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Robert Goldstone

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MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021. Goldstone can be reached by ­telephone at 949-943-2310. Emaill: [email protected].

Liver Function Testing: How Significant Of A Problem?

Insurance blood testing inevitably contains liver function testing, and just as inevitably will reveal abnormalities out of the normal range. In fact one in five or six sets of tests may show values above normal. Sometimes the results are abnormal enough to spur further testing and reveal significant health problems. Other times they have little if any mortality significance or may already be accounted for in an insured’s list of health conditions. Identifying which conditions have at most mild consequences in evaluating mortality help insurers separate uninsurable or highly rated risks from those which can be often taken as applied for.

Liver chemistry tests include alanine transaminase (ALT) and aspartate transaminase (AST). They may also be known as SGOT and SGPT respectively. Not every lab references the same normal range for these tests—some use 30 U/L, other use 45 U/L. It’s important to look at the reference ranges provided for each test to see what values fall into each’s lab normal range. The American College of Gastroenterology segregates rise in LFTs (liver function tests) as mild, moderate and severe. Less than two times the normal range classifies as mild, while 10-15 times normal is severe. Mild increases can be associated with severe disease, so putting a picture together of overall health is essential. But mild increases can also be classified as standard medical risks, and those are the ones that are most insurable.

The most common cause of mildly elevated liver function testing is metabolic dysfunction, sometimes known as fatty liver disease. These are most typically represented by mild (or normal) AST levels and elevated ALT levels. Overweight individuals, those with Type 2 diabetes and those with metabolic syndrome most fit this profile. Physicians rarely work these cases up in clinical practice unless the values are significantly abnormal, and ultrasound and the use of fibrosis scores are the most common further testing that is used. Those whose build or diabetes control is already factored into a mortality assessment don’t need additional ratings for these testing elevations. Loss of weight, better diabetes control, exercise and medication are the usual treatments, and good risk factor control more often than not mitigates any risk represented by small LFT elevation.

An opposite pattern occurs in a condition that represents more serious overall mortality—alcohol induced liver disease. Alcohol excess isn’t often admitted by a client, and even an APS may underestimate the problem when the doctor relies on the patient’s self-reporting of alcohol use. In these situations, the opposite ratio is exposed—AST is higher than ALT, usually in a ratio of 2:1 or more. Other associated lab testing increases the suspicion of alcohol over-use—A GGTP is often elevated, HDL is higher than would be expected and certain parameters on a CBC may be suspicious. Insurers now routinely get CDT (carbohydrate deficient transferrin) as reflex testing when LFTs are elevated or fit this pattern, and this test has been shown to be quite specific for alcohol abuse. It’s a difficult situation when an agent or broker tries to broach alcohol as a cause for rating or decline with a client in denial, but the testing usually speaks for itself. Cessation of alcohol usually returns all testing to normal unless the abuse has been chronic over years and is causing liver injury.

Chronic hepatitis (both B and C) are notable causes for liver function abnormalities, hepatitis C now overtaking hepatitis B in frequency in part because of the hepatitis B vaccine now required of school age children. Often considered uninsurable years ago (especially hepatitis C), antiviral treatment has helped to arrest the virus and liver function is preserved in many under treatment. Insurers may screen for hepatitis B and C as a reflex test when certain parameters are met, but in those under treatment whose current viral loads are absent and under treatment mild LFT abnormalities may persist. These are accounted for and a good percentage are insurable at standard or close to standard rates.

There are many other causes for mild liver function abnormalities, including thyroid disease, Wilson’s disease, autoimmune hepatitis and other viral infections. Two others are worth discussion: Hemochromatosis and drug induced liver abnormalities. Hereditary hemochromatosis is a condition where there is hepcidin deficiency, resulting in iron overload in the liver. Further testing illustrates the condition, and treatment by phlebotomy keeps the condition in check. Drug induced liver function abnormalities is also a restively common cause of an increase in LFTs. This is not so much drugs of abuse but often commonly ones used for other medical conditions, such as atorvastatin (Lipitor) or other statin drugs used to lower cholesterol. Stains are metabolized in the liver and the ALT elevations are thought to be the result of a toxic intermediate of drug metabolism. Stopping the medication reverses the test abnormality, but many doctors will choose to continue the statin if the LFT elevations are mild, and the medication has a beneficial effect on cholesterol as a risk factor. These elevations are minor and generally don’t figure into any kind of rating once the cause is identified.

Elevations in liver function testing are in a large majority of applicants unknown to anyone (even their primary care physician) and asymptomatic, resulting in an unwelcome surprise in risk evaluations. Mild elevations with a known cause however are very often no cause for alarm and can result in standard or as applied for insurance applications.

Managing Client Expectations: The Medical Side

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Successful business transactions require a high degree of satisfaction on the part of the client. The results don’t always have to be perfect, but they have to meet the anticipated outcome. A dissatisfied client for whatever reason might not be just a one-time outcome but a continuous loss of business from both the individual, his or her continued needs, and to referrals to family and friends. It might not even stop there, as the internet is now the great perpetuator of personal experiences, both good and bad, to those doing their homework on where to purchase. This is a somewhat melodramatic way of saying that managing client expectations is now more critical than ever and has extended quite firmly into medical underwriting.

