Case Clinic: Chronic Lymphocytic Leukemia

Case Clinic:
Chronic Lymphocytic Leukemia

Munich Re’s medical experts respond to challenging underwriting scenarios

4.5 minutes read

Published 07/11/2025

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This series presents individual medical cases that feature challenging conditions, uncommon diseases, or an unusual presentation of symptoms. Below, we summarize a case, explain our research and analysis, and suggest an underwriting recommendation. Munich Re’s team of global medical directors continually tracks medical research so that primary insurers may benefit from evidence-informed risk assessments. It is our hope that analyses of more challenging cases will foster a greater awareness of medical progress and will help to expand insurability.

Case: Chronic Lymphocytic Leukemia

The Munich Re medical team investigated the insurability of a 71-year-old male applicant who, on routine examination 18 months earlier, was found to have an elevated white blood count (WBC) of 18,300 (normal = 3,800-10,500). The WBC differential showed 79% lymphocytes for an absolute lymphocyte count of 14,800 (normal = 1,000-4,000), and the complete blood count (CBC) was otherwise normal. Blood chemistries, including liver function tests and gamma globulin levels, were also well within normal ranges. He denied having any symptoms and his examination at that time was completely normal.

A hematologist evaluation was obtained, and additional testing with a blood peripheral smear and immunophenotypic analysis by flow cytometry demonstrated findings consistent with chronic lymphocytic leukemia (CLL). Molecular cytogenetics testing was subsequently obtained and demonstrated fluorescence in situ hybridization (FISH) positive for deletion 13q, and negative for deletion 11q, deletion 17p, and trisomy 12. Gene mutational status was positive for mutated immunoglobulin heavy chain variable region (IGHV) genes and negative for TP53. The beta-2-microglobulin was normal at 1.2, as was an LDH of 204.

No plans were made for any treatment, and he was advised to receive follow-up in three months.

Since then, the applicant has been seen every three to six months and has been without reported symptoms or exam findings. His WBC was 19,400 at the three-month follow-up and has gradually increased thereafter to 24,600 two months before applying for insurance. The subsequent absolute lymphocyte counts were: 15,400; 16,800; 17,200; 18,500; and, most recently, 19,300. The CBC results have otherwise remained normal, and there has been no treatment given or additional testing advised.

The team asked, “What is the appropriate management for this condition? Is he insurable?”

Munich Re medical's response

What is Chronic Lymphocytic Leukemia?

Chronic lymphocytic leukemia (CLL) is a mature B cell neoplasm characterized by a progressive accumulation of monoclonal B lуmрhοсуteѕ. It is the same disease as small lymphocytic lymphoma (SLL), which is diagnosed when the monoclonal lymphocytes accumulate in lymph nodes.
CLL/SLL is the most common leukemia in North America and is mainly a disease of older adults (median age at diagnosis is ~70).
Genetic factors play some role in the cause; unlike other forms of leukemia, there are no clear occupational or environmental risk factors.
CLL/SLL presents most often in an asymptomatic individual with lymphocytosis found on a routine CBC or at times as painless lymphadenopathy.
More advanced cases may present with splenomegaly, symptomatic lymphadenopathy, “B” symptoms like night sweats, fatigue, or weight loss, or as consequences of cytopenias such as anemia, recurrent infections, or bleeding. These are important components of the clinical staging of CLL (Rai and Binet staging).
The diagnosis is based on a persistent absolute B lymphocyte blood count >5,000 and clonality of the B cells confirmed on flow cytometry.

Is the management in this case appropriate, given a diagnosis of leukemia?

The natural history of CLL is quite variable, but since it is often an indolent condition, and given the lack of symptoms or cytopenias in this situation, close observation alone is recommended.
Therapy is generally reserved for patients with advanced features as indicated above, or if there is rapidly progressing disease (e.g., when the lymphocyte doubling time is less than six months).
Unlike other types of leukemia, there is no indication for bone marrow biopsy in most cases.

What is the significance of the cytogenetics results?

In addition to the clinical staging of CLL/SLL and the lymphocyte doubling time, genomic markers are also important prognostic factors and have become a standard part of CLL management.
Although often an indolent disease, CLL can at times progress rapidly or transform into a high-grade malignancy (Richter transformation), and the risk of this occurring depends heavily on these cytogenetic results.
In addition, these markers are important predictors of response to treatment and useful in determining therapy selection when indicated.

Final recommendation

Given that the applicant has remained asymptomatic and without evidence of advanced disease, and that the lymphocyte count is only slowly rising, Munich Re’s medical team agreed that observation alone is appropriate management. He has no adverse cytogenetic or gene mutation findings and, in fact, the common 13q deletion and the positive IGHV mutation are both favorable predictive and prognostic factors. At this age in particular, it was determined that there was only a small amount of excess mortality risk and that, for most insurers, this would fit within a standard rate classification.

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