Naturopathic Medicine: Flags in Insurance Underwriting
MSc., FLMI, ND/PhD (cand.)
In 2003, more than 5 million Canadians age 12 or older used alternative healthcare (Statistics Canada 2003). In the United States, approximately 38% of adults (about 4 in 10) and 12% percent of children (about 1 in 9) are using some form of complementary and alternative medicine, including naturopathy (NIH 2007). This has immense implications for risk assessment in underwriting.
What strategy would an underwriter employ if an individual disclosed the use of a high dose essential fatty acid as opposed to St. John’s Wort? St. John’s Wort (also known as Hypericum perforatum) is often utilized for depression and other psychiatric diagnoses, whereas a high dose essential fatty acid could be used for daily supplementation or cardiac care post-myocardial infarction.
The array of implications of alternative care provides immense food for thought. Trends in alternative care and naturopathy must be noted and carefully taken into context when underwriting for medical risk.
Naturopathy is a rapidly growing field of medicine that focuses on the identification of the root cause of disease. It utilizes several modalities including but not limited to traditional Chinese medicine (also referred to as TCM, it includes acupuncture, traditional Chinese herbs and tongue/pulse diagnostic patterns to assess pathology), homeopathy, physical medicine, botanical medicine and nutritional medicine. The scope of practice ranges from acute ailments to minor surgery.
In Canada, naturopathic practitioners are licensed after completing a four-year set of postgraduate training modules including clinic hours, extracurricular requirements and regulated board examinations. Regulated jurisdictions in North America include British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia and a growing number of states in the United States (CAND 2011).
Naturopathy is built on six key principles that embody the type of therapeutic approach used. The six tenets of naturopathic medicine are: doing no harm, treating the whole person, utilizing the healing power of nature, educating and encouraging self-responsibility for health, finding the true cause of disease and utilizing prevention as part of health promotion (Kaur 2006).
These principles are relevant to us because they demonstrate the following: a) that naturopathic practitioners are thorough and very detailed in their differential diagnosis, and b) that patients who usually seek naturopathic care are generally well informed about their health and willing to make positive changes in life.
It should be noted that patients may seek naturopathic care in several sequences: a) the patient who wishes to go the “natural” route before trying conventional medication, b) the patient who wishes to supplement with naturopathic therapies in addition to conventional (sometimes referred to as allopathic medicine and loosely defined as a branch that utilizes pharmacological and physiological means to treat or suppress symptoms of pathological disease processes), and c) the patient for whom conventional medication is not working and who wishes to try alternative therapies. These groups of diagnoses include but are not limited to: alterations in mental health, immunological disease, gastrointestinal dysfunctions and cardiac diagnoses.
There are several diseases that are treated by both conventional and alternative means; however, there are several flags, both red and green, that underwriters must consider when evaluating the groups of conditions referred to below.
The question on the application that asks “What other medications or supplements are taken in addition to the ones listed or prescribed” can alert the underwriter to diagnoses that may not be emphasized or disclosed on other parts of the application. We refer to these as red flags.
1. Immunological disease: Several immunopathologies are well controlled by naturopathic therapeutics through approaches that sustain remission or promote regression. These include treatments for Crohn’s disease, ulcerative colitis, celiac disease and diabetes mellitus. Naturopathic doctors employ a variety of strategies to treat these immune conditions, such as nutrition, botanical medicine and TCM.
a) Crohn’s, celiac disease and ulcerative colitis (Pizzorno 2006, Kaur 2006):
- Nutritional approach/supplements: very high dose probiotic strains, L-glutamine
- Botanical medicine: herbs that are demulcents (soothe intestinal irritation), Matricaria recutita, astringents (reduce blood loss), Myrica cerifera and anti-inflammatory Dioscorea villosa
- Things to consider: Naturopaths are very detailed in their documentation and will make notes on gastrointestinal bleeding (color, frequency), bowel movements (color, shape, consistency, frequency) and review diet diaries with their patients.
b) Diabetes mellitus (Martini 2010, Pizzorno 2006, Singh 2008):
- Nutritional approach/supplements: chromium, alpha lipoic acid
- Botanical medicine: herbs that are insulin regulating, such as Momardia charantia and hypoglycemic herbs such as Gymnema sylvestre and Olea Europaea
- Other: hypoallergenic diet (a diet to eliminate foods that enhance inflammation and dysfunctional immune responses)
- Things to consider: Some patients want to try exercise and dietary control before medication, while others use a combination. Naturopaths obtain laboratory test results either from patients’ family MDs or through independent laboratories (HbA1c and microalbumin should be available on these reports).
