Posts filed under 'angioplasty'
It’s amazing how a heart attack or a visit to the ER with chest pain can make you consider mortality. Even when you come away with a quick fix like a stent, life just seems a bit more fragile. So how do life insurance underwriters view cardiac issues? Can you get approved after someone has tuned up your ticker?
Several years ago I had a call from a man that explained that he had recently had a two vessel angioplasty and was wondering if he could get life insurance. I explained that in a lot of cases life insurance is very attainable after a cardiac procedure, but I needed a bit more information. I asked him where he was calling from, meaning with my question what state. He said he was calling from the hospital. I asked him how long ago he had the stents placed and he told me two days earlier. This guy had a sudden understanding of mortality and wanted to get protection in place right away.
I explained to him that in most cases we were looking at a year out from the angioplasty and a stress test showing good results, most importantly a strong ejection fraction which is an indicator of how much, if any, heart damage was done. We weren’t able to help him that day, but a year later he became a customer.
So, what does an underwriter want to see for optimal results in applying for life insurance after a cardiac event? First is some time. A year out from the treatment is pretty standard unless you are willing to take a big hit on rates. A few companies will consider prior to one year but they charge according to their perceived risk in stepping up early. The stress test is critical. Most cardiologists are going to have you do a stress test 6 months or so after the procedure just to see how well the repair is doing. Some wait as much as a year.
The primary indicator from the stress test that underwriters look for is the LVEF, left ventricular ejection fraction, a measure of how efficiently your heart pushes blood out of the left ventricle. Normal is in the 65% to 70% range for a person with no heart damage. Very few companies will consider coverage if a person’s LVEF is under 50%.
Other factors that they look at would be your age when the event happened. Prior to age 50 is problematic. Truth is that heart attacks at that age are out of the ordinary and indicative of aggressive heart problems. The possibility of recurrence is high. Prior to age 40 is going to be hard to find any takers at all.
Changes in life style play into underwriting. With obesity being a major risk factor for heart disease, a patient who aggressively undertakes a diet and exercise regime aimed at taking weight out of the equation will get more favorable consideration.
Cardiac rehab is something that is good to do and underwriters recognize that. What they are looking at is who is taking the issue seriously after the emergency has passed.
Bottom line. After a cardiac event you will not see preferred plus rates again, but if you do all of the right things and the damage was minimal, affordable life insurance is certainly a possibility.
July 18th, 2009
Angioplasty has been praised for its’ less invasive approach to fixing clogged arteries than the traditional bypass surgery by many and it has been labeled a dangerous scam by others.
In light of a couple of takes on angioplasty by CBS news this week I want to throw out some discussion about the subject from a life insurance standpoint and from a medical point of view.
Angioplasty has kind of devolved over the past ten years in the eyes of life insurance underwriters. At first seen as “the new and better way” to address clogged arteries, angioplasty received more favorable underwriting than the other surgical alternative, open heart bypass surgery. With, for instance, a 3 vessel angioplasty versus a 3 vessel bypass, in the absence of a heart attack, the angioplasty would have had about a two table edge in the past.
Today there is virtually no difference in the underwriting outcome between the two procedures. Mortality experience post procedure is almost identical and underwriters who once thought the angioplasty would have a better experience because it was less invasive now have enough data to dispel with that notion.
Then there’s the issue of overuse of angioplasty, whether you believe that’s because it’s so easy or it’s so easy and lucrative. The truth is that a doctor may be inclined to be too aggressive in using angioplasty because of its’ ease when the blockage could, in at least 30% or more of cases, be controlled and reversed medically. From an underwriting point of view there is a huge difference between someone diagnosed with coronary artery disease who is treated successfully with medicine and someone with an identical situation that undergoes angioplasty or bypass surgery. Whether right or wrong there is a perception that if surgical intervention of any type is warranted, the CAD must be more advanced.
Doctors often tout angioplasty as the safe way to address arterial blockage. The problem lies in the fact that the procedure is often done in non emergency situations where there is no real need for easy or fast. And it is often done in hospitals that don’t have a cardiology unit backup so if something does go wrong the option of open heart surgery is still available.
