Robert Goldstone

From the initial recognition of HIV virus in 1981, HIV infection has turned from an almost universally fatal infection, to one that could be managed with medication to extend life, to a disease which can be controlled with newer and revolutionary medication therapies.  While many companies continue to see the HIV virus as uninsurable, that corner has also been turned, and life insurance in selected cases of treated HIV infection is now possible.  Even though the conditions that must be met are numerous and the criteria stringent, applicants with HIV now have the possibility of acceptable insurance offers.

We’ll concentrate here not on the history and diagnosis of HIV, but rather the circumstances that may result in a placeable offer for infected individuals.  It’s important to note that people who are living with the HIV virus have longer and longer life expectancies with successful treatment and can approach or even achieve a normal life span with the available combination antiretroviral therapies.  However, they are not “cured” of HIV but rather have the virus remain in a latent state.  HIV virus is able to replicate itself into DNA and rest in an inactive state—the medication itself attacks the actively replicating virus.  So medication “forever” is the rule, although recent advances may have monthly shots be given instead of daily regimens depending on the situation and response to the treatment by the body.

HIV is called a retroviral disease, which is the cause of AIDS (acquired immunodeficiency syndrome).  HIV affects mainly immune system cells known as CD4+ T helper lymphocytes.  When these cells decrease below a critical level (usually 200/mm3), cell mediated immunity is lost and the body is unable to fight even basic infections.  Eventually CD4 cells are depleted, and the overwhelming infection causes body failure.  CD4 counts are a consistent mortality risk factor.  Others that lead to a poorer prognosis include high viral loads, IV drug use history, concurrent infection with hepatitis B or C,  irregular use of medication, and any other condition that affects overall body health.

A number of conditions must be met for an applicant with HIV to qualify for life insurance coverage.  There must be a minimum of six months to a year of treatment with highly active antiretroviral therapy.  Viral load must be undetectable, indicating latent virus stage rather than active.  CD4 counts have to be well above the minimum 200/mm3 mentioned previously, usually in excess of 500/mm3.  There must be no concomitant infection with hepatitis B or C virus.  There have to be complete and current medical records showing continuous follow-up and therapy.  And, of course, there must be neither active substance abuse nor ratable medical condition in addition that would increase mortality assessment.

Another thing to consider is the course of the HIV virus and its effect on the body over time, regardless of current appropriate medical treatment.  Even those on lifelong drug therapy suffer from higher rates of cardiovascular, kidney, liver, and neurologic disease.  The disease takes a great toll even when successfully fought, and particularly those who did not receive the most recent effective classes of medication will have had their bodies decompensate over time, adding to mortality.  Virtually any offer of life insurance in HIV infected individuals will be a rated one, even if all conditions for insurance are met and the applicant appears healthy. 

Throughout the years in our columns, I get both regular mail (yes, it still exists) and emails with a variety of questions.  This month would be a good time to share some of these questions (and perhaps make this an occasional column) to address some pertinent things in the current.  After all, questions some of you ask, often many of you have as well…

Why do different companies price the same case at different underwriting ratings?  Don’t you use the same underwriting manuals anyway?
It’s a great question, and it makes business what it is—a competitive situation between companies.  Since no two cases are ever the same, a variety of scenarios, impairments, and interaction on overall health of these impairments leave some subjectivity. Underwriters generally use a manual for their overall impressions (based on extensive experience from previously insured lives and their outcomes) but combining the entire evaluation based on all factors may come out a little differently in the eye of the beholder.  Companies may have different experience with different impairments, or may decide they will be more aggressive in a certain area to attract business.  Most cases work from the same parameters: standard and preferred cases are generally uniformly so (as are declines), and the shades of 50 shades of gray within them represent the differences.  Pricing may also enter into the offer (in other words, it isn’t only underwriting or risk classification) as might the different levels of pricing (number of categories of preferred or even of impaired pricing bands); even if two companies make the same exact evaluation of mortality risk, the illustrations may be different.  And by the way, there are different manuals that companies use, and variances within those sets of experienced lives may make a difference depending on the company who provides the data and underwriting suggestions.

