CASE: 66 y/o man who had applied for life insurance; was unhappy when he got a moderate rating for life insurance, as “there is nothing significantly wrong with me. I feel fine”. After you (as a consulting underwriter) review of the medical records you find that the medial problems are increased build, coronary artery disease (s/p mi and stent placement in 2008), hypertension, LVH, diabetes mellitus – type 2 (+ neuropathy) and sleep apnea / cpap and that the medical records often cite compliance issues. Assuming you had reviewed the records and felt that the underwriting decision was appropriate and even generous, what are some things you might do to get the case issued and why this path? As a producer whose underwriting staff reviewed the records and arrived at the same conclusion, what path might you take? Feedback please on how you would manage this case …..

 

Dr. M. Jack Cotlar, President

Strategic Medical Consulting, Inc.^®

Voice: 317.536.2603 (ET)

Email: jcotlar@strategicmedconsulting.com

Important Notice:

The opinions and examples contained in this article are those of Strategic Medical Consulting, Inc. (SMC). As each case is fact sensitive, it would be ill-advised to take action on any given case based on the conclusions from examples that are included in this communication. Whether or not they are appropriate for a specific medical underwriting situation must be determined by the producer who will assume all responsibility should the outcome not be favorable. The examples illustrated herein are what SMC provides on a case-by-case basis for and to its clients. In addition, the opinions are not medical advice and they do not establish any physician-patient relationship.

The absence of information often forces underwriters to assume a more conservative posture. Case in point is an underwriter’s question similar to the following: I have a 63F with a history of breast cancer. Out of 170 pages of medical records, I have no details about her breast cancer except it was in 1988 and that she had reconstruction surgery. Her other medical history is insignificant. In response to this referral, I would have liked to have be able to make a standard offer without delay. My problem with going standard is that the life insurance carrier has no way of knowing with enough assurance that there has not been a recent recurrence, which may be why life insurance is being sought. If on the life insurance application the applicant had stated an accurate account of the history, something like, “in 1988 I had a left-side mastectomy for breast cancer, I had no radiation therapy or chemotherapy and I have never had any recurrence of breast cancer”…. underwriting would be in a much better position to make assumptions as to the current status of the cancer history. 

The take home message is that an applicant who has had a history of cancer may help himself or herself by providing as much accurate detail about the cancer as possible when he or she fills out the life insurance application. These details are explained in my earlier post, but at the very least, the information should include the type of cancer, the type of treatment(s), when the treatments ended and whether or not there has ever been any recurrence of the cancer. The applicant’s statements must be truthful and the applicant should be aware that providing this type of information is no guarantee that a favorable underwriting decision will be made. However, this simple step of providing the underwriters needed detail upfront can save a lot of time and aggravation for the applicant and the insurance agent. 

 

Dr. M. Jack Cotlar, President

Strategic Medical Consulting, Inc.^®

Voice: 317.536.2603 (ET)

Email: jcotlar@strategicmedconsulting.com

Important Notice:

The opinions and examples contained in this article are those of Strategic Medical Consulting, Inc. (SMC). As each case is fact sensitive, it would be ill-advised to take action on any given case based on the conclusions from examples that are included in this communication. Whether or not they are appropriate for a specific medical underwriting situation must be determined by the producer who will assume all responsibility should the outcome not be favorable. The examples illustrated herein are what SMC provides on a case-by-case basis for and to its clients. In addition, the opinions are not medical advice and they do not establish any physician-patient relationship.

Cancer is one of the more concrete medical underwriting problems that underwriters see. In order for the producer to have some idea of what a rating might be for the client, he or she can ask the underwriter by phone call or email. So what specifics does the underwriter need to know? They are the same ones that underwriters must discover in order to use their company’s reinsurance manual:
1.    Type of cancer (breast, prostate, colon, etc)
2.    What the pathology report says about the cancer
   a.    Stage, for example, “T1N0M0”
   b.    Grade, for example “well-differentiated” or grade 2 or, for prostate cancer, “Gleason      3+3=6”
   c.    Margins of the specimen removed: free of cancer or not free of cancer
3.    How was the cancer treated? Generally it would be by radiation, chemotherapy, surgery or some combination of these.
4.    What was the date of the last form of therapy? For example: if radiation follows surgery, then it would be the date of the last dose of radiation.
5.    What type of surveillance testing is being done?
a.    Type of test (colonoscopy for colon cancer, PSA for prostate cancer or mammogram for breast cancer, etc)
b.    Date of most recent test and its result
6.    Has there been a recurrence of the cancer, if so, when?
7.    Is the client currently in remission (is free of cancer)?

This information can be found in the medical records, often included in the most recent pages of the physician following the client for cancer and from the client himself or herself. If you are able to relate as much of this information as possible to the underwriter, he or she will be able to give you an accurate rating for this condition from which you can plan your strategy with confidence.

Contact me if you have any questions or comments.

Dr. Jack Cotlar

With so much emphases given to social media and the like, sometimes it is helpful to step back and reassess. We may find that some of the “old fashion” methods allow us to live and work in a more healthy and successful fashion. 

