Robert Goldstone

There is nothing much worse than finding out that a completed application is suddenly incomplete—especially when a medical factor is holding things up. Attending physician’s statements, lab tests, hospital notes and the like are hard enough to get in the first place, and that much more difficult when both client and doctor feel they have provided everything needed. In these cases, it’s best to immediately find out what caused the hold up and the easiest ways to proceed quickly and painlessly.

Follow-up of a medical condition or abnormal finding is helpful but not always necessary. For instance, notes may be missing from the past which are well-addressed by a subsequent visit or further testing. The 2008 abnormality or APS visit may not be needed if one from 2010 brings everything up to speed.

Likewise, the doubts of an underwriter from one physician’s note may be adequately explained by a specialist’s or consultant’s note. If the past result really isn’t going to influence underwriting in the present, that requirement can be waived and additional sources can be relied upon.

Much of whether follow-ups are necessary depends on the underlying condition. In cancer cases—especially when the cancer is relatively recent—a follow-up note or test that shows the applicant remains cancer free is of course essential. Likewise in heart disease, an underwriter may want to see that a client is following through on care and that long term compliance translates to long term survival. However, when the disease is more chronic, waiting for a subsequent note or test to show “status quo” probably won’t influence an offer; a recent “good health” visit may be all that’s required.

Recommendations for specialists can often be dicey in evaluating whether a case should be held until follow-up is obtained.

Radiologists are particular sources of delay—many times due to the way they are trained to communicate their findings. Radiologists usually don’t have the luxury of either knowing the background of a case or meeting and examining the insured. Their only contact may be with the films they receive and a terse one-line request for the procedure. As such, they will cover their bases by trying to include or exclude even minute possibilities and ask for follow-up films to see progress of what they are looking at.

A quick note from a primary care doctor who knows the patient may reassure an underwriter that follow-up isn’t truly required. Likewise, the longer the interval recommended to follow-up, the more likely the finding in question is benign. Most doctors or radiologists won’t let a patient go six months between exams if they are truly suspicious of an active disease process and, as such, there isn’t the need to wait that period of time before making an offer on a case.

Sometimes determining when a follow-up visit is necessary, as opposed to precautionary, can be a very sticky subject in terms of reassuring an underwriter that the primary reason for the consultation wasn’t a potentially mortal one. Doctors are all trained in this “never can be too sure” world to warn patients of most any possible end result of their complaint—sometimes the reason is to make sure the patient doesn’t ignore serious changes and other times more an attempt to legally cover any potential liability. Either way, an explanation by the insured or the health care provider can go a long way in breaking open the log-jam.

Basically, then, a “holding for follow-up” doesn’t always have to be like sailing into the Bermuda Triangle.
•  First, ask the underwriter for exactly what he needs. The solution may be as simple as a statement from the insured or a small note from the doctor addressing the specific curiosity.
•  Ask if a subsequent visit or appointment with another physician would adequately answer the question.
•  See if an “as is” offer is available without the information—sometimes that is satisfactory to issue a policy and a request can be made later on for a reduction in rating class if subsequent information is favorable.
•  Remember to stress to the health care provider the importance and simplicity of getting a short, directed note that answers the small question being asked, not another lengthy narrative or summary of all the patient encounters.

If all else fails, find out exactly what is needed—no more, no less—and try to get it. It certainly beats the alternative!

Smoking, as most of us know, carries quite measurable health risks. The Surgeon General warning on every pack of cigarettes is virtually self-explanatory. The increased mortality risk of heart attack, stroke, worsening of diabetes, lung cancer, chronic pulmonary disease, and vascular disease is well studied, and even smokers without complications pay an increased premium for their policies. This is why many smokers have decided to find e-liquids instead. Vaping using these liquids removes the consumption of tobacco, giving users an intake of just nicotine. This can help to prevent your lungs from suffering the effects of smoking tobacco. Many people have found that vape pens are great for switching from smoking to e-cigarettes, therefore helping them to reduce their tobacco intake.

Needless to say, there is a lot at stake for both the insurer and applicant in smoker and non-smoker classification.

