiatric disorder post-COVID-19.7 The main three conditions were anxiety, insomnia, and dementia. The study considered “diagnosis” as anywhere between 14 and 90 days after a COVID-19 diagnosis.
Studies mention reduced attention and memory, as well as impaired general mental processing capabilities, especially high executive cognitive functioning.
The potential effect of COVID-19 on the heart is well described in an article published in Science.8 Unlike MERS and SARS, where a limited number of patients presented with cardiac disease, a distinct feature of SARS-CoV-2, the virus which causes COVID-19, is a marked effect on the heart that can lead to myocarditis, arrhythmias, and acute or protracted heart failure. The necrosis of heart cells may mimic a heart attack.
Cardiac complications are not only present in people with comorbidities but can at times be the only feature of COVID-19, and they have been found in young, healthy individuals. From a claims management point of view, it is important to consider that claimants with no significant cardiac history or obvious comorbidities may present with cardiac impairments post-COVID-19. Furthermore, cardiac complications also occur in patients that had mild symptoms during the acute infection phase; therefore, the severity of the infection may not be a clear indicator of potential cardiac involvement.
Cardiac complications are not only present in people with comorbidities but can at times be the only feature of COVID-19, and they have been found in young, healthy individuals.
Acute kidney injury (AKI) is a common complication of hospitalized COVID-19 patients and is correlated with high mortality risk. Those who survive are at an increased risk of developing chronic kidney disease (CKD). Poor prognosticators for developing AKI include older age, the presence of comorbidities, and patients requiring mechanical ventilation.9
A median length of stay for patients with AKI requiring dialysis was one month compared to five days for those who did not develop AKI. Nearly one-third of people surviving AKI who were receiving dialysis remained on this treatment post-discharge.10
Those who survive are at an increased risk of developing chronic kidney disease (CKD).
Although it is important to understand the longer-term effects that COVID-19 may have on the body once the acute infection has subsided, the evaluation of impairment, irrespective of condition, illness, or disease, on the ability to work is the core nature of disability claims adjudication. It is therefore essential that claims assessors apply usual assessment principles to determine whether an insured event has occurred and to maintain an open mind when adjudicating these claims.
Claims evidence should include objective and functional documentation, with a clear understanding of how the claimant’s quality of life and functional ability have been impacted. Some clinical manifestations have been highlighted above; however, most of the current evidence on COVID-19 effects indicate that further research is required before a full understanding can be reached.
Admission to ICU (in general, not specific to a particular diagnosis) is a poor prognosticator for return to work, with only approximately 50% of people retuning to work one year post-admission.11 Furthermore, even people who do return to work initially experience some impact on their work capacity, either through a reduction in work hours, a change in occupation, or job loss. The full extent of the impact can take up to three years to transpire.12 This highlights the importance of continued case management to support claimants during their recovery plan, and to anticipate that some claimants may require support to return to work multiple times, rather than only once.
In addition to the direct effects discussed, the interruption of health services as a result of the pandemic is another factor to consider in the context of claims management. A survey by the World Health Organization (WHO) in June 2020 indicates that services have been interrupted in many countries; half of respondents either partially or fully ceased their hypertension and diabetes treatment regimens, and cancer treatments and cardiovascular emergencies reduced by 42% and 31%, respectively. Almost two-thirds of countries (63%) have stopped their rehabilitation services. Given the potential long-term health consequences of COVID-19, these interruptions can be damaging to people who require rehabilitation to improve their function to be able to return to work.13
Alternative strategies are being implemented, and survey respondents indicated increased adoption of telemedicine to replace in-person consultations (42% - 58%) or to triage cases and determine priorities (66%). As an example, partnerships between some universities and healthcare providers in the U.S. have resulted in the provision of support to patients with COVID-19 to rehabilitate at home, with a higher success rate than traditional home-based therapy and lower levels of anxiety compared to the hospital in-patient setting. 14
Ongoing research is required to fully understand the long-term health effects of COVID-19. The available evidence indicates potential claims may present in various ways long after the initial COVID-19 infection. Claims teams should ensure that they are able to identify these claims and have a good clinical and functional understanding of potential claim causes, while applying sound practices when adjudicating claims. More than ever it is important to consider the individual circumstances of a claim, particularly the impact on functional ability, and evaluate how that relates to the ability to work, or the clinical and functional parameters that may be included in the policy definition of incapacity.
References
1 https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html
2 https://doi.org/10.1378/chest.12-0685
3 https://www.thecardiologyadvisor.com/home/decision-support-in-medicine/cardiology/the-6-minute-walk-test/
4 Herridge, M., Tansey, C., Matte, A., Tomlinson,G., Diaz- Granados, N., Cooper, A. et al (2011) Functional disability 5 years after Acute Respiratory Distress Syndrome New England J. Med. 364(14) p. 1293-1304.
5 https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html
6 Angus, D.C. , Musthafa, A., Clermont, G. ,Griffin. MF., Linde-Zwirble., Dremsizov, T., Pinsky,M. (2001) Quality - adjusted survival in the first year after the acute respiratory distress syndrome. American Journal of Respiratory Critical Care Med. 163 (6) p. 1389 1394.
7 https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30462-4/fulltext
8 https://science.sciencemag.org/content/370/6515/408
9 https://www.medscape.com/viewarticle/938317_print
10 https://www.medscape.com/viewarticle/938317_print
11 McPeake, J., Mikkelsen,M., Quasim, T. et al (2019) Return to employment after critical illness and its association with psychosocial outcomes Ann Am Thorac Soc. 16 (10) p.1304-1311
12 Riddersholm,S., Christenson,S., Kragholm, K., Christiansen, C., Rasmussen, B. (2018) Organ support therapy in the Intensive Care Unit and return to work: A nationwide, register –based cohort study. Intensive Care Med 44 p. 418-427. DOI: 10.1007/s00134- 018-5157-1
13 https://www.who.int/news/item/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable- diseases
14 https://mhealthintelligence.com/news/boston-ny-hospitals-collaborate-on-telehealth-platform-for-covid-19-rehab
