Robert Goldstone

Sometimes agents, brokers and even applicants would like to have a general idea of how their insurance application will proceed before an official submission is made.  There are all sorts of reasons for this, which may include whether their medical condition is insurable, whether their finances or accompanying information qualify them for the coverage they are requesting,  and, if the application is going to be rated, to what degree and what kind of resulting premium they can expect.  An informal application allows the underwriter (and often the doctor) to review information that would be submitted as part of the application and give a good idea of the risk assessment to follow.  

 Of course the value of the quote or assessment given is all dependent on the amount and the detail of the information submitted.  The depth of the information allows the best and most accurate forecast of what will follow to happen.  No one on either side wants an educated guess that turns out to change when an official application is submitted.   Sometimes, in a competitive situation, the applicant is relying on your assessment of where the case is best going to be placed and surprises may sabotage the case altogether when they are completely unexpected.  So remember, the accuracy of what you’re getting as a quote is directly proportional to the amount of information the underwriter and insurance company has at its disposal.

 Quick Quotes are often used when the insured’s medical condition is unique or it involves a certain underwriting philosophy on the part of the company being queried.  For example, “I have a man with Ehlers-Danlos type 3 and an enlarged aorta.”  A doctor can look at the condition and give a pretty good assessment of whether the case will be insurable, or what additional information he needs to finalize that assessment.  “I have a 63-year-old female with type 2 diabetes and no complications and her last hemoglobin A1C is 7,” will likewise get a good ballpark figure—better than “I have female diabetic on insulin…what do you think?”  A short email will get a short and quick response, but the accuracy may be ultimately lacking.

 Sometimes you will submit detailed Attending Physician Statement summaries.  These are far more helpful, as they contain most of the information an underwriter needs to make a much more accurate assessment.  They should include any or all the information you have on the case and should include as much recent information as possible.  In cardiac cases for instance, the result of a heart catheterization can be worth a thousand words in terms knowing where the case is likely to end up premium-wise.  Again the more information given, the closer the assessment can be to the actual outcome of a submitted case.

 A full informal basically gives the insurer the right to access the other necessary information it will need to come up with a final quote.  It allows the insurer to access the Medical Information Bureau (MIB) for codes from previous applications, a check of the master prescription data base for medication taken, driving records, and all the necessary parts that a full application will need to be completed.  If laboratory results were drawn for another company, it will allow the company being presented with the informal to access those as well.  You want to be as accurate at presenting a scenario to your client as you can be, so the more information that is presented the fewer surprises that occur.  No information submitted on an informal basis will be submitted to the MIB, so the client has confidentiality up through this process.  A well-presented informal allows you not only to know where a case will lie on the premium spectrum (insureds generally don’t take well to being presented a rated premium if they are expecting a standard or preferred rate) and generally no surprises means a more favorable outcome in case placement.  

 General questions are best answered on a call to an underwriter with whom you have a good relationship.  They might involve a sensitive question you want an answer to before you put pen to paper (“How do you treat an occasional marijuana smoker, and what would you need to be sure the case is not rated as a user or a full smoker premium?”).   Full informals are best submitted with a detailed cover letter, where you present all the positive factors about a case.  For instance, “I know my client had cardiac bypass but is a nonsmoker, nondrinker, walks three miles a day and has a cardiologist following his care.”   The more information that helps an underwriter not leave things to his or her imagination, the more competitive a quote will be.

 Companies expect informals will be less pristine than clean applications (or they wouldn’t be informals in the first place) and that many informals will not proceed to formal application.  To insure that your request is taken very seriously and substantial time is put into it, realize that the more information that is presented, the more serious the application process becomes.  The whole submission process is designed for the underwriter to examine detailed and probably unusual circumstances and have them reviewed without having to go through the full application process (with all medical requirements) until you and they are sure how to proceed.  Make the process work for you by taking it as seriously as a full application.  Remember, the best outcome is always no surprises. 

Much progress has been made in combating cancer, but pancreatic cancer still sticks its ruthless head up as an actually increasing and an equally deadly one.  In 2016, The American Cancer Society estimates almost 55,000 new diagnoses of pancreatic cancer will be made and 42,000 deaths will ensue.  Cancer of the pancreas has recently surpassed breast cancer as a cause of death in the United States and now ranks third behind lung cancer and colorectal cancer in the number of cancer related deaths.  Globally the International Agency for Research on Cancer predicts 340,000 new diagnoses of cancer of the pancreas worldwide, with no decline in the mortality rate noted over the last decade.

