Sport-related traumatic injuries:
Impacts on critical illness underwriting & claims
Sport-related head injuries linked to early neurodegenerative disease (NDD) have gained significant media attention in recent years. This is driven by the growing recognition of the issue and a lawsuit in which former rugby professionals are suing governing bodies for negligence, echoing similar cases in the NFL in the US. In this article, Paul Edwards, Underwriting Research & Systems Development Manager and Jennifer Catterill, Deputy Claims Manager and Claims Specialist at the Hannover Re UK Life Branch explore the unique challenges of diagnosis and assessing traumatic brain injuries and chronic traumatic encephalopathy (CTE), and how evolving medical insights may shape the industry’s approach to underwriting and claims.
Traumatic brain injury:
Traumatic brain injury is a major risk factor for neurodegenerative diseases (NDD), accounting for approximately 3% of dementia cases in the general population.[1] Full recovery from traumatic brain injury is not universal with 53% of individuals reporting persistent symptoms 12 months post-injury.[2]
Chronic traumatic encephalopathy (CTE):
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disorder associated with repetitive head trauma. Initially identified in boxers in the 1940s, CTE has since been linked to contact sports like football and rugby, where frequent head injuries contribute to neurodegenerative disease. It is characterised by the pathological accumulation of hyperphosphorylated tau protein (p-Tau), resulting in neurofibrillary tangles (NFTs), which differ from those in Alzheimer’s disease due to the lack of amyloid deposition.
A 2023 study of 152 young contact sport athletes revealed that at least 41.4% showed signs of mild CTE, emphasising the risk even in amateur sports.[3]
Another recent study from 2022 examined the findings of a retrospective cohort study involving 412 Scottish rugby internationals compared to 1,236 peers from the general population. The study revealed that neurodegeneration rates were higher in the rugby group, with 11.4% of former rugby players and 5.4% of the comparison group diagnosed with incident neurodegenerative disease (HR 2.67, 95% CI 1.67 to 4.27, p<0.001). These results enhance an understanding of the connection between participation in contact sports and the increased risk of neurodegenerative disease.[4]
CTE claims and traumatic head injury definitions:
As the industry navigates the complexities of claims and underwriting related to traumatic brain injury and CTE, it's essential to consider the relevance of this subject matter to the work carried out by claims teams. Claims related to CTE are beginning to emerge, highlighting the importance of understanding the broader implications for the life & health industry.
Currently, CTE is not explicitly defined within critical illness (CI) policies. Claims have been submitted under both the Dementia and Traumatic Head Injury definitions. As the index event, however, it stands to reason that Traumatic Head Injury is the definition most readily claimed against.
Read the CI definition for Traumatic Head Injury here.
There are several key requirements to validate a Traumatic Head Injury claim: evidence of the death of brain tissue, either through physical damage to the brain tissue itself or as a result of the interruption of the oxygen-rich blood supply the brain needs to survive. Although not explicitly detailed in the majority of definitions, our industry also requires death of brain tissue to be radiologically confirmed. Lastly, the traumatic injury must result in a permanent neurological deficit (symptoms of dysfunction in an individual’s nervous system which must be expected to persist for the duration of the individual’s life, irrespective of when cover ends or the insured person retires.)
CTE is however, not solely an issue relating to the Traumatic Head Injury definition; it is intertwined with several other neurological critical illness conditions, including Dementia, Parkinson’s Disease and Motor Neurone Disease, all of which are associated with the abnormal buildup of proteins in the brain, commonly as a result of traumatic impact. Learnings and considerations must extend to underwriting practices, risk management strategies, and our overall claims philosophy, particularly in light of regulatory expectations.
Diagnosing & assessing Traumatic Head Injury claims:
It is now understood that the classifications of mild, moderate and severe traumatic brain injuries are often unhelpful. Mild traumatic brain injury is not mild for many individuals, with studies suggesting some 50% of sufferers remain symptomatic a year on from their injury.
