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.

Total life insurance: Logics of anticipatory control and actuarial governance in insurance technology

Calling attention to the growing intersection between the insurance and technology sectors-or 'insurtech'-this article is intended as a bat signal for the interdisciplinary fields that have spent recent decades studying the explosion of digitization, datafication, smartification, automation, and so on. Many of the dynamics that attract people to researching technology are exemplified, often in exaggerated ways, by emerging applications in insurance, an industry that has broad material effects. Based on in-depth mixed-methods research into insurance technology, I have identified a set of interlocking logics that underly this regime of actuarial governance in society: ubiquitous intermediation, continuous interaction, total integration, hyper-personalization, actuarial discrimination, and dynamic reaction. Together these logics describe how enduring ambitions and existing capabilities are motivating the future of how insurers engage with customers, data, time, and value. This article surveys each logic, laying out a techno-political framework for how to orient critical analysis of developments in insurtech and where to direct future research on this growing industry. Ultimately, my goal is to advance our understanding how insurance-a powerful institution that is fundamental to the operations of modern society-continues to change, and what dynamics and imperatives, whose desires and interests are steering that change. The stuff of insurance is far too important to be left to the insurance industry.

Community concerns about genetic discrimination in life insurance persist in Australia: A survey of consumers offered genetic testing

Fears of genetic discrimination in life insurance continue to deter some Australians from genetic testing. In July 2019, the life insurance industry introduced a partial, self-regulated moratorium restricting the use of genetic results in underwriting, applicable to policies up to certain limits (eg AUD$500,000 for death cover).We administered an online survey to consumers who had taken, or been offered, clinical genetic testing for adult-onset conditions, to gather views and experiences about the moratorium and the use of genetic results in life insurance, including its regulation.Most respondents (n = 367) had undertaken a genetic test (89%), and had a positive test result (76%; n = 243/321). Almost 30% (n = 94/326) reported testing after 1 July 2019. Relatively few respondents reported knowing about the moratorium (16%; n = 54/340) or that use of genetic results in life insurance underwriting is legal (17%; n = 60/348). Only 4% (n = 14/350) consider this practice should be allowed. Some respondents reported ongoing difficulties accessing life insurance products, even after the moratorium. Further, discrimination concerns continue to affect some consumers' decision-making about having clinical testing and applying for life insurance products, despite the Moratorium being in place. Most respondents (88%; n = 298/340) support the introduction of legislation by the Australian government to regulate this issue.Despite the introduction of a partial moratorium in Australia, fears of genetic discrimination persist, and continue to deter people from genetic testing. Consumers overwhelmingly consider life insurers should not be allowed to use genetic results in underwriting, and that federal legislation is required to regulate this area.

Financial Advisers' and Key Informants' Perspectives on the Australian Industry-Led Moratorium on Genetic Tests in Life Insurance

INTRODUCTION

Genetic discrimination (GD) in the context of life insurance is a perennial concern in Australia and internationally. To address such concerns in Australia, an industry self-regulated Moratorium on Genetic Tests in Life Insurance was introduced in 2019 to restrict life insurers from using genetic test results in underwriting for policies under certain limits. Financial advisers (FAs) are sometimes engaged by clients to provide financial advice and assist them to apply for life insurance. They are therefore well-placed to comment on GD and the operation of the Moratorium. Despite this, the financial advising sector in Australia has yet to be studied empirically with regards to GD and the Moratorium. This study aims to capture this perspective by reporting on interviews with the financial advising sector.

METHODS

Ten semi-structured qualitative interviews were conducted with FAs and key informants and were analysed using thematic analysis.

CONCLUSION(S)

Participants' level of awareness and understanding of the Moratorium varied. Participants reported mixed views on the Moratorium's effectiveness, how it operates in practice, and perceived industry compliance. Participants also provided reflections on Australia's current approach to regulating GD, with most participants supporting the concept of industry self-regulation but identifying a need for this to be supplemented with external oversight and meaningful recourse mechanisms for consumers. Our results suggest that there is scope to increase FAs' awareness of GD, and that further research, consultation, and policy consideration are required to identify an optimal regulatory response to GD in Australia.