So, medically speaking, the question is drugs versus angioplasty? A 2007 study showed that in non emergency situations (no heart attack happening), there was virtually no statistical difference between the choice to have an angioplasty or take clot busting drugs.
Bottom line. From a medical point of view, in non emergency situations it certainly seems prudent for doctors to ease the panic of the situation and discuss the alternatives. Please understand that I would never suggest that someone dictate medical choices based on how it might affect future life insurance premiums. What I am saying is that it appears there is ample evidence of the overuse of angioplasty and that overuse is affecting patients far beyond the medical issue.
June 11th, 2009
A month or so ago I talked about a client of mine who, over the course of 4 years, has been working with me to get his rate down from the very first approval we were able to get through Empire General at a table 8, to a just approved standard plus rate with Banner Life.
I hold this client up as an example of how, when a client is really involved with the process, positive things can happen. This is a guy who has provided study results, pathology reports, and gone out of his way to get a checkup that he wasn’t even due for, simply because he knew that it would help our battle to win him better rates. We were able to improve the rate each year because of his willingness to do whatever it took. His rates were over $12,000 a year. They’re now under $4,000.
In contrast are people who contact me for insurance quotes and know little or nothing about their medical situation and for sure aren’t going to call their doctor or run by the doctor’s office to get a copy of labs or a pathology report or a copy of a stress test or a sleep study. The act as if I am imposing on them to ask for more information than they can provide me right then and there when, all I’m really asking for is exactly what an underwriter needs.
If I am providing a quote for someone with diabetes, I need to know their A1c. If it’s a history of cancer I need to know the stage and grade. If it’s heart disease or if someone has had an angioplasty or bypass surgery, I need a copy of their stress test so I know what their ejection fraction is. With sleep apnea, a copy of the sleep study is needed like all of those other things, to ensure that the quote I provide is accurate.
I can’t tell you how many times I’ve heard over the years, “Well, if it’s going to be that much of a hassle, just forget it.” I always wonder if they then turn around and tell their wives that they would have bought life insurance but the agent wanted me to call my doctor’s office and it was just too much hassle.
I suppose I am beat out of some of this business by agents who don’t hassle anyone and just quote what they want to hear, or just shoot from the hip without all the facts, but the truth is that asking for that information serves two purposes in the process. First, if the client provides the requested information, it ensures an accurate quote and generally means that I can expect them to stay involved through the application process. Second, if they don’t take that small part in their own quest for life insurance, at least in my experience, they won’t end up being a cooperative client through the rest of the application and they also have a higher lapse rate than those who really get involved.
Bottom line. Not everyone gets preferred plus rates and those with serious health issues need to find a good independent agent and get involved in their own destiny if they don’t want to over pay or explain to their spouse why they are just going to go without.
May 5th, 2009
I think on some level we all carry a bit of denial along with us. It’s probably a chromosomal kind of thing, like there are x, y, z and denial chromosomes.
Unfortunately for those most affected by denial there is bad news from life insurance underwriters. Probably the best example of this is the underwriting treatment of those who really don’t believe the link between smoking and heart disease. There is probably nothing that is more likely to lead to a highly rated policy or with most companies, a decline, than someone who continues to smoke after they have had coronary issues.
Literally the best case would be if someone had a one vessel angioplasty with no heart attack and a great followup history of stress tests, complicated only by the fact that they still smoke. In the absence of smoking a case like this could get as good as a standard rate, with the norm being a lightly rated approval. Add in smoking and most companies will decline it. Those that do approve it will approve it at highly rated prices.
Why the big underwriting slap in the face? Well, the beginning and the end of the argument go like this. Smoking is the leading cause and accelerator of heart disease! Why should life insurance underwriters cut you a break when you are knowingly doing yourself damage? You don’t really have to answer that because the answer is that they won’t.
