Robert Goldstone

Diverticulosis (the anatomical condition) and diverticulitis (active inflammation) are very common, particularly here in the United States. The American Society of Colon and Rectal Surgeons estimates that up to half of all Americans have diverticulosis by the age of 60, and it is nearly a universal condition after the age of 80.

While mostly an asymptomatic condition, those affected by diverticular disease can have uncomfortable symptoms when the condition is acute, and potentially life-threatening complications can occur without adequate treatment.

Diverticula are sac-like formations in the mucosa of the colon that protrude out from the muscular layer. They are most commonly found on the left side in the sigmoid colon, but can appear virtually anywhere in the colon.

The term diverticulosis describes the existence of these pockets and diverticulitis is the inflammation or complications within the diverticula.

The increasing lack of fiber in the commercially available diets of today has been implicated in diverticular development, because the pressure to move small, hard stool through the colon causes the muscular wall of the colon to work harder.

As mentioned previously, most people with diverticular disease do not have symptoms. Diverticulosis is often found incidentally when running tests for abdominal pain or other gastrointestinal disease. Most often it is discovered during routine colonoscopy for cancer screening. Symptoms can be related to complications including infection and bleeding—diverticular disease is the most common cause of significant colonic bleeding.

An inflammation in one or more of the pockets is most commonly associated with acute abdominal pain, fever, chills and change in bowel habits. While nausea, vomiting, low-grade fever and abdominal discomfort are common, more intense symptoms develop when the wall of the pocket ruptures and an abscess or fistula forms. A fistula is an abnormal connection between the colon and the skin or another organ and serves as an escalating area of infection.

In diverticula without symptoms, increasing dietary fiber such as grains, vegetables and legumes reduces pressure within the colon and helps transit waste material through the gastrointestinal system. Such high fiber diets or use of fiber supplements such as bran powder decrease the likelihood of future complications. While diverticula are permanent anatomic conditions, they can remain without problem virtually forever.

When diverticulitis occurs and is acute, most affected individuals are treated successfully through medical management with a clear liquid diet and antibiotics. At times diverticulitis can become acute and necessitate surgical management. A ruptured abscess or persistent fistula may require surgery and even resection of the affected part of the colon. In those cases hospitalization and intravenous fluids are mandatory.

Cases in which there is perforation of a pocket and rupture of contents into the body and abscess formation have the highest degree of life-threatening complications. Cancer is the number one “rule out” diagnosis and CT scanning and colonoscopy may be required once the infection is quieted.

While diverticulitis can recur in those who have been affected, thankfully the disease is usually well managed, and standard and preferred issues are likely when the process has subsided and is not recurrent. Permanent dietary changes significantly lessen subsequent attacks and symptoms.

With winter firmly upon us, depression is an increasingly diagnosed disease. The lack of sunlight in shorter days, cold weather, and otherwise dreary settings limit mobility and increase one particular form of depression called seasonal affective disorder (aptly abbreviated SAD). This leads people to try and find an outlet for their depression and anxiety during this time, such as looking into how a THC Delta 8 vape can help them relax and calm them down during heightened stress.

SAD is considered a serious mental health problem by the American Psychiatric Foundation and may affect as many as one in ten people living in northern areas.

Seasonal affective disorder is both recurrent and significant in its duration, and symptoms can last up to half of the year. It can have a serious effect on an individual’s health (neglect of self-care), on families and on maintaining employment. SAD is more prevalent in females by a ratio of about four to one. Children can also be susceptible to seasonal affective disorder, with high depression rates and poor performance in school.

SAD has been well studied, and several biologic mechanisms are thought to play a part. The circadian rhythm phase delay or advance appears to be the number one cause implicated, but differences in retinal sensitivity to light, serotonin levels, neurotransmitter dysfunction and genetic variations are also prominently mentioned. Many sufferers are thought to be more vulnerable to stress than others; and the lack of outside stimulation, cold weather and decreased sunlight compounds this weakness.

