Impairment Library

This page provides information related to a multitude of medical and non-medical underwriting impairments. The information can be used as guide when you are underwriting a case or as an educational resource.

For information regarding an impairment and its underwriting impact, simply click on the impairment name.

If you have any questions, contact [email protected]

Non-Medical Impairments

Avocation

Risk classification considerations:

The greatest hazard associated with recreational and professional sports and avocations is accident. Although tighter safety regulations, training standards and improved equipment and facilities have had a positive effect on many ‘traditional’ sports risks, the extremes at which people participate in newer sports have increased. ‘Extreme sports’ are on the increase worldwide and ‘adrenaline junkies’ and ‘thrill-seekers’ are continually pushing the boundaries of sporting activities. When assessing avocation risks, a number of factors must be considered, including, proficiency, qualification, physical condition, reckless behavior, involvement in multiple high risk sports, and social behavior.

Participants who take their sport seriously and commit to developing and maintaining their skills present a better risk than those who take part on an occasional, informal basis. Similarly, participants with a proven track record of qualification and safe participation present a better risk than novices.

Aviation

Risk classification considerations:

The diversity of aviation activity along with the specific risks associated with each type of flying can be challenging from an underwriting perspective. Therefore, when evaluating individuals who engage in aviation activities, the underwriter must consider more than the possible extra risk created by the proposed insured’s intended flying activity. Past aviation violations, an unfavorable driving record, a history of alcohol or drug abuse, participation in hazardous sports, and an indication of a reckless lifestyle can contribute to the overall accident risk inherent in the individual’s participation in aviation activities. In addition, any impairment that may cause an individual to lose consciousness is an extra concern and individual judgment by the underwriter is necessary.

DWI (Driving While Intoxicated)

32% of traffic fatalities involve alcohol use1.

Alcohol decreases a person’s ability to drive a motor vehicle safely. The more you drink, the greater the effect. The amount of alcohol required to become impaired differs according to how fast you drink, your weight, your gender, and how much food you have in your stomach2.

Factors Impacting the Underwriting Decision

Motor Vehicle Record (MVR)
The carrier will pull your client’s MVR if they have a history of DUI/DWI. They will look at the number of and types of violations.

Age
When your client receives a DUI/DWI under the age of 21, it is seen even less favorably than if the client was of legal drinking age. The client would have been breaking multiple laws by drinking under age as well as driving under the influence.

Number of DUI/DWIs
This one is pretty self explanatory. When your client has had more than one DUI/DWI underwriters are going to postpone for a much more significant period of time to see if the client has made behavior/lifestyle changes.

Charged with vehicular assault, homicide, manslaughter or cause of fatal accident
Carriers will postpone for a longer period of time when the client has this history. This is considered a criminal history which is an additional underwriting issue. In these scenarios most carriers are going to decline for a period of years and after that period they will underwrite these cases on an individual consideration basis. Possible underwriting decision

For some carriers DUI/DWI cannot be considered for a minimum of six months following completion of suspension, for others it will be a longer postpone period. If you are trying to get best class for a client that has a DUI/DWI in their history, there will be a minimum wait period of five years, for many carriers it is ten years and for some carriers they will not offer their very best class to someone who has a record of DUI/DWI at all. Preferred class is also typically a five year waiting period. Many carriers will offer standard after two years. Flat extras are common with a history of DUI/DWI. It is not uncommon for the carrier to order reflex testing on insurance labs for CDT. For carrier specific guidelines please go to UnderwritingExpert.

Tips for Getting the Most Favorable Outcome
A cover letter is key, carriers generally stick to their guidelines with this issue but a cover letter can be helpful if you are close to the time period of a postpone ending or a flat extra dropping off. It’s best to be proactive and provide a detailed cover letter upfront. Providing an alcohol use questionnaire up front is a positive and it is also seen as being proactive. Click here for more help with cover letters.

1. http://www-nrd.nhtsa.dot.gov/Pubs/811172.pdf
2. Mothers Against Drunk Driving

Foreign Travel

Risk classification considerations:

The diversity of aviation activity along with the specific risks associated with each type of flying can be challenging from an underwriting perspective. Therefore, when evaluating individuals who engage in aviation activities, the underwriter must consider more than the possible extra risk created by the proposed insured’s intended flying activity. Past aviation violations, an unfavorable driving record, a history of alcohol or drug abuse, participation in hazardous sports, and an indication of a reckless lifestyle can contribute to the overall accident risk inherent in the individual’s participation in aviation activities. In addition, any impairment that may cause an individual to lose consciousness is an extra concern and individual judgment by the underwriter is necessary.

Older Age

Providing a profile of your older age client to the underwriter will in most cases provide them with a snapshot of individual that may assist them in having an enhanced view of the risk.

By being aware of what factors to highlight and providing additional details you can provide a great service to the applicant. When known highlight the following information:

Medical/Social factors:

  • Non Smoker
  • Regular routine medical care
  • Receiving preventive screenings (mammograms, colonoscopies, PSA’s)
  • Compliance with medical treatment
  • Moderate use of alcohol
  • Stable weight
  • Well nourished
  • Good renal functions
  • Stable cholesterol
  • Family history of longevity
  • Very physically fit – What sports do they participate in and how often?
  • Other physical activity (include detailed information regarding activity (include household chores vacuuming, shoveling, lawn work)
  • Good exercise tolerance on stress tests
  • Social support and activities including: family involvement, work, travel, volunteering or pets
  • Higher educational level

Non Medical information:

  • Do they manage their own finances? It is very favorable when an older adult is able to manage/make decisions regarding their own finances.
  • Are they financially independent with sufficient income to pay future premiums?
  • What is the reason for purchasing life insurance?
  • Are they still driving and do they have a clear driving record?

Signs of frailty: Knowing what will be a concern for underwriting is also important. Frailty is a term used to describe a body wide set of linked deteriorations including muscular skeletal, cardiovascular, metabolic and immunologic systems that lead to a loss of function and structure. When these deteriorations occur they lead to a decline in physical activity and decreased reserves.

When 3 of the 5 of the measurable signs of frailty are noted in the APS or Exam they indicate the applicant may be a poor risk. (Fried, et al: Frailty index)

  • Unintentional weight loss (10# or 5% weight loss in the previous year)
  • Muscle weakness
  • Slow walking speed
  • Low physical activity
  • Exhaustion (self reported), low energy level
  • Sedentary lifestyle

Laboratory findings that can be a sign of frailty

  • Albumin- a falling albumin is a red flag and can be a sign of cancer, poor nutrition
  • Cholesterol- a falling cholesterol can be a sign of cancer- note the trend and if they are medications
  • Renal functions:
    • Albuminuria- strong indicator for all cause mortality in all ages
    • Creatinine- even a mildly elevated creatinine can point to renal insufficiency
  • More Info on labs
    • Lab Test – Basic Blood Chemistry Tests
    • Lab Test – Complete Blood Counts – CBC
    • Lab Test – Urinalysis

Older age evaluations

  • MMSE: Mini Mental Status Exam- this test is copyrighted and seen more often in the APS it measures orientation, registration, attention, calculation, recall and language, a score of between 23-26 is considered borderline and a score below 22 is abnormal.
    • What is the year, season, date and month?
    • What country, city, state
  • MCAS: Minnesota Cognitive Acuity Screen- is a 15 minute telephone interview screen that tests for judgement, short term memory, reasoingi and comprehension (see type of questions below)
  • Clock Drawing- applicants are asked to draw a clock put in the numbers and show the time as 11:10, this requires planning, remembering the task and carrying out the task. This test can be done quickly, some subjectivity in scoring, seen often in insurance setting
  • Get Up and Go test: Sit in a chair without arms, rise from it without using hands, walk a distances (8-10 feet) , pivot/turn around, walk back and sit down expect applicant to complete the test in 10 seconds or less. A lower score indicates good functional independence and less risk of falling.
  • 10 word delayed word or object recall (DWR), seen in the clinical setting, easy and free

Tips and talking points for preparing applicants for the senior portion of the insurance exam:

As part of the insurance application you may be required to complete what is known as a senior supplement or an older age questionnaire. This information will provide the insurance carrier with information regarding your reasoning, awareness and judgment.

The types of questions you will be asked are similar to what a physician might ask you during a physical exam to measure your memory. The questions may appear simple but it is important that you take the test seriously however it is also important that you are not overly anxious regarding the test questions. You will not be able to use a paper or pen during the questioning so it will be important to concentrate. Our goal is to assist you in obtaining the best possible offer.

To prepare for the memory portion of the exam:

  • Schedule an early morning appointment if possible generally we are more alert in the A.M.
  • Get good nights sleep
  • Take your medications

Below are the types of questions you may be asked during the interview:

You may be asked questions to test your orientation to person, place and time. You may be asked your date of birth, US President, your home address, the day of the week, month and the year.

An example of a question that would measure your judgment would be:

  • What would you do if you were locked out of your home?
  • Where should you keep a carton of eggs?

You may be given 10 simple everyday words to use in a sentence and then asked to repeat those words sometime later in the test.

Medical Impairments

Abdominal Aortic Aneurysm (AAA)

Definition

An abdominal aortic aneurysm is when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally large or balloons outward.

What is the underwriting impact?

The majority of Abdominal Aortic Aneurysms have no symptoms and are discovered during routine medical exams or serendipitously as a result of other diagnostic studies. Once a suspected AAA is found, the client will have the diagnosis confirmed with imaging studies (ultrasound or CT scan). It is important to know exactly when the AAA was diagnosed.

Aneurysms are dilatation (expansion) of blood vessels. Abdominal aortic aneurysms, represent a segment of the abdominal aorta (the part below the kidneys) with a diameter at least 50% greater than normal.

Clients with AAAs can be medically managed (without surgical repair) based on the following guidelines:

  • The client is asymptomatic.
  • The AAA is less than 5cm or less than half the infrarenal aorta diameter (the aorta just below the kidneys).
  • The AAA is NOT growing more that 0.5cm per year.
  • There is NO evidence of complications from the AAA (blood clots).
  • These clients are followed closely with examinations that include ultrasound or CT scan studies.

Clients who fail to meet the above criteria will need to undergo surgical repair of their AAA.

The waiting period for clients with a newly discovered AAA is generally six months to one year for individual coverage. The same applies to clients who undergo surgical repair of their AAA.

Hypertension is a known risk factor for AAA. It is important to identify all of the medications the client is currently being prescribed.

Clients with AAA, with or without surgical repair, will have ongoing surveillance of the dilatation site. It is important to document that the client is compliant with follow-up visits and, to the best of their knowledge, the client believes all of the follow-up studies have been normal (no evidence of enlargement or return of the AAA).

Abnormal Liver Enzymes

Definition

Inflamed or injured liver cells leak higher than normal amounts of certain chemicals, including liver enzymes, into the bloodstream, which can result in elevated liver enzymes on blood tests. Elevated liver enzymes may indicate inflammation or damage to cells in the liver. The specific elevated enzymes most commonly found are:
• Alanine transaminase (ALT) – more specific indicator for liver damage.
• Aspartate transaminase (AST) – indicator of liver, heart or muscle disease.

What is the underwriting impact?

The goal in underwriting abnormal liver tests is to determine the underlying cause and then classify the risk accordingly. The underwriter will consider the degree of elevation, the clinical history, and the current physical findings.

For example, excessive alcohol consumption can cause liver inflammation. Even some medications like aspirin or acetaminophen can sometimes cause elevations. That is why it is important for the underwriter to understand the underlying cause.

