Download New Business Submission Strategy

Underwriting the Elderly
Cas Pengelley
General Director, Life Underwriting
April 2013
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02116 (not licensed in New York) and John Hancock
Life Insurance Company of New York, Valhalla, NY 10595. Insurance policies and/or associated riders and features may not be available in all states.
© 2013 John Hancock. All rights reserved. MLINY
For Agent Use Only. Not for Use with the Public.
Agenda
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Introduction
Underwriting Older Ages
Common Examination Tools
Conclusions
Questions
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Are these Older Age Applicants
Insurable?
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Population Trends
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Causes of Death
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Pearls: Vitality, Energy,
Dexterity & Strength
• Education closely related to lifetime income
• Better educated = better health = lower risk of disability
• Health at age 65*:
– 80% have at least one chronic health condition
– 50% have at least two
– 30% have three or more chronic diseases*
• How are their vitality, energy, dexterity and strength (VEDS)?
* US Census Bureau, Current Population Reports, pp. 23-209, 65+ in the United States, 2005
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Underwriting Considerations
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Underwriting
• Do we underwrite the older age applicant like any
other applicant?
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What to Expect as “Normal”
Cartoon used with permission from www.CartoonStock.com
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What to Expect As “Normal”
(cont’d)
• Slower reflexes
• “Hardening of the arteries”
• Decrease in renal function, liver function, lung capacity
• Depressed immune system, more susceptible to infections
• “Benign forgetfulness”
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What are the Red Flags?
• Underlying/pre-existing disease
• Weight loss
• Depression and withdrawal from outside activities
• Memory loss
• Mobility issues
• Falls
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Good, Bad, Ugly
• Good:
– Routine medical care
– Cognitive functioning
– Activities (work, volunteer, travel)
– Build (BMI 22-26)
– Serum albumin (> 4.2gm/dl)
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Good, Bad, Ugly
• Bad:
– Sporadic medical care, lack of follow-up
– Cognitive dysfunction (some impairment)
– Limited activities – fall history
– Build, loss of weight – co-existence depression
– Serum albumin (<3.8gm/dl)
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Good, Bad, Ugly
• Ugly:
– No medical care within the last 2 years
– Cognitive impairments – family concerns
– No outside activities – fall history with fractures or
significant injuries
– Build – loss of more than 10% body weight within
the last six months
– Serum albumin (< 3.5gm/dl)
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Gathering of Information
• Listing of all doctors, including specialists (type) –
be aware of dual residence
• Listing of all medications
• Last visits, why (routine, referral)
• History, diagnosis, treatments
• Areas of focus
– General health
– Cognition and functional status
– Favorable VEDS
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Common Examination Tools
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Tools Commonly Used
• Older age examination
• Cognitive assessment screening (MMSE)
• Serum albumin
• Pulmonary function tests (PFTs)
• Glomerular Filtration Rate (eGFR)
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Older Age Examination
• Older age examination includes:
– Activities of daily living (ADLs) – bathing, dressing,
eating, transferring, toileting
– Instrumental activities of daily living (IADLs) –
cooking, meal preparation, house cleaning,
handling finances, laundry, using phone, shopping,
taking medication
– Driving history
– Work/volunteer/travel – exercise
– Assistive devices – gait/mobility issues
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Older Age Examination (cont’d)
– Fall history
• If functioning, have 15-35% risk of death within
the first year following the fall
• 33% end up in nursing home with only 33% of
them regaining pre-fracture functional status
• Recurrent falls is defined as > 2 falls in a
six-month period of time
– Delayed Word Recall (DWR)
– Clock/pentagon
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MMSE
• Mini-Mental State Examination (MMSE):
– 30-point standardized questions evaluating:
• Orientation
• Concentration
• Verbal skills
• Visual-spatial skills
– Easy to perform
– Portable
– Can be done by primary medical doctor,
paramedical vendor
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MMSE (cont’d)
• MMSE scoring system
MMSE Score Range (0-30)
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24-30
No impairment
18-23
Mild impairment
0-17
Moderate to severe impairment
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MMSE (cont’d)
Orientation
What is the (year) (season) (date) (day) (month)?
5
Where are we: (country) (city) (part of city) (number of flat/house)
(name of street)?
5
Registration
Name three objects: one second to say each.
Then ask the patient to name all three after you have said them.
Give one point for each correct answer.
Then repeat them until he learns all three.
Count trials and record.
TRIALS
Attention and calculation
Serial 7s: one point for each correct.
Stop after five answers.
5
Recall
Ask for the three objects repeated above.
Give one point for each correct.
3
Language
Name a pencil and watch (two points).
Repeat the following: 'No ifs, ands or buts' (one point).
Follow a three-stage command: 'Take a paper in your right hand,
fold it in half and put it on the floor' (three points).
Read and obey the following: Close your eyes (one point).
Write a sentence (one point).
Copy a design (one point).
