Australian researcher's perspectives on the Australian industry-led moratorium on genetic tests in life insurance.

Fear of insurance discrimination can inhibit genetic research participation. In 2019, an industry-led partial moratorium on using genetic results in Australian life insurance underwriting was introduced. This mixed-methods study used online surveys (n = 59 participants) and semi-structured interviews (n = 22 participants) to capture researchers' perceptions about the moratorium. 66% (n = 39/59) were aware of the moratorium before the survey. Of researchers returning genetic results, 56% (n = 22/39) reported that insurance implications were mentioned in consent forms, but a minority reported updating consent forms post-moratorium (n = 13/39, 33%). Most researchers reported that concerns regarding life insurers utilizing research results inhibited recruitment (35/59, 59%), and few perceived that the moratorium positively influenced participation (n = 9/39, 23%). These findings were supported by qualitative findings which revealed that genetic discrimination concerns were a major issue for some individuals, though these concerns could be eclipsed by the promise of a diagnosis through research participation. The majority thought a regulatory solution should be permanent (n = 34/51, 67%), have financial limits of at least ≥1,000,000 AUD (37/51, 73%), and involve government oversight/legislation (n = 44/51, 86%). In an era where an increasing number of research studies involve genomics as a primary or secondary objective, it is crucial that we have regulatory solutions to address participants' hesitation.

Pollution risk and life insurance decisions: Microgeographic evidence from the United Kingdom.

Recent research documents that exposure to air pollution can trigger various behavioral reactions. This article presents novel empirical evidence on the causal effect of pollution risk on life insurance decisions. We create a unique dataset by linking microgeographic air quality information to the confidential UK Wealth and Assets Survey. We identify an inverse N-shape relationship between pollution risk and life insurance adoption by exploiting the orthogonal variations in meteorological conditions. Over a given range above a threshold of exposure, rising pollution is associated with rising demand for life insurance, whereas at lower than the threshold levels of pollution, higher exposure risk reduces demand for insurance. Our findings indicate-for the first time-a nonlinear relationship between local pollution risk and life insurance demand.

How the Medical Director Should Use Data Sources.

The life insurance industry is transitioning towards precision underwriting driven by increased data availability and access to advanced analytical tools. Effectively utilizing diverse data sources in life insurance underwriting presents an opportunity for medical directors to fully leverage their skillset in this evolving environment. By navigating these changes, balancing the value of data against its limitations, and fostering collaborative approaches to enhance risk assessment and underwriting processes, medical directors can maintain a pivotal role in the life insurance companies of tomorrow.

Identification and Assessment of Undiagnosed Fetal Alcohol Spectrum Disorder: A Report of Three Cases.

Fetal alcohol spectrum disorder (FASD) and its associated physical and mental conditions is the most prevalent congenital impairment causing developmental and intellectual disability worldwide. Like alcohol abuse, FASD is typically undiagnosed by primary care providers. And like alcohol abuse, life underwriters and medical directors need to be aware of the signs, symptoms, and behaviors associated with FASD to accurately detect, identify, evaluate and assess the mortality risk. Three cases of suspected undiagnosed FASD that were underwritten for life expectancies in legal matters are discussed in this report. Not only were these patients' risks for excess mortality elevated due to their initial neurologic injury due to prenatal exposure to alcohol, but these cases demonstrate the importance of the stability and care needed to make them insurable. The following paper discusses the clinical and social settings at birth that may give underwriters and medical directors some clue to a potential case of the child having FASD and then to assess their statistical and lifestyle mortality risks.

Mortality Risk of Low BMI in Life Insurance Applicants.