SAD is classified as a major depressive disorder, similar to bipolar disorder. It is differentiated by its pattern of seasonality and somewhat regular recurrence at a specific time of year. Depression is quite serious-particularly when major and recurrent-and can lead to changes in health or morbidity and mortality when severe and untreated. Many people nowadays are game for trying CBD products such as edibles Canada or other places where it’s legal in order to treat depression and related issues. Other diagnoses that could be considered when SAD is entertained include manic depressive disorder (bipolar), chronic fatigue syndrome, drug or alcohol use, and even hypothyroidism.

SAD is now taken quite seriously, and treatment instituted promptly will often have favorable consequences. A light therapy box is used for one to two hours a day with good results, although relapse is shown to occur when the treatment is stopped. It should be continued throughout the season until a normal remission of symptoms happens in either spring or summer. Antidepressants have been shown to have good outcomes, and ones that work on serotonin receptors are particularly effective. People have also turned towards medical marijuana recently, which companies such as I Love Growing Marijuana are involved in with supply for businesses that distribute, as well as people who are just starting out. Favorable results have recently been shown with cognitive behavioral therapy and, when combined with light therapy, have high rates of success.

Most cases of SAD are successfully treated and don’t lead to life-altering consequences or adverse underwriting decisions. Since it is a severe form of depression, however, underwriters look to success of therapy, stability of job and working history, and continued good care of any concurrent illness which can become worse through neglect due to depression.

Migraine headaches are often disabling and caused by abnormal brain activity-many nerve pathways and neuropetides are involved in activating nerves that affect sensory tracts in the brain.

While migraine headaches are thought to be caused from a dilation of blood vessels along the path of the fifth cranial nerve (trigeminal nerve) the actual chain of events still is not clear. Imaging studies taken during migraine headaches suggest a failure of normal sensory processing.

The most important consideration in life underwriting is determining the diagnosis and understanding the radiologic testing that may appear quite striking and associated with more disabling disease.

Migraines are classically associated with a pattern familiar to most sufferers. Most of those affected get an aura of symptoms that are a warning sign preceding the severe headache. These symptoms-which can occur a few minutes to several hours before the headache-include nausea, vomiting, light sensitivity and visual disturbances. These headaches may become throbbing and can affect sense of taste, smell and vision in addition to the characteristic pain. Disturbances of neurologic function may accompany the headaches and are thought to be caused by constriction of branches of the internal carotid artery. Visual disturbances may take the form of light flashes, hallucinations, and changes and narrowing of the visual fields. Numbness, tingling, as well as problems with speech and balance may also occur during the course of an attack.

The headache itself is usually pulsatile, one-sided and very severe. Alcohol, anxiety, stress or even bright lights may begin an attack. Other triggers can be smoke, low blood sugar, changes in sleep patterns, physical stress or even certain foods. The most common include those with added MSG; those that contain tyramine, such as cheese, red wine and smoked fish; chocolate; nuts; or fruits.

Migraines are more common in women than men, can begin as early as adolescence, and may appear later in life, sometimes after age 40. They have an increased occurrence within families, and pregnancy appears to decrease the incidence in known sufferers.

Most physical exams show little during a migraine attack. The diagnosis of migraine is made by establishing the typical pattern of pain and evolution of symptoms. Severe headaches such as cluster headache, post-trauma head pain and other neurologic causes have to be ruled out. Medications to treat migraines start with simple over-the-counter medicines when the attack is mild, narcotic pain relievers, anti-nausea medicines, and those that treat blood vessel dilation when it is severe. Recreational drugs such as cannabis are also taken by many. However, does weed help migraines? The answer is, yes. It is found that CBD and THC do have a positive influence in reducing the intensity of migraine pain in people. Therefore, these natural pain relievers could be put to use in addition to medications, such as yoga, acupuncture or even remedies like these oils that users in the Netherlands may consider the “beste CBD olie“. Occasionally, the migraine will be quite extreme and some necessitate trips to the emergency room for acute pain relief.

While disabling when present but with a return to normal between attacks, what makes migraine headache difficult to underwrite?

