Here Karen McLeod continues the discussion on COPD. If you haven’t read part one, check it out for an overview of what life underwriters need to know about COPD. Then, read below to discover key information underwriters should consider when underwriting applicants with COPD.
Why is This Important to Life Underwriters?
Underwriters with a strong understanding of COPD will know what to look for in their cases and be able to better identify when a case may be an uninsurable risk.
Understand the Function of a Normal Respiratory System
Starting with the basics can set the foundation for a strong understanding of COPD and more general risks.
The respiratory system provides the means through which the body is supplied oxygen and also facilitates the disposal of carbon dioxide, a waste product of the body’s metabolic processes. The respiratory system is responsible for the transfer of oxygen and carbon dioxide that takes place within the lungs.
The lungs are surrounded by a sheath called pleura, consisting of two membrane layers enclosing a small amount of fluid. This allows respiration and body movement to occur without one restricting the other.
The lungs are not identical in shape. The right lung is divided into three lobes and the left into two. The lungs have a generous excess capacity of function. An otherwise healthy person can survive the removal of one of the lobes, or even one of the lungs, with no extra risk of mortality and often with no noticeable loss of function.
There are approximately 600,000,000 alveoli in a healthy pair of lungs. These alveoli are where most of the oxygen/carbon dioxide transfer takes place.
5 Tests Life Underwriters Can Use to Diagnose COPD
The following tests may be completed to identify and diagnose COPD:
- Spirometry: This is the most reliable way to diagnose COPD. It is a simple breathing test that measures the speed and amount of air you are able to blow out of your lungs.
- Chest X-Ray: This helps physicians see if there is damage to the lungs. However, it is a poor indicator of the severity of COPD, asthma, and many heart impairments such as myocardial infarction.
- Oximetry: This test measures the amount of oxygen saturation in your blood. It is completed through a painless finger prod.
- Timed Vital Capacity Test (TVC): This test has the greatest value for underwriters. It identifies people with asymptomatic or unadmitted lung disease and can also provide valuable information about the severity of an impairment in a person with a known pulmonary disease. By comparing a series of test results over a period of time, the rate at which a disease is progressing can be determined. Studies have shown that the TVC test is a reliable, independent predictor of longevity. The information obtained by the TVC cannot be obtained any other way or through any other test. The TVC test is completed using a spirometer which measures the amount of air exhaled. It measures the total volume of air a person can expel by exhaling as hard as possible for as long as possible (normally 6 seconds) is called the “vital capacity” or “Forced Vital Capacity” (FVC). The Forced Expiratory Volume at one second (FEV1), is normally 75-80% of the total vital capacity. Once these two values are obtained, they are compared to healthy values that are expected for a person of the same sex, height, and age. Common ratios seen in underwriting are FEV1/FVC, FEV1 (observed)/FEV1 (predicted), and FVC (observed)/FVC (predicted). It is common to test the effects of a bronchodilator on these TVC results. In this case, the test is done before the bronchodilator, then again after administering the bronchodilator. If the post-bronchodilator results are much improved, this may mean the disease is less severe.
- ECG or Echo: These tests can determine the presence of pulmonary heart disease. ECG may show right axis deviation, right atrial enlargement, abnormal P-waves, tachycardia, or low voltage. Echo may show right ventricular enlargement, and a diagnosis of pulmonary hypertension can be made from an abnormal pulmonic valve motion visible on M-mode echocardiography.
What Information is Required When Underwriting COPD Cases?
To sufficiently underwrite COPD cases, you need information describing the extent of the current damage and the rate at which the disease is progressing. These two factors are essential in properly evaluating the risk.
12 Key Questions to Ask When Underwriting COPD Cases
Consider the following questions when completing your risk assessment.
- Is the disease stable or progressing?
- What is the extent of the current damage?
- Is there potential for future damage?
- Are there additional diseases, disorders, or other complications which influence the overall prognosis present?
- What is the effect of the disease on the circulatory system? When the blood is poorly oxygenated, polycythemia and pulmonary hypertension can develop, which can lead to cor pulmonale (right heart enlargement due to lung disease). Any problem with myocardial function is further magnified by a respiratory disease.