Why do the classifications of select and standard vary so much, and how does a company decide where a client falls?  
There are really two answers to this.  First, when considering where an applicant will fall on the preferred to standard curve, different companies value a potpourri of favorable health factors in their considerations.  These “credits” (which make a person better than the standard mortality in terms of longevity) can include objective factors such as lab results, build, blood pressure, etc., and lifestyle results (never smoked, exercise, diet, activity).  Each finding counts to a varying degree amongst insurers.  The second is the pricing involved for each category.  

In the movie Bruce Almighty, Jim Carrey in his role as Supreme Being decides to grant everyone’s wish to win the lottery.  As a result, the grand prize turns out to be $17.  The more aggressively preferred is priced, the less people will qualify—but the more the savings will be for those who do.  The bottom line is, ultimately, the combination of all these factors, health being the major but not the only one.  

Is a cover letter absolutely necessary even when we’re shopping cases?
Three word answer: Absolutely, positively, yes.  It’s your chance to make a case for what you are seeking and to make your applicant shine.  There’s no way to alter objective medical facts, but there are so many cases where there are explanations—places where your client makes a real difference in his or her care and can stand out as health conscious and diligent in self care—that make a difference to an underwriter.  Think of it as if your son or daughter were applying to college or a professional school.  Who stands out—the person who just fills in all the blanks or the one who makes a case why they are the more qualified?

What is your company good at?
That’s one of the hardest points to address.  If you state you are better in a disease or impairment than anyone else, you will be expected to perform in all cases regardless of severity, other health factors, or comorbidities, and to beat all others in a consistent mortality.  There are some impairments where a company may choose to take a more aggressive approach, but not uniformly.  Most companies over the years who have gambled on this (like with abnormal liver function tests for instance, or being too forgiving with blood sugars) have gambled incorrectly.  Each case stands on its own merits, and again emphasizing the overall health picture goes much further than submitting all of a certain type of case to one insurer. 

Where has the most progress been made over the last decade?
Overall, medical progress has influenced probably every major disease category for the positive.  Some have come a very long way.  Hepatitis C, once a deadly ailment, is now not only insurable in most cases but considered cured in many.  Companies are beginning to consider HIV as an insurable disease. Certain cancers, such as thyroid, testicular, skin and prostate cancer, can be considered preferred cases in many instances. And lifestyle credits, with people demonstrating excellent self-care and modifying risk factors, has resulted in better offers than ever before.

Once a disastrous disease with markedly shortened life expectancy, hemophilia is now both a treatable as well as insurable disease in most instances.  It is important to realize that hemophilia not only comes in many types, but also in many degrees of severity.  Other mortality factors, such as diseases which were contracted from actually receiving blood and blood products are substantially decreased as screening has become much more vigilant, and awareness of the disease by those affected with it has resulted in faster and more effective treatment of bleeding episodes.

The two major types of hemophilia generally recognized are hemophilia A (factor 8 deficiency) and hemophilia B (factor 9 deficiency).  Hemophilia A represents 75-80 percent of hemophilia disease and affects about one in 5,000 people.  The genetics is called X-linked recessive, meaning only males can actually come down with the disease and females may carry it but not actually be affected (this is true for hemophilia B as well).   In addition to the common thought that hemophiliacs may die when they bleed from an external factor or trauma and blood cannot be replaced in an appropriate or timely manner, spontaneous bleeding into soft tissues, joints, and other locations can occur as early as from childhood on.  Additionally those who have had the disease for many years, before blood screening became better and more technical, contracted HIV as well as hepatitis C from contaminated blood products which also affected their mortality and morbidity.

Hemophilia B (factor 9 deficiency) is also called Christmas disease and is less common (one in approximately 25,000 people affected) and less severe.  Still, it can result in serious hemorrhage as a response to trauma.  It also affects males only and can be carried by females.  Even simple procedures such as removing a tooth or minor surgery can cause excessive bleeding in hemophiliacs.  It is also important to know that the degree of factor deficiency is quite important in determining prognosis—mild cases do substantially better than moderate or severe ones.