Perhaps the biggest problem is that over four-fifths of pancreas cancers are detected too late—at advanced stages when they cannot be removed surgically and essentially are incurable.  Even resectable cancers are not always fully cured.  The non resectable ones are either metastatic already to the rest of the body or locally advanced—about a 50-50 ratio.  The metastatic ones are generally treated with chemotherapy and then focused on palliation and end of life care.  The biggest challenge is in the nearly one-third of cancers that are said to be in the intermediate zone—they are locally advanced but cannot be surgically excised due to local invasion.  They have not yet spread beyond the pancreatic bed, and new treatments are focusing on this group of patients. 

The most common type of pancreatic cancer is an adenocarcinoma—in about 85 percent of cases.  They generally start in the area of the pancreas where digestive enzymes are made.  One in every hundred cases or so are neuroendocrine tumors, arising from the hormone producing cells of the pancreas.  These are generally less aggressive than the adenocarcinomas, but equally deadly—just taking more time to inflict their grim eventual prognosis.  Signs and symptoms of pancreatic cancer are generally unexplained weight loss, yellow skin, abdominal pain, and a mild feeling of nausea.  There are generally few symptoms in early disease and as such, unless discovered “accidentally” looking for something else at the time of diagnosis, the disease has spread to other parts of the body.

Pancreatic cancer is rare at younger ages; commonest over the age of 70.  Diabetes, obesity and smoking are major risk factors.  The cause is genetic inheritance in about 10 percent.  Limited consumption of red meats and alcohol are also thought to lower the risk.  Even with some of the leading treatments, the median survival for advanced pancreatic cancer is 9-11 months.

But how about when cancer of the pancreas appears to have been diagnosed “in time” and appropriate treatments have been given to hopefully affect a cure?  Surgery is generally only possible in trying to affect a cure in about 20 percent of new cases, and there is always the worry that even in successful surgery, cancerous cells may be found at the margins of the tissue left behind and continue to grow and spread.  Surgery is probably still the only possibility of cure—chemotherapy is used to extend life, and secondarily quality of life, but is generally not curative.  Some forms of the neuroendocrine type are amenable to longer life spans but generally recur over a longer time horizon.  

Underwriters look for information such as all the details of tumor type and staging, details of all treatment including surgery, radiation and/or chemotherapy, and continued follow-up including all imaging and tumor marker testing.  Certain tumors such as islet cell tumors or gastrinomas may be eligible for consideration after two years with temporary flat extras, and standard after 6-8 years.  The unfortunately more common adenocarcinomas are usually declined for a minimum of five years and then always carry a flat extra or table rating as there is late mortality risk that has to be accounted for.  The hope is that some diagnostic testing can spot cancer of the pancreas earlier making it more amenable to cure, as no agents seem to be consistently effective once the cancer has begun its spread. 

On February 1, 2016, the World Health Organization (WHO) declared Zika virus a health emergency of international concern, and a week later, the U.S. Centers for Disease Control and Prevention (CDC) elevated its response to the highest level 1.  WHO estimates that 4 million people will be infected with Zika virus this year alone, and 30 countries have reported confirmed transmitted cases of Zika virus in the last 9 months, with that number increasing regularly.  So what mortality risk does Zika virus carry in underwriting, and how concerned should we be?

Zika virus is a single stranded RNA virus transmitted by mosquitoes.  It belongs to a family of viruses called flavavirus, which is known for producing other diseases such as yellow fever, West Nile virus, dengue and encephalitis.  It is named after a forested area in Uganda, and is not a new virus—cases have been identified since the 1950s.  Originally limited to Asia and Africa, 2014 saw the first case that was found in the Western Hemisphere.  In May 2015, dramatic increases of Zika virus transmission were found in Brazil, and now most countries in South and Central America and the Caribbean report multiple cases.

While commonest in contact with affected carrying mosquitoes, Zika virus now is known to have multiple routes of transmission.  These include sexual intercourse, blood transfusions, and in what has become the most alarming finding, mother to child transmissions.  In Brazil, reported cases of fetal microcephaly (small head) expanded ten-fold in the second half of 2015.  Although Zika virus can be transmitted through breast milk, no known transmission through breastfeeding has been documented at this time. 

Most Zika virus transmissions in adults have little to no symptoms.  The illness in those who contract the virus is generally mild and self-limited, and most manifestations (like with any other common virus) are gone within seven days.  The most common serious manifestations are fever, headache and rash.   More recent investigation is now appearing to confirm a link between Zika infection and the neurologic Guillain-Barre syndrome in adults.  The reported incidence of this in Zika predominant regions is up to five times the normal occurrence.

