Health Risks

Improved survivability after severe traumatic brain injury

There is considerable debate in the media over the consequences of severe traumatic brain injury following former F1 champion Michael Schumacher’s recent skiing accident. Medical advances have improved both survivability from this type of injury and insurability for patients.


Traumatic brain injury (TBI) is defined as an injury resulting from a violent trauma to the brain. The most common causes are road traffic accidents followed by falls, sports accidents, and assault. Brain trauma can be caused by a focal impact upon the head, by a sudden acceleration and deceleration of the head or by a complex combination of both movement and impact. In addition to the damage caused at the moment of injury, secondary injury to the brain can be caused by alterations in cerebral blood flow and increased pressure within the skull. This secondary damage occurs in the first hours or days after the initial injury and contributes substantially to the resulting brain damage. TBI can cause a number of neurological, cognitive, social, and behavioural problems, and outcome can range from complete recovery to permanent disability or death. TBI must be distinguished from non-traumatic brain injuries, such as a stroke. TBI is a one-time event whereas a stroke is often the result of a longer-term disease process.

Long-term follow-up studies

Severe TBI is a life-threatening event with mortality rates of over 30% within the first six months. However, modern intensive care medicine and advances in neurosurgery have increased the chances of surviving even severe TBI. This has in turn resulted in more focus being placed on the question of long-time survival prognosis. Data gathered over the last 20 years on survival after moderate to severe TBI has also grown thanks to long-term follow-up studies of TBI survivors. It shows that two factors are central to both survival and recovery: age and functional disability. For those at the severe end of the spectrum, who required 24-hour nursing care, the estimated median survival time for a 40 year old male was only 13.4 additional years. For those with minimal disability and being mainly independent, the estimated survival curve was only slightly worse than that of typical 40-year-old men in the general population. These studies have also revealed that those survivors who did not require assistance had a significantly better chance of survival compared to those requiring mechanical aid or assistance.

Insurability thanks to MIRA

MIRA – Munich Re’s underwriting manual – provides support for underwriters dealing with applicants suffering from TBI. The applicant’s functional status should be carefully assessed, as this is the main prognostic parameter. This includes any neurological deficit, functional disability, respiratory problems or mental disorders. Applicants who after three years remain free of any conditions attributable to severe TBI can in very favourable cases be accepted even at standard rates. The same applies to all disability cover. However, long-term complications, especially sensory, behavioural and cognitive problems, may slowly develop years after the initial injury. Consequently, individuals who have both survived and fully recovered from severe TBI can be accepted for disability products. However, weighting needs to be applied to cover the risk for long-term complications.

More survivors with a higher instance of increased functional disability

For the assessment of sports and pastime risks, Michael Schumacher’s tragic accident teaches us that no one is immune against the dangers of (extreme) sports. Thanks to modern emergency medicine, intensive care and the widespread adoption of protective equipment (skiing helmets, etc.), the chances of surviving a severe head trauma have improved significantly. However, these advancements have also had the result that hospitals are releasing more and more patients with severe and, in some cases, irreparable functional impairments. For insurers, this means that the number of disability claims will continue to climb. What's more, depending on the extent of injury involved, such cases can prove to be highly complex when it comes to evaluating them in terms of insurance medicine.