There are other types of bleeding disorders of which we should be aware.  Von Willebrand’s disease is similar to Hemophilia A but more common (close to one percent of the population affected) and less severe in symptoms.  Unlike hemophilia A and B, the genetic abnormality is not associated with the X chromosome and can occur in males and females.  There are three types of Von Willebrand’s, with type 1 affecting three-quarters of the cases and being the mildest in severity.  Von Willebrand’s can also be acquired through cancer and blood malignancies, autoimmune disorders (such as lupus),  thyroid disease, and with administration of certain medications including anti-seizure medications and antibiotics.  Other types to be mentioned are deficiencies of factor 1, 2, 5, 7, 10 and 12 (there are 13 clotting factors overall) and factor 11 deficiency, also called hemophilia C, and commonest in Ashkenazi Jews.

Treatment is by replacement of the missing factor and careful control of situations that can cause bleeding.  Trauma may require blood and factor replacement and careful fluid evaluation.  Some cases that involve inhibitors and antibodies to transfused factors have to be recognized expediently and either avoided or treated aggressively.  Medications that release factor stores or breakdown blood clots can also be used.

The prognosis and overall mortality with the various hemophilia conditions depend on the clotting factor levels, the frequency and severity of symptoms, and the treatment used.  Other things underwriters look for are amount and duration of any hospital stays, complications, and the extent of any disabilities the hemophilias cause.  Age is important—younger applicants have higher ratings in that their future course is unknown, as is severity of disease—severe cases are obviously much higher rated than mild.  Ratings are also subject to negative HIV status, and recent hepatitis B and C testing is also a must.  Von Willebrand’s with no symptoms or complications, and very mild hemophilia A or B, are usually the only conditions considered for a standard rating.

If you can remember the original commercial for this, touting a product called Tegrin (1963), you are an experienced producer. The term though has long outlived the television spot, and in fact many newer commercials for immunosuppressant agents now populate the airways. All for psoriasis, a roughened, reddened area of the skin caused by an increase in the proliferation of epidermal cells. Although there is no cure for this, there are alternative methods that people suffering from psoriasis can try that may help with the irritation. Some people may even try using CBG oil to help with the symptoms, especially if they feel like they have tried everything else already. Others have said they have tried CBD cream as a topical medication as it can help to reduce inflammation and has also been said to soothe skin. If you currently purchase CBD cream then this CBDistillery Coupon will give you 25% off your next order. As living with something like this can be tough for anyone who has it, it comes as no surprise to find that people are doing all they can to find a method that may work for them.

The characteristic white scales and irregular patches make the disease, as least from a skin aspect, relatively unsightly. It is a chronic and recurrent condition that rarely clears completely. The treatment has shifted from topical formulas to more complicated systemic monoclonal antibodies and phosphodiesterse 4 inhibitors. Needless to say psoriasis and its more destructive systemic form, psoriatic arthritis, are more than merely skin diseases and can have a mortality aspect associated with them beyond any cosmetic concerns.

As a topical disease, psoriasis runs the gamut of smaller unaesthetic patches of involvement to a systemic arthritis that can be crippling. When the disease reaches this point, it becomes a sero-negative inflammatory arthritis that may cause actual joint destruction. There may be a few joints involved or it can affect much of the skeleton including hands and spine. Excepting for the characteristic skin changes, it can become indistinguishable from the much more serious rheumatoid arthritis and ankylosing spondylitis.

Psoriasis is more common than expected, affecting about 1.5 percent of the population. Only five to seven percent go on to develop the serious psoriatic arthritis component, but at least a quarter of this subset go on to develop severe deformity of the joints and subsequent disability. Psoriatic arthritis generally is more common in younger adults aged 30-50, but the very severe types seems to occur at the older end of the spectrum. 30 percent of cases may affect the eye and cause marked irritation and compromise of vision during an acute flare.

As mentioned, new treatments are coming out to help both the physical appearance of psoriasis and the systemic and more destructive effects of psoriatic arthritis. All have side effects, and those have to be carefully monitored. There are items made to reduce the effects of arthritis and prevent further injury, such as an Elbow Arm Brace for Arthrtis, however a cure is still yet to be found. The elderly have to be particularly careful, since interactions of other medications they may be taking can cause heart failure and particularly severe complications such as pneumonia. Alcohol abuse often worsens the side effects.