The most serious consequences of Zika virus are currently amongst newborn children.  Besides a higher rate of miscarriage in pregnant women with the virus, the diagnosis of microcephaly has been well documented.  Affected children have a very small brain, lack of development of the brainstem, abnormally defined cerebral structures, and malformations in the spinal cord.  The long term effects on these children are obviously quite ominous and will be borne out in years ahead.

At the moment there is no treatment for Zika virus, either in an affected adult or child.  In adults the disease is self-limiting, and recovery even in more symptomatic cases is usually complete.  The effects on children affected by Zika virus in utero are generally evident at the time of underwriting.  Applicants from endemic areas who are attempting to insure children should have evidence from an APS of an unaffected child with normal growth milestones.  No vaccine is yet available against Zika virus, but progress is being made toward that end and hopes for one by year end are promising. 

The carotid arteries are the two large blood vessels you can feel the pulse of in your neck that bring oxygenated blood to the brain.  Narrowing or blocking of these arteries can cause life threatening consequences, including a major stroke.  Often diagnosable by a doctor during the exam by listening for a bruit over the arteries themselves, it is just as often found after a major event such as a transient ischemic attack or a full blown stroke.   There’s still not universal agreement on a uniform treatment for carotid stenosis, and confusion has been added by the U.S. Preventative Services Task Force which recommends against routine screening for carotid stenosis in the general population.  Nonetheless, it is an important consequence of vascular disease and always has to be accounted for in underwriting.

Stroke is the third leading cause of death in the United States and the leading cause of disability.  A narrowing of the carotid artery (or arteries) may be a precursor to strokes or transient ischemic attacks (TIA) because of small emboli (clots) that can pass unimpeded to the brain or from significant narrowing that limits proper blood flow.  10-15 percent of strokes are associated with carotid artery stenosis, and up to eight percent of adults are estimated to have some degree of carotid narrowing.

Usually carotid artery stenosis isn’t an isolated finding.  If there is stenosis present, there is likely narrowing of other blood vessels in the body as well.  Most cases are from a plaque buildup (atheroma) at the origin of the carotid artery.  Sometimes it is caused as a complication from another procedure being done in the same anatomical vicinity.   Stenosis is somewhat more common in women than men and is often a disease of aging. 

A doctor can diagnose carotid artery stenosis often by listening above the artery with a stethoscope.  A loud rumbling noise (called a bruit) shows rough and somewhat impeded blood flow.  Stenosis can occur without a bruit, and unfortunately the result of the narrowing or closure (like the TIA or stroke mentioned) often leads to the diagnosis after the fact.  Generally the initial test done is an ultrasound, which can diagnose a blockage or the presence of an obstruction.  MRI then gives a better quantitative measure of how extensive the blockage is and where exactly the lesion is compromising blood flow.  

With this, despite several major trials on the proper treatment of carotid stenosis including the Endarterectomy for Asymptomatic Carotid Atherosclerosis Study, the Asymptomatic Carotid Surgery Trial, and the Veterans Affairs Cooperative Study, there’s no uniform agreed upon path for treatment.  Obviously, the end goal is the prevention of future strokes and other complications of atherosclerosis.  Medications that reduce the tendency to form clots (such as aspirin and ticlopidine) and blood thinners are used on both an acute and chronic basis.  Control of high blood pressure is instituted and carefully monitored, diseases like diabetes are more firmly controlled, and above all smoking cessation is recommended.

When carotid stenosis or closure of the arteries enters the 60-70 percent range, surgical procedures come to the forefront.  A carotid endarterectomy is a procedure where the carotid artery is opened and surgical removal of plaque is accomplished.  A newer alternative approach is carotid artery stenting where, as in similar procedures done in the heart, a stent is put in to prop and keep the artery open.  So far when feasible, endarterectomy is the procedure more often used since stenting carries a higher short term stroke and death risk even if less invasive.    

Underwriters look at age of diagnosis, time since the procedure was successful, severity of disease (and how prevalent it is in other arteries besides the carotids), and other contributory diseases (such as high blood pressure, diabetes, etc.) and how well they are being controlled.  There generally has to be a minimum of 6 months of recovery after a procedure, and younger ages are treated more severely than if it occurs further into the process of aging.  Presence of diabetes and hypertension adds to the rating as an ongoing risk factor for recurrent stenosis or stroke.  Continued smokers are routinely declined.  

Bladder cancer is now one of the 10 most common cancers in the United States and the second most common urological cancer.  Men are four times as likely as women to develop it, but women more frequently have advanced disease at the time of diagnosis.  The mean age of development is about age 65 and can range from benign easily treated lesions to invasive cancer.