In the past there was a great degree of variability in medical offers one could receive from individual insurers. Those who remember the days of Wild West substandard underwriting and the Term Wars can bear direct witness to the same case getting standard to decline arrays of results. With less insurers and an increased involvement of large reinsurers in the process, the individual outcomes have become more streamlined. Involvement of multiple insurers on the same case now lean to more consistent guidelines and policies. The old adage of “show me the impairments your company is good at” rarely exists anymore, since if you are too good at something you are probably wrong. Reinsurers now have thousands and thousands of additional lives they have tracked over the years and are closer to having seen it all than ever before. You are likely to get more similar outcomes wherever you go out with a policy.

Perhaps this is nowhere better illustrated not in the substandard array of underwriting but in the numerous amounts of preferred, select and standard issues where outcomes are tight and price improvements are finite. Many brokers and agents will illustrate a best-case scenario with the lowest pricing in most any event. When there are what the client feels are minor or controlled impairments, they are still looking toward optimal pricing. At one time, the medical director or chief underwriter had a good deal of discretion in adjusting the policy and hoping that investment or volume results would help negate any mortality giveaways. Now, most underwriting is automated, and the results are strict “kick-outs” where blood pressure or cholesterol values or glucose measurement and even build parameters will assign a class well before an underwriter gets to a case, if he gets to it all before a tentative offer is made. These parameters are generally made known to most agents and brokers from the start, so an exaggeration into a better class may meet with preventable failure just with a little due diligence to start.

Sadly, there is less of an appetite for substandard cases than ever before. In the search for predictable results, clean cases provide fewer poor outcomes and variability in mortality. Many companies will set a limit as to the amount of tables they will assess on a case, and sadly decline ones that require too much discovery or expense or even acquisition costs. In these cases, steering clients away from the disappointment of an unexpected decline and into products they can more easily qualify for will meet their needs and may be the better part of valor.

There are other things that can be done to maximize meeting client expectations while still maintaining control of a case and getting the expected outcome. If clients know what kickout rules apply and that their cholesterol measurement or blood pressure measurements and treatment for example are going to fall outside the line of best possible rate, illustrating the expected rate provides a mutually beneficial result. It’s not that you have to under-promise and overdeliver as the saying goes—under-promising may lose the case to another firm who correctly anticipated what would be offered. But more exactly promising and meeting that goal generally does get the job done. It requires a little research which is readily available or provided by the insurer to make this more easily attainable.

Letting a client know that there is a difference between clinical medicine and insurance medicine is another key. Individuals may have multiple impairments all of which are “controlled” and as such are expecting the same rate as those who have none of these conditions. You may have hypertension that is controlled, diabetes which meets treatment guidelines, and sleep apnea which by itself might not cause problems, or coronary atherosclerosis that may not merit a rating in and of itself. But the combination of all of these in a single individual does increase the risk and makes for pricing above the most favorable level. Doctors in clinical practice often tell their patients they are doing as well as can be expected, and patients take that literally as meaning they are in great health. When confronted by one of their patients that their insurance policy was priced higher than they expected, doctors may become patient advocates against the big bad insurance company and feel this is a criticism of their more than adequate care. When explained how risk assessment works and that the client is indeed doing well considering what the impairments are, doctors then become friends rather than enemies in helping the patient/insured understand what the actual problems and assessments really are.

Lastly, candor is probably the most important thing that influences the result of any policy, including providing for loved ones or businesses as was the original intention. In the initial phases, the agent, broker and client must be upfront about any problems or health abnormalities. An initial opinion or tentative quote will not hold if the underwriting process or underwriting results don’t bear that out—in the same way a driving record will flush out previous infractions or DUIs, each application generally will provide a list of every medication a client takes or prescription he or she has ever filled—and leads to more suspicious and detailed underwriting when it doesn’t bear out what the application has represented. In addition, particularly in the contestable period but throughout the life of the policy, if fraud is suspected, answering “No” to all medical questions or omitting significant parts of the medical history that is asked about will result in the policy being rescinded and the expected proceeds not being paid. This results in the ultimate bad will of beneficiaries who are blindsided by what the deceased did or did not say to have the policy issued in the first place.

Expectations that are met result in positive outcomes for all. We all as members of the insurance team must realize that. We are all on the same side trying to issue profitable business for ourselves and those we represent. The better we deliver, the more our industry will thrive.

Fibromyalgia

Fibromyalgia is a disease categorized by widespread musculoskeletal pain, fatigue and poor sleep of at least three months duration that is not characterized by any other systemic or rheumatic disorder. While fibromyalgia is often a disease of exclusion after other causes are ruled out (such as rheumatoid arthritis and lupus for example), a good detailed history and physical exam can lean strongly toward the diagnosis. Changes in the diagnostic criteria in the recent literature have resulted in more cases meeting the diagnostic criteria for this disorder.