In the purely cosmetic cases of psoriasis, preferred issue can occur. It requires mild status, younger age at onset, use of only the mild anti-inflammatory medications and full activity with no physical impairment or disability. When treatment starts to involve systemic administration of medications, polydrug therapy, pain medication, or limitation of movement and motion, it can be a more serious disease. Arthritis, another autoimmune disease, to the point of disability requires a rating. Again, younger patients with more limited disease do better than older ones who require more involved treatment remembering that these treatments also carry their own set of side effects and potential problems in and of themselves. You can learn more about autoimmune diseases, other than psoriasis, on different medical blogs and journals, like the ones by Lomibao Rheumatology and Wellness Care.

Thankfully the heartbreak of psoriasis is lessening with medical advances, and most people affected will have positive life insurance consequences and favorable evaluations. But not every case is a benign one, which is what underwriters look for in evaluating this disease.

Most of us are programmed to know what our cholesterol levels are, and doctors are constantly cautioning us to watch our cholesterol or to take medication which helps in lowering our blood level.  High cholesterol in addition to such health conditions as heart disease, diabetes, hypertension and vascular disease pose higher risks in overall health and in underwriting.  How about triglyceride levels however?  They are part of virtually every comprehensive medical panel and enter into underwriting and health risk as well.

Triglycerides are one of the fats found in blood.  They are stored in fat cells in the body and are usually the storage for calories the body doesn’t immediately burn.  They are often liberated into the bloodstream at times when there is little or no caloric intake.  Increased triglycerides are associated with atherosclerosis even when total cholesterol may not be elevated.  Elevated triglycerides predispose to heart attack, stroke and cardiovascular disease and also increase the risk of acute pancreatitis.  Poor diets that are high in sugar and carbohydrates generally cause higher levels of triglycerides because they are easy fats hanging around for use when taken in at a higher rate than they can be burned for fuel or energy.  Obesity, insulin resistance, diabetes and alcohol abuse are also causes of high triglycerides.

There are generally no symptoms of high triglycerides, and the diagnosis is made on a blood test.  Because the body instantly starts breaking down sugars and carbohydrates on ingestion, most insurance physicals ask that you fast before the blood is drawn.  Most people have normal triglycerides even after a meal, but this is one part of the blood profile that is influenced by not being taken fasting.  Cholesterol however is generally a more stable number and is more minimally affected.  

Some people are affected by diseases that are genetic and which raise triglycerides well above normal at virtually all times.  Familial hypertriglyceridemia is inherited as an autosomal dominant condition that causes an increase in triglycerides early in life.  Other conditions such as familial lipoprotein lipase deficiency do the same thing.  Most of these cases are diagnosed on a routine blood draw or by family history.  When the condition is inherited, there can be physical signs such as xanthomas (skin eruptions), eye abnormalities (a lipid “ring” can be seen on an eye exam), enlargement of the liver and spleen, and pancreatitis.  They can be quite serious and generally require medical intervention as soon as they are diagnosed.

Medications can cause increased triglyceride levels.  Corticosteroids (like Prednisone for example), estrogens, and beta blockers for hypertension are all known causes.  Certain diuretics, skin products and protease inhibitors can do the same.  Other medical conditions such as hypothyroidism, lupus, and medication for HIV infection are also implicated in high readings.  High triglyceride levels are also quite common in alcohol abuse.

Since high triglycerides are also found with many primary diseases, it is important to identify those coincident risks and be sure they are treated appropriately.  Diabetics whose blood sugars are out of control have high triglycerides.  High cholesterol levels have their significance increased when accompanied by high triglyceride levels.  Elevated levels may contribute to hypertension and the risk of vascular events such as strokes.  And very high levels are strong irritants to the pancreas and can cause  attacks of acute pancreatitis.

The primary therapy for high triglyceride levels (in the absence of any primary conditions that naturally need to be treated in and of themselves) is dietary.  Alcohol avoidance, ingestion of lesser forms of simple sugars, starches and foods high in saturated and trans-fatty acids are immediate goals.  The use of medications such as niacin and omega-3 fatty acid supplements are helpful.  Most all of the statin class of drugs is also successfully used, especially in combination with elevated levels of cholesterol as well.  Normal triglyceride levels are under 150 mg/dl, levels above 200mg/dl start to involve ratable risks and numbers over 500 mg/dl are indications for active medical treatment in addition to dietary modification.  Preferred consideration is more limited to consistently lower triglyceride levels and the absence of other cardiovascular risk factors such as hypertension, diabetes and smoking. 

