Outcome of early surgery compared to surveillance in the management of small aortic aneurysms--a comparative mortality analysis

When underwriting individuals with aortic aneurysms, the following factors are used in risk selection: location, initial size, stability or velocity of change in size and co-morbid impairments. Treatment options based on clinical and ultrasonic findings are either surveillance or surgical resection. A recent study examined the 8-year outcome of early-surgery vs surveillance in small (4.6 cm) aortic aneurysms. Over the duration, the early-surgery group had a mortality ratio of 170% and excess death rate of 28; the surveillance group had a mortality ratio of 215% and excess death rate of 45. First-year mortality was expectedly high in the early-surgery group. Excluding first-year experience, the early-surgery group had an improved mortality ratio of 160% and excess death rate of 22. After 6 months, the death rate in the early-surgery group was about three fourths that of the surveillance group. However, due to high initial mortality cumulative survival curves did not cross in favor of early-surgery until about 3 years.     

Questionnaire based mortality assessment: an exploratory analysis of NHANES III

The need for speed and efficiency in life insurance underwriting has never been greater. With increasing acquisition costs, the need for timeliness to complete the sales process, and the need for accurate mortality prediction a great deal of resources have been devoted to the development of non-traditional underwriting processes and criteria in hopes of streamlining the process. In this paper, we describe an exploratory analysis of mortality linked data from the US NHANES III study. Our goal for this analysis was to identify mortality predictors that would be good candidates for further investigation in insurance applicants, especially in the context of simplified issue products which focus on younger age applicants. We identified aerobic exercise, dental health, alcohol beverage type and quantity, and dietary components and patterns as factors that may hold promise as mortality predictors in persons age 17-65. Though the limitations of this analysis preclude the immediate use of these factors as underwriting criteria, it does appear that several of these hold promise, and should be tested in an insurance application context. Focus groups, market testing, or even insertion as non-actionable questions in a subset of applications may be ways to collect further data on them.     

Pricing implications of trends in population mortality and underwriting effectiveness

Pricing actuaries try to anticipate insured lives mortality rates for decades into the future by considering historic relationships between population and insured lives mortality and trends in population mortality. The degree to which underwriting might decrease insured lives mortality relative to population mortality is of particular importance. A comparison of trends in population and insured mortality is presented to illustrate historic relationships. Two theories for future life expectancy trends are: 1) no foreseeable limit to life expectancy, and 2) life expectancy limited by biological forces. Factors that may increase or decrease the future effectiveness of underwriting are reviewed.     

Structured settlement annuities, part 1: overview and the underwriting process

Structured settlement underwriting is the underwriting of medically impaired lives for the purchase of an annuity to fund the settlement. Other than risk assessment, structured settlement (SS) underwriting has little in common with traditional life insurance underwriting. Most noteworthy of these differences is the relative lack of actuarial data on which to base decisions about mortality and the necessity for prospective thinking about risk assessment. The purpose of this paper is to provide a foundation for understanding the structured settlement business and to contrast the underwriting of structured settlements with that of traditional life insurance. This is the first part of a two-part article on SS annuities. Part 2 deals with the mortality experience in SS annuitants and the life-table methodology used to calculate life expectancy for annuitants at increased mortality risk.     

Effective Underwriting in the Genetic Testing Era

This paper notes that prior to the availability of genetic test results, conventional life insurance underwriting had produced satisfactory mortality results even though a number of applicants insured at standard or better must have had serious genetic markers. The paper discusses the problems that may affect underwriting when an applicant is aware of a genetic risk factor.

The paper suggests use of pre-genetic testing era underwriting methodology, including medical history and family history, with strict financial underwriting to control antiselection. A set of underwriting rules is provided. The need for a sales organization that can produce a substantial amount of business is cited as necessary for success.

To spread equitably any excess cost on account of insuring persons with genetic markers, a risk pool is suggested. The pool manager would also inform a company of additional applications to other companies by genetically impaired applicants.

The purpose of the proposal is to deflect ill-advised political solutions and, at the same time, to control expenses by ensuring a high ratio of paid-for policies to applications.     