The standard of NHS follow-up care can often present challenges to patients. The vast majority of head injuries also do not lead to hospital admission, and many individuals with head injuries do not seek medical attention. Expected side effects such as headache, dizziness, visual disturbances, mood disturbance and cognitive changes are commonly vague, unspecific in nature and not always easily treatable, especially if intertwined with symptoms of a psychiatric nature. Evaluating the permanence of symptoms associated with traumatic brain injuries, and allowing sufficient reasonable time for them to be described as permanent is challenging, often requiring 12 to 18 months to evaluate. Such prolonged assessment periods can lead to consumer frustration, contentious claims, and an increased potential for complaints.
Additionally, the exclusion of psychiatric trauma in the Association of British Insurer’s (ABI’s) definition of permanent neurological deficit presents another challenge. Such deficits could arise from brain tissue damage or psychological factors, which may stem from the injury, be present before the injury or be exacerbated by it. For example, PTSD is common after any traumatic injury, and people with traumatic brain injury experience depression and suicide rates that are double those of the general population.[6]
The complexity of traumatic brain injury extends to the potential long-term effects on brain health. Current theories suggest that even mild traumatic brain injury disrupts essential brain networks and neuronal pathways, especially the axonal pathways, which are the circuitry of the brain and make up most of the white matter of the brain. Axonal damage is commonly not visible on standard imaging however, it is thought that traumatic impacts on the brain set about a catastrophic accumulation of abnormal proteins in the brain, such as Tau and Amyloid, which are responsible for such conditions as CTE and Alzheimer’s.
Traumatic brain injury sufferers are also at a heightened risk for developing mental disorders, including a 2-3 times increased risk of suicide.[6]
Microhaemorrhaging is also a significant concern in traumatic brain injury. The cortical and subcortical layers of the brain are vulnerable to microhaemorrhages - small bleeds that may not be immediately visible but indicate underlying damage. Tests showing iron in the cerebrospinal fluid (CSF) can suggest red blood cell loss, often indicative of haemorrhage in the brain, as the breakdown of red blood cells releases iron into the CSF. Imaging limitations significantly add to the challenges of defining and diagnosing traumatic brain injuries, and correspondingly our assessment of Traumatic Head Injury claims. Standard CT and magnetic resonance imaging (MRI) scans often fail to detect the more subtle brain tissue damage which occurs in traumatic head injury due to limited resolution, potentially leading to misdiagnoses. Conventional imaging techniques typically visualise structures down to about 0.2 mm, while axons are just 1/1000th of a mm. How can we therefore, expect a claimant to evidence something that medical science does not allow them to?
Advanced imaging techniques like Diffuse Tensor Imaging (DTI) and functional MRI (fMRI) are suggested as a potential emerging tool for traumatic brain injury diagnosis, prognosis and treatment. DTI shows how water diffuses through the brain and is currently able to visualise 77 neural pathways and deviations from expected diffusion patterns. It remains unclear, however, whether these abnormalities represent physical brain damage or altered brain function. The imaging is also not currently available in clinical practice and is solely used in research fields and universities. fMRI, which monitors brain activity over time, revealing changes in blood flow that indicate shifts in brain function post-injury also faces challenges in standardising results across different settings.
Of note, rugby union players involved in the class action suit are typically having DTI scans and this is being provided in support of their claim, with the suggestion of ‘clear’ evidence of brain damage, but as noted above, little is currently understood about this imaging modality. If we do go on to accept DTI as evidence of death of brain tissue, this would create a two-tier claims environment, where some policyholders with access to advanced imaging have their claims validated while others relying only on traditional imaging, do not – raising issues of fairness and consistency in claims processing.
Looking ahead, the field of traumatic brain injuries is evolving, particularly with conditions like CTE gaining attention amid rising litigation. The interconnectedness of various neurological conditions, such as Parkinson’s, Alzheimer’s, and Motor Neuron Disease (MND), further increases our risk and exposure in this field. From an underwriting and claims perspective, the litigation findings will impact processes with more and more people joining this litigation piece.
