Robert Goldstone

GERD, or gastroesophageal reflux disease, is when reflux (backward flow) of stomach contents in the body causes symptoms or complications. While the stomach lining has protection against the effects of its own acid, the esophagus and upper gastrointestinal tract do not. The acid and the enzymes of digestion produced can cause damage when they are passed above the stomach level, and heartburn is the number one symptom, as well as pain and discomfort in the neck, throat and sometimes even the face. GERD may affect up to one in five adults, with half of those complaining of daily discomfort.

Most people with GERD have mild disease, but damage to the mucosal lining of the esophagus (also called reflux esophagitis) can occur in a third of cases and more serious complications may occur in others.

When functioning normally, food, enzymes and acid are prevented from flowing backward in the gastrointestinal tract by a ring-shaped muscle called the lower esophageal sphincter (LES). When a person is standing, all the contents naturally flow downward, so symptoms of GERD are minimized. That’s generally why heartburn is worse while lying down. Smoking and certain foods (chocolate is implicated) may also interfere with the sphincter muscle, making reflux worse. And reflux is worse after a meal, when the stomach is full and the acidity in trying to digest contents is highest.

As mentioned, heartburn is the primary symptom. It is worse up to an hour after meals and when lying down. The flow back of contents starts to transform or change normal cells in the esophagus, which leads to complications as will be mentioned below. The degree of heartburn doesn’t always correlate with the actual physical damage being done, so even mild symptoms can have striking and pathologic changes.

There are some unusual signs and symptoms of GERD, including cough, asthma, chronic pain and even chest pain. One of the more difficult differential diagnoses is with cardiac chest pain. Some people may feel pain that mimics a heart attack; others may actually be having angina or cardiac disease and dismiss the pain as heartburn. Physical signs and examination are usually normal in most people with GERD.

What are the major complications of GERD? Barrett’s esophagus is a condition in which the squamous epithelium of the normal esophagus is replaced by metaplastic cells. Some types of the metaplastic cells (usually specialized intestinal metaplasia type) go on to become esophageal adenocarcinoma—one of the most deadly gastro-intestinal cancers. One half of a percent of patients diagnosed with Barrett’s esophagus are diagnosed with adenocarcinoma each year. That’s a 40-fold increase in risk over those without Barrett’s, which emphasizes the need for prompt and ongoing treatment.

Another complication is peptic stricture, which is the gradual development of inability to swallow. This is progressive over months to years and may occur in 5 percent of affected people. The stricture is virtually a narrowing of the esophagus by scarring and may need to be manually dilated periodically with surgical instrumentation.

Medical treatment involves antacids and smaller amounts of non-acidic food if symptoms are mild. Antacids have been used for years, but are limited by their short (two hours or less) duration of action. Newer medicines include H2 receptor antagonists (many of the now over-the-counter formulations found in most pharmacies) or longer term therapy with proton pump inhibitors, which not only control heartburn symptoms but heal the erosive esophagitis in more than 80 percent. These are used for more extended periods of time or can be continual therapy. Surgical treatment (fundoplication) may be used when medical treatment is ineffective.

Most people with GERD have their symptoms well controlled and do not go on to develop serious disease or complications, resulting in both standard and preferred issues. Barrett’s esophagus may require a rating or rarely be declined, depending on how extensive it is and what the pathological changes are. In those cases, an underwriter may want to see results of endoscopy (a tube/endoscope inserted by the gastroenterologist to assess damage and healing and to biopsy if needed) to show healing and a good response to therapy. 

There are times when an insurer asks for an attending physician statement (APS) and it truly becomes an impossible task. An underwriter relies on an APS to give detailed doctor’s information crucial to an underwriting decision. Having the most complete picture of an applicant’s health goes a long way toward being able to offer the most competitive rate and knowing there are no surprises lurking in an accurate risk assessment. There are times, though, when an APS isn’t that easy to obtain (or even just about impossible) and a “Plan B” has to go into effect.