First, migraine may be confused with other more serious entities, such as brain tumors, cerebral hemorrhage or narrowing of important blood vessels in the brain. Migraine headache is a risk factor for stroke in both men and women, especially in those where an aura is prominent. Those who have other stroke risk factors, such as hypertension, smoking or women on birth control medications are particularly prone to problems. Dependence on pain medications and narcotic overuse are also concerns.

Most of those with controllable and non-disabling migraines are underwritten at standard and even preferred rates when cases are non-complicated. Those whose migraines are prolonged, have neurologic compromise, show residual abnormalities after imaging such as CT or MRI, or who have other complicating risk factors for stroke are considered individually and constitute more serious risk.

At this time of year it seems like we are all tired; however chronic fatigue syndrome (CFS) is a debilitating fatigue that is not helped with rest. Where many people can rest up and take supplements to help themselves through this lazy time of year, such as those recommended by dr steven gundry, others struggle with CFS. Taking supplements might help build mineral and vitamin levels, however those tackling chronic fatigue will not find energy from sleeping or taking supplement products like other people.

Thought in years past to be a psychiatric diagnosis or findings more compatible with the emotional disease, chronic fatigue syndrome affects from one to four million U.S. adults, according to the 2010 Center for Disease Control Statistics. CFS is more common in women than men and in those older than 40. It can truly be disabling to those who suffer from it.

The primary symptom of CFS is, obviously enough, fatigue. There is a definite onset of symptoms, and the fatigue is disabling, quite severe, and affects both mental and physical functioning. The diagnosis is made mainly by exclusionmeaning that all other known medical causes for symptoms are ruled out before the diagnosis is established.

The Center for Disease Control Diagnosis criteria for CFS includes severe fatigue for more than six months, headache, multi-joint pain without swelling or redness, muscle pain, post-exertional discomfort for more than 24 hours, significant impairment in short term memory or concentration, tender lymph nodes, and disturbed sleep. Four of these criteria must be present for CFS to be considered.

When doctors are looking for the physical signs of CFS, their exam often fails to reveal any specific findings. Occasionally, lymph nodes will be tender and there will be trigger point pain in specific muscles on palpation. Basically there are no other physical findings specific to the disease. The differential diagnosis is extensive, including blood diseases, endocrine disorders, neurologic problems, psychiatric disorder (particularly depression) and rheumatologic disease.

Blood testing is done for the most obvious cases and viral studies are ordered when the history suggests exposure to a certain pathogen. People with CFS generally endure rigorous work-ups before a diagnosis is settled on.

The cause of CFS is still unknown. A major thought is that the immune system is involved and that the same virus that causes mononucleosis might be involved, but there is only a passive association. The notion that it involves the immune system is the main thinking behind supplements that boost the immune system and therefore assist fatigue. The immune system is controlled by many things, one of them being gut health. Many supplements that help the gut (such as gundry md bio complete 3), therefore, improve the overall immune system and fatigue. Sufferers of CFS might be less likely to benefit, but those who are suffering with less strong fatigue take supplements to help (there are usually offers such as gundry md offers on these supplements). Genetics have been looked into, as has the involvement of the adrenal system because cortisol levels have been found to be low in those with CFS. Depression and sleep disorder as primary causes for CFS have also been explored, but without clear-cut evidence of a cause and effect relationship.

Sadly, to date, there hasnt been an effective treatment for CFS. Most pharmacologic and medical treatments have been unsuccessfulantiviral agents, cortisone replacement, melatonin, antidepressants, and medicine used in neurologic problems have not shown consistent benefit.

Cognitive behavior therapy, which emphasizes the role of thought and resulting action, has helped somewhat, as has progressive exercise therapy. Some people respond to treatment, some respond to time, and some dont respond at all. Additionally, something as simple as changing the mattress on the bed may make a difference to people living with CFS. As it is about comfort, this may be a topic worth looking into. Also, it may be worth checking out sites like best mattress-reviews, in the hopes of finding a mattress that can assist with any personal needs.