Home office specimens are routinely tested for cotinine/nicotine. While laboratories used to exactly quantitate the amounts, they are reported now as greater or less than 0.5 in most testing labs. When positive, the testing is quite specific, and there is truly no amount of underwriting investigation that can determine with certainty that there was not ingestion or inhalation of nicotine. Retesting is also not an option, since an offer to retest or a request for an explanation can be too easily manipulated.

Most companies will wait for at least 12 months before reclassifying a smoker as a nonsmoker, because the recidivism rate on resuming smoking is quite high. Preferred classes are even more stringently controlled, with no cigarettes used in the last five years often a requirement. Preferred smoker rates, while seemingly an oxymoron, can be given, but the smoker rating outweighs anything gained, premium-wise, on the preferred classification.

There are other unique circumstances in which tobacco can be used and a nonsmoker classification can be given.

?Cigar or pipe smokers may receive such a policy when it is the only form of tobacco used.
??Preferred premiums can be considered when no cigarettes have been used for five years, cigar or pipe smoking is admitted on the application, and there is no nicotine in the testing sample.
??Those on nicotine gum, patch, or lozenges can qualify for a nonsmoker classification, but generally not preferred consideration, since even if smoking was discontinued more than 12 months prior, the ongoing use of these products likely indicates that the insured is still dependent upon nicotine and the risk of resumption of smoking is quite high.
??The use of newer medications such as varenicline (Chantix) for smoking cessation is considered similarly.

E-cigarettes are becoming more popular as an alternative to smoked tobacco products. Due to the increased popularity of e-cigarettes, more people may feel more inclined to check out brands such as smok to find the best electronic cigarette related products for them. These devices are usually battery powered and provide inhaled doses of nicotine by means of a vaporized solution. It is an alternative to smoked tobacco products, and the vapor often has a flavor and sensation similar to inhaled tobacco smoke. The FDA classifies these as drug delivery devices; and since nicotine is still being delivered into the system, e-cigarette users are classified as smokers by most insurers. If smokers wish to intake the same amount of nicotine that’s provided by these vapes but don’t want to be classed as smokers by an insurer, they may need to look into other means of being able to consume this, for example, by taking tobacco-free, nicotine pouches instead. However, there are plenty of options one can look into to avoid being classed as a smoker by their insurance company.

Smoking definitely increases mortality and worsens insurance company experience, and as such is severely priced. False statements regarding smoking, even with a “clean” specimen, can be grounds for rescission of the policy. Insurers are very specific about disclosure of tobacco use on their application, at the time of the medical exam, and on the laboratory ticket, which the insured must sign. If there are any disclosures about pipe smoking or chewing tobacco, etc., they must be made up front and at the time of application, as most companies will not readily believe a change in the story after adverse results are reported.

Benign prostatic hypertrophy (BPH) is an inevitable result of aging in men. An overgrowth of the prostate gland with either benign enlarged tissue or small nodules, the prevalence of this condition goes from about 20 percent in men 40 years old to almost 90 percent when they reach their 70s.

BPH, while not cancer, can cause problems with both obtrusive symptoms for men as well as possibly even urinary blockage and chronic kidney disease in more extreme cases. It is a very common condition that is encountered while underwriting male lives.

The most common symptoms of BPH are divided between obstructive and irritative complaints. Obstructive problems include hesitancy, decreased caliber and force of urinary stream, straining to urinate, and incomplete bladder emptying. Irritative symptoms include urgency, frequency and nocturia. Common television commercials describe the condition as a “going” problem, and indeed it is, with both frequency and urgency.

A doctor can easily make the diagnosis on the basis of symptoms and a physical exam with rectal examination to feel the size of the prostate. Urinalysis and a PSA (prostate specific antigen) are done in the laboratory to look for other concomitant or more serious causes. Imaging (x-ray) and cystoscopy generally are reserved for those undergoing invasive therapy as a treatment.

While there used to be only surgical treatments for the disease (with incontinence and loss of sexual function and erection as significant side effects) there are many different medical treatments now available as well.

Medications called alpha-blockers and 5 alpha-reductase inhibitors minimize symptoms.