It is estimated that about two percent of the population in the United States has fibromyalgia. It is significantly more common in women than men and may be diagnosed in both adults and children. Other terms given to the disease include fibrositis, chronic pain syndrome, muscular rheumatism and myofascial pain syndrome. While the exact cause of fibromyalgia cannot be pinpointed, it appears to involve disordered signal processing that involves the pain pathways. Suggested as possible causes are hypothalamic-pituitary-adrenal axis dysfunction, inflammation, small fiber nerve problems, and infections such as Epstein-Barr, Lyme disease and even viral hepatitis. Bottom line—it remains unknown.

Pain is the most common symptom, involving muscles and ligaments and most common in neck, shoulder, back and hips. Diagnostic criteria historically involved multi-site pain from six or more of nine possible sites: Head, left arm, right arm, chest, abdomen, upper back and spine, lower spine, left leg and right leg. Sleep disorder, cognitive symptoms (such as poor concentration and forgetfulness), and diffuse tenderness in multiple areas are also accompaniments. The three-month period is used to exclude such causes as acute injury, viral infection, etc., owing to the chronic nature of fibromyalgia as a disorder.

The differential diagnosis of fibromyalgia is difficult because it shares symptoms with so many other diseases. In addition to the aforementioned rheumatoid arthritis and lupus, systemic sclerosis, polyarthralgia rheumatica, Lyme disease, hyperthyroidism, hypothyroidism and even early multiple sclerosis have to be considered and ruled out. Even medications such as statins in treatment for high cholesterol may cause symptoms similar to fibromyalgia. There are no specific blood tests or imaging that are specific for the disease, and as such it remains an exclusion diagnosis.

Treatment for fibromyalgia has been less than satisfactory. Patient education and self-management, exercise, cognitive behavioral therapy and hot and cold application have been used with only varying degrees of success. Studies with cannabinoids and marijuana use are early and have shown some benefit. Analgesics are given but not as primary therapy, as addiction to chronic pain medication is a worry. Antidepressant drugs such as amitriptyline (Elavil), pregabalin (Lyrica) and duloxetine (Cymbalta) also have been used, but often the side effects cause just as many problems as the disease itself. No universal treatment regimen to this point has proved satisfactory.

Fibromyalgia is generally not a concern in life underwriting for mortality, excepting that chronic pain may cause significant emotional distress and consequences. Associated depression, suicide, accidents, excessive use of alcohol or drugs, and adverse drug effects from treatment certainly affect prognosis. It is more the effects of chronic pain and disability (including absences and time off of work) that comprise the risk more the disease itself. Those must be considered in waiver of premium and disability riders and applications.

Perhaps the one limitation with fibromyalgia is in consideration for preferred status. Preferred consideration may be given when pain is mild, there are no physical limitations, low dose medication is used, there is no change in medication dosage and no continuous opioid or benzodiazepine use (which carry their own risks). Likewise there should be no concerns regarding alcohol or drug misuse and no associated psychiatric or concurrent medical diagnosis that increases risk on their own.

Managing Client Expectations: The Medical Side

0

Successful business transactions require a high degree of satisfaction on the part of the client. The results don’t always have to be perfect, but they have to meet the anticipated outcome. A dissatisfied client for whatever reason might not be just a one-time outcome but a continuous loss of business from both the individual, his or her continued needs, and to referrals to family and friends. It might not even stop there, as the internet is now the great perpetuator of personal experiences, both good and bad, to those doing their homework on where to purchase. This is a somewhat melodramatic way of saying that managing client expectations is now more critical than ever and has extended quite firmly into medical underwriting.

In the past there was a great degree of variability in medical offers one could receive from individual insurers. Those who remember the days of Wild West substandard underwriting and the Term Wars can bear direct witness to the same case getting standard to decline arrays of results. With less insurers and an increased involvement of large reinsurers in the process, the individual outcomes have become more streamlined. Involvement of multiple insurers on the same case now lean to more consistent guidelines and policies. The old adage of “show me the impairments your company is good at” rarely exists anymore, since if you are too good at something you are probably wrong. Reinsurers now have thousands and thousands of additional lives they have tracked over the years and are closer to having seen it all than ever before. You are likely to get more similar outcomes wherever you go out with a policy.

Perhaps this is nowhere better illustrated not in the substandard array of underwriting but in the numerous amounts of preferred, select and standard issues where outcomes are tight and price improvements are finite. Many brokers and agents will illustrate a best-case scenario with the lowest pricing in most any event. When there are what the client feels are minor or controlled impairments, they are still looking toward optimal pricing. At one time, the medical director or chief underwriter had a good deal of discretion in adjusting the policy and hoping that investment or volume results would help negate any mortality giveaways. Now, most underwriting is automated, and the results are strict “kick-outs” where blood pressure or cholesterol values or glucose measurement and even build parameters will assign a class well before an underwriter gets to a case, if he gets to it all before a tentative offer is made. These parameters are generally made known to most agents and brokers from the start, so an exaggeration into a better class may meet with preventable failure just with a little due diligence to start.

Sadly, there is less of an appetite for substandard cases than ever before. In the search for predictable results, clean cases provide fewer poor outcomes and variability in mortality. Many companies will set a limit as to the amount of tables they will assess on a case, and sadly decline ones that require too much discovery or expense or even acquisition costs. In these cases, steering clients away from the disappointment of an unexpected decline and into products they can more easily qualify for will meet their needs and may be the better part of valor.

