Robert Goldstone

The last touches on wrapping up a case can be some of the most difficult ones. Most everything is in, the case is ready to be paid for, but there is underwriting information that is outstanding: a test result unaccounted for; an APS that hasn’t come in; a doctor’s office that is taking its time in getting out information that is critical. There’s got to be an easier way.

Fortunately, sometimes there is. There may be more than one way to skin a cat, and what the underwriter is looking for may be available in a different way, a different format, or perhaps even the information is already contained elsewhere. No case will be held up waiting for Godot, because it’s to the company’s benefit to place it as much as it is to you and to the client. The needed information has to be pertinent to the case, necessary for the insurer to assume risk, and sometimes required by a reinsurer that is partnering in accepting part of the face amount. It all starts by asking the critical question: “What’s missing?”

You’ll want to know more than just the basic “the APS from Dr. Smith is missing.” What in the APS is it that’s essential? First, there’s a good chance that there is already information from a subsequent doctor’s notes that makes obtaining Dr. Smith’s notes less imperative. Second, there may be information in labs or testing done by a specialist that spells out what Dr. Smith was trying to ascertain. If Dr. Smith was seen for a non-essential reason (urgent care, etc.) his note may not be of much additional value.

What if Dr. Smith is the specialist? Often, his note is summarized or parroted by the primary doctor after seeing your client again in resuming care. You may already have the information you need. If Dr. Smith is the primary care physician, do you have enough information from the specialist to proceed? If yet another doctor is involved, there may be enough that you already have in the file to address an underwriter’s concern. Find out from the underwriter as closely as possible what he is looking for, as there is more than one source for obtaining that information in many cases.

Sometimes you may be waiting on a critical pathology report that may assess whether a cancer, for instance, is insurable at this stage. The doctor may have written everything you need to know in his note on a post-surgical visit, summarizing the pathology. If it’s the doctor’s report that is lacking, remember there are other places to obtain a pathology report—e.g., the hospital records. Or a third consulting specialist may have recorded in his notes everything you need to know. Find out if there’s any other place in what the underwriter already has that contains enough information for a decision to be made.

Doctors sometimes are over-cautious in their notes. In this day and age, with legal recriminations for just about anything, a doctor may advise a patient to get a benign-looking mole checked, to see a specialist if certain symptoms continue, or to obtain a certain investigation as a back-up. The client/patient hears it differently, and what the doctor has basically told him is that everything is okay and there’s no need to follow up if the problem disappears. Yet the underwriter is waiting for the follow-up test, or dermatology to look at that suspicious skin problem, etc. In that case, a short note from the doctor explaining this goes a long way. It’s a minimal inconvenience for a two or three line note explaining this to the underwriter. And the request is taken very seriously when made by the patient, because he is in effect the doctor’s client, and therein lies the good will of a ­physician-patient relationship.

One other difficult situation is when the request for information goes out and is met by “clinic no longer in business,” “doctor retired,” or “doctor’s office wants an ungodly sum of money for the records.” In these cases, the best answer is “be specific.” If you need one particular piece of information, ask for a short note from the doctor directly to address it. If the office is no longer in business, see if something in another doctor’s note addresses the question. When the clinic notes can’t be located, ask who got their medical records, or how old the information is that the underwriter is looking for.

An underwriter only gets one chance to ask for information, and once the policy is issued, unless there is outright fraud, there are no second chances. Be sensitive to that and ask the underwriter what it is that would put his comfort level high enough to issue the case on information that is already present. If a simple blood test or note from a current physician will suffice, it beats the frustration of waiting for notes that may never come to allow the case to go to competition. Ask if the underwriter will allow the medical director to have one more look at the case to see if he can be satisfied with existing information. Encourage that communication. And if the competition is willing to issue without that missing note, let the underwriter know that as well. It’s called “risk assessment” for a reason. Do anything you can on your end to make it as easy as possible to give the underwriter the assurance he needs to turn it into an issued case.

Underwriting younger ages can be one of the most difficult tasks of an underwriter. Besides the obvious task of determining insurable interest on individuals with no employment, no immediate financial need, little track record on health and few clues on the medical end, most underwriters have the least experience working on this age group. It is also the lowest risk reward for a company—smallest premium relative to policy face amount—so it raises caution flags at each step in the process.

