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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: drbobgoldstone@yahoo.com.

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.

Impaired Risk Life Underwriting: Evolving With The Process

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When asked to write on advances in impaired risk underwriting, I began to question the term “advances.” There are no arguments that technologically we have moved far ahead of where we were 10, 20, and 30 years ago. Ease of application has become a true benefit for the potential insured. It is far easier to compare products and nuances in pricing than ever before. Big data has allowed us to factor in so many more variables than we previously could in underwriting. However, in terms of advances, we tend to look toward whether the process and results are better for us as brokers, agents, and insurers. Here, especially in impaired life insurance, the answer is far from clear.

As we complete more years in our business, the natural tendency is to assume it was better in “the good old days” and that the modern evolution of doing business is just more difficult and technologically advanced, not necessarily better. Realistically, things that make it easier to do business with a carrier are a welcome step forward. However, the things that many of us have come to appreciate as part of the business over the years have started to evaporate. As insurance evolves from a relationship business into a commodity purchase, the skills we need as representatives and sellers must evolve as well. The road to prosperity is littered along the way with the shadows of those who would not or could not keep pace with the realities of the new world of business and technology. As we grow with the process, our survival will be much more assured. In underwriting impaired risk business, this is no longer optional but necessary.

Life insurance for the younger, healthy individual is now completely data driven. Besides the medical variables of blood and urine testing, factors we would not have previously dreamed of being factored in, such as credit reports, zip codes, purchases, etc., are now part of the routine. There is not a lot of argument with the results: There are enough insured lives and experience to assure that if enough applications are taken in, the mortality will be predictable and reproducible. There are enough variables in interest rate, lapse, economy, pandemic, etc., that actuaries have to worry about that the more constant their underwriting mortality, there is far less worry in the outcome. An increasing amount of this insurance buying population is now self-purchasing policies, often bypassing the input that can be given by an insurance professional on what is truly needed and for how long at various stages of their life and work.

With this in mind, it is easier to see why insurers are shunning the risks and costs involved with impaired risk underwriting. Those same inputs that make standard and preferred underwriting so consistent are what make impaired risk more challenging. Insurers are no longer willing to take part in the aggressive pursuit of impaired cases as in the “Wild West” days of business growth and acquisition but rather may decline a case that presents challenges at its inception. The outcomes are more variable, the range of possibilities wider in scope, and the acquisition costs of evidence in more medically challenged individuals is significantly higher, much less the time delay needed to obtain them.

We are certainly not giving up on this market, which has historically been one of the most lucrative in the life insurance field. We must know how to evolve with it however, and give our cases the best chance of succeeding. To this end, the most important factor in moving ahead with these cases is to know them backwards and forwards. What sounds intuitive is more critical than ever. Most companies have less underwriters than they have ever had, both in number and in experience. The pandemic has resulted in older, more experienced underwriters leaving the workforce, and employing fewer new ones in their place. Ditto for medical directors, whose number is less than a third of what it was 25 years ago. Less time is spent with the more time consuming cases and, in fact, many companies actually set strict mortality limits in what they will accept at different age limits. Cases over age 65 may have to fit in two-table mortality, and those over 70 may face standard or bust ultimatums. While the clientele is still there, the opportunity to obtain placements that are more successful has significantly decreased.

Knowing what you have at the onset and presenting it in its more favorable light is more important than ever. If there is any question that there is a medical impairment that requires investigation, submissions have to be tailored to having all the details that an underwriter will require right at the get-go and making sure each circumstance is presented in its most favorable light. It means research, communication with the carrier prior to submission, and a detailed conversation with the potential insured to be sure that all facts are out on the table. It is critical that the case reach the active consideration stage without a “just because” decline at an early stage.

Reading through an impairment is critical before submission. You do not have to be a doctor to use the resources on the internet to judge the severity of a problem. Many companies have copies of a somewhat advanced underwriting manual for agents to use, and when there are questions, the underwriter should get at least a written request from you for what they are looking at (with a brief and concise summary); often the doctor may get a look at the case early when the impairment is unusual. It allows you to go back and ask the necessary questions before case submission. If your small summary does get a tentative quote or opinion, that is a good thing; companies hesitate to go back on that quote unless the case ends up materially different than was presented the first time.

Make sure there is follow-up that shows good care and management of the impairment in question. Sometimes it is as simple as getting the result of a recently obtained check-up. Other times, you may delay submission until an upcoming appointment has occurred. Having the client be his own best advocate may also be helpful, as a letter obtained from the doctor or specific reference to the favorable parts of the history in the current APS note may be obtained at the time of the visit. Insureds may be more amenable to this at older ages or with known impairments as insurance may be a more critical part of their financial age than it is when a 20-year term case is submitted to 15 companies at a time for a comparative quote. It is more important to get these factors ironed out in advance, to avoid having to answer the inevitable “Has your application ever been rated or declined?” especially when your case would have been perfectly insurable if the questions were addressed earlier.

Look into habits and medications early in the process as well. Medications that have psychiatric applications may be easily explainable, as in reaction to the loss of a job or family member. If full care was obtained and the problem addressed has been taken care of, that should be pointed out up front. Also note that certain medications may be prescribed for more benign conditions, like an antidepressant or anti-seizure medication for something like post herpetic neuralgia (post singles) and not a chronic psychological or neurological condition.

Know in advance what the company’s rules are that you are applying to concerning impairments. Many may automatically decline a case at a certain age or impairment level regardless of what that impairment may be or how well it is being cared for. Network with your peers about how companies have handled some of their more complicated cases; there is no universal manual or rules for handling individual medical problems or combinations of impairments and certain companies may be more lenient on what risks they will take with such problems as hepatitis, diabetes, or cholesterol and hypertensive abnormalities. And if you really feel you have little to lose, and the impairments don’t seem complicated or deal breakers, don’t hesitate to lend the case out to outfits that will actually shop it to multiple carriers at the same time. In borderline cases it only takes a single “yes” or favorable opinion to get the case signed, sealed and delivered.

One final caution is to be as upfront as you can with the facts of a case, especially as they relate to habits. Doctors are generally very complete in their progress notes as to annotating smoking, alcohol and drug concerns, as well as any other dangerous habits their patients have that may compromise their health. When an insured denies any of the above, and the medical record indicates differently, the case shuts down almost instantly even if it were truly insurable. Additionally, if hospitalizations or medical care was either undisclosed or denied, there is nothing worse than an insurer obtaining said records and denying a claim, often blindsiding a family counting on a payment. Fraud and misrepresentation are frowned upon to say the least by insurers, and they will take appropriate action on same.

Much has changed and is changing in impaired risk. The requirements of yesterday are no longer those of the present. Bloods, EKGs, X-Rays and routine labs are being replaced by genetic testing, sophisticated labs such as BNP testing often not even obtained by the insured’s personal physician, and many non-medical facets that a bank would obtain for a loan more than an insurer traditionally would are part of what is now standard underwriting procedure. Impaired risk cases are still a little different though, as they require many of the same requirements that have been traditional except now with less risk tolerance than before. Evolving with the process is now key to making it work successfully for you.

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