The urinary bladder, located in the pelvic area, has the main function of emptying and storing urine.  The most common forms of bladder cancer are transitional cell carcinomas, and arise mainly from the lining of the bladder itself.  Tumors of the bladder can vary from lesions that resemble polyps and have a slow recurring course over years, to deeply invasive growths when they are found that tend to be much more aggressive.  The more differentiated the cells appear (the most like “normal” bladder cells), the better the prognosis is.  The undifferentiated cell type predisposes to invasion and spread to nearby pelvic structures, lymph nodes, liver and bones.  

Tobacco smoking is a clear risk factor in the development of this disease, and people who smoke have four times the risk of bladder cancer than those who don’t.  There is a strong association between bladder cancer and work related exposure to certain chemicals, such as in the rubber, aluminum, dye and leather industries, and in painters, machinists and even hair stylists.  Most industrial sites now have protection against these chemicals, but exposure earlier in life has still shown to elevate the risk in later years.

The most common sign of bladder cancer is hematuria, or blood in the urine.  In many cases it is microscopic, and found in the course of a urinalysis done as part of a physical exam.  Other times it can be visible blood, like small clots or a change in urine color with a pink or red hue.  Cytology is then run to see if any cancer cells are present, and appropriate evaluation of hematuria involves a procedure called cystoscopy, which is the doctor’s view of the inside of the bladder with an instrument that has a thin, tube like camera.    Sometimes a CT urogram is done to make sure that the source of bleeding is indeed the bladder and not a trickle-down effect from the kidneys or ureter.

Earliest stage bladder cancers (which have not invaded the muscle layers of the bladder wall) can be treated with resection and fulguration (destruction by cauterization of the area) at the time of cystoscopy.  This treatment is often followed by chemotherapy or immunotherapy with the installation of a substance called BCG (bacillus Calmette-Guerin), which reduces recurrences.  This treatment may be instilled into the bladder for six consecutive weeks, and there are maintenance doses given over the course of a year which help overall outcome success.  If the cancer has grown into the muscle layers of the bladder wall, complete removal of the bladder is usually recommended.  To replace the bladder, a short piece of intestine can be used.  In some cases, chemotherapy and radiation are used as an alternative to bladder removal.

 The prognosis for those with superficial cancers treated by resection and BCG installation is favorable, but close surveillance, rapid recognition and prompt treatment of recurrences is necessary.  Those with multiple or recurrent low grade tumors do a little less well, and removal of the bladder is usually the treatment of choice in these cases.  Muscular invasion and aggressive spread have much lower survival and cure rates.  Likewise, the overall prognosis is less favorable in older age individuals (above age 70).

Low grade histology with no spread and complete and early treatment often result in standard mortality.  Those who need recurrent treatment may be insurable after a disease free interval.  Those where muscle has been invaded or extension has occurred do the least well.  Most bladder cancers because of their nature are not eligible for preferred issues. 

Bradycardia-tachycardia syndrome, or sick sinus syndrome (SSS), is actually a collection of diseases where the heart is no longer able to effectively perform its regular pacemaking duties.  A small area of the heart located in its right upper chamber is composed of special fibers in what is called the sinus node.  It is responsible for all the normal and regular heartbeats we have when no one is thinking about it, as well as speeding the heart up when necessary (as in exercise or increased blood flow needs) and slowing it down (in periods of rest or sleep).  When the sinus node malfunctions, or wears out, or is prevented from performing its “command” function in keeping an appropriate and regular rhythm, the heart rate no longer is regular (arrhythmia) or appropriate to the stimulating action in the body.  It may provide an inadequate heart rate response to stress or exercise which, needless to say, can lead to serious consequences if not attended to.

While primarily a disease of those in their seventies and older, SSS can occur in much younger ages.  It’s estimated that more than one in every 600 cardiac patients over the age of 65 has this syndrome.  The majority of cases involves a “remodeling” of the tissues of the sinus node, such that they may become hardened or fibrosed and, as a result, less and less effective at putting out a signal strong enough for the heart to march to.  Often coexisting cardiac conditions such as heart failure, heart blockages near the area, or infiltrative diseases such as sarcoidosis or hemochromatosis may be involved.  Intrinsic cases such as electrolyte and metabolic disturbances or the actions of certain cardiac medications that slow conduction in the heart can mimic SSS, but withdrawal of the medication or correction of the imbalance generally restores the sinus node function to normal.