Converting Clinical Literature to an Insured Population: A Comparison of Models Using Nhanes

Abstract

The use of clinical literature to set risk classification standards for life insurance underwriting stems from the need to set the most accurate standards using the best available information. A necessary hurdle in this process is converting any excess mortality observed in a clinical study to the appropriate rating for use in underwriting. A widely accepted model in the insurance industry, the Excess Death Rate model, treats the excess as additive to the conditional probability of death for an insurance company’s unimpaired class.

In this paper we test the validity of that model versus other common predictive models of excess mortality in an insured population. Applying these models to National Health and Nutrition Examination Survey (NHANES) data, we derive estimates for excess mortality from three commonly seen underwriting impairments in what could be considered a clinical population. These estimates are added to an estimate of an insurance company’s unimpaired mortality class and then used to predict deaths in an “insurable” subset of that clinical population.

The Excess Death Rate model performed the best of all models, having the smallest cumulative difference of actual to predicted deaths. The use of publicly available data, such as that in NHANES, could help bridge the gap between clinical literature and its application in insurance underwriting if insurable cohorts can be reliably identified from these generally healthy, ambulatory groups.     

Pricing Term Insurance in the Presence of a Family History of Breast or Ovarian Cancer

Abstract

We estimate the increased mortality and term life insurance costs for women who have a family history of breast or ovarian cancer. Using data from the medical literature on age-specific and family history-specific incidence rates, we develop double-decrement models to evaluate the actuarial impact of breast cancer and ovarian cancer in the family. We also calculate the increased mortality and term insurance costs for women who test positive for the BRCA1 or BRCA2 gene mutation. We find that the type of affected relative and her age at onset of the disease are key underwriting factors. We find substantial mortality increases (up to 100%) for women with two relatives with cancer and women with a first-degree relative who developed cancer at an early age. Mortality increases for women with the BRCA gene mutation reach 150%. While some females with a family history of cancer can be accepted at standard rates, others may need to be quoted substandard rates, depending on the underwriting policy of the company. Females with the gene mutation can possibly be accepted at a rate that incorporates a severe mortality surcharge.     

Optimal Risk Classification with an Application to Substandard Annuities

Abstract

Substandard annuities pay higher pensions to individuals with impaired health and thus require special underwriting of applicants. Although such risk classification can substantially increase a company's profitability, these products are uncommon except for the well-established U.K. market. In this paper we comprehensively analyze this issue and make several contributions to the literature. First, we describe enhanced, impaired life, and care annuities, and then we discuss the underwriting process and underwriting risk related thereto. Second, we propose a theoretical model to determine the optimal profit-maximizing risk classification system for substandard annuities. Based on the model framework and for given price-demand dependencies, we formally show the effect of classification costs and costs of underwriting risk on profitability for insurers. Risk classes are distinguished by the average mortality of contained insureds, whereby mortality heterogeneity is included by means of a frailty model. Third, we discuss key aspects regarding a practical implementation of our model as well as possible market entry barriers for substandard annuity providers.     

Ankle/arm blood pressure index: an insurance perspective

Recent studies conclude that the ankle/arm blood pressure index (AAI) is a useful clinical tool for refining cardiovascular risk classification in the elderly. A reduction in the AAI to 0.9 or less is associated with increased risk for both coronary heart disease and total cardiovascular disease morbidity and mortality, as well as all-cause mortality. This relationship persists after adjusting for traditional risk factors and known cardiovascular disease. AAI will appear more common in attending physician's statements, prompting a need to educate underwriters about this technology. AAI may be of particular interest to insurers dealing in the elderly market, to those with strong physician examiner systems, and in markets where blood or urine tests are not commonly used in underwriting.     