Home bias and local equity portfolio decisions of Chinese insurance institutional investors

Our paper explores whether Chinese insurance companies exhibit a local preference in deciding their equity portfolios and the incentive of this preference. Our research finds that Chinese insurance institutional investors significantly tilt to invest in local firms geographically close to them, and local investments do not significantly outperform non-local investments. The results indicate that the behavioral aspect of home bias, rather than information advantage, play a more significant role in deciding equity holdings of China's insurance companies. Additionally, local equity preference is more pronounced in dialect-segmented areas and life insurance firms. This paper incorporates hometown identification into the analysis framework of insurance companies' portfolio decision-making and enriches the research of their investing strategies from the perspective of behavioral finance.

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.

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.

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.

[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.

Genomic discrimination in New Zealand health and life insurance. AGenDA: Against Genomic Discrimination in Aotearoa

Nil.

Suicide and Life Insurance

Much has been written about the history of suicide and, notably, about societies that condemned both the act and the actor, resulting in a perpetuation of suicide being stigmatized in many cultures. One aspect of this perceived stigmatization involves exclusionary clauses in life insurance policies that reject paying benefits to survivor-beneficiaries of the decedent if the decedent has died by suicide within a prescribed time frame. From the perspective of the individual, life insurance is designed to protect the estate of a decedent from a significant financial burden. From the insurer's perspective, there are essentially 2 reasons for having a suicide exclusion clause: limiting risk and preventing or discouraging fraud. This column examines these rationales in light of the estimated few suicides that do occur during exclusionary clause time frames. Observations are made about the effect of these clauses on those impacted by the loss of a loved one who died by suicide within the exclusionary time frame. An examination of the perspectives of both the life insurance industry and the impacted survivors of suicide decedents raises questions about what are reasonable and appropriate exclusionary clause time frames that protect both the insurer and survivor-beneficiaries. The forensic expert consulting on such cases should be cognizant of these competing perspectives and engage in therapeutic assessment whenever possible, identifying opportunities to promote thoughtful suicide postvention.

Genetic risk scores in life insurance underwriting

Genetic tests that predict the lifetime risk of common medical conditions are fast becoming more accurate and affordable. The life insurance industry is interested in using predictive genetic tests in the underwriting process, but more research is needed to establish whether this nascent form of genetic testing can refine the process over conventional underwriting factors. Here, we perform Cox regression of survival on a battery of genetic risk scores for common medical conditions and mortality risks in the Health and Retirement Study, without returning results to participants. Adjusted for covariates in a relevant insurance scenario, the scores could improve mortality risk classification by identifying 2.6 years shorter median lifespan in the highest decile of total genetic liability. We conclude that existing genetic risk scores can already improve life insurance underwriting, which stresses the urgency of policymakers to balance competing interests between stakeholders as this technology develops.

All-Cause Mortality for Life Insurance Applicants with the Presence of Bundle Branch Block

Objective.-To determine the all-cause mortality of life insurance applicants who have a bundle branch block. Background.-Bundle branch block is an electrocardiographic pattern that has variable prognostic implications. Research studies have shown that both left and right bundle branch block are associated with increased mortality among cases that have heart disease. In the general population and life insurance applicant population, the prevalence of bundle branch block is relatively low, and its effects on long-term prognosis are not as well established. Methodology.-Life insurance applicants with reported bundle branch block were extracted from data covering United States residents between October 2009 and October 2016. Information about these applicants was matched to the Social Security Death Master (SSDMF) file for deaths occurring from 2009 to 2012 and to another commercially available death source file (Other Death Source, ODS) for deaths occurring from 2009 to 2016 to determine vital status. Actual to expected (A/E) mortality ratios were calculated using the Society of Actuaries 2015 Valuation Basic Table (2015VBT), select and ultimate table (age last birthday). All expected bases were not smoker distinct. Confidence bands around these mortality ratios were calculated. The variables of interest were applicant age, gender, location of the bundle branch block, and the presence of cardiac or cardiovascular conditions. Results.-There were 258,529.85 person-years exposure for applicants with bundle branch block. Of the applicants, 57.2% had right bundle branch block. Of person-years exposure, 11.5% had a cardiac condition along with the bundle branch block, and 4.4% had an underlying cardiovascular condition. Female mortality ratios were higher than those for males, but due to the low number of deaths, this difference was not significant. Left bundle branch block mortality ratios (1.01) were 1.4 times higher than those with right (0.74). Those applicants with a cardiac condition along with their bundle branch block had between 1.6 to 1.8 times the mortality ratio depending on the bundle branch block location, and those with a cardiovascular condition had between 1.5 to 1.7 times the mortality ratio over those applicants with just bundle branch block alone. Conclusion.-The presence of bundle branch block in an insurance applicant may be associated with increased all-cause mortality. In this study, life insurance applicants overall had a mortality slightly lower than the expected mortality based on the 2015 VBT. However, applicants with bundle branch block and a cardiac or cardiovascular comorbid condition had a significantly higher mortality ratio.

