INTERNAL USE ONLY GI ISSUES IN UNDERWRITING April 16, 2013 Eileen M. Ehlers VP Underwriting and New Business

© Zurich American Life Insurance Company INTERNAL USE ONLY GERD H. PYLORI ULCERATIVE COLITIS CROHN’S DISEASE COLON CANCER GASTRIC BYPASS/BANDING STUDIES/TESTS WHAT AN UNDERWRITER IS LOOKING FOR WHY AN UNDERWRITER WANTS TO SEE CERTAIN STUDIES/TESTS 2 GI Disorders

© Zurich American Life Insurance Company INTERNAL USE ONLY 3 What is it? The return of the stomach’s contents back up into the esophagus Studies: EGD – Esophagogastroduodenoscopy What an Underwriter Looks for: Esophageal obstruction, Esophageal Ulceration, Barrett’s Response to treatment Proper follow-up with EGD if Barrett’s/Dysplasia Why does an Underwriter need to see this information? Dysplasia Adenocarcinoma GERD – Gastroesophageal Reflux Disease

© Zurich American Life Insurance Company INTERNAL USE ONLY 4 What is it? A bacterium found in the stomach that is linked to chronic gastritis, gastric and duodenal ulcers and stomach cancer Studies: Blood tests, breath tests, Stool tests What an Underwriter Looks for: H. Pylori is eradicated via antibiotics and proton pump inhibitors Why does an Underwriter need to see this information? 10-20% of those colonized by H. pylori develop gastric and duodenal ulcers Small percentage of people with H. pylori infection that are at risk of stomach cancer. H. Pylori (Helicobacter Pylori)

© Zurich American Life Insurance Company INTERNAL USE ONLY 5 What is it? Inflammatory condition of the colon Studies: Stool tests, flexible sigmoidoscopy, colonoscopy, CT scan, Barium enema x-ray What an Underwriter looks for: Extent of disease, type of treatment, i.e., medications vs. surgery Routine colonoscopies, even if in remission (every 2-3 years in cases of longstanding disease of 8 yrs. or more) If total colectomy, the risk is +0 – curative Why does an Underwriter need to see this information: Severe attacks can be life threatening As long as the colon is intact (even if in remission), there is a risk of cancer Cancer risk usually begins in 8 years with total colon involvement Frequent relapses or continuous symptoms also increase the cancer risk Ulcerative Colitis

© Zurich American Life Insurance Company INTERNAL USE ONLY 6 What is it? Chronic inflammatory bowel disease that may affect any part of the gastrointestinal tract Studies: Barium Enema, small bowel contrast X-ray studies, colonoscopy, CT scan What an Underwriter looks for: Treatment, extent of disease, stable weight No. of years since diagnosis or major attack Why does an Underwriter need to see this information: Cancer risk is similar to Ulcerative Colitis. Routine follow-up is essential. Crohn’s Disease

© Zurich American Life Insurance Company INTERNAL USE ONLY 7 What are they? A benign tumor or growth which arises on the inner surface of the colon Studies: Colonoscopy, biopsy What does an Underwriter look for? The type of polyp- adenomatous, hyperplastic, inflammatory, villous adenoma or tubulovillous adenoma Follow-up colonoscopies depending on the type, size and number of polyps Why does an Underwriter need to see this information? Certain polyps are at high risk for colon cancer Because they are slow growing and do not typically have symptoms, it is important that routine colonoscopies are done Colon Polyps

© Zurich American Life Insurance Company INTERNAL USE ONLY 8 What is it? Cells that line the colon or rectum become abnormal and grow out of control. The abnormal cells create a tumor Studies: Biopsy/pathology report What does and Underwriter look for? Stage, treatment, length of time since treatment ended Follow-up colonoscopies at 6-12 months after surgery: if normal, 3 years later; if normal, every 5 years thereafter Why does an Underwriter need to see this information? Follow-up for reoccurrence of colon cancer Colon Cancer

© Zurich American Life Insurance Company INTERNAL USE ONLY 9 What is it? Surgery to bypass a portion of the digestive tract preventing absorption of calories and nutrients. Often used for weight loss resulting in control of Diabetes, hypertension, sleep apnea and cardiovascular disease Studies: Psychological testing, abilities to change life and health habits demonstrated by diet and weight loss prior to surgery. What an Underwriter Looks for: Successful weight loss, complications from surgery, nutritional deficiencies Why does an Underwriter need to see this information? Weight dictates an individual’s overall health and mortality Gastric Bypass

© Zurich American Life Insurance Company INTERNAL USE ONLY Zurich American Life Insurance Company 7045 College Boulevard, Overland Park, Kansas Insurance coverages underwritten by Zurich American Life Insurance Company, an Illinois domestic stock life insurance company. Certain coverages may not be available in all states and policy provisions may vary by state. ©2013 Zurich American Life Insurance Company A A (03/13)