There are other things that can be done to maximize meeting client expectations while still maintaining control of a case and getting the expected outcome. If clients know what kickout rules apply and that their cholesterol measurement or blood pressure measurements and treatment for example are going to fall outside the line of best possible rate, illustrating the expected rate provides a mutually beneficial result. It’s not that you have to under-promise and overdeliver as the saying goes—under-promising may lose the case to another firm who correctly anticipated what would be offered. But more exactly promising and meeting that goal generally does get the job done. It requires a little research which is readily available or provided by the insurer to make this more easily attainable.

Letting a client know that there is a difference between clinical medicine and insurance medicine is another key. Individuals may have multiple impairments all of which are “controlled” and as such are expecting the same rate as those who have none of these conditions. You may have hypertension that is controlled, diabetes which meets treatment guidelines, and sleep apnea which by itself might not cause problems, or coronary atherosclerosis that may not merit a rating in and of itself. But the combination of all of these in a single individual does increase the risk and makes for pricing above the most favorable level. Doctors in clinical practice often tell their patients they are doing as well as can be expected, and patients take that literally as meaning they are in great health. When confronted by one of their patients that their insurance policy was priced higher than they expected, doctors may become patient advocates against the big bad insurance company and feel this is a criticism of their more than adequate care. When explained how risk assessment works and that the client is indeed doing well considering what the impairments are, doctors then become friends rather than enemies in helping the patient/insured understand what the actual problems and assessments really are.

Lastly, candor is probably the most important thing that influences the result of any policy, including providing for loved ones or businesses as was the original intention. In the initial phases, the agent, broker and client must be upfront about any problems or health abnormalities. An initial opinion or tentative quote will not hold if the underwriting process or underwriting results don’t bear that out—in the same way a driving record will flush out previous infractions or DUIs, each application generally will provide a list of every medication a client takes or prescription he or she has ever filled—and leads to more suspicious and detailed underwriting when it doesn’t bear out what the application has represented. In addition, particularly in the contestable period but throughout the life of the policy, if fraud is suspected, answering “No” to all medical questions or omitting significant parts of the medical history that is asked about will result in the policy being rescinded and the expected proceeds not being paid. This results in the ultimate bad will of beneficiaries who are blindsided by what the deceased did or did not say to have the policy issued in the first place.

Expectations that are met result in positive outcomes for all. We all as members of the insurance team must realize that. We are all on the same side trying to issue profitable business for ourselves and those we represent. The better we deliver, the more our industry will thrive.

Testosterone Therapy

There’s a great commercial on television that takes place on a golf course. A well-meaning man, who doesn’t look like he is testosterone deficient, sits next to an ex-football player and ex-baseball player, who look like they have enough testosterone to supply the entire country club. Of course, this leads to the question of whether or not testosterone supplementing agents should be used, with a conclusion that doesn’t leave much to the imagination. This raises a wonderful question on when testosterone therapy should be a concern, and if there aren’t a slew of underlying problems that didn’t make the final commercial cut.

Without going into the synthesis and essential functions of the hormone (careful, this is being written by an endocrinologist), we’ll limit this to testosterone supplementation and when it can do more harm than good. Male testosterone levels naturally drop as they age, and some men have low testosterone levels “just because.” The emphasis on promoting emotional, physical, sexual, and mental health is one guide, and bodybuilding, and muscle development is another. Most underwriting manuals don’t address testosterone and as such underwriting elevated testosterone levels can be murky. An entire cadre of physicians has gone into the “wellness” business, and for men testosterone supplementation is a regular prescription.

Normal testosterone ranges are wide. The labs give the expected range as between 300-1200 ng/dl. But as is the case with many hormone levels in the body, you can feel very normal at either end of the spectrum. With normal muscle development, sexual function, and activities of normal living, a level of 400 ng/dl in one man may be just as adequate as an 800 ng/dl in another. The Endocrine Society as well as multiple other endocrine associations recognize testosterone replacement only for testosterone deficiency or for cases of hypogonadism. It is sometimes used as an adjunct in treating frailty from chronic disease or malnutrition. In real life, a man complains of feeling tired, not being as muscular as he was earlier in life, depressed, or having some degree of sexual dysfunction. He is often prescribed testosterone no matter what the starting level of the hormone was. Testosterone is also a cornerstone in advanced bodybuilding. It may be used with other anabolic steroids not to treat a deficiency but to achieve a more desirable body image or status.

An astute question follows: “Should we look at it differently if there was a true diagnosis or deficiency rather than just used without a specific indication more than increasing the levels?” Assuming there are no other endocrine diseases associated with simple hypogonadism or even what would be considered a low normal value, the simple answer to the question is no. When testosterone levels increase to high levels, there are untoward consequences. High testosterone levels are implicated with increased incidence of myocardial infarction and stroke. There is increased blood clotting. Secondary polycythemia, with high hemoglobin and hematocrit values often result. High testosterone chronically drops HDL (good cholesterol), increases propensity to deep vein thrombosis and pulmonary embolus, may predispose to heart failure, and have an increased incidence of obstructive sleep apnea. While testosterone doesn’t cause prostate cancer per se, existing cancer uses testosterone almost as a fuel, and malignancy speeds up in growth rate. It is one of the reasons in biochemical recurrence or metastatic prostate cancer, therapies that essentially cut testosterone to zero are used (androgen deprivation therapy). Most consider it a contraindication to ever prescribe testosterone to those with a history of breast or prostate cancer.