Most sick sinus syndrome is progressive.  In the beginning it may be picked up as an uncomfortable feeling by the affected individual, whether the heart is going too fast or too slow.  Either case (when the heart is going too slowly and providing too little blood to the brain or too quickly and not having a chance to fill adequately before pumping) causes signs of what is called cerebral hypoperfusion.  This lack of adequate blood flow to cerebral tissues can cause transient lightheadedness, confusion, palpitations, chest pain, heart failure or even stroke. An EKG generally shows either the very slow or very fast heart rate or the lack of progression from any activity of the sinus node to initiate a forceful and normal heart beat.

Generally it makes sense that a failing natural pacemaker in the heart would cause a slow rhythm and an escape heartbeat as some other part of the heart struggles to take over a function not natural for it.  Without the pacemaker area taking its normal dominant role, fast rhythms may occur in up to 50 percent of those affected including very chaotic ones like atrial fibrillation—when it’s almost fireworks between different areas of the heart.  If not immediately obvious on a single EKG tracing, a Holter monitor or prolonged cardiac monitoring makes the diagnosis, particularly in the evolutionary stage of SSS. Treatment of known SSS then generally involves the implanting of a permanent pacemaker, which relieves symptoms and improves quality of life, but again doesn’t reverse the primary process (whether it be aging or disease) of the rest of the heart.  It does however help against potentially lethal outcomes of chaotic atrial rhythm such as embolism, thrombotic stroke and accidents from losing consciousness when heart rate slows and the brain does not receive sufficient oxygen at any given time.

Most people who end up with pacemakers or have SSS have an increased mortality over time and are rated higher if it occurs at younger ages, and certainly higher if there is other underlying heart disease to account for.  Some cases may be offered at standard if there is a specific cause and all other investigations show cardiac function to be otherwise normal.  Those in whom extrinsic factors cause SSS (like correctable medical conditions or medications that slowed heart conduction that were stopped) are looked upon more favorably as well. 

The “forecasting” issue of Broker World wouldn’t be complete without a look into the future of medical underwriting.  Will a person come to our house, swab the inside of our cheek, and be done with the medical end of things?  Will we step into a machine that records height, weight, lean body mass and then proceed to CT scan our entire body?  And even if they could, would we let them?  The sky may be the limit, but we as a government and privacy protective population may not let it get that far.

If you grew up watching “The Jetsons”, what really hasn’t come true in the years since the cartoon was on the airwaves?  Maybe not flying transport saucers through space or vacations on Mars, but an awful lot.  You can step into one of those machines and have everything from coronary calcium to every body organ scanned and outlined.  You can have blood analyzed for almost anything, and now genetic prediction of what will happen in the future.  You can have doctors diagnose you by Smartphone and remote television from virtually anywhere.  You can have physicians doing surgery not even standing in the same room as the patient. 

In the rather recent past, certainly in the 25+ years I have been writing this column for Broker World, requirements in underwriting have certainly changed.  Chest X-rays, almost routine in large amount cases, are almost obsolete as a requirement for any applicant.  Treadmill exams, done at specific age and amounts without cause, are not really done now except for cause, and the standard of medicine has changed so that if there is cause, the likelihood such testing (and more) will already be part of the APS is high.  MD exams, an integral part of even applications of as low as half a million dollars previously, are now the exception rather than the rule.  As Bob Dylan forecast, “The times, they are a-changin’…”

Blood requirements currently available tell us more than ever before.  Before we could tell if liver function tests were up—now we can obtain any serology to tell us what’s causing the elevation and why.  A blood marker, BNP, is starting to be used and advocated in place of EKGs in routine screening for many companies.  Paramedicals now perform almost every task in collection and obtaining data instead of physicians.  So much more is available to us in “routine” care that we are virtually up-to-date without age and amount requirements at times.  We can even obtain pharmacy data that allows us to know every medicine that was prescribed by your doctor without getting the actual records.

Genetic testing is now at the forefront of research.  You can mail a sample to a testing facility independent of a request from your doctor and find out your likelihood of developing (or even having in the current) one of 1,000 diseases—and that list expands yearly.  We are on the verge of walking into a neighborhood drugstore for just a finger prick and being able to have at our disposal every test a doctor would have normally had to order on a physician visit.  Newer applications developed by testing companies can feed every lab result into a vast array of experience data and find out where you stand in mortality without even additional testing—imagine being rated for a life insurance policy when every result is “normal” because the combinations of how normal they are will experience-rate differently.

