One of the exciting new trends in risk selection is what could be called “customized underwriting,” the personalization of the risk appraisal process.
In customized underwriting, the attempt is, when possible, to make decisions based on the actual risk posed by the individual applicant rather than on broad, population-based guidelines.
One area where this type of underwriting is being increasingly used is in the evaluation of coronary artery disease.
Coronary disease has traditionally been viewed in black and white terms. Certain cholesterol levels were seen as good, while others were seen as bad. Arteriosclerosis was said to progress in a methodical way, gradually narrowing the coronary artery until it eventually became totally occluded. Lesions were not viewed as warranting concern until blood flow to the heart muscle was reduced. Diagnosis relied on demonstrating obstructive disease with the exercise stress test or cardiac catheterization.
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In recent years, however, it has become clear is that the quality of the atherosclerotic coronary plaque is at least as important as the quantity of disease.
We now know that the severe blockages are not the ones that kill people. Rather, it is the innocent looking, minor obstruction–the so-called vulnerable plaque–that is the culprit. When this plaque ruptures, the artery is suddenly occluded by a blood clot and the individual has a heart attack.
This can happen even if the individual just passed a stress test with flying colors.
The task in underwriting is to find the individuals who are at higher risk of experiencing these types of events. With this in mind three key points have become clear.
First, the total amount of atherosclerotic plaque, not just the number of obstructive lesions, is important.
Second, inflammation is a key player in the cascade leading to a heart attack. Inflamed plaques are unstable and rupture at a greater rate.