In part one of this series I brought you back in time to the good ol’ game of Operations to lay out the foundation of what to look for when underwriting coronary artery disease (CAD). We even made it halfway through the game! I walked you through the instructions (the ‘must-know’ list for CAD), set up the board game (looking at the bigger cardiac picture and understanding anatomy) and then we started the operating game, carefully identifying when the buzzer was most likely to go off (knowing the red flags and risk factors to look for). Now you are in full game mode AKA ready to actually identify coronary artery disease, accurately assess it and of course master cases as an underwriter. Let’s dive right in!
Make your game plan
You are starting to get a feel for the game, now you need a strategy to win. And in the case of underwriting, a strategy to identify Coronary Artery Disease.
PRO TIP: To accurately assess the presenting cardiac risk, use all the information at hand.
Start by asking these key questions:
- What is the size and function of the ventricles?
- What is the left ventricular ejection fraction?
- How many blockages are there?
- Where are the blockages?
- How significant are they?
- What is the treatment? Surgical? Non-surgical?
- Has the proposed insured made modifications to the risk factors?
- Are they compliant with the recommended treatment and follow up?
Get helpful hints: Look for these medical tests
You are nearing the end of the game and need a few extra hints to win the game of Operations. When it comes to CAD, looking for past medical testing can be of great assistance when identifying abnormalities and assessing the risk. Look out for these common tests that were done previously for diagnosis;
- Exercise Stress Test (GXT, TST, TMT)
- Thallium Stress Test
- Stress Echocardiogram
- Cardiac Perfusion Imaging
- Cardiac Catheterization (the gold standard for CAD diagnosis!)
- CT Coronary Angiogram
- Magnetic Resonance Angiography (MRA)
- Electron-Beam Computed Tomography (EBCT)
Underwriters should be focusing on anything new, as well as any progression of previously abnormal findings.
CONGRATS! You made it through the game of Operations and successfully saved Sam! But you know there were definitely areas where you could improve your game, as is the case with underwriting. It is a profession of continuous learning, development and improvement
How can you build your expertise in underwriting coronary artery disease?
At the end of the day it’s an underwriter’s job to effectively capture all relevant information from the evidence presented and evaluate the information for mortality impact. So how can you master this? Well, it all comes down to experience and education.
Practice makes perfect
Identifying CAD requires the ability recognize abnormal results. The more cases with cardiac history you come across the more you’ll be able to identify modifiable and non-modifiable risk factors, what results and conclusions to look for in the various cardiac investigations and what they mean. As you get more experience with these cases you’ll feel more secure and confident in your underwriting decision.
Education goes a long way
In order to be able to master that handy dandy list I laid out in part 1 of this article (i.e instructions of the game), education will be crucial. As a reminder underwriters should be aware of:
- The anatomy and physiology of the heart with specific reference to coronary artery disease
- Diseases and disorders of the coronary arteries
- Treatment required to control the symptoms
- Understand how the disease progresses
- Know the potential complications of the disease which can worsen the mortality
- Be able to read and interpret an angiogram and the information required to classify the risk
- Evaluate all evidence and identify impact on mortality
What underwriting resources are available?
Mastering CAD as an underwriter starts with a solid understanding of how a normal heart functions. From here, you need to learn about all of the intricacies of the disease. There are many great resources available when it comes to learning about CAD – and because this disease is so complex your company may even offer internal training on the subject.
If you are working full time and your company doesn’t offer training, RGAX Underwriting Training is a great way to educate yourself at your own pace. This not only applies to underwriters but life advisors as well who need a better understanding of this disease to submit timely applications for their clients. Contact us.
So, my fellow underwriters, the next file you open that happens to have cardiac history, don’t stress! Take one piece of evidence at a time and soon enough those cardiac files will not seem as intimidating.