»
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3
9
Total Score_
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MMSE & Level of Education
Age
18-69
70-79
80+
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Education
Score
High School
28-29
College
29
High School
27-28
College
28
High School
25-26
College
27
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Memory Loss, Alzheimer’s
Disease & Vascular Dementia
• NOT a part of normal aging
• Risk of developing disease increases with age –
severity increases with age
• Defined as cognitive impairment
– to include memory impairment as well as at least
one of the following: aphasia, apraxia, agnosia,
executive function disturbance
– impaired social or occupational functioning
– gradual onset/continuing decline
– other causes ruled out
• National Institute of Aging – for every five-year age
group beyond 65, the percentage of people with
symptoms doubles
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Medications for Dementia
• Commonly seen medications used to halt the
progression of dementia include:
– Cognex (tacrine)
– Aricept (donepezil)
– Namenda (memantine)
– Exelon (rivastigimine)
– Razadyne (Reminyl) (galantamine)
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Clock Test
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Pulmonary Function Test
• Pulmonary function, as measured by forced
expiratory volume in one second (FEV1) or forced
vital capacity (FVC) are important independent
predictors of morbidity and mortality in the elderly
• Lung function declines slowly throughout adult life,
even in healthy individuals
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Serum Albumin
• Serum albumin level is an independent risk factor for
all-cause mortality in older persons
• A combined measure of albumin and disability
reveals a strong gradient in mortality risk and may
serve as a simple but useful index of frailty that can
identify a high-risk group of older men and women
who could be targeted for preventive and
treatment efforts
Source: JAMA: The Journal Of The American Medical Association, Vol. 272, No. 13, October 5, 1994.
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Serum Albumin (cont’d)
• Serum Albumin
– Normal = 3.6 g/dL – 4.9 g/dL (prefer >4.2 g/dL)
– Abnormal = <3.6 g/dL
**concerned when <3.8 g/dL with loss of more
than 10% body weight within the last six months
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Kidney Function &
Cardiovascular Disease
• Long-term adverse outcomes associated with chronic
kidney disease include kidney failure, complications
of impaired kidney function, and more commonly, an
increased risk for cardiovascular disease and death
– Annual mortality from CVD is increased 10-100
times with kidney failure
– Risk of CVD is increased 1.4-2.05 times with
creatinine > 1.4-1.5 mg/dL
– Risk of CVD is increased 1.5-3.5 times with
microalbuminuria
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Glomerular Filtration Rate –
eGFR
• eGFR is equal to the sum of the filtration rates in all
the functioning nephrons – how well kidneys are
filtering wastes
• Normal value of eGFR depends on age, sex, body size
• Not an exact correlation between loss of kidney mass
and loss of kidney function
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Clinical Implications – eGFR
• eGFR is used to assess degree of kidney impairment
and to follow the course of the disease
• Using serum creatinine alone to estimate eGFR is
unsatisfactory and leads to delays in diagnosis &
treatment of CKD (chronic kidney disease)
• Elevation in serum creatinine does not always occur
until there has been approximately a 50% loss of
kidney function
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Serum Creatinine
• Mean serum creatinine:
– Women: 0.93 mg/dL
– Men: 1.13 mg/dL
• Varies by race
• Value lower in women due to less muscle mass and
therefore less production of creatinine
• Increased weight = increased creatinine production
• With age, there is a decline in creatinine production
(muscle mass decreases with age)
• Declines by approximately 1mL/min per 1.73m2 per
year after 40 years of age
• Increasing age is NOT invariably associated with an
abnormal eGFR
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Stages of Chronic
Kidney Disease
Stage
Description
GFR Level
Normal kidney
function
Healthy kidneys
90 mL/min or more
Stage 1
Kidney damage with normal
or high GFR
90 mL/min or more
Stage 2
Kidney damage and mild
decrease in GFR
60 to 89 mL/min
Stage 3
Moderate decrease in GFR
30 to 59 mL/min
Stage 4
Severe decrease in GFR
15 to 29 mL/min
Stage 5
Kidney failure
Less than 15 mL/min
or on dialysis
Source: National Kidney Foundation
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Conclusions
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Underwriting Tools Review
• Cover letter
• John Hancock exam includes:
– Details of medical questions
– Exam findings
– Older age section
• Word recall and orientation
• Mobility test
• Functionality
– Blood and urinalysis results
• APS information
– Remember dual residence
– Dual medical care
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Putting It Together
Are these older age applicants insurable?
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Putting It Together (cont’d)
• YES!!!! Older age applicants are insurable!!
• Stay informed, be prepared to ask for more details if
necessary with a focus on VEDS: Vitality, Energy, Dexterity
and physical Strength
• Some mortality risks at younger ages taper off with
advancing age
• Risk of co-morbidities – and how it impacts VEDS
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The Challenge
• Putting it all together:
– Look at all the information
– Identify favorables and unfavorables
– How do the co-morbidities fit together?
– How do any functional capabilities or limitations
factor into assessment?
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Underwriting Tips
• Underwriting the older age applicant is an “art”
• Look at the picture displayed by the information carefully
• Those that present favorable VEDS are best risks
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Questions?
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