OBJECTIVES: -This study seeks to quantify the mortality effect of low levels of body mass index (BMI) on life insurance applicants who, based on their laboratory profile and other information, appear to be suitable for life insurance coverage. BACKGROUND: -It has been demonstrated that low BMI is associated with higher mortality risk than normal or near-normal BMI. METHODS: -Data were collected from over 4.7 million life insurance applicants with available BMI tested between 1995 and 2021, and vital status was assessed via the Social Security Death Master File. Cox models treating BMI as continuous and as a categorical variable were constructed, controlling for age, and split by sex after excluding those with laboratory or biometric test results, which were far enough outside the normal range to imply elevated mortality. RESULTS: -Models treating BMI as a continuous variable and allowing an interaction term for age showed that low BMI was strongly associated with mortality at ages 50 and above in both sexes. In the categorical models, only the lowest category of BMI (below the 1st percentile) in men aged 40-60, the lowest 2 categories (below the 5th percentile) in women aged 40-60, and the lowest 3 categories (below the 10th percentile) in those aged 60-80 years, were significantly associated with elevated mortality. No elevated mortality was detected in those under age 40 with low BMI. CONCLUSION: -Based on this study, low BMI is associated with elevated mortality in otherwise healthy applicants, but this association is dependent on age.

Through the Looking Glass Darkly: How May AI Models Influence Future Underwriting?

Applications of Artificial Intelligence (AI) deep-learning models to screening for clinical conditions continue to evolve. Instances provided in this treatise include using a simple one-view PA chest radiograph to screen for Type 2 Diabetes Mellitus (T2DM), congestive heart failure, valvular heart disease, and to assess mortality in asymptomatic persons with respiratory diseases. This technology incorporates hundreds of thousands of CXRs into a convoluted neural network and is generally named AI CXR. As an example, the AUROC (Area Under Receiving Operator Characteristic) of screening for T2DM was 0.84, with sensitivity and specificities that exceed those of the United States Preventative Services Task Force (USPSTF) guidelines for screening with HBA1c or blood glucose studies. The AUROC's for diagnosing ejection fractions less than 40% was 0.92, and for detecting valvular heart diseases was 0.87. The potential implications for underwriting life and disability policies may be significant. A companion article in the Journal of Insurance Medicine addresses this same technology using a simple 12-lead ECG, generally named AI ECGs.

Life and Disability Insurance for People with or at Risk of HIV: Aligning Policy with Evidence.

Antiretroviral medications have substantially improved life expectancy for people with HIV. These medications are also highly effective in preventing HIV acquisition in people who do not have HIV, a strategy known as HIV preexposure prophylaxis (PrEP). Despite these advances, some life and disability insurers continue to deny or limit coverage for people with HIV, and some have even refused to cover people who are using PrEP to protect themselves. These policies unfairly deny people with HIV, PrEP users, and their families the peace of mind and financial protection that can come with life and disability insurance coverage. This article summarizes the current evidence on HIV treatment and prevention, arguing that underwriting decisions by life and disability insurers should not be made based on HIV status or use of PrEP.

A step forward, but still inadequate: Australian health professionals' views on the genetics and life insurance moratorium.

BACKGROUND: In 2019, the Australian life insurance industry introduced a partial moratorium (ban) limiting the use of genetic test results in life insurance underwriting. The moratorium is industry self-regulated and applies only to policies below certain financial limits (eg, $500 000 of death cover). METHODS: We surveyed Australian health professionals (HPs) who discuss genetic testing with patients, to assess knowledge of the moratorium; reported patient experiences since its commencement; and HP views regarding regulation of genetic discrimination (GD) in Australia. RESULTS: Between April and June 2020, 166 eligible HPs responded to the online survey. Of these, 86% were aware of the moratorium, but <50% had attended related training/information sessions. Only 16% answered all knowledge questions correctly, yet 69% believed they had sufficient knowledge to advise patients. Genetics HPs' awareness and knowledge were better than non-genetics HPs' (p<0.05). There was some reported decrease in patients delaying/declining testing after the moratorium's introduction, however, 42% of HPs disagreed that patients were more willing to have testing post-moratorium. Although many (76%) felt the moratorium resolved some GD concerns, most (88%) still have concerns, primarily around self-regulation, financial limits and the moratorium's temporary nature. Almost half (49%) of HPs reported being dissatisfied with the moratorium as a solution to GD. The majority (95%) felt government oversight is required, and 93% felt specific Australian legislation regarding GD is required. CONCLUSION: While the current Australian moratorium is considered a step forward, most HPs believe it falls short of an adequate long-term regulatory solution to GD in life insurance.

