Posts filed under 'heart disease'
I’m always on the hunt for innovative underwriting. I like to find those nuggets when a company finally has an “aha” moment and decides that, for instance, maybe there’s some slack that can be applied to family history without risking the risk pool.
So today I get an email from Nationwide Insurance Company providing a lesson on the coronary artery disease world according to them. If offers up two proposed insureds with completely different backgrounds, their commonality being they are both 58 and both had a one vessel angioplasty with a stent two years ago.
From these two specimens I, as an experienced life insurance professional, am supposed to choose “Who receives the better rating?”
Insured #1:
* Male, age 58, 5’10”, 170 lbs.
* No previous medical history
* Exercises 5 days per week, healthy diet
* Non tobacco, rare alcohol consumption
* Father died at 55 of MI
Insured #2:
* Male, age 58, 5’10”, 250 lbs.
* No previous medical history
* Sedentary lifestyle, diet includes fast food and pizza
* Tobacco, regular alcohol consumption
* Negative family history
OK, knowing that I am going to be wrong according to Nationwide for someone as yet unknown reason, I’m going with the healthy guy. True enough he does have a family history of heart disease and has it himself, but I can’t help myself when you stand him next to a fat guy that smokes, drinks regularly, doesn’t exercise and eats junk food.
Dang. Knew I was going to be wrong. According to Nationwide #2 wins because he has more areas he can improve in. “Insured #2 could receive a more aggressive underwriting decision because he has the potential to modify his risk factors. Insured #1 already had a healthy lifestyle and his only risk factor was his family history. If we have documentation that Insured #2 is active and consistent with eliminating his risk factors, he may be able to obtain a better offer.”
Do you have any idea how long it will take #2 to eliminate his risk factors?
First, let’s deal with reality. #1 should have no problem being approved right now at a standard non smoker table 2 rate. For $500,000 of 15 year term that would run about $4300 annually. FYI. I have no idea what Nationwide would do to the guy. My rate is based on shopping it.
#2 today could at best be approved as a standard smoker table 4 and that would be a stroke of luck. At table 4 the same policy today would be around $14,500 a year. So, he quits smoking and starts on a diet and exercise program. A year from now he will be a non smoker but will still be very close to his smoking history and even if he tries hard he will be overweight. Best case a year older and now a standard non smoker table 4, about $6200 a year.
A year later he might finally get all his demons out of the picture and at his now age 60 qualify for standard non smoker table 2, about $5400 a year. Now that time line and those events are the absolute best case scenario. That is assuming this guy immediately quits smoking, stops drinking too much, goes on a diet and starts exercising and doesn’t let up until he is essentially the mirror image of #1. In my experience, even after a cardiac scare, about 25% of men would actually follow through that quickly and methodically.
Bottom line. I think whoever wrote that email at Nationwide really worked for another company and wanted to mess with their underwriting department. #1, in spite of the family history, should and would receive the best underwriting and #2 would never be able to catch up to the rates that #1 would receive. Never!
February 26th, 2010
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
There was a time when I had a whole different view of obesity and gastric bypass. I think the majority of folks still look at the whole thing through somewhat jaded and certainly uneducated eyes.
I will just be right up front and ask to be forgiven for the way I felt about the issue. I truly had no idea back then just how hard it can be to break the cycle of obesity and I truly had no idea just how at risk of premature death someone could be if they were extremely overweight. I just thought of it as a control problem and a gastric bypass as an easy way out.
After years of study I have a much different view of obesity and just how difficult it is to make meaningful changes in your weight and I also had a much greater appreciation for just how much danger a person was in the longer the weight stayed on. The risk of high blood pressure and stroke, diabetes and heart disease are not things that can be taken lightly and certainly aren’t health issues that, if a person has a way of stopping them, should be put off or ignored.
The studied truth is that for those whose health is at risk due to obesity, gastric bypass is starting to not just be seen as measure of last resort, but as a prudent medical decision. Studies have shown that most people being treated for hypertension or type 2 diabetes can be off of medication completely within just a few weeks of having the surgery. In the truest sense the bypass surgery isn’t just a treatment, but a cure.
From a life insurance standpoint, gastric bypass is viewed cautiously until the weight loss has stabilized. This usually takes about a year. It’s during this year that complications can still crop up. Then, most of the companies that are good with obesity issues will want to see a year of stability before they will approve at standard or better rates.
Bottom line. Gastric bypass surgery is not just an obesity easy button. It’s a measured decision that can help save a person’s life.
May 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
When I do an on the phone interview with a potential life insurance client I ask a series of medical questions that help me to decide the appropriate rate classification to quote. Part of the application process, whether it is done with your agent or with the examiner is called Part 2 of the application. This is where you get the opportunity to divulge your entire medical history.
I consider Banner Life’s Part 2 medical-history to be one of the more thorough. Some of the forms ask about medical history for the last 10 years and I think this misleads potential insureds into believing that medical history prior to that doesn’t matter. You may have survived breast cancer more than 10 years ago or recovered from a stroke more than 10 years ago, but those are still relevant events that will impact underwriting. Even if you answer no to something because it happened over 10 years ago, in all likelihood there is reference to that event in your medical records and it will come out anyway. Might as well lay the cards on the table.