So, what should you do if you have had cardiac issues and smoke and want life insurance. I recommend you apply and if you get approved, put as much in force as you can comfortably budget, then quit with the denial stuff and quit smoking. When you are 12 months out from the last nicotine entering your body, reapply and watch your rates be cut dramatically to something around 1/3 of what you were paying before. “Well, why not”, the denialist asks, “just quit smoking and wait a year and then I won’t have to pay higher prices for that period?”
Bottom line. Once you learn denial it’s a hard thing to shake. The reason you don’t wait a year is because you will feel so stupid leaving your family behind with no life insurance. Do what you can now and do more after you’ve corrected your bad habits.
January 3rd, 2009
There isn’t any question that given the clear choice between suffering a potentially fatal heart attack and having the artery opening procedure called angioplasty, the prudent thing to do is to stack the deck in your favor and open those arteries.
But there is a serious question about the use of angioplasty as a preventive measure. In other words, if you are not in imminent danger of a heart attack and arteries that have begun to clog are treatable with medicine, is the risk of an invasive procedure still prudent and reasonable. Recent studies have shown that there appears to be enough inappropriate recommendations for the procedure that the American Heart Association and others will be releasing new guidelines within a few months regarding when an angioplasty should be set aside for treatment through cholesterol lowering and clot busting drugs combined with exercise.
Medically this is a huge issue. From a life insurance standpoint it can make the difference after the diagnosis of how soon a person can get life insurance and how much they will pay. If a person is found to have blockage that is successfully treated medically and those results can be substantiated on a subsequent stress test they could be looking at standard rates, possibly better, within six months. If they have an angioplasty, whether it was needed or not, it will be at least a year and a good stress test and then the rates will generally be higher than standard rates.
The good news is that, given a good stress test, either way you would be insurable. The bad news is that an over zealous doctor might do more damage than just handing you a large cardiologist’s bill.
Bottom line. Second opinion, second opinion, second opinion……unless you are having a heart attack.
November 17th, 2008
For as long as there has been life insurance and heart attacks there has been misinformation about the impact of the event on future ability to obtain the insurance.
Two of the most common myths are that 1. If you’ve had a heart attack then you are simply toast and will not be able to get life insurance and 2. There is a five year waiting period after you’ve had a heart attack before you can apply for life insurance. If this was a multiple choice test the answer would be 3. none of the above.
With heart disease testing and detection improving all the time and with post heart attack treatment doing the same, the chances of having a heart attack and the actual damage from any heart attack have greatly diminished. New testing helps detect blockage early enough that often cholesterol lowering and clot prevention drugs keep patients from having any procedures at all. If blockage has reached a point where there is potential for damage, state of the art angioplasty or bypass surgery can be performed.
If blockage is caught early enough to treat with medication there is a good chance that, given no other risk factors, rates can be as good as preferred or preferred plus soon after treatment has started and a positive stress test has shown that the treatment is working.
If there is an angioplasty or bypass surgery with no heart attack, insurance can be applied for as soon as 6 months to a year after the procedure, again, as long as there has been a stress test completed that can address the current condition of the heart and any arterial blockage. The rates that can be approved will depend on an applicant’s age. Like diabetes, age of onset is a real hang up with underwriters. Anything prior to age 50 will incur a higher rate than post 50 and prior to 40 will be rated even higher.
If there has been a heart attack followed by angioplasty or bypass surgery, the same 6 months to a year and a good stress test applies, but you can assume the rate will be higher simply because a heart attack causes heart muscle damage that is often not reversible.
Bottom line. Heart issues don’t deal a death blow in most life insurance situations. It may make it a little harder work for your agent and you, but in most cases realistically priced insurance should be available through a knowledgeable independent agent.
October 31st, 2008
You don’t buy life insurance, rather, you apply for it. Because there is an application there should be a common understanding that there is a chance that your application will be rejected. The industry term is decline.
While declines are far more the exception than the rule, there are some common threads found in declines. These same threads are often found in applications that are asking for preferred rates and come back at standard or higher rate approvals.
I know. You’re used to me eating the face off of clients for their lack of knowledge or lack of candor when it comes to their medical history, but today we start with the insurance professional, the agent. In most cases a knowledgeable independent agent will know enough after an initial interview with you to know if you will be approved and within a reasonable margin of error (not politics, lab results), they should be able to quote you the rate class you will be approved at.