Yet another question in underwriting comes up with concomitant anabolic steroid use with testosterone therapy. Many bodybuilders use both, which in addition to all the complications above will include liver failure and liver cancer. While we generally will not ensure men known to be taking anabolic steroids, detecting which clients may be users is a quandary. Lab testing may detect this, but we often don’t get specific labs on everyone we underwrite. Looking for low HDL with high liver function tests and secondary polycythemia can be a strong hint in that direction.

Replacement of testosterone in men who are deficient with levels that fall within the normal range during therapy pose little underwriting risk from that. Those however who show high testosterone levels over what would be needed in simple replacement, who show increasing weight and muscle development and perhaps increasing serum creatinine levels, who have a tendency toward the cardiac and clotting phenomena that increased testosterone promotes, or those who have secondary polycythemia, high liver function tests or decreasing HDL levels have to be underwritten with caution, and underwriting conservatively (or questioning specifically) is a wise option.

Image by JR from Pixabay

Raynaud’s Phenomenon

Raynaud’s phenomenon (RP) is a disease when sudden ischemia of the digits appears, generally as a response to small arterial blood vessels going into spasm. Most commonly the underlying cause is cold or emotional stress. The term Raynaud’s is used to describe both a disease and a phenomenon. Raynaud’s disease is symmetrical, most often appears in the fingers, and does not progress to anything serious. Raynaud’s phenomenon (or Raynaud’s syndrome) can be part of a much more serious group of impairments which can affect the esophagus, skin and fingers, and progress to gangrene in its more severe form.

The disease in Raynaud’s is more of an annoyance than a problem. Those affected can complain of sensitivity to the cold, and a pain and stinging feeling in their digits that gradually subsides with no long-lasting effects. It is the more common of the two. Raynaud’s phenomenon is often associated with rheumatic disease (especially systemic sclerosis) and can be quite severe.

RP generally starts slowly with several fingertips involved, but as it progresses, it starts to involve the entire palm. Intense throbbing, numbness and tingling, pain, and swelling then ensue. Numbness and an aching pain can last longer. It is a disease that primarily affects younger women.

RP can evolve and become secondary to many serious rheumatologic diseases. These include collagen vascular disease such as systemic sclerosis, systemic lupus, and
rheumatoid arthritis. Arterial diseases, arteriosclerosis and arterial occlusion can be primary causes. Neurologic disease, blood disorders, certain medications (like ergots given for migraine), and frostbite may also precede or be associated with RP. In other words, the associated conditions are quite concerning.

RP in its benign form is generally easily diagnosed from the short acting symptoms with no sequelae. Men suffer from a similar set of symptoms (particularly male smokers) called Buerger’s disease, but in Buerger’s lower pulses are absent. Frostbite is more easily distinguished by the characteristic exposure to severe cold.

Primary Raymand’s disease generally has no findings in between attacks, and physical findings are absent. When associated with a more ominous disease such as progressive systemic sclerosis, the underlying disease generally becomes apparent in the 24 months after diagnosis. The most common cause of PSS involves a syndrome known as CREST: calcinosis, Raynaud’s, problems with swallowing (esophagus), sclerodactyly (thickening of the skin), and telangiectasia. It may actually eat away bone when the disease is active.

When the diagnosis of the more serious Raynaud’s phenomenon is entertained, a series of specialized blood tests looks to determine the underlying cause. An X-ray of the thoracic outlet, sedimentation rate, CBC, antinuclear cytoplasmic antibody, antinuclear factor (ANF), cryoglobulins, and cold agglutinins blood testing is drawn. An angiogram may have to be performed to look for obstructing lesions. Gangrene and progressive internal organ damage are late and very damaging signs of the disease.

In assessing Raynaud’s phenomenon, underwriters look first and foremost for an underlying condition that may significantly affect mortality. The severity must be assessed, as well as any underlying complications, and prompt and effective treatment. Most simple cases of Raynaud’s disease do not result in any rating and preferred status is available. Raynaud’s phenomenon however is underwritten according to the severity and prognosis of the underlying disease, which may result in rating or decline.

The False Positive Drug Test

It’s a nightmare ending to a slam-dunk case: Everything looks solid heading into routine blood and urine requirements and a positive drug test sends the case into question or, even worse, into decline. The applicant is surprised, disappointed, perhaps even angry that he or she would test positive when they are not taking what is being suspected. And a company may be adamant about not allowing a repeat or maintaining an original decline. How can such problems be anticipated and properly explained before they even reach the problem stage?

Insurance labs are excellent and make very few errors in testing. The quandary usually becomes what is the insured taking that may have caused a false screening into a more serious drug or compound of abuse or danger? Unlike the who-dun-its on late night television, no one is slipping you a “mickey” (chloral hydrate in the days it was used as a sleep aid) or foreign substance to sabotage the test. It is much more likely another medication or substance used for a benign indication is causing the problem. What can be done to prevent this?