Minimally invasive therapy such as laser treatment or needle ablation or even transurethral electro vaporization destroys excess prostate tissue with a far lesser degree of unacceptable side effects. The 5 alpha-reductase inhibitors help shrink the size of the gland.

Problems with BPH during underwriting are usually two-fold.
The first is when it must be differentiated from prostate cancer. Most insurance blood work contains a measurement of prostate specific antigen. As everyone doesn’t have a rectal exam done on application or a detailed physical exam, the PSA helps screen for hidden problems. While BPH, because the volume of prostate tissue is high, will usually result in an elevated PSA, prostate cancer causes elevations far higher.

An elevated PSA result, coupled with a lowered “free” fraction of measurable PSA (done on the same sample) are suspicious for prostate cancer and will cause a trip back to the doctor and/or urologist for further testing, which can involve multiple biopsies of the gland. That line between what is BPH and what is a malignant process (cancer) has to be assessed before an insurance offer is given.

Sometimes the prostate gland becomes so enlarged as to cause almost complete obstruction of urine from the urinary tract. In these cases, the urine refluxes back upward toward the kidneys and can cause eventual kidney failure. While the process is a “benign” one, the end result can be quite serious, and that, too, must be remedied before an insurance offer is made.

One other problem that arises in BPH with high PSA levels involves the insured or his physician’s attitude toward a definitive treatment. BPH is not a cancerous process, but the obstructive part can cause eventual problems in other organs in the genitourinary tract. Likewise where PSA levels are high and the probability of cancer must be determined, some men feel that prostate cancer is slow growing enough that they will take their chances with “watchful waiting” to avoid any of the side effects of surgery that can affect both continence and sexual performance with their physician’s blessing.

Treated or monitored BPH almost always is compatible with a best class issue, but avoidance of the diagnosis and eventual treatment often results in postponement or declination of the policy application.

A blood profile is part of most insurance application requirements and sometimes leads to adverse results or even a decline. Testing by insurance company laboratories is both accurate and quality controlled, and the chain of command is always checked carefully. There are some instances, however, when blood results may not be the most representative evaluation of an applicant’s state of health, because of problems in the timing of the collection of the sample or in handling the blood in transport.

While an insured never has to “study” to pass a blood test, certain circumstances can cause results to be elevated. For example, having blood drawn after eating may lead to an increase in blood sugar. While this may be corrected by a fructosamine or hemoglobin A1C result run simultaneously, it still doesn’t put a client’s best foot forward.

Cholesterol may be slight elevated and triglycerides even more so if not done when an applicant is fasting—generally not a life changing event, yet very important in placement of a preferred versus standard policy. Taking large amounts of supplements—both vitamin and body-building—can sometimes influence the lab sample measurements as well. Taking the sample on an optimal day for the client can lead to a more favorable result in the lab profile.

Another example of when blood results can be affected is a condition called hemolysis, which can occur as a result of imprecise collection, delays in processing, or even other underlying body diseases that influence the chemistry determination. While there are many technical reasons why a sample may have been positively or negatively influenced, the important part is in deciding which of the chemistries can be affected. Retesting in those circumstances may be helpful.

Serum glucose can actually fall in a hemolyzed sample. Usually there are two tests that counterbalance or help insurers put such a finding in context: (1) fructosamine (measures average glucose control for the last two to three weeks) and (2) hemoglobin A1C (measures average blood glucose control over six to eight weeks). Ironically, fructosamine can rise in a hemolyzed sample at the same time glucose falls. Hemoglobin A1C is the fallback test in these instances. If not obtained, a new sample may have to be drawn to properly evaluate the body’s blood glucose situation.

At times the doctor’s office or paramedical may meet with a delay in sending out a sample, or the sample may be delayed in getting to the lab. In such cases, changes can occur: Glucose, LDH, fructosamine, AST (SGOT) and total bilirubin are the most susceptible. Usually the underwriter or medical director will realize this and correlate the results with previous ones, or take this into account. However, if a declination or action other than applied for is received and the problem is the blood work, it pays to ask about the sample condition (which is illustrated on the laboratory report) to see if a repeat sample is indicated.

