1. For Agent Use Only. Not for Use with the Public. Underwriting the Elderly Cas Pengelley General Director, Life Underwriting April 2013 Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02116 (not licensed in New York) and John Hancock Life Insurance Company of New York, Valhalla, NY 10595. Insurance policies and/or associated riders and features may not be available in all states. © 2013 John Hancock. All rights reserved. MLINY

2. For Agent Use Only. Not for Use with the Public. 2 of 41 Agenda Introduction Underwriting Older Ages Common Examination Tools Conclusions Questions

3. For Agent Use Only. Not for Use with the Public. 3 of 41 Are these Older Age Applicants Insurable?

4. For Agent Use Only. Not for Use with the Public. 4 of 41 Population Trends

5. For Agent Use Only. Not for Use with the Public. 5 of 41 Causes of Death

6. For Agent Use Only. Not for Use with the Public. 6 of 41 Pearls: Vitality, Energy, Dexterity & Strength Education closely related to lifetime income Better educated = better health = lower risk of disability Health at age 65 * : –80% have at least one chronic health condition –50% have at least two –30% have three or more chronic diseases * How are their vitality, energy, dexterity and strength (VEDS)? * US Census Bureau, Current Population Reports, pp. 23-209, 65+ in the United States, 2005

7. For Agent Use Only. Not for Use with the Public. 7 of 41 Underwriting Considerations

8. For Agent Use Only. Not for Use with the Public. 8 of 41 Underwriting Do we underwrite the older age applicant like any other applicant?

9. For Agent Use Only. Not for Use with the Public. 9 of 41 What to Expect as “Normal” Cartoon used with permission from www.CartoonStock.com

10. For Agent Use Only. Not for Use with the Public. 10 of 41 What to Expect As “Normal” (cont’d) Slower reflexes “Hardening of the arteries” Decrease in renal function, liver function, lung capacity Depressed immune system, more susceptible to infections “Benign forgetfulness”

11. For Agent Use Only. Not for Use with the Public. 11 of 41 What are the Red Flags? Underlying/pre-existing disease Weight loss Depression and withdrawal from outside activities Memory loss Mobility issues Falls

12. For Agent Use Only. Not for Use with the Public. 12 of 41 Good, Bad, Ugly Good: –Routine medical care –Cognitive functioning –Activities (work, volunteer, travel) –Build (BMI 22-26) –Serum albumin (> 4.2gm/dl)

13. For Agent Use Only. Not for Use with the Public. 13 of 41 Good, Bad, Ugly Bad: –Sporadic medical care, lack of follow-up –Cognitive dysfunction (some impairment) –Limited activities – fall history –Build, loss of weight – co-existence depression –Serum albumin (<3.8gm/dl)

14. For Agent Use Only. Not for Use with the Public. 14 of 41 Good, Bad, Ugly Ugly: –No medical care within the last 2 years –Cognitive impairments – family concerns –No outside activities – fall history with fractures or significant injuries –Build – loss of more than 10% body weight within the last six months –Serum albumin (< 3.5gm/dl)

15. For Agent Use Only. Not for Use with the Public. 15 of 41 Gathering of Information Listing of all doctors, including specialists (type) – be aware of dual residence Listing of all medications Last visits, why (routine, referral) History, diagnosis, treatments Areas of focus –General health –Cognition and functional status –Favorable VEDS

16. For Agent Use Only. Not for Use with the Public. 16 of 41 Common Examination Tools

17. For Agent Use Only. Not for Use with the Public. 17 of 41 Tools Commonly Used Older age examination Cognitive assessment screening (MMSE) Serum albumin Pulmonary function tests (PFTs) Glomerular Filtration Rate (eGFR)

18. For Agent Use Only. Not for Use with the Public. 18 of 41 Older Age Examination Older age examination includes: –Activities of daily living (ADLs) – bathing, dressing, eating, transferring, toileting –Instrumental activities of daily living (IADLs) – cooking, meal preparation, house cleaning, handling finances, laundry, using phone, shopping, taking medication –Driving history –Work/volunteer/travel – exercise –Assistive devices – gait/mobility issues