Once upon a time, being a standard risk in the underwriting process was the best you could hope for.  It meant that your health was at the top of the group of insured lives being considered and eligible for the best rate, and that you would live all the way out to the prediction of the actuarial life tables.  Now, life insurers have created a whole tier of preferred and super preferred pricing that makes a standard issue almost seem like a rated policy.  The use of underwriting credits is getting more and more sophisticated, and helps companies attract the most favorable risks, but if not priced for properly can work suboptimally in the final tally.

Better than standard risks were created with the idea that someone’s health and longevity status would be longer than the actual mortality tables predicted.  Because advances in medicine and medical science continued to increase actual longevity estimates, pricing was less of a concern.  People were indeed living longer as a whole and any overestimates or aggressive approaches taken to mortality were almost self-corrected by medical advances.  Competition though has forced these previous advantages to become smaller and smaller and, in some company pricing systems, actually anticipated in calculations.  So now many grades of pricing better than standard can exist, depending on what triggers the company has set up as credits.

Original credits were set up on traditional risk systems.  For instance, the Framingham Risk structure for cardiac risk factors would include blood pressure, build, cholesterol and the absence of diseases such as diabetes and hypertension for example.  Credits eventually expanded to other degrees of healthy living, such as diet, exercise, frequency of health exams, and degrees of preventative health measures (mammograms, prostate checks, blood work, etc).  More and more are being developed (even considering favorable genetic testing) as guides to separate the “super healthy” and reward them with policy discounts to court their business.

Credits are also used when people are not standard risks in the underwriting process.  For instance, take the example of a male who has had bypass surgery for coronary artery disease.  Credits might be issued for normal cholesterol with the help of a statin medication, or for a negative treadmill done post surgery, or for regular medical and specialist visits to maintain good health.  Diabetes may have a general mortality, but credits may be given for better than average blood sugar control, normal build, good cholesterol, or any testing showing a lack of progression of potential complications.  There are credits for good family history, having always been a non-smoker, and for an active lifestyle as well.  The use of physician documentation on attending physician statements helps to confirm these factors more than just subjective comments by the potential insured.

Credits have to be carefully considered however and not just sprayed around willy-nilly or they defeat the purpose for which they were developed.  For instance, if an insured has trouble breathing from pulmonary disease and smoking, how much credit should a family history for non-smoker parents or having normal cholesterol give you?  When the credits can be applied directly to the overall health of the insured and be related to the disease or condition for which they are being credited, they are far more useful than where it is more like a department store where discounts are looked for in any random order.  

Another potential problem with credits is that if applied too liberally, they affect mortality reserves and pricing.  There was a scene in the movie “Bruce Almighty” where Jim Carrey becomes the Supreme Being and decides to grant the wishes of everyone who prays to him.  One of those prominent requests was that everyone wanted to win the lottery.  So many people did that the payout turned out to be $17 for the grand prize.   If a product is priced for preferred so that 35 percent of people can qualify, and if credits push that number to 50 percent or more, it is no longer profitable.  Crediting systems have to be carefully correlated with the mortality they are predicting, because, in a sense, if everyone “wins”, no one wins— when pricing has to be adjusted.

When applications come in, both broker and insured have to be proactive in pointing out the best part of the health status.  Underwriters don’t always automatically apply credits and sometimes it takes a reminder to have them do so.  Cover letters help do that and point out the most favorable parts of an insured’s health, whether it is excellent to start or impaired but with favorable aspects that put them ahead of others in their similar risk class.  Also remember to ask for changes in underwriting philosophies and requirements at the time of application—knowing where the sweet spots are can improve even a good classification that much more favorably. 

Genetic testing is being promoted as one of the top advances of this century to date in helping people with the prevention, treatment and early diagnosis of disease.  At first, genetic testing was very limited, expensive, and usually limited to one specific test of a suspected abnormality.  Since the Human Genome Project was completed in 2003, the cost of  testing has fallen dramatically and the widespread platform of different tests that can be run on one sample has grown substantially.   The use of genetic testing in clinical medicine has certainly advanced how patients are diagnosed and treated, and is welcome. It is likewise welcome in life insurance underwriting, but only to the degree it is accurately and fully disclosed.