There are all sorts of legitimate reasons an APS can’t be completed: A doctor may have retired and closed his practice. An applicant for insurance may not properly recall his doctor’s name or address. A doctor may not have kept records past a certain date or may have merged with another medical practice, making older files difficult to locate. An applicant’s files may have something personal or confidential in them which causes his doctor’s office to refuse to release them to a third party. And finally, although insurers pay quite reasonable amounts for the time and expense necessary for retrieving records, some offices insist on astronomical amounts to complete such a request.

After a number of good-faith efforts to get medical information, both the broker/agent and insurer need to focus on ways to gather the same information from other sources. Inordinate delays can result in a case going to the competition or making the applicant impatient enough to change his mind about the whole process going forward. Time is always of the essence in policy placement.

The age of the information is sometimes relevant, too. For instance, cancer or another condition that no matter what the pathology report showed would be standard at this point. Evidence of proper follow-up care could also make an original report not valuable enough to wait on. Good enough detail in succeeding notes may give the underwriter all he needs to know without chasing the original report, or summaries from other consultants seen may often give enough information to proceed.

If a hospital report is what is missing, notes from a doctor’s follow-up visit are often detailed enough not to wait for the hospital’s confirmation. Many times a consultant from another field may have the pertinent information. For example, a kidney specialist may have summed up everything that was being waited on from an oncologist; in fact, consultations are notorious for repeating past medical history almost ad infinitum. In rare circumstances a hospitalization may sum up the pertinent medical history that cannot be obtained from an outside physician’s office.

A letter from a physician can help to clarify if he specifically addresses the condition or history in the present, minimizing the need for the original notes. When a physician’s office asks for unreasonable fees, a reminder from the proposed insured that this is important to him as a consumer—much less as a patient—will encourage the office to be more cooperative.

In cases in which the original information is confidential and a doctor does not want to release it, either a confidential summary from the physician or a one-to-one talk with the insurer’s physician may be the solution.

Insurers know that if they waive an APS and issue a policy their right to go back and get it after the fact is lost. Short of proving fraud, a company would prefer to have all the information it needs at its disposal before offering or issuing a policy.

For those times when an APS just seems too impossible to obtain, both an insurer and agent must work together to see if new information or information already available may be enough for an “as-is” decision.

If you have ever been required to go for a blood test before, you will know that most test results return from the laboratory, accompanied by xylene resistant slide labels, that indicate a measured value and a reference range next to it. The reference range is supposedly the “normal” range of values for the population being tested. The range is wide (after all, normal is relative) from a low end of the scale to an upper limit.

There are times, though, when normal truly isn’t-when the value is in range, but represents a change from prior measurements or a proportion relative to another value that makes it indicative of a problem.

Kidney function testing is one example. Generally, besides a urine specimen, the serum measurements for kidney function are creatinine and blood urea nitrogen.

Creatinine, the more sensitive one, has a range of approximately 0.8-1.6 mg/dl. A value of 1.6 may fall within that range, but if the value had been 1.3 six months before and 1.0 the previous year, this could be indicative of impending or insidious renal failure. The next value may be far outside the reference range, but it could have been easy to see coming, despite being a “normal” value.

PSA, or prostate specific antigen, is another one where one value doesn’t tell the whole tale. Normal value on PSA is between 0.0 and 4.0 ng/ml. A 3.5 may be highly abnormal when it follows a reading of 1.6. An isolated abnormal PSA value can be a predictor of prostate cancer when it’s doubling time is short or the rate of the rise of PSA (PSA velocity) is high. Each time, this normal value really isn’t normal relative to its predecessor.

Another instance is after treatment for prostate cancer. After a radical prostatectomy (removal of the gland by surgery), the PSA level should be very close to zero, if not exactly that. A well within normal range number of 2, for instance, can be proof that the cancer was not fully eradicated and there is a recurrence of the disease.

Cholesterol levels are the subject of both wide normal ranges and controversy. Older reference ranges have an upper level of cholesterol of as much as 260 mg/dl. However, the American Heart Association, as well as the American Diabetes Association, would prefer levels south of 200 mg/dl, and even under 160. In addition, as cholesterol has both good (HDL) and bad (LDL) fractions, a “normal” cholesterol of 190 may not be normal if the good fraction is only a small percentage of it. That, too, would be grounds for medical treatment.