Other common Liver Function Test Elevations
• Total Bilirubin – measures the amount of bile pigment in the blood.
• ALP (alkaline phosphate) – indicator of liver and other diseases.
• GGT (gamma-glutamyl transpeptidase) – often elevated for those who use alcohol.

Many diseases and conditions can contribute to elevated liver enzyme. More common causes of elevated liver enzymes include:
• Certain prescription medications, including statin drugs used to control cholesterol
• Drinking alcohol
• Heart failure
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Nonalcoholic fatty liver disease
• Obesity
• Over-the-counter pain medications, particularly acetaminophen (Tylenol, others)

Other causes of elevated liver enzymes may include:
• Alcoholic hepatitis (severe liver inflammation caused by excessive alcohol consumption)
• Autoimmune hepatitis (liver inflammation caused by an autoimmune disorder)
• Celiac disease (small intestine damage caused by gluten)
• Cirrhosis (early stages of liver scarring)
• Cytomegalovirus (CMV) infection
• Dermatomyositis (inflammatory disease that causes muscle weakness and skin rash)
• Epstein-Barr virus
• Gallbladder inflammation (cholecystitis)
• Hiatal hernia
• Hemochromatosis (too much iron stored in your body)
• Hypothyroidism (underactive thyroid)
• Liver cancer
• Mononucleosis
• Pancreatitis (pancreas inflammation)
• Polymyositis (inflammatory disease that causes muscle weakness)
• Toxic hepatitis (liver inflammation caused by drugs or toxins)
• Wilson’s disease (too much copper stored in your body)

Angina

Definition

Angina is chest pain or discomfort you get when your heart muscle does not get enough blood. It may feel like pressure or a squeezing pain in your chest. It may feel like indigestion. You may also feel pain in your shoulders, arms, neck, jaw or back.

Angina is a symptom of coronary artery disease (CAD), the most common heart disease. CAD happens when a sticky substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow.

What is the underwriting impact?

There are basically two kinds of angina: stable and unstable. Stable angina is usually related to physical effort (i.e. walking up a hill or stairs), stable and managed by medications and lifestyle changes. s with stable angina are insurable. Unstable angina is not related to effort (i.e. chest pain at rest), is unstable (i.e. progressively worse despite medications) and usually signals the onset of a cardiac event (i.e. heart attack, coronary angioplasty, coronary bypass). Clients with unstable angina are uninsurable.

Stable angina can be managed by a variety of medications. Beta blockers (i.e. Tenormin), calcium channel blockers (i.e. Cardizem) and nitroglycerin preparations (i.e. Isordil, Imdur) are all used to manage chest pain. Unstable angina may require more frequent use of nitroglyercin preparations (i.e. Nitrostat, Nitropaste, Minitran, etc.).

Clients who have a history of angina and continue to smoke may not be insurable. Smoking is a major risk factor for heart disease and one that can have a dramatic impact on outcome (i.e. life expectancy). The good news is that clients who have been diagnosed with angina and quit smoking have better survival rates and better pricing for life insurance.

Angina superimposed on other forms of cardiac disease almost universally renders the uninsurable. Clients who have had a heart attack, coronary angioplasty, or coronary bypass surgery and go on to have angina are not insurable on an individual basis.

Lifestyle changes such as quitting smoking, exercise, diet, and stress reduction are major components to the successful management of angina. They are also major components in the final risk analysis. The more documentation that you can provide regarding improvements in health habits, the better the underwriting outcome for the client.

Asthma

Definition

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night.

When your asthma symptoms become worse than usual, it’s called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks.

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

What is the underwriting impact?

Any client with a known history of asthma, even mild asthma, who continues to smoke is marginally insurable. Clients who quit smoking have the possibility of stabilizing their asthma and enjoy a better medical and underwriting outcome.

Mild asthma may require no medications or only the occasional use of inhalers for acute attacks. Moderate asthma may require the chronic use of oral medications and inhalers. It may also necessitate the periodic use of oral steroids (i.e. prednisone) to treat acute attacks. Severe asthma may require the chronic use of inhalers, oral medications and oral steroids. Clients with severe asthma are only marginally insurable. It is important to carefully document the exact medications a client is taking to treat their asthma.

Asthma is a chronic disease that is marked by acute episodes or “attacks.” The major underwriting issues are the degree of underlying breathing impairment and the degree of control of acute attacks. Clients who experience attacks severe enough to be hospitalized obviously have problems with managing their asthma. It is important to know when the client had their last major attack and how it was treated (i.e. at home, office visit, outpatient in ER or hospitalization).

Many clients with pulmonary disease also have heart problems. While there is no association between asthma and heart disease, it is important to know if the client has this problematic combination of impairments. Clients with asthma and heart disease (i.e. heart attack, coronary angioplasty, etc.) are only marginally insurable.

Functional limitations for clients with asthma involve shortness of breath with climbing stairs or walking a short distance. Clients who exhibit these kinds of functional limitations on a chronic basis (as opposed to only during acute attacks) are generally uninsurable.

Lifestyle changes can have an enormous impact on the underwriting outcome for asthma cases. These changes would include quitting smoking and participation in an exercise program, especially swimming. It is important to document all lifestyle changes that would indicate a decrease in any pulmonary risk.

Cancer - Bladder

Definition

The bladder is a hollow organ in your lower abdomen that stores urine. Bladder cancer occurs in the lining of the bladder. It is the sixth most common type of cancer in the United States.

Smoking is a major risk factor for bladder cancer. Exposure to certain chemicals in the workplace is another. People with a family history of bladder cancer or who are older, white or male have a higher risk.

Treatments for bladder cancer include surgery, radiation, chemotherapy and biologic therapy. Biologic therapy, or immunotherapy, boosts your body’s own ability to fight cancer.

What is the underwriting impact?

Bladder cancer can be insurable, in some cases less than one year following the end of treatment. The exact date of diagnosis is the starting point for the risk assessment process.

Bladder cancer is a by-product of industrialization and its incidence is growing. 52,900 new cases were diagnosed in 1996 and 11,700 died from the disease. The most common cause of bladder cancer is cigarette smoking. The most common clinical presentation is blood in the urine either visible or invisible (microscopic hematuria).

The size of the tumor, the tumor’s aggressiveness and the degree of the tumor’s invasion will determine the kind of treatment. Treatment options for bladder cancer include:

  • Resection (surgical removal)
  • Laser removal
  • Chemotherapy directed at the tumor site in the bladder (intravesical therapy)
  • Immunotherapy against new tumors (BCG, interferon alfa and interleukin 2)
  • Chemotherapy for metastatic disease

The “waiting period” for a client with a history of bladder cancer begins from the last date of treatment. However, clients that are being maintained on immunotherapy (i.e. BCG) may be insurable based on their last date of occurrence of a bladder tumor.

Successful treatment of bladder cancer involves no on going use of oral medications. As with all clients, it is important to document the medications they are taking for any medical problem.

Clients in post-treatment care for bladder cancer will undergo the following tests and studies to screen for tumor reoccurrence:

  • Urine studies (blood and cancer cells)
  • Direct visualization of the bladder (cystoscopy)
  • Biopsy samples

Cancer - Breast

Definition

Breast cancer may originate from either the glands or the ducts of the breast.

If cancer originated from the glands, it is called lobular carcinoma. The lobules are the special milk-producing glands.

When cancer occurs in the ducts of the breast it is known as ductal carcinoma.

When the cancer extends beyond its immediate surroundings, it is known as “infiltrating” or “invasive” cancer.

Cancer that has not crossed beyond the involved lobule or tubule is very limited in nature and is called “in-situ” carcinoma.

Breast cancer may involve more than one member of a family; this is usually called familial breast cancer. There may be some hereditary and genetic cause for this type of breast cancer. Recent genetic advances have allowed the detection of some of these genes.

Women with familial breast cancer can definitely benefit from genetic counseling and possible genetic testing.

What is the underwriting impact?

Breast cancer can be insurable, in some cases, in less than one year following the end of treatment. The exact date of diagnosis is the starting point for the risk assessment process.

The size of the tumor, the tumor’s aggressiveness and the degree of the tumor’s invasion will determine the kind of treatment. Small tumors that are confined to the breast can be successfully treated with a partial removal of the breast called a lumpectomy. This may or may not be followed by a course of radiation. Larger tumors with greater invasion may require the complete removal of the breast called a mastectomy. In cases where a mastectomy is necessary the local lymph nodes (glands) in the armpit on the same side as the cancerous breast are also removed to check for cancer. In cases where the cancer has spread to these lymph nodes, additional treatment in the form of chemotherapy or radiation may be necessary. In very advanced cases the may be required to undergo a bone marrow transplant.

The “waiting period” for clients with a history of cancer before they are insurable for individual coverage begins from the last date of all forms of treatment.

Successful treatment of breast cancer can also involve on going chemotherapy in the form of an oral medication called Tamoxifen. This may be taken for many years following the initial surgical treatment. The use of this medication in the post-operative period does not necessarily imply a worse outcome either medically or for pricing for life insurance.

Mammogram studies are used to monitor breast cancer patients following the completion of their initial treatment. These are generally done on a six-month basis in the first three years of follow-up. Any abnormality in a follow-up mammogram suggests the possible return of the cancer.

Cancer - Colon

Definition

Colon cancer is fairly common. About 1 in 15 people develop colon cancer.

Colon cancer can be a life threatening condition that affects the large intestine. However, if it is found early, it is a highly curable form of cancer.

What is the underwriting impact?

Colon cancer can be insurable, in some cases, in less than two years following the end of treatment. The exact date of diagnosis is the starting point for the risk assessment process.

The size of the tumor, the tumor’s aggressiveness and the degree of the tumor’s invasion will determine the kind of treatment. Small tumors that are confined to inside of the wall of the colon can be successfully treated with surgical removal. These small tumors do not require additional treatments (i.e. chemotherapy or radiation). Larger tumors with invasion into the wall of the colon and beyond to the lymph nodes may require both surgery and additional treatment (i.e. chemotherapy or radiation).

The “waiting period” for clients with a history of cancer before they are insurable for individual coverage begins from the last date of all forms of treatment.

Successful treatment of colon cancer generally involves no on going medications.

Colonoscopy is used to monitor colon cancer patients following the completion of the initial treatment. These are generally done on a six-month basis in the first three years of follow-up.

Cancer - Kidney

Definition

Kidney cancer is a cancer that starts in the kidneys.

Renal cell carcinoma (also known as renal cell cancer or renal cell adenocarcinoma) is by far the most common type of kidney cancer. It accounts for about 9 out of 10 kidney cancers.

Less common cancers of the kidney include transitional cell carcinomas, Wilms tumors, and renal sarcomas.

What is the underwriting impact?

The “peak” incidence of cancer of the kidney occurs in sixty-year-olds with a male-to-female ratio of 2:1. Blood in the urine (hematuria), either apparent or microscopic, is the most common finding leading to the diagnosis.

The size of the tumor, the tumor’s aggressiveness and the degree of the tumor’s invasion will determine the kind of treatment. If the tumor is confined to the kidney, surgical removal of the kidney is an effective treatment. These tumors do not require additional treatments (i.e. chemotherapy or radiation). Tumors that spread beyond the kidney and into the lymph nodes may require both surgery and additional treatment (i.e. chemotherapy or radiation).

The “waiting period” for clients with a history of cancer before they are insurable for individual coverage begins from the last date of all forms of treatment.

