1. Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

2. Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

3. Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

4. Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

5. Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. Prevalence of Type II Diabetes

7. www.cdc.gov/diabetes County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2004 Percent

8. www.cdc.gov/diabetes Percent County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2005

9. www.cdc.gov/diabetes Percent County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2006

10. www.cdc.gov/diabetes County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2007 Percent

11. www.cdc.gov/diabetes County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2008 Percent

12. In 2011: 25.8 million children and adults had diabetes ( 8.3%) Diagnosed: 18.8 million Undiagnosed: 7.0 million Pre-diabetes: 79 million! New cases: 1.9 million new cases in 2010 Age 20 or older - 11.3% Age 65 or older- 26.9% Diabetes Type II

13. Diabetes- complication statistics Diabetics have 2-4 times the incidence of heart disease Diabetics have 2-4 times the incidence of stroke Diabetes is the leading cause of blindness Two-thirds of diabetics also have hypertension Diabetes is the leading cause of kidney failure Leading cause of non-traumatic limb amputations

14. Causes of Surprises Newly found diabetes Many undiagnosed diabetics discovered on insurance testing Newly found Hepatitis Six kinds of viral hepatitis: A,B,C etc Hepatitis A: food borne, usually short illness, self limited Hepatitis B & C are public health concerns

15. Hepatitis B Endemic in many parts of the world e.g. SE Asia, China, India, Africa Vaccination is available and routine in most countries Most frequent cause of chronic active hepatitis (CAH) CAH is the leading cause of hepatic carcinoma and cirrhosis Diagnosis requires blood testing and many times liver biopsy Treatment is available, response