In the cases where there are health issues a prudent agent will take all the information and send it out for trial offers from underwriters. Expect a good agent to dig for as much information as they can get because insufficient information will lead to an inaccurate quote and an unsatisfactory outcome. I have had people tell me that I ask too many questions or even tell me “that I don’t need to know that, just quote me”, but trust me, you want an agent who knows what questions to ask to get to the underwriting bottom line.
Let’s say you have diabetes. I can ask you what your most recent hbA1c is up front and if you don’t know it, insist that you call the doctor’s office and find out what it is or, I can quote you a best case scenario and when your hbA1c comes back high in your medical records we can have a friendly chat about why the cost of your insurance just doubled over what I quoted. Or I could call you to explain that you were declined. Some wise guy once said “knowledge is power” and when it comes to successfully coming through with good life insurance rates in the face of health issues, it most certainly is true.
The agent has a professional obligation to be a fact finding animal. It’s the best way to serve clients. Clients, if they want the best possible service, have an obligation to be accurate and forthcoming to the max. Don’t ask, don’t tell, is not the relationship that wins in insurance underwriting. A recent example would be a client who answered no to chronic respiratory disease because I didn’t ask them about reactive airway disease. Get real!
Truth is that even if I ask someone to disclose everything that has ever been a health issue, in their mind a heart attack might not be a health issue because they lived through it and after the five vessel angioplasty their doctor said they are just fine. Would you take your car into a mechanic because it’s running really bad and just neglect to tell them that because of the price of gas you tried watering that $3 a gallon stuff down a bit?
Bottom line. Garbage in, garbage out! If the agent doesn’t do their job the end result isn’t what you expected and conversely, if you aren’t completely forthcoming with the agent, don’t expect them to pull off a miracle for you.
October 29th, 2008
I think I’ve been very clear over the years about unexplained information in medical records and how life insurance underwriters deal with it. They ask questions!
Sometimes the mystery information isn’t relevant once it is explained. Sometimes the information doesn’t even pertain to the patient. I think I’ve shared this before, but several years ago a client was declined after a review of medical records due to not admitting a history of heart disease.
After calling the client with the news, she was adamant that she had never had any kind of cardiac event and had never consulted a doctor for any potentially cardiac related symptoms. After speaking to the underwriter, he said that the records clearly mentioned the word angioplasty. He gave me the page number and said the word was circled. I passed this on to the client who pursued a review of her medical records. She and her doctor were finally able to nail down the reason for the note. It seems she had a friend who was going to undergo an angioplasty and she had asked the doctor to explain what it was. As he explained, he doodled and subsequently left the word angioplasty in the records of someone who didn’t even know what it was.
Doctors are notorious for doodling or writing down some thought with no further explanation. And generally I become the messenger, being shot on sight because the underwriter is asking for clarification. It means homework for the potential insured and while some don’t mind, most feel as though they are being asked to do the work that someone else should do.
This came to a head with one client the other day when I called and asked if she could get a letter from her doctor explaining why he had circled a certain condition on two separate visits, something not done on any other visits. Without clarification the company was willing to offer coverage at a higher rate than originally quoted. With an explanation we could likely have had a policy issued at the same rates originally quoted. She refused. She said it was obvious to her and if it wasn’t obvious to the insurance company, then they were just trying to gouge her for additional premium. The circled condition with no explanation needed clarification. She shot the messenger and withdrew her application.
Bottom line. Underwriters have to try to make sense of your medical records. If you think that’s easy, you’ve either never been sick or never looked in your medical records. If an agent comes back to you asking for clarification, it’s not because the insurance company wants to raise the premium, but rather because they are looking for an explanation that would help them avoid that.
August 14th, 2008
Early on in my work with cardiac patients needing life insurance I learned to ignore what they remembered their cardiologist telling them about their prognosis, and just dig for facts. The most important fact that we needed uncovered and on the table was the amount of damage the heart muscle incurred.