The aforementioned insurable interest is of key concern. The policyholder must have a reliable financial interest in the child being insured. What might have once been insurance for medical expenses and burial insurance has progressed quite far into financial plans of insurance and savings. The death of a child generally produces little if any current financial loss to the beneficiary, so future needs of what are becoming higher and higher face amount policies are really guesstimates on the family’s socioeconomic status. Without carrying the financial element of this further, simply put the application has to make sense to the underwriter for it to proceed to the next level.

The younger the child, the more difficult the underwriting task from a medical aspect. There are generally few medical records, and any conditions that will compromise a child’s eventual life expectancy may not yet have made themselves known. Generally, insurance will not be sought until after most causes of immediate or neonatality have come to pass. Country specific mortality also varies—in the United States, postnatal care is usually quite good, and global causes of mortality are either bypassed or effectively managed.

One constant state an underwriter looks at is prematurity. Despite the high and advanced technical support in supporting children who are born before 37 weeks of gestation, there are still longer term consequences that include lung maturity, impaired development and growth, and mental and physical developmental delays that may have an underwriter postpone a case until these occurrences would become manifest.

Heart malformations and chromosomal abnormalities are also leading causes of mortality and morbidity in the earliest years of life. Heart defects such as a persisting hole in the heart (patent ductus arteriosis) or defects in the heart chambers (atrial and ventricular septal defects) may have to wait to be surgically corrected, and these lives are not immediately insurable. Chromosomal abnormalities such as Down’s syndrome, Marfan’s syndrome, hemophilia and thalassemia, or sickle cell disease may not be insurable at this time. Developmental delays may be forerunners of severe autism or mental deficiencies in which a child may be incapable of self care or independent living in later years. Conditions like this have to play themselves out over time and may be postponed until a definitive diagnosis is made or a child’s progress in school is assessed.

Evidence of well baby checkups and good medical care is always considered. A child who is well cared for, does not show signs of increased accidents or neglect/abuse, gets normal vaccinations and has a normal course in school is the most reassuring prospect. A lack of regular care leaves the underwriter guessing and may require further medical evaluations that delay the issuance of the policy. Normal physical growth and development of appropriate motor and psychological milestones are also important to demonstrate, particularly in applications for preschool children.

What used to be a more unusual occurrence of insurance on juvenile lives has now become an important part of many estate plans and trusts, as well as an anticipation of future insurance needs. Education, savings and the establishment of future insurability are now recognized by both parents and grandparents. As our bank of knowledge is much less and our health experience limited in younger individuals, anything that can be provided to the underwriter to show a justified need or reason for insurance in a normally developing child (both physically and developmentally) speeds the process and allows for a successful placement.

Although better surveillance and control of high blood pressure has led to a decreased incidence of stroke, it remains the third leading cause of death in the United States. Risk factors for stroke include the aforementioned hypertension, as well as diabetes, high cholesterol, smoking, heart disease, alcoholism and drug usage. Additionally, family history is a key risk factor. In women, migraines and the use of oral contraceptives are also implicated.

A stroke (also known as a cerebrovascular accident or CVA) is either a blockage or significant disturbance of blood flow to an area of the brain resulting in a permanent neurological effect or deficit. The diminished blood flow causes decreased oxygenation to the brain and either a motor or sensory deficit occurs, which persists for a period of time, often indefinitely. The deficit depends on which area of the brain is involved. A motor area may result in paralysis of a limb or an inability to speak. A mental deficit or weakness of a particular body area are also common presentations.

Strokes are generally defined by their causes. A lacunar infarct is a small lesion that most often occurs when blood pressure is so high as to interrupt circulation in a small blood vessel, or from poorly controlled diabetes. A cerebral infarction occurs when a small blood clot or fat or cholesterol embolus obstructs a vessel. Cardioemboli are small blood clots thrown from the circulation and pooling of blood in the heart. Strokes can also happen from hemorrhage, where a blood vessel bursts and there is bleeding into the brain.

Onset of a stroke is abrupt and may range from having sensory deficits to paralysis of a side of the body, or even to coma and death. The findings can be localized to where the interruption of blood flow occurred and how much certain parts of the body are supplied by the affected area. Virtually all of those who are affected should be admitted to the hospital and undergo neuroimaging with a CT scan or MRI. The cause of stroke is important to identify, and chest x-ray and heart echo (for cardiac causes), cholesterol and blood analysis (for thrombosis and blood clots/cholesterol emboli) and carotid artery studies are done. Conditions that may mimic stroke, such as seizure, low blood sugar, migraine and even structural abnormalities such as a brain tumor all have to be considered as well.