19. For Agent Use Only. Not for Use with the Public. 19 of 41 Older Age Examination (cont’d) –Fall history If functioning, have 15-35% risk of death within the first year following the fall 33% end up in nursing home with only 33% of them regaining pre-fracture functional status Recurrent falls is defined as > 2 falls in a six-month period of time –Delayed Word Recall (DWR) –Clock/pentagon

20. For Agent Use Only. Not for Use with the Public. 20 of 41 MMSE Mini-Mental State Examination (MMSE): –30-point standardized questions evaluating: Orientation Concentration Verbal skills Visual-spatial skills –Easy to perform –Portable –Can be done by primary medical doctor, paramedical vendor

21. For Agent Use Only. Not for Use with the Public. 21 of 41 MMSE (cont’d) MMSE scoring system MMSE Score Range (0-30) 24-30No impairment 18-23Mild impairment 0-17Moderate to severe impairment

22. For Agent Use Only. Not for Use with the Public. 22 of 41 MMSE (cont’d) Orientation What is the (year) (season) (date) (day) (month)?5 Where are we: (country) (city) (part of city) (number of flat/house) (name of street)?5 Registration Name three objects: one second to say each. Then ask the patient to name all three after you have said them. Give one point for each correct answer. Then repeat them until he learns all three. Count trials and record.3 TRIALS Attention and calculation Serial 7s: one point for each correct. Stop after five answers. 5 Recall Ask for the three objects repeated above. Give one point for each correct.3 Language Name a pencil and watch (two points). Repeat the following: 'No ifs, ands or buts' (one point). Follow a three-stage command: 'Take a paper in your right hand, fold it in half and put it on the floor' (three points). Read and obey the following: Close your eyes (one point). Write a sentence (one point). Copy a design (one point).9 » Total Score_

23. For Agent Use Only. Not for Use with the Public. 23 of 41 MMSE & Level of Education AgeEducationScore 18-69High School28-29 College29 70-79High School27-28 College28 80+High School25-26 College27

24. For Agent Use Only. Not for Use with the Public. 24 of 41 Memory Loss, Alzheimer’s Disease & Vascular Dementia NOT a part of normal aging Risk of developing disease increases with age – severity increases with age Defined as cognitive impairment –to include memory impairment as well as at least one of the following: aphasia, apraxia, agnosia, executive function disturbance –impaired social or occupational functioning –gradual onset/continuing decline –other causes ruled out National Institute of Aging – for every five-year age group beyond 65, the percentage of people with symptoms doubles

25. For Agent Use Only. Not for Use with the Public. 25 of 41 Medications for Dementia Commonly seen medications used to halt the progression of dementia include: –Cognex (tacrine) –Aricept (donepezil) –Namenda (memantine) –Exelon (rivastigimine) –Razadyne (Reminyl) (galantamine)

26. For Agent Use Only. Not for Use with the Public. 26 of 41 Clock Test

27. For Agent Use Only. Not for Use with the Public. 27 of 41 Pulmonary Function Test Pulmonary function, as measured by forced expiratory volume in one second (FEV1) or forced vital capacity (FVC) are important independent predictors of morbidity and mortality in the elderly Lung function declines slowly throughout adult life, even in healthy individuals

28. For Agent Use Only. Not for Use with the Public. 28 of 41 Serum Albumin Serum albumin level is an independent risk factor for all-cause mortality in older persons A combined measure of albumin and disability reveals a strong gradient in mortality risk and may serve as a simple but useful index of frailty that can identify a high-risk group of older men and women who could be targeted for preventive and treatment efforts Source: JAMA: The Journal Of The American Medical Association, Vol. 272, No. 13, October 5, 1994.

