Robert Goldstone

When cardiac events occur, such as a heart attack or the need for a revascularization procedure, there is quantifiable risk that can be identified and priced for. Likelihood of further cardiac damage, arrhythmias, contribution of concurrent risk factors and estimates of cardiac reserve post damage help paint a picture for future assessment. Sometimes though, cardiac testing in advance of a definitive event helps insurers to evaluate if future problems are in the cards or, on the contrary, whether a positive test may not necessarily have an adverse outcome.

An EKG is the least invasive of the cardiac screening tests and helps paint a picture of the “now” in an individual. The EKG may show evidence of an old myocardial infarction, a disturbance in heart rhythm or conduction, heart irritability, hypertrophy, or even evidence of a heart lacking proper oxygenation. Along with risk factors and symptoms such as chest pain or shortness of breath, it helps get the initial evaluation rolling. An EKG used to be almost a universal requirement in underwriting any significant amount policy, but now is generally obtained from previous medical records or required for cause, such as symptoms combined with risk factors such as hypertension, diabetes, obesity and smoking.

An exercise electrocardiogram is a test where an individual is put through exercise stress on a treadmill (hence the other synonym “stress test”) and the heart is evaluated by EKG testing until a predicted maximal heart rate (which varies by age) is reached. A positive stress test is measured by either the shape or appearance of the complexes seen, a change in heart rhythm, symptoms (such as shortness of breath or chest pain) or a sudden unexpected drop in heart rate during exercise. A positive stress test (which doesn’t always indicate cardiac disease but has a high predictive value) often indicates a compromised heart and is an impetus for further medical testing, which may include radionuclide tracer dye or an angiogram to visualize the patency of the heart vessels. Historically stress testing also was a part of requirements in high face amount cases and those where multiple risk factors were involved, but has now given way to use only for “cause” or a high incidence of suspicion.

An exercise echo is generally a next step when suspicion of myocardial compromise is high or a regular stress test is equivocal. The same type of exercise is done as in a regular exercise EKG, except that all the heart chambers contractility is evaluated at the same time. When all walls contract smoothly and normally and the heart’s maximal output (also known as an ejection fraction) is normal, then the suspicion of cardiac problems is markedly lowered. It has decreased the progression to an angiogram in cardiac testing (where dye is injected into the bloodstream and arteries are directly visualized) to more of an “as needed” test when other testing is suspicious and risk factors are present.

Blood testing has now been added into the chain of risk assessment. BNP, or B-type natriuretic peptide, is secreted in increased amounts by heart muscle in response to stressors, which include heart failure, fluid retention, and myocardial ischemia (a lack of oxygen supply to the heart). A low BNP has been associated with improved survival, particularly in advanced age, but increased amounts of BNP at any age may predict long term mortality, in either undiagnosed or even previously stable cardiac disease. While certain conditions such as renal insufficiency, obesity or the use of certain medications may falsely elevate levels, from a risk perspective elevated BNP levels are useful in predicting increased mortality, particularly in older age applicants.

The chain of testing helps to eliminate what are referred to as false positive tests. For instance, an EKG may show changes that are compatible with old cardiac damage, but may also be someone’s normal tracing. The stress testing or exercise EKG help to evaluate the significance of these changes. An exercise test may be positive, but perhaps secondary to a valvular abnormality which may not confer the same degree of risk. The exercise echo helps to define that risk. Tracer testing with either thallium or technetium radioisotope is much less commonly used, but also may precede the necessity for an angiogram, which is a more invasive test and certainly not part of a routine insurance requirement protocol.

Cardiac testing, while very helpful, isn’t always foolproof. A negative EKG as an initial screen doesn’t rule out the presence of heart disease, as it is often normal until one day it isn’t. A negative stress test certainly decreases the odds of significant heart disease, but risk factors, amount of time on the treadmill and fitness assessment are also parts that need to be considered. A negative exercise echocardiogram doesn’t always trump a positive regular stress test: When the stress test is significantly positive and the exercise echo is normal there still can be significant heart disease that may need further testing for evaluation. A negative angiogram is certainly the gold standard to rule out occlusive heart disease, but isn’t a test to be jumped to without significant suspicion as it has its own procedural risks.

Finally, a word about risk factors. Smoking history, presence of significant family history, high blood pressure, increased cholesterol and triglyceride levels, diabetes, and inactivity are among many factors that increase the risk of heart disease, morbidity and mortality. They may make the need for more advanced testing necessary even when questionable signs and symptoms may exist. They also are progressive in nature, and may be just a small step away from influencing a borderline or negative picture in the present. Each of these has to be added into the risk assessment profile to decide which tests are necessary, when to perform them, and how far to go along the cardiac decision tree.