That is why my phone and personal interviews always start with “Have you ever been diagnosed with or treated for?” and end with “Is there anything else in your medical records that we haven’t covered?”. You can see by the medical history form that very few stones are left unturned, but obviously every possible medical issue can’t be listed. That is another radar people will try to fly under thinking that if they don’t divulge it, the underwriter won’t know it. Trust me. You want them to know it up front.
Banner Life’s form has the most extensive family history question I’ve seen. Most companies only ask about heart disease, stroke, cancer and diabetes. I always get a chuckle out of their alcohol question, “Have you ever consumed alcoholic beverages?”
My best advice whether asked by an agent or an examiner, or left to answer these questions on an application on your own….be honest. Your life is chronicled in your medical records and even in information from other insurance applications. Independent agents are good at making lemonade out of lemons. Let them do it for you.
Bottom line. We all have a medical history, or at least all of us old folks. You might be able to slide one by an underwriter, but if your policy is approved in the absence of information known to you and withheld from the underwriter, it is contestable. Don’t do that to your family.
May 4th, 2009
Sleep apnea is one of those health issues that can elicit anything from a best rate class approval to a decline depending on two things, which company’s underwriter was involved and if you are truly treating the issue seriously.
A layman’s sleep apnea definition might give the wrong impression of why underwriters are concerned. Apnea is actually a period during sleep when a person quits breathing. It is almost always, when they start breathing again, followed by a loud snore or gasping. Sleep apnea is not a mortality issue in the sense that people quit breathing and don’t start again. Think of it as a more severe instance like those when you have been reading or something relaxing and you just haven’t been breathing deeply, and you suddenly have the need for a good deep breath.
So the issue isn’t about whether a person will forget to start breathing or not. Our body takes care of that quite well, albeit a bit loudly. The real issues have to do with the stress put on your body by two things. First, especially in more severe apnea where a person can quit breathing up to 50 times per hour, there is an issue with a lack of oxygen during sleeping hours. The other is that sleep apnea simply disrupts normal sleep patterns and makes for a tired, sleep deprived person the next day.
So the real mortality issues become sleep deprivation and the possibility of a higher rate of accidents, and the oxygen deprivation causing high blood pressure, heart disease and stroke. The other less talked about mortality issue is that your spouse may cause you substantial harm because of your snoring.
So, what do underwriters want to see for optimal results? A good sleep study that defines the problem as mild, moderate or severe. Mild or moderate bring the best results from a rate class standpoint. Probably the biggest issue for an underwriter is what you do about the apnea and how compliant you are with whatever treatment is chosen. If you have a sleep study with a cpap on that shows the cpap reduces your instances of apnea to almost nothing, but you then only use the cpap once in a while, or half the night, compliance is poor and control isn’t good. You aren’t going to win any underwriter points. Surgically corrected obstructive sleep apnea, if success is documented by a study, can put you back into best rate class running barring any other risk factors, such as obesity.
Bottom line. There are real reasons for underwriter caution with sleep apnea, but if you are serious about your approach to treatment there’s no reason you can’t walk away paying very reasonable rates.
May 1st, 2009
I’ve written plenty about the road that someone with diabetes has to deal with in getting life insurance, but for just a few minutes I’d like to step out of my life insurance shoes for a minute and talk about the critical issue of those who don’t have or don’t have enough health insurance.
Diabetes is a costly disease to deal with when you factor in the testing materials, drugs and regular MD visits. I read an article today that underscored the impact of this recession and the imperative need to find some way to make health care available to those who can’t afford it. The fact that really drove home what is happening is the fact that while 1.3 million more people were diagnosed with diabetes during the last year, sales of diabetes medications dropped. People are going without treatment and medical followup.
I don’t know any sensitive or gentle way to put this, and believe me this is not aimed at those suffering financially, but not treating or under treating diabetes is a slow, painful death sentence. As your treatment wanes and your glucose levels rise your body begins to succumb to the collateral health issues that have been held at bay. Heart disease and kidney failure become immediate concerns. Neuropathy and retinopathy can take hold quickly when glucose control goes out the window. Diabetes is simply not something that you can let slide for a while.
Bottom line. In my quest to help people understand the implications of good or poor control of diabetes and what that means for life insurance, and for their life, I haven’t been as in tune as I should have with what the cost of maintaining that control can be.
April 15th, 2009
With statins being prescribed for people with perfectly normal lab results it kind of makes you wonder if we haven’t gone a little overboard in our quest to avoid heart attacks. Clearly if you never leave your house you have almost no chance of being hit by a car, but are the side effects of being a recluse worth it.
Life insurance companies have not weighed in on this practice of preventive lipid control other than the fact that they aren’t real keen on seeing total cholesterol too low. When you take someone with normal cholesterol and add a statin regimen it isn’t too hard to drive your total cholesterol down in the low 100’s or even below 100. Studies have yet to decide whether this is really a good thing or not.