With all that being said, medical underwriting is unlikely to move much more quickly than the field of medicine does itself.  Convenience has become the key word, and making it easy for the applicant to get a product (perhaps as easy as ordering a product on Amazon) is the eventual goal.  However, there are fail-safes that will prevent the cart from getting ahead of the horse which will limit insurers’ ability to get too cutting edge in the immediate future.

Insurers are allowed to obtain quite a bit of information in underwriting for a life insurance policy.  Your height, weight (who else in your life knows that?), vital signs, laboratory work, and everything your physician knows about you are available in underwriting.  Consent for testing for even sensitive tests like HIV and hepatitis C are part of the signed consent.  Urine screens for drugs and your whole prescription history is available.  That’s an awful lot, and allows insurers to predict mortality and morbidity well enough to design competitively (and now more conveniently obtained) policies for the public.  The information is sensitive and protected, and government regulations make it stay that way.

What will limit it is truly what the public allows insurers to know or how much privacy they wish to protect in the process.  If insurers actually have a test that tells them if you will develop Alzheimer’s for instance, do you want them to have this information?  Maybe more telling: do you want to know this information?  An insurer may promise not to tell you the result, but you draw the conclusion when you think you are fine and a company rates or declines your application without telling you why.  Yes, we want to be screened for cancer and have doctors know what will happen if a condition is left untreated and for it to be cured before it is too late.  No, perhaps we don’t want to know when we die, what of, and how.  Or want someone else to know that either, with or without a complicity to warn or the ability to take action on it—the “secret” result.   If an insurer pushes for too much information, the golden goose may be strangled and the government may not allow it to have even the information it is already able to gather.  Then what happens to pricing and prediction?

Insurers are also going to have their work cut out for them the more information that comes out to the public that they are not privy to.  If you find out an adverse result in obtaining genetic testing, will you tell the insurer?  If blood testing you get in a pharmacy is abnormal, will it be disclosed?  Will the insurer lose the sentinel effect, not being able to run the same test an applicant can and then finding a slew of individuals with a particular disease suddenly applying for insurance?

In the near future medical underwriting will continue to advance, but likely not much faster than the state of the art of general medicine itself.  Sure, if a specialized CT scan or genetic procedure is done by a physician, the insurer will have access to it and the ability to underwrite the result appropriately.  But the public being able to understand the processes an insurer uses to arrive at a conclusion or policy rate has to be transparent to the applicant, the applicant’s doctor and essentially everyone who has a legal right to the information.  If information available to the applicant that is adverse leads to higher claims and adverse outcomes, no one wins, as the price of the policy just increases for all concerned (especially the healthy).  In health care, there may be arguments as to the right of everyone to coverage—life insurance is more discretionary in its purchase.  For that reason medical underwriting is likely to move in lockstep with medicine in general—information becoming as convenient to obtain for the applicant as possible without anti-selection influencing the overall outcome for all successful insurers in the field.

An underactivity of the thyroid gland, hypothyroidism, is quite common—affecting probably one percent of the population and rising to five percent over the age of 60.  The thyroid gland is responsible for controlling the metabolic rate of most of the body.  When the rate slows, both mental and physical systems are involved.  In its severest form, called myxedema, it is capable of causing permanent dementia and even death.  Thankfully, however, it is generally an easily treatable disorder.

Hypothyroidism is more common in females than males, as much as five to one, and is usually recognized by symptoms in the 30s and 40s.  Often times it is the result of an autoimmune process, when the body produces antibodies which destroy the cells of the thyroid for unknown reasons.  The autoimmune version is known as Hashimoto’s thyroiditis and is generally slow in onset.  Measurement in blood of thyroid autoantibodies confirms this diagnosis, along with low thyroid function results.  People who have been hyperthyroid, or with an increased thyroid function, are often rendered hypothyroid as the result of treatment;  this is whether through drugs, surgery, or the use of radioactive iodine to destroy the overactive gland.  Certain types of inflammation of the gland (called thyroiditis) often result in hypothyroidism when the primary process resolves. Less common causes involve the pituitary gland in the brain, which is the feedback center for when to have thyroid hormone released or inhibited.

Hypothyroidism is usually a slow onset disease which can take months to years to diagnose as the process is often quite slow.  Mild hypothyroidism may not even show up on blood testing—in fact since every person’s thyroid “set” is an  individual one, a “normal“ blood result can still be hypothyroid if it is less than the original values that the body was used to.  Initial symptoms include weight gain, water retention, depression, weakness and muscle discomfort.  Hair can become more coarse and brittle, and affected people become cold intolerant. Heart rate generally slows and blood pressure rises.  Dry, almost craggy skin ensues, and the doctor may be able to feel an enlarged thyroid gland on physical examination.  