Marfan’s syndrome is a systemic connective tissue disease that is inherited. It is characterized by abnormalities of the skeletal, cardiovascular and ocular systems predominantly. It also can involve the eyes and lungs. It is a disease that there must be a keen suspicion of based on the physical findings, as there is no specific test for the disorder. Genetic testing can implicate the particular abnormality, but no laboratory test supports the diagnosis in questionable or milder cases.

Most people affected with Marfan’s are tall, with particularly long arms, legs and digits (a condition known as arachnodactyly). What makes Marfan’s a more difficult diagnosis though is the variability in which the findings can occur. There is a high arched mouth palate and an anterior chest deformity, such as pectus excavatum. Joints can be very lax and almost “too” flexible, and dislocation is quite common. Ectopia lentis (dislocation of the ocular lens) and severe myopia is present in about half the cases. Retinal detachment is not an uncommon presentation.

Cardiovascular complications are the most critical in Marfan’s. Mitral valve prolapse (floppy valve) is found in more than four out of five presentations. Dilation (widening) of the aortic root is a classic and dangerous finding: It may lead to a leaky aortic valve and also to aortic rupture. The progressive dilatation of the aortic root causes valvular insufficiency and is one of the leading causes of sudden death in people afflicted with Marfan’s. Family history helps to develop the diagnosis in questionable cases, but there needs to be characteristic features in the skeletal system, two other organ systems, and one of the major criteria of lens dislocation, dilation of the aortic root, or aortic dissection.

Laboratory findings are generally absent in the disease. Mutations in the fibrillin gene (FBN1) on chromosome 15 is the commonest presentation when genetic testing is done, but it is not always found in that defects in fibrillin itself without genetic findings may also occur. Other genetic conditions that cause aortic aneurysm and dissection can also be confused with Marfan’s, and there is no predictive value in the eventual prognosis of the disease for any of the genetic findings.

The complications of Marfan’s, as mentioned, are the biggest problem in underwriting it. The affectation of the mitral valve and aorta are critical, as sudden death may be the first presentation in those affected but not yet conclusively diagnosed with the disorder. Scoliosis is found in more than half of cases, ectopia lentis is almost 80 percent and some cardiac complication in almost nine of ten with the disease. These often are significant before the age of 50 and quite often by the age of 40.

There is no treatment of Marfan’s except for early recognition of the disease and careful monitoring for complications. Annual echocardiograms are done to assess heart size, aortic root size, and valvular function. Medication can be given to delay aortic complications. Prophylactic surgery and replacement of the aortic root may be done when the aortic diameter reaches a critical measurement. Women affected with Marfan’s must be monitored carefully during pregnancy and sometimes valve and aortic root surgery may have to be done before a pregnancy is undertaken.

Marfan’s has all degrees of severity, and as such some cases are insurable. Those who do not have cardiac involvement, are watched regularly and under a physician’s care and who have a normal echocardiogram and blood pressure can be offered ratable policies. Those with cardiac findings are generally not offered insurance; untreated Marfan’s patients often die in their fourth or fifth decade of life from aortic or valvular complications. Prophylactic surgery, medication, and earlier diagnosis and intervention has prolonged life expectancy, but most importantly early suspicion and diagnosis allows Marfan’s to be recognized and worked with earlier, and those (along with those who have milder forms of the disease) have the best prognosis.

Back in 1963, the first commercials on television came out for a coal tar product named Tegrin. It was a coal tar preparation made to combat “the heartbreak of psoriasis.” The commercials have graduated to include stars (singer Cyndi Lauper among them) and biological treatments that go far beyond topical use. While psoriasis is generally a benign (if not inconveniencing and troubling) skin condition that has little mortality complications, both an extension of the disease into a systemic component and the use of medication that has significant potential side effects have to be evaluated and monitored aside from the skin component of the disease itself.

Psoriasis is a common inflammatory skin condition that is characterized by bright red plaques, generally looking like silver scales, and most often present on elbows, knees and scalp. Its major symptoms are itching and sometimes bleeding from the lesions if scratching is too intense. Psoriasis may take several forms, from the common plaque type to the eruptive type (called guttate psoriasis) to actual life threatening forms (generalized pustular psoriasis, fortunately rare). The diagnosis is generally a simple one made by a trained dermatologist.