One more example of normal values raising red flags is in tests where the proportion of one value to another is not as expected. Total proteins, one of the insurance tests run routinely and usually present in comprehensive metabolic panels run by medical practitioners, measures the total amount of proteins in the blood plasma. Proteins are important building blocks of cells and tissues, and they are important as measurements of good health and body regulatory functions.

There are two types of proteins-albumin and globulin-found in the blood. Albumin is a carrier of small molecules and keeps fluid regulation in blood vessels orderly. Globulins have enzymes, antibodies for fighting disease, and other proteins. Normally, albumin levels are about 3.5 to 5.5 g/dl and globulins 2.1 to 3.9 g/dl. The ratio of albumin to globulin is around one and a half to two times, with albumin the higher absolute value.

What happens when albumin is 3.6 and globulin is 3.9? Both are normal values on the reference range, but an inverted albumin to globulin ratio (in this case a fraction less than one) can indicate underlying cancer, immune system deficiencies, intestinal, kidney or liver disease. It would have to be looked into much more closely than a “normal” set of values would indicate.

Normal is certainly relative. Normal laboratory values are what we all hope for, but ironically, some are more normal than others.

Underwriting requirements are a necessary part of an insurance application even if they are sometimes inconvenient or trying for broker, agent and client. Getting as much favorable information as possible allows insurers to offer competitive and often preferred rates when good health is affirmed. However, in the world we live in today, when time is of the essence and competition rules, most companies have cut back on what is being routinely asked for as part of the underwriting process.

An insurance exam by a physician was once always considered an important part of a case, particularly for middle to older age groups and higher amounts of coverage. Doctors’ offices were accurate at height, weight and blood pressure measurements, and not only did a doctor usually get accurate answers to each question on the exam form, he was able to expound in a way to be more helpful to the insurer when there was a positive finding. Physicians elicited more detailed responses and could pick up a cardiac murmur or physical abnormality as part of their training.

Alas, getting a routine appointment for an insurance physical or exam has become more difficult, and clients often have to wait to be seen, causing an inconvenience to them as well as their representatives. Plus, fees have become difficult to negotiate. As a result, insurers now accept the more convenient and easily obtainable paramedical exam with the hope that information they receive (along with the normal attending physician statement) will be adequate for an accurate assessment.

EKGs were once routine for almost all adult ages, but again the ability to get a screening EKG in an easy and timely manner sometimes has become a hindrance to a busy client’s schedule. Fortunately, studies by insurers have found that the utility of the EKG in otherwise asymptomatic individuals is not cost-effective. Even at relatively higher amounts (up to millions of dollars of risk), an EKG in the absence of symptoms or obvious abnormal family or personal history is not helpful.

In fact, particularly in athletes, an EKG can be positive only because these clients are highly trained with hearts that compensate for their higher levels of aerobic activity. While there have been well known athletes who died sudden cardiac deaths from abnormal hearts, they generally had symptoms that were known to their teams and doctors.

Today, EKGs are only routinely obtained in very high face amount cases in those under 40 years of age.

Chest x-rays and treadmills were also common requirements whose routine use has been curtailed by insurers because both required an office visit, a larger outlay of time, the expense of procurement, and specialized equipment that not every doctor’s office could make readily available. As a result, insurance companies performed large case studies that found chest x-rays were needed for only a specific cause or history and treadmills were needed for smokers only. Many companies limit treadmills to age and amount requirements for smokers (where the incidence of cardiac disease is greater) and in more limited age brackets (e.g. 56 to 69).

The next “at-risk” requirement appears to be blood testing. No one loves to have their blood taken, but the amount of information available in testing is invaluable for predicting current and future risk and using favorable results to be more aggressive in competitive pricing. Some companies are working with oral swabs as a substitute for blood (a swab is inserted in the client’s mouth and held for a period of time).