As well as that, clinical trials are ongoing with newer medications to see if there is any long-lasting beneficial effect.

CFS generally doesnt have increased mortality, although resulting depression and inactivity can cause other medical problems which may require a rating. There is also a significantly increased incidence of unemployment with CFS, and disability is quite common. There should always be a work-up for other causes of serious and treatable disease before the diagnosis of CFS is given as a lasting one.

Falls are difficult under the best of circumstances-painful when we are younger, but often catastrophic when we are seniors. The leading cause of injury-related visits to emergency departments in the United States for people 65 years of age and older, falls are the single largest cause of injury mortality for this group. There is little wonder why an underwriter looks carefully at a history of falls in the senior population applying for insurance.

The mortality rate from falls reported by major studies is frightening. Data from the Major Trauma Outcome Study database suggests an almost 12 percent mortality rate for falls in geriatric patients. In addition, a large Dade County, FL, study showed that almost half of the fall injury events that occurred at home resulted in discharge to a nursing home. Almost 90 percent of hip fractures that occur do so as a result of falls, and the immobility associated with surgery and recovery are striking-according to a major textbook on gerontology, about one-fourth die within six months of occurrence.

What are some of the risk factors for falls? Older age, house-bound status and living alone head the list. Historical factors such as previous falls, acute illness, use of a cane or walker, and chronic conditions that affect the neuromuscular system are prevalent. Medications which decrease awareness or sedatives and medication in combination are also cited as contributors. Physical defects, of course, such as poor vision, difficulty in rising from a chair, neurologic changes (even age-related without a specific etiology) and decline in hearing are also major factors.

Cognitive impairment is also at the top of the list in the absence of a distinct physical cause. Elderly people become more susceptible to falls when presented with difficult physical or mental challenges. Confusion or distraction about a condition that could have been avoided can become an accident. When judgment is impaired, the ability to carry out tasks that were easier when younger becomes much more challenging in older age groups.

Falls in the senior population are much more catastrophic when bones are not strong and balance is impaired. Getting out of bed may cause a fall. Common medications or the use of alcohol-even at previously acceptable social limits-may cause instability. Disturbances of gait, balance or even avoidance of pain from arthritis can tip someone into a fall.

External factors are also quite common-homes or workplaces where people are unable to or have decided not to make necessary repairs, or clean up and removing tripping hazards. Many falls in the under 65s demographic often occur with manufacturing or warehouse jobs. Lack of safe ladder or elevation equipment (such as: https://www.platformsandladders.com/folding-ladders) can lead to devastating falls from height if one slips.

If you think only the very elderly who barely manage on a walker are the typical victims of a fall, you might be surprised to know that this often proves not to be the case.

The age 75-to-85 market has expanded rapidly for life insurance, and many of those who initially are managing daily activities with a maximum amount of effort soon are over the threshold for optimal self-care. For instance, diseases such as Parkinson’s cause tremors, shuffling gait, lack of momentum to propel, and inability to stop an accident or a fall. Causes such as this from chronic disease are virtually endless.

Medical exams for older-aged applicants (sometimes referred to as the “senior med”) may seem inconvenient, yet can be very telling when evaluating insurance applicants. Tests for cognitive awareness are not necessarily ones that require someone to be a genius to pass, but orientation to person, place and time, as well as the ability to have more than basic memory (delayed word recall) are often parts of the exam.

A Get Up and Go test, where an applicant must rise from a chair, navigate a small distance in a reasonable amount of time, and return to the starting point helps measure gait, stability and strength. And of course, attending physician statements are of paramount importance in assessing whether older-age applicants can accomplish the activities of daily life without being unduly subject to accident and trauma.

As individuals age, even into years that are now more commonplace for survival-well into the seventies and eighties-they also accumulate larger numbers of chronic disabilities and conditions. While some of those conditions might be considered benign, when combined they can substantially increase the risk of falls.

Falls are a condition an underwriter looks at very seriously when assessing insurability.