Successful treatment of cancer of the kidney involves no on going use of medications.

A combination of physical examination and tumor marker testing (i.e. a specialized blood test that detects the presence of tumor reoccurrence) is used for follow-up in the post-treatment period.

Cancer - Prostate

Definition

The prostate is the gland below a man’s bladder that produces fluid for semen. Prostate cancer is the third most common cause of death from cancer in men of all ages. It is rare in men younger than 40.

Levels of a substance called prostate specific antigen (PSA) is often high in men with prostate cancer. However, PSA can also be high with other prostate conditions. Since the PSA test became common, most prostate cancers are found before they cause symptoms. Symptoms of prostate cancer may include

  • Problems passing urine, such as pain, difficulty starting or stopping the stream, or dribbling
  • Low back pain
  • Pain with ejaculation
  • Prostate cancer treatment often depends on the stage of the cancer. How fast the cancer grows and how different it is from surrounding tissue helps determine the stage. Treatment may include surgery, radiation therapy, chemotherapy or control of hormones that affect the cancer.

What is the underwriting impact?

Prostate cancer can be insurable, in some cases, in less than one year following the end of treatment. The normal period of postponement is two years. The exact date of diagnosis is the starting point for the risk assessment process.

The Gleason Score and the Staging are crucial to pricing a prostate cancer case. Most clients won’t know this information, but they can get it in minutes by calling the physician treating their prostate cancer.

The kind of treatment will be determined by the size of the tumor, the tumor’s aggressiveness, the degree of tumor’s invasion and the age of the patient.

Small cancers well contained in the prostate of older men (i.e. age 70 or older) may require only “watchful waiting.”

Advanced cancers that have spread outside the prostate gland may require multiple treatment modalities.

There are generally four treatments available for prostate cancer:

  • Watchful Waiting—This is reserved for older clients (i.e. 70 and older) who have slow growing, well contained tumors.
  • Surgery—This involves the complete removal of the prostate gland (called a radical prostatectomy). At the time of surgery lymph nodes from the prostate gland area and lower abdomen will be removed to see if the cancer has spread.
  • Radiation—This involves either direct beams of radiation to the cancerous areas of the prostate gland or a newer approach that involves a radioactive seed being implanted in the cancerous areas of the prostate.
  • Chemotherapy—This involves the use of medications that will turn off the hormonal stimulation of the tumor and slow down its spread and growth. These are used for advanced cases of prostate cancer where surgery or radiation either can not be used or have failed.

The “waiting period” begins from the last date of all forms of treatment. The waiting period for insurability can be from 6 months to 5 years.

Successful treatment of prostate cancer involves no on going medications. If a client is currently taking medications for prostate cancer (i.e. Lupron or Eulexin) it either represents a primary tumor that has metastasized (spread) outside of the prostate gland or a tumor that has reoccurred following initial treatment with surgery or radiation.

The PSA blood test is used to monitor prostate cancer patients following their treatment. It should remain essentially zero (i.e. undetectable). This means the prostate cancer is in remission.

Any rise in the PSA presumes that the prostate cancer has returned. In the case of a client who has undergone the surgical removal of the prostate, a rise in the PSA blood test suggests a distant spread (called a metastasis) of the disease. This type of client is uninsurable for individual coverage.

Cancer - Testicular

Definition

Testicular cancer forms in a man’s testicles, the two egg-shaped glands that produce sperm and testosterone. Testicular cancer mainly affects young men between the ages of 20 and 39. It is also more common in men who

  • Have had abnormal testicle development
  • Have had an undescended testicle
  • Have a family history of the cancer

Symptoms include pain, swelling or lumps in your testicles or groin area. Most cases can be treated, especially if it is found early. Treatment options include surgery, radiation and/or chemotherapy. Regular exams after treatment are important. Treatments may also cause infertility. If you may want children later on, you should consider sperm banking before treatment.

What is the underwriting impact?

Testicular can be insurable, in some cases, in less than one year following the end of treatment. The exact date of diagnosis is the starting point for the risk assessment process.

Testicular cancer occurs in men between 20-35. It presents as a painless nodule usually discovered by the patient.

The size of the tumor, the tumor’s aggressiveness and the degree of the tumor’s invasion will determine the kind of treatment. The majority of tumors are confined to the testicle and are surgically removed. These small tumors do not require additional treatments (i.e. chemotherapy or radiation). Larger sized tumors or tumors that spread beyond the testicle and into the lymph nodes may require both surgery and additional treatment (i.e. chemotherapy or radiation).

The “waiting period” for clients with a history of cancer before they are insurable for individual coverage begins from the last date of all forms of treatment.

Successful treatment of testicular cancer involves no on going use of medications.

A combination of physical examination and tumor marker testing (i.e. a specialized blood test that detects the presence of tumor reoccurrence) is used for follow-up in the post-treatment period.

Cancer - Thyroid

Definition

Thyroid cancer is a cancer that starts in the thyroid gland. In order to understand thyroid cancer, it helps to know about the normal structure and function of the thyroid gland.

The thyroid gland contains mainly 2 types of cells — thyroid follicular cells and C cells (also called parafollicular cells).

Different cancers develop from each kind of cell. The differences are important because they affect how serious the cancer is and what type of treatment is needed.

Many types of tumors can develop in the thyroid gland. Most of these tumors are benign (non-cancerous). Others are malignant (cancerous), which means they can spread into nearby tissues and to other parts of the body.

Only about 1 in 20 thyroid nodules is cancerous. The 2 most common types of thyroid cancer are called papillary carcinoma and follicular carcinoma. Hürthle cell carcinoma is a subtype of follicular carcinoma. There are some other types of thyroid cancer, such as medullary thyroid carcinoma, anaplastic carcinoma, and thyroid lymphoma, but these occur less often.

What is the underwriting impact?

There are 11,000 new cases of thyroid cancer each year in the United States. Females are more likely to have thyroid cancer at a ratio of three to one. Thyroid cancer can occur at any age, although it is most common after age 30. The majority of patients present with a nodule on their thyroid, which typically does not case symptoms. It is important to establish the exact date of the diagnosis.

Although as much as 10% of the population will have thyroid nodules, the vast majority are benign (only 5% of all thyroid nodules are malignant). To determine if a nodule is malignant, a client may undergo an ultrasound of the thyroid or a fine needle aspiration biopsy. The ultrasound study may prompt the needle biopsy.

The following are four types of thyroid cancer and their incidence:

  • Papillary 75%
  • Follicular 15%
  • Medullary 7%
  • Anaplasic 3%

Treatment for the majority of thyroid cancers consists of surgical removal of part or all of the thyroid gland followed by chemotherapy (radioactive iodine). It is important to document what kind of treatment the client underwent and the exact date ALL treatment was completed.

Most thyroid cancers are curable. Younger clients with papillary and follicular type tumors have a better than 95% cure rate.

Successful surgical treatment of thyroid cancer generally involves the client taking a thyroid hormone replacement for the rest of their life.

Follow up for thyroid cancer includes iodine uptake scans (I-131 scans), yearly chest x-rays as well as thyroglobulin levels (testing for the possible reoccurrence of the malignancy). Approximately 10-30% of patients felt to be disease-free after initial treatment will develop recurrence with possible metastases. Of patients who recur, approximately 80% recur with disease in the neck alone and 20% with distant metastases. The most common site of distant metastases is the lung. The prognosis for patients with clinically detectable recurrences is generally poor. It is important to document that the client is receiving follow-up care and that all of the studies confirm they are still in remission.

Cardiac Arrhythmia

Definition

An arrhythmia (ah-RITH-me-ah) is a problem with the speed or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. A heartbeat that is too fast is called tachycardia. A heartbeat that is too slow is called bradycardia.

Most arrhythmias are harmless, but some can be serious or even life threatening. When the heart rate is too slow, too fast, or irregular, the heart may not be able to pump enough blood to the body. Lack of blood flow can damage the brain, heart, and other organs.

What is the underwriting impact?

Clients who smoke and have a cardiac arrhythmia are not automatically uninsurable. However, smoking is a major risk factor for all forms of coronary disease and will adversely affect medical outcome (i.e. shorter life expectancy) as well as the pricing (i.e. higher premiums).

The most common types of cardiac arrhythmias include:

  • Premature beats (PACs or VPCs)
  • Atrial Fibrillation/Flutter
  • Super Ventricular Tachycardia
  • Ventricular Tachycardia

Medications or other interventions can control many arrhythmias. It is important to establish whether or not the arrhythmia is “chronic” (on going) or “paroxysmal” (intermittent).

An irregular heart rhythm can be benign or it can be lethal. It may require only simple observation or “layers” of medications. Some clients require a pacemaker. Knowing the current medications provides important insight to both the client’s insurability and the pricing costs.

Some cardiac arrhythmias require a pacemaker. A client with a pacemaker is not automatically uninsurable. However, the presence of a pacemaker verifies that the arrhythmia is complicated and potentially lethal. The majority of these clients, who are insurable, are highly rated.

Cardiac arrhythmias superimposed on other types of heart disease severely complicate the underwriting process. A history of coronary artery disease (i.e. angina, heart attack, coronary angioplasty, or coronary bypass surgery) combined with an ongoing cardiac arrhythmia usually results in a declination for individual coverage.

Clients who smoke and have a cardiac arrhythmia are not automatically uninsurable. However, smoking is a major risk factor for all forms of coronary disease and will adversely affect medical outcome (i.e. shorter life expectancy) as well as the pricing (i.e. higher premiums).

Claudication

Definition

Claudication (pain in the leg while walking that is relieved by rest) is caused by hardening of the arteries (atherosclerosis) in the legs. It is essentially the same disease as coronary artery disease (hardening of the arteries of the heart). Factors that contribute to the development of claudication are the same as those that cause coronary artery disease:

  • Smoking
  • Hypertension (high blood pressure)
  • Hyperlipidemia (high cholesterol levels or high cholesterol/HDL ratios)
  • Family history of heart or vascular disease
  • Diabetes
  • Obesity

What is the underwriting impact?

Claudication (pain in the leg while walking that is relieved by rest) is caused by hardening of the arteries (atherosclerosis) in the legs. It is essentially the same disease as coronary artery disease (hardening of the arteries of the heart). Factors that contribute to the development of claudication are the same as those that cause coronary artery disease:

  • Smoking
  • Hypertension (high blood pressure)
  • Hyperlipidemia (high cholesterol levels or high cholesterol/HDL ratios)
  • Family history of heart or vascular disease
  • Diabetes
  • Obesity

Clients diagnosed with claudication who continue to smoke represent poor underwriting risks. However, clients with claudication who quit smoking have better medical and underwriting outcomes.

The term peripheral vascular disease refers to other vascular diseases in addition to claudication, which is a disease of the arteries of the legs. Other forms of peripheral vascular disease include carotid disease (primary blood supply to the brain), abdominal aorta disease (primary blood supply to the lower body) and renal artery disease (primary blood supply to the kidneys).

The goal of treatment of claudication is to improve the symptoms and stop the progression of the disease. Medications can help symptoms, but lifestyle changes can successfully treat claudication. These lifestyle changes include stopping smoking, regular exercise, loosing weight and a reduction in blood cholesterol. When lifestyle alone is not enough to treat the symptoms or stop the progression, angioplasty of the affected artery or an actual bypass graft around the blocked artery are treatment options. It is important to document the original date of diagnosis and the kind of treatment the client received for their claudication.