Treatments of limited disease were with coal tar preparations, topical corticosteroids, or ointments which contain Vitamin D analogs. More moderate disease was often amenable to Ultraviolet light phototherapy. Generalized disease (more the “heartbreak” type) was treated with photochemotherapy and drugs originally used in the diagnosis of cancer or neoplastic disease (like methotrexate) which helped reduce skin turnover and the severity of scaling. The drugs however had significant side effects (long term methotrexate for instance was associated with the development of liver cirrhosis) and this mode of therapy is now rarely used.

At times psoriasis is accompanied by systemic symptoms. Psoriatic arthritis is a symmetric polyarthritis that mimics the more severe rheumatoid arthritis. Fewer joints are involved with psoriatic arthritis, but joint destruction can occur in both conditions. Psoriasis generally proceeds the arthritis in most cases, and the severity of the skin disease mirrors the severity of the arthritis. Joint pain is a common finding, and lab tests aren’t always specific for the disease. Severe cases may be accompanied by anemia and spinal involvement.

Newer medications have come out to treat psoriasis and belong to a class of drugs known as tumor necrosis factors (TNF). They include medication known more commonly by their trade names of Humira, Enbrel and Remicade. The medications have significant side effects and have to be monitored carefully. Newer medications such as Otezla and Stelara are often being used even for what are characterized as “resistant” cases of psoriasis even when there is no systemic involvement, and in effect they are cosmetic treatments.

Additionally, older patients who take the medications have a high prevalence of polypharmacy effects, with medications being used for different conditions interacting with the ones given for psoriasis. The medications are directly advertised via television and journal advertisements directly to the consumers, and many now ask their doctors for the drugs at the first sign of a persistent skin condition. While they have a good degree of effectiveness, the side effects of even the newer medications must be watched for closely.

Most cases of psoriasis are not ratable. When psoriatic arthritis and other systemic conditions coexist, the disease is underwritten for the underlying condition. Those under treatment with biologics must be followed regularly for potential side effects from their medication.

Bronchiectasis is a disease that is characterized by chronic dilation and widening of the smaller bronchial tubes and bronchi and destruction of the bronchial walls. It can either be congenital (such as in cystic fibrosis, the cause of almost half the cases) or acquired via recurring inflammation or infection of the airways. It can be either a localized or diffuse disease and is more common in the lower dependent lobes. Bronchiectasis often coexists with chronic obstructive pulmonary disease.

Symptoms of bronchiectasis are dominated by a productive cough with large amounts of sputum production. About three quarters of those affected will have shortness of breath and wheezing. Chest pain upon taking a deep breath, weight loss, and anemia often accompany the condition. There aren’t a lot of physical signs on examination besides the wheezes and lung crackles. The large amount of generally foul smelling sputum produced is most characteristic. Lung function testing shows an obstructive pattern and lowered oxygen levels.

Chest x-rays are often diagnostic for bronchiectasis, but a high resolution CT scan shows the characteristic changes best. Bacteria are often cultured from the sputum, necessitating antibiotic therapy. As the disease progresses, the number of respiratory infections annually increase and progressive shortness of breath becomes very limiting for the affected individual.

Treatment of acute episodes of bronchiectasis are based on antibiotics from the results of cultures of the sputum that is produced. Hemophilus influenza is the most common organism, but virtually any pathogen can be an offender. Drainage may be necessary to allow better breathing, and surgery to remove a very affected area is still done in severe cases. Complications of the disease can be quite serious and include life threatening bleeding from the respiratory passages, heart and lung failure, collapsed lungs and the inability to breathe well enough to keep oxygen levels up in the body.

There are many underwriting considerations in bronchiectasis. When the disease occurs as part of a congenital syndrome, the accompanying problem often makes the case uninsurable. These include cystic fibrosis, Kartagener’s syndrome (when it is associated with heart abnormalities), alpha-1 antitrypsin deficiency, and many immunodeficiency states. In the absence of any of these (when the disease is acquired), the degree that the lungs are affected governs a rating. Mild disease will have a small rating, where the pulmonary function tests only show early or mild abnormalities. As the disease progresses, mortality increases, to the point where severe disease (when testing is quite abnormal and when there is shortness of breath on even minimal activity) makes ratings severe.

A few other points to mention: Continued smoking with bronchiectasis accelerates the process and is not looked on favorably. Even e-cigarette use or vaping has significant consequences. Bronchiectasis does worse when a systemic disease is combined in its outcome. When active diseases such as pulmonary tuberculosis, heart failure, immunodeficiency disease and the need for oxygen coexist, the prognosis becomes quite poor.

