As an in-house underwriter for an independent marketing organization, the most important functions of my job are threefold: a) find the carrier or carriers that will have the most aggressive underwriting stance given each proposed insured’s specific medical history; b) help our sales team and advisors sell those cases that are rated substandard to ensure the client gets the coverage that they truly need; and c) help educate our sales team and advisors to understand, at least in a rudimentary way, the medical history that has led to their client being rated substandard or declined.
I believe that this third aspect of the in-house underwriter’s job is the most important as it actually assists and ensures that the first two goals are reached in their most efficient and expeditious ways. First, by helping the advisor understand why a particular medical condition won’t qualify for preferred rates; second, to help the advisor communicate this to their client; and, third, to help the advisor obtain the most accurate and pertinent information to help obtain the most accurate and favorable offer for their client. As the axiom goes, you can’t sell what you don’t understand.
I’ve found over the past 19 years that coronary artery disease (CAD) and cardiomyopathy are two of the most confusing subjects for advisors and their clients. Most of the general public understands very little about coronary artery disease; most only know that it can cause a heart attack. Most don’t understand the underlying physiology of the condition or the underwriting ramifications. I’ve had many advisors over the years tell me that they’ve always thought that someone who has had a heart attack or has had bypass surgery or an angioplasty is an automatic decline. This is definitely not true. Even though CAD is the number one cause of death in the United States and almost every person reading this article knows somebody that has had a heart attack or has required some kind of revascularization surgery such as angioplasty or a coronary artery bypass graft, CAD is still mostly a mystery to the general public.
The other primary cardiac condition that regularly crosses underwriters’ desks is cardiomyopathy (cardio = heart; myo = muscle; pathy = disorder). Because it’s not nearly as common as CAD, cardiomyopathy is a complete mystery to almost every individual who hasn’t specifically studied this condition. Knowledge of it is becoming much more important, however, as detection of this condition has become more commonplace in the clinical setting as tests such as echocardiograms and SPECT’s are becoming cheaper every year. But, with these more common diagnoses, underwriting offers become more difficult.
What is Coronary Artery Disease?
Coronary artery disease is simply the obstruction of the coronary arteries by plaque build-up. The heart is a muscle and, like any muscle, it needs oxygen to survive and perform correctly. If this oxygen is restricted, or blocked altogether, the muscle can atrophy and die.
The coronary arteries that run along the outer layer of the heart muscle constantly feed it with oxygen-rich blood, but when plaque builds up in these arteries a condition called myocardial ischemia occurs. Myocardial ischemia (is-kee-mi-a) is simply a deficiency of blood supply, causing less oxygen to reach a particular region of the heart. A heart attack is the necrosis of heart tissue due to long term ischemia.
Anatomy and Physiology
There are 5 major coronary arteries and multiple smaller coronary arteries. The names of the major arteries are the Left Main, the Left Anterior Descending, the Left Circumflex, the Ramus Intermedius, and the Right Coronary Artery.
The severity of coronary disease is determined by which of these arteries are experiencing blockage, where in each artery the blockage is occurring (closer to the aorta which feeds the arteries, or further away), and the severity of the narrowing, as expressed as a percentage, i.e. 50 percent narrowing versus 70 percent narrowing. An easy way to understand this is by palming a baseball. Your fingers represent the coronary arteries that wrap around the baseball and your wrist represents the aorta, which feeds the blood into the arteries. If a blockage occurs at the first knuckle of one of your fingers, then blood flow is kept from reaching the rest of your finger, which causes more damage. If the blockage occurs at your fingernail, then less damage will occur as this is at the terminus of the artery. Therefore, a 30 percent blockage in the distal (further away from the aorta) circumflex artery isn’t nearly as concerning to an underwriter as an 80 percent blockage to the proximal (closer to the aorta) circumflex artery. The next section will explain how the cardiologist and the underwriter can determine where these blockages have occurred and the severity of each blockage.
Investigational Procedures and Treatment
The three primary and most common diagnostic and investigational procedures for CAD in ascending order of both accuracy and invasiveness are the resting EKG, the stress EKG (including some types that include imaging components) and the cardiac catheterization. The resting EKG measures electrical activity of the heart and is able to determine possible ischemia (deficiency of blood supply to parts of the heart). The stress EKG does the same thing but adds stress to the heart. The heart reacts differently while under stress and so the stress test is more diagnostic of ischemia than the resting EKG. The cardiac catheterization is a surgical procedure where a dye is injected into the coronary arteries and then x-rays are taken that show exactly where blockages in the coronary arteries exist and how severe they are. The cardiac cath is the gold-standard for diagnosing coronary artery disease.
The primary treatments for coronary artery disease are medical management, angioplasty with stent, and coronary artery bypass graft. Medical management includes using prescribed medications such as statins, blood thinners and ace inhibitors to reduce the progression and possibly reverse the plaque build-up in the coronary arteries. Angioplasty with a stent is a surgical procedure where a catheter is inserted into the affected artery and a balloon is inflated to re-open the blockage. A mesh spring is then inserted to keep the artery open. Coronary artery bypass graft is a surgical procedure where the blockage in the affected artery is bypassed using a blood vessel from another part of the body.