The number 1, 2 and 3 answer: Be sure the applicant admits to everything they are taking up front when they are asked for their list of medications. Simple prescribed or over the counter medications can occasionally test positive for drugs that raise red flags. Which drugs? Ones like THC (cannabis), opioids (both prescription and illegal), PCP, cocaine, amphetamines, benzodiazepines and barbiturates. Medications like LSD and ecstasy can also be detected in urine drug samples, even when those aren’t the ones being suspected or looked for.

Let’s go over a few that are common offenders. Certain decongestants that are commonly used (like Sudafed) may come up as a positive test result for amphetamine. Diphenhydramine (or commonly used Benadryl) can turn a test positive for PCP. Some over the counter anti-inflammatory medications (even like Aleve, Naprosyn or Advil) can rarely test positive as a barbiturate. This doesn’t happen often or half our laboratory tests would be positive. But sometimes people’s individual metabolism may fool an assay into being reported as a positive substance.

Prescribed medications for legitimate use may cause trouble even when they might not have been any cause for alarm in underwriting an application. Phentermine is a weight loss medication (one of the phens in phen-fen), but may cause a positive urine test for amphetamine. Antidepressants are not uncommon sources of positive tests for other substances. Venlafaxine (Effexor) and the newer compound desvenlafaxine (Pristiq) may result in a positive PCP test. Sertraline (the commonly prescribed Zoloft) may turn up a positive benzodiazepine test. Trazodone, sometimes given as a sleeping aid, may result in a positive amphetamine test. So may bupropion (used in smoking cessation or as a mild antidepressant) that likewise may show up as amphetamine positive.

The list is pretty extensive. A couple more to note: Proton pump inhibitors, most commonly Protonix, used to treat GERD, may test as THC positive. Quinolone antibiotics may test as opiate positive. Promethazine, often given for nausea and vomiting, may test as amphetamine positive. And finally Tramadol, a commonly prescribed pain medication given when a doctor doesn’t want to prescribe codeine, may result as a positive test for methadone.

When a positive drug test comes up out of the blue, the underwriter will immediately question its veracity or look to see if a medication is being taken or prescribed that could possibly have caused a false positive. When admitted upfront, it isn’t a problem at all. When the test comes up positive and there is no available explanation, an underwriter will more likely assume the worst and give the applicant the more difficult task of explaining it away. This also goes for legitimately prescribed drugs that aren’t admitted on application. If there is a reason codeine or amphetamine or any drug being taken for a medical reason will show up as a positive test, admission upfront almost always has no consequences. Non-admission, and the post decline “Oh yeah, I was taking “XYZ” (for whatever cause) will raise questions of honesty on all parts of the application.

There are also unusual circumstances that no one expects but are discovered with some good old-fashioned detective work. An older couple in their late 60s both tested positive for cocaine in their urine. They were aghast at the result and we were just as surprised. A second test (“of course it must be a lab mistake”) came up with the same finding. We asked the couple to be sure their daily routine was as they represented to us. Weeks later, we received a call that the couple was always prepared a calming tea by their maid before bedtime. Their maid was a trusted part of their household ever since emigrating from Columbia 20 years before. The tea was Coca tea—made with Coca leaves. Having heard similar stories, I dared them to send me the tea bag. It came Express mail the next day. The amount of coca leaf was miniscule, but enough to turn the test positive. In my 30+ years of underwriting, unbelievably this has happened three times. Each time, to paraphrase Jerry Maguire, I said “Show me the teabag.” And each time, it arrived promptly and resulted in a policy issued as applied for after a good laugh.

Pulmonary Nodules

Pulmonary nodules are almost always incidental findings on a chest X-Ray that are either discovered accidentally or when looking for something else. With the advent of new screening programs for high risk adults with a previous smoking history, more than a million new cases of pulmonary nodules are found, with approximately a five percent malignancy rate. It is no wonder underwriters and physicians take these findings seriously, and a thorough work-up is done to be sure any nodule encountered has a benign outcome.

People with cough, suspected pneumonia, difficulty breathing, or an abnormal lung field exam on physical are obvious candidates for X-Rays that may discover a lung nodule. In addition, the US Preventative Services Task Force (USPSTF) now recommends annual screening for lung cancer with low dose CT scanning in adults aged 50-80 who have a 20 pack year history and are either current smokers or who have quit smoking in the previous 15 years. The objective evidence is striking for this testing: findings showed a 20 percent reduction in lung cancer related mortality as a result of the scanning.

While multiple nodules may involve a more systemic process such as fungal infection, sarcoid, bacterial infection or tuberculosis, the single pulmonary nodule is most concerning as the risk of malignancy is significant. The growth may be a primary cancer or a secondary malignancy (metastasis) from a different body organ, and work-ups to try to determine the etiology as the only certain method of distinguishing a malignant from a benign process is by biopsy, which is often invasive.

The risk of malignancy is highest in solid nodules that are large sized, have calcifications that are not symmetric, and that double in size between one month and one year of observation. Nodules that grow more quickly are more likely inflammatory or infectious, and a different cause should be sought. Other characteristics of suspicious nodules include irregular or spiculated borders, ground glass appearance on X-Ray, and location in the upper lung lobes. Increasing age and cigarette smoking are associated with higher risk of lung cancer.