In the vast majority of cases, laboratory findings are extremely accurate and actions taken on them are representative of an underlying condition. Sometimes, however, the condition and preparation of the sample can make a difference, and even a small difference can sometimes push an applicant out of the cutoff for a preferred or select policy. Be sure to ask the underwriter to review this when the blood work is the deciding factor for someone without a history of an underlying problem.

In the same way you wouldn’t apply for a job without a detailed résumé of your qualifications, the cover letter in underwriting can be key to a successful case placement. A good cover letter immediately makes obvious to the underwriter what is clearer to you. It not only helps accent the favorable parts of an application but also saves endless time by guiding an underwriter through detailed information. It allows a more accurate initial assessment of the case and allows you to know what is needed immediately instead of halfway through the process, when time is of the essence.

A cover letter not only highlights the purpose of insurance and amount applied for, but paints a picture of your client the way you see him or her. An absence of facts that makes an underwriter guess generally leads to a more conservative initial offer and/or a lengthy underwriting process in order to try to fill in missing pieces—even when they do not exist. Medical records or conditions may not spell out behind-the-scenes information needed for a competitive offer. That is where the cover letter—as detailed as necessary—fills in the blanks and accelerates the requests for needed information.

What should a good cover letter include? A favorable start would be in addressing the purpose of the insurance. Once an underwriter is comfortable about the justification for the amount of coverage, things go more smoothly. In larger amount cases and for business insurance, addressing what is being protected, how you arrived at the amount of coverage, and some details about the company business are a good start. The rest can be documented as the process evolves. Addressing financial justification is critical, and a short description of assets of the client or business when it is not obvious from the application is likewise important.

Telling a company about the proposed insured really helps short circuit many questions before they hold up an application, limiting the imagination of the underwriter about what may be behind the scenes. If you have known the proposed insured for a long time, it is helpful to share your insights—especially those that an underwriter could not be privy to. Any positives about lifestyle are helpful to disclose, since many companies now offer underwriting credits for things like being a lifetime nonsmoker, regular exercise, etc. If tobacco is a consideration, and someone has stopped smoking sometime in the recent past, it’s important to know when for classifying the policy. No one wants to be surprised when the application contains a markedly higher premium status than illustrated because a smoking history wasn’t disclosed.

Family history is important. Those with longevity in the family generally have better mortality and insurers take this into account. Knowing what medications a proposed insured takes, and why, is helpful. Many times, medications are given for conditions that are minor, but an underwriter may fear the worst disease is being treated if it is unexplained. A recent EKG, medical exam, treadmill, or other studies that were recently completed help the underwriter know there is good medical care and follow-up. Also, taking aspirin and statins has a favorable mortality implication and should be noted. Of course, documenting any medical illness with details you know helps to produce a more accurate and binding initial offer—no one likes an offer worse than they were anticipating, particularly the client.

If there are aspects of the case that need explaining early, the cover letter is the place to do it. Anything unusual, including the possibility of ratable travel, avocations, habits or medications should be noted and explained as best as possible. Often situations are better than they seem when you know the story behind them, but not if you don’t share them with the person underwriting the application.

Competition and previous or pending offers should be divulged to the insurer as soon as possible. Knowing what another company offered immediately narrows the playing field, and the underwriter will know if they have the ability to meet or beat the offer that much more quickly. Competition generally means that the case is further down the line in placement, and a rapid response keeps everything on track in your perspective as well as the client’s.

It takes a little extra work to write a good cover letter, but it is nearly always worth the time. The same detailed and meticulous preparation you put into the sales, illustration and marketing part of the application with your client should be put into the cover letter. If you aren’t enthusiastic in selling the case and presenting details, how should the underwriter feel? A good cover letter not only accelerates the application process and gets to approval more quickly, it also presents the same picture of the client to the underwriter that you see, limiting his imagination about non-disclosed details.

In a sense, a cover letter is your client’s résumé, and you want it to be as attractive as possible for an optimal result.

Much of underwriting over the years has been a debit assessment program. A case starts at standard or preferred, and then debits for medical impairments or habits that adversely affect overall health are applied.