Transient ischemic attacks (TIAs) are temporary interference of cerebral blood flow, the effects of which reverse within 24 hours, and generally in the first hour or two. TIAs are associated with development of future strokes as well as an increased mortality risk. Treatment for both stroke and CVA are completely related to their cause and may include blood thinners, medications to dissolve blood clots, blood pressure lowering agents, and supportive care in the hospital, often in a stroke care unit.

A stroke is a serious medical impairment that has to be accounted for in underwriting. Most important is treatment of the cause so that a subsequent stroke doesn’t occur. Fibrillation in the heart causing blood to pool may need either eradication or blood thinners to prevent it from happening again. Narrowed circulation in the carotid arteries supplying the brain may have to be surgically treated. Blood pressure may have to be optimally controlled, as well as blood sugar. Smoking is a direct contributor to narrowing of blood vessels and must be permanently discontinued.

A second consideration is what is called “post stroke level of function.” Many strokes can be reversed when adjoining areas of the brain take over function for inactive or dead neurons and there are no permanent motor or sensory deficits. When the deficit is persistent the mortality risk is much greater. When ambulation is affected it is generally most severe, and the inclusion of mental impairment makes the condition likely uninsurable.

The most favorable considerations given to stroke are with TIAs (when the reversible deficit does not reoccur) and when the cause of a stroke can be directly remediated, or a one-time event, such as the use of the birth control pill. A six-month waiting period is usually in effect to see how the insured progresses and if contributors to the stroke are well controlled, such as blood pressure, blood sugar and cholesterol. Strokes are more seriously rated at younger ages, and the absence of permanent deficits generally coincides with the most favorable offers or lower mortality impairment ratings.

It certainly isn’t an uncommon occurrence. An offer on a submitted case comes back worse than you were expecting. Or worse than you hoped. Or, heaven forbid, as a decline. While you know not every case comes back with a positive outcome, you’ve reviewed the particulars and feel a better offer could still be placed. What’s your next option?

A case isn’t only declined on medical grounds. It’s an easier explanation when an attending physician statement or lab findings lead to a rating or declination. Sometimes financial considerations sink a case. It could be habits, sensitive information or missing information. But particularly on a medical appeal, it helps to be on top of your game and be able to converse intelligently on the positive factors in the case and why you feel there should or could be a different outcome.

You don’t have to be an underwriter or a physician to discuss a case you submitted. When you call for details, both underwriter and medical officer will give you as clear a reason for the decision as can be made while preserving doctor-patient confidentiality. Applicants certainly wouldn’t want you discussing sensitive medical history behind their backs. On the other hand, often the decision was made on admitted history. Or perhaps you were one who facilitated the sending of the records. You’ll have a good idea of what the problem was.

Have the facts on your side. You may know an applicant is a cardiac risk, for instance. But you also know he takes pristine care of himself, doesn’t smoke or drink, and is always the one to order salad at the nearest carnivore restaurant. Put these in writing, send them, and then call to discuss. Tell us what’s more favorable about this case than we could know only from papers and records. If there are other physicians an insured has seen, get additional information that helps the case. If the client is willing to do additional testing to get a lower rating, not only volunteer that, but ask the underwriter what result would make him more comfortable if it came back favorable. And if a personal doctor has information that is enlightening, get it in writing to be part of the file. Doctor to medical director or doctor to underwriter conversations are generally counterproductive, as differences between clinical medicine and insurance medicine are not easily explained in a simple phone call.

To make an appeal as successful as possible, know what you are asking for and know if your request is a reasonable one. Getting a decline changed to a standard generally doesn’t happen. Decreasing the offer to something you can more easily place does. Know your client. Don’t promise an unattainable result when what you might have put forward on a realistic basis is more likely. A client may be irate when a standard shows up instead of preferred—to him it seems like a rated case, as the amount is higher than what they were expecting. But almost all companies make clear what their preferred criteria is—and build, blood pressure or cholesterol clearly out of guidelines isn’t going to get preferred. Thinking a repeat blood test will turn a diabetic into a nondiabetic isn’t going to happen. But if a client didn’t fast, a number is close, or is not consistent with other numbers in the charts, a repeat may be a much more reasonable request.

