Underwriting long term care insurance: a primer

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1 By Lori Boyce, AVP Risk Management and R&D Underwriting long term care insurance: a primer Every day Canadians die, are diagnosed with cancer, have heart attacks and become disabled and our insurance solutions are there to provide options at a time when our clients and their loved ones may be feeling they have lost control of their lives. Underwriting long term care (LTC) insurance, however, represents a unique risk. When it comes to life insurance, the leading causes of death in Canada are cancer, heart disease and cerebrovascular diseases 1. These diseases also dominate our critical illness claims experience. The life and critical illness underwriter seeks out early predictors of these conditions. We evaluate smoking, build, blood pressure, cholesterol, blood sugar, ECGs, pathology reports and family history. We review the results of paramedicals, blood profiles, urinalysis, pathology reports and Attending Physician Statements as we strive to accurately assess life and critical illness risk factors. A look at LTC claims In comparison, underwriting LTC insurance represents a unique risk. A look at LTC claims helps explain why. Claims are paid based on a loss of independence the client s inability to perform two of the six activities of daily living. This means that the client requires assistance to care for themselves or supervision because they have suffered a cognitive impairment that represents a threat to their healthy and safety. Spinal Cord Injury The leading causes of LTC claims in younger clients are accidents and a variety of diseases, viruses and infections that injure the spinal cord. Approximately 40,000 Canadians are currently living with a spinal cord injury that can result in partial or complete paralysis. About 1,000 Canadians a year acquire a spinal cord injury or disease 2. 1

2 Causes of Spinal Cord Injury Eighty percent of spinal cord injuries occur in men. These are the main causes of this type of injury: Car Collision 35.0% Falls 16.5% Medical 10.8% Sports 6.7% Other Motor Vehicle Collision 6.2% Diving 5.3% Industrial 5.3% Other 14.2% From the Canadian Paraplegic Association website With access to professional and effective rehabilitation programs, many may regain their independence or learn how to maximize their abilities. Alzheimer s disease As clients age, more claims will be related to a severe loss of intellectual and social abilities that interferes with their ability to function. Dementia is the leading cause of both home care and facility care claims in the U.S. Alzheimer s and related dementias are progressive, degenerative diseases that destroy vital brain cells. Symptoms include a gradual and continuing decline in memory that impacts day-to-day function and is coupled with a change in judgment or reasoning, mood and behaviour, and an inability to perform familiar tasks. Simple words may be forgotten or substituted making sentences difficult to understand. People may become disoriented in terms of time and place they can become lost on their own street. They may misplace things, lose their initiative, and become withdrawn, confused, or suspicious 3. People often live with Alzheimer s for seven to 10 years post-diagnosis. The greatest risk factor is age although it is not a normal stage of aging. Currently, approximately 500,000 Canadians are living with Alzheimer s or a related dementia. About 50,000 of them are under the age of 60. The Alzheimer Society of Canada has warned that, within five years, the number of Canadians living with this dreadful disease that robs people of their independence and dignity may increase by 50% 3. Risk factors for Alzheimer s disease To properly assess a client for LTC, we must identify and assess early predictors of Alzheimer s and other dementias. Age Gender Lifestyle Education Level Mild Cognitive Impairment (MCI) Almost 50% of people over age 85 will have a form of dementia Women are more likely to develop the disease partly because they live longer High blood pressure, high cholesterol, poorly controlled diabetes: the same risk factors as heart disease and stroke Studies have found an association between less education and Alzheimer s, leading some to suggest that the more the brain has been used, the greater the reserve as you age. However, it may also just be that those with higher levels of education have a greater capacity to mask the symptoms longer. A transition stage between the cognitive decline of normal aging and more serious problems caused by dementia. People with MCI have memory problems that are worse than what might be expected for their age, but not bad enough to interfere with their daily functioning. Many will develop Alzheimer s within the next seven years. 2