Bipolar disorder (also known as manic depressive disorder) is a quite common and recurrent mental health disorder that occurs in all levels of severity. The World Health Organization has ranked bipolar disorder as the twelfth most common moderately to severely disabling condition in the world for any age group, and estimates a lifetime prevalence of 4 percent in the United States.

While there is no predilection for race, sex or ethnicity, the diagnosis is first entertained under the age of 25 years. Children of parents with bipolar disorder have about a 5 to 15 percent risk of being affected, compared with 2 percent of the general population.

Bipolar disorders consist of episodic mood shifts which may begin with mania and hyperactivity. There is an almost over-involvement in life activities, increased irritability and flight of ideas, easy distractibility and relative insomnia. Sometimes initially seen as an endearing quality by acquaintances and friends, the irritability, rapid mood swings, aggressive behavior and grandiose thinking soon leads to interpersonal difficulties and problems in maintaining relationships. Activities that seem like a good idea at the time can have regrettable consequences, such as overspending, committing to unsustainable relationships, and alienation of friends and family.

Eventually, this feeling is replaced by depression-some are “rapid cyclers” while others are more slow in their course. Unfortunately the depression phase lasts longer than the manic phase and can be quite disabling. These are major depressive episodes and, in fact, those with untreated bipolar disorder have significantly higher rates of death from both cardiovascular causes and suicide.

Suicide rates are 20 times higher in patients with bipolar disorders than the general population and up to one-third of those with this affliction attempt suicide at one time or another-a rate that is among the highest of any psychiatric disorder.

Bipolar disorder is a tough diagnosis at first, because those affected usually present with one extreme or another. Doctors have to get a very detailed history and call on others who have observed these changes on a cyclical basis before they know if the problem is bipolar disorder or major depression.

The medications for manic depression differ for those given for the single diagnosis of depression. Early diagnosis and treatment of the mood disorder is key in reducing the risk of relapse and improving the rate of response to medication.

Previously a disease where life insurance was rarely available, improved recognition and treatment has improved the prognosis for a more normal, productive lifestyle. According to Special Risk Managers, at least 1% of the population in Australia will experience bipolar disorder at one point or another in their lives. Getting help from somewhere like Special Risk Managers could help to match them with insurance coverage that bests suits them.

The biggest risk is suicide in affected individuals, followed by accidents (putting oneself in dangerous and provocative situations with inappropriate behavior and delusions of grandiosity) and also cardiovascular causes as well.

Insurers look for a stable pattern of adherence to regular psychiatric follow-up and medication use. Most are rated cases-even in the most favorable of circumstances.

Poorest outcome is associated with major and prolonged depressive episodes, severity of illness and increased cycling of symptoms as well as concurrent illnesses besides the psychiatric problem. Even in its best and most favorable presentations, bipolar disorder is a very difficult condition to control and manage effectively over a lifetime.

Laboratory findings are a usual part of the insurance application and, hopefully, complete the picture of a healthy applicant issued as applied for.

Sometimes, lab abnormalities are ex­pected and go along with already known disease entities, such as diabetes and abnormal (even when mostly controlled) blood sugar measurements. Sometimes they may show entities that have to be declined or further investigated, such as with kidney failure or newly found elevated PSA levels. However, out of the clear blue, lab tests can come back abnormal and provide an unexpected surprise. They may be run again to make sure the results are matching to the initial ones, this is where drying tools can be useful. By preserving biological products tightly so that no cells are destroyed or tampered with, this gives the chance for the technician to run tests again without external interference.

At times when an insurer declines or rates a case for abnormal laboratory values, the first step is to find out more about the problem by asking, “Does it make sense?” given the applicant’s history and medical condition.

For example, a very high hemoglobin A1C for an applicant with diabetes will show that the disease is not controlled properly and must be taken into consideration when underwriting. Sometimes such a finding indicates newly found diabetes-before the applicant has been diagnosed by his physician.

Sometimes, though, the handling of samples, the conditions in which they were processed, and even the background of an applicant make the results less drastic than they initially appear.