New Frontier in Lipids: PCSK9 Inhibitors and Implications for the Life Insurance Industry

Since the Framingham Heart Study solidified cholesterol as a causative agent in the development of coronary heart disease there has been an explosion of research in the field of lipidology. Many therapeutic options have come and gone as we have been refining the goals of therapy to match the mortality outcome data of large clinical trials. A new frontier has emerged with the introduction of the PCSK9 inhibitors that are able with monthly injections to lower LDL cholesterol >60% with favorable side effect profiles and recently published favorable mortality data. This ushers in a whole new era of cholesterol management. Life insurance medical directors will need to be informed of how these drugs are being used and for conditions such as homozygous hypercholesterolemia, a condition with a very high mortality risk, and for new genetic analysis of affected patients, who are not as rare as once thought. This article provides the background about the development of these drugs, their expanded indications, how they may slip through the cracks of prescription drug (Rx) database inquiries, and touches on therapies in development beyond this class of medications. Medicine is an evolving field. With the new gene editing CRISPR technology it will truly be transformational for these genetically driven conditions with the potential for curative therapy. If curative therapy comes to pass it will, of course, have favorable implications for our evolving life insurance guidelines.

All-Cause Mortality for Life Insurance Applicants with a History of Breast Cancer

Breast cancer is the most commonly diagnosed cancer worldwide. Breast cancer is also the second leading cause of cancer death among women in the United States after lung cancer with over 40,000 breast cancer deaths occurring each year. The purpose of this research was to determine the all-cause mortality of applicants diagnosed with breast cancer currently or at some time in the past. Life insurance applicants with reported breast cancer were extracted from data covering United States residents between November 2007 and November 2014. Information about these applicants was matched to the Social Security Death Master (SSDMF) file for deaths occurring from 2007 to 2011 and to another commercially available death source file (Other Death Source, ODS) for deaths occurring from 2007 to 2014 to determine vital status. If there was a death from the other death source, then the SSDMF was searched to verify the death. The study had approximately 561,000 person-years of exposure. Actual-to-expected (A/E) mortality ratios were calculated using the Society of Actuaries 2008 Valuation Basic Table (2008VBT), select and ultimate table (age last birthday) and the 2010 US population as expected mortality ratios. Since the A/Es presented in this paper were known to be an underestimate due to the exclusion of the recent SSDMF deaths, comparative analysis of the mortality ratios was done. Since there was no smoking status information in this study, all expected bases were not smoker distinct. Overall, the 35-44 age group had 6.3 times the relative mortality ratio than those in the 65-75 age group. The relative mortality ratio for the 35-44 age group applicants, when cancer severity was accounted for in combination with 3 or more nodes of cancer involvement, was 29.3 times that when compared to those in the 65-75 age group having localized cancer, where no nodes are involved. The 35-44 age group applicants who were diagnosed with cancer within the last year had over 10-fold increase in relative mortality ratios compared to the 65-75 age group, who were over 10 years from diagnosis. Taking the severity of cancer along with time from diagnosis showed over a 12 times relative mortality ratio between the low rate of over 10 years from diagnosis and localized involvement to those diagnosed within the last year having 3 or more nodes with cancer. Applicant age, time since diagnosis and cancer severity were the most significant variables to predict the relative mortality ratios.