Celiac disease is a dietary disorder caused by an immunologic response to gluten, which is a storage protein found in many grains. Known by several other names (sprue, gluten enteropathy, refractive celiac disease), it results in significant damage to the intestinal mucosa which causes malabsorption and numerous other gastrointestinal symptoms. While celiac disease may be suspected and diagnosed in infants and young children who are diagnosed with “failure to thrive” on a typical baby’s diet, the majority of cases present in late adolescence and early adulthood.

Classic symptoms of celiac disease include diarrhea, weight loss, fatty stools, weakness and muscle wasting. The older someone is at diagnosis, the less pronounced the symptoms are. Many of the findings depend on which nutrients are being predominantly malabsorbed: Weight loss and muscle wasting can be from malabsorption of fats, carbohydrates and protein; anemia from malabsorption of folate and Vitamin B12; and bone pain and skeletal problems from malabsorption of calcium. There are no identical findings in those affected, and in many it is a diagnosis of exclusion or recognized when the disease gets better when certain foods are excluded from the diet.

Celiac disease when mild or early in the course does not present with any marked physical findings. Years ago the disease was thought to be rare, but more recent studies estimate that up to one in 200 may be affected with some form of the disease. It is most common in those living in North America and Europe, and can present at virtually any age. Those affected can have only vague or mild discomfort and some can feel very sick. While genetics are suspected in some cases (identical twins show a high rate of concordance of symptoms when affected), environmental factors may also play a role.

Routine lab tests may raise a suspicion of celiac disease but are non-diagnostic in and of themselves. When the disease is suspected, serologic testing should be performed. The best test is the IgA tissue transaminase (IgA tTG antibody), which is both 98 percent sensitive and specific. Endoscopy with mucosal biopsies is the standard test for confirmation of celiac disease in those whose serologic blood tests are positive. Endoscopy is a procedure that requires the use of specific medical devices designed and engineered to be robust and fit for purpose through the use of certain materials and parts – perhaps like tungsten wire due to its strength and resistance to certain conditions and environments (check out a post on the topic) – that together can be used effectively in such a setting. A less scientific but tell-tale test is improvement clinically and with lab markers when gluten is completely withdrawn from the diet.

Celiac disease causes its most profound effects when it affects the young. Nutrients and vitamins that are essential for normal growth are malabsorbed. As such bone loss (osteomalacia and osteoporosis), reduced stature, clotting abnormalities (malabsorption of Vitamin K) and increased risk of gastrointestinal malignancies may present, as well as autoimmune disorders such as Type 1 diabetes and Sjogren’s syndrome. Delayed diagnosis in older individuals exists when misdiagnosis is made: As irritable bowel syndrome, acid hypersecretion or even psychogenic abdominal pain and discomfort associated with anxiety.

Treatment is the removal of all wheat, rye and barley products from the diet. It is often not a simple task, because many commercial products can be contaminated with wheat and barley even when the ingredient list doesn’t include them. Removal of gluten results in marked improvement within weeks, but a re-challenge with gluten (even accidentally when a product is consumed of unknown ingredients) can cause severe and explosive symptoms even worse than existed before the disease was treated.

When appropriately diagnosed and treated, celiac disease has an excellent outcome. The best cases in underwriting involve a proven diagnosis, normal weight (no signs of malabsorption), established diagnosis for several years, and regular doctor follow-up. The most difficult cases arise when concurrent disease (like osteoporosis or diabetes) is found or when the celiac disease is refractory to treatment or withdrawal of gluten. Many of those affected stumble on the causative agents and foods by trial and error, and strict dietary adherence is essential to continued well-being.

One of the conditions met with a lot of confusion by brokers and agents in trying to assess where it falls underwriting-wise is bipolar disorder. Those with the disorder often represent it as if it were a minor inconvenience, and oftentimes any period of remission is met with a request for a standard or preferred issue. But bipolar disease (formerly known as manic depressive illness) has a lot of red flags both in how it behaves over time and in unexpected mortality, and has to be investigated quite carefully.

Bipolar disorder is characterized by episodic and marked mood shifts that can include major depression, mania, and virtually every shade in-between. Bipolar patients often present with a significant finding that mimics virtually any other coincident major mental health disorder, but the potential swing from one end to another makes it a major concern for treatment. Bipolar individuals have a very high comorbidity with substance abuse, which may make it difficult to diagnose as the major underlying problem. It may be a good idea to get in touch with a rehab centre to help the patient come off their addiction. They can get in contact with Integrated Healthcare Services in New Mexico to find these programs, for example, but there will no doubt be a selection within the local area. This means the diagnosis of mental health will be easier to make as the symptoms won’t be mistaken for the effects of the substance abuse. Bipolar disease is now characterized in two major subsets: Bipolar I, which is when there is significant mania, and bipolar II, where the manic episodes are less pronounced. Depression of course is a major part of the disease and represents the other end of the mood continuum.