Kidney function tests are a good example. Creatinine and BUN are two tests used from the blood profile (besides the additive help of a urine specimen). When both are highly elevated, they are most often indicative of kidney function compromise. However, BUN can be elevated with a normal creatinine when a person is simply dehydrated-either from water deprivation or even from a diuretic given to control blood pressure. Certainly, this is an explainable rather than a declinable circumstance. Other times, creatinine will come back very elevated and the case will be declined as renal failure even though BUN is normal.

Samples that are run many days after being drawn or manhandled in the mail are likely suspect, especially when an applicant’s previous health has been normal. Asking for a repeat test generally solves this dilemma.

Elevated PSA (prostate specific antigen) is a result that can cause adverse action on an application but does not always mean a policy won’t be issued. An elevated value shows an increased likelihood of prostatic cancer, but sometimes a value that has been previously investigated and is within the norm for that individual is as good as normal. Pointing that out to an insurer keeps the case moving along successfully.

In some circumstances, though, a normal PSA value may result in an adverse action. For example, a change in a short period from the low end of the normal range to the high end may show a disease process in evolution. In such circumstances, a doctor visit may either find a transient cause (infection, irritation) or one that requires further investigation to rule out a malignancy.

One other commonly found quandary is with liver function tests. Even in the absence of occult hepatitis, most individuals feel absolutely fine even though they have significant liver function test abnormalities. Liver disease can occur in conditions such as increased alcohol intake, which make them a serious finding. Yet liver function test abnormalities can also be found when an applicant has a reaction to medication taken for something else.

Common medications given to decrease cholesterol often elevate liver tests and the findings are completely reversible when the medicine is stopped. Other examples can be a severe viral infection or even a mild form of infectious hepatitis, when tests rise to significantly high values during the acute illness and return to normal a short time later. Repeating the test after an illness has passed or medication is stopped often normalizes the situation without permanent harm-to either the applicant or the application for coverage.

Always find out exactly what the problem is when an abnormal blood value causes an adverse action, even if there is an underlying disease entity. At worst it will be something an applicant must take to his doctor for further examination and treatment; at best, it is a finding that turns out to be only a moment in time without any consequence whatsoever. 

Coronary artery disease is currently the leading cause of death and disability in the United States. Doctors have identified risk factors for treating and delaying cardiac disease, and this testing has likewise become more sophisticated.

One of these tests that doctors order and underwriters assess carefully is the coronary artery calcium score, or CAC. While it is an independent predictor of coronary artery disease, the score is combined with information from conventional cardiac risk factors to provide very useful information.

In coronary artery disease, a fatty material called plaque narrows the coronary artery diameters and limits blood flow crossing the heart. This is the most common cause of heart disease in both women and men and leads to chest pain, heart attack, arrhythmia and, in advanced cases, heart failure. Coronary artery calcium screening is done with an electron beam CT scan which looks for coronary calcium on the cardiac vessel walls. Calcification within the arteries can be one of the earliest signs of heart disease and can precede any signs and symptoms of the disease.

In 1990 Arthur Agatston (the same cardiologist we know from the South Beach Diet fame) and his colleagues showed that individuals with high coronary calcium scores were at 10 times the risk of developing coronary artery disease than those with lower scores. Other studies showed that individuals with coronary calcium scores above the 75th percentile for age were 11 times more likely to develop a cardiac event compared to others having scores in the lower 25th percentile, and significantly elevated scores in the 90th percentile were 23 times more likely to develop coronary artery disease.

Testing results start with a score of zero, which is when no calcium is seen. A score of 80 or more is associated with an increased likelihood of coronary artery disease, independent of the presence or absence of any other risk factors. Risk increases with higher calcium scores, and a result of more than 400 is quite significant. That being said, scores can rise into the thousands, with 3,000 being close to the upper limit.