Our new digitalized society enables individuals to communicate with others around the world from the comfort of his or her home. This is good. Using these same tools we may find ourselves communicating “remotely” even to our own family members who are in the same home! This is not so good. In this brief musical YouTube clip, I am reminded of the joy and benefits of real interpersonal interaction; how much each individual can add to the effort of others and how many people can benefit from what they accomplished. Enjoy this uplifting clip.

Conventional wisdom is that the process of selling life insurance involves only the interaction between producer and client; it is only the client who needs to be “sold” in making the transaction. This is not correct. Who is the other “decision maker” in the sales process? It is the carrier’s underwriter. Why? The answer lies in their job descriptions.

The underwriter’s job is to determine whether or not the case makes financial sense and whether or not the premium is in sync with the applicant’s health status, i.e. they determine whether or not the carrier is able to make an offer, and if so, at what rating (price). So the producer needs to “sell” the underwriter the idea that the contract will be profitable for the carrier.  A forward thinking and experienced producer understands that he or she should interact with the underwriter as business partner and not as an adversary. So how is this done?

 

The experienced producer will …	The inexperienced producer might …
provide the carrier the necessary underwriting information in a timely manner,	fail to meet deadlines and will give push back for any requested information,
avoid errors that create work for the underwriter,	carelessly complete forms and create problems that cause the underwriter to do additional work, needlessly,
provide an accurate and informative cover letter that provides relevant financial and medical information, succinctly and …	not bother to create a cover letter, of if he or she does, it contains little more than “fluff”, and …
communicate in a fashion appropriate for a business partner relationship	interact with the underwriter in a non-professional manner, then he or she will wonder why there appears not to be a good working relationship

 My point? Building sound relationships with both your client and the carrier’s underwriter evaluating your client’s case and providing the underwriter with tangible reasons to prove that a case is worthy of consideration are critical to the success of your placing your cases.

How do you define the role between you and your carrier’s underwriter? What do you do to make this happen?

Here’s the scenario. You as the writing agent receive unexpected bad news from the life insurance carrier’s underwriter. The underwriter says that the insurance lab showed blood in the urine so another sample will be needed from your client or that a rating will be placed on the case. Is this an appropriate underwriting action? Well … maybe yes, but often no.

The initial test on the urine is a screening chemical analysis for blood. A positive result for blood is simply a color change due to oxidation of a test-strip reagent but it does not confirm that red blood cells are present. Confirmation that there are red blood cells present in the urine is made by using a microscope to look for them. If the microscopic evaluation does not show a significant number of red blood cells, then the urine would NOT be positive for urinary blood. In sum, the diagnosis of microhematuria (blood in the urine not visible with the naked eye) should not be made from the results of only a dipstick result. Unless red blood cells are seen microscopically, the term hematuria or microhematuria is inappropriate. Many individuals with a positive “dipstick” blood test are labeled as having dipstick urinary blood cells although microscopic analysis would show that red blood cells are absent.

B-type natriuretic peptide (BNP) is a blood test that some life insurance carriers use as a screening test in their applicants, particularly those older than age 65.

N-terminal pro-BNP and NT-pro-BNP are other names for BNP. Its elevation may indicate heart disease, especially a higher probability of developing congestive heart failure. The levels are generally higher in women, older people and individuals with kidney disease; the laboratory has different values for different age groups. So what might a life insurance underwriter do with this information?  If the level is very low, the underwriter might look upon this as being favorable in terms of the probability of heart disease. If it is a little higher than the normal value for that age group, the underwriter may or may not take an adverse action (like placing a small to medium rating). If the test is very high, the underwriter is likely to place a high rating or postpone the case until the applicant is evaluated from a heart standpoint. In the absence of any information about the applicant's health, an underwriting decision might be based solely on the BNP value, not knowing with certainty if the abnormal or normal value is a "true" one or a "false" one. However when possible, this BNP value (be it normal or abnormal) should be assessed in context to other heart related data such as an echocardiogram's findings, exercise stress test results and/or how physically robust the applicant is. A more accurate underwriting assessment is generated when the value of a test put into context with other related information. The insurance producer who knows his client well is in a good position to work collaboratively with the underwriter and provide him or her with this missing information. A well-written and factually correct cover letter can accomplish this. Questions? Please contact me.

Dr. M. Jack Cotlar, President

Strategic Medical Consulting, Inc.^®

Voice: 317.536.2603 (ET)

Email: jcotlar@strategicmedconsulting.com

Important Notice:

The opinions and examples contained in this article are those of Strategic Medical Consulting, Inc. (SMC). As each case is fact sensitive, it would be ill-advised to take action on any given case based on the conclusions from examples that are included in this communication. Whether or not they are appropriate for a specific medical underwriting situation must be determined by the producer who will assume all responsibility should the outcome not be favorable. The examples illustrated herein are what SMC provides on a case-by-case basis for and to its clients. In addition, the opinions are not medical advice and they do not establish any physician-patient relationship.

 

MIB is as important to the insurance underwriting process as it is misunderstood. What MIB is, what it does and what it does not do was the?topic of my most recent blog, “What you need to know about MIB and how it functions.” It generated several emails from life insurance agents.

