As I write this, my home state of California has reported over 2.3 million cases of COVID-19, and recorded over 26,000 deaths. The United States has already seen over 20 million recorded COVID cases, and the death toll stands at over 350,000. These are only “so far” numbers, and the slow vaccine roll out to date ensures we are nowhere near the final count on these statistics. And these numbers are only the cases we know about, not the equally massive number of cases where there was a recovery without a laboratory diagnosis or deaths where COVID may have been a major unreported factor—particularly in the elderly.
Thankfully, the number of COVID affected individuals has resulted in a large amount of recovered cases. Or what we assume are recovered cases. Many have gone back to their lives and situations with residual symptoms, even if mild. A small but significant amount who have “recovered” from the acute phase of the illness still have a degree of disability which affects their day-to-day living. These are the “long haulers”—those in whom COVID has spared in the short term but in whom we have truly no idea of what the long term prognosis will be, either morbidity or mortality wise.
Disease-impacted underwriting depends on estimating life expectancy (for life insurance), degree and duration of disability, and long term costs of care for health, disability and long term care. Much of this is based on experience of watching the course of illnesses in multitudes of people and understanding both the process and course of the disease. COVID however is a horse of a different color—we have no experience in how this has played out at other times and only guesstimates of how it will work in the future. Cases followed in the United States have barely reached the one-year point. It has become obvious, even in that short time, that recovery is not always complete, and that remaining objective signs and symptoms have potential to cause continued decompensation in the long run.
Cases of regular exposure where a COVID test is positive and there are minimal symptoms and a return to work without problems are still standard to preferred cases as they were before the infection. Those who were admitted to the hospital but required no ICU care or intubation and had a recovered course likewise don’t appear to date to have recurrent symptoms or compromise. Where it gets more difficult are three categories where more intensive treatment was necessary. Those include admission to the hospital with symptoms and the need for more than routine treatment (remdesivir, oxygen support, etc.), those who were hospitalized for a significant amount of days and whose course required an ICU admission (even not intubated), and those with an ICU admission where other medical problems surfaced with a prolonged hospital stay and where rehabilitation was needed.
Underwriting these cases requires much more care toward these latter classes. Besides perhaps a postpone period to see how symptoms persist or progress, additive testing may be required. Repeat chest X-rays and even chest CTs may be required. Laboratories in follow-up visits must be reported. Face-to-face follow-up care may be required above and beyond tele-visits. Exercise echocardiograms may be particularly helpful in assessing any long lasting cardiac compromise or continued decompensation. And even psychometric testing to screen for PTSD, continued severe anxiety and depression and failure to cope post infection may also be important to assess.
Maybe most perplexing are the long haulers still affected after what seem to be mild or moderate symptoms from the initial infection. Many patients haven’t fully recovered their normal activity level, and remain incapacitated or house bound. Coronavirus may leave patients with a condition called POTS (postural orthostatic tachycardia syndrome), where heart rates can double or triple on standing, blood pressure can drop precipitously, and just about all conditions that are dependent on normal regulation of blood pressure and pulse go out of whack. Dizziness, headaches, shortness of breath, chest pain and “brain fog” (where periods of time without clear thinking occur) cause short term problems and may worsen other body functions. The long effects of this on the heart, the autonomic nervous system, and pulmonary and brain functions are truly unknown. What is the course of COVID induced POTS? We truly don’t know with this limited time experience.
Underwriting is going to be a lot tougher and with a lot more caution in COVID cases and certainly in long haulers where the infection continues to cause symptoms and impairments well into months after infection. Careful examination of medical records and longer periods waiting for in-person visits may be necessary. Testing, whether as routine as for blood, or with scanning and testing cardiac and lung function, may be required. Return to work for a defined period of time without decompensation may need to be demonstrated. And in long haulers, an indefinite period of postponement may be required until we are best able to evaluate the long term effects of this pandemic virus which has caused so much disruption and harm in our lives as a people.