Breathing for most of us comes easy, and we proceed through each day without a thought about how critical this bodily function could be when compromised.
When Chronic Obstructive Pulmonary Disease (COPD) is present, however, the picture changes. Advisors need to be aware of this disease and of the underwriting implications for life insurance.
COPD includes 2 main lung disorders–chronic bronchitis and chronic emphysema. Both conditions develop gradually over many years, entail obstruction of airflow which inhibits normal breathing, and are linked to tobacco use.
COPD is the fourth leading cause of death in the United States, claiming over 120,000 lives in 2004, and approximately 41.5 deaths per 100,000 in the U.S. population. About 13 million people in the U.S. live with this disease. (See National Center for Health Statistics, Report of Morbidity Statistics 2005 and Report of Mortality Statistics 2004.)
Chronic bronchitis, one of the associated disorders, is characterized by a frequent and persisting cough that produces sputum (saliva mixed with mucus). It causes mucus glands in the lungs to increase in number and size, resulting in mucus buildup that leads to airway obstruction. Though there are many causes, cigarette smoking is the most common.
This condition is often neglected until it advances to chronic obstructive bronchitis. In this stage, symptoms include dyspnea (difficulty breathing). The resulting weakness makes the lungs more susceptible to viral and bacterial infections.
The other disease associated with COPD, chronic emphysema, obstructs the airways by destroying the alveoli or air sacs in the lungs. When these air sacs are destroyed, the lungs are unable to move oxygen freely to the bloodstream, causing shortness of breath.
Other symptoms may include rapid breathing or wheezing which can be heard through a stethoscope. There may also be cyanosis (causes a bluish discoloration of the skin), which results from inadequate oxygen in the blood and is associated with lung diseases and heart failure.
A history of cigarette smoking is also strongly associated with this disease. Other risk factors include pollution and occupational pollutants. Individuals at risk for occupational pollutants are coal workers, construction and metal workers. A genetic predisposition, history of childhood respiratory infections and second hand smoke may be relevant factors as well.
As with chronic bronchitis, emphysema does not occur suddenly. It develops gradually with years of exposure to irritating pollutants and cigarette smoke.
Individuals suffering from COPD are usually diagnosed by symptoms, smoking history, and physical examination. No single test is absolutely definitive; however, lung or pulmonary function is determined by using a “spirograph.” This is an instrument that measures breathing movements into and out of the lungs by calculating the volume and speed that air can be inhaled and exhaled.
COPD’s severity is most often categorized as mild, moderate or severe. The results of the spirograph or spirometry test can provide an indicator of this severity. So can the timed vital capacity (TVC) test, which indicates the presence of obstructive and restrictive breathing defects. (Here, the individual inhales as much air as possible and exhales into a tube with a measuring device that records the forced expiratory volume.)
COPD, including chronic bronchitis and chronic emphysema, cannot be reversed or cured. The damage it causes to the airways and lungs is permanent.
Although the disease almost always progresses, the progression can be slowed–for instance, by smoking cessation. Those who quit smoking immediately have a better outcome, because further lung damage does not occur.
Treatments such as bronchodilators make the patient feel less breathless and expand the airways. Inhaled steroids also help breathing capacity; however prolonged treatment with these steroids risks serious side effects.
Pulmonary rehabilitation is often used to manage the disease and help aid with fatigue. All treatments provide relief, help combat complications, and will assist in slowing progression as well. For severe cases, oxygen, respiratory or ventilator therapy may be necessary.
When focusing on risk selection during the life underwriting process, it’s best to consider the degree of the client’s COPD impairment, any complications and treatment.
If the person is currently smoking, for instance, this may increase risk of disease progression and involvement. Pulmonary function declines in smokers almost 40% faster as compared with non-smokers.
Complications of high blood pressure and weight loss should also be considered. A history of asthma resulting in inflammation of the airways would also play a large role in assessment.
Review of spirometry results indicating a mild to severe impairment would need to be considered. Today, many carriers frequently use a TVC test on older individuals during the exam process–because it gives the underwriter a better indication of an individual’s pulmonary function as a possible result of past smoking history or exposure to pollutants and any damage gradually caused over the years.
Treatment with bronchodilators used to relax and open the airways is an effective way to manage and relieve symptoms. However, this may have varying success in some individuals who may not show a substantial improvement in spirometry results after treatment was started. As a result, further therapy may be required, by using inhaled steroids (which have a greater effect on reducing inflammation and narrowing of the airways).
When reviewing this for underwriting, the use of the inhaled steroids would likely lead to an individual receiving a higher rating; this is due to the side effects associated with the steroids. Of course, individuals using oxygen or receiving respiratory therapy would be considered uninsurable since these cases would be categorized as severe and usually are accompanied by further complications, such as respiratory failure.
Nevertheless, those who receive immediate treatment are favorably insurable if COPD is diagnosed early and pulmonary function remains mild to moderate.
Advisors should remember to review the workup including smoking history, physical exam, and testing. Review any other factors such as increased weight loss of more than 15 pounds, blood pressure readings and any history of asthma. If these factors remain favorable, the client will likely be considered a standard risk.
Elizabeth V. Cammarota is vice president of Brokerage Professionals, Inc., Phoenix, Ariz. Her email is firstname.lastname@example.org.