Sometimes medical findings are what they are and business considerations are necessary. For instance, a small change in a key man rating that would bring other valuable partner business with it. A competing company made an offer close to the one you received and you could place additional business if only your preferred company would match the offer. Underwriters are fond of saying that “underwriting is an art, not a science,” and in those cases a company may match the competition because it makes business sense to do so. In those cases, have the competing offer or details of the offer in hand—no underwriter takes kindly to being bluffed into competing with an offer that isn’t real (and generally has a long memory for the next time a similar situation comes up).

An appeal is a real tool when used wisely, and not infrequently it is granted. But you don’t want to be a serial appealer, screaming for a re-look at every case you get back, no matter whether the offer is reasonable or not. The “cry wolf” syndrome will make it so even your legitimate requests are bypassed. When you know what you need and you feel that another look can yield an outcome more favorable, or a rating that is more placeable, coming with as much supplemental or new information as you can provide gives both underwriter and doctor a reason to reconsider a case more favorably. When push comes to shove and an appeal isn’t going to yield a positive outcome in the short term, ask when the case can be reconsidered and what you would need to bring to get the offer you’re hoping for. After a waiting period, or when new information comes up favorable to the client, the process is much more expedited and may lead to a successful placement.

It’s on every pack of cigarettes sold in this country in one form or another. “Surgeon General Warning: Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.” And according to the CDC (Center for Disease Control and Prevention) the number of U.S. adults aged 18 and older who smoke cigarettes is now down to 17.8 percent. Public service announcements, warnings and education classes are everywhere warning of the dangers of smoking with its accompanying health risks.

In spite of this, the numbers concerning smoking and lung cancer are still alarming. Approximately 200,000 people in the United States in 2010 were diagnosed with lung cancer, and almost 160,000 died of the disease, according to the National Vital Statistics Report. The other way to look at it is that more than 42 million people in the United States are still smokers, and more than 16 million live with a smoking related disease. Cigarette smoking is still the leading cause of preventable disease and death in the United States, accounting for more than one in five deaths-more than half a million per year.

Tobacco smoke is the leading cause of lung cancer. Four out of five cases of lung cancer are directly attributable to smoking. Secondhand smoke exposure is also associated with a higher risk of lung cancer, and many of us are old enough to remember when smoking was a part of all airline flights. Although there were “smokers’ rows,” the smoke was rarely smart enough to confine itself to just those sections on an enclosed plane. Since the average age of most who are affected by lung cancer is in the late 60s, the effects of even more prevalent smoking from years ago are still manifesting themselves today.

Luckily, smokers seem to be slowly shifting towards vaping instead, which is considered a much healthier (although not entirely healthy) alternative. Vapes contain none of the harmful substances found in cigarettes, but they do still contain nicotine. So, whilst it’s much better for your lungs, vapers are still at risk of nicotine addiction. CBD vape oil does offer an alternative to nicotine, however, and is commonly used for reducing anxiety levels. In this way, we may begin to see a shift away from nicotine altogether, towards more medicinal products such as CBD.

Tobacco smoke is not the only risk for lung cancer. Exposure to radon gas makes up a little more than 10 percent of cases. Likewise, exposure to asbestos is a slow ticking time bomb that results in much higher risks of lung cancer. People living in densely populated cities have a higher risk of lung cancer, and while stopping smoking is good for you, the risks never fully evaporate. Lung cancer also occurs in non-smokers, and genetic and familial factors as well as exposure to pollutants and toxins that may not be documented are the highest in suspicion.

The two major types of lung cancer are small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Non-small cell cancer is also known as squamous cell carcinoma, adenocarcinoma and large cell carcinoma, and accounts for about three-quarters of the cases. Small cell cancer comprises about 20 percent and is almost exclusively a disease of former smokers. Benign lung tumors make up the outstanding amount. They are more prevalent in younger people and their cause is not fully known.

Lung cancer is difficult in that those who have the disease generally have symptoms when it is found. Cough, bloody sputum, chest pain and wheezing are some of the most common presentations. Weight loss, shortness of breath and signs of coexistent emphysema may first lead to the diagnosis. In late stages symptoms can be caused by the spread of the tumor to other body organs (metastatic disease). A normal x-ray of the chest or the appearance of lung nodules doesn’t completely rule out lung cancer. Blood findings, clinical presentation and CT scanning are the mainstays of diagnosis. Sputum cytology may also show cancer cells. A biopsy, whether directly or by means of a bronchoscope passed into the lungs, helps treating doctors and oncologists come up with the best management plan.