Clients with claudication normally take an aspirin a day to reduce the chances of developing a blood clot at the blockage site. In addition, they may also take medications for high cholesterol, high blood pressure or diabetes. They may also take medications to reduce the symptoms of claudication (i.e. Trental). It is important to document ALL the medications the client is taking.

As indicated above, lifestyle changes can be very effective in literally stopping the progression of peripheral vascular disease. It is important to document all the positive lifestyle changes the client has adopted to insure the client is given the appropriate credit in his or her underwriting assessment.

Statistics recently reported in the New England Journal of Medicine demonstrated a high death rate from heart disease among patients with even mild peripheral vascular disease. The study demonstrated that for patients with severe claudication the ten-year mortality for cardiovascular disease was as much a 15 times that of persons who no peripheral vascular disease. Clients who have claudication and coronary artery disease present underwriting problems that may preclude them form offers for individual coverage. It is important to ask all clients with known claudication if they have any history of any form of heart disease.

Coronary Bypass Surgery

Definition:

If you have coronary artery disease (CAD), the arteries that supply blood and oxygen to the heart muscle become hardened and narrowed. If lifestyle changes and medicines don’t help, your doctor may recommend coronary artery bypass surgery.

The surgery uses a piece of a vein from the leg or artery from the chest or wrist. The surgeon attaches this to the coronary artery above and below the narrowed area or blockage. This allows blood to bypass the blockage. Some people need more than one bypass.

What is the underwriting impact?

Clients with uncomplicated coronary bypass surgery could be insurable as early as 6 months after the procedure.

It is important to know whether the underlying disease of the coronary arteries involves one or more blockages. Single bypass procedures are rare. More commonly, the surgery involves between two and four bypasses. The greater the number of bypasses, the greater the extent of the coronary disease.

Follow-up cardiac testing provides objective evidence that the coronary bypass surgery was successful. Thallium treadmills and stress-echo treadmills provide more useful information than a basic treadmill ECG. Any follow-up cardiac testing that is abnormal will result in the client being highly rated or declined for individual coverage.

An uncomplicated coronary bypass operation requires minimal medications following the procedure (i.e. aspirin). A complicated bypass procedure requires more potent medications such as Lanoxin, Imdur, Isordil or Minitran. Knowing the current medications will provide important pricing insight into both the client’s insurability and pricing costs.

Clients who continue to smoke after undergoing coronary bypass surgery may not be insurable. Smoking is a major cardiac risk factor that adversely affects outcome following bypass surgery. The good news is that a client who quits smoking following bypass surgery has a better life expectancy and better pricing for life insurance.

Any reoccurrence of chest pain signals a return of the original problem (i.e. significant blockage of a coronary artery). Clients who experience chest pain in the post-coronary bypass period, regardless of the amount of time since the procedure, are uninsurable.

Lifestyle changes can have an enormous impact on the underwriting outcome for a cardiac case. There are excellent medical studies that verify that mortality outcome is greatly improved with positive lifestyle changes such as quitting smoking or beginning an exercise program. It is important that you document all lifestyle changes that would indicate a decrease in any cardiac risk factors.

Coronary Angioplasty & Stenting

Definition:

Coronary angioplasty (AN-jee-oh-plas-tee) is a medical procedure in which a balloon is used to open a blockage in a coronary (heart) artery narrowed by atherosclerosis (ATH-er-o-skler-O-sis). This procedure improves blood flow to the heart.

Atherosclerosis is a condition in which a material called plaque (plak) builds up on the inner walls of the arteries. This can happen in any artery, including the coronary arteries. The coronary arteries carry oxygen-rich blood to your heart. When atherosclerosis affects the coronary arteries, the condition is called coronary artery disease (CAD).

Angioplasty is a common medical procedure. It may be used to:

  • Improve symptoms of CAD, such as angina and shortness of breath.
  • Reduce damage to the heart muscle from a heart attack. A heart attack occurs when blood flow through a coronary artery is completely blocked. Angioplasty is used during a heart attack to open the blockage and restore blood flow through the artery.
  • Reduce the risk of death in some patients.

 

Angioplasty is done on more than 1 million people a year in the United States. Serious complications don’t occur often, but can happen no matter how careful your doctor is, or how well he or she does the procedure.

Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people.

What is the underwriting impact?

Clients with an uncomplicated coronary angioplasty are insurable 6 months after the procedure. The “failure rate” (i.e. the reclosing of the opened coronary artery) can be as high as 30% in the first 6 months following the original procedure.

It is important to know whether the underlying disease of the coronary arteries involves one or more arteries. Clients may not know the exact nature of their coronary disease (i.e. single vessel versus multiple vessel). They may know how many blockages were treated. There is a marked pricing difference between single vessel coronary disease and multiple vessel coronary disease.

It is important to know if the client had a heart attack before the angioplasty procedure. Clients who have not had a heart attack are priced different than clients who have sustained some form of damage to the heart muscle. Both clients may prove insurable, but the pricing will be higher for the prior heart attack clients.

Follow-up cardiac testing provides objective evidence that the coronary angioplasty was successful. Thallium treadmills and stress-echo treadmills provide more useful information than a basic treadmill ECG. Any follow-up cardiac testing that is abnormal will result in the client being highly rated or declined for individual coverage.

An uncomplicated coronary angioplasty is usually managed with minimal medications following the procedure (i.e. aspirin). A complicated angioplasty is managed with more potent medications such as Lanoxin, Imdur, Isordil or nitroglycerin. The medications will provide a very important pricing insight into not only the insurability of the client, but the actual pricing costs.

Clients who have had coronary angioplasty and continue to smoke may not be insurable. Smoking is a major risk factor for heart disease and one that can have a dramatic impact on outcome (i.e. life expectancy). The good news is that clients who have had coronary angioplasty and quit smoking have better survival rates and better pricing for life insurance.

Any reoccurrence of chest pain signals a return of the original problem (i.e. significant blockage of a coronary artery). Clients who experience chest pain in the post-angioplasty period, regardless of the time since the procedure, are uninsurable.

Lifestyle changes can have an enormous impact on the underwriting outcome for a cardiac case. There are excellent medical studies that verify that mortality outcome is greatly improved with positive lifestyle changes such as quitting smoking or beginning an exercise program. It is important that you document all lifestyle changes that would indicate a decrease in any cardiac risk factors.

Crohn's Disease

Definition

Crohn’s disease causes inflammation of the digestive system. It is one of a group of diseases called inflammatory bowel disease. The disease can affect any area from the mouth to the anus. It often affects the lower part of the small intestine called the ileum.

Crohn’s disease seems to run in some families. It can occur in people of all age groups but is most often diagnosed in young adults. Common symptoms are pain in the abdomen and diarrhea. Bleeding from the rectum, weight loss, joint pain, skin problems and fever may also occur. Children with the disease may have growth problems. Other problems can include intestinal blockage and malnutrition.

Treatment may include medicines, nutrition supplements, surgery or a combination of these options. Some people have long periods of remission, when they are free of symptoms.

What is the underwriting impact?

Crohn’s disease is a chronic inflammatory disease of the large and small intestines; its cause is unknown. Like ulcerative colitis, it attacks the intestine in a “flare”/remission pattern. Unlike ulcerative colitis, Crohn’s disease attacks both the large and small intestines. The attacks may include abdominal pain, bloody diarrhea and even bowel obstruction. The disease is universally progressive over time. The majority of cases (i.e. >70%) will eventually require surgical intervention. 50% of patients who have had surgery can expect a recurrence of symptoms within four years following surgery. 30% require a repeat surgery in five years.

The diagnosis of Crohn’s disease is based on the clinical presentation (i.e. abdominal pain, diarrhea, vomiting, fever and weight loss) along with indirect (i.e. barium enema) or direct visualization of the intestines (i.e. colonoscopy).

Medications are used to treat both the “flare” episodes as well as prolong the remission in Crohn’s disease. These drugs range from simple salicylates (Azulfidine, Dipentum, Asacol and Pentasa) to drugs that suppress the immune system (Imuran, Purinethol, Sandimmmune and Rheumatrex). Steroids, either orally (Prednisone) or used in enemas (Cortenema) may also be part of the client’s medication schedule. Lastly, antibiotics (Flagyl) can also prove beneficial especially in patients with large intestine disease. It is important to obtain the names of all of the medications the client is taking.

It is important to clarify the client’s “flare”/remission pattern. Significant “flares” usually involve the same symptoms that lead to the original diagnosis (i.e. abdominal pain and bloating, bloody diarrhea, vomiting, etc.) and may require hospitalization.

As indicated above, the majority of patients with Crohn’s disease require surgery at some point in their illness. It is important to find out both when the most recent surgery was done and what has happened since the last surgical procedure (i.e. has there been any “flares?”).

Crohn’s disease can affect more than the intestinal tract. It can also cause inflammation of the joints, spine, eyes, liver.

Dementia/Alzheimer's Disease

Definition

Alzheimer’s disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities.

AD begins slowly. It first involves the parts of the brain that control thought, memory and language. People with AD may have trouble remembering things that happened recently or names of people they know. Over time, symptoms get worse. People may not recognize family members or have trouble speaking, reading or writing. They may forget how to brush their teeth or comb their hair. Later on, they may become anxious or aggressive, or wander away from home. Eventually, they need total care. This can cause great stress for family members who must care for them.

AD usually begins after age 60. The risk goes up as you get older. Your risk is also higher if a family member has had the disease.

No treatment can stop the disease. However, some drugs may help keep symptoms from getting worse for a limited time.

What is the underwriting impact?

It is important to know if there is only suspicion or an actual diagnosis of dementia or Alzheimer’s disease. It is not uncommon for older clients to have memory loss and cognitive problems (i.e. language disturbances, failure to recognize objects, planning or organizing problems and inability to carry out motor functions in the presence of an intact motor system). Memory loss and cognitive problems are not “automatically” Alzheimer’s disease. They may be part of the normal aging process. They can also be caused by:

  • Cerebral vascular disease (TIAs, mini-strokes, full strokes)
  • Parkinson’s disease
  • Huntington’s disease
  • Brain tumors
  • Normal pressure hydrocephalus
  • Depression
  • Schizophrenia
  • Low thyroid function (hypothyroidism)
  • Vitamin deficiency (B12 or folic acid)
  • High serum calcium levels
  • Substance abuse

Dementia is a clinical “state” not an actual disease. There are many different types of dementia (i.e. nearly 80). Dementia represents a decline from a previous higher level of functioning and involves memory as well as cognitive impairments.

If the suspected or confirmed diagnosis is Alzheimer̢۪s disease, then the client will have some or all of the following problems:

  • Memory and Cognitive decline
  • Behavioral disturbances
  • Changes in personality

Clinical stability argues against progressive causes of dementia like Alzheimer̢۪s disease. It is important to find out if the memory and cognitive problems are getting worse or have remained the same for an extended period of time.

Caring for oneself is a complex process especially at older ages. If a client lives alone and manages all of their normal affairs, then the suspected dementia is probably mild. Dementia represents a progressive decline from a higher level to a lower lever. If the memory loss and cognitive changes are mild and stable, then dementia is an unlikely diagnosis.

Driving a car and managing personal finances represent the highest level of ADLs (activities of daily living). If a client can continue do both of these, then any suspected problems with memory loss of cognitive functioning are presumed mild.

If the client needs full time assistance or needs to live in an assisted living environment, then the suspected dementia is most likely more severe. Clients who need an assisted living environment, at home or in an institution, due to suspected dementia (any form) are uninsurable for individual coverage.