Oral swab tests are less inclusive and less accurate, and usually not amenable to the degree of additional testing that can be done on a blood sample. For example, if an abnormality is detected, the existing blood can be further tested in other confirmatory ways to rule out any false positive finding. A questionable swab may lead to a requirement of blood testing afterward—an inconvenience far worse than having blood drawn in the first place.

As much as underwriting requirements are a necessary evil in the application for a life insurance policy, they give an insurer the information and scientific backing to be able to price policies both competitively and aggressively, and make policies even more affordable than they otherwise would be.

The incidence of kidney stones is rising worldwide, especially with increasing age and among women. The risk of developing a kidney stone has now risen to between 10 and 15 percent and is trending higher. A probability of stone formation after an initial episode is 20 to 50 percent for the next ten years. Some contributing factors for kidney stones are insulin resistance, obesity, gastrointestinal and absorption problems, and specific diets and medications.

The pain of a kidney stone is extremely severe. It starts with sudden pain and cramping, usually in the flank, as the stone begins to travel slowly down the urinary tract. There can be nausea, vomiting, fever, chills and blood in the urine. Stones located in the middle of the renal pelvis may not have symptoms, but urine will be abnormal and sometimes testing may show impaired kidney function.

The types of stones and their composition depend on many factors. The most common type is calcium oxalate, making up about 60 percent of all stones. Calcium phosphate makes up another 10 to 15 percent. Cystine stones—the third most common type—may have genetic factors as a cause.

Geography plays a significant role in stone formation. High temperature and high humidity are contributing factors, and indeed hot summer months are the most common time for presentation of stones.

Diagnosing a stone is quite easy when the presenting pain in the flank area is sharp and associated with nausea and vomiting. Most affected individuals are unable to find any comfortable position to relieve the pain, which may be migratory as a stone works it way down from the kidney through the ureter and into the bladder.

Examination of urine will show blood on most occasions, and a stone that is passed should be analyzed to determine its composition. X-rays and ultrasound can demonstrate a stone’s composition, particularly when calcium based (which is radio-opaque).

Uric acid may also be a culprit for stone formation. Affected individuals may either over-produce uric acid or they may have too much uric acid in their bloodstream. This may eventually lodge in a spot in the kidney’s delicate filtration tubules and begin to form a stone. Uric acid is radiolucent and not seen on x-rays, so ultrasound is important in making the diagnosis for these cases.

Recurrent stones pose problems (besides the obvious pain and discomfort that accompanies them) when they obstruct the kidney and prevent normal urine flow. The backup not only distorts parts of the urinary tract with urine, but can compress and eventually cause renal failure if allowed to collect and form recurrently. Large stones may form in the pelvis of the kidney (staghorn calculi) and may have to be removed surgically to prevent permanent renal compromise.

Stones have the worst prognosis when they are bilateral, recurrent and/or lodge in the kidneys and are unable to be passed (staghorn). Medication, such as thiazide diuretics for calcium stones, allopurinol and dietary changes for uric acid stones, and increased fluid intake in almost all types of stones work effectively to avoid long term complications and, therefore, standard and preferred ratings are available in most cases.

Laboratory testing is an essential part of risk selection. Most insurers run PSA levels to help test and screen for prostate cancer. In fact, the FDA has approved the use of the PSA test to help detect prostate cancer in men 50 and older.

The PSA test has been scrutinized for its value because incidentally found prostate cancer does not always become life threatening and false positives occur when this biomarker is elevated due to secretions from noncancerous inflamed prostate glands. However, it provides valuable information when risk factors such as degree of elevation and rate of rise are combined with a physical exam.

The recent release by the United States Preventive Services Task Force (USPSTF) has certainly stirred controversy, not only among the practicing medical community, but also in our insurance industry as well.

Basically the USPSTF’s message is that healthy men should not be screened with PSA testing because the test does not save lives overall and often leads to additional testing and treatments that cause pain and complications. The chairwoman of the USPSTF (ironically a pediatrician) stated that PSA testing cannot tell the difference between cancers that will and will not affect a man during his lifetime. That being said, there will be a lot of reaction in the medical field over the next weeks and months on this controversial recommendation. There are strong opinions on both sides of the PSA controversy.