Sadly, the prognosis for lung cancer remains bleak if the disease is found in an advanced stage or has spread to distant sites. Stages 3 and 4 lung cancers, which also include when the tumor has caused other organs to secrete inappropriate hormones into the system, have five-year survival rates, despite all treatment being in the 5 percent range. Five-year survival rates for those with local disease can be as high as 50 percent when the disease is caught early and amenable to surgical removal. Associated chemotherapy and radiotherapy are given to prolong survival when the disease is thought to be more widespread.

Can lung cancer cases be insured? Those with stage 1 disease who have passed through an appreciable period without recurrence may be offered insurance as quickly as three years post surgery and be eligible for standard rates further down the line if there are no other associated diseases of smoking (emphysema, heart disease, etc.).

Stage 2 cancers may have to wait a much longer period until the occurrence of the disease is remote. Stage 3 and 4 are generally uninsurable at any time. Of course inherent in all this is that good overall general health must be maintained, and applicants must have become complete nonsmokers from the time of diagnosis and treatment.

Transient global amnesia (TGA) is a sudden episode of confusion in which an affected individual has sudden memory loss and a period of amnesia which generally lasts from a few minutes to a few hours. A condition usually of older and middle-aged adults, the feeling is stupefying to those it affects. Many people are taken to an emergency room or hospital believing they are suffering from the after-effects of a stroke, but there are no other associated neurological signs, and a complete return to normal (excepting having no recollection of the events that transpired during that time) is the rule.

The condition was first described in 1956 and is often mistaken for a transient ischemic event or a neurologic occurrence such as a mini-stroke. A person will go blank for a short period of time and appear to have acutely lost the ability to understand where he is, what is going on in his surroundings and what happened in the interim from when the amnesia started. He will not understand why he has been taken somewhere for evaluation, have no idea of time when he was acutely aware of it pre-attack, or figure out how he got to the present surrounding environment. The amnesia covers a longer period at first and then is limited to the period of the attack only, as days pass. In the long term, memory is completely preserved except for anything that happened during the time of the episode. It’s not a sudden “where am I” feeling, but more a loss of recollection of any events surrounding the event.

There are diagnostic criteria that must be fulfilled to make the diagnosis of TGA and separate it from something more severe neurologically. The attack has to have been witnessed by someone who was present for the majority of the time. There has to be complete amnesia during the attack, not a partial recollection of what was going on. There can be no acute or associated neurological events such as slurring of speech, inability to move an extremity or anything associated with a neurologic pathway which would be diagnostic of a stroke. The cognitive part has to be limited just to the time of the amnesia period, and full resolution of all the occurrences must be within a 24-hour period, usually less. There can be no history of epilepsy or head trauma around the event, as those two types of events may be confused with things like petit mal seizures or concussive symptoms.

Most people are brought in for testing post TGA, particularly in a first occurrence. Twenty percent of people will have a recurrence, though only a couple of times rather than a regular repetition. Blood testing is unremarkable in TGA. While there may be evidence of some restricted blood flow in the hippocampal area on an MRI, the results of most imaging studies with this are not remarkable. Blood vessel studies in arteries supplying the brain as well as EEG and other neurologic testing are generally normal.

Besides fulfilling the criteria mentioned for transient global ischemia, TGA is most often settled on as a diagnosis when other causes are ruled out. Focal seizures can mimic TGA, but they are generally shorter in duration and more recurrent. Low blood sugar (hypoglycemia), particularly in those on insulin, can have similar findings, but sugar reverses the findings and there is generally an accompanying history of such problems. Stroke and transient ischemic attack are important to differentiate. Those conditions are generally associated with more specific neurologic findings and abnormal imaging such as on an MRI. In addition, the duration of the episode will be longer with some sort of neurologic finding which gradually passes.

Thankfully, transient global amnesia is generally a benign condition, and most people recover fully. Recurrent attacks (more than four or five) have to be studied and another cause has to be sought if TGA is too recurrent. Some younger individuals have migraine equivalents which may mimic TGA symptoms. TGA doesn’t appear to be a forerunner of a stroke. However, studies are underway to see if people who have recurrent TGA do have more rapid progression toward intellectual decline or long term risk of epilepsy. Most cases are taken at standard or preferred issue, particularly in one-time events and when other, more serious disease entities have been ruled out with appropriate testing.