All-Cause Mortality for Life Insurance Applicants with a History of Prostate Cancer

OBJECTIVE

- To determine the all-cause mortality of life insurance applicants diagnosed with prostate cancer currently or at some time in the past.

BACKGROUND

- Prostate cancer is common and a frequent cause of cancer death. Both the frequency of prostate cancer in men and its propensity for causing premature mortality require insurance company medical directors and underwriters to have a good understanding of prostate cancer-related mortality trends, patterns, and outcomes in the insured population.

METHODOLOGY

- Life insurance applicants with reported prostate cancer were extracted from data covering United States residents between November 2007 and November 2014. Information about these applicants was matched to the Social Security Death Master (SSDMF) file for deaths occurring from 2007 to 2011 and to another commercially available death source file (Other Death Source, ODS) for deaths occurring from 2007 to 2014 to determine vital status. Actual to Expected (A/E) mortality ratios were calculated using the Society of Actuaries 2015 Valuation Basic Table (2015VBT), select and ultimate table (age last birthday) and the 2013 US population as expected mortality ratios. All expected bases were not smoker distinct.

RESULTS

- The study covered applicants between the ages of 45 and 75 and had approximately 405,000 person-years of exposure. Older aged applicants had a lower mortality ratio than those who were younger. Applicants 45 to 54 had the highest mortality ratios in the first year after diagnosis which steadily decreased in years 6 to 10 with an increase in the mortality ratio for those over 10 years from diagnosis. Relative mortality rate was close to unity for those with localized cancer across all age groups. The mortality ratio was 2 to 4 times greater for those with cancer in 1 positive node, and much greater with 3 positive nodes. For each time-from-diagnosis category, the relative mortality ratios compared to age were highest in the 45-54 age group. The A/E mortality ratios based on the 2015VBT were consistently 3 to 4 times that of the mortality ratios based on the 2013 US population.

CONCLUSION

- The mortality patterns of insurance applicants with prostate cancer were similar to that observed in individuals with prostate cancer in the general population. Applicant age, time to diagnosis and cancer severity were the most significant variables to predict mortality.

All-Cause Mortality for Diabetics or Individuals with Hyperglycemia Applying for Life Insurance

Diabetics and individuals with lab results consistent with a diagnosis of diabetes or hyperglycemia were extracted from data covering US residents who applied for life insurance between January 2007 and January 2014. Information about these applicants was matched to the Social Security Death Master File (SSDMF) and another commercially available death source file to determine vital status. Due to the inconsistencies of reporting within the death files, there were two cohorts of death cases, one including the imputed year of birth (full cohort of deaths), and the second where the date of birth was known (reduced cohort of deaths). The study had approximately 8.5 million person-years of exposure. Actual to expected (A/E) mortality ratios were calculated using the Society of Actuaries 2008 Valuation Basic Table (2008VBT) select table, age last birthday and the 2010 US population as expected mortality rates. With the 2008VBT as an expected basis, the overall A/E mortality ratio was 3.15 for the full cohort of deaths and 2.56 for the reduced cohort of deaths. Using the US population as the expected basis, the overall A/E mortality ratio was 0.98 for the full cohort of deaths and 0.79 for the reduced cohort. Since there was no smoking status information in this study, all expected bases were not smoker distinct. A/E mortality ratios varied by disease treatment category and were considerably higher in individuals using insulin. A/E mortality ratios decreased with increasing age and took on a J-shaped distribution with increasing BMI (Body Mass Index). The lowest mortality ratios were observed for overweight and obese individuals. The A/E mortality ratio based on the 2008VBT decreased with the increase in applicant duration, which was defined as the time since initial life insurance application.