Most manic episodes are characterized by hyperactivity, over-involvement in activities, irritability, flight of ideas, inflated self-esteem or grandiose thinking, and agitation. Initially the involvement is admirable and attracts the interest of others, but the grandiosity and aggressive behavior associated with it becomes less charming over time. There may be increased involvement in work activities, but also an unhealthy involvement in thrill seeking or pleasurable activities, with inherent danger therein. It can result in unreasonable purchasing and accumulation of things, and in taking risks that are unhealthy. Since bipolar or manic depressive disorder is a psychosis, the behavior can soon become psychotic and, when out of control, necessitate hospitalization. This is most characteristic of bipolar I disorder.

Bipolar II disorder has less elevated mood and mania but again similar findings in the underlying picture. The disease is often treated as exclusively depression without the underlying manic component. Missing the mania makes bipolar II almost as dangerous because treatment isn’t instituted appropriately until later in the disease. The manic episodes generally are not as long lasting as the depressive component.

One of the bigger problems in the ultimate prognosis of manic-depressive or bipolar illness is the big difference in the peaks and valleys of the mood swings. Mania has its own set of problems with risk taking behavior and putting oneself increasingly in a dangerous path. Even moderate treatable depression can seem like such a low relative to the initial starting point as to put an affected person in what seems like a hopeless situation. The co-involvement of substance abuse as well as thoughts of suicide make bipolar disorder a disease that must be recognized and treated as early as possible.

Most who have bipolar disorder have depression and manic episodes in a cyclic manner. As time goes on the cycles appear to have increased frequency between events, and a significant subset of people will have this occur three to four times per year. Substance abuse is a common finding as mentioned, and a disturbing number will die of completed suicide. Those with intense symptoms will have higher social disruption including job loss, divorce, and often rapid changes in domicile.

There is currently a large number of therapies being used to treat bipolar disorder, with more being researched all the time. For instance, the use of pure CBD tincture and other similar CBD products has gained much popularity with various mood disorders as it has shown increasing success in helping people with bipolar disorder to manage some of their symptoms. Also, like CBD, there is another budding resource in the herbal category, Kratom, which is an evergreen tree found in Southeast countries like Indonesia. It can be found online, on this site for example, and if consumed in the right dosage, it can help with problems like depression, mood disorders, anxiety, and more. It is important to remember, however, that this disease is an ongoing one, and that when an individual feels they are in remission and stops their medication, or when they become more tolerant to the treatment, symptoms may recur. Manic depression is more often controlled than cured and remains a lifetime worry for those affected. Later in the disease depression becomes more pronounced than mania, with its own set of problems and worries attached.

Bipolar disease rarely if ever is a preferred issue, and unlikely a standard issue as well. Severe cases are declined, as well as those where there is substance abuse or a history of suicide attempts. Mild or moderate disease can be insured if medical and psychiatric follow-up is both regular and ongoing. The longer the history of successful treatment and control of symptoms, the more favorable the underwriting will be in these situations.

Lab results often fit a pattern, since the body’s physiologic system is generally in sync with each of its organ systems. If heart, liver, kidneys or metabolic results are affected, there will generally be a pattern where tests rise in conjunction with each other. Then there are “outliers,” profiles where one test stands front and center out of the normal and without any lab value friends to put it in perspective.

Some outliers have significance in and of themselves in the absence of any other findings. For instance, a high alkaline phosphatase in the absence of any other elevations in bone or liver enzymes can indicate a disease process that must be identified. It can come from bone, as in people with Paget’s disease (a metabolic problem where bone gets resorbed and put back again in the skeleton haphazardly), where alkaline phosphatase can stand by its lonesome. Most often it is accompanied by liver abnormalities or some evidence of primary bone disease, but it may also be an outlier when cancer that is in its early spread to bone is the cause. Such levels have to be investigated for such a cause before a case proceeds.

AST, ALT and GGTP are liver function tests that elevate in any number of liver abnormalities from hepatitis or fatty liver disease to alcohol overuse and medication side effects. The pattern in which they rise generally give us hints as to which of the causes they may be, or one may rise out of proportion to the others and also give us clues. Occasionally, however, one will be an outlier. For instance, an AST level may be twice normal with every other test well within normal limits. A repeat test will show everything WNL. The way a test is run or even problems with handling of the sample may be the very remediable cause without a disease entity being present.