Life insurance pricing is dependent on many things, but for underwriting purposes, the accuracy of the information given the insurer is paramount.  Every applicant, broker and agent wants the best and most competitive price for their client. This has become so much truer in the expanding field of “preferred” underwriting, where a standard issue can sometimes be looked at as a rated policy and the degree to which preferred and super preferred issue can be achieved is key to policy placement.  This generally requires information that illustrates to the underwriter a mortality which will be better than that of the average applicant, and much better than that of the rated one.  Favorable genetic testing is one way to get there, and also of tremendous benefit when there is a disease in the family history that the applicant can show he or she did not inherit.

Life insurers are allowed to consider genetic testing in their underwriting—in the United States, the Genetic Information Non-Discrimination Act of 2008 prohibits insurers from using genetic information to discriminate with respect to health insurance but does not cover life insurance. Canada also has no such prohibitions for life insurance.  Insurers do not order genetic testing as part of requirements for their applicants in the U.S., but can certainly use such information that is known or revealed in their underwriting process.     

When the information is known by the client or agent but not disclosed, the problem for all applicants becomes more evident.  There is a difference between anti-selection and non-disclosure.  Non-disclosure is the failure to provide information material to underwriting (“I know what the result is, but I’m not telling you”).  Anti-selection is the choice of an insurance company because the information is not specifically requested or required by the insurer, even though the applicant knows it might represent an adverse consequence.  Either way, the result is the same: that the insurer has likely underpriced that particular risk, or accepted it when it might have declined to issue a policy if it knew the results in question.  

The consequences to an insurer are obvious when it is making decisions without full knowledge of genetic information.  First and foremost, eventual mortality will be higher than an insurer has priced for.  The consequences will lead to someone having to share the deficit or shortfall and, after poor company results, is generally extended to the entire applicant pool.  As such, healthy or preferred risks will bear the consequences for anti-selection or non-disclosure.  Prices will rise, product design will become more conservative and perhaps more limited to account for the results, and suspected higher risk lives will be priced even more expensively.  Of course, even the “preferred” issue will have pass along costs that will have to be absorbed.  As life insurance is still a discretionary purchase, it is one that will be omitted if its costs rise too much relative to its value.

The increased availability of predictive and reliable health information from genetic testing only increases the risk of anti-selection for insurers.  People have easy and affordable access to genetic testing that usually even their primary care physicians would not run (and as such, the information isn’t available on Attending Physician Statements).  There was a time insurers (from the requirements asked of applicants) often knew more than the applicants about their individual health.  Now that balance has changed, and it is much more likely to be quite the opposite.  The internet also allows incredible access to information about risks as well as allows people to freely exchange information about their conditions.  Generally, that is good; more shared information increases an individual’s ability to be exposed to more potentially positive information.  At the insurance end, it can allow agents and clients to steer toward companies who do not test for a specific condition or are less likely to discover it without disclosure, and share that with potential clients.  In the short run this is problemsome for the particular insurer involved but over the long run is harmful to all insurers.

Insurers welcome genetic information in that it makes their underwriting of risks more accurate.  It allows lower risks to receive more competitive pricing.  The better that pricing becomes, the more people potentially come into the market for life insurance. But when a lack of information causes clients who are impaired to apply for greater amounts of insurance than the population who is less at risk, the more difficult it becomes for everyone—first for the insurer and eventually for the future purchaser.  Insurers are working toward narrowing this information deficit, with the use of more innovative underwriting systems, better and more precise questioning of applicants, additional testing for medications on blood and urine samples and the use of pharmacy profiles, and a better business intelligence system to close any information gaps.  But unless the insurer at least can stay on pace with the rapidly increasing amount of readily and affordable information that an individual can get without any way that an insurer can reference those findings, the more difficult it becomes to maintain a level playing field for all those applying for life insurance, particularly the healthier applicants to which insurers are marketing discretionary and fiscally competitive products.

It’s a word that can strike fear into the hearts of any insurance professional, whether a broker, agent, or even an insurer.  But far from a dreaded submission to a department for checking and cross checking, evidence of compliance in an insurance application by an insured is a good thing.  Essentially it is the client showing an underwriter that his care is good, and that he has taken all steps to present himself as a better than average risk to a company evaluating his application.