Thousands of men who have had complications from being treated for prostate cancer of unknown virulence (including incontinence, impotency, bleeding, and effects of radiation on neighboring body organs) are vehement about the adverse effects. On the other hand, there is seemingly no end to the men who believe PSA detection and subsequent treatment saved their lives—men such as Major League Baseball’s Executive Vice President Joe Torre, bond financier Michael Milken, and former NYC Mayor Rudy Giuliani.

Two major health insurers are currently paying for testing and have affirmed they will do so in the short term. Others have taken a wait-and-see approach on their future position. The question of whether money will be saved administering the tests and avoiding end-stage cancer treatment versus the cost of the test and the complications of treatment make it a financial and political issue as much as a strictly medical one.

From a life insurance perspective, the choice about PSA testing seems a bit more clear-cut. Life insurers are in the business of assessing risk. Life insurance is priced on relative risk—those at the lowest end of the spectrum receive the best pricing and those at higher risk are likewise priced accordingly. Life insurance does not dictate who to treat, nor what treatment modalities should be chosen after evaluating complications and benefits. It is about life expectancy and providing for financial loss and beneficiary protection in that event.

PSA screening helps life insurers estimate a risk and provide more competitive rates to those whose risk is lowest. While no one can truly predict who will live for a long time and who will not survive prostate cancer, certain factors are quite clear and borne out medically.

Those whose PSAs are highest are most likely to have prostate cancer. Those with a lower free fraction PSA are more likely to have cancer than those in which an elevated PSA has a high free fraction. Those in whom PSA velocity rise is fastest are more likely to have cancer than those who don’t have this finding. Finally, those in whom prostate cancer is detected and definitively treated have better mortality than those who are untreated. This is not meant to take into account complications of treatment that are not life-threatening, but simply life expectancy—the tenet of life insurance underwriting.

Men have the option of treating prostate cancer or following it with their urologist for progression. They likewise have the option of not treating or not knowing; however, testing is a matter of preventive health.

Several years before, the USPSTF came out with a similar recommendation on mammograms: that they should be used far less or not at all as a screening procedure for women. That recommendation was met with even more controversy and has not appreciably decreased mammogram testing (which can certainly be life-saving when cancer is detected early).

Life insurers order tests all the time that assess risk but do not cause intervention. In fact, the entire blood profile—from liver function tests to evaluation of kidney status, fructosamine and hemoglobin A1C screening for diabetes and cholesterol and lipid panels—is designed to segregate risk and reward for those in whom the results show the best outcomes.

Life insurers do not practice medicine nor do they tell men and women what treatments or interventions they should be receiving. Likewise this will apply to PSA, where risk will be assessed just like any other parameter and priced accordingly.

Men have the right to know or decide not to know what their health status is or, with the counsel of their doctor, whether to pursue further treatment for any medical result. The right to be informed is a controversial issue—a decision that some don’t want to face while others insist on knowing. Either way it falls, knowing someone has a lower risk of disease is paramount to life insurance underwriting—and particularly the preferred pricing which the industry consumers demand.

All life insurers will be monitoring the debate on PSA testing very closely, conducting their own mortality studies and carefully monitoring those of major medical trials to see if any changes need to be made to the current model as well as what will work best and most economically for the life insurance purchaser and consumer.

In the meantime, PSA testing is a part of risk assessment that allows insurers to continue to make the most competitive offers possible, working with information that certainly helps to predict life expectancy over the long term.

Diabetes still remains one of the most prevalent diseases in the United States—an estimated 24 million Americans have insulin dependent type 1 diabetes mellitus, and there are many more with type 2 disease.

While diabetes is easy to diagnose when blood sugar values and other measurements are high, the lower level required for the diagnosis has always been in question. In particular, is there such a thing as pre-diabetes, and how is it treated differently than a diagnosis of type 1 or 2 diabetes?

Generally the diagnosis of diabetes takes into consideration three values, used not only in clinical practice but also in insurance laboratory evaluation.

The blood glucose level is a measurement of blood sugar in the body at any given time. It may vary from hour to hour, and minute by minute.