At times an outlier can be an abnormal test of no underlying significance. Bilirubin is another liver test that often elevates with hepatitis infections. Sometimes however the test can be two to three times elevated while every other test is fine. The test is abnormal for a reason, but is the reason one that would influence mortality or morbidity? Gilbert’s disease is an inherited disorder where unconjugated bilirubin is high and the only adverse effect is a darker color of skin than might be expected. Knowing that a single test can be elevated even for an appropriate reason doesn’t have to be a ratable effect in underwriting.

Sample handling is often a cause of isolated and unexpected abnormalities. Triglycerides may appear to be high, HDL cholesterol may be inappropriately low, blood sugar readings may look like they’re close to zero. Samples are taken and transported and knocked around and treated in ways only known to FedEx and the US Postal Service. There is hemolysis and changes in the sample that cause abnormalities or even a single value to go haywire. None of which indicate disease.

When I was a medical student we drew blood on each other and sent it for testing. I was walking on the hospital wards and got a frantic call on the pager system. The lab was hysterical. “Do you have a patient, Mark William?” Looking at my patient list, was this one I had forgotten? His blood sugar is 3 and his potassium is 10! Just then I remembered. It was Bill Mark, my medical school friend I had drawn blood on. He would have been presumed dead except there he was, standing alongside me. He’d taken the sample home, it went through the wash in his jacket, and he’d submitted it the next day.

When there is an insurance rating or decline based on a blood value, most companies will send a copy of your blood work to you, or certainly to your physician. Find out if the problem was an “outlier.” If so, have the result repeated either by the insurer or the attending physician, especially if it doesn’t correspond to any known illness or disease. It can be the difference between an unwarranted decline and an issued as applied for.

Cognitive testing in life insurance is becoming more and more prevalent, particularly as the number of older age applicants grows. You can expect testing now as a routine at age 70 or older, and although the platform isn’t rigorous, it can derail an application almost irreversibly if performance is poor. Given that it can surprise many applicants who either don’t understand what is coming or blow the test off as “trivial,” it helps if a client knows what is coming and develops an ease at performing his or her best.

Certainly cognitive testing is not meant to discourage application or sabotage the elderly applicant. There’s a lot of money in older age insurance, and companies want the process to go as seamlessly as possible. They do, however, want to avoid unpleasant surprises such as Alzheimer’s disease and the advanced form of mild cognitive impairment (MCI). It is estimated that over 20 percent of Americans over the age of 70 have some form of MCI, and that a fair number go on to develop Alzheimer’s as time goes on. Mortality in Alzheimer’s is noteworthy: While we sometimes view the process as a slow, ongoing one with many years of life ahead, the incidence of underlying disease, lack of adequate self-care, and accidental injury such as falls and placing oneself in harm’s way increase early death significantly in those affected.

Alzheimer’s in its moderate or advanced disease is generally apparent in the underwriting process via APS notes and activity. MCI though isn’t, particularly to a doctor who may see a patient periodically over time and not be looking for its occurrence. MCI happens to just about everyone over a long enough period of time, but when it is obvious and advancing and when it occurs ahead of where we would expect it is what cognitive testing is trying to uncover. Loss of attention, orientation or memory to a greater degree than expected of normal aging will stop an insurance application in its tracks.

General underwriting looks for both current and future risk factors in prematurely developing cognitive decline. As mentioned, the APS is of key importance. Signs and symptoms of MCI may be noted by doctor or family. Medical impairments such as diabetes, high cholesterol, heart disease, and anything that impairs circulation or predisposes to possible clots or infarction/stroke are looked for. Family history, age, and a genetic marker such as APOE genotype epsilon 4 are being studied. A history of stroke, Parkinson’s, chronic vascular disease and smoking are all taken into account.

Letting a client know what is coming can be very helpful. We are all fearful that testing will expose disease, but the way to approach the test is—confidently. There are no trick answers, and questions are only designed to confirm normal functioning. An older aged client should be comfortable and confident of their knowledge and not get so nervous as to not give answers that would have come naturally to them.

A test that is commonly given is called delayed word recall (DWR). In it, a client will be given 10 words and asked to use each in a sentence. The examiner then will go on to other tasks, such as asking routine questions for orientation to person, time and place (“What day is today, where do you live, who is the President, what is the date”, etc.). Then the insured will be asked to recount as many of the 10 words as he or she can remember. I’ve tried this with myself, friends and family and rarely does anyone score more than between six and eight. What is being looked for is maybe a score of three or four or almost no memory at all. Reminding a client to put the words together in a way he or she may remember them in a sentence often helps. After all it’s a memory test, and any way you remember works!

