Your feedback on how you would manage this substandard case

Posted by Jack Cotlar, M.D. on Sun, Mar 09, 2014 @ 05:32 PM

Substandard case managementCASE: 66 y/o man who had applied for life insurance; was unhappy when he got a moderate rating for life insurance, as “there is nothing significantly wrong with me. I feel fine”. After you (as a consulting underwriter) review of the medical records you find that the medial problems are increased build, coronary artery disease (s/p mi and stent placement in 2008), hypertension, LVH, diabetes mellitus – type 2 (+ neuropathy) and sleep apnea / cpap and that the medical records often cite compliance issues. Assuming you had reviewed the records and felt that the underwriting decision was appropriate and even generous, what are some things you might do to get the case issued and why this path? As a producer whose underwriting staff reviewed the records and arrived at the same conclusion, what path might you take? Feedback please on how you would manage this case …..

Dr. M. Jack Cotlar, President
Strategic Medical Consulting, Inc.®
Voice: 317.536.2603 (ET)

Important Notice:

The opinions and examples contained in this article are those of Strategic Medical Consulting, Inc. (SMC). As each case is fact sensitive, it would be ill-advised to take action on any given case based on the conclusions from examples that are included in this communication. Whether or not they are appropriate for a specific medical underwriting situation must be determined by the producer who will assume all responsibility should the outcome not be favorable. The examples illustrated herein are what SMC provides on a case-by-case basis for and to its clients. In addition, the opinions are not medical advice and they do not establish any physician-patient relationship.

Topics: Life insurance medical underwriting, Dr. Jack Cotlar, case management, rating, communicate, Underwriting, substandard case, diabetes, underwriting assessment

MIB and coding

Posted by Jack Cotlar on Mon, Feb 27, 2012 @ 04:55 AM

MIB is as important to the insurance underwriting process as it is misunderstood. What MIB is, what it does and what it does not do was the?topic of my most recent blog, “What you need to know about MIB and how it functions It generated several emails from life insurance agents.

Their main concern was that if a test is "coded" because of being abnormal, an adverse underwriting decision will necessarily?happen. This is not the case. Often the abnormal test result does not have underwriting significance and because, by MIB rules an adverse underwriting decision is not to be based solely?upon an MIB code. In addition, a subsequent test that was coded normal might negate the significance of the earlier abnormally coded test. Case in point ... as the Medical Director of?an insurance company I was asked to interpret an EKG done in February 2012, which was normal. We are aware that there is an abnormal MIB EKG?code from January 2011. The underwriter will "code" the current EKG as being normal so that another underwriter seeing the case in the future?will have a more complete and accurate picture of the EKG information.

Topics: Life insurance medical underwriting, Dr. Jack Cotlar, Underwriting, Insurance medical underwriting, MIB, Strategic Medical Consulting

What you need to know about MIB and how it functions | Underwriting for life insurance

Posted by Jack Cotlar on Mon, Feb 20, 2012 @ 09:34 AM

Who reports information to MIB? Any life insurance application sent to a MIB Member Company that includes a signed authorization obligates the company's underwriting department to report to MIB, as a code, certain underwriting information disclosed in the medical records and application and insurance exam. This is done regardless of whether the case is issued, not issued or withdrawn. What are not coded are adverse underwriting decisions such as declinations and ratings. Another misunderstanding is that attending physicians report information to MIB; they do not. MIB currently purges the MIB records after seven years.

MIB Group, Inc. is a membership corporation owned by about 470 member insurance companies in the US and Canada. MIB's services "protect insurers, policyholders and applicants from attempts to conceal or omit information material to the sound and equitable underwriting of life, health, disability income, critical illness and long-term care insurance ... Authorized underwriting personnel of the Member company review the application information provided by the person applying for insurance and compare it to what is in the person's MIB file. The information in the person's MIB file is used only as an alert. No underwriting decision can be made solely on the basis of a coded report, such as issuing a policy with an extra premium or declining to offer coverage."