While it has proved an effective system in calculating and pricing for overall mortality, it hasn’t worked the other way—crediting those who show evidence of a healthy lifestyle or who take better care of themselves than most. These situations can help overcome the effect of some impairments and minimize the risk of others when positive factors are considered. This is the new system of underwriting credits.

The concept of crediting makes a lot of sense when estimating life expectancy. You would expect better outcomes in people who have disease who don’t drink or smoke, for instance. Likewise, those who visit doctors and specialists regularly to stay on top of things and have their treatment adjusted accordingly would have better outcomes.

There are best case scenarios to every health situation, and applying credits in those situations makes underwriting offers not only more fair but also more competitive when assessing and pricing a risk.

Smoking is a known hazard to overall good health. The many effects nicotine and smoking have on the body—from coronary artery disease to emphysema, vascular disease to cancer—have all been well-studied and documented. Stopping smoking is an overall benefit to health. Never having smoked at all is even more beneficial. Credits can be applied in a situation like this for lifelong non-smokers.

Family history is one of the best predictors of long life. You really can’t pick your genetics, but those born into families with a history of long life have a built-in advantage. You can obviously override this advantage with poor lifestyle habits, but whether it is an increased immunity to disease or a lack of genes known to accelerate disease, there is no denying the benefit of a history of family longevity. Parents living into their eighties or who are alive and well in their seventies are a good opportunity to credit an insured.

Wellness and lifestyle credits are also given when an insured has regular medical care and follow-up, including regular routine physicals and blood testing. The use of cardio-protective medication such as aspirin and cholesterol lowering drugs (statins) also has positive outcomes. And of course, a favorable lipid profile on no medication is likewise a plus.

Wellness credits can also be given when more advanced or sophisticated testing goes beyond the norm in showing good health. For example, those who have negative stress tests and/or a negative echocardiogram show positive cardiac status above what is unknown in most applicants. Further testing, such as a negative EBCT test (electron beam computerized tomography) or negative CT angiogram, may demonstrate a lack of calcification in coronary arteries and a more favorable prognosis, and can also be credited as positive factors.

Underwriting often starts at a known stage of disease or health and then works backward, depending on what other conditions may adversely affect mortality. However, there are cases where even with a known impairment, positive factors that lead to a better than expected outcome may work in the client’s favor. In these cases, credits can actually be issued to improve the case and make it a better outcome for both insurer and client.

Unfortunately, it is all too common to read about cases of sudden cardiac death in well-conditioned young athletes. This also strongly highlights the need for athletic recovery programmes and for this to be taken seriously when it comes to athletics as a sport. Insurers see many cases of high-face-amount applications to insure large money contracts and to protect teams against economic loss. These policies, written on young and ostensibly healthy individuals, are very low premium cases relative to the net amount at risk; thus, companies have to be very careful to get enough information in order to accurately underwrite these high amount cases.

Sudden cardiac death (SCD) is defined as death that occurs within one hour of symptoms in someone without a previously recognized cardiovascular abnormality. It excludes other causes of sudden death including respiratory (e.g., life-threatening asthma) and drug-related overdoses. The estimate is that 300,000 cases a year of sudden cardiac death occur in the United States population each year, and 1 to 2 percent of those are in people under the age of 35. The risk is five times greater for males than females, three times higher for young athletes when compared to non-athletes, and twice the average for African Americans.

There are three main categories of sudden cardiac deaths for young athletes.
 • The first is structural heart disease. This includes coronary artery disease (premature), abnormalities of the blood vessels themselves, myocardial bridges (where the electrical system jumps and short circuits), and hypertrophic cardiomyopathy (enlarged heart).
 Hypertrophic cardiomyopathy (HCM) makes up the largest part of these categories-almost 40 percent. The annual mortality with this condition is about 1 percent per year, half of it presenting as sudden cardiac death. Athletes generally have larger hearts than non-athletes because of their increased conditioning and the heart’s need to pump larger amounts of blood at increased heart rate during maximal exercise. However, the pattern of HCM is generally marked and has unique features that allow it to be differentiated from the normal athlete’s heart in most cases.
 • The second category of SCD involves primary cardiac electrical deficits. They have names such as long QT syndrome (a measurement of the time between the start of the Q-wave and the end of the T-wave in the heart’s electrical cycle), Brugada syndrome, and catecholinergic polymorphic ventricular tachycardia. Most are genetic, and unfortunately do not cause marked symptoms until sudden death. During exercise in particular, these patterns may present themselves, and screening should be done for any athlete who complains of abnormal tiring, fatigue or lightheadedness during normal exercise.
 • The last category is caused by external factors such as trauma. Commotio cordis is the second most common cause of SCD in athletes and depends on a projectile striking the chest at a critical point in ventricular repolarization, meaning wrong hit at the wrong time. Quick cardio-pulmonary resuscitation can reverse this, unlike other causes which may have structural problems that prove more difficult to treat.