Fructosamine is the glucose level on serum proteins and provides the state of glycemic control for the preceding one to two and a half weeks.

Hemoglobin A1C is a measurement of glucose on red blood cells that provides an evaluation of the state of glycemia for the preceding 8 to 12 weeks.

While blood glucose and fructosamine are ideal in clinical practice for adjusting doses of medication and evaluating short term control of diabetes, hemoglobin A1C (HbA1C) has proven to be the best indicator of longer or sustained diabetic control.

In January 2010 and again in January 2011, the American Diabetes Association (ADA) began recommending HbA1C as a criterion for the diagnosis of diabetes and prediabetes. Traditionally, the ADA had relied on values of plasma glucose (a fasting level of 126 mg/dl or higher), a glucose load value of no more than 200mg/dl (as in the older and more frequently given glucose tolerance tests), and any random blood sugar over 200mg/dl at any time with symptoms of hyperglycemia. As the measurement of HbA1C has become more standardized and accurate, the ADA now relies on it for classifying and making the diagnosis of diabetes as a more representative single blood test.

The ADA considers a Hb A1C of 6.5 percent or greater to be diagnostic of diabetes. Since the median length of time that this blood marker measures in terms of control is an average of 8 to 10 weeks (a red blood cell lives up to 120 days in the body), it assumes that the level of glucose has been higher than normal for a sustained length of time. The “normal” level for Hb A1C is anything less than 6.0 percent, although a majority of healthy non-diabetic individuals have numbers from 4.0 to 5.5 percent.

Since 1997, the ADA has recognized the existence of intermediate levels of glucose elevation that are out of normal range but have not yet reached the diagnostic levels for diabetes. These levels make up the diagnosis of what is now called pre-
diabetes. They apply to fasting glucose, to levels based on values obtained on a glucose tolerance test, and now to Hb A1C. The new ADA guidelines recommend HbA1C levels of 5.7 to 6.4 percent for the diagnosis of prediabetes.

Why is a diagnosis of prediabetes important? The American Academy of Clinical Endocrinology emphasized that individuals with Hb A1C levels between 6.0 and 6.5 are at substantially increased risk of developing diabetes—up to 10 times the risk. Knowing this fact can allow people to make both lifestyle changes and dietary changes that can significantly delay the onset of diabetes and resultant complications. Doctors sometimes institute pharmacological therapy as well at this stage (including medications such as metformin), which improve blood sugars and are considered first-line drugs in keeping blood sugar in control in non-insulin dependent diabetes.

What is considered adequate control? In non-insulin dependent diabetics, the American Diabetes Association recommends keeping HbA1C levels as close to 6.0 percent as possible. It is shown by multiple studies that doing this reduces the risk of diabetic eye disease (retinopathy), nerve disease (neuropathy), kidney failure or compromise (nephropathy), and cardiovascular events.

In those who are older, have cardiovascular disease or need multiple medications or insulin, a less aggressive goal of 7.0 percent is set, because control of diabetes that is “too tight” has a whole set of problems, including low blood sugar, difficulty in consistent control, and neurologic compromise.

Most, if not all, blood panels that insurers obtain have HbA1C levels as a part of them. Others reflex the value if a high glucose or fructosamine level is found. Those with prediabetes or borderline values can qualify for both standard and preferred policies when the rest of their history and self-care/doctor follow-up is evaluated and found to be favorable. Many doctors are quite proactive in starting medication at a very early stage when the risks of diabetes are higher and insurers focus on the degree of blood sugar control and positive lifestyle changes to make competitive offers rather than the fact that a medication is being used.

Older age underwriting remains a very important part of business strategy for life insurers. Medical advances that increased longevity and life expectancy have helped more senior applicants obtain life insurance at affordable rates, but experience has worsened in the last few years as premium financing and third party assignment have become a significant percentage of submitted business. As a result, anti­selection, both medically and financially, has become an important consideration for insurers to take into account.

