Most cases of bronchial asthma are not an underwriting worry. It is a common disease, affecting between five to 10 percent of the population. But asthma is also becoming more concerning than it was ten or twenty years ago. Prevalence, hospitalizations, and fatal asthma cases have all increased, and there were close to 4,000 asthma deaths in the United States last year. Knowing which cases are the most concerning is the key to successful underwriting and case placement.
Asthma specifically consists of airway obstruction (usually acute), airway hyperresponsiveness and airway inflammation. A specific response to an allergen is the most common presentation, but exercise, respiratory tract infections, sinusitis, GERD, stress, and even a change in the weather can precipitate an attack. The commonest allergens on an external basis are usually house dust mites, upholstered furniture and carpets, animal fur and dander and seasonal pollens. Tobacco and smoking of any kind from exposure to products of combustion increase asthma symptoms and are common precipitants of an attack.
Clinical findings can vary widely among patients. Most common is episodic wheezing, chest tightness, difficulty breathing and cough. The attack may come on suddenly or just increase slowly over a period of time. Asthma symptoms are frequently worse at night, and the shortness of breath may initiate an emergency room visit. In older individuals asthma may be mistaken for signs of congestive heart failure, and testing must be done to differentiate the two conditions.
The underwriter first looks at asthma and determines whether the condition is mild, moderate or severe. The National Asthma Education and Prevention Program Expert Panel Report is a good reference for this. Mild asthma is not a daily occurrence, a chest examination is generally clear, inhaled corticosteroids help greatly in control, and there is generally no morbidity or time off of work. Moderate asthma may occur daily, wheezing will be heard on physical examination, asthma medication is generally used on a regular basis, and time off work is minimal. Severe cases will occur throughout the day, hospital admission is not uncommon, wheezing or chest tightness does not readily respond to bronchodilator medication, and there is significant morbidity.
Testing the underwriter may reference involves the evaluation of pulmonary function testing. FEV1, which is the amount of air expelled by the lungs in one second of forced expiration, is generally decreased proportionally to the severity of the attack. Peak expiratory flow is a measurement many patients measure with a flow meter at home to assess when they are getting into trouble with an attack. An FEV1/FVC ratio measures the degree of airway obstruction. Abnormal results and the degree of abnormal findings generally dictate the measures of treatment needed.
Certain rules of thumb help in the evaluation and assessment of the asthma patient when evaluating an insured. How often are the attacks, and what is their severity? What medications are needed to control an attack—generally the use of inhalers is a lot more benign than the use of systemic corticosteroids taken on a regular basis. How often does an individual need to go to the emergency room—the severity of an attack is a predictor of possible adverse mortality in those affected. And also, what other comorbid conditions exist in an asthmatic—obesity is a poor coexisting factor as well as diseases such as diabetes, sleep apnea and chronic smoking.
Asthma may not be ratable at all and considered for preferred classification if the symptoms are infrequent (less than twice/month), they are low intensity, there is no time off work, control is with minimal medication, and the applicant is a non-smoker. When the symptoms are moderate, pulmonary function tests are abnormal, there is use of chronic bronchodilator medication and/or corticosteroids and there are co-morbids, a rating is generally applied. When attacks are frequent, require regular trips to an emergency room setting, or require hospitalization for control, a decline is the more usual outcome.
Particularly difficult situations may be encountered at either end of the age spectrum—in the very young and the elderly. In infants and young children, acute shortness of breath can be quite severe and intervention is more difficult when instructions can’t be followed and the small anatomy of the child is considered. In the elderly, co-morbids often significantly contribute to problems in control and diseases like congestive heart failure have to be considered and co-managed. Those with asthma of long duration may have more severe asthma that is associated with irreversible airway obstruction which leads to a much more difficult prognosis.