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Underwriters To Producers: The Jury Is Still Out On HRT

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“We havent received even one call from agents who have clients worrying about how hormone replacement therapy might affect their life insurance rates.”

Thats the word from General Agent John Felton over at the Tennessee Brokerage Agency. The firm is a Knoxville, Tenn., brokerage shop specializing in placing life insurance for people with complicated medical histories or impairments.

To date, Felton says, HRT has not become a concern on the applications his firm submits to underwriters. No one asks about what to do if a female applicant has taken HRT for a long period of time, he says, “and no home office underwriters have been telling us to look for anything special in applications that show HRT among the prescriptions taken by the client.”

HRT is a regimen of hormones that some women take to relieve symptoms related to menopause and also sometimes for preventive care. There are four types of HRT, the two most common being pills and patches, taken as estrogen alone or estrogen combined with progesterone, says Hank George, president of Hank George Inc., a Greendale, Wis., risk consulting firm. (See chart on this page.)

The therapy is making headlines this year because, in the summer, a unit of the federal National Institutes of Health put an early stop to a major clinical trial on the risks and benefits of one type of HRT regimen–the use of estrogen combined with progestin by healthy menopausal women who have an intact uterus, says Laura Vecchione, M.D., second vice president and medical director of General Cologne Re, Stamford, Conn.

Conducted through NIHs Womens Health Initiative, the study followed over 16,000 women, age 50 to 79. According to NIH, the study was stopped early, after an average follow-up of 5.2 years, due to “increased risk of invasive breast cancer” as well as increases in coronary heart disease, stroke and pulmonary embolism (see chart on page 5). There were also fewer cases of hip fractures and colon cancer in the tested group, NIH says, but, “on balance the harm was greater than the benefit.”

The Journal of the American Medical Association announced the halt in its July 17 issue, and the popular media has been running stories about HRT risks ever since. Today, it is widely reported that doctors have been flooded with calls from worried women, to the point that some medical offices are now sending out letters to patients, summarizing the findings and suggesting that women come in to the office to review options.

Many women are reportedly electing alternatives to estrogen and progestin, and some are said to be going “HRT-free.” Although national statistics on these shifts are not yet available, most experts characterize the public mood regarding HRT as worried and confused.

All this poses some key questions for the insurance community. What, for instance, should producers say to clients who express worry about whether their current or past HRT use will hurt their ratings, when applying for insurance? And, how are insurance underwriters assessing the new HRT findings–i.e., will the findings prompt them to make HRT a negative when assessing applicants?

For producers, the word seems to be: No changes for now. Therefore, if an applicant says she is concerned about her HRT usage, “suggest that the client discuss the matter with the physician,” recommends Jill Mocarski, M.D., medical director at Northwestern Mutual Life Insurance Company, Milwaukee, Wis.

Starting or stopping HRT is a very individual decision, she explains, and it does have benefits as well as risks, but the producer is not the one to review that with the client.

Regarding the impact on insurance underwriting, underwriters at her own company do not credit or rate HRT in any way, Mocarski notes. They look at the persons impairments and the condition, but not HRT use, she says. For example, life underwriters will look at such things as build, blood pressure, family history, heart disease, and so on, but “weve never taken underwriting action on HRT.”

In fact, Mocarski says, there only are few medications–such as the blood thinner Coumadinthat Northwestern Mutual underwriters do consider in underwriting.

Another suggestion for producers from Mocarski: Do not offer the client any anecdotal information, such as about how a relative or friend has responded to the HRT scare. The message to deliver, she says, is “this decision needs to be based on clear scientific evidence and be customized to each person.”

Producers can be sympathetic, she adds, but they should avoid offering medical advice or information that might be interpreted as such.

If a client is persistent about finding out the underwriters probable response to her HRT usage and if the producer knows the policy of the company regarding this, the producer might relay that policy to the client, Mocarski says. But if the producer doesnt know the companys policy, the producer can say: “I am not aware of this, but I will write your question down and get back to you.”

The approach being used at the Impaired Risk Marketing brokerage in Glenview, Ill., “is to underwrite the medical condition, not the individual,” says Diane Bobinas, national marketing manager. She says the firm does this regardless of prescriptions or any other medical treatment.

“We always look at what the person does to help their condition,” she says.

Where HRT is concerned, she suggests agents take history as they do on any medication: “Ask the client why is she on the med, for how long, and what are the results.”