Their main concern was that if a test is "coded" because of being abnormal, an adverse underwriting decision will necessarily?happen. This is not the case. Often the abnormal test result does not have underwriting significance and because, by MIB rules an adverse underwriting decision is not to be based solely?upon an MIB code. In addition, a subsequent test that was coded normal might negate the significance of the earlier abnormally coded test. Case in point ... as the Medical Director of?an insurance company I was asked to interpret an EKG done in February 2012, which was normal. We are aware that there is an abnormal MIB EKG?code from January 2011. The underwriter will "code" the current EKG as being normal so that another underwriter seeing the case in the future?will have a more complete and accurate picture of the EKG information.

Who reports information to MIB? Any life insurance application sent to a MIB Member Company that includes a signed authorization obligates the company's underwriting department to report to MIB, as a code, certain underwriting information disclosed in the medical records and application and insurance exam. This is done regardless of whether the case is issued, not issued or withdrawn. What are not coded are adverse underwriting decisions such as declinations and ratings. Another misunderstanding is that attending physicians report information to MIB; they do not. MIB currently purges the MIB records after seven years.

MIB Group, Inc. is a membership corporation owned by about 470 member insurance companies in the US and Canada. MIB's services "protect insurers, policyholders and applicants from attempts to conceal or omit information material to the sound and equitable underwriting of life, health, disability income, critical illness and long-term care insurance ... Authorized underwriting personnel of the Member company review the application information provided by the person applying for insurance and compare it to what is in the person's MIB file. The information in the person's MIB file is used only as an alert. No underwriting decision can be made solely on the basis of a coded report, such as issuing a policy with an extra premium or declining to offer coverage."

A consumer may request free disclosure of his or her consumer report once annually. Only he or she can request an MIB file on his or her behalf. A U.S. resident can call MIB's toll-free telephone number 866-692-6901 to request disclosure of the file. Specifics about how to do so can be found HERE.

For more information go to MIB's Consumer Guide.

Amie Hobbs, a paramedical examiner posted an interesting question in the Linkedin group, “Life Insurance Underwriters”.

“Hello all:) I am a Paramedical Examiner for over 9 years now and have been following this conversation. …. More often then not there is little or no feedback from Paramedical Companies … I would have to say it's definitely not adequate, especially missing information, what information? I need details so it does not happen again. What I would like to see is some sort of yearly evaluation, a made up scenario from a underwriter that a examiner must answer and then underwriter could critique examiners work.

EXAMPLE of scenario examiner would be given:
Applicant had Urgent care visit dx with blood clot.”

Amie’s answer:
“Applicant dx rt lower leg blood clot aprox 6/2011 admitted to hospital for 1day and given meds to thin blood. Tests done, MRI of rt leg, blood work showed non genetic per applicant. Tx now coumadin 4mg x 1 a day-ongoing, last INR 2/2012 2.5. Per applicant goes for routine checkups every 6 months last visit 1/2012, doctors orders continue coumadin and recheck in 6 months, dr's info to follow.

Dr. Cotlar’s response?to Amie:

Amie, I applaud your interest in becoming more proficient in your work and in the manner in which you seek to do so, by trying to determine what type of information is best for the end user(s), the underwriter, agent and client. By way of example look at my posted article, “Making the life insurance application work for your client”.

The short answer to your question is that the information the examiner records on to the exam should provide the underwriter with as much information about the “impairment” (medical condition or event) that he or she needs to determine the next action he or she needs to take.

Some of these actions might include: 1. Getting an APS (medical records), or not. 2. Declining the case based on these facts. 3. Rating this impairment, or not and if so, how much of a rating. 4. Asking the agent/producer to get more details about the impairment. 5. Noting the entry about this condition and not taking an adverse underwriting decision. These proposed insured could really help himself or herself by providing as much relevant detail as possible. This is because the underwriter looking an incomplete answer may assume that the condition is worse than it really is. The example you gave and the “answer” you outlined would have done a great service. It was complete in that it adequately described the condition, date of occurrence, tests done (and results), and the absence of an underlying genetic cause of the blood clot. It also mentioned the treatment and plans for follow-up. The details in your example may have allowed the underwriter to justify not needing to secure medical records from this facility, the applicant may have gotten a more favorable underwriting decision and a the agent may have gotten the underwriting response much quicker all because of a thorough and thoughtful description on the exam. You might consider becoming part of groups for agents as they, too, are end users of your service and they have their own set of expectations and needs. In addition, I suggest your talking to underwriters one-on-one and attend some of their educational conferences. You live in a city where there is a large re-insurer carrier. If cleared by management, you would be well served by asking to spend time in its underwriting department looking over someone’s shoulder and asking questions. Alternately, you could use as an information source, Risk Tutor (I have no vested interest in this and its views are not necessarily my own). In summary, if the paramedical examiner knew what the details are about any given medical condition from which an underwriting decision is determined, then the examiner would know what to ask the proposed insured. In other words, working backwards is the key.

Jack Cotlar, M.D.

Strategic Medical Consulting, Inc.^?

Linkedin: http://www.linkedin.com/in/jcotlar

Phone: 317-536-2603