A major challenge to insurance companies comes with requirements at younger ages. For the convenience of higher end athletes, as well as the fact that they are assumed to be in superior physical shape at younger ages, requests to waive exercise testing and even a basic resting EKG are often encountered. While EKGs are frequently abnormal in athletes, who have larger hearts and slower pulse rates due to their increased conditioning, the fact is that an EKG picks up many etiologies for sudden cardiac death (including hypertrophic cardiomyopathy, the long QT syndrome, Brugada syndrome and conduction abnormalities).

Most athletes are in quite pristine cardiac condition and will qualify for best available rates. Insurers look at family history, personal history (for things like a murmur, chest pain, palpitations, or fainting) and any physical examinations done as part of team sports. Indeed, many teams now put their athletes through extensive cardiac testing to protect the investment of a large multi-year contract just as an insurer must insist on a little more cardiac information for an athlete before issuing a policy. The risk certainly warrants going the extra step in evaluation.

Atrial fibrillation (AF) is the most common chronic arrhythmia, and its incidence rises over age. Nearly 10 percent of the population is affected by AF by the age of 80, and it presents with very severe cardiac conditions (heart failure) as well as reversible ones which have less permanent consequence (thyrotoxicosis).

Atrial fibrillation is often declined by life insurers, but newer research and study shows that while not usually standard, many AF cases can be insured at moderate ratings.

Atrial fibrillation is a condition in which the heart loses its dominant pacemaker. Instead of a steady paced rhythm, which speeds up or slows down at a regular rate, many pacemakers in the heart compete for primary status. As a result, the heart rate can become rapid and irregular. Blood that is not pumped forcefully from the heart can stand and coagulate in the chambers and, as a result, AF is one of the most common causes of stroke. In fact, 15 percent of strokes in the United States can be attributed to AF.

There are many ways atrial fibrillation can cause problems. Blood pressure can drop suddenly and severely when pumping capacity of the heart is affected. So can myocardial ischemia (lack of oxygen to heart tissue); rapid heart rates causing cardiac dysfunction; and, of course, stroke. AF is associated with an increase in mortality from 1.3 to 2 times expected in those affected with it. How it is dealt with depends on the cause and the degree of control of the arrhythmia.

When atrial fibrillation occurs as a new finding on an insurance exam, it may be postponed pending an evaluation of the cause. Heart pump failure is a particularly ominous sign. So are advanced pulmonary disease, congestive heart failure, and stroke or heart attack history. Some reversible causes are alcohol excess/bingeing (“holiday heart”), medication excess, and inflammation of the sac surrounding the heart by a virus (pericarditis). Once the cause is determined not to be life threatening in and of itself, attention is paid to the management of the arrhythmia and treatment of the underlying condition.

Previously, it was thought that atrial fibrillation was a lethal rhythm that should be converted to normal sinus rhythm whenever possible. This often involved electrical shocks to the heart (cardioversion) or large doses of antiarrhythmic medications that often had significant side effects. However, newer studies show that control of the heart rate may be just as important and equally effective.

Studies published in the New England Journal of Medicine comparing  rhythm control versus cardioversion showed no increase in mortality, no overall difference in quality of life, and no overall difference in stroke. Anticoagulation (keeping the blood thinner to avoid blood clot formation) was found to have a significant positive effect, however, in many subsets of patients.