A consumer may request free disclosure of his or her consumer report once annually. Only he or she can request an MIB file on his or her behalf. A U.S. resident can call MIB's toll-free telephone number 866-692-6901 to request disclosure of the file. Specifics about how to do so can be found HERE.

For more information go to MIB's Consumer Guide.

Topics: Dr. Cotlar, Life insurance medical underwriting, MIB, Strategic Medical Consulting, underwriting for life insurance, medical undewriting, medical underwriting guidelines

A competent paramedical examiner is a key component for good underwriting

Posted by Jack Cotlar on Thu, Feb 09, 2012 @ 04:45 AM

Amie Hobbs, a paramedical examiner posted an interesting question in the Linkedin group, “Life Insurance Underwriters”.

“Hello all:) I am a Paramedical Examiner for over 9 years now and have been following this conversation. …. More often then not there is little or no feedback from Paramedical Companies … I would have to say it's definitely not adequate, especially missing information, what information? I need details so it does not happen again. What I would like to see is some sort of yearly evaluation, a made up scenario from a underwriter that a examiner must answer and then underwriter could critique examiners work.

EXAMPLE of scenario examiner would be given:
Applicant had Urgent care visit dx with blood clot.”

Amie’s answer:
“Applicant dx rt lower leg blood clot aprox 6/2011 admitted to hospital for 1day and given meds to thin blood. Tests done, MRI of rt leg, blood work showed non genetic per applicant. Tx now coumadin 4mg x 1 a day-ongoing, last INR 2/2012 2.5. Per applicant goes for routine checkups every 6 months last visit 1/2012, doctors orders continue coumadin and recheck in 6 months, dr's info to follow.

Dr. Cotlar’s response?to Amie:

Amie, I applaud your interest in becoming more proficient in your work and in the manner in which you seek to do so, by trying to determine what type of information is best for the end user(s), the underwriter, agent and client. By way of example look at my posted article, “Making the life insurance application work for your client”.

The short answer to your question is that the information the examiner records on to the exam should provide the underwriter with as much information about the “impairment” (medical condition or event) that he or she needs to determine the next action he or she needs to take.

Some of these actions might include: 1. Getting an APS (medical records), or not. 2. Declining the case based on these facts. 3. Rating this impairment, or not and if so, how much of a rating. 4. Asking the agent/producer to get more details about the impairment. 5. Noting the entry about this condition and not taking an adverse underwriting decision. These proposed insured could really help himself or herself by providing as much relevant detail as possible. This is because the underwriter looking an incomplete answer may assume that the condition is worse than it really is. The example you gave and the “answer” you outlined would have done a great service. It was complete in that it adequately described the condition, date of occurrence, tests done (and results), and the absence of an underlying genetic cause of the blood clot. It also mentioned the treatment and plans for follow-up. The details in your example may have allowed the underwriter to justify not needing to secure medical records from this facility, the applicant may have gotten a more favorable underwriting decision and a the agent may have gotten the underwriting response much quicker all because of a thorough and thoughtful description on the exam. You might consider becoming part of groups for agents as they, too, are end users of your service and they have their own set of expectations and needs. In addition, I suggest your talking to underwriters one-on-one and attend some of their educational conferences. You live in a city where there is a large re-insurer carrier. If cleared by management, you would be well served by asking to spend time in its underwriting department looking over someone’s shoulder and asking questions. Alternately, you could use as an information source, Risk Tutor (I have no vested interest in this and its views are not necessarily my own). In summary, if the paramedical examiner knew what the details are about any given medical condition from which an underwriting decision is determined, then the examiner would know what to ask the proposed insured. In other words, working backwards is the key.

Jack Cotlar, M.D.

Strategic Medical Consulting, Inc.?