With a given impairment, compliance involves regular checks to a physician to make sure than the condition has adequate surveillance and proper treatment.  In the case of a cardiac event for instance, it may involve regular checks with the cardiologist to minimize future complications and insure the event was a singular happening.  At a certain point, that care may be passed on to an internist.  But the concept of physician follow-up is key. Someone who had a heart attack or a coronary bypass for example and then hasn’t seen a physician in several years is looked upon far less favorably than someone who has kept regular check-ups.  In these cases, a big APS is more likely a good one rather than a sign of a problem. 

Often physicians request follow-up by a specialist for a condition that could have an adverse outcome.  Take sleep apnea for instance.  A client’s wife may complain her husband actually stops breathing during sleep.  A sleep study is recommended.  If the client goes in and has it done, even if it results in treatment such as CPAP, it is a treated condition and considered favorably.  Much more so than when the client blows off the suggestion, and the underwriter has no idea of what the severity of the condition is.  In these cases, the worst outcome is assumed and the underwriting consequence is usually worse than it would have been no matter what the consultation turned up.

There are regular health surveillance events that are recommended as proper follow-up at certain ages.  Mammography, colonoscopy, PAP smears, cholesterol and blood pressure screenings are all included in these categories.  While most insurers will not penalize applicants whose health care is irregular, the majority will actually credit a client who keeps regular physical exams and health maintenance.  This can mean the difference between preferred issue and standard for instance, and significant premium savings.  Insurers are even starting to move toward evaluating healthy living choices, and a display of these in an insurance application will result in better classes of preferred issue and significant discounts for participating insureds. 

Some conditions have to have compliance as a necessary part of issue.  Someone who has had cancer for instance must participate in regular checks to see that the cancer has not recurred.  Those with precancerous conditions, such as known genetic disorders or dysplastic nevi syndrome (of the skin) for instance can’t be lost to follow-up without consequences.  An insulin dependent diabetic who never sees his physician is likely not going to be looked upon favorably, and sometimes outright declined.  “New” EKG changes may be quite serious, but even abnormal EKGs that have shown stability over time may not result in an adverse consequence.  The theme is simple—what an insurer knows to be a stable, non-progressive condition (through compliance by the insured in seeking regular medical care) is always a good thing.

Again, compliance isn’t always the follow up of a disease with checks and rechecks.  The trend in insurers is to reward those in good health with better premiums, and to recruit that population when possible.  Compliance to good diet, prescribed health maintenance, exercise, and regular periodic physical exams has positive consequences.  As in any situation in an insurance company, compliance requires taking a few extra steps to insure a good outcome.  But in underwriting, it may result in even better than expected consequences. 

Gestational diabetes is a term used to describe diabetes or abnormal glucose tolerance discovered during pregnancy.  While many women enter pregnancy with a diagnosis of diabetes (whether on medication or not), gestational diabetes is used to describe diabetes that is diagnosed in the second half of pregnancy.  Insulin resistance is common during pregnancy, and the result of hormonal changes as well as increased body weight essentially causes there not to be an effective dose or uptake of insulin.  As such, serum glucose levels rise in this setting and can continue to rise as pregnancy hormones and body weight continue to increase.

Gestational diabetes is caused by an inadequate level of insulin combined with the cell’s inability to take insulin into the cell properly (insulin resistance). Risk factors for gestational diabetes include a family history of type 2 diabetes, a previous pregnancy with gestational diabetes, delivery of a large infant previously, and increased sugar in the urine.  Diagnosis is made by elevated blood glucose levels.  While the majority of the problems and risks are assumed by the fetus during the pregnancy period, over 30 (and as high as 50) percent of individuals with a history of gestational diabetes will go on to develop non -insulin (type 2) diabetes on their own within 10 years.

The highest risk of gestational diabetes include older age at pregnancy, overweight, a history of previous abnormal glucose metabolism or tolerance tests, a sedentary lifestyle, and coexisting high blood pressure or metabolic syndrome.  Women with a condition known as polycystic ovary syndrome also have higher risks.  Women who are diagnosed with gestational diabetes are considered to have high risk pregnancies and are generally followed in a specialty obstetrics clinic along with a diabetes nurse educator and a dietician.