Clients with suspected Alzheimer̢۪s disease may be taking one of two FDA-approved medications:

  1. Cognex (tacrine)
  2. Aricept (donepezil)

If clients are taking either medication, they are uninsurable for individual coverage.

Depression

Definition

Depression is a serious medical illness that involves the brain. It’s more than just a feeling of being “down in the dumps” or “blue” for a few days. If you are one of the more than 20 million people in the United States who have depression, the feelings do not go away. They persist and interfere with your everyday life. Symptoms can include

  • Sadness
  • Loss of interest or pleasure in activities you used to enjoy
  • Change in weight
  • Difficulty sleeping or oversleeping
  • Energy loss
  • Feelings of worthlessness
  • Thoughts of death or suicide

Depression can run in families, and usually starts between the ages of 15 and 30. It is much more common in women. Women can also get postpartum depression after the birth of a baby. Some people get seasonal affective disorder in the winter. Depression is one part of bipolar disorder.

There are effective treatments for depression, including antidepressants and talk therapy. Most people do best by using both.

What is the underwriting impact?

Depression can vary from a short-lived episode related to stressful life events (i.e. illness or death of loved one) to a prolonged affliction that requires years of therapy and medications. It is important to establish when the client was first diagnosed as being depressed.

Depression is extremely common with up to 30% of primary care patients having depressive symptoms. Depression should not be confused with grief. Grief is usually accompanied by intact self-esteem. Depression is marked by a sense of guilt and worthlessness.

The inability of the depressed patient to cope with the normal demands of life may lead to a period of hospitalization. It is important to document the exact dates of hospitalization and the length of the stay.

Many times the initial depressive crisis the prompts the diagnosis will lead to a short period of hospitalization. After this initial stabilizing event, the client may make excellent progress on a strictly out patient basis. The fact that the client underwent initial hospitalization does not imply a worse underwriting outcome than the client who was never hospitalized for depression.

There is an extensive list of medications that are used to treat depression. They are divided into the following categories:

  • Tricyclic and clinically similar compounds (see examples below)
  • Elavil
  • Asendin
  • Sinequan
  • Wellbutrin
  • SSRIs and other new compounds (see examples below)
  • Prozac
  • Zoloft
  • Effexor
  • Paxil
  • Monoamine oxidase inhibitors(see examples below)
  • Nardil
  • Pamate

It is important to document the exact medications the client is taking to manage their depression.

Clients who have close follow-up care with a mental health professional have the best medical and underwriting outcome. Clients who simply obtain prescription refills and avoid follow-up care have less successful medical and underwriting outcomes.

Many times a mental health breakdown also marks an important breakthrough for the client. It is important to document lifestyle changes that have improved the client’s life in a positive manner. This may include ending a dysfunctional relationship, resolving issues of guilt and fear, changing jobs or location, beginning an exercise program or discovering a new spiritual meaning in their life. It is important that you help the underwriter understand the lifestyle progress the client has made as part of their dedication managing their depression.

Diabetes

Definition

Diabetes is a disease in which your blood glucose, or sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With Type 1 diabetes, your body does not make insulin. With Type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood.

Over time, having too much glucose in your blood can cause serious problems. It can damage your eyes, kidneys, and nerves. Diabetes can also cause heart disease, stroke and even the need to remove a limb. Pregnant women can also get diabetes, called gestational diabetes.

Symptoms of Type 2 diabetes may include fatigue, thirst, weight loss, blurred vision and frequent urination. Some people have no symptoms. A blood test can show if you have diabetes. Exercise, weight control and sticking to your meal plan can help control your diabetes. You should also monitor your glucose level and take medicine if prescribed.

What is the underwriting impact?

The pricing of a diabetic client has three elements:

  1. The age of the client at the time of the diagnosis
  2. The length of time since the original diagnosis
  3. The degree of diabetic control and complication status.

The younger the age at the time of the original diagnosis, the more difficult the case. This is because diabetes extracts its toll on various body organs and systems over time. The longer you have it, the more damage is done. This is also why the degree of diabetic control is so important to the risk assessment. In general, the better the diabetic control the slower the development of diabetic complications. Less diabetic complications mean a better underwriting outcome.

Diabetics are divided into two classes: insulin dependent and non-insulin dependent. There is also a group of diabetics who are on combination therapy (i.e. oral medications and insulin shots). With insulin diabetics it is important to obtain the “total” daily dose of insulin. This is reported in insulin units such a “regular” and NPH. It is also important to remember that many diabetics have problems with elevated blood pressure (hypertension) as well as elevated cholesterol levels (hyperlipidemia) that may also require medication.

This is the key to the eventual pricing of a diabetic case. Control is measured from a clinical perspective in two ways: Random Blood Glucose and A1-C. The Random Blood Glucose is what the client measures with a home monitoring device. If the client has been fasting for at least 10 hours, the test can be called Fasting Blood Glucose. The A1-C is a blood test that is done at the physician’s office. It is a retrospective test that looks backward approximately 90 days and measures the “average” daily blood glucose control. A “good” A1-C is between 6.0 and 8.0. A “fair” A1-C is between 8.0 and 10.0. A “poor” A1-C is anything above 10.0.

High blood pressure is not uncommon in diabetics. If well controlled with medication, exercise and diet, it should not increase the pricing of the case. However, if poorly controlled (i.e. not medicated, under medicated or non-responsive), it will have a negative impact on the ultimate assessment. This is because that high blood pressure accelerates the damage to certain body organs (i.e. heart, kidney, and brain) with fatal consequences.

The diagnosis of diabetes in of itself “doubles” the risk of heart disease for the client. It is the number one cause of death for all diabetics either insulin dependent or non-insulin dependent. Therefore it is common to find many diabetics with some form of heart disease. This can be in the form of a previous heart attack, coronary angioplasty or coronary bypass surgery. It is important to obtain all the details of a diabetic client’s cardiac history to adequately price the case.

The number two cause of death for all diabetics is renal disease. The most important finding that may signal the onset of kidney problems for the diabetic is protein spilling in the urine. Normally the kidney will act as a selective filter and not allow protein to be spilled in the urine. But a kidney damaged by diabetes begins to “leak” protein as a first sign of a damaged filter. This initial spilling may be on a microscopic level and detected only by special testing. It is important to question the client for any history of protein spilling in the urine. Protein spilling in any diabetic is generally the basis for a declination.

Emphysema (COPD)

Definition

Emphysema is a type of chronic obstructive pulmonary disease (COPD) involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. Emphysema makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise.

What is the underwriting impact?

Any client with a known history of emphysema (also known as COPD, Chronic Obstructive Pulmonary Disease) who continues to smoke is universally uninsurable. Clients who quit smoking have the possibility of stabilizing the loss of pulmonary function and a better medical outcome.

Mild emphysema treatment usually does not include medications. The clients are encouraged to quit smoking and undergo pulmonary rehabilitation (i.e. cardiovascular exercise). Moderate emphysema treatment includes various inhalers and oral medications. Again, the clients are encouraged to quit smoking and undergo a pulmonary rehabilitation program. Severe emphysema treatment includes medications and the addition of supplemental oxygen. Clients who use oxygen are universally uninsurable.

Functional limitations for clients with emphysema involve shortness of breath with climbing stairs or walking a short distance. Clients who exhibit these kinds of functional limitations are generally uninsurable.

Many clients with pulmonary disease also have heart problems. Mild, well controlled hypertension and mild to moderate emphysema in a non-smoking client is insurable. Clients with more complicated heart disease (i.e. angina, myocardial infarction, etc.) and moderate emphysema are generally uninsurable.

Lifestyle changes can have an enormous impact on the underwriting outcome for emphysema cases. There are excellent medical studies that verify that mortality outcome is greatly improved with positive lifestyle changes such as quitting smoking and beginning an exercise program. It is important to document all lifestyle changes that would indicate a decrease in any pulmonary risk.

Heart Attack

Definition

A heart attack occurs when blood flow to a section of heart muscle becomes blocked. If the flow of blood isn’t restored quickly, the section of heart muscle becomes damaged from lack of oxygen and begins to die.

Heart attacks occur most often as a result of a condition called coronary artery disease (CAD). In CAD, a fatty material called plaque (plak) builds up over many years on the inside walls of the coronary arteries (the arteries that supply blood and oxygen to your heart). Eventually, an area of plaque can rupture, causing a blood clot to form on the surface of the plaque. If the clot becomes large enough, it can mostly or completely block the flow of oxygen-rich blood to the part of the heart muscle fed by the artery.

During a heart attack, if the blockage in the coronary artery isn’t treated quickly, the heart muscle will begin to die and be replaced by scar tissue. This heart damage may not be obvious, or it may cause severe or long-lasting problems.

Severe problems linked to heart attack can include heart failure and life-threatening arrhythmias (irregular heartbeats). Heart failure is a condition in which the heart can’t pump enough blood throughout the body. Ventricular fibrillation is a serious arrhythmia that can cause death if not treated quickly.

What is the underwriting impact?

Clients with uncomplicated heart attacks (also called myocardial infarction, literally meaning to strike heart muscle dead) are insurable 3 to 6 months following the actual event

There are essentially three treatment options for clients who have heart attacks:

  • Clot dissolving therapy to interrupt the actual heart attack.
  • Angioplasty (balloon expansion of a blocked artery usually using a metal stent).
  • Coronary bypass surgery.

It is important to know what treatment option the client had to accurately assess the risk. Please note that it is possible for a client to have all three options in the treatment of a heart attack. Clot dissolving therapy could be used initially to abort the heart attack. The blocked artery could then be opened using balloon angioplasty. The angioplasty could prove ineffective (i.e. the open artery could close) and bypass surgery ultimately used to solve the blocked artery problem.

Follow-up cardiac testing provides objective evidence of the client’s cardiac status post-heart attack. Thallium treadmills and stress-echo treadmills provide more useful information than a basic treadmill ECG. Any follow-up cardiac testing that is abnormal will result in the client being highly rated or declined for individual coverage.

Uncomplicated heart attacks are usually managed with minimal medications such as aspirin. Complicated heart attacks are managed with stronger medications such as Lanoxin, Imdur, Isordil or nitroglycerin. Knowledge of the client’s current medications is mandatory for an accurate risk assessment.

Clients who have had heart attacks and continue to smoke may not be insurable. Smoking is a major risk factor for heart disease and one that can have a dramatic impact on outcome (i.e. life expectancy). The good news is that smokers who quit following a heart attack have better survival rates and better pricing for life insurance.

Chest pain or other cardiac related symptoms (i.e. irregular heart rhythm, weakness, etc.) after a heart attack carries with it a marked increase in mortality. Clients who report pain or other cardiac related symptoms in the post-heart attack period are universally uninsurable for individual coverage.

Lifestyle changes can have an enormous impact on the underwriting outcome for a cardiac case. There are excellent medical studies that verify that mortality outcome is greatly improved with positive lifestyle changes such as quiting smoking or beginning an exercise program. It is important that you document all lifestyle changes that would indicate a decrease in any cardiac risk factors.

Heart Murmur

Definition

A heart murmur is an extra or unusual sound heard during a heartbeat. Murmurs range from very faint to very loud. They sometimes sound like a whooshing or swishing noise.

Normal heartbeats make a “lub-DUPP” or “lub-DUB” sound. This is the sound of the heart valves closing as blood moves through the heart. Doctors can hear these sounds and heart murmurs using a stethoscope.