Beyond the Genetic Information Nondiscrimination Act: ethical and economic implications of the exclusion of disability, long-term care and life insurance

The Genetic Information Nondiscrimination Act (GINA) was intended to protect individuals in the USA from discrimination based on their genetic data, but does not apply to life, long-term care or disability insurance. Patient advocates and ethicists have argued that GINA does not go far enough. Others express concerns for the viability of insurance companies if millions of potential customers know more than professional actuaries. Here we discuss the exclusion of certain insurance types from GINA. We explore the ethical and economic implications of this distinction, and potential paths forward. We suggest that because long-term care and disability insurance can be essential for well-being, there is no good reason to place them in a class with life insurance and therefore beyond GINA's reach.

2014 CRL Build Study of Life Insurance Applicants

Objective .- Determine the impact of build on insurance applicant mortality accounting for smoking, laboratory test values and blood pressure. Method .- The study consisted of 2,051,370 applicants tested at Clinical Reference Laboratory between 1993 and 2007 with build and cotinine measurements available whose body mass index (BMI) was between 15 and 47. Vital status was determined as of September, 2011 by the Social Security Death Master File. Excluded from the primary study were applicants with HbA1c values ≥6.5%, systolic BP ≥141 mmHg, albumin values ≤3.3 g/dL or total cholesterol values ≤130 mg/dL. Relative mortality was determined by Cox regression analysis for bands of BMI split by age, sex and smoking status (urine cotinine positive). Results .- A majority of applicants had BMI >24 (overweight or obese by WHO criteria). After the exclusions noted above, relative mortality does not increase by >34% unless BMI is <20 (<18 for female non-smokers age 18 to 59) or BMI is >34. BMI values in the range of 22 to 24 and 25 to 29, overall, had similar and the lowest relative risks. For most nonsmokers, risk was lowest in the lower of these two BMI bands but for smokers (and non-smoking males age 60 to 89) risk was lowest in the higher BMI band. Additional analysis showed limited reduction in relative risk by accounting for all laboratory test values as well as continuing the exclusions. Eliminating the exclusions resulted in only a modest increase in relative risk because the mortality rate of the reference band increased as well. Conclusion .- After excluding elevated HbA1c and blood pressure (associated with high BMI) and low albumin and cholesterol (associated with low BMI) which are usually evaluated separately, mortality varies by a limited degree for BMI 20 to 34. Accounting for the mortality impact of other test values, in addition to the exclusions noted, reduced mortality associated with high BMI to a limited extent, but had little impact on mortality associated with low BMI.

[Quantified self movement--the new mantra of life insurance companies]

Wearables are small personal minicomputers that register biometric data. In such a way, the insurance industry hopes to create new sales opportunities and products, and simplify underwriting. Lower premiums will promote the use of wearables. The related possibilities and unanswered questions are discussed in this article. Utilisation of big data offers the insurance industry a range of new opportunities. The benefit must be proven in the future, however.

TANTAMOUNT TO FRAUD?: EXPLORING NON-DISCLOSURE OF GENETIC INFORMATION IN LIFE INSURANCE APPLICATIONS AS GROUNDS FOR POLICY RESCISSION

Many genetic counselors recommend that individuals secure desired insurance policies, such as life insurance, prior to undergoing predictive genetic testing. It has been argued, however, that this practice is "tantamount to fraud" and that failure to disclose genetic test results, or conspiring to secure a policy before testing, opens an individual up to legal recourse. This debate traps affected individuals in a Catch-22. If they apply for life insurance and disclose a genetic test result, they may be denied. If they apply without disclosing the information, they may have committed fraud. The consequences of life insurance fraud are significant: If fraud is found on an application, a life insurer can rescind the policy, in some cases even after the individual has passed away. Such a rescission could leave family members or beneficiaries without the benefits of the life insurance policy payment after the individual's death and place them in in economic difficulty. Although it is clear that lying in response to a direct question about genetic testing would be tantamount to fraud, few, if any, life insurance applications currently include broad questions about genetic testing. This paper investigates whether non-disclosure of unasked for genetic information constitutes fraud and explores varying types of insurance questions that could conceivably be interpreted as seeking genetic information. Life insurance applicants generally have no duty to disclose unasked for information, including genetic information, on an application. However, given the complexities of genetic information, individuals may be exposed to fraud and rescission of their life insurance policy despite honest attempts to truthfully and completely answer all application questions.