Insurance blood testing for most, if not all, insurers includes a PSA (prostate specific antigen) test in males above a certain age range. Unlike testing for diabetes or kidney or liver disease, however, the PSA test is more controversial. It allows insurers to price more aggressively with a favorable result and requires more investigation with a questionable one. On the surface it appears no different from any of the other tests that screen applicants and reward good health with lower premiums.

Yet PSA is still very controversial. Enough so that the U.S. Preventive Services Task Force recommends against screening with PSA for men unless there are prostate disease symptoms or a strong family history. The American Society of Urological Surgery, as well as the American Cancer Society, disagrees with this approach. Diseases such as prostate cancer may well have passed the curable state if not screened for and found at the vulnerable period. Perhaps the biggest problem lies in how an applicant or patient handles the information and the consequences involved with next step testing and treatment.

Certainly no one disagrees that prostate cancer is significant-it is the most common malignancy in men and the second leading cause of cancer death in men behind lung cancer. The lifetime risk of developing prostate cancer at some point in a male is as high as 40 percent, with evidence of clinical disease evident in almost 20 percent, and approximately 5 percent of men afflicted with prostate cancer will eventually die from the disease. Pre-malignant conditions such as prostatic intraepithelial neoplasia (PIN) also are associated with higher risks of prostatic carcinoma. There are many reasons as to why someone may develop prostate cancer, but according to a 2004 and a 2016 study, males who ejaculate more frequently are less likely to develop prostate cancer than those who ejaculate less frequently. Therefore, studies suggest a prostate orgasm could help reduce the chances of prostate cancer, so you may want to add this to your routine. It is significant enough that many men would want to know this risk to make their own decisions on doctor follow-up and potential therapy, as would an insurer in trying to arrive at an estimate of life expectancy.

PSA is the marker that is clinically used in initial screening for prostate cancer. PSA is produced by the prostate gland only, and significantly higher than normal numbers are suspicious for prostate cancer. There are other conditions of the prostate that may elevate PSA, such as inflammation of the gland, infection in the cells, and even a larger size prostate than normal. At a point where symptoms develop (such as urinary blockage, blood in the urine, pain), a doctor may suggest a further step in evaluation, such as a biopsy of the gland. The biopsies are uncomfortable, sometimes painful, and certainly inconvenient. They may also be repeated over time depending on measurements.

Rather than indiscriminately biopsying every man with an elevated PSA, doctors have more tools on their side in testing. Free PSA (a fraction not bound to proteins) is considered a non-pathologic form, and elevated levels generally are just followed. PCA3 is another, newer test that allows a doctor to decide if a biopsy is prudent. Many physicians have a protocol of watchful waiting, where results are monitored closely, particularly a sudden or determined surge or increase in PSA (called PSA doubling time). Treatments range from an entire removal of the gland to use of radiation, ultrasound and cryotherapy, each with its own set of risks and potential benefit.

The Task Force recommendations are most influenced by the fact that every prostate cancer does not turn ruthlessly malignant, and depending on age, other coinciding health conditions and quality of life considerations, will not be the absolute cause of death in people who do have more indolent cancers. Many are slow growing and don’t reach a point where they metastasize into bones or other organs, depending on a number of factors, including the age at diagnosis, the aggressiveness of the cells and the rate of PSA increase over time. The surgery itself is not without consequence-most men will be incontinent for a period of three to six months (although more than 96 percent recover fully) post surgically, and there is the definite risk of impotence, sometimes partial, sometimes critical. Again the odds are in favor of the individual on these counts as well, but a risk some men are not willing to take.

Insurance companies include PSA as a screen because the risk of cancer is significant enough to do so with an elevated PSA and no follow-up. When a doctor/urologist is following the case and the results favor a benign process, even best class rates are available to those with elevated PSA levels. In those with cancer that has been treated, the same guidelines apply for all cancer-free individuals who get policies as time bears out their successful result. The Task Force looks at things like potential costs of treatment, possibility of complications, and the fact that quality of life may be unacceptable to those whose treatment may result in a cure but a compromise in male or urologic function. However, you only have to ask one man who is dying of the painful bony metastasis of this disease in a hospice what it would have meant to have his life saved by judicious treatment.