A clock draw is another test that is often given. A client will be asked to draw a clock and put the hands to a specific time, such as ten minutes after 11. It measures orientation and spatial skills. It doesn’t have to be a work of art, but it shows a steady hand, orientation of numbers in the proper position, and an understanding of command. Some clocks are rickety, and sometimes mistakes are made such as ten before 11 instead of 10 after 11. Occasionally though the numbers are completely out of order and there is no orientation to command and an abnormal response is easy to spot. One of the funniest was a client who drew us a digital clock that said 11:10 in a rectangle. We passed him right away for cleverness and ingenuity.

Other tests used for screening may be a telephone interview or an MMSE, which is a more detailed test of mental function and reasoning. Again, the tests aren’t made to get one to slip up. It is a basic assessment of intellectual competence and mental status. One thing a client should speak up for is if he or she doesn’t understand the examiner. This can be with a client whose English skills aren’t polished, or an examiner who speaks with an accent that an older individual isn’t able to understand. Stopping the test or making note of that will allow an alternative way to test or a different exam or examiner. Flippant answers may throw off an examiner as well—this isn’t a time to display humor or sarcasm for a test a client may see as a bother or a waste of time. And sadly, being overly friendly with an examiner may distract the client from the task at hand. This is an exam, not a social visit.

It’s best to perform well on the test the first time around, as questions on performance may create insurmountable obstacles to issuing the policy. A “fail” on mental status may require advanced testing (CT, MRI), blood testing for possible reversible causes of disease (thyroid, B12 deficiency, sleep disorder, drugs, neurologic disease) or a complete neuropsychiatric profile by a neurologist and can get costly and very inconvenient. When a client knows what is coming and is comfortable with the exam and examiner, the test is straightforward and a ten-minute investment. No studying is necessary but, like when we were in school, a little preparation is worth everything.

While it sounds like something Joe Friday of Dragnet or the FBI would do, medical surveillance involves the following of a condition before deciding whether or when to take a definitive action of treatment. The waiting period can precede a possible surgery, a medical intervention, or an institution of therapy that disrupts the status quo. That’s what surveillance truly is: Waiting and watching before deciding whether to take an action that will disrupt the status quo.

One of the biggest differences in clinical and insurance medicine has to do with the process of surveillance. In clinical medicine, a doctor may watch a condition carefully before deciding when or where a therapeutic action is mandated. It is a fluidly changing picture that evolves over time. In insurance medicine there is only one chance to make a decision—at the time before issue. A disease may go south in a hurry and a clinician may change his or her mind, but it doesn’t happen that way in insurance underwriting. As such, watchful waiting (another term that may be interchangeably used) is an option that may be possible in the clinic that isn’t always possible in risk assessment.

Take prostate cancer for instance. A newer school of thought has arisen from the fact that every prostate cancer does not evolve into a lethal process. Many men will die of another cause before prostate cancer would have become terminal and, in fact, prostate cancer on autopsy that was never diagnosed is not an uncommon finding. Underwriting is straightforward when there is diagnosed and treated prostate cancer. It is less clear when the diagnosis of early disease is made and both the surgeon and insured/patient have decided to wait and see how things go. The answer is murky from an insurance aspect on how to proceed.

Cancers diagnosed by biopsy as early stage (Gleason 6 or stage 0/1) or what are called PIN (prostate intraepithelial neoplasia) are processes that can either stay in this form indefinitely or progress to an incurable cancer. Men who do not want their prostate removed or to be irradiated and subject themselves to possible impotence and incontinence may wait for periods of time to decide how to proceed. Insurers don’t have the luxury of waiting. Their decision has to be made early in the course, and as such based on far less than optimal information.

Thyroid cancers also can lend themselves to active surveillance. There is an increasing amount of new thyroid cancers being diagnosed over the last 30 years, some due to increased toxic exposures and some just from better diagnostic methods. Not all thyroid cancers progress to metastatic or terminal stages and, even in the hands of the most experienced surgeons, thyroid surgery carries risks of paralysis of important nerves and of anesthesia complications. Surveillance can be accomplished by active follow-up, and those in whom progression is unacceptably rapid may have surgery while others never have to be treated. Which ones are which though can’t be determined by an insurance underwriter who is essentially working with a snapshot in time.

