It’s a little like a spellbinding murder mystery, when there is cause for alarm and the clues are put out there, but no one investigates or tells you the final outcome. While every medical story or set of symptoms may not be New York Times best seller material, there are frequently open case files and dangling suspicions that need to be investigated and confirmed or shut down as problems. Ironically, problems such as these have often been fully investigated and become closed cases, but the APS trail still appears open to an underwriter and keeps an application from reaching a successful sale and conclusion.
The doctor thought it was nothing can certainly be the case in many instances. For example, chest pain originally thought to be angina turns out to be nothing more than musculoskeletal discomfort. Yet the doctor mentioned treadmill, catheterization, further work-up, but the follow-up isn’t there. The underwriter can’t keep from wondering if an applicant just never returned for necessary testing and diagnostics or if the testing was done and was negative—there must be a successful conclusion. If everything was benign, the doctor needs to say so in writing. If a necessary follow-up visit had to be made, it needs to occur. The “story” must be finished.
The last testing showed everything was okay. For instance, a PAP smear showed pathological abnormalities (human papilloma virus or cervical intraepithelial neoplasia changes) and the gynecologist remedied it with a procedure. Yet no follow-up testing is in the file showing that this was eradicated. Or, a PSA was elevated and a trip to the urologist was made. If everything was fine, a value was repeated and it was normal, or an intervention was made, these actions or procedures need to have follow-up documentation. An applicant may have had everything done to show resolution of a problem, but to an underwriter, the clues are out there and the alibi hasn’t been established. Finish the story.
Many times a doctor visit is established with a bizarre set of symptoms that could be serious disease. Numbness and tingling in extremities could be multiple sclerosis or new onset neuropathy. Severe headache and double vision could be a bad viral infection or brain tumor. Loss of balance and fall could be neurologic disease or inner ear infection. All these could have been transient occurrences of a very benign process; yet if nothing says they were solved, there is a problem. Finish the story.
Sometimes as underwriters we understand when a set of signs and symptoms are not things to be worried about from a mortality standpoint but, on the other hand, some set off fire alarms that need a response. When statements such as “throwing up blood,” “coughing up blood,” or “suspicious for melanoma” are made in a doctor’s notes without a follow-up, it’s not a closed case until proven to be so. It may require a follow-up visit to the doctor to be cleared, or a note back from the doctor with his impressions or suggestions for further study (if any). These are situations with potentially very serious outcomes. The loop needs to be closed, and a resolution demonstrated.
Far more often than not, the necessary information to give the underwriter enough peace of mind to issue the case is right at the applicant’s fingertips—it has already been done but just needs to be shared and communicated by the investigating physician. Other times, only a quick follow-up visit or test is required.
Above all, finish the story! We all want a happy ending.