Again, inherent in risk assessment pricing is knowing the odds of a cancer shortening life when determining premiums and insurability. If you are diagnosed with diabetes, for example, you know the risks of treating or not treating yourself with insulin, and you make an informed choice. The same occurs with hepatitis B and C, or kidney disease or heart blockage. You may turn down interferon or dialysis or coronary artery bypass, but you would most likely want to know the facts of the situation in order to make your best informed choice. As would your insurer in determining your policy status. So it is no different for PSA. I can tell you as a physician what my recommendations would be, and as a patient you have the option to pursue that course or another. Since the “other” choice definitely impacts the overall life mortality and morbidity in an insurance product, PSA is and remains a “must see” for the insurer in the blood profile results.

The proper assessment of current health is essential for underwriters to come to the best (and hopefully most aggressive) decision on policy pricing. This is straightforward when tests and current assessment of well being have been done by an attending physician and favorable results lead to standard and preferred issues. What about screening tests for health that assess risk and allow both the doctor and patient/insured to look for disease that isn’t currently causing symptoms? The United States Preventative Services Task Force has recommendations for screening, but instead of being straightforward, many remain quite controversial.

The Task Force, for example, recommends  mammography every two years for women aged 50-74. Just about everyone, however, knows someone or has a friend or relative in whom breast cancer has been diagnosed well before age 50. Organizations such as the American Cancer Society and the American Congress of Obstetricians and Gynecologists start screening at age 40. Is there a right answer? Most insurers and the majority of women concerned about their health would agree with the earlier age. But is it a bigger risk for all involved not to screen until a later age, if at all?

Most insurers require PSA testing above a certain age, 50 being a common norm. But the U.S. Task Force recommendation was that screening did more potential harm than good unless certain men were deemed to be high risk. Both the American College of Physicians and the American Cancer Society suggest full conversations with men regarding risks and potential benefits before screening is decided upon. There are many documented cases in which insurers were the first to catch a rising PSA, indicative of cancer, but the prostate cancer screening guidelines remain controversial.

Colonoscopy recommendations have been more uniformly agreed upon. Screening at age 50 should begin (at earlier ages if a strong family history exists) and done periodically every 5-10 years depending on findings. Colorectal screening has been found to be an effective preventative measure in removing precancerous polyps as well as looking for occult cancer in an earlier stage when it is not symptomatic. Both the Preventative Task Force and the American Cancer Society agree on these recommendations.

Other screening tests are also recommended. Cervical cancer screening with Pap smear and HPV testing is recommended every five years for women over 30. While CT scanning for lung cancer is not routine, it is recommended yearly beginning at age 55 for those who have a 30 pack/year or more history of smoking, using the low dose CT technology. Screening for abdominal aortic aneurysm is recommended as a one-time test for male smokers and former smokers age 65-75. The easiest and most efficient way for trained professionals to screen for abdominal aortic aneurysm is by using a portable ultrasound, which has a maximum scanning depth of 30cm.

One thing that is universally agreed upon is health screening with periodic history, physical and routine lab testing. Insurers would not want to participate in risk taking where there was no evidence of health maintenance and some periodic screening for heart disease, cholesterol, general medical health and wellness. Regular medical checkup and wellness visits are generally looked for in both males and females over the age of 50, with periods in between dependent on age and results of previous testing. Preferred and super-preferred status is certainly benefited by a track record of good health and continued preventative health measures. 

  Those of you old enough to remember the last Nash automobile that rolled off the production line in 1957 know that it is extinct and only available as a collector car. But the liver disease NASH (nonalcoholic steatohepatitis) is far from extinct, and unfortunately it has been rising in prevalence in the United States. NASH affects between 2 and 5 percent of Americans and is not always a benign disease or an incidental finding. Along with hepatitis B and hepatitis C, it is attracting large amounts of research dollars in the study of its prevention and treatment.

 As people develop more sedentary lifestyles, obesity, diabetes, cholesterol abnormalities and a lack of exercise have caused a higher incidence of fatty liver. It becomes more serious as the entity of NASH, where additional findings of liver cell injury and inflammation develop. It’s a disease that can only be proven from a biopsy, where tissue is obtained and looked at under a microscope, and indeed early on there are few if any symptoms. Most cases are discovered accidentally through normal screening laboratory results as part of a history and physical exam. Alcohol may cause these changes (and often does), but when alcohol is determined not to be a causative factor, the suspicion swings to NASH.