Hypothyroidism is a difficult diagnostic dilemma in older age.  A slow, sad looking, somewhat confused individual may not be suffering from the inevitable effects of aging, or dementia, but may just be clinically and profoundly hypothyroid.  Screening for thyroid disease is a must in this setting when individual behavior patterns change for no apparent or discernible reason.  If treatment isn’t instituted in a reasonable period of time, the dementia, cardiac abnormalities, and hypertension can become permanent.

Generally symptoms can be put together to arrive at a diagnosis, and increasingly screening blood tests are done which may diagnose the problem before the problem is clinically apparent.  Blood thyroxine levels (also called T4) are drawn, but because it’s normal range is wide it’s not always the best test to use for screening.  TSH (thyroid stimulating hormone) is produced in the pituitary gland in the brain and is the sensing center for the amount of thyroid needed by the body—too little thyroid causes TSH to rise (to stimulate the gland to increase production and release) and too much slows down the release mechanism.  TSH measurements are the best way to diagnose hypothyroidism, and combined with the thyroid measurement provide a good pair to guide treatment.

Once diagnosed, thyroid replacement or augmentation is quite easy—given as an oral tablet, the amount can be adjusted to put the body in an appropriate set.  The purpose is to replace thyroid hormone—too much hormone given to try to rev up body metabolism or lose weight doesn’t work as it is catabolic and breaks down muscle as much as anything else.  The dose is easily adjusted by blood testing and how the patient is feeling.

If caught appropriately and permanent changes have occurred, standard issue is the rule and preferred consideration is open for those who are successfully on long term replacement therapy with normal blood testing and no complications such as cardiovascular or cognitive disease.   It is lifetime therapy though, so while it is not fatal if you miss a few doses (the average half life of the most common replacement medicine is a week, meaning you have 50% of the dose still in your body if a week is missed) compliance is very important for long term health and well-being. 

From ancient times to the first mortality statistics related to build published in the United States in 1903, abnormal build (both under and overweight) has been recognized as a contributor to a higher death rate.  Whereas when communicable disease such as tuberculosis and chronic fungal infections showed underweight to be a significant predictor of earlier mortality, later in the century overweight was recognized as a contributor to earlier mortality as well.  Subsequent studies began to link conditions such as diabetes, hypertension, vascular disease and heart disease to obesity, and a better grasp of excess weight was added to the overall concept of impaired health.

The first set of insurance tables on ideal height and weight were published by Metropolitan Life, first in 1942 and then revised in 1959 to a “desirable weight table.”  Eventually the tables evolved by the 1980s to height and weight measurements stratified to small, medium and large build.  The definition of who was which build was quite arbitrary, and anyone approaching the upper limits of the table or beyond were quite naturally “large build” or “big boned.”  Looking retrospectively at the tables, designed to express which range of weight for a particular height afforded the greatest longevity, the ranges are by today’s standards quite slim, and a significant percentage of adults (particularly middle aged and older males) would overwhelmingly qualify as outside the desired build.

Rather than using height and weight on their own, most physicians have turned to a calculation called a body mass index (BMI).  It is measured as weight/height squared where weight is measured in kilograms (most of the world is on the metric system) and height in meters.  The BMI is used by the World Health Organization as the basis for calculation of build.  When using build as an underwriting measure however, most underwriting tables in the United States still are calibrated for height and weight.

Most insurers publish (or at least allow agents to be aware of) maximum weight for height that would fall into a standard category, and many also allow knowledge of which builds qualify for preferred or best class rates.  Significant overweight has been widely shown to correlate with increased mortality, as has significant underweight.  The gray zones really are where build combines with other health impairments.  For instance, in type 2 diabetes significant overweight not only has its own health impairment consequences but the diabetes is additive to the risk rather than independent.  Sometimes the diabetes itself is worsened by the increased weight. Other conditions including but not limited to cardiovascular disease, high blood pressure, stroke, fatty liver, gallstones, sleep apnea and certain cancers are related to increased body weight either by cause or effect.   

When build is the only ratable factor in an underwriting application, there are credits which may lessen the effect of any rating imposed.  With favorable blood pressure, normal cholesterol values, a negative treadmill test, good blood sugars and other testing showing a normal cardiovascular system, higher build may qualify for standard and even best class consideration.  However the bets are off when there is coincident diabetes, abnormal blood pressure, known heart disease or kidney impairment as just a few examples, and the debits imposed may not only be a sum of rating debits but in certain cases worse—where each contributor makes the next problem even more significant.  One other significant factor to mention is smoking, which severely worsens the consequences of abnormal build (both underweight and overweight) and may add up to more than just the sum of the parts.  On the opposite end of the spectrum, underweight may be a marker for disease, and unexplained recent weight loss and underweight may be associated (particularly in the elderly) with cancer or other significant and as yet undiagnosed disease.

