We hear a lot about the life insurance gap—according to LIMRA, 30 percent of Americans state they need more life insurance. Perhaps more important than the life insurance gap is the immense need for long term care insurance (LTCI). According to the Centers for Medicare and Medicaid Services, at least 70 percent of people over age 65 will need long term care services and support at some point in their lives.1 Yet less than five percent of Americans have any kind of long term care insurance at all.2
And this care will be expensive. According to the Genworth 2015 Cost of Care Survey,3 the national median annual cost of nursing home care in 2015 was $91,250, ranging from $51,100 for a semi-private room in Texas to an incredible $281,415 for a private room in Alaska. Even homemaker’s services had a median annual cost of $44,616.
Based on these numbers, the greatest opportunity for brokers only selling life insurance would appear to be an aggressive move into the LTCI space; however, many brokers don’t know how to field underwrite LTCI. So let’s take a look at some of the big differences between quoting and underwriting life insurance and LTCI and, in the process, take some the scariness out of quoting LTCI.
The BIG Differences
1. Mortality and morbidity
Without question, life insurance underwriting has more moving parts than LTCI underwriting—financial, avocation and occupational expertise are required to be a successful field underwriter of life insurance, and then you need to master all those rate classes and flat extras. The saving grace is that mortality is all you have to deal with on the life insurance side.
However, when it comes to LTCI, mortality and morbidity both come into play, complicating LTCI underwriting. It is increasingly evident that mortality plays a bigger part in the underwriting of LTCI than previously thought. While better than expected mortality results (fewer people dying) are almost always better for life insurers, that is generally not so for LTCI. The simple fact is that those who live long enough are more likely to become disabled and need long term care services.
2. Cognitive impairment
From a mortality perspective, cognitive impairment is the number six cause of death in the United States, behind cancer and cardiovascular disease. However, in terms of dollars, cognitive impairments are far and away the number one cause of concern in LTCI. At Genworth, close to 40 percent of all claims dollars are related to cognitive claims. Thorough screening of potential LTCI applicants for cognitive impairment is critical. You should be cautious when an applicant relates memory concerns or mentions the need for help with simple everyday tasks such as balancing a checkbook or taking medications. Many long term care companies are now screening for early cognitive impairment at ages as low as 60, so prepare your clients for the screening, making sure they understand the need to take the testing seriously. For best results, cognitive screening should be conducted in a quiet, private location. Applicants need to pay attention and carefully follow the instructions.
3. Cardiovascular disease
Cardiovascular disease is more important in the life insurance world and is generally more leniently underwritten by LTCI carriers. The exception being cerebrovascular accidents, also known as strokes. Strokes are a significant cause of life insurance and LTCI claims and are usually treated conservatively by both life insurance and LTCI underwriters. Outside of a history of a stroke, don’t hesitate to send your clients with other cardiovascular impairments to your long term care carrier after around six months—as long as the applicant is stable without complications and there are no other significant impairments present. In life insurance these disorders would likely not be standard for many years if ever.
4. Cancer
LTCI carriers tend to be more aggressive than life carriers on cancer history because cancer often leads to early mortality rather than extended periods of long term care. On the LTCI side low and even medium stage cancers are usually underwritten at standard rates as early as six months after treatment, while life underwriters would not consider standard for several years after treatment. Here, the key is staging and any recurrence of the cancer.
5. Musculoskeletal disorders
Musculoskeletal disorders are impairments involving joints, muscles and bones. With the exception of the presence of a waiver of premium rider or the continued use of narcotic drugs, life insurance carriers are typically aggressive on these disorders as the mortality risk is low.
LTCI carriers, on the other hand, are concerned with chronic neck, back, spine and other such disorders as these can lead to functional limitations over time. When field underwriting these disorders, you should pay careful attention to medications and physical limitations.
The use of narcotics for pain control is a warning flag, so, to avoid a decline, any such history should be fully developed before an LTCI application is submitted. Question the applicant carefully to determine if the underlying impairment is impacting job performance or other daily activities. Observe any physical limitation that might be present. Does the applicant have a normal walking gait? Can he or she easily rise from a chair? Are there signs of an active lifestyle?
Other signs of concern here are a history of falls and obesity. Falls can be a sign of imbalance as well as limited mobility. Obesity puts stress on already impaired joints, so screen carefully for a history of joint and other musculoskeletal concerns with an applicant nearing the maximum build guidelines. And always question the applicant carefully on build, as it is a major cause of declination and is often inaccurately reported. If the given build does not match your observation, politely re-ask the question.
6. Requirements and rate class structure
When selecting an LTCI carrier you will not only have to screen based on the likelihood of acceptance, but also select the carrier with the best rate class structure for the applicant and determine the willingness of the applicant to complete medical requirements. While most life carriers have the same basic requirements, long term care carriers vary greatly as to the need for a paramedical exam and labs.
The number of rate classes available varies with each carrier and it is sometimes difficult to compare rate classes across companies. The use of a carrier’s field guide is encouraged when selecting a rate class as most guides have clearly laid out matrixes of what it takes to obtain each class. In general, classes are based on criteria such as nicotine use, blood pressure, build or body mass index (BMI), and impairments present. Some companies have taken criteria further to include family history and cholesterol.
In an effort to provide rate class determination support, Genworth has made eValuate, its field underwriting tool, available to brokers. By entering the applicant’s medical history into eValuate, a quick estimate of expected rate class can be obtained.
With the strong likelihood that people over age 65 will require long term care services during their lifetimes, there is an immense need for long term care insurance given the aging demographics of the United States. Current life producers can tap into this important market by working closely with their selected carrier to master underwriting field guides to better understand how to screen and quote correctly.
Footnotes:
1. 2015 Medicare & You, National Medicare Handbook, Centers for Medicare and Medicaid Services, Revised September 2014.
2. Robert Wood Johnson Foundation, Policy Snapshot, Health Issue Brief, February 2015
3. Genworth 2015 Cost of Care Study, April 2015
