Our eighth edition of the Dread Disease Survey examined the experiences in China, Hong Kong, Malaysia, and Singapore for the period of 2015‑2019. Due to the global pandemic, we have just concluded the study with publishing our report for the Hong Kong, Malaysia, and Singapore markets; the report for China is underway. For more information than is presented here about our eighth survey, please visit Gen Re’s website for infographics of each market and our blog series on specific diseases.

Participation

With Critical Illness (CI) being a top-selling product in many regions in Asia, we were able to study a record high of about 12.4 million policies in‑force and close to 140,000 claims from 24 participating companies across the three markets.

Key Findings

Product – Age of Customers

The majority of new business remains with the key age range of 20 to 49, accounting for over 60% share in all three markets. As we explore how best to reach out to Gen Z, it is worth noting that the Singapore market has increased the share of new business from young adults (ages 20‑29), while the Hong Kong market has been successful in selling to parents of young children (ages 0‑9).

Figure 1 – Distribution of New Business Policies by Age Group

Product – Sum Assured

There has been a significant increase in the average sum assured (SA) for both Hong Kong and Singapore during this study period. The average SA for Malaysia has also been steadily increasing after a long period of remaining stable. This is a good sign that consumers are becoming more aware of the importance of adequate insurance coverage for CI, hopefully helping to close parts of the protection gap. By the end of the study period, average SA for the three markets had risen to USD 113,014 (Hong Kong), USD 90,982 (Singapore) and USD 19,663 (Malaysia) respectively.

Figure 2 – Average Sum Assured (in USD) by Issue Year

Product – Number of Diseases Covered

In recent years, we have seen many CI products in Asia competing based on the number of diseases covered. The figure below shows that Hong Kong and Singapore markets have quickly ramped up the number of diseases covered in their CI products, while in Malaysia, most policies still cover fewer than 50 diseases. While it is important to be innovative and offer comprehensive coverage to insureds, it is questionable whether there is true value in piling up additional diseases to CI products. As mentioned in my previous blog “Critical Illness in Asia – Product Evolution and its Implications”, only 5% of conditions covered had a significant number of claims during this study period.

Figure 3 – Number of Diseases Covered (by Policy Count) by Issue Year

Claims – Top Causes for Major Claims

Cancer continues to be the most significant cause of claims in all three markets, although the relative importance differs between markets and genders. Cancer, together with heart diseases and stroke, constitute the “Big 3” and represent the bulk of claims, accounting for at least 70% (Males, Malaysia) to over 90% (Females, Hong Kong and Singapore) of all claims. This reiterates the point that adding more diseases to CI products may not necessarily provide more value.

Figure 4 – Top Claim Causes for Major Disease and Death

Claims – Top Causes for Minor Claims

As we progress in offering coverage for minor diseases in our CI product suite, we have started to accumulate enough claims from minor diseases to provide some early insights into the incidence rates. Angioplasty was a dominant cause of claim for males in Hong Kong. While the incidence of angioplasty was particularly high for males in Hong Kong, we also observed a corresponding lower incidence of heart attack and coronary artery bypass graft. Another observation was the rising number of claims for autism in males of Hong Kong, an area that we need to continue to monitor closely.

Figure 5 – Top Claim Causes for Minor Disease

Experience – Overall

Unfortunately, this survey revealed a deterioration in CI experiences across all three markets compared to our last survey. From a longer-term perspective, females in Hong Kong and Malaysia experienced the most deterioration.

Figure 6 – Claims Index Ratio¹ by Calendar Year and Market – Male

Figure 7 – Claims Index Ratio by Calendar Year and Market – Female

Experience – Trend by Cancer Sites

As we accumulate more and more data from various cancer sites from our surveys started in the 90s, we are able to capture deteriorating, stable, and improving trends of different cancer sites. We hope this will provide the industry with information on emerging risk areas to better manage our CI portfolios.

