BRAe KE N RI D G E' s MEDICAL SELECTION o f - - LIFE RISKS FIFTH EDITION EDITORS DR R. D. C. BRACKENRIDGE DR RICHARD S. CROXSON DR ROSS MACKENZIE BRACKENRIDGE'S MEDICAL SELECTION of LIFE RISKS FIFTH EDITION EDITORS DR R. D. C. BRACKENRIDGE DR RICHARD S. CROXSON DR ROSS MACKENZIE palgrave * © in editorial matter, selection and updates to Chapters 5, 10, 12, 19, 32, 34, 35, to editors, 2006 © in original version of Chapter 8, Palgrave Macmillan, 1998 © in all other chapters, Palgrave Macmillan, 2006 Softcover reprint of the hardcover 5th edition 2006 978-1-4039-0676-2 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 wn Tottenham Court Road, London 4LP. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2006 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N. Y. 10010 Companies and representatives throughout the world PALGRAVE MACMILLAN is the global academic Imprint of the Palgrave Macmillan division of St. Martin's Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN 978-1-349-72326-3 ISBN 978-1-349-72324-9 (eBook) DOI 10.1007/978-1-349-72324-9 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. A catalogue record for this book is available from the Library of Congress. 10 9 8 7 6 5 4 3 2 1 15 14 13 12 11 10 09 08 07 06 CONTENTS Acknowledgements viii Preface ix The contributors xi Part I 1. A historical survey of the development of life assurance 3 R D C Brackenridge 2. Types of life and health insurance policies 21 Peter Maynard 3. Principles of risk selection and classification 33 Harry A Woodman 4. The application of life table methodology to risk appraisal 45 Richard B Singer 5. The rating of substandard lives 71 Michael W Kita International tables of mortality and expectations of life 88 6. Underwriting genetic diseases 99 J Alexander Lowden 7. Older age underwriting 115 Linda Goodwin 8. Underwriting younger ages: pediatric mortality risk evaluation 133 Patrick D Snow 9. Principles of disability: benefits and underwriting 145 John LoCascio 10. Long-term care underwriting 163 Daniel C Elliott, Emilio Rubi 11. Impaired life annuities 177 Geoffrey H Robb, Richard Willets VI CONTENTS 12. Structured settlements 183 James A Ryan Jr, Roger F Harbin 13. Application processing 189 Gary Bundock 14. Life underwriting and information technology 195 David Hodkinson Part II 15. The concept of health and disease 207 R D C Brackenridge 16. The physical examination 221 R D C Brackenridge 17. Laboratory testing and risk classification 241 Richard E Braun 18. Build 251 Kevin Somerville 19. Blood pressure 271 W John Elder, revised by R D C Brackenridge 20. Diabetes mellitus 289 Geoffrey H Robb, Ross Lawrenson 21. Cardiovascular disorders 317 Part A: Coronary heart disease Ross MacKenzie Part B: Arrhythmias, valvular heart disease and other cardiovascular disorders Richard S Croxson Part C: Congenital heart disease Gordon R Cumming 22. Electrocardiography 545 Michael Clark 23. Respiratory disorders 559 Martin L Engman, Rodney C Richie 24. Diseases of the kidneys and urinary tract 611 Howard L Minuk 25. Diseases of the liver and alimentary tract 655 M EC Thorpe 26. Oncology 711 Shanklin B Cannon 27. Diseases of the blood 745 Ursula B Wandl 28. Endocrine disorders 781 Anthony Toft CONTENTS vii 29. Diseases of the nervous system 799 F Clifford Rose, R D C Brackenridge 30. Psychiatric disorders 839 Ursula B Wandl 31. Substance abuse 873 Part A: Drugs and alcohol Robert W Watson Part B: Tobacco Robert W Watson 32. Rheumatic disorders 895 Neil Cardoe, revised by R D C Brackenridge 33. Musculoskeletal disorders 911 Part A: The skeleton R D C Brackenridge Part B: Muscle, joint and soft tissue disorders Geoffrey H Robb 34. Infectious diseases 935 Jan von Overbeck 35. HIVand AIDS 969 Jan von Overbeck, Annelies S Zinkernagel 36. Tropical diseases 991 Jan von Overbeck, Fajah S Peshi 37. Pregnancy and female reproductive disorders 1011 Polly M Galbraith 38. Miscellaneous impairments 1021 R D C Brackenridge Appendix 1037 Conversion factors 1037 Abbreviations 1038 Index 1043 ACKNOWLEDGEMENTS We would like to thank the many people who have which our job would have been much harder. helped in the production of this, the fifth edition Lucie Stokoe from the actuarial department of of Medical Selection of Life Risks. Swiss Re provided the life tables in the appropri First and foremost, our colleagues in clinical and ate formats. insurance medicine for