There are maternal complications to gestational diabetes.  There are increased risks to spontaneous abortion, an increased risk of premature delivery, increased frequency of eclampsia (high blood pressure and kidney problems), premature labor, and a higher likelihood of Cesarean section. Needless to say, in some women insulin will have to be started in order to control blood sugars, and that can have effects on the mother if the dosage is not well applied. Most women after delivery will be able to discontinue the insulin and go back to their previous state of health. It goes without mentioning that newborns are all subject to similar risks, including congenital malformation, larger babies, stillbirths, and other complications.   

While there was a time when insurance applications were universally postponed until a pregnancy was completed, most cases can now be considered at the same rates at which they would have been issued if there was not a pregnancy in process.  In gestational diabetes however, the underwriter looks for good control of blood sugars and watches for any other complications that can develop, such as high blood pressure or kidney problems.  Some cases will be postponed if complications develop until the baby is delivered.  When insulin is used or blood sugars prove to be hard to control, there is always the consideration that gestational diabetes is a risk factor for not only type 2 diabetes in the future but for a risk of diabetes with subsequent pregnancies.  A case may indeed be postponed until delivery, but applicants can be offered preferred rate consideration if 5-10 years have passed since the last episode of gestational diabetes and general health remains otherwise good.  

There are a lot of ways people refer to ventricular premature beats (VPBs) or contractions (PVCs).  They may be described as a skipped beat, or a flutter, a hiccup, or even a palpitation.  While palpitations can sometimes just be a sensation of a rapid heartbeat, often they are ventricular premature contractions, particularly when they are intermittent.  Not everyone who has PVCs needs to see a cardiologist, or has a serious health problem, but some do and those are the ones underwriters look at most carefully.

A physician can easily spot a PVC on an electrocardiogram—since the beat initiates in a different part of the heart than a normal sinus beat, it has an unusual and unmistakable appearance.  Doctors first take a history from the patient, such as when the palpitations or sensations occur, medications the person may be taking, signs of possible heart failure or previous surgery for heart problems, other cardiac risk factors, and if the sensation of syncope (passing out) accompanies the premature beats.  The biggest red flags for the doctor include the aforementioned light-headed syncope feeling, palpitations that are worsened by exertion or exercise, known heart disease, or a family history of sudden death.  And an EKG is a standard part of the workup, even at a time when there are no symptoms.

When the PVCs are not documented on the doctor visit, extended monitoring is usually the next step. With frequent palpitations, a 24 hour Holter monitor is generally used—like a tape recorder for the heart that is worn and documents when and how often the contractions occur.  If the palpitations are infrequent and the doctor is still concerned, 14 to 30 day monitors can also be used.   Patients generally write down what they are doing and when they have sensations, and it is paired up and matched to the times on the recorder. The recorder can tell what kind of beats they are and if they are coupled or frequent.

Simple PVCs are infrequent, and may be up to 4-5 per minute or less.  The benign ones are generally single beats.  They will appear identical on the monitoring strip or EKG.  The complex ones are more problemsome.  They include patterns (like every other beat or every third beat being a premature), consecutive (PVCs that come one after another are more dangerous), multifocal (they have different shapes meaning they come from different areas) or in runs where they will be consecutive and have more marked symptoms.  

When infrequent, they may be common and of little or no significance.  Without heart disease or problems with cardiac valves, doctors are more concerned with something that hasn’t been diagnosed.  An echocardiogram may be the next part of the workup—disorders of the mitral valve on the left side of the heart (mitral valve prolapse) are a common benign finding.  In the absence of cardiac disease and when they are infrequent, PVCs require no treatment and do not have underwriting significance.  PVCs become significant when they occur in runs of three or more, occur with known heart disease, are frequent (more than 10/minute), or come from different parts of the heart.  Their timing may also be problemsome; a PVC that comes at the end of a completing contraction (called R on T phenomenon) can be very serious.

Underwriters look for frequency and complexity of the PVCs, symptoms and complications (syncope), other underlying cardiac disease, treatment and medications used, and the results of any cardiac evaluation.  There are also some positive underwriting considerations—PVCs that decrease during stress or during exercise testing for instance are much more likely to be benign that those who have more PVCs with faster heart rates.  Preferred consideration is possible when the PVCs are infrequent and without symptoms or associated heart disease.