 There are really no symptoms until later in the disease, when weakness, fatigue and weight loss may develop. The progression can take years, and in some cases even decades. Sometimes the progression actually stops. Other times it worsens into fibrosis (where the liver becomes inelastic and nonfunctioning) and cirrhosis (an end-stage liver disease usually associated more with alcohol overuse). Once cirrhosis is in the picture, no real treatment short of eventual liver transplantation exists at this point in time. NASH ranks only behind hepatitis C and alcoholic liver disease as a cause of cirrhosis.

 Tests early on in the disease involve monitoring liver function tests and ruling out other causes of fatty liver disease, such as viral, hemochromatosis, diabetes, metabolic syndrome, and medication taken for other causes, just to name a few. Liver imaging (ultrasound) and CT scanning help to determine the extent. Lifestyle changes such as improvement of diet, weight loss and exercise are incorporated, and blood testing is followed. If the results fail to correct, a liver biopsy confirms the diagnosis.

 The goals of therapy once a diagnosis is made are to try and reverse hepatic injury and prevent further fibrosis. No specific therapies at present exist for NASH. Weight reduction, balanced and healthy diet, increased physical activity and avoidance of alcohol and other offending medications help. More vigorous treatment of adjuvant disease such as diabetes, heart disease and high cholesterol also are a net benefit. Medications such as bile acids, antioxidants, metformin for insulin resistance states, and vitamin E haven’t shown a sufficient proactive benefit to be recommended. 

  The National Institute of Diabetes and Digestive and Kidney Diseases funds the NASH Clinical Research Network, which is doing active research into therapies and progression of the disease.

 Fatty liver disease in itself usually isn’t rateable separately from any assessment of the primary cause, such as cholesterol, diabetes, etc. When the diagnosis is biopsy-proven NASH, the mortality is increased due to the eventual appearance of significant fibrosis and cirrhosis and a mild to moderate rating may be added. Advanced liver disease and those cases in which liver transplantation is being considered are generally not insurable. Cases in which there is no documented progression of disease over time are looked at more favorably, as are the institution and persistence of positive lifestyle changes.

Bell’s palsy is an acute affliction of the facial nerve, resulting in sudden weakness or paralysis of the muscles on one side of the face. First described by Sir Charles Bell, a Scottish surgeon and anatomist in the early 1800s, it is an acute finding that often brings affected individuals into the emergency room with a possible diagnosis of stroke. The condition can affect people of any age but is most common between the ages of 40 and 50. Partial paralysis almost always recovers, but in some cases a permanent affliction may occur.

The facial nerve (7th cranial nerve of 12) is in charge of passing electrical impulses through the facial muscles, which  controls expression and movement on each side of the face (there are two facial nerves, one on each side). Inflammation of one of those nerves causes it to swell and be compressed in the channel that leads from the brain stem and makes it unable to conduct nerve impulses to the muscles on the affected side. The paralysis that results can be either partial or total. The severity ranges from either slight weakness on close inspection all the way to a complete nonfunctioning of the facial muscles on the affected side.

The paralysis comes on over a time frame of minutes to hours. The corner of the mouth begins to droop, the side of the face affected becomes flattened and unable to show expression, and the lower eyelid starts to fall. Often it is noticed by someone else rather than the individual, but soon there may be difficulty with drinking or eating, headache, or impaired taste, and sometimes hearing sensitivity is likewise affected. Diabetes has been shown to be involved more often in those with Bell’s palsy, and at times facial palsy is also associated with Lyme disease. Other viruses can cause Bell’s palsy, and doctors do careful examination to rule out stroke, with the finding that only the territory involving the facial nerve is affected.

Bell’s palsy generally has a predictable pattern—between 70 and 80 percent will completely recover within weeks or up to three months after the diagnosis. Those who have continued problems may undergo an MRI to see the pattern of swelling and whether surgical management to free the nerve is indicated. Corticosteroids orally are instituted early in the disease process. Antiviral medication has not been shown to be helpful, but is sometimes instituted at the same time when facial palsy is severe. Physical therapy, electro-stimulation, exercise and massage are often employed, but only of mild help until the disease has run its course.

Underwriting Bell’s palsy generally means ruling out more significant neurological disease and being sure the findings are contained to the facial nerve distribution. A definite diagnosis is required and any underlying cause (such as diabetes or Lyme disease) has to be evaluated independently. A waiting period of three to four months is generally observed, after which time best class may  be allowed with complete recovery. Permanent paralysis is evaluated on a case-by-case basis.