their individual chapter con Thanks also to our publishers for their cooper tributions, both new rewrites and updates. We ation and understanding over the past 2-3 years of thank them for their expertise, time and effort and production. for the pleasure it has given us to edit their work. Finally, special thanks to our long-suffering sec Diana Harding came on board later as Project retaries and families for their forbearance through Coordinator, and her extensive experience in the out this project. insurance industry made her the ideal person for such a difficult task, persevering in collecting and R D C Brackenridge collating the various chapters from North Amer R S Croxson ica, Australia and Europe. RMacKenzie Swiss Re generously gave us access to secretar ial, copying and communication facilities, without PREFACE It is now almost fifty years since Sir Daniel Davies, (ALIMDA), later to become the American Acad CMO of Guardian Assurance in London, ap emy of Insurance Medicine (AAIM). proached me to ask if I would be interested in The next edition of the book, published in writing a booklet for the guidance of life under 1985, was an important landmark in its history. writers in their daily work and for doctors issuing Up until then, I had been the sole author of the reports on applicants for insurance. text, with the welcome assistance of various col For my sins I said I would be interested and leagues. However, the increasing specialization of prepared a draft of my plans, which was approved the medical disciplines and the expansion of life although it was rather more extensive than origin insurance to include other markets, such as dis ally intended. So, what was supposed to be a ability and critical illness, put the task beyond the booklet was eventually published as a hardback scope of a single author. Accordingly, the pub volume of 480 pages in 1962 under the title of lishers and I agreed that any future editions The Medical Aspects of Life Assurance. This volume should be edited, with experts from the insurance had mainly a local appeal in the UK although it industry and insurance medicine invited to con was also published in the USA. tribute chapters. I therefore asked my friend and Following the regional success of this book, it colleague W. John Elder MD to join me as co was decided that if there were to be any follow-up editor of the third edition of the book. John, with volumes, the life insurance interest would have to his experience as editor of the Journal of Insurance be widened to include North America, which has Medicine, recruited contributors from North the largest insurance base worldwide. With this in America while I lined up contributors from the mind, plans were made to produce another vol UK and elsewhere. ume of the book, which was re-named Medical And now we have reached a fifth edition. With Selection of Life Risks and was published in 1977. the passage of time editors have changed, and so This was later to be known as the first edition. At have our contributors. In this edition there are this point in my task as author, I was fortunate to several chapters completely re-written by new receive encouragement from some eminent fig contributors and having exceptional merit. Other ureheads of the life insurance industry, such as chapters have been revised where necessary. All Arthur Steeds FIA of the Mercantile and General these contributors have been acknowledged else Reinsurance Co. in London, Harry Ungerleider, where and have my grateful thanks. Medical Director of North American Re in New As senior editor, my input to this edition has York and that doyen of all life underwriters, Char been severely restricted by my failing vision and lie Will. My cause was also helped considerably has been mainly advisory. I have had to leave the when I became a member of the Association of serious editing to my co-editors in Toronto and Life Insurance Medical Directors of America London. X PREFACE Looking back over the past fifty years I must my part, I shall be quite content to retire to the say that the work involved in writing and editing sidelines and observe events unfolding whilst Medical Selection of Life Risks has been challen maintaining a benevolent presence. ging, but in the end, intellectually rewarding. It is now time for me to bow out and leave R D C Brackenridge future development of the book to others. For