Abnormal build on either end of the table is often a subject of debate by broker, agent and insurer, as “only a couple of pounds” may influence premium significantly—particularly when considering better than standard rates.  While insurers often bend over backwards to keep that from making or breaking a policy, rest assured that the published limits are very liberal, and what falls into standard category is very often considered as overweight by the lay public or the client himself.  A good percentage of preferred policies are issued to applicants who would not be considered “trim.”  Likewise when adverse action is taken on underweight it would be noticeable to most people as not the norm.  Remember also that build has less consequence in the absence of other disease and more significance when it is contributory or caused by another condition which has added mortality in and of itself.

Genetics are obviously one of the important factors in assessing longevity and in performing life underwriting.  Family history is asked about on virtually every application for life insurance.  Longevity helps in looking for preferred issues, and hurts when the pervasive pattern is an increased risk of early disease.  Whether it be a tendency toward a disease that does run in an individual’s DNA, a preponderance toward a specific type of cancer, or a process that has a known percentage of occurring in an individual’s lifetime, all are taken into account during the underwriting process.

Some genetic diseases, such as Huntington’s disease, have a more severe underwriting consequence than others.  For instance, if heart disease runs strongly within a family, behavior may be modified and treatments may be instituted to markedly decrease this risk.   When there is a strong chance an organ will be involved with cancer (such as in BRCA positive individuals), intervention may be undertaken to decrease this risk (as Angelina Jolie did with prophylactic organ removal surgery).   In certain genetic inheritance however, such as Huntington’s disease, there is a genetic inevitability to developing a disease for which there is no cure or beneficial intervention and that must be taken into account upfront.

Huntington’s disease thankfully isn’t that common—it affects less than one in ten thousand individuals.  It distributes in a pattern called autosomal dominant inheritance.  That means if a parent is affected with the disorder, there is a 50 percent chance an offspring will eventually come down with the disease as well.  For instance, if a father or mother has one of two genes for the disease, its 50/50 the child will inherit either the affected or unaffected one.  As such, both sexes are affected equally.  As will be touched on later, there is the ability to know if a child is affected by using genetic testing virtually at birth.

Huntington’s disease has a particularly sad progression.  At first, small abnormal movements such as grimaces, blinks and jerks start to appear.  Muscles in time become very uncoordinated, movement slows, walking, eating, drinking and speaking become progressively impaired.  Impulse control decreases and depression, memory loss and irrational behavior often follow.  The disease is almost uniformly fatal within 15 years of the initial onset, and the last years are usually spent with nursing assistance and dementia.

On the face of things even trying to cover and price for Huntington’s Disease, knowing 50 percent of people will be affected and die significantly before a normal life expectancy, would seem impossible, but the early age of onset of symptoms helps give a window of insurability for those who don’t choose to be tested for the gene.  The disorder begins to manifest as early as age 25, so if by age 30 someone with a history of Huntington’s in the family is unaffected the risk decreases by about five percent.  By age 40 without symptoms the risk may be closer to one third, and those unaffected at age 50 have an increased mortality as a whole but a slowly diminishing chance they have the gene.

It is certainly a matter of individual discretion whether to be tested for the Huntington’s gene when there is a definitive family history.  Not everyone wants to know what their individual mortality is or whether they are standing under the sword of Damocles, and of course many are able to better plan their lives and decide family planning as well if they pursue the knowledge.  Either decision can be priced for, except the one that is one of antiselection—where the individual knows the outcome of genetic testing but does not admit same to the potential insurer.  While a claim of eventual fraud (and perhaps non-payment of a claim) benefits no one, an insurer has only one chance to go after pertinent information that is properly disclosed when making its decision.  So the process may be a bit longer than usual when such a condition is involved.  Of course, Huntington’s disease that has been ruled out by genetic testing is underwritten normally.

There is discretion in underwriting genetically modified disease on the whole, because so many things may be done to decrease a risk of coming down with a disease.  Likewise, the appearance of many diseases that have heredity behind them may be postponed with optimal care, and often greatly diminished by prophylactic surgery of a potentially involved body organ and more intense surveillance along the way to intercede earlier in the process.   Huntington’s disease, however, is at this time still a non-modifiable and inevitable disease if inherited genetically and a difficult underwriting situation for all involved.