 Why aren’t all insurance applicants (and for that matter, all individuals) subject to a calcium scan as a routine for their health care? The scan is painless, is usually completed within 15 minutes, and involves less than 60 seconds of actual scanning time in most cases. The major reasons are the cost, the absence of a need for excess radiation, and the fact that most people can be risk stratified without such a scan. First, the test is of low value in those who are already at low risk of coronary artery disease and who don’t have significant risk factors. The Framingham Risk score, which is a combination of risk factors evaluated that include high blood pressure, age, smoking status, diabetes, obesity, cholesterol and physical activity can help define risk noninvasively. So in those at low risk of developing cardiac disease, the test is not useful.

In those in whom cardiac risk is high, such as people who have several risk factors, have suffered a cardiac event, or have illness relatable to cardiac disease, the score adds little. Those individuals will have more conclusive testing for cardiac disease and active modification of risk factors by their doctors, whether by medication, intervention or increased lifestyle modification. So the scan isn’t additionally helpful in this situation either. For those who are close to someone who might fit into this category, it might be wise to complete some CPR training at the Vancouver C2C First Aid Aquatics Training facility or somewhere similar so they are better equipped to deal with a cardiac event.

Scanning may be most helpful in intermediate risk cases in which doctors are deciding whether to add medication or make major modification in risk factors. Much stricter control of blood sugar, blood pressure or cholesterol may be undertaken with an intermediate risk score. Likewise, insurers make use of these scores in order to quantify risk. Those with higher scores who are not modifying risk factors aggressively or are at higher risk for future events when the score is combined with other risk factors are assessed differently regarding future risk than those whose scores are low and in whom risk factors are either minimal or treated aggressively.

It’s a little like a spellbinding murder mystery, when there is cause for alarm and the clues are put out there, but no one investigates or tells you the final outcome. While every medical story or set of symptoms may not be New York Times best seller material, there are frequently open case files and dangling suspicions that need to be investigated and confirmed or shut down as problems. Ironically, problems such as these have often been fully investigated and become closed cases, but the APS trail still appears open to an underwriter and keeps an application from reaching a successful sale and conclusion.

The doctor thought it was nothing can certainly be the case in many instances. For example, chest pain originally thought to be angina turns out to be nothing more than musculoskeletal discomfort. Yet the doctor mentioned treadmill, catheterization, further work-up, but the follow-up isn’t there. The underwriter can’t keep from wondering if an applicant just never returned for necessary testing and diagnostics or if the testing was done and was negative—there must be a successful conclusion. If everything was benign, the doctor needs to say so in writing. If a necessary follow-up visit had to be made, it needs to occur. The “story” must be finished.

The last testing showed everything was okay. For instance, a PAP smear showed pathological abnormalities (human papilloma virus or cervical intraepithelial neoplasia changes) and the gynecologist remedied it with a procedure. Yet no follow-up testing is in the file showing that this was eradicated. Or, a PSA was elevated and a trip to the urologist was made. If everything was fine, a value was repeated and it was normal, or an intervention was made, these actions or procedures need to have follow-up documentation. An applicant may have had everything done to show resolution of a problem, but to an underwriter, the clues are out there and the alibi hasn’t been established. Finish the story.

Many times a doctor visit is established with a bizarre set of symptoms that could be serious disease. Numbness and tingling in extremities could be multiple sclerosis or new onset neuropathy. Severe headache and double vision could be a bad viral infection or brain tumor. Loss of balance and fall could be neurologic disease or inner ear infection. All these could have been transient occurrences of a very benign process; yet if nothing says they were solved, there is a problem. Finish the story.

Sometimes as underwriters we understand when a set of signs and symptoms are not things to be worried about from a mortality standpoint but, on the other hand, some set off fire alarms that need a response. When statements such as “throwing up blood,” “coughing up blood,”  or “suspicious for melanoma” are made in a doctor’s notes without a follow-up, it’s not a closed case until proven to be so. It may require a follow-up visit to the doctor to be cleared, or a note back from the doctor with his impressions or suggestions for further study (if any). These are situations with potentially very serious outcomes. The loop needs to be closed, and a resolution demonstrated.