Work-up of the nodule is done in a sequential manner. If discovered on X-Ray, a CT scan is usually the next step to identify exact size and characteristics. Smaller lesions are generally monitored with serial CT scans. If a generalized process is suspected, that is worked up at the same time. Bronchoscopy can help make a diagnosis with direct visualization and cell washings from the suspicious area. CT guided biopsies are often sufficient for a definitive diagnosis, but open lung biopsies may have to be obtained when the lesion is small or in a spot that is inaccessible to the bronchoscope or to getting tissue in a vulnerable area.

The recommended management of an incidentally detected solid pulmonary nodule as defined by CHEST (the American College of Chest Physicians) recommends follow-up based on nodule size and intermediate and high risk factors that combine the aforementioned characteristics favoring malignancy. Nodule biopsies and bronchoscopy are considered when the nodule is within the reach of either procedure. When the risk of malignancy is significantly high, surgical resection is the procedure of choice. Nonsurgical options like ablative therapy or stereotactic radiotherapy may be considered for those who are at high risk of complication or death from a resection.

Underwriting a case with a pulmonary nodule starts with the results of investigation—a new nodule has to be worked up and evaluated before any case can proceed. There should be a good description of the nodule or nodules, including size, consistency, shape and margins from the original study. There should be follow-up of the nodule to see if it has been increasing in size, and how long that interval is. Biopsy and bronchoscopy results and the work-up from the chest physician and/or surgeon should have detailed and inclusive notes. If the nodule is for a more generalized cause, that should also have been worked up and treated.

A solitary pulmonary nodule is never a welcome and most often an unanticipated finding, but the good news is that most turn out to be benign lesions or part of a more generalized treatable cause. Either way, results from a detailed investigation are necessary for a good and expedient case outcome.

Fibromyalgia

Fibromyalgia is a disease categorized by widespread musculoskeletal pain, fatigue and poor sleep of at least three months duration that is not characterized by any other systemic or rheumatic disorder. While fibromyalgia is often a disease of exclusion after other causes are ruled out (such as rheumatoid arthritis and lupus for example), a good detailed history and physical exam can lean strongly toward the diagnosis. Changes in the diagnostic criteria in the recent literature have resulted in more cases meeting the diagnostic criteria for this disorder.

It is estimated that about two percent of the population in the United States has fibromyalgia. It is significantly more common in women than men and may be diagnosed in both adults and children. Other terms given to the disease include fibrositis, chronic pain syndrome, muscular rheumatism and myofascial pain syndrome. While the exact cause of fibromyalgia cannot be pinpointed, it appears to involve disordered signal processing that involves the pain pathways. Suggested as possible causes are hypothalamic-pituitary-adrenal axis dysfunction, inflammation, small fiber nerve problems, and infections such as Epstein-Barr, Lyme disease and even viral hepatitis. Bottom line—it remains unknown.

Pain is the most common symptom, involving muscles and ligaments and most common in neck, shoulder, back and hips. Diagnostic criteria historically involved multi-site pain from six or more of nine possible sites: Head, left arm, right arm, chest, abdomen, upper back and spine, lower spine, left leg and right leg. Sleep disorder, cognitive symptoms (such as poor concentration and forgetfulness), and diffuse tenderness in multiple areas are also accompaniments. The three-month period is used to exclude such causes as acute injury, viral infection, etc., owing to the chronic nature of fibromyalgia as a disorder.

The differential diagnosis of fibromyalgia is difficult because it shares symptoms with so many other diseases. In addition to the aforementioned rheumatoid arthritis and lupus, systemic sclerosis, polyarthralgia rheumatica, Lyme disease, hyperthyroidism, hypothyroidism and even early multiple sclerosis have to be considered and ruled out. Even medications such as statins in treatment for high cholesterol may cause symptoms similar to fibromyalgia. There are no specific blood tests or imaging that are specific for the disease, and as such it remains an exclusion diagnosis.

Treatment for fibromyalgia has been less than satisfactory. Patient education and self-management, exercise, cognitive behavioral therapy and hot and cold application have been used with only varying degrees of success. Studies with cannabinoids and marijuana use are early and have shown some benefit. Analgesics are given but not as primary therapy, as addiction to chronic pain medication is a worry. Antidepressant drugs such as amitriptyline (Elavil), pregabalin (Lyrica) and duloxetine (Cymbalta) also have been used, but often the side effects cause just as many problems as the disease itself. No universal treatment regimen to this point has proved satisfactory.

Fibromyalgia is generally not a concern in life underwriting for mortality, excepting that chronic pain may cause significant emotional distress and consequences. Associated depression, suicide, accidents, excessive use of alcohol or drugs, and adverse drug effects from treatment certainly affect prognosis. It is more the effects of chronic pain and disability (including absences and time off of work) that comprise the risk more the disease itself. Those must be considered in waiver of premium and disability riders and applications.

