Substandard Underwriting Structured Settlements

Transcription

1 Substandard Underwriting Structured Settlements Structures 101-Back to Basics February 20-22, 2013 Las Vegas, Nevada Rosemary Brindamour BSN CSSC Chief Medical Underwriter

2 Structured Settlement Underwriting A complex process of determining a life expectancy of an individual through medical record review. The process gives rise to a rated age and need not have any relation to the injury Other than risk assessment Structured Settlement Underwriting has little in common with the traditional life insurance underwriting.

3 Rated Age This is not the chronological age of the individual. It is the adjusted age to reflect the life expectancy of an individual. The life expectancy generates a rated age and is based on the medical conditions of an individual with consideration to the following Current trends in medical care National mortality studies The medical information provided The type of care being provided

4 Important Information Name and any alias Date of birth Gender Date an description of Injury/Illness Current medical information Past medical history Broker name, location, fax or for response

5 Acceptable Information May vary by Life Company Physician statements Hospital admission and discharge summaries Independent medical information ( IME) Life Care Plans (LCP)

6 Neurological Conditions Cerebral Palsy, Hypoxic Encephalopathy, adverse reaction to immunizations ( post vaccine encephalopathy), bilirubin brain injury, birth trauma, near drowning Important consideration Ability to feed self and to function physically and mentally (cognitive). Current information Co-morbidities such as frequent pneumonia, UTIs, Incontinence, tracheostomy and gastrostomy tube Children under age two

7 Traumatic Brain Injuries Usually after 24 months there is no further gains in recovery Important Information Date of Injury Location of injury Glasgow coma scale ( GCS) Current medical information Feeding ability Cognitive deficits Controlled or uncontrolled seizures Mobility ie hemiparesis paraplegia/quadriplegia Neurological and neurocognitive tests X rays and CT scans.

8 Spinal Cord Injuries Nearly all SCI occur in younger males and are from trauma Paraplegia Lower extremity involvement Quadriplegia Paralysis of all four limbs Level of injury Hospital records Current functional abilities Past medical history ASIA (American Spinal Injury Association) levels A- No motor function (complete) B-Sensory but not motor function ( incomplete) C-Motor and sensory function below the level on injury but the motor function is useless. (incomplete) D-Useful motor function but not normal function below the level of the spinal cord injury.

9 Co Morbidities for SCI Recurrent pressure sores ( decubiti) Recurrent kidney infections or pyelonephritis Chronic depression Self neglect/ non compliance Substance abuse Recurrent pneumonia Recurrent deep vein thrombosis ( DVT)

10 Chronic Pain Frequently seen in workers compensation cases with back injuries (Myofacial Pain) Usually results from a physical deformity of muscles or bone Will not alter life expectancy unless complications for opiates or co-morbidity is present. Neuropathic Pain Complex Regional Pain ( RSD) Results from damage to the nerves and secondary changes in the spinal cord signaling to the brain Opiate resistant at normal dosages Disabling causing depression and suicidal risk

11 Co-Morbidities Diabetes Smoker Non compliance Depression Suicide attempts Substance abuse

12 Important Information Cancer Stage (1-4) Location of primary site and other site involvement ( metastasis) Biopsy results Size, Nodes, Mets ( T4NOMO) Clark Classification for Melanomas (Level 1-V) Recurrence Surgical treatment, chemotherapy and radiation therapy Small or large cell cancer (Lung) Complications from treatment Co-Morbidities

13 Cardiac / Circulatory Conditions Myocardial Infarction ( MI) Arteriosclerosis ( ASHD) Coronary Artery Disease ( CAD) Congenital Heart Defects Peripheral Vascular Disease ( PVD) Cerebral Vascular Accident ( CVA)

14 Important Information! Cardiac classification (Class I-IV) New York Heart Association Cardiac testing results Doppler studies ( PVD) Ejection Fraction (55-70) Treatments, angioplasty (PTCA) and bypass surgery (CABG) Risk factors, smoker, Obesity diabetes and hypertension (htn) Any weakness or paralysis ( CVA)

15 Co-Morbidities for Evaluation! Diabetes Depression Recurrent illness Pressure sores Living condition Suicide attempts Compliance Obesity Uncontrolled hypertension Renal disease/ dialysis Uncontrolled seizures Smoking

16 Summary! Do Send current information Sent correct Broker location and response information on cover sheet Include claimants name, dob and gender on cover sheet Check rated age confirmation for correct information Call and ask questions Be aware of the Life company policy for rated age expiration date Avoid Highlight medical information Send medicals without return information on cover sheet. Send requests without the date of birth Send medical information that is not dated

17 Considerations Rated age determination expiration dates will vary for Life Companies Acceptable information If additional Broker information is available to you Current medical information will provide the better ratings. Depositions and life care plans may result in conservative ratings when submitted alone Rating individuals over 80 yrs. old usually results in a standard rating When in doubt call and ask the Life Company

18 Questions