Cardiologists, as near as I can tell, are taught in school to tell their patients that, having survived a heart attack or angioplasty or bypass surgery, “that they now had the heart of a much younger person”. That would be nice if it was true. A brush with the leading cause of death in men somehow does not equate to you somehow, suddenly, having the heart of a much younger person unless you happened to have a transplant in the mix and literally did have the heart of a younger person.
The measure of strength of the heart and therefore the measure of how much damage has occurred is generally drawn from one of the results of an imaged stress test, the left ventricular ejection fraction (LVEF). It is literally a measure of how effectively the heart is able to move blood out of the left ventricle, the heart’s primary pumping chamber. The heart’s function is to pump blood and if that ability is impaired, the rest of the body that is dependent on that flow suffers to some extent.
Clients often get weary of my need for the facts, but it is those facts that lead to accurate life insurance quotes and ultimately a successful search for the best possible life insurance rates. When I don’t take the cardiologist’s rosy synopsis without seeing a copy of the last stress test I am often perceived as “asking too many questions”. I am told more often than I can count that “other agents will give me quotes without all of that”. What life insurance seekers don’t understand is that ultimately the underwriters at the insurance companies will be looking for the very information I asked about and, if they deferred to an agent who wasn’t so bothersome up front, the chances of the end result, the approval, being the same as the beginning, the quote, is very slim indeed.
Underwriters evaluating risk in cardiac cases want to know your age when the condition was first diagnosed. They want to know what happened and what was done. They want to know how many vessels were affected. They want to know how often you see your cardiologist and when your last stress test was. (I just had one client who told me it was two years ago, which is kind of a hinge time for underwriters. Less than two years is good, more isn’t. So I asked him to check and he came back and said it was actually 5 years ago. My how time flies when you are ignoring your health and your cardiologist’s recommendations). They want to know your LVEF. If it is more than 50% you are still in the game. If it is less than 50% you had better hope that some offsetting factor will lead an underwriter to make a highly rated offer. That would be good news as most often less than 50% is an automatic decline.
Bottom line. Most doctors aren’t going to do it for you, so educate yourself. If you can’t answer the question, “how much damage was done”, get copies of your tests and Google the results and find out what they mean. Make a list of questions and demand answers. If a run at life insurance is in your future, seek out the independent agent that asks the most questions, not the least.
July 30th, 2008
One of the challenges we face each week is finding affordable life insurance for people who have suffered a heart attack, or have undergone angioplasty or heart bypass surgery after having chest discomfort due to blocked arteries. The good news! The folks we are helping are alive and with the often hidden heart problem revealed, they have a greater chance of avoiding having a major cardiac event in the future that could end their lives. They have a new lease on life.
Heart attack survival has been on the rise for several years due primarily to advances in rapid response treatment and more aggressive treatment to open blocked arteries. The playbook has been rewritten in the past decade concerning how emergency response crews and emergency room staff react to heart attacks with more emphasis being put on rapid use of clot busting drugs and quicker intervention through angioplasty.
Another boon to survival rates has been the acknowledgment that post cardiac event exercise plays a huge role in how quickly a patient recovers and their chances of not having a recurrence.
From a life insurance perspective there are several points for optimism. First and foremost, you survived. Whether that is due to your event being a mild one or due to more advanced and aggressive treatment, the result is the same. Second, the damage your heart incurred was likely less than it would have been in the past and the amount of damage to heart muscle is a carefully viewed measure in underwriting. Third, the long term chances of not having a recurrence have improved due to recommended lifestyle changes and newer cholesterol lowering drugs so another underwriting challenge, avoiding chronic coronary artery disease (CAD), is avoided.
How long does it take to get good offers after a cardiac event? While there are exceptions, generally you will need to be one year out from the event and you will need to have completed an imaged stress test, either an echocardiogram or a thallium stress test.
Bottom line. While you will likely never see preferred plus rates again, there is every reason to believe that standard to slightly substandard rates will be available. In layman’s terms, you should be able to obtain affordable life insurance.
July 21st, 2008
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