Then there’s the other three rodents in the haystack, HDL (high density lipoprotein or good cholesterol), LDL (low density lipoprotein or bad cholesterol) and triglycerides. Life insurance companies go especially bonkers when you don’t have enough HDL, even when everything else is normal. They break into a sweat when someone has a cholesterol ratio, total cholesterol/HDL, that is too high. A case I am currently shopping is at the far end of this spectrum with a completely acceptable total cholesterol of 169 and HDL of 19, making his ratio 8.8. By the book, with all insurance companies, that is a standard or worse rating.
This may be one of those areas that in spite of there not being a proven link between low HDL and heart disease when the rest of the lipid profile is well within normal range, that underwriters simply stick to their guns (written underwriting guidelines). I had a somewhat protracted battle with ING Reliastar underwriters recently over a case where the cholesterol ratio was 5.1 and they maintained, given his total cholesterol of 226 it had to be 5.0 in order to qualify for preferred rates. While we finally won that battle, it’s just a sign of how entrenched underwriters can get on certain subjects and how they don’t want to get mired down in studies that show that their one size fits all guidelines aren’t weighed down by medical reality.
So, the tossup may come down to what is acceptable to you and your doctor, weighed against what is acceptable for the cost of life insurance. There do appear to be some non medical ways to raise HDL although the conclusion is, again, that there isn’t any proven link between those results and a lowering of risk of coronary artery disease.
Bottom line. While I continue to shop this case, at least for now it appears that underwriters are choosing to err on the side of caution.
April 10th, 2009
Let’s don’t mince words on this subject. If someone is 40% overweight they are twice as likely to die prematurely than someone of average build. It’s not the fat that kills you, but the strain that all that extra weight puts on your body making you a prime target for obesity caused health risks.
The point I want to drive home and the key to reasonable life insurance rates for the overweight is to consider the insurance before any other health issues show up. Weight by itself can increase your life insurance rates, but not to the extent that weight plus diabetes or weight plus heart disease or weight plus cancer will.
A good example of this is a client just recently, who at 6′3″ and 325#, was able to get a standard rate through Prudential because all of the risk factors were excellent. He had blood pressure and cholesterol numbers that anyone would love to stuff in their medical records. His glucose was 87 on the exam. We talked at length and he recognized that he had a need for life insurance and that there was simply not a better time. He knew that because of his weight, his long term health could be an issue.
I was recently contacted by a man who had undergone gastric bypass surgery several years ago and had been told that, because of that surgery, he was uninsurable. Gastric bypass carries less of a stigma than it used to. It used to be looked at as kind of a lazy man’s diet, and a dangerous one at that. But more recent studies have shown that the reward of the drastic action may in fact trump the risks of whittling away at weight a few pounds at a time. The person who contacted me ultimately got a standard plus offer from Banner Life insurance, a classic case of having contacted the wrong agent who applied with the wrong insurance company the first time around.
Bottom line. It won’t cost you anything to find out what life insurance would cost you right now, but the cost of waiting could be the addition of health complications.
April 9th, 2009
I knew a guy who made cabinets for a living. He bid jobs through local contractors and directly to homeowners and I could never figure out how he arrived at the prices he presented. There didn’t seem to be a lot of equity between one quote and the next.
Now I know there are differences in materials and I suppose mileage to and from the job site might play into it, but well, it just didn’t add up, so I asked. He explained to me that the calculation was very simple. He could figure the materials right down to the nearest dollar with very little waste. He then added that figure to how much he felt he needed to live on during the period that it would take him to complete the job. If the job was calculated when he had a vacation coming up it tended to be higher than at other times. Very scientific!
Not sure what made me think about that. In life insurance the cost of the job is determined by the health of the applicant and a mortality table, a table that gives the average life expectancy of a person at any given age. Of course in the final price are things like reserve requirements, factors for whether it is paid annually or monthly and, who knows, maybe how much the president of the company feels he will need from each policy sold to live through the next month.
The health of the applicant is a big swing factor since obviously there are those health issues that have an impact on mortality. While we all know people who have lived to better than average mortality experiences while smoking, statistics would show that life expectancy for smokers is shorter than non smokers.
By manipulating the different factors such as family history, driving and drinking habits and whether you have or are treated for high blood pressure, you can see for instance how a 35 year old male who smokes, drinks more than 3 drinks once a week, has 3 or more traffic violations in the past 3 years, has a family history of heart disease and is treated for hypertension, has a life expectancy of 62.3 years.
Compare that with a 35 year old male non smoker, who doesn’t drink and drives very prudently, has a good family history and no problems with blood pressure with a life expectancy of 79.5 years. Even if all of the other factors are in his favor, just smoking reduces mortality by 7 years.
And that is just the surface of a very complex practice known as underwriting. When you consider that obesity is the leading risk factor for diabetes which is a leading risk factor for heart disease, and that each of those health issues has possible collateral health issues, well, sometimes I find it amazing that we can get good, affordable rates for someone who is overweight.
Bottom line. When you apply for life insurance the underwriter has to go figure. While they use mortality tables, they also follow guidelines that have a lot to do with company philosophy. Unless you are perfectly healthy and don’t have any risk factors, the underwriter will have to mix it all together and determine what part of the risk pool you should be paying for.
March 23rd, 2009
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