In the past, most all early or pre-cancers were postponed in underwriting until a definitive treatment was undertaken. With active surveillance and better experience by the clinician of which cases were most likely to have untoward consequences, many are underwritten without a rating or with a small one that covers the difficult outcomes with the majority of the favorable ones. The key word here though is “active.” It is always assumed that if pathology takes a turn for the worse, the physician and surgeon will intercede before catastrophic circumstances prevail. Underwriters don’t know, however, what will happen after a case is issued, so there are no second chances. Thus a track record of good and continuous care is often necessary to make this assumption. The better overall care has been prior to a cancer or pre-cancer diagnosis, the more likely a positive underwriting decision will follow.

Sometimes though, doctor, underwriter and patient/insured are truly in the dark. An example of this is called MGUS, or monoclonal gammopathy of unknown significance. This is a blood condition that may be found in up to one percent of adults and may progress to overt malignant disease in less than 10 years. Patients with MGUS are observed without treatment until (or if) they take a turn for the worse, when the condition becomes life threatening and not always successfully treated. So underwriting this population may have to be done without ever knowing who will progress and who will not. It may result in an adverse action or where the policy isn’t issued as applied for in people who may never have any progression of the condition. This is another incidence where surveillance (whether it is active or passive surveillance) may have a different consequence clinically than it does in insurance medicine.

Liver fibrosis is the replacement of functioning hepatic tissue with fibrous tissue. Alcohol overuse, hepatitis of any kind, and nonalcoholic steatohepatitis (NASH) often leave behind damage with not only an active process but one where compromise may persist long after the cause has been controlled or eradicated. Knowing how to assess liver fibrosis in the aftermath of these conditions is an important part of underwriting liver disease.

Chronic liver disease may occur in over 10 percent of the population, and the National Vital Statistics Registry lists it as the 12th leading cause of death in the United States. The most common causes of chronic liver disease are nonalcoholic fatty liver disease (NAFLD—very commonly associated with obesity and present in over one quarter of the US population), the aforementioned NASH (a more aggressive form of the disease) and post hepatitis C infection. Hepatitis C is now potentially curable, but the damage left behind from the course of the illness may be permanent. A way to determine liver disease aside from just the blood testing that is done is certainly necessary in determining both prognosis and treatment.

Liver fibrosis (depending on the staging system used) has 4-6 stages. Stage 0 represents no fibrosis, stage 4-6 marked fibrosis with cirrhosis of the liver, and the remainder some degree in-between. Liver failure is the most extreme consequence and staging is a predictive factor for it. Additionally, conditions like hepatocellular cancer and bleeding vessels in the esophagus (varices) are high risks of advanced liver failure and have to be accounted for as well. Even potential treatments (like those for hepatitis C) need to have the degree of fibrosis assessed to choose the most appropriate drug treatment.

Historically, a liver biopsy was the only way to know for sure the degree of fibrosis and residual liver damage. Biopsies are not only painful but may result in excessive bleeding and complications that may require hospitalization. Additionally, a biopsy report is only as good as the area it is representative of. If placed in the most affected area (or least affected) a result may be misrepresentative of the overall state of disease.

Staging scores have been developed based on various testing. FIB-4 is based on the use of four factors that are representative of fibrosis: Age, AST and ALT levels (liver function tests), and platelet count. NAFLD score generally is in post biopsy patients and additionally adds body mass index as well as the absence or presence of diabetes. These are helpful but not fully diagnostic of the degree of liver involvement with fibrosis.

Newer testing has been developed with better accuracy. Fibrosure is a formula that takes into account age, sex, bilirubin, haptoglobin, GGTP, apolipoprotein A and alpha-2-macroglobulin to assess fibrosis. It has good predictive value—better than its predecessors. Imaging such as transient elastography (done with ultrasound waves), acoustic radiation force imaging (where a transducer is involved) and MRI elastography are also used and provide more definitive quantification of the degree of fibrosis that is being measured.

Many Attending Physician Statements reference this advanced testing, especially in biopsy proven disease, in assessment of post hepatitis C infection, and in diagnosing the more virulent NASH. Many drug companies are spending millions of dollars in attempting to find medication that treats or improves NASH finding or slows fibrosis. The common fatty liver disease associated with obesity generally has very limited fibrosis and is underwritten on the basis of underlying conditions. NASH is often ratable based on biopsy results or higher score indices based on the testing involved, including liver enzyme results. Even successfully treated hepatitis may be rated if the disease resulted in substantial liver damage left behind after the successful cure.