Figure 8 – Overview of Trend by Cancer Sites

Experience – Highlight from the Hong Kong Market

One area where we observed rapid deterioration in this survey for the Hong Kong market was thyroid cancer. This is partly due to the significant difference in incidence rates between Hong Kong residents and the Mainland Chinese Visitors (MCV) purchasing insurance policies from Hong Kong. Incidence rates of MCV were three to four times higher than Hong Kong residents in this survey.

Figure 9 – Age-Standardized Thyroid Cancer Incidence Rates (per 1,000) by Year – Hong Kong

Most thyroid cancers were of the common type, papillary thyroid carcinoma, which is localized, highly treatable, develops more slowly than other types of cancer, and has a 5‑year relative survival rate of over 99.5% according to the American Cancer Society.²

Experience – Highlight from the Singapore Market

Prostate cancer is a prevalent cancer worldwide, with the peak rate of diagnosis occurring in the 75 to 79 age group according to Cancer Research UK³. We are seeing an upward trend in the Age-Standardized Incidence Rate⁴ (ASIR) of prostate cancer across all three markets, with the highest incidence rate in Singapore.

Figure 10 – Age-Standardized Prostate Cancer Incidence Rates (per 1,000) by Year and Market – Male

In regions where prostate cancer screening is becoming more common, it is likely that we will see more prostate cancer claims, especially from policies that have not excluded T1c tumors. T1 is a stage where the tumor is too small to be seen on a scan or felt during a physical examination. It is further divided into T1a, T1b, and T1c, where T1c is defined as a tumor found during a needle biopsy performed due to an elevated PSA level. Therefore, it is not surprising that within T1, most cases currently came from T1c.

Figure 11 – Proportion of Prostate Cancer by Size of Cancer Tumor (T1a and T1b Against All of T1 – T1abc)

Note: US SEER Data for Asian 2004‑2015

With the bulk of our claims coming from ages 40 to 59, and as our CI portfolio matures, we will likely see more prostate cancer claims in the future.

Experience – Highlight from the Malaysia Market

Although accidental death is not an intentional CI coverage, as many CI products provide a death benefit as well, it is a cause of claim that we have been monitoring. We found that Malaysia has the highest accidental death rate among the three different markets in our survey, indicating that Malaysia potentially lags behind Hong Kong and Singapore in road and occupational safety.

Figure 12 – Age-Standardized Accidental Death Incidence Rates (per 1,000) by Duration and Market

Final Remarks

I hope you find our Dread Disease Survey report informative and insightful. As we gather more data and longer trends, we have been able to capture new insights into the prevalence, incidence, and impact of Critical Illness. Should you be interested in any aspect of this survey, do contact us, and we would be happy to discuss any questions or concerns you may have. Also, please contact us if you would like to participate in our next survey or would like Gen Re to conduct the survey for a new market.

Lastly, I would like to once again thank the survey participants for their invaluable contribution in preparing, checking, and submitting data. Without them, it would not have been possible to gain these insights for the industry.

Endnotes

1. The Claims Index Ratio was built using a similar concept of an A/E methodology commonly used in actuarial analysis. The expected (E) refers to the graduated rates (ix - kxqx + qx) that were derived from our 2000‑2004 survey based on the combined results of Hong Kong, Malaysia, and Singapore. This gives us a consistent basis for comparison from survey to survey and from market to market.
2. American Cancer Society, https://www.cancer.org/cancer/types/thyroid-cancer/detection-diagnosis-staging/survival-rates.html
3. Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/incidence
4. The Age-Standardized Incidence Rate (ASIR) was a direct standardization on a reference population that was derived since our 2000‑2004 survey. Such a method can be commonly seen in epidemiology studies, and we will be using two different sets of reference population to ensure consistency with previous surveys:
   1. Ages 20 to 59 (for comparison of duration)
   2. Ages 20 to 64 (for comparison of trend)