Peripartum cardiomyopathy: mortality outcomes

Mortality estimates of peripartum cardiomyopathy have been reported to be between 18 and 56% without reference to time frames. Although this is an unusual impairment, medical directors need accurate information to meet the gold standard of underwriting: decisions must be based on sound underwriting and actuarial principles reasonably related to actual or anticipated loss experience. In an insurance purchasing population, the excess mortality in peripartum cardiomyopathy can be nearly eliminated by not insuring those with the impairment within the first 6 months postpartum or until all abnormal physiologic parameters have resolved. Thereafter, the risk is probably negligible. This abstract illustrates the challenge to determine expected mortality when the study population exhibits strong racial diversity and when available expected life tables contain raw data of only alive and dead at each yearly interval.     

Marfan syndrome: literature review of mortality studies

Marfan syndrome is an autosomal dominant heritable disorder of fibrous connective tissue due to mutation in the fibrillin-1 gene, located on chromosome 15. Early mortality from Marfan syndrome results from aortic dilatation. The medical literature contains long-term follow-up series of patients with Marfan syndrome accrued at major medical centers that address overall survival following surgical intervention, and prognosis in relation to certain risk factors such as family history and aortic root diameter. Mortality analyses based on these data are presented in this paper. Advances in surgical and medical therapy have improved mortality of affected individuals over the past 2-3 decades. However, significant mortality occurs, peaking in the third and fourth decades of life. Although surgery is successful treatment of aortic dissection, one cannot conclude that surgical repair confers a mortality advantage. Emergency surgery and history of aortic complications in first-degree relatives are associated with a higher mortality. Chronic beta-blocker therapy may slow the rate of aortic dilatation and may be associated with more favorable prognosis. Clinical research evaluating beta-blockade, echo assessment of the aortic root diameter progression, and gene mutation analysis may provide tools useful for future morality assessments.     

Forecasting Longevity Gains for a Population with Short Time Series Using a Structural SUTSE Model: An Application to Brazilian Annuity Plans

In this article, a multivariate structural time series model with common stochastic trends is proposed to forecast longevity gains of a population with a short time series of observed mortality rates, using the information of a related population for which longer mortality time series exist. The state space model proposed here makes use of the seemingly unrelated time series equation and applies the concepts of related series and common trends to construct a proper model to predict the future mortality rates of a population with little available information. This common trends approach works by assuming the two populations’ mortality rates are affected by common factors. Further, we show how this model can be used by insurers and pension funds to forecast mortality rates of policyholders and beneficiaries. We apply the proposed model to Brazilian annuity plans where life expectancies and their temporal evolution are predicted using the forecast longevity gains. Finally, to demonstrate how the model can be used in actuarial practice, the best estimate of the liabilities and the capital based on underwriting risk are estimated by means of Monte Carlo simulation. The idiosyncratic risk effect in the process of calculating an amount of underwriting capital is also illustrated using that simulation.     

Underwriting lethal genetic diseases

There are thousands of single gene deposits that cause increased morbidity or mortality risks. Few have complete penetrance leading to certain death. Most can be underwritten with affordable increases in premium; many at standard rates. As we learn more about penetrance for specific mutations we can learn to be more aggressive in underwriting inherited risks. I have described approaches to underwriting untested applicants to Huntington disease, and tested applicants who carry dominant mutations leading to breast, ovarian and colon cancer.     

An Empirical Investigation of the Effect of Growth on Short-Term Changes in Loss Ratios

Given the use of premium growth as a risk measure in regulatory and private risk assessment models, the impact of growth on underwriting profitability is an important question. Our results show a negative relationship between premium growth and changes in loss ratios, suggesting that premium growth alone does not necessarily result in higher underwriting risk. Further, there is a positive relationship between claim count growth and changes in loss ratios, suggesting that claim count growth may be a preferred measure of underwriting risk.     

The Theory of Optimal Stochastic Control as Applied to Insurance Underwriting Cycles

We use the theories of optimal stochastic control and engineering process control to analyze the well-known phenomenon of insurance underwriting cycles in continuous time. We show in a continuous time framework that underwriting cycles can be explained with a model where premiums are set rationally, but where there are various reporting and regulatory lags. We find that the observed cycle length depends on the length of these underlying lags. Our result can be seen as consistent with previous empirical work showing underwriting cycles varying across countries and lines of insurance. In the event that no lags exist, our result is also consistent with more recent literature suggesting that insurance cycles may not exist.     