When atrial fibrillation has a one-time cause, such as thyroid disease, infection or mild alcohol use, and that problem is addressed, those who return to normal rhythm can be offered standard insurance. In those who have atrial fibrillation where cardiac disease is mild, there is no true alcohol criticism, and there is good physician follow-up, a mild to moderate rating can be considered. Those whose underlying conditions are cause for concern in and of themselves will likely be declined.

A “restless” heart may not always be an uninsurable case.

Underwriting older age applicants is certainly difficult from a medical perspective. The effects of aging present difficult and sometimes unique disease entities not present in the everyday population, much less in combination with each other. While no one expects an older age applicant to be in perfect health, an underwriter has to differentiate pathological disease-that will cause premature mortality-from the normal aging process. In addition, a key part of underwriting is functional status of an older age applicant.

As self-care is so important in any individual, the functional assessment starts with an evaluation of the activities of daily living. The basic activities, or ADLs, which can’t be taken for granted, include bathing, eating, toileting, dressing, transferring from a chair or bed, and bowel and urinary continence. The mortality associated with not being able to do one of these, much less several, is quite significant. Those unable to perform daily life tasks generally are found to have advanced underlying disease and are at risk for prolonged hospitalization, nursing home confinement and earlier death.

There are additional sets of activities for evaluating older age clients. IADLs, or instrumental activities of daily living, involve housework, managing one’s own finances, using transportation independently, meal preparation and telephoning. One step above is what are called advanced activities of daily living, or AADLs. These are more voluntary and include working, driving, going out socially, participating in a hobby or other recreation, and attending religious services. Those who participate in most AADLs are generally the best insurance risks over time.

Social involvement is paramount to extended living. Not only does it show an advanced degree of mental and physical capability, it shows a positive attitude toward life. Depression is definitely a risk factor for the worsening of many underlying diseases, and suicide is a reality for many elderly who do not feel life has anything more to offer them. The suicide rate doubles after age 75 and quadruples after 85. In addition, all of us know about mortality of bereavement, where a supposedly healthy partner dies shortly after the loss of a significant other for no obvious reason traceable to overall health. Technology can be a great tool in keeping an elderly person integrated within a society where they would otherwise regress into solitude. The prospect of learning new skills can seem daunting as we grow older, but it can also fulfill us with a sense of purpose. You can read here about alexa skills for elderly and how technology can improve your quality of life.

Cognition, or the active thought and reasoning process, is another key to extended survival in the elderly. Applicants who have dementia, even a slight amount, put themselves at risk for death. Wandering, falling, behavioral problems, accidents and lapses in good judgment put those at older age at elevated risk for mortality. Most companies require a supplemental part of the insurance exam which checks basics such as memory of a few words (short term memory), orientation to time, place and person, and reasoning processes such as being able to draw a specific time on a clock face. These are not advanced college exam type material questions, but rather just enough to see that there isn’t significant dementia to factor in.

Exercise capacity is quite important. Those who are physically active have a significantly lowered rate of both cardiovascular disease and all-cause mortality. While older applicants are excused from the treadmill EKG exam as they age, those who can actually perform even to a lower level on one are shown to be better than average long term health risks. Those who swim, dance or walk for extended periods of time in an exercise capacity are shown to have better than average cardiovascular status. A sedentary life is a risk factor for earlier mortality.

One other factor that is very important to an underwriter is the occurrence of falls in the elderly. Not only are they a marker of poorer health and equilibrium, they are an independent risk factor for death. Falls put the elderly at risk for prolonged disability, fractures and even the inability to summon help when there is a physical injury. Fractures and surgery in these cases are particularly ominous: The mortality post hip fracture, for example, can be more than 700 percent of normal mortality from all sorts of complications such as stroke, pneumonia, heart attack and pulmonary embolus (a blood clot to the lungs).

Many elderly and older age clients are quite vigorous past the age of 75, continuing well into their eighties. It is important to document these positive attributes and bring them to the underwriter’s attention in a detailed cover letter.

Remember that there are any number of reasons-physical, medical and cognitive-to decline an insurance application on the elderly because of the complexity of underwriting and the fear of taking on an early claim. The ability to show that an applicant has positive attributes that will lead to extended life is vital to successful case placement.