29. For Agent Use Only. Not for Use with the Public. 29 of 41 Serum Albumin (cont’d) Serum Albumin –Normal = 3.6 g/dL – 4.9 g/dL (prefer >4.2 g/dL) –Abnormal = <3.6 g/dL **concerned when <3.8 g/dL with loss of more than 10% body weight within the last six months

30. For Agent Use Only. Not for Use with the Public. 30 of 41 Kidney Function & Cardiovascular Disease Long-term adverse outcomes associated with chronic kidney disease include kidney failure, complications of impaired kidney function, and more commonly, an increased risk for cardiovascular disease and death –Annual mortality from CVD is increased 10-100 times with kidney failure –Risk of CVD is increased 1.4-2.05 times with creatinine > 1.4-1.5 mg/dL –Risk of CVD is increased 1.5-3.5 times with microalbuminuria

31. For Agent Use Only. Not for Use with the Public. 31 of 41 Glomerular Filtration Rate – eGFR eGFR is equal to the sum of the filtration rates in all the functioning nephrons – how well kidneys are filtering wastes Normal value of eGFR depends on age, sex, body size Not an exact correlation between loss of kidney mass and loss of kidney function

32. For Agent Use Only. Not for Use with the Public. 32 of 41 Clinical Implications – eGFR eGFR is used to assess degree of kidney impairment and to follow the course of the disease Using serum creatinine alone to estimate eGFR is unsatisfactory and leads to delays in diagnosis & treatment of CKD (chronic kidney disease) Elevation in serum creatinine does not always occur until there has been approximately a 50% loss of kidney function

33. For Agent Use Only. Not for Use with the Public. 33 of 41 Serum Creatinine Mean serum creatinine: –Women: 0.93 mg/dL –Men: 1.13 mg/dL Varies by race Value lower in women due to less muscle mass and therefore less production of creatinine Increased weight = increased creatinine production With age, there is a decline in creatinine production (muscle mass decreases with age) Declines by approximately 1mL/min per 1.73m 2 per year after 40 years of age Increasing age is NOT invariably associated with an abnormal eGFR

34. For Agent Use Only. Not for Use with the Public. 34 of 41 Stages of Chronic Kidney Disease StageDescriptionGFR Level Normal kidney function Healthy kidneys90 mL/min or more Stage 1Kidney damage with normal or high GFR 90 mL/min or more Stage 2Kidney damage and mild decrease in GFR 60 to 89 mL/min Stage 3Moderate decrease in GFR30 to 59 mL/min Stage 4Severe decrease in GFR15 to 29 mL/min Stage 5Kidney failureLess than 15 mL/min or on dialysis Source: National Kidney Foundation

35. For Agent Use Only. Not for Use with the Public. 35 of 41 Conclusions

36. For Agent Use Only. Not for Use with the Public. 36 of 41 Underwriting Tools Review Cover letter John Hancock exam includes: –Details of medical questions –Exam findings –Older age section Word recall and orientation Mobility test Functionality –Blood and urinalysis results APS information –Remember dual residence –Dual medical care

37. For Agent Use Only. Not for Use with the Public. 37 of 41 Putting It Together Are these older age applicants insurable?

38. For Agent Use Only. Not for Use with the Public. 38 of 41 Putting It Together (cont’d) YES!!!! Older age applicants are insurable!! Stay informed, be prepared to ask for more details if necessary with a focus on VEDS: Vitality, Energy, Dexterity and physical Strength Some mortality risks at younger ages taper off with advancing age Risk of co-morbidities – and how it impacts VEDS

39. For Agent Use Only. Not for Use with the Public. 39 of 41 The Challenge Putting it all together: –Look at all the information –Identify favorables and unfavorables –How do the co-morbidities fit together? –How do any functional capabilities or limitations factor into assessment?

40. For Agent Use Only. Not for Use with the Public. 40 of 41 Underwriting Tips Underwriting the older age applicant is an “art” Look at the picture displayed by the information carefully Those that present favorable VEDS are best risks

41. For Agent Use Only. Not for Use with the Public. 41 of 41 Questions?