Far more often than not, the necessary information to give the underwriter enough peace of mind to issue the case is right at the applicant’s fingertips—it has already been done but just needs to be shared and communicated by the investigating physician. Other times, only a quick follow-up visit or test is required.

Above all, finish the story! We all want a happy ending. 

The simplification of EKG requirements in recent years is certainly well-documented and also well-appreciated. Brokers and agents, as well as company management, are always looking for ways to decrease acquisition costs and make the insurance process simpler. This has been no more evident than with EKGs and treadmill exams, where the age and amount requirements have become more liberal in requiring them less often.

One newer blood test, referenced often in previous Broker World columns, that has been making progress as both a screening and diagnostic test is the NT-proBNP.

BNP (B-type natriuretic peptide) is a substance secreted from the ventricles of the heart in response to excess stretching of the heart muscle cells. Looking at it a different way, BNP increases when heart failure develops or worsens and is associated with several conditions such as acute coronary syndrome and cardiac failure. If BNP is extremely accurate in picking up conditions that compromise the heart’s function, can a simple blood test replace EKGs and treadmill stress tests in underwriting?

First, let’s discuss what BNP is good at uncovering. BNP rises significantly in what is called a hemodynamically stressed myocardium, meaning a heart having trouble performing at its maximum efficiency. BNP level in blood rises when there is active ischemia—times when the heart is lacking oxygen and failing as an efficient pump and it correlates quite well with three vessel, or advanced, heart disease. BNP level is also very good in diagnosing pump failure in the elderly, whose activity is decreased but overt signs of impending heart failure may not be obvious in physical examination or even in an electrocardiogram at rest.

Like all tests, BNP has its shortcomings and cannot be expected to be a “one-result diagnoses all heart problems.” It doesn’t directly correlate well with ischemia on exercise—one of the most telling ways heart blockage or occlusion at stress manifests. It is not a predictor in and of itself for future cardiac intervention like bypass or angioplasty. It does not show heart valvular disease. In addition, BNP levels can be increased in smokers and obese individuals even though heart function is normal in some circumstances.

When should an EKG be used in underwriting in addition to a blood test? An EKG shows an abnormal heart rate—important in diagnosing many underlying disease abnormalities, whether lower or higher than normal. It shows abnormal heart rhythms, which can lead to morbidity and mortality even in the absence of occult heart failure. In many cases, it shows a previously undiagnosed heart attack, which is important in patient prognosis even when the heart has recovered and a BNP level may have fallen back to normal range. An EKG is a relatively simple test a paramedical can perform even at the point of exam, and doesn’t cause a lot of inconvenience in obtaining it.

The treadmill EKG is a little more labor intensive and likely requires an applicant to go to a facility or doctor’s office to have it performed. It is quite helpful in diagnosing heart ischemia or blockage and, in some cases, can assist in locating a blockage and diagnosing severity. A treadmill EKG can detect abnormal heart rhythms during stress or times of increased heart rate—important because people can die of heart disease in other ways than just heart blockage or cardiac failure. In the face of questionable symptoms of chest pain or shortness of breath, it is an important adjunct to diagnosis.

That being said, a treadmill EKG’s yield as just a screening tool in asymptomatic people hasn’t been cost effective nor has it been worth the inconvenience in obtaining it routinely. Therefore, most companies only require the test in certain narrow age bands and, in fact, may reserve the test for only smokers with high face amount policies (where the incidence of undiagnosed heart disease is much higher). Many of those who have heart disease have already had extensive heart testing as part of their regular medical care, which even further limits the need for stress testing by the insurer.

So what part do NT-proBNP and EKGs have in insurance medicine and underwriting? The BNP is certainly becoming an important underwriting resource in diagnosing heart failure, allowing it to be priced appropriately as a risk factor or obtaining best rate consideration when it is in the normal range.

EKGs certainly still have their place in the current system of cardiac evaluation and medical screening in underwriting—at least until perhaps another “magic bullet” blood test adds to the progress of diagnosis in medicine, both in clinical and insurance medicine.