In cases of long-term use of medications, Bobinas says it is especially helpful to find out if the client has been doing what she was supposed to do with the medication–i.e., following the directions.

Someday, insurance companies might send out questionnaires for the field to use when talking with clients about HRT history, suggests Felton, the Tennessee agent. Such questionnaires are routinely available for common diseases like diabetes, he notes, and they do provide agents with guidance on what to ask.

But, for companies to develop similar questionnaires for HRT, Felton adds, there would have to be a lot of cases where HRT is seen as a problem. That is not happening now, he says.

Experts say the dearth of rapid-fire underwriting response to study-related HRT questions is part and parcel of the way underwriters respond to any medical trend. The response is slow and deliberate.

The HRT discussion “is not new to us, and there are studies pro and con” on HRT use, points out Vecchione of General Cologne Re. The insurance industry has been watching HRT studies all along, as it does with all news on medicines, she says. But the industry generally takes no underwriting action on a development unless the findings are conclusive.

For instance, General Cologne, a reinsurance company, wont take adverse action related to HRT, Vecchione says.

Primary insurance companies can always take different positions, she allows, but she said she has not yet heard of other approaches to date.

(Note: National Underwriter has heard scuttlebutt that some underwriters are considering no longer giving HRT a “positive” in the assessment process, but NU could not obtain confirmation of that.)

The insurance underwriting approach is “dont let one study overstate the situation,” says George, the Wisconsin consultant. There are many studies to consider, and other HRT studies are still coming out or continuing, he adds, and so far, “although there is a lot of generalization, not everyone agrees.”

Besides, he says, the federal study that was halted concerned only one type of HRT–estrogen plus progestin–but “the jury is still out” on the other types.

Whats more, George continues, evidence is growing that the so-called “healthy user effect” may influence whether HRT is favorable or unfavorable, from an underwriting standpoint. By “healthy user effect,” he says he means the watershed, or collective positive, benefits that result when a person has good health habits–exercise, diet, etc.–and good health care.

For instance, if a healthy female life insurance applicant has used a transdermal HRT patch for four years, the underwriter could interpret the HRT as having no adverse effect on her insurability, George says. “Because of the healthy user effect, the HRT may even be seen as favorable,” he says, if the woman has followed medical advice, gone for checkups and so on.

In an applicant who has multiple medical conditions, the approach could be different, he allows. “A company might decide to discontinue the credit for HRT in such cases,” George says, “but I dont see that any would apply HRT as a debit.”

The studied insurance approach to HRT differs from that of the medical community, which responded fairly quickly to news of the HRT trial, observes Vecchione.

The medical communitys quick response is understandable, she allows, given the fact that doctors are “right there” getting calls about the study from patients, and that JAMA, the medical association publication, has called attention to the medical issues. Further, chances are that, because of the studys results, doctors probably will no longer recommend the use of HRT as across-the-board preventive therapy.

“Besides, doctors now have many attractive alternatives to HRT, for treating some of the symptoms for which they previously prescribed HRT,” says Norm Kono, research chair of LTCIF, a Grapevine, Texas, trade association focused on long-term care insurance. He alludes to new medications for osteoporosis as one example.

The insurance community is not “treating” patients, experts stress. It is looking at mortality risk, in terms of life insurance applicants, and morbidity risk, in terms of LTC and disability insurance. Assessments of studies related to this process take time.

That is why Allianz has decided not to focus on the HRT factor in underwriting, says Robert Watson, M.D., vice president and chief medical director of Allianz Insurance Company of North America and Allianz Re, both of Minneapolis. “There are good studies that show post menopausal women who have been on HRT have lower overall mortality risk,” he explains.

One reason for this may be that HRT patients tend to be in a higher socioeconomic class, he says, and they go to doctors regularly, adhere to taking medicine as prescribed, and otherwise take good care of themselves.

“Good self care is a marker for improved mortality risk,” Watson stresses.

Therefore, whether women who take care of themselves stay on HRT or go off is a non-issue for his company. Such women will care for themselves anyway, he predicts.

In sum, says George of Wisconsin, “the industry is nowhere near to having the information necessary to take underwriting action on HRT. It is rare when one study, however excellent, changes underwriting thinking on a particular medical treatment. This issue is far from settled, but the message for now is, Dont worry. It will be an unusual situation where HRT would be seen as a negative.”

Reproduced from National Underwriter Life & Health/Financial Services Edition, November 18, 2002. Copyright 2002 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.


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