The Risk Factors of CAD
Risk factors that can help your case if your client has a history of coronary artery disease include: a lack of family history of CAD, no tobacco use, no history of diabetes, well-controlled cholesterol and blood pressure even if medication is required, normal BMI, and an active lifestyle. Of course the lack of any of these factors would harm a case, all other factors being equal.
Impact on Underwriting
Underwriting CAD has become much more favorable over the past twenty years. When I began my career 19 years ago, many carriers would outright decline any client with a history of a heart attack, angioplasty procedure or heart bypass surgery, regardless of which arteries were involved, the extent of disease, amount of damage to the heart muscle, risk factor modification after the event, or the patient’s commitment to cardiac follow-up after the event.
Over the past twenty years however, most carriers, even those not known as “impaired risk specialty” carriers, are now able to offer coverage to individuals with CAD; and with tools such as table-shave programs and crediting programs that many carriers now have, standard offers are now possible on many cases. Of course each case is unique and each offer is dependent on the risk factors previously noted—the extent of any damage to the heart muscle, which arteries had plaque build-up, the extent of that plaque build-up, and where exactly in each artery that build-up occurred. This is why the cardiac catheterization is the most important tool we use to price these cases.
Coronary artery disease is the #1 cause of death in the United States, so most people have at least a rudimentary understanding of what it is and how it manifests itself. Cardiomyopathy, on the other hand, is a mystery to most of the general public including most financial advisors. The cost of tests like single-photon emission computed tomography (SPECT) and echocardiograms are dropping every year, and more and more doctors are using them as screening tools. More and more cases of cardiomyopathy are being detected that would have gone undiagnosed in the past, causing some difficulties from an underwriting standpoint.
What is Cardiomyopathy?
While coronary artery disease is a process where the heart muscle is starved of oxygen due to narrowing or blockages in the coronary arteries, cardiomyopathies are conditions that affect the actual heart muscle, making it unable to function as efficiently as it should. Causes of cardiomyopathies are varied, but in about 30 percent of cases no cause is ever identified. Some causes include things like infections, long-term alcohol abuse, drug abuse and cardiomyopathy caused by coronary artery disease itself. Specific causes and types aren’t as important to underwriters as the extent of damage to the heart muscle, current function of the heart muscle, and whether heart function is documented to be stable or to be deteriorating.
The most common type of cardiomyopathy is Hypertrophic Cardiomyopathy. Most cases are genetic, and the disease causes the walls of the left ventricle (the chamber of the heart that actually pumps blood to the rest of the body) to become thickened and less able to contract correctly. As contractility decreases, the blood pumped to the body is reduced.
Anatomy and Physiology
The heart can be thought of as the body’s engine. The heart is powered by electricity, it has valves, and the more efficient it is the more efficient the body is that it’s powering. And just like any other mechanical device, it can become broken and not perform like it should. When a car’s engine doesn’t perform correctly, the car either gets worse gas mileage or it stops working entirely. When the human heart stops working correctly, it doesn’t pump blood efficiently and so we develop symptoms such as arrhythmias, shortness of breath, or swelling of the hands and feet. However, as I’ll mention later, many times there are no symptoms—which can cause sales problems, not just underwriting problems.
Investigational Procedures and Treatment
The echocardiogram is the gold-standard test for cardiomyopathies. The echocardiogram is an ultrasound of the heart and works very similarly to the ultrasound performed on pregnant women to determine the health and progress of the baby. The echocardiogram can determine, among other things, the size of the heart, the size of each chamber of the heart, the wall thickness between the atria and ventricles, and the efficiency of the pumping action of the heart using a measurement called the ejection fraction. The ejection fraction is a measurement of how much blood is being pumped out of the left ventricle of the heart.
The one drawback to echocardiograms is that sometimes the individual performing the test or the individual interpreting the images can affect the results if they’re not experienced. This is one reason that serial echocardiograms are so important on cases like this. When two echocardiograms done 12 to 24 months apart can be compared, stability or progression of the disease can be determined and a more accurate diagnosis can be made–and many times a more aggressive underwriting offer can be made.
Unfortunately, there is no treatment for cardiomyopathy until it gets so advanced that a heart transplant is needed. Doctors normally just treat the symptoms.
Impact on Underwriting
Cardiomyopathy is one of the most difficult medical conditions that life insurance underwriters must evaluate. Many times after the underwriter reviews the case, one of the insurance company’s in-house MDs also reviews it, specifically analyzing the echocardiograms. There is no treatment for cardiomyopathy, so moderate to severe cases aren’t usually insurable. For those cases that are insurable, stability over a period of time is very important and, as stated previously, serial echocardiograms are the gold-standard for determining this.
One of the biggest sales challenges that cardiomyopathy presents for advisors is the fact that many doctors downplay the significance of the diagnosis with patients and therefore, when the client is rated or declined, they’re confused. This disconnect between what the advisor is telling the client and what their doctor is telling them can sometimes cause friction between the client and the advisor. So care must be taken when communicating this information to the client.
Coronary artery disease and cardiomyopathy can be two of the most complicated and confusing issues that advisors must deal with when working with clients who have these conditions. Having at least a basic understanding of these conditions—how they’re similar and how they differ, and how underwriters view them—will help any advisor feel more comfortable in all steps of the sales process.