There are two types of heart murmurs: innocent (harmless) and abnormal.

People who have innocent heart murmurs have normal hearts. They usually have no other signs or symptoms of heart problems. Innocent murmurs are common in healthy children. Many, if not most, children will have heart murmurs heard by their doctors at some time in their lives.

People who have abnormal murmurs may have other signs or symptoms of heart problems. Most abnormal murmurs in children are due to congenital heart defects. These are heart defects that are present at birth.

In adults, abnormal murmurs are most often due to heart valve problems caused by infection, disease, or aging.

A heart murmur isn’t a disease, and most murmurs are harmless. Innocent murmurs don’t cause symptoms or require you to limit physical activity. Although an innocent murmur may be a lifelong condition, your heart is normal and you likely won’t need treatment.

The outlook and treatment for abnormal heart murmurs depends on the type and severity of the heart problem causing them.

What is the underwriting impact?

Heart murmurs in adults are caused by changes to one or more valves of the heart. The heart has four valves that operate as floodgates for the movement of blood through the four chambers of the heart. A murmur represents some alteration of one of these floodgates. Knowing how the client’s murmur was discovered provides important underwriting clues as to the underlying valve problem. An incidental discovery in an otherwise healthy client may have little impact on the underwriting outcome. On the other hand, the discovery of a murmur in a client who has a cardiac arrhythmia or shortness of breath identifies a client who is in most cases uninsurable for individual coverage.

It is important to find out if the client has any history of an abnormal heart rhythm. Valve disease can cause arrhythmias some of which can be lethal. Clients with a combination of valve disease and a cardiac arrhythmia are generally uninsurable for individual coverage.

It is important to find out if the underlying valve disease is causing any clinical symptoms. Symptomatic valve disease is usually a prelude to some form of major intervention (i.e. surgical replacement of a diseased valve). Clients with symptomatic valve disease are universally uninsurable for individual coverage.

The majority of clients with known heart murmurs are not on chronic medication. They do take antibiotics for dental procedures as well as all surgical procedures. Clients who are chronically medicated represent a more serious underwriting challenge. Generally they are either being treated to prevent clotting problems (i.e. stroke or blood clot to the lungs) or an irregular heart rhythm. It is important to identify all the medications the client is taking to gain the most accurate overview of the severity of the heart murmur.

The assessment of cardiac valves is done using echocardiograms. It is important to know where and when the client had their last echocardiogram. The final decision regarding the client’s insurability is based on these results and the client clinical status (i.e. any shortness of breath, etc.).

Hepatitis C

Definition

Hepatitis C is one type of hepatitis – a liver disease – caused by the hepatitis C virus (HCV). It usually spreads through contact with infected blood. It can also spread through sex with an infected person and from mother to baby during childbirth. Most people who are infected with hepatitis C don’t have any symptoms for years. A blood test can tell if you have it. Usually, hepatitis C does not get better by itself. The infection can last a lifetime and may lead to scarring of the liver or liver cancer. Medicines sometimes help, but side effects can be a problem. Serious cases may need a liver transplant. There is no vaccine for HCV.

What is the underwriting impact?

The majority of clients with Hepatitis C (75%) are asymptomatic (without symptoms) and the diagnosis is usually “discovered” during an investigation of abnormal liver enzymes.

The most common means of transmission of Hepatitis C is contaminated blood products (before 1992) and intravenous use of drugs. Sexual transmission, though possible, is rare. Approximately 4,000,000 Americans have been infected with Hepatitis C. In 40% of reported of cases of Hepatitis C the exact cause is classified as “unknown” (i.e. the client is unwilling to disclose the source of the infection).

A liver biopsy is a critical piece of underwriting information that helps determines both the severity of the Hepatitis C as well as treatment options.

While clients with Hepatitis C may be asymptomatic, the disease is anything but benign. Chronic liver disease develops in 70% of infected individuals leading to cancer of the liver as well as liver failure. The number one cause of liver transplantation in the United States is Hepatitis C.

The majority of clients with Hepatitis C will be monitored without any treatment. Other clients will be treated with medications (interferon and ribavirin) in an attempt to eradicate the Hepatitis C virus. Treatment is only effective in 10-40% of cases.

Even with the new “combination approach” to treating Hepatitis C (interferon and ribavirin), there can be problems with side effects and treatment failures. There is no known cure for Hepatitis C and most cases eventually progress to marked liver dysfunction.

Clients with Hepatitis C are usually aware of the status of their liver enzymes. They may not know the exact readings but they do know if their condition is stable, improving or deteriorating.

The client’s current medications are an important “underwriting clue” to possible complications of Hepatitis C or other medical problems (you can find out any medication’s color code in Pharmacy Tutor).

Clients with known liver disease are usually advised to curtail or quite their alcohol consumption. With liver disease, even modest amounts of alcohol can increase the severity and complications of the problem.

Hypertension

Definition

High blood pressure (HBP) is a serious condition that can lead to coronary heart disease, heart failure, stroke, kidney failure, and other health problems.

“Blood pressure” is the force of blood pushing against the walls of the arteries as the heart pumps out blood. If this pressure rises and stays high over time, it can damage the body in many ways.

About 1 in 3 adults in the United States has HBP. HBP itself usually has no symptoms. You can have it for years without knowing it. During this time, though, it can damage the heart, blood vessels, kidneys, and other parts of your body.

This is why knowing your blood pressure numbers is important, even when you’re feeling fine. If your blood pressure is normal, you can work with your health care team to keep it that way. If your blood pressure is too high, you need treatment to prevent damage to your body’s organs.

What is the underwriting impact?

Smokers who are hypertensive are insurable. However, smoking only adds to the potential negative outcome (i.e. heart attack, stroke, etc.) for hypertensive clients even if their blood pressure is under good control.

Hypertension is treated in a “step-wise” protocol. If the blood pressure can not be kept in the normal range with a single medication (i.e. 140/90 or preferably less), then a second medication is added. If two medications fail to keep the client in the normal range than a third medication is added. The more medications the client is taking, the more severe the hypertension and the more likely there will be some form of “target organ” damage.

Hypertension is officially classified as a form of heart disease. The cardiac complications of hypertension could include angina, heart attack, coronary angioplasty, coronary artery bypass surgery or heart failure. It is important to find the details of any possible complications to accurately assess the risk.

Roadblocks

Hypertension that is not well controlled (i.e. reading that are greater than 140/90 with one or both numbers) is a lethal condition. It can lead to heart attack, stroke and kidney failure. The longer a client has hypertension that is poorly controlled, the greater the possibility of “target organ” (i.e. heart, brain, kidneys) damage. Knowing when the client was initially diagnosed with hypertension is the starting point of the risk assessment process.

Weight loss, exercise, low fat diet, and reducing alcohol intake all have beneficial effects on blood pressure. Any of these positive lifestyle changes also have a positive impact on the underwriting outcome.

The biggest concern with a hypertensive client is the potential for heart disease (coronary artery disease). Clients who have undergone cardiac testing (i.e. exercise treadmill testing) with good results may qualify for preferred rates.

Melanoma

Definition

Melanoma is the most serious type of skin cancer. Often the first sign of melanoma is a change in the size, shape, color or feel of a mole. Most melanomas have a black or black-blue area. Melanoma may also appear as a new mole. It may be black, abnormal or “ugly looking.”

Thinking of “ABCD” can help you remember what to watch for:

  • Asymmetry – the shape of one half does not match the other
  • Border – the edges are ragged, blurred or irregular
  • Color – the color in uneven and may include shades of black, brown and tan
  • Diameter – there is a change in size, usually an increase

Melanoma can be cured if it is diagnosed and treated early. If melanoma is not removed in its early stages, cancer cells may grow downward from the skin surface and invade healthy tissue. If it spreads to other parts of the body it can be difficult to control.

What is the underwriting impact?

Melanoma can be insurable, in some cases, in less than one year following the end of treatment. The normal postponement period is one to two years. The exact date of diagnosis is the starting point for the risk assessment process.

Clark Level refers to how deep the melanoma tumor has invaded the skin. See this link for diagram of the different Clark levels: Clark Level Diagram. Staging refers to the spread of the tumor at the time of diagnosis and is scored from I to IV. See this link for an overview of staging for melanoma: Melanoma Staging.

The kind of treatment will be determined by the size of the melanoma lesion (skin tumor), the lesion’s aggressiveness (how fast it is spreading) and the degree of lesion’s invasion. Superficial melanomas that only invade the upper portion of the skin require only simple surgical excision. Lesions that penetrate deeper into the skin may require a more sophisticated surgical process to insure the removal of the entire lesion. Melanomas that spread to lymph nodes or other body organs require aggressive treatment programs that include chemotherapy.

The “waiting period” for clients with a history of cancer before they are insurable for individual coverage begins from the last date of all forms of treatment.

Successful treatment of melanoma generally involves no on going medications.

Any reoccurrence of a melanoma lesion or the discovery of a second melanoma lesion almost universally renders the client uninsurable for individual coverage.

Multiple Sclerosis (MS)

Definition

Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS. They can include

  • Visual disturbances
  • Muscle weakness
  • Trouble with coordination and balance
  • Sensations such as numbness, prickling, or “pins and needles”
  • Thinking and memory problems

No one knows what causes MS. It may be an autoimmune disease, which happens when your body attacks itself. Multiple sclerosis affects woman more than men. It often begins between the ages of 20 and 40. Usually, the disease is mild, but some people lose the ability to write, speak or walk. There is no cure for MS, but medicines may slow it down and help control symptoms. Physical and occupational therapy may also help.

What is the underwriting impact?

Multiple sclerosis is classified according to the pattern of the disease activity. In general, the longer a client has MS the more likely that the pattern will evolve from acute episodes followed by recovery (called “relapsing-remitting) to one of progressive deficits (called “secondary-progressive”). About 10 percent of clients have a pattern of steady progressive deficits without any recovery from the initial onset of the disease (called “primary-progressive”). It is important to document when the diagnosis of MS was first confirmed.

MS cannot be diagnosed from a single event (i.e. one acute episode). It’s diagnosis is based on a pattern. It requires at least two episodes involving two separate sites in the central nervous system.

Clients with MS may have “flares” and then go into a recovery phase without any disease progression between the acute attacks. It is also possible that clients with MS can develop progressive deficits with each flare. It is important to document that exact pattern of the client’s MS to determine the degree of clinical stability.

The functional consequences of MS can be profound. Up to 50 percent of clients are disabled within 10 years. Less than two-thirds of clients can walk after 30 years. It is important to document the functional status of the client. Clients who are wheelchair bound are generally uninsurable.

MS can now be treated with medications that are designed to limit the flares and potentially slow down the progression of deficits. These include steroids (i.e. methylprednisolone), beta-interferon (Betaseron and Avonex) and copolymer (Copaxone). It is important to document the exact medications the client is taking to treat their MS.

Obesity

Definition

Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat and/or body water. Both terms mean that a person’s weight is greater than what’s considered healthy for his or her height.

Obesity occurs over time when you eat more calories than you use. The balance between calories-in and calories-out differs for each person. Factors that might tip the balance include your genetic makeup, overeating, eating high-fat foods and not being physically active.

Being obese increases your risk of diabetes, heart disease, stroke, arthritis and some cancers. If you are obese, losing even 5 to 10 percent of your weight can delay or prevent some of these diseases.

What is the underwriting impact?