Underwriting, misrepresentation & policy definition considerations:
It's also essential to reassess underwriting processes and rules engines to consider whether to include disclosures around concussions and both past professional and amateur sports participation as well as how to handle these disclosures ethically and responsibly. Application forms tend to currently focus only on current professional sports participation, not former professional sports or amateur contact sports. This gap results in limited insight into the true risk profile of customers, many of whom may have been involved in contact sports from childhood into middle age and beyond, experiencing multiple concussive impacts - yet, the associated risks remain unrecognised. Similarly, while application forms often ask about "blackouts," applicants commonly interpret this as a sudden, unexpected loss of consciousness. To capture concussion history, it is imperative to specifically ask about this.
However, if better disclosure is drawn out from applicants, how should this risk be underwritten? Should all neurodegenerative critical illnesses be excluded, and would this approach sufficiently cover the risk? More importantly, is this an ethical approach?
Misrepresentation considerations are also involved in the context of Traumatic Head Injury claims. Traumatic brain injury patients often experience longstanding, non-specific symptoms, making it essential to determine the point at which they became aware of symptoms as such. Blanket statements made in hindsight risk inaccuracy, highlighting the importance of multiple evidence sources, including medical records and personal assessments, to support a thorough evaluation.
Another key consideration is whether to exclude sport-related injuries and CTE from coverage. This brings forward ethical questions about coverage limitations: should coverage be restricted to single, isolated traumatic events or continue to allow the inclusion of progressive injuries caused by repeated trauma? Furthermore, should injuries sustained before the policy’s inception be excluded—although some Financial Ombudsman Service (FOS) evidence suggests caution here.
Additionally, we must recognise that CTE can result from non-sports-related factors, such as poorly controlled epilepsy or other repetitive head trauma. Defining "death of brain tissue" is a critical step, particularly as diagnostic technologies evolve. A key question is whether it can be inferred from other types of evidence or if we continue to require radiological proof and proceed to accept new forms of imaging such as DTI. Future definitions may also consider incorporating new technologies including magnetoencephalography, which is suggested to show abnormal brain wave activity as a result of brain damage, and also biochemical markers specific to traumatic head injury (akin to troponins for myocardial infarction) to enhance precision in identifying and validating injury severity.
The evolving understanding of traumatic brain injury’s long-term effects, along with the complexities surrounding its detection and diagnosis, calls for our industry to proactively rather than reactively update its underwriting and claims approach to these applicants and these claims.
Jennifer Catterill
Deputy Claims Manager & Claims Specialist
Tel. +44 20 3206 1700
jennifer.catterill@hannover-re.com
Paul Edwards
Underwriting Research & Systems Development Manager
Tel. +44 7584 529136
paul.edwards@hannover-re.com
References
Header video: Gorodenkoff.stock.adobe.com
[1] Livingston, Gill et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission The Lancet, July 2024, Volume 404, Issue 10452, 572 - 628
[2] Nelson, L. Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study. JAMA neurology. https://doi.org/10.1001/jamaneurol.2019.1313.
[3] McKee AC, Mez J, Abdolmohammadi B, et al. Neuropathologic and Clinical Findings in Young Contact Sport Athletes Exposed to Repetitive Head Impacts. JAMA Neurol. 2023;80(10):1037–1050. doi:10.1001/jamaneurol.2023.2907
[4] Russell ER, Mackay DF, Lyall D, Stewart K, MacLean JA, Robson J, Pell JP, Stewart W. Neurodegenerative disease risk among former international rugby union players. J Neurol Neurosurg Psychiatry. 2022 Dec;93(12):1262-1268. doi:10.1136/jnnp-2022-329675. Epub 2022 Oct 4. PMID: 36195436; PMCID: PMC9669247.
[5] Medical Research Council, Traumatic Brain Injury across the life course: priorities, challenges, and opportunities, Workshop report – 15th June 2022. https://www.ukri.org/wp-content/uploads/2022/12/MRC-07122022-MRC-Traumatic-Brain-Injury-Workshop-report_June-2022.pdf Accessed 6-1-25
Image: Connect Images.stock.adobe.com
[6] Howlett JR, Nelson LD, Stein MB. Mental Health Consequences of Traumatic Brain Injury. Biol Psychiatry. 2022 Mar 1;91(5):413-420. doi: 10.1016/j.biopsych.2021.09.024. Epub 2021 Oct 2. PMID: 34893317; PMCID: PMC8849136.
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