3 Assessing the cognitive risk We interview all LTC applicants; those aged 70 and younger are interviewed by telephone. Those over age 70 are interviewed in person. The interviewer asks questions and gently probes: Employment history Living arrangements Daily activities (i.e., social activities, hobbies, volunteer work, exercise, walking, travel, etc.) Ability to manage finances, make reasonable decisions (select appropriate clothes for weather, pay bills on time, manage their medications, etc.) Medical history Medication name, dosage, prescribing physician and reason for the medication. These questions help to paint a picture of the applicant s health, independence, social interaction and engagement. We also conduct a cognitive exercise during the interview. We will ask your client to repeat a list of words, one at a time. Later, we ask your client to repeat the list. We also ask your client to compare three objects. There are no wrong answers just insights into your client s ability to focus, pay attention to instructions, comprehend language, use judgment and reasoning, and remember. We use the Enhanced Mental Skills Test which was developed jointly by LifePlans and the Medical Care Corporation. LifePlans is a leader in the LTC industry with over 20 years experience in data analysis and information, while Medical Care has spent 10 years developing technologies to precisely measure and monitor cognitive performance. Their test uses an algorithm that differentiates cognitive impairment from lapses in concentration due to stress, depression, sleep deprivation, cerebrovascular disease and other disorders. The test was developed specifically to identify early states of mild cognitive impairment which is important for LTC insurance. Alzheimer s centres in the U.S. and Japan currently use this test. In 2008, Manulife declined fewer than 1% of LivingCare applicants based on their cognitive assessment. For those we interview face-to-face, in addition to the telephone interview questions, the interviewer will record height, weight and blood pressure. Your client will be also be asked to do a simple get up and go test (get up from a seated position, stand without using their arms for assistance, walk several paces, return to the chair and then sit back down without using their arms for assistance). This monitors gait, steadiness and general mobility. LivingCare LTC insurance can provide your clients with an essential level of dignity, peace of mind and financial stability. Footnotes Statistics Canada, 1997 Toronto Rehab Alzheimer Society of Canada 3

4 Long Term Care Insurance: Medical Underwriting By Rubin Becker, M.D., FRCP(C) As a geriatrician, I have witnessed the extraordinary costs, associated disabilities and arising needs of old age. In the face of a dramatic increase in the number of people over 85 and with an anticipated four-fold rise in this age group in the next 40 years the future cost of caring for this population will pose a major threat to our economy and health care system. Long term care (LTC) insurance is an extremely important tool to help our society prepare for the tremendous costs associated with aging. Ideally, people in their 40s and 50s will understand the impending needs and plan appropriately. Publicly funded social and health care programs will not be able to adequately provide for the rising needs of our frail elderly. LTC insurance is challenging for underwriters as they attempt to anticipate which individuals carry an increased risk of premature disability, which will lead to earlier assistance for activities of daily living. The key categories to consider are diseases affecting neurological function and musculoskeletal status. In addition, medical advances have successfully reduced cardiovascular mortality and cancer death, with the consequence that these conditions have become more chronic with associated increased risk of being more dependent and requiring long term care. Neurological concerns The key neurological diseases are those associated with cognitive dysfunction. Cognitive impairment is a clear trigger for a long term care claim. Consequently, we must be vigilant to rule out the presence of any early cognitive impairment as well as any conditions that may predispose to cognitive loss. Today we are becoming more familiar with the early signs of Alzheimer s disease and related dementias and we have introduced cognitive testing as part of the general medical examination. In addition, we are more cognizant of the role of vascular risk factors in the development and progression of dementia. Most dementias are actually mixed dementias that represent a combination of typical Alzheimer pathological changes as well as vascular changes in the brain. Therefore, the presence of premature atherosclerosis signals an increased possibility of an early long term care claim. Early-onset Alzheimer s disease also has a strong genetic basis often transmitted by an autosomaldominant genetic defect. Therefore, a strong family history of early-age onset dementia would raise a concern about an LTC applicant. Other common neurological conditions such as Parkinson s and cerebrovascular disease presenting as a TIA or stroke would also lead to the client being declined. As well, irreversible vision loss for any reason would also be a cause for decline as these individuals are more likely to require assistance with basic activities of daily living. 4

5 Any neurological, cardiac or musculoskeletal disorder that leads to a significant increase in the risk of falls would be a reason to decline an LTC applicant. Repeated falls are a major cause of morbidity and the requirement for increased assistance. One third of those over 65 and 50% of those over 85 have at least one fall per year and mobility impairment is present in nearly half of those over 85. Consequently, if your client has a history of frequent falls at a younger age, this would raise a red flag in the underwriting process. Musculoskeletal concerns Arthritis of any cause and premature severe osteoporosis are the key musculoskeletal conditions that may cause concern when an underwriter considers LTC insurance. Mobility impairment may be associated with the increased need for help with toileting and bathing, which are two of the activities of daily living (ADL) that would trigger a claim. Finally, any end-organ damage may result in early end-organ failure, which would result in an increased risk of requiring assistance with basic activities of daily living. End-stage cardiac disease and respiratory disease are the two very common conditions leading to such a loss of independence. In the underwriting process, we look for early manifestations or an increased likelihood of the possibility of progressive endorgan disease. Despite the many conditions that would potentially lead us to decline an LTC application, it is generally unlikely that we would decline an applicant. We readily accept most LTC applications. As well, the screening for ADL dependency, cognitive impairment and gait impairment is a relatively simple and acceptable process. The insurance industry can play a vital role in encouraging people to plan for their long term care needs. Clear-cut underwriting guidelines with a simple and acceptable screening process for applicants are important in promoting the growth of long term care products. 5

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