Correlates and Predictors of NT-proBNP in Life Insurance Applicants.

OBJECTIVES: -To document the various laboratory and demographic/historical correlates of NT-proBNP levels in applicants for life insurance, and to explore the accuracy of a prediction model based on those variables. METHOD: -NT-proBNP blood test results were obtained from 1.34 million insurance applicants between the age of 50 and 85 years, beginning in 2003. Exploratory data analysis was carried out to document correlations with other laboratory variables, sex, age, and the presence of relevant diseases. Further, predictive models were used to quantify the proportion of the variance of NT-proBNP, which can be explained by a combination of these other, easier to determine variables. RESULTS: -NT-proBNP shows the expected, negative correlation with estimated glomerular filtration rate (eGFR) is markedly higher in those with a history of heart disease and is somewhat higher in those with a history of hypertension. A strong, unexpected, negative correlation between NT-proBNP and albumin was discovered. Of the variables evaluated, a multivariate adaptive regression spline (MARS) model automated selection procedure selected 7 variables (age, sex, albumin, eGFR, BMI, systolic blood pressure, cholesterol, and history of heart disease). Variable importance evaluation determined that age, albumin and eGFR were the 3 most important continuous variables in the prediction of NT-proBNP levels. An ordinary least squares (OLS) model using these same variables achieved a R-squared of 24.7%. CONCLUSION: -Expected ranges of NT-proBNP may vary substantially depending on the value of other variables in the prediction equation. Albumin is significantly negatively correlated with NT-proBNP levels. The reasons for this are unclear.

Number Needed to Treat (NNT): Evaluation Tool Used in Health and Wellness Program.

As life insurance companies evaluate prospective health and wellness programs, one frequently used tool is the number needed to treat (NNT) calculation. It is helpful to identify what the NNT might be for individual components of the program as well as for the whole program when all components are combined.

Association of Liver Function Tests with Mortality in an Insurance Applicant Population.

OBJECTIVES: -Determine the relationship between liver function test (LFT) results (GGT, alkaline phosphatase, AST, ALT and albumin) and all-cause mortality in life insurance applicants. METHOD: -By use of the Social Security Master Death File, mortality was examined in 15,272,955 insurance applicants for whom blood samples were submitted to the Clinical Reference Laboratory. There were 268,593 deaths observed in this study population, after an average follow-up time of 10.9 years. Results were stratified by sex and by age less/greater than 60, creating 4 groups. Liver function test values were grouped using percentiles of their distribution within these age/ sex groups - so as to update the results generated in prior publications. Additional models were fit using different exclusions and percentile groups within single year age groups. Also, LFTs were treated as continuous variables and included in Cox models with age and smoking status. RESULTS: -Using the risk of the middle 50% of the population by distribution as a reference, relative mortality observed for GGT and alkaline phosphatase was linear with a steep slope from very low to high values. AST showed a J-shaped association with mortality. ALT showed a low-magnitude inverse correlation with mortality. Albumin demonstrated a higher-magnitude inverse correlation with mortality, especially at values below the median. The overall risk associated with LFTs was durable over at least 10 years of follow-up. CONCLUSION: -Liver function tests show a strong and durable correlation to mortality in a large group of insurance applicants. The durability over time suggests that even older values of LFTs found in medical records could be of use in mortality risk prediction.

Justice for Our Genes: The Case for Genetic Non-discrimination Regulations in the New Zealand Life Insurance Industry.

While most comparable jurisdictions have adopted more restrictive positions, life insurers in New Zealand remain permitted to request the disclosure of predictive genetic test results from applicants, driving up the cost to obtain life insurance for those with known susceptibilities to genetic disease. The permissive approach is now an outlier, and risks disincentivising health care and research innovation, facilitating irrational discrimination, and compounding existing health inequities. This article examines the New Zealand position through a consequentialist lens. It analyses justifications for the status quo, as well as international approaches, before concluding that genetic non-discrimination regulations governing New Zealand's life insurance industry should be introduced to enhance public wellbeing.

[The actual aspects of medical health and life insurance of members of ships' crews].