Mortality risk assessment in the elderly: the utility of delayed word recall

Cognitive impairment is an important predictor of mortality in the elderly. An extended delayed word recall (DWR) is one of the most sensitive tests for cognitive impairment. A mortality study was performed on a population of long-term care insurance applicants aged 70 and older who were underwritten during the years 1995-2003 and who had cognitive testing by DWR. Within this relatively short period of time, individuals with DWR score of 0-5 compared to those with DWR score of 6-10 had a markedly worse mortality outcome overall and also when analyzed by gender, underwriting age, underwriting year or smoking status.     

How to prepare a life expectancy report for an attorney in a tort case

The purpose of this methodology article is to describe a suitable format for a legally acceptable report on the life expectancy of the principal in a tort case that is being advocated or defended by an attorney. Life insurance medical directors and underwriters are clearly skilled and experienced in mortality risk classification for life insurance. However, the judicial system is accustomed to measuring excess mortality only in terms of reduced life expectancy. The analyst preparing the report must convert the excess mortality into a figure for reduced life expectancy and compare this with the life expectancy of persons matched by age, sex and race in the latest Decennial US Life Tables. This process is different from the life insurance underwriting process. A life table projected to age 109 must be constructed as an essential part of the report, and the entire process must be presented clearly and convincingly. There are good reasons why the excess death rate (EDR) should be used as the index of excess mortality in constructing the life table, in preference to the mortality ratio (MR), which is used most of the time in life insurance risk classification. All of these considerations are discussed in this article, which is based on a sample of 40 cases handled by the author, a retired life insurance medical director.     

非寿险承保风险引发系统性风险的复杂网络分析

本文基于我国财险业2009～2018年数据,用复杂网络理论模型构建了财险业承保业务网络,并模拟了承保风险传染过程,分析了承保风险对财险业系统性风险的影响轨迹及程度.研究发现,我国财险业承保业务网络的联系越来越密切,承保风险的增加会引发传染风险,进而导致爆发系统性风险.但当前我国财险业整体稳定,只有发生1600亿元及以上...     

Immediate Annuity Pricing in the Presence of Unobserved Heterogeneity

Abstract

One of the acknowledged difficulties with pricing immediate annuities is that underwriting the annuitantis life is the exception rather than the rule. In the absence of underwriting, the price paid for a life-contingent annuity is the same for all sales at a given age. This exposes the market (insurance company and potential policyholder alike) to antiselection. The insurance company worries that only the healthiest people choose a life-contingent annuity and therefore adjust mortality accordingly. The potential policyholders worry that they are not being compensated for their relatively poor health and choose not to purchase what would otherwise be a very beneficial product.

This paper develops a model of underlying, unobserved health. Health is a state variable that follows a first-order Markov process. An individual reaches the state “death” either by accident from any health state or by progressively declining health state. Health state is one-dimensional, in the sense that health can either “improve” or “deteriorate” by moving farther from or close to the “death” state, respectively. The probability of death in a given year is a function of health state, not of age. Therefore, in this model a person is exactly as old as he or she feels.

I first demonstrate that a multistate, ageless Markov model can match the mortality patterns in the common annuity mortality tables. The model is extended to consider several types of mortality improvements: permanent through decreasing probability of deteriorating health, temporary through improved distribution of initial health state, and plateau through the effects of past health improvements.

I then construct an economic model of optimal policyholder behavior, assuming that the policyholder either knows his or her health state or has some limited information. the value of mortality risk transfer through purchasing a life-contingent annuity is estimated for each health state under various risk-aversion parameters. Given the economic model for optimal purchasing of annuities, the value of underwriting (limited information about policyholder health state) is demonstrated.     

A case of cutaneous lymphoma

Cutaneous lymphomas are relatively rare neoplasms, yet they are occasionally encountered in underwriting. The classification of cutaneous lymphomas leaves many in a quandary. The following case represents an uncommon cutaneous lymphoma. It will be used as a springboard to present a classification of cutaneous lymphomas, the staging definitions, prognostic variables, and some mortality data.