One of the most important parts added to the insurance application process for those over a certain age is cognitive testing. While no one is testing for “Einstein IQs” or the ability to run a multinational corporation, screening for dementia or significantly diminished mental capability is important for senior applicants. While the transition to lowered intellectual capacity with aging is inevitable, dementia results in a sharp decrease in life expectancy compared to the average population of similar age. In fact, life expectancy can be decreased by five and six times normal in males and females, respectively.

Dementia cases are often not picked up in traditional underwriting without cognitive testing. Earlier cases are missed when questioning is more conversational than factual. Those with dementia don’t often admit it to a doctor or anyone else for fear of losing their independence. Doctors likewise are not proactive in recording information about cognitive impairment in their medical notes.

There are a variety of tests administered as part of the insurance application for older age applicants. They include an Alzheimer’s quick test, a clock drawing test, a delayed word recall (ability to remember words mentioned five to ten minutes later), a mini-mental status exam and cognitive activity screens. Companies also have their own forms, which are a composite of information needed to make a reasonable assessment of mental function.

Cognitive questions often include orientation to month, year, day of the week and time of year. Anywhere between three and 10 objects will be repeated to the applicant, and a short time later the applicant will be asked to recall those objects. Not even the sharpest of us always can remember them all, but clearly there are normal and abnormal results. Clock drawing (to a specific time) has also shown to be a good indicator in picking up more advanced cases of cognitive impairment.

Many older age supplemental exams will include activity questions and assistance/mobility questions (these, by the way, may be performed by a doctor or a trained paramedical). The ability to exercise, drive, or either work or volunteer outside the home are positive prognostic factors toward longevity. Likewise, those that are able to complete activities of daily living without assistance and manage their own household have better long term mortality experience as well.

Testing may have its occasional drawbacks—at times everyone has a bad day or misinterprets the directions to the test, or sometimes even English as a first language (for both the paramedical and the applicant) can get in the way of proper exam performance. So can reduced hearing.

Most companies find that those performing well on cognitive and activity/mobility questioning experience greater longevity than those who are compromised and, as such, insurers can offer insurance at both affordable and competitive rates with the addition of this information.

As early detection and treatment for people with cancer becomes increasingly improved and widespread, more and more cancer survivors are applying for insurance with favorable outcomes—and receiving standard policies.

Unfortunately, initial treatment with radiation, chemotherapy, hormonal therapy or surgery can sometimes result in both local and systemic problems years forward, including treatment-related new cancers. Careful surveillance for both a late recurrence of a primary cancer and the evolution of a second primary one is essential, not only to prolonged survival but also to successful underwriting.

There are not a lot of statistics and studies available that address long term monitoring, surveillance and preventive care for cancer survivors. Many cases in which cancer has been successfully addressed don’t have necessary follow-up by experts such as oncologists. Plus, primary care physicians sometimes lose sight of a previous cancer diagnosis in treating other problems of age. The coordination of care with an oncologist is important—not only in maintaining good health in the present but also in being on the lookout for potential problems before they become difficult to address in the future.

Breast cancer, for example, is still one of the most common of all malignancies developing in up to one in eight women. Yet successful initial treatment doesn’t always guarantee a lifelong cure. Breast cancer can recur as either local disease or as distant metastasis years after treatment has been completed. Remaining affected and even unaffected breasts must be examined regularly to detect any early recurrence.

When treated with radiation, second malignancies may occur later in the radiation field. This is similarly true with chemotherapy, where bone marrow suppression, cardiotoxicity and second malignancies can likewise occur. Long term survivors have also been found to have a higher risk of cardiovascular disease and must be monitored carefully over the years.

Prostate cancer is another disease in which late recurrence can happen even after early successful therapy. Lifelong follow-up must occur, with clinical examinations and PSA measurements.

Colorectal cancer that has been treated with surgery has a 10 to 50 percent recurrence rate (depending on stage, pathology and degree of extension); thus, regular colonoscopies should be done in succeeding years. No follow-up can be potentially fatal with colon cancer that is not monitored over time.

Head and neck cancer is particularly deserving of careful follow-up. The most common cause of death three or more years after treatment is actually a second primary cancer, because aero-digestive cells are also affected by the same carcinogens (tobacco and alcohol) that were contributory to the original malignancy. Continued smoking after cancer treatment is particularly ominous in this regard. Thyroid cancer is quite common when a neighboring organ has been treated.