The Maritime industry plays one of the key role in world economy, occupying central position in becoming unified system of global transportations. At that, crew members ensure necessary vessel seakeeping and high-quality and safe delivery of cargo under contract of sea transportation. In accordance with requirements of the legislation any employer is obliged to insure health and life of employees under professional duties performance. However, this issue has its own specific aspects in shipping. The article considers in detail procedure of insuring health and life of the crew members, considering current trends in medical care support under professional duties performance on voyage. The key problematic aspects are identified. The corresponding recommendations are proposed.

Japanese insurers' attitudes toward adverse selection and genetic discrimination: a questionnaire survey and interviews with employees about using genetic test results.

Since the 1990s, insurance has been the primary field focused on the social disadvantages of using genetic test results because of the concerns related to adverse selection. Although life insurance is popular in Japan, Japan does not currently have any regulations on the use of genetic information and insurers have largely kept silent for decades. To reveal insurers' attitudes on the topic, we conducted an anonymous questionnaire survey with 100 insurance company employees and recruited nine interviewees from the survey respondents. We found that genetic discrimination is not generally considered as a topic of human rights. We also found that insurers have uncertain fears and concerns about adverse selection in terms of actuarial fairness but not regarding profits. When it comes to preparing guidelines on the use of genetic information by Japanese insurers, we believe that public dialog and consultation are necessary to gain understanding of the people.

The Social Survey, the Metropolitan Life Insurance Company, and the Beginnings of the US Public Health Service's Sickness Surveys.

The earliest sickness survey of the US Public Health Service, which started in 1915, was the Service's first socioeconomic study of an industrial community. It was also the first to define illness as a person's inability to work. The survey incorporated the Metropolitan Life Insurance Company's definition of illness, which, instead of sickness rates, focused on duration of illness as a proxy of time lost from work. This kind of survey took place in the broader context of the reform movements of the Progressive Era and the social surveys conducted in the United States, which led to the creation of the Federal Commission on Industrial Relations, where the Service's sickness survey originated. The Service's focus on the socioeconomic classification of families and definition of illness as the inability to work enabled it to show the strong link between poverty and illness among industrial workers. The leader of the survey, Edgar Sydenstricker, and the Metropolitan Life Insurance Company came up with new ways to measure the health of the population, which also influenced the Service's studies of the effects of the Great Depression on public health and the National Health Survey of 1935-1936. (Am J Public Health. 2021; 111(11):1960-1968. https://doi.org/10.2105/AJPH.2021.306454).

Study protocol: the Australian genetics and life insurance moratorium-monitoring the effectiveness and response (A-GLIMMER) project.

BACKGROUND: The use of genetic test results in risk-rated insurance is a significant concern internationally, with many countries banning or restricting the use of genetic test results in underwriting. In Australia, life insurers' use of genetic test results is legal and self-regulated by the insurance industry (Financial Services Council (FSC)). In 2018, an Australian Parliamentary Inquiry recommended that insurers' use of genetic test results in underwriting should be prohibited. In 2019, the FSC introduced an industry self-regulated moratorium on the use of genetic test results. In the absence of government oversight, it is critical that the impact, effectiveness and appropriateness of the moratorium is monitored. Here we describe the protocol of our government-funded research project, which will serve that critical function between 2020 and 2023. METHODS: A realist evaluation framework was developed for the project, using a context-mechanism-outcome (CMO) approach, to systematically assess the impact of the moratorium for a range of stakeholders. Outcomes which need to be achieved for the moratorium to accomplish its intended aims were identified, and specific data collection measures methods were developed to gather the evidence from relevant stakeholder groups (consumers, health professionals, financial industry and genetic research community) to determine if aims are achieved. Results from each arm of the study will be analysed and published in peer-reviewed journals as they become available. DISCUSSION: The A-GLIMMER project will provide essential monitoring of the impact and effectiveness of the self-regulated insurance moratorium. On completion of the study (3 years) a Stakeholder Report will be compiled. The Stakeholder Report will synthesise the evidence gathered in each arm of the study and use the CMO framework to evaluate the extent to which each of the outcomes have been achieved, and make evidence-based recommendations to the Australian federal government, life insurance industry and other stakeholders.