Perhaps the one limitation with fibromyalgia is in consideration for preferred status. Preferred consideration may be given when pain is mild, there are no physical limitations, low dose medication is used, there is no change in medication dosage and no continuous opioid or benzodiazepine use (which carry their own risks). Likewise there should be no concerns regarding alcohol or drug misuse and no associated psychiatric or concurrent medical diagnosis that increases risk on their own.

Controversies In Prostate Cancer

Prostate cancer is a significant disease—approximately 10 percent of men will be diagnosed with prostate cancer in their lifetime and the lifetime risk of dying of the disease is three percent. In addition, prostate cancer is one of the few cancers that is actually rising in incidence, with a five percent year over year increase in diagnosis of men with advanced stage disease. While recognizing it is a significant disease, controversies on how often to screen for it (or whether to screen for it at all) exist within not only insurance medicine but in the population in general, as well as other differences in our field in rating and insuring the disease.

Screening recommendations for physicians (my son, in his third year of medical school, is being taught to rely on these guidelines) is under the oversight of the USPSTF (the United States Preventive Services Task Force). Their recommendations cover just about every suggested cancer screening from colon to breast to reproductive cancers. In their statement regarding prostate cancer, they advocate that the decision to undergo PSA screening on a periodic basis should be up to the individual and not the doctor. Excepting in very high risk individuals, the USPSTF would not screen for prostate cancer with PSAs at all. I can’t tell you how many men I’ve personally known who likely wouldn’t be here today without screening and prompt treatment of elevated PSA values. Yet the USPSTF comes to the conclusion from their data that the complications involved in prostate testing and/or prostate disease treatment outweigh the number of lives saved by said screening.

Many insurers include PSA screening as part of age and amount requirements when blood work is being done. The screening catches cases where prostate cancer is undiagnosed or when a workup should at least exclude cancer from the differential diagnosis. It also catch cases of non-disclosure where prostate cancer is a known disease and there is no treatment being chosen. Since this cancer is often a slow growing one, anti-selection may occur as the cancer may be an eventual death well after the contestable period has passed but well short of a standard or preferred priced mortality. While death certificates may reveal when prostate cancer is the proximate cause of death, those where the cancer contributes to a premature death from a different cause often isn’t captured in the statistics. Suffice to say, insurance experience favors a use of the screening PSA in mortality experience.

It is also controversial in obtaining the result just in and of itself. Most insurance applicants consent to a blood test when required, but few actually review what is being tested for. It absolves liability, but a man who consciously chose not to be screened by his personal physician may find he is non-consciously screened by his insurer. Harmless when negative, if positive and a cause for declination, just inquiring as to the reason for the decline may implicate the problem. The insured still has the option to consult with his physician as the next course to take (if any), but it is still an open ethical question.

Many men who are diagnosed with prostate cancer (particularly early in the disease) choose not to have active treatment but rather a process known as “active surveillance.” Here, both insured and doctor delay any intervention until a point where they deem the cancer to be aggressive enough to warrant it. The cancer may never become aggressive and last an indefinite number of years in an early state. Treatment may also be postponed until a man either has a medical risk that outweighs the benefit of treatment or postpones a procedure that may interfere with his sexual function until an indefinite point in time. Active surveillance is well recognized in the urological community of physicians as a very acceptable process in early or non-aggressive stages, but the insurance company is in a bit more of a difficult position. An insured may be lost to follow-up, or choose non-treatment regardless of any malignant change, or the cancer can progress to an incurable stage during the time period. Most insurers will take such cases if the stage of the cancer is early, the aggressiveness (Gleason score) is low, and the period of time being watched increases without any malignant change. But it is always an insurance risk, particularly if aggressively priced for.

The mode of treatment is also somewhat controversial, even amongst Urologists. Surgical resection is the most clear of the treatment modalities, but radiation treatment has been found to be very effective for qualifying individuals. Radiation is a little more difficult to follow clinically, since PSA (which drops to zero if the prostate is removed successfully) always has a measurable PSA in its aftermath. Cryotherapy, high intensity focused ultrasound (HIFU), and proton beam radiation are also less invasive modes of therapy, but with different overall success rates, and are looked at differently in terms of acceptable mortality by insurers.

Most insurers in known prostate cancer will insist on regular follow-up, and many will require that follow-up to be by a urologist. Specialist treatment is often a bit of contention—a family practice physician or internist may feel he or she is quite capable of managing the insured, but a specialist is more equipped to have dealt with similar problems and be current on the latest literature and treatment modalities. Either way, the more reassured an insurer can be, the better the offer that will result.

One more difference in opinion in insuring prostate cancer, whether treated or observed, has to do with the period of stability. There will be differences in how long after surgery (or radiation) an insurer may choose to wait before issue, and how long a period of time is considered adequate for stability of disease (and lack of aggressiveness) in active surveillance. There’s no concrete data regarding an absolute time period in either scenario, so the actual decision may vary amongst companies and underwriters.

Cancer treatment in the United States and results from same have improved markedly in the last decades. While some cancers remain uniformly deadly, others have progressed to remarkable cure and remission rates that would have been unheard of in years past. Most disturbing about prostate cancer though is its increased incidence particularly in advanced disease, and as such controversies remain not only in its clinical diagnosis and screening but in its insurance outcomes as well.