Obesity is a risk factor for hypertension, diabetes and heart disease. Smoking only increases these risks or intensifies their complications. Obese clients who smoke have poor underwriting outcomes in terms of pricing and ultimate mortality. The good news is that obese clients who have quit smoking (i.e. twelve months or longer) have improved outcomes in terms of premium cost and life expectancy.

Obesity is a risk factor for hypertension, diabetes and heart disease. The degree of obesity is a function of the client’s height and weight. Guessing at a client’s weight to “be polite” only creates poor underwriting outcomes and frustration for everyone. Be polite, be sensitive, but obtain an accurate height and weight.

It is not surprising to find overweight clients taking medications to control high blood pressure (hypertension), elevated blood sugar (diabetes) or elevated blood fats (hyperlipidemia).

Not all clients with elevated blood pressure are on blood pressure medications (i.e. do not assume because they are not on blood pressure medications they do not have high blood pressure). Some clients are managed with exercise, weight loss and diet alone. Others may have taken medications in the past but have stopped their medications for variety of reasons (i.e. side effects of the medication, their blood pressure improved, etc.).

Elevated blood pressure is defined as readings of greater than 140/90.

Not all clients with elevated blood sugars are on diabetic medications. The initial treatment of clients with elevation of blood sugar includes exercise, weight loss and diet. If these measures fail to reduce the blood sugar, the client will usually be placed on oral medications to reduce blood sugar levels (i.e. Diabeta, Glucophage, Glucotrol, Micronase, etc.).

Elevated blood sugar is defined as blood glucose level above 110 mg/dl (fasting) or a random blood glucose level of 200 mg/dl.

Fen/Phen (fenfluramine and phentermine) had been used extensively to treat obese patients before it was taken off the market by the FDA. Sadly, it proved to have serious side effects, which included damage to heart valves as well as lung tissue. It is important to document how long these medications were taken by the client and what kind of follow-up care the client has received to rule-out potential side effects.

Osteoporosis

Definition

Osteoporosis makes your bones weak and more likely to break. Anyone can develop osteoporosis, but it is common in older women. As many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis.

Risk factors include:

  • Getting older
  • Being small and thin
  • Having a family history of osteoporosis
  • Taking certain medicines
  • Being a white or Asian woman
  • Having osteopenia, which is low bone mass

Osteoporosis is a silent disease. You might not know you have it until you break a bone. A bone mineral density test is the best way to check your bone health. To keep bones strong, eat a diet rich in calcium and vitamin D, exercise and do not smoke. If needed, medicines can also help.

What is the underwriting impact?

Osteoporosis is the most common metabolic bone disease in the USA and the cause of hundreds of thousands of fractures each year. The morbidity and indirect mortality rates are very high. The primary defect is an internal weakening of bone structure that at some point becomes unable to maintain the structural integrity of the skeleton.

Osteoporosis is usually without any symptoms until an actual fracture occurs. The most common areas of fractures are the spine and the pelvis. Women are more frequently affected than men.

The morbidity and indirect mortality from osteoporosis is related to impaired functional ability. It is important to document the client’s basic and advanced activities of daily living (ADLs).

There are various medications that used to either prevent or treat osteoporosis. These include:

  • Estrogen: used in postmenopausal women to prevent or delay the development of osteoporosis.
  • Alendronate and Etidronate: used to prevent the internal weakening of the bone that leads to the eventual fracture.
  • Miacalcin: a nasal spray that is used to diminish the bone pain of osteoporosis.

It is important to document all medications that the client is taking to manage their osteoporosis.

Parkinson's Disease

Definition

Parkinson’s disease is a disorder that affects nerve cells, or neurons, in a part of the brain that controls muscle movement. In Parkinson’s, neurons that make a chemical called dopamine die or do not work properly. Dopamine normally sends signals that help coordinate your movements. No one knows what damages these cells. Symptoms of Parkinson’s disease may include

  • Trembling of hands, arms, legs, jaw and face
  • Stiffness of the arms, legs and trunk
  • Slowness of movement
  • Poor balance and coordination

As symptoms get worse, people with the disease may have trouble walking, talking or doing simple tasks. They may also have problems such as depression, sleep problems or trouble chewing, swallowing or speaking.

Parkinson’s usually begins around age 60, but it can start earlier. It is more common in men than in women. There is no cure for Parkinson’s disease. A variety of medicines sometimes help symptoms dramatically.

What is the underwriting impact?

Parkinson’s disease is a chronic illness of the brain. Certain cells in the brain called neurons deteriorate over time. The longer the client has had Parkinson’s disease, the greater the likelihood of significant primary and secondary symptoms.

Parkinson’s disease is diagnosed based on a neurological examination and an evaluation of symptoms (i.e. tremor at rest, stiffness of the limbs, gait disturbances, etc.). CT scans and MRI scans are used to rule out other diseases whose symptoms resemble Parkinson’s disease.

Primary symptoms include:

  • Stiffness
  • Tremor
  • Slowness of movement
  • Difficulty with balance
  • Difficulty with walking

Secondary symptoms include:

  • Depression
  • Senility
  • Difficulty speaking

It is important to try to obtain an accurate assessment of the client’s symptoms as well as their severity.

The goal of treating Parkinson’s disease is to help control the symptoms. There are no medications currently available to stop the progression of the disease. The mainstay of therapy is Sinemet (carbidoa/levodopa). This combination medication can help control tremor and slowing (i.e. difficulty in initiating movements) and is effective long term. Another commonly prescribed medication, Eldepryl (selegiline) may slow the course of the illness.

Some Parkinson’s patients remain stable for many years with medications. Others undergo a steady deterioration with serious primary and secondary symptoms. It is important to obtain an accurate assessment of the client’s clinical pattern (i.e. stability or deterioration). The best way to answer this question is to try and determine the client’s functional ability (i.e. are there any limitations to normal activities like walking, eating, etc.?).

Clients who are wheelchair bound or have dementia are uninsurable for individual coverage.

Rheumatoid Arthritis (RA)

Definition

Rheumatoid arthritis (RA) is a form of arthritis that causes pain, swelling, stiffness and loss of function in your joints. It can affect any joint but is common in the wrist and fingers. More women than men get rheumatoid arthritis. It often starts between ages 25 and 55. You might have the disease for only a short time, or symptoms might come and go. The severe form can last a lifetime. Rheumatoid arthritis is different from osteoarthritis, the common arthritis that often comes with older age. RA can affect body parts besides joints, such as your eyes, mouth and lungs. RA is an autoimmune disease, which means the arthritis results from your immune system attacking your body’s own tissues.

No one knows what causes rheumatoid arthritis. Genes, environment and hormones might contribute. Treatments include medicine, lifestyle changes and surgery. These can slow or stop joint damage and reduce pain and swelling.

What is the underwriting impact?

Rheumatoid arthritis is a chronic, autoimmune (i.e. the body attacks itself) disease that is characterized by acute episodes (called “flares”) and periods of remission. However, the longer the client has had rheumatoid arthritis the greater the chances of significant underwriting concerns from either the disease itself or the medications used to treat it.

Rheumatoid arthritis is diagnosed using a combination of blood studies (i.e. rheumatoid factor, ANA and ESR) and clinical findings (i.e. symmetrical swelling of the joints of the hands, wrists and feet). It should not be confused with another form of arthritis that is a “wear and tear” arthritis called Osteoarthritis.

Medications used to treat rheumatoid arthritis are divided into first line and second line drugs. First line drugs are used to treat the acute phase of the disease (i.e. reduce pain and inflammation). The second line drugs are used to promote disease remission and prevent progressive joint destruction. In many cases, the client may be taking both types of medications (i.e. they are having a “flare” as well as being medicated for long term disease management). It is important to obtain an accurate list of all of the medications the client is taking to treat their disease.

The medications used to treat rheumatoid arthritis can be a simple as aspirin or as complicated as drugs that suppress the immune system. In some cases the side effects of the medications can present greater underwriting challenges that the disease itself.

It is important to obtain an accurate assessment of the impact of rheumatoid arthritis on the client’s functional abilities. Many clients enjoy a normal lifestyle and use minimal medications. Other clients become severely impaired even with the strongest medications.

Rheumatoid arthritis, in some cases, can affect other parts of the body. This could include the eyes, the lungs, the heart, the bone marrow, and the blood vessels. Involvement of other systems of the body will have a negative impact on the underwriting assessment.

Seizure Disorder (Epilepsy)

Definition

Seizures are symptoms of a brain problem. They happen because of sudden, abnormal electrical activity in the brain. When people think of seizures, they often think of convulsions in which a person’s body shakes rapidly and uncontrollably. Not all seizures cause convulsions. There are many types of seizures and some have mild symptoms. Seizures fall into two main groups. Focal seizures, also called partial seizures, happen in just one part of the brain. Generalized seizures are a result of abnormal activity on both sides of the brain.

Most seizures last from 30 seconds to 2 minutes and do not cause lasting harm. However, it is a medical emergency if seizures last longer than 5 minutes or if a person has many seizures and does not wake up between them. Seizures can have many causes, including medicines, high fevers, head injuries and certain diseases. People who have recurring seizures due to a brain disorder have epilepsy.

What is the underwriting impact?

Seizure disorders are a chronic neurological disorder that may result from brain injury, developmental malformation or a genetic abnormality. They are caused by sudden, excessive electrical activity in the brain. Seizure disorders affect up 1% of the population of industrialized countries with the highest rates occurring in children and adolescents. It is important to document at what age the client had their first seizure.

Seizures are classified as GENERALIZED (Grand Mal) and PARTIAL ONSET. Generalized seizures create an electrical discharge throughout the brain. Partial onset seizures create an electrical discharge in a localized part of the brain. Partial onset seizures are classified into two general categories: simple and complex. With the simple version, consciousness is maintained. With the complex version, consciousness is altered. Most seizures (60%) are complex partial or secondarily generalized It is important to document the client’s seizure type.

The underwriting of seizure disorders is in part based on the client’s degree of clinical stability (i.e. seizure free periods). It is important to document the last time the client has a seizure whether or not they sought medical care.

Many patients with seizure keep a “seizure diary” which details their seizures as well as their medication schedule.

Seizures significant enough to require hospitalization are significant to the underwriting process. It is important to document if the client has ever been hospitalized for a seizure and the dates that occurred.

Seizure disorders are treated with medications. In many cases, this involves more than one drug. Seizure control with tolerable side effects can be achieved in 50% to 80% of patients with using only one medication. Common medications used to treat seizures include Tegretol, Zarontin, Lamictal, Dilantin, Depakote and phenobarbital. Some patients may become seizure free without medications indicating that a seizure disorder is not always a lifelong condition. It is important to document all of the medications the client is currently taking to manage their seizure disorder.

The severity of a seizure disorder can also be measured in terms of functional ability. Clients who can not work or obtain a driver’s license present serious underwriting concerns for individual coverage. Clients who are employed on a full time basis and have a valid driver’s license, on the other hand, can have excellent underwriting outcomes.

Sleep Apnea

Definition

Sleep apnea is a breathing disorder (i.e. periods where the patient stops breathing) that is most commonly seen in overweight, middle aged men who have history of restless, loud snoring. In its mildest form, it is an annoyance. In its severest form, it can produce life threatening cardiac arrhythmias that may prove fatal. The risk selection process begins with knowing when the client was diagnosed as having sleep apnea.

What is the underwriting impact?

Most sleep apnea is classified as “obstructive” meaning the back of the throat collapses during sleep and obstructs the normal breathing process. A high percentage of persons with sleep apnea also have hypertension.