A Perplexing ECG

An unusual appearing electrocardiogram (ECG) is sent to the medical director's department for interpretation prior to receiving the actual life insurance application. As a result, no background details are available to provide a clinical context. Preliminary perusal of the ECG suggests several diagnostic possibilities.

Public awareness of genetic nondiscrimination laws in four states and perceived importance of life insurance protections

Genetic testing has grown dramatically in the past decade and is becoming an integral part of health care. Genetic nondiscrimination laws have been passed in many states, and the Genetic Information Nondiscrimination Act (GINA) was passed at the federal level in 2008. These laws generally protect individuals from discrimination by health insurers or employers based on genetic information, including test results. In 2010, Connecticut, Michigan, Ohio, and Oregon added four questions to their Behavioral Risk Factor Surveillance System (BRFSS) survey to assess interest in genetic testing, awareness of genetic nondiscrimination laws, concern about genetic discrimination in determining life insurance eligibility and cost, and perceived importance of genetic nondiscrimination laws that address life insurance. Survey results showed that awareness of genetic nondiscrimination laws was low (less than 20 % of the adult population), while perceived importance of these types of laws was high (over 80 % of respondents rated them as very or somewhat important). Over two-thirds of respondents indicated they were very or somewhat concerned about life insurance companies using genetic test results to determine life insurance coverage and costs. Results indicate a need for more public education to raise awareness of protections provided through current genetic nondiscrimination laws. The high rate of concern about life insurance discrimination indicates an additional need for continued dialogue regarding the extent of legal protections in genetic nondiscrimination laws.

The Essential Types of Insurance for New Dentists

Although these insurance options may seem overwhelming and expensive, consider the cost of not having proper coverage in place if something catastrophic happens, such as a disability or lawsuit early in your career. Being a dentist is one of the best occupations there is. The future of dentistry is bright and new dentists can make a great living with a successful career that lasts as long as they want. Part of that successful career is being sure you have the right type of coverage in place so that if something catastrophic happens the insurance company takes the risk rather than your practice, your professional reputation, or your pocket book.

"MODY2" (maturity onset diabetes of the young type 2)

A 25-year-old male with "MODY2" (maturity onset diabetes of the young type 2) applied for life and disability insurance. MODY2 is also identified by the glucokinase gene that is mutated in this disorder. The etiology, clinical characteristics, and long-term risks of this disorder are reviewed.

Apical hypertrophic cardiomyopathy--a benign condition?

Apical hypertrophic cardiomyopathy (ApHCM) is a less common type of hypertrophic cardiomyopathy (HCM) and is often characterized as benign. However, more recent publications indicate that there is significant heterogeneity among individuals with ApHCM and that for many the condition is less than benign. This review will discuss the most recent understanding of ApHCM in the context of a case presentation and will provide a basic framework for risk stratification.

As long-term care insurers abandon the marketplace, what other options will appear?

Less than 20 years ago there were more than 100 major insurance companies selling long-term care insurance (LTCi). Today there are less than 30. Home care providers stood to be one of the primary recipients of LTCi payments for their services, but there's a paradox at work. Just as the baby boomers started turning 65 at a pace of 10,000 per day, the LTCi market is shrinking instead of "booming."

A drop dead healthy ECG

The diagnostic and risk stratification implications of a borderline electrocardiogram, which could be a normal variant or a marker for sudden cardiac death, are explored.

Brief case report: dopa-responsive dystonia

A 42-year-old female applied for life insurance. She was diagnosed with dopa-responsive dystonia as a child. Just prior to applying for insurance, she attempted to go off her carbidopa-levodopa resulting in increased symptoms of stiffness with some imbalance. Her neurologist advised her to restart her Sinemet and titrate dosages to maintain her best function. The diagnosis and risks are discussed.

"Flat line" in a limb lead

A life insurance applicant's electrocardiogram shows a flat line in one of the standard leads and new Q waves in the inferior leads. The clinical and risk assessment implications are reviewed.

Acute ischemia in an insurance applicant's electrocardiogram?

A life insurance applicant's electrocardiogram shows ST elevation and terminally negative T-waves suggestive of acute myocardial ischemia.