Lung cancer is another type that is noteworthy to mention. More people now survive lung cancer than ever before; however, continued and careful follow-up is necessary for those survivors. For instance, patients who have received chemo or radiation therapy for lung cancers have a two to three times higher risk of developing cardiovascular disease. Respiratory problems are also common in lung cancer survivors. Many have some degree of chronic obstructive lung disease before treatment, and surgery and chemo-radiation can further compromise lung function.

Chest wall malignancies such as sarcoma are also found in higher frequency post radiation therapy for lung cancer.

Medical advances have created more and more cancer survivors, and many of those survivors have insurance needs as their lives are graced with more years. While many of them now have standard life expectancy, they are at higher risk for recurrence and complications of therapy. For that reason, careful and regular follow-up and health maintenance are keys to an underwriter in making the best offer possible for insurance.

Not a disease you might choose as a common underwriting impairment, malaria, a parasitic disease in humans, is far more common than anticipated and potentially deadly when contracted-causing hundreds of millions of illnesses and probably more than a million deaths a year worldwide. While much of the insurance buying population may not live in endemic areas for malaria, if you find to have a mosquito problem in and around your home, you need to make sure that you have the relevant protection. Whilst insurance is vital for people who are traveling to areas where malaria is known to be, something as simple as looking at these Illinois terminix locations, for example, can help you to establish which pest control companies are in your area. Regardless of where you live, there will be similar companies near you, so if you feel that you have a mosquito problem, don’t be afraid to reach out to the relevant people. When it comes to insurance though, it is quite common in travelers from non-endemic areas who have visited the tropics.

Malaria is transmitted by the bite of infected female anopheline mosquitoes. During feeding (or a bite), mosquitoes inject sporozoites, which circulate to the liver and start an infection, often without symptoms. They are then released by the liver into the bloodstream and rapidly infect red blood cells. One of the biggest problems with malaria is that many forms are not killed with most commercially available drugs and, in addition, even getting over a severe illness is not protective from a relapse of parasites still in the system. Immune status is also important-those who have not been exposed to the disease are at high risk to develop severe forms of it.

A classic attack of malaria begins with a headache and fatigue, followed rapidly by fever. Chills, high fevers and sweats are the classic triad of infection, and in between episodes, affected individuals will look well. Fevers may come in 48 to 72 hour cycles and convulsions and liver failure can occur. Anemia, jaundice, nausea, vomiting and muscle aches are also common.

Since malaria isn’t always suspected early in the disease cycle, diagnosis and treatment may be delayed. Prompt treatment is essential, since uncomplicated malaria responds well when treated appropriately. The overall mortality is close to one in one thousand with prompt diagnosis and therapy. Evaluation for malaria is imperative for those who have traveled to endemic areas and experience sudden and sharp fever.

When diagnosed, malaria should be treated quickly-blood smears show the most accurate diagnosis and rapid serologic diagnostic tests are also helpful. Since symptomatic malaria is caused in the earlier stage when the disease is released by the liver into the red blood cells, prompt administration of anti-malarial drugs is effective at this stage. Therapy, with drugs such as chloroquine, amodiaquine, mefloquine and primaquine, must be administered in adequate doses and for sufficient periods of time.

Travel to some areas of Africa, Southeast Asia and Central America require prophylaxis with medication, administered a few days before leaving on the trip and continued for at least a week after arrival at home. Sometimes the parasites become resistant to medication and newer drugs have to be administered to eradicate the infection.

In those who have had malaria which has been adequately treated and who have gone a significant period of time without reinfection or fevers, the disease is considered eradicated and has no underwriting consequence. However, chronic cases have a much poorer prognosis, and an applicant known to be harboring the infection in spite of treatment would not be considered insurable. Cases in which the disease has affected the heart may suffer from chronic arrhythmias, conduction defects and heart failure, and likewise have poor long term outcomes. Fortunately, most cases of malaria eradicated early and treated adequately do well over time.