2. Depression and anxiety (Pizzorno 2006, Singer 2011):
- Nutritional approach/supplements: 5- Hydroxytryptophan, (5-HTP), S- Adenosylmethionine (SAMe)
- Botanical medicine: Herbs that are nervines/hypnotics (central nervous system depressants and nervous system tonics), such as Passiflora incarnata, Valeriana officinalis and St. John’s Wort
- Things to consider: Patients who do not want to go on conventional medications due to the high number of side effects require assessments on the severity of the diagnosis. Naturopaths also use the Beck Depression Inventory and the DSM manual.
3. Gastric and duodenal ulcers (Li 2009, Murray 2002):
- Nutritional approach/supplements: licorice tablets, L-glutamine
- Botanical medicine: herbs such as vulneraries (aid healing of ulcerations), mucus membrane regulator, Hydrastis canadensis
4. Congestive heart failure and post MI, coronary artery disease care (Murray 2002, Kaur 2006, PIzzorno 2006):
- Nutritional approach/supplements: coenzyme Q10, L-carnitine, L-arginine, ultra high dose fish oils
- Botanical medicine: herbs that are cardiotonics or cardioactive drugs, such as Crataegus species, Tillia platyphyllos and Leonurus cardiaca
- Things to consider: Patients will often seek naturopathic (cardiac focused) care after a recent myocardial infarction. Naturopaths will obtain copies of electrocardiograms and other cardiac tests from their family doctors. Although supplements such as Coenzyme Q10 and fish oils are utilized for mild conditions such as hypertension and high cholesterol, respectively, they can also be used to manage more serious cardiac diagnoses.
There are a several indicators of good health when individuals seek naturopathic care. These reasons to seek alternative care are often for preventative purposes and lifestyle improvement. These can therefore be referred to as green flags. They include:
1. Stress and anxiety
- Many patients attempt to do stress-relaxation, visualization and similar types of exercises to avoid anxiety medication. These techniques are often used for mild anxiety and situational stress.
- People often seek naturopathic care to improve their diets and lifestyles before disease occurs. They utilize diet diaries, seek nutritional counselling and obtain the appropriate supplements to prevent disease.
3. Digestive health
- Traditional Chinese Medicine emphasizes a harmony of all organ systems. This harmony begins with proper breathing and good digestion. There are many supplements and acupuncture points used to enhance digestion before any pathology can develop.
4. Sports medicine
- Competitive athletes and others who are athletically inclined seek natural therapies to strengthen muscles and modulate injury. TCM methods and acupuncture are often used instead of pain medication that can lead to dependency.
Many naturopathic therapies are extremely beneficial and benign when utilized in preventative care, as well as for treatment. It is up to an underwriter to determine whether the treatment and/or supplement itself is used for benign or concerning causes. Naturopathic medicine and reports from naturopathic doctors should be used in context with the associated impairment in insurance medicine.
Patients can often self-treat serious disorders in erroneous, even dangerous, ways. Additionally, immunological conditions are difficult to treat. This has been demonstrated by recent trends showing a rapidly growing percentage of the population turning to alternative medicine.
The use of naturopathic therapies should not lead us to assume that an ailment is benign. It should be emphasized that sources of information about alternative therapies from patients or their practitioners are very helpful; however, in the context of insurance, this information may be a double-edged sword. Some therapies could only be used for prevention and could have demonstrated that the person was in superior health, while others could have indicated serious underlying diagnoses. Interestingly enough, both naturopathic doctors and underwriters seek the same end-points: identifying the root cause of disease and assessing the associated risk.
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About the Author
Prior to underwriting and medical writing, Rochelle Fernandes gained experience in naturopathic medicine and clinical research in prostate cancer, as a student at the Canadian College of Naturopathic Medicine and the University of Toronto, respectively (with an interest in immunity, and molecular diagnostics in cancer pathology). Prior to this, she completed her MSc. in Molecular Immunology and Virology at McMaster University with a specialty in allergy and asthma.
Currently, Rochelle is an underwriter at Manulife Financial, Toronto. She has also started a research firm, known as RD Research Consult that specializes in clinical research and integrative journalism. She enjoys exploring new developments in both research and underwriting. She may be reached at Rochelle_Fernandes@Manulife.com