- What is the frequency and severity of symptoms and exacerbations?
- What are the results of pulmonary function tests - especially FEV1?
- What is the functional capacity or exercise tolerance?
- Has there been any time off work?
- Is there a past and/or current smoking habit?
- Has there been any oral or IV corticosteroid therapy in the past year?
- Is there an Alpha-1 antitrypsin deficiency?
Complications Related to COPD to Consider in the Underwriting Process
It is critical to understand the likely causes of death associated with each impairment. COPD is a chronic progressive disease that stresses the lungs and heart beyond their considerable ability to adapt.
While quitting cigarette smoking can improve the risk of early mortality, some excess risk will remain even fifteen years after smoking. Smoking-particles from tobacco smoke can accumulate in the lungs as the intense and constant exposure overwhelms the lungs’ natural cleansing system.
It is important when underwriting any respiratory disease, especially chronic diseases as COPD, to pay close attention to related complications that can be exacerbated, such as hypertension or being underweight.
Stages of COPD
Understanding the common stages of COPD can be helpful in determining the longevity, severity, and likely path of a case.
- Early or no changes on chest x-ray with minimal changes on spirometry
- No daily medication
- No functional limitations
- FEV1 >60% of predicted value
- FEV1/FVC ratio is greater than 75%
- Moderate changes in spirometry with or without moderate COPD changes on chest x-ray
- May be taking one or more routine pulmonary medications
- No functional limitations
- Rare hospitalization and occasional physician visits
- FEV1 55% to 65% of predicted values
- FEV1/FVC ratio 60-75%
- Dyspnea on ordinary effort (climbing stairs) or at rest
- Multiple pulmonary medications
- Has had hospitalizations due to COPD
- Followed routinely by physician for pulmonary problems
- FEV1 less than 55% of predicted values
- FEV1/FVC ratio less than 60%
Classifying Risk Through the "Timed Vital Capacity" Test
The Timed Vital Capacity pulmonary function test is the best tool an underwriter has in evaluating current damage and the rate of progression.
Classifying the risk can be completed with the following calculation: If the FEV1 (or PEF) percent predicted is greater than 60% it is mild; if it is 40-59% it is moderate; if it is less than 40% it is a severe case.
Mortality is related to the degree of respiratory impairment and continuing smoking status. Smoking status and mortality is related to the age at starting smoking, the number of packs per years, and current smoking status.
Morbidity from COPD relates not only to the severity but also the frequency of acute chest infections which may be responsible for days lost from work.
12 Ways to Determine if a Case Might be an Uninsurable Risk
Some COPD cases are simply too high risk to be insurable. Red flags to watch for:
- A rapidly progressive disease may not be insurable. This can be determined if there is a decrease in FVC or FEV1 values of more than 100ml per year.
- If the FEV1 or FEV1/FVC ratio is less than 55%.
- Chronic or long-term steroid use currently or in the past can be a strong indicator.
- Body weight of 10% or more below expected for height may be uninsurable.
- Chronic supplemental oxygen use indicates high risk.
- Evidence of progression (deterioration of pulmonary function tests, more frequent hospitalization, progressive weight loss, etc.)
- History of hospitalization in which intubation or mechanical ventilation was necessary.
- Continued smoking or ongoing occupational exposure.
- Absence of pulmonary function test in any person who is on routine pulmonary medication.
- Development of progressive asthma in someone over the age of 40.
- Presence of Cor Pulmonale indicates severe disease.
- Total vital capacity (TVC) is equivalent to Forced Vital Capacity (FVC).
With increased familiarity and armed with the criteria outlined above, you should be able to make informed assessments about the risk severity and insurability of individuals impacted by COPD. Learn more about this common disease in Part 1.
COPD Diagnosis Treatment, COPD Definition, COPD Definition II, COPD Definition III, COPD Definition IV, Stages of Chronic Obstructive Pulmonary Disease, COPD Prognosis, COPD Life Expectancy and Prognosis, COPD Life Expectancy II, COPD Risk Factors, COPD Symptoms and Causes, COPD Signs and Symptoms