Phone: 317-536-2603

Topics: Dr. Cotlar, Life insurance medical underwriting, Strategic Medical Consulting, medical undewriting

The Producer’s Participation in Medical Underwriting

Posted by Jack Cotlar on Tue, Jan 17, 2012 @ 04:57 AM

istockphoto 6131779 the main part of mechanismSuccessful entrepreneurs know that what separates them from the competition is doing a few things of value really well. Often, one of these is a task that others ignore. In the life insurance industry, some producers either ignore the field underwriting piece of the case development, i.e. they simply don’t do it, or they delegate this task to staff that are not trained in this area. Life insurance company carriers have well trained professionals, underwriters, who make a risk assessment based upon the financial and medical data they see and this determines how much your client will be asked to pay for the product you sell. This simple concept should provide incentive to apply some of the sales energy into case management. What do I mean “case management”? This in part means to gather the necessary financial and medical data, ask the questions and record the answers on the insurance application (to gain first-hand knowledge and to cement the producer-client relationship), anticipate what the underwriting issues are or might be and take necessary steps to preempt underwriting problems. Any underwriter would say, “the devil is in the details”. This characteristic as it relates to medical underwriting is often outside the producer’s comfort zone. Because it is, any producer has an opportunity do standout from the others and to provide the kind of expertise your clients expect.

Jack Cotlar, M.D.
Strategic Medical Consulting, Inc.
Phone: 317-536-2603

Topics: Dr. Cotlar, Life insurance medical underwriting, case management, medical underwriting, Straegic Medical Consulting

How to manage an error in the medical records

Posted by Jack Cotlar, M.D. on Wed, Jan 04, 2012 @ 06:50 AM

dreamstimefree 164477 resized 600Problem: You or your underwriting adviser discovers an error in the medical records that will probably adversely impact the carrier’s underwriting assessment (rating). What might you do, prior to case submission or after the carrier informs you there is a problem? Example: The records state that your client has a permanent pacemaker and you do not think he or she does.

Example solution:

1. Verify with your client whether or not he or she currently has a pacemaker. If not, then ...

2. Find the page in the medical records that makes the statement that there is a permanent pacemaker in place.

3. Circle the statement that you believe is in error or ambiguous.

4. Have your client provide his physician a copy of this page (#3 above) along with a cover letter that addresses this issue.

5. If there is an error or a significant ambiguous statement in the medical record then your client can discuss with his or her physician the appropriate way to correct it or to clarify it.

6. Obtain a copy of the “corrected” statement and provide it to your carrier when the case is submitted.

In my opinion, explaining a potential underwriting issue and working with the client in order to solve the problem pays dividends, especially if problems are solved before the case is initially submitted. Addressing medical underwriting problems in this fashion may not only resolve the underwriting problem, but the client will appreciate your expertise that separates you from others. To see similar case examples, GO?HERE.

Topics: Dr. Cotlar, Life insurance medical underwriting, Strategic Medical Consulting, medical undewriting, medical records, Errors in medical records

A Proactive Way to Avoid a Possible Medical Underwriting Glitch

Posted by Jack Cotlar, M.D. on Mon, Sep 05, 2011 @ 10:19 AM

dreamstimefree 168394 resized 600Question: You have a client who is applying for a large amount of life insurance coverage and he sees a therapist for anxiety. The “APS” or attending physician’s statement you receive from the therapist is a one-page document that cites a diagnostic code for “anxiety” or only a diagnosis and no other useful descriptive information. You are concerned that the carrier’s underwriter will want more information given the size of the case, and you cannot afford a time delay. How would you manage this situation?

The most simple and direct way is to go to the client explaining the underwriting dilemma and to do so before the case is submitted. Providing the carrier up front what he or she will need to do their work properly is likely to greatly expedite the case being issued. There will be occasions when providing answers to key questions in a cover letter will allow the underwriter to make a decision about this issue without needing another APS. To see a brief case example, go HERE.

Topics: attending physician statement, underwriting glitch, underwriting dilemma, Dr. Cotlar, Life insurance medical underwriting, medical underwriting, Strategic Medical Consulting, medical records