Impaired Risk Underwriting

1. Impaired Risk Underwriting

2. Impaired Risk UnderwritingToday’s Topics: • Myocardial Infarction (Heart Attack) • Coronary Artery Bypass Graft (CABG) • Percutaneous Transluminal Angioplasty • Prostate Cancer

3. Myocardial Infarction(Heart Attack) • Heart attack is the leading cause of death in America • 1.3 million people per year in the U.S. have a heart attack • 500,000 die suddenly from their heart attack before ever reaching a hospital • 45% are under age 65; 5% are under age 50

4. Myocardial Infarction • A heart attack occurs when part of the heart muscle dies due to loss of blood supply, usually as a result of coronary artery disease. • A blood clot can form on an area of partial blockage suddenly stopping all blood flow to the heart muscle beyond.

5. Myocardial Infarction • Spasm of the artery can occur at a site of partial blockage or in a totally normal artery causing a heart attack • It only takes 3 - 6 hours of total blockage for that area of the heart muscle to die completely leaving scar tissue

6. Myocardial Infarction • Diagnosis of myocardial infarction can be made by • ECG changes • Cardiac muscle enzyme elevation • Echocardiogram (wall motion) abnormality • Thallium treadmill (fixed defect) • Heart catheterization

7. Myocardial Infarction • Prognostic factors • There is an increased risk of sudden death within the first year (7%) • The risk of late death is related to the degree of left ventricular dysfunction, further ischemia and arrhythmias • Most patients are evaluated by a treadmill before discharge - an abnormal test is a poor prognostic sign

8. Myocardial Infarction • Underwriting considerations • Following a heart attack , the applicant will usually be rated a minimum Table D • Favorable features include: • Normal left ventricular function • Mild underlying coronary artery disease • No arrhythmias • No recurrent chest pain

9. Myocardial Infarction • Underwriting considerations • Following the heart attack, a normal treadmill of adequate duration completed within the past year could reduce the rating by one table

10. Myocardial Infarction • Underwriting considerations Unfavorable features include: • More than one heart attack • Current episodes of chest pain or angina • New ECG changes • Diabetes • Age under 50 • Uncontrolled hypertension

11. Coronary Artery Bypass Graft (CABG) • Two types of bypasses • Saphenous vein • Internal mammary • As many as 6 separate grafts may be constructed to the side of the aorta

12. Coronary Artery Bypass Graft • Following surgery • Patient usually can be moved out of the Intensive Care Unit within 2 days and discharged from the hospital within 7 days • 30 - day mortality rate is 6.5% • One - year mortality rate is 12%

13. Coronary Artery Bypass Graft • Graft closures remain a limiting factor to the success of CABG • The internal mammary graft is more likely to remain open than the saphenous vein grafts Int. mammarySaphenous vein open 1yr later 88% 76% open 10yrs later 84% 53% no atheromatous 84% 25-50% changes at 10 yrs • 20 - 30% of CABG patients will require a second CABG procedure within 10 years (a few will require a third)

14. Coronary Artery Bypass Graft • Underwriting Considerations: Best Case Scenario = Table C -Assumes normal left ventricular function and normal follow-up treadmills with no history of recurrent angina -Single vessel CABG with no atherosclerosis present in other vessels may be considered more favorably

15. Coronary Artery Bypass Graft Positive Factors Negative Factors No complications from surgery Multiple cardiac risk factors Use of the internal mammary artery Younger age of onset Normal follow-up treadmills Left ventricular dysfunction

16. Percutaneous Transluminal Angioplasty (PTCA) • A “balloon” is attached to the end of a catheter • This balloon is then expanded over the area of blockage to reduce the amount of blockage

17. Percutaneous Transluminal Angioplasty • During the first 6 months - 1 year after the procedure, restenosis occurs in 25-40% • This has not improved despite medical therapy or use of newer-type devices

18. Percutaneous Transluminal Angioplasty • Underwriting Considerations Rating will depend upon the extent of disease present, success of the procedure, and cardiac risk factors present • Best case scenario = Table B Only single vessel disease with no atherosclerosis present in other vessels

19. Percutaneous Transluminal Angioplasty • Underwriting Considerations With more than single vessel disease, the minimum rating is Table C Favorable features include: • Normal left ventricular function • Mild underlying coronary artery disease • Normal treadmills of adequate duration following the procedure and no chest pain

20. Prostate Cancer • The most common cancer in men in America • 1 in 5 men will be diagnosed with prostate cancer in their lifetime • Second leading cause of cancer deaths • 95% are adenocarcinomas

21. Prostate Cancer • The incidence of prostate cancer increases with age and affects: *10% of men in their 50s *40% of men in their 70s *70% of men in their 80s

22. Diagnosis • Digital rectal exams (DRE) Will pick up only half of prostate tumors • Transrectal ultrasound (TRUS) • Prostate specific antigen (PSA) Tumor marker specific to the prostate

23. PSA • PSA will vary with age Age Average PSA50-59 0.9 60-69 1.5 70-74 1.9 • When the PSA is > 10, 67 % of those biopsied had cancer

24. Prostate Cancer • The severity of the cancer is measured by stage and grade • Stage refers to the extent of the cancer • Tumor size and/or spread • Grading is done by the Gleason Score • 2 - 5 = low grade • 6 - 10 = high grade

25. Stage

26. Grade

27. Prostate Cancer • Underwriting ConsiderationsStage Rating • A1 (best cases treated with Tumor Table E prostatectomy or radiation) • Other Stage A Tumor Table D • B Tumor Table B • C (spread outside of the Individual the prostate gland) Consideration • D (positive lymph nodes Usually Declined of distant metastasis)

28. In Summary • The Underwriting Process Packaging your case for effective underwriting • Impaired Risks Learn how underwriters look at specific impairments