This will be a short post.
There is an ongoing court case about whether a Critical Illness insurance policy should cover a certain newer treatment modality over a more traditional one. The dispute arose because a policyholder (now 45-years old) tried to claim from a critical illness policy she had bought after she suffered a cerebral aneurysm haemorrhage in 2023. She had bought the policy issued by Prudential around 2016 through an approach made by Standard Chartered Bank.
Reference: https://www.channelnewsasia.com/singapore/woman-sues-prudential-payout-stroke-aneurysm-6000751
Prudential is now refusing to make the payout of $100,000 because it claimed it had stated in the policy terms that the policy will only cover haemorrhages treated by open craniotomy (and subsequent coiling) and not by endovascular surgery (ES). The policyholder was travelling on a bus when she had the ruptured aneurysm and was brought by an ambulance to NUH where she was treated by ES. One can surmise that the treatment was rather successful because she is now representing herself in court without hiring lawyers.
As this is an ongoing case, this hobbit will refrain from trying to advocate for a certain outcome over another. However, this hobbit will try to simply state the scientific evidence and historical facts.
This hobbit found out that the first cerebral endovascular surgery (i.e. coiling) procedure was performed in Singapore in a public restructured hospital in 1996. Not all hospitals in Singapore offer endovascular surgery services even now, but for those who do, endovascular surgery is offered as an option for suitable patients. This hobbit is told that if it is not offered as an option in patients who are suitable, one may even run the risk of being medically negligent. As mentioned in a previous post, about 80% to 90% of such haemorrhages are treated by ES nowadays in public hospitals that offer such a service.
The first ES procedure or coiling was performed in the US in 1990 and then in Europe in 1992.
It is true that ES procedures may often cost more than open craniotomy and clipping. But since this is a critical illness policy with a fixed payout to the policyholder, the costs of treatment do not matter to the insurance company.
The case for ES as a viable option to the traditional craniotomy arose from the results published in a landmark trial in 2002. It is commonly called the ISAT trial. The full reference for this paper is:
Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. The Lancet. 2002 Oct 26; 360(9342): 1267–1274. DOI: 10.1016/S0140-6736(02)11314-6 PMID: 12414200
That this paper is truly landmark if not monumental is given by the fact that it has garnered an astonishing 3,382 citations so far.
As a result of this paper, many more follow-up papers were published, which more or less supported the adopting of ES as a viable alternative to craniotomy and clipping.
The American Stroke Association (ASA) and American Heart Association (AHA) Aneurysmal Subarachnoid Haemorrhage (aSAH) Guidelines evolved over the years to reflect this.
These Guidelines formally recognized ES coiling as the equivalent alternative to craniotomy and clipping in 2009. In the 2012 edition, the recommendation was strengthened to “preferred” alternative (Class IB evidence). In 2023, it was upgraded that ES is “recommended” over clipping under the correct circumstances.
While these American Guidelines do not regulate how doctors in Singapore practice, Singapore doctors generally follow them as the recommended standard of care. Indeed, methinks should a case of medical negligence lawsuit take place in Singapore, if a doctor can show he has followed these guidelines appropriately, then there is a good chance he will not be found to be negligent.
Of course, ES is not without any downside. It shows a higher chance of needing retreatment and a slightly higher long-term chance of rebleed. But generally, it offers better survival and risk reduction over craniotomy coiling. The ISAT trial showed a 6.9% in absolute risk reduction in deaths at one year. Many further studies have strengthened the advantages of ES over coiling over the years.
The court case will eventually be judged by how the facts of the case turn, which includes not just scientific evidence but contractual terms as well. Nonetheless, a summary of the timeline is provided here for easy reference:
| Year | Event |
| 1990 | First Endovascular Surgery (ES) coiling done in USA |
| 1992 | First ES Coiling done in Europe |
| 1996 | First ES Coiling done in Singapore |
| 2002 | ISAT Trial is published in Lancet |
| 2009 | AHA/ASA aSAH Guidelines recognizes ES as equivalent alternative to coiling |
| 2012 | AHA/ASA aSAH Guidelines upgrades ES as preferred alternative |
| 2016 | Critical Illness Policy sold |
| 2023 | Policyholder suffered stroke and received ES treatment at NUH. Claim denied. AHA/aSAH Guidelines further upgrades ES as recommended alternative |
Interesting factoid: some of the information found in this post was provided by an interventional radiologist who does ES procedures for a living. He must have saved many lives with ES. He has since found out that he has bought the same Prudential Critical Illness Policy with the same exclusion clause.
Please note: No CME awarded for reading this post 😊
hobbitsma 