Long COVID - An Early Perspective.

A new syndrome called "Long COVID" has emerged amongst the survivors of acute COVID-19 infection. Its protracted and debilitating nature will almost certainly result in many short and long-term disability claims. Insurers need to understand the nature of Long COVID, including its definition, its prevalence, its natural history, and underlying risk factors. This article will summarize current knowledge of Long COVID and provide a perspective on its evolution and its impact.

Navigating a Pandemic: The Unique Role of the Medical Director.

The sudden emergence of the COVID-19 pandemic in early 2020 presented a unique challenge for medical directors of life insurance companies. Company leadership required quick answers about many issues, but two in particular: 1) the magnitude of the pandemic's impact on the insured lives portfolio and 2) the underwriting of new applicants during a pandemic. This article will describe the experiences of a global team of reinsurance medical directors during a pandemic. It may also serve to provide guidance for medical directors facing a similar challenge in the future.

A survey of U. S. state insurance commissioners concerning genetic testing and life insurance: Redux at 27.

Nearly three decades ago, scientists set out on one of the largest research endeavors in modern history-mapping the human genome. The research not only sparked new technologies and genetic tests, but also concomitant concerns regarding ethical, legal, and social implications of the technologies. These developments ultimately resulted in an expanded role for genetic counselors to educate consumers about the possible consequences of receiving genetic test results. In particular, many individuals undergoing testing worry that the resulting information could be used by social actors, such as life insurers, in harmful ways. Because life insurance is regulated at the state level, there is significant variability across the United States in laws and enforcement protecting consumers' genetic information. This article reports the results of a survey of U.S. state insurance commissioners regarding regulation of genetic testing and life insurance. The survey builds on a 1992 survey conducted by Jean E. McEwen et al. It returns to current U.S. state insurance commissioners to investigate changes in the climate surrounding genetic information use and risks of misuse within the insurance industry. In their 1992 survey, McEwen et al. found that: (a) genetic testing was not yet perceived to pose a significant problem for insurance rating, (b) life insurers had quite a bit of legal freedom to require and use genetic test results, and (c) insurance commissioners had received few consumers' complaints about the use of genetic information. Twenty-seven years later, our survey finds an increase in regulation protecting genetic information in insurance, but at a pace much slower than that of advances in new DNA technologies. This lag in policy to match technology increases potential risks for consumers. Our study further reveals certain inconsistencies in the letter of state law protecting consumers' genetic information and how state insurance commissioners apply that law. The study also shows that despite empirical evidence in the literature demonstrating consumer fear about genetic discrimination, consumers do not report these concerns to their state insurance commissioner. We suggest genetic counselors are key stakeholders who can help fill current gaps between consumers and the insurance industry.

Predictors of Health Insurance, Life Insurance, and Retirement Savings Among NYC's Immigrant Taxi and For-Hire Vehicle Drivers.

Taxi and for-hire vehicle (FHV) drivers are a predominantly immigrant population facing a range of occupational stressors, including lack of workplace benefits and increasing financial strain from tumultuous industry changes and now COVID-19's devastating impact. Bilingual research staff surveyed 422 New York City taxi/FHV drivers using a stratified sampling approach in driver-frequented locations to examine drivers' health and financial planning behaviors for the first time. Drivers lacked health insurance at double the NYC rate (20% vs. 10%). Life insurance and retirement savings rates were lower than U.S. averages (20% vs. 60%, 25% vs. 58%, respectively). Vehicle ownership was a significant predictor of health insurance, life insurance, and retirement savings. Compared to South Asian drivers, Sub-Saharan African drivers were significantly less likely to have health insurance and North African, and Middle Eastern drivers were significantly less likely to have retirement savings. Although most drivers indicated the importance of insurance and benefits, < 50% understood how to use them. Drivers felt primary care coverage to be most important followed by other health-related coverage, retirement benefits, and life insurance. Results reveal compelling addressable gaps in insurance and benefits coverage and the need to implement accessible financial literacy with navigation and advising services and programs.