Cigarette smoking is a risk factor for sleep apnea. Alcohol, especially before sleeping, may precipitate or worsen sleep apnea.

Like alcohol, sedatives (i.e. Valium, Ativan, Xanax, etc.), especially before sleeping, may precipitate or worsen sleep apnea. There is also a likelihood the client may be taking medications for high blood pressure.

While it is possible to make the diagnosis of sleep apnea based on history alone, a sleep study is needed to determine the severity of the condition. The information gained from a sleep study determines the client’s treatment strategy.

The treatment of sleep apnea may be as simple as the “tennis ball” strategy (i.e. a tennis ball is placed behind the client as he or she sleeps on their side to wake them up if they try and sleep on their back). It may be as involved as extensive throat surgery and use of a special breathing device called CPAP. CPAP, continuous positive airway pressure, is worn at night to prevent the apnea episodes.

The non-surgical treatment of sleep apnea, especially with CPAP, requires a high degree of patient cooperation. It is important to document the degree of patient compliance with their treatment program.

Weight loss, exercise, quitting smoking, and reducing alcohol intake all have beneficial effects on sleep apnea. Any of these positive lifestyle changes also have a positive impact on the underwriting outcome.

Stroke (Cerebral vascular accident or CVA)

Definition

A stroke is an interruption of the blood supply to any part of the brain. A stroke is sometimes called a “brain attack.”

A stroke can happen when the following occurs:

  • A blood vessel that supplies blood to the brain is blocked by a blood clot. This is called an ischemic stroke.
  • A blood vessel breaks open, causing blood to leak into the brain. This is called a hemorrhagic stroke.

If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage.

What is the underwriting impact?

There is a postponement period between six to twelve months following the diagnosis of a stroke. The exact date of the last stroke is the starting point of the risk assessment process.

Strokes are the permanent destruction of brain tissue. They either represent a bleed into the brain tissue or a clot that stops all blood flow to a portion of the brain.

A single episode of a stroke is priced much differently than multiple episodes of strokes. Multiple strokes indicate a poor medical and underwriting outcome.

The severity of a stroke can range from mild to fatal. Most strokes leave some form of permanent damage (neurological sequelae). It is important to document the exact nature of the damage the stroke has caused for the client (i.e. paralysis of an arm or leg, changes in ability to walk or talk, etc.).

Clients who experience a stroke are placed on some form of clot prevention therapy (i.e. anti-coagulants). These medications include aspirin, Persantine or Coumadin.

Strokes are by definition neurological changes that last beyond twenty-four hours. It is important to clarify if any of these symptoms have reoccurred since the last stroke. Reoccurring symptoms indicate clinical instability and generally render the client uninsurable for individual coverage.

The major risk factors for strokes are a history of smoking, diabetes (insulin dependent or non-insulin dependent) or hypertension. It is important to know if these risk factors exist in the client’s medical history. Poorly controlled diabetes or hypertension combined with smoking in clients who have had a stroke generally renders the client uninsurable for individual coverage.

Irregular heart rhythms or disease of the heart valves can create clotting events that lead to strokes. It is important to know if these risk factors exist in a client’s medical history. Cardiac arrhythmia’s or heart valve disease combined with a history of a stroke generally renders the client uninsurable for individual coverage.

Substance Abuse

Definition

Excessive or otherwise inappropriate ingestion of alcohol, drugs, tobacco, or other chemical or organic substances, often impairing physiological and/or psychological functions.

What is the underwriting impact?

The hallmark of substance abuse is denial. Clients who are successful in their recovery from substance abuse are generally open about their addiction and the progress they have made in their recovery. The opposite is true of clients who still in denial and defend their right to continue to use the substance.

There are two kinds of treatment for substance abuse: 1) an organized treatment program (usually in-patient) conducted by medical professionals who are experienced with substance abuse; 2) a “self-directed” program conducted by the client who has made a decision to quit using one or more substances. The greatest clinical and underwriting success is obtained from an organized program. It is important to document when and for what period of time the client was treated for substance abuse.

The “postpone” period for substance abuse can be between two to five years. It is important to document the exact date the client ended their substance abuse. This will be the “starting” date for underwriting purposes.

Substance abuse can be singular or multiple in nature. Older clients tend to have singular addiction patterns (i.e. alcohol only). Younger clients tend to have multiple addiction patterns (i.e. cocaine, alcohol, sedatives). Underwriting outcome is dramatically different for singular versus multiple substance abuse. Being very clear on this issue will prevent unpleasant underwriting surprises after the case is submitted formally to a carrier (i.e. the underwriter discovers the client was abusing more than one substance).

Getting clean and sober is one thing, staying clean and sober is another. The highest success rate for recovery from substance abuse is with those clients who receive after-care. This is generally provided through AA or NA. It is important to document both the type and level of participation of the client’s after-care (i.e. AA three times a week with a sponsor).

Habits do not exist as singular entities. Habits are really extensive networks of habits that reinforce each other. Success recovery depends on creating new networks of habits. After-care is one vehicle for creating new networks. Reconnecting with family, friends and church are other vehicles to new networks. It is important to document what steps the client has taken to build new habit networks in his or her recovery.

All substance abuse cases can be divided into two distinct categories: 1) clients who are “clean and sober;” 2) clients who are not “clean and sober.” If a client with a document history of substance abuse is still using the substance (i.e. alcohol, pain killers, sedatives, cocaine, marijuana, etc.), they are universally uninsurable for individual coverage. Being clear on this question will save the agent and support staff hours and hours of wasted time and effort.

Systemic Lupus Erythematosus (SLE)

Definition

If you have lupus, your immune system attacks healthy cells and tissues by mistake. This can damage your joints, skin, blood vessels and organs. There are many kinds of lupus. The most common type, systemic lupus erythematosus, affects many parts of the body. Discoid lupus causes a rash that doesn’t go away. Subacute cutaneous lupus causes sores after being out in the sun. Another type can be caused by medication. Neonatal lupus, which is rare, affects newborns.

Anyone can get lupus, but women are most at risk. Lupus is also more common in African American, Hispanic, Asian and Native American women. The cause of lupus is not known.

Lupus has many symptoms. Some common ones are

  • Joint pain or swelling
  • Muscle pain
  • Fever with no known cause
  • Red rashes, often on the face (also called the “butterfly rash”)

There is no one test to diagnose lupus, and it may take months or years to make the diagnosis. There is no cure for lupus, but medicines and lifestyle changes can help control it.

What is the underwriting impact?

Spontaneous remissions and relapses mark the clinical course of lupus. The disease can remain reasonably stable for years or it can become rapidly fatal. Generally the disease becomes progressively more severe the longer the time since diagnosis. The first step in risk assessment is to identify when the diagnosis was confirmed.

The diagnosis of lupus is based on a combination of physical and laboratory findings known as the four out of eleven criteria (i.e. you must have four out of the eleven criteria to be diagnosed with SLE).

The heart and the kidneys are common sites of secondary complications that in many cases prove fatal. You need to document the nature of any complications (i.e. what organ system do they involve) and how long they have been present.

The cornerstone of treatment for lupus is oral steroids (i.e. Prednisone). Initially this may be a dose of 40-60mg/day, which is reduced to a lower maintenance dose as the client stabilizes

TIA (Transient Ischemic Attack or near stroke)

Definition

A transient ischemic attack (TIA) is a stroke that comes and goes quickly. It happens when a blood clot blocks a blood vessel in your brain. This causes the blood supply to the brain to stop briefly. Symptoms of a TIA are like other stroke symptoms, but do not last as long. They happen suddenly, and include

  • Numbness or weakness, especially on one side of the body
  • Confusion or trouble speaking or understanding speech
  • Trouble seeing in one or both eyes
  • Loss of balance or coordination

Most symptoms of a TIA disappear within an hour, although they may last for up to 24 hours. Because you cannot tell if these symptoms are from a TIA or a stroke, you should get to the hospital quickly.

What is the underwriting impact?

There is a postponement period between six to twelve months following the diagnosis of a TIA. The exact date of the last TIA is the starting point of the risk assessment process.

A single episode of a TIA is priced much differently than multiple episodes of TIAs. Multiple TIAs indicate a poor medical and underwriting outcome.

The major risk factors for TIAs are a history of smoking, diabetes (insulin dependent or non-insulin dependent) or hypertension. It is important to know if these risk factors exist in the client’s medical history. Poorly controlled diabetes or hypertension combined with smoking in clients who have had a TIA generally renders the client uninsurable for individual coverage.

Irregular heart rhythms or disease of the heart valves can create clotting events that can present as TIAs. It is important to know if these risk factors exist in a client’s medical history. Cardiac arrhythmias or heart valve disease combined with one or more TIAs generally renders the client uninsurable for individual coverage.

Clients who experience one or more TIAs are placed on some form of clot prevention therapy (i.e. anti-coagulants). These medications include aspirin, Persantine or Coumadin.

TIAs are by definition neurological changes that last for less than twenty-four hours (i.e. one-sided numbness, loss of the ability to speak, etc.). It is important to clarify if any of these symptoms have reoccurred since the last TIA. Reoccurring symptoms indicate clinical instability and generally render the client uninsurable for individual coverage.

Ulcerative Colitis

Definition

Ulcerative colitis is a disease that causes ulcers in the lining of the rectum and colon. It is one of a group of diseases called inflammatory bowel disease. Ulcers form where inflammation has killed the cells that usually line the colon.

Ulcerative colitis can happen at any age, but it usually starts between the ages of 15 and 30. It tends to run in families. The most common symptoms are pain in the abdomen and bloody diarrhea. Other symptoms may include anemia, severe tiredness, weight loss, loss of appetite, bleeding from the rectum, sores on the skin and joint pain. Children with the disease may have growth problems.

About half of people with ulcerative colitis have mild symptoms. Several types of drugs can help control ulcerative colitis. Some people have long periods of remission, when they are free of symptoms. In severe cases, doctors must remove the colon.

What is the underwriting impact?

Ulcerative Colitis is most common in young adults, but can occur at any age. Generally, the longer the client has the disease, the greater the likelihood of medical and underwriting complications. The most serious complication is cancer of colon. The only exception to this pattern is the client who undergoes removal of the colon to treat the disease. It is important to obtain an accurate assessment of the original date of diagnosis.

The diagnosis of ulcerative colitis is based on the clinical presentation (i.e. abdominal pain, diarrhea, rectal bleeding, weight loss, etc.) and direct visualization of the colon (i.e. sigmoidoscopy, colonoscopy).

Ulcerative colitis tends to occur in a “flare”/remission pattern. The flares are marked by the onset of typical symptoms (i.e. diarrhea, rectal bleeding, etc.). The remissions are marked by a return to essentially normal bowl function. Medications are used to treat both the flare and prolong the remission. These range from simple salicylates (Azulfidine, Dipentum, Asacol and Pentasa) to drugs that suppress the immune system (Imuran, Purinethol. Sandimmmune and Rheumatrex). Steroids, either orally (Prednisone) or used in enemas (Cortenema) may also be part of the client’s medication schedule. It is important to identify all of the medications the client is taking to treat the disease.

It is important to clarify the client’s “flare”/remission pattern. Significant “flares” usually involve the same symptoms that lead to the original diagnosis (i.e. abdominal pain and bloating, bloody diarrhea, etc.) and may require hospitalization.

Surgically removing the colon permanently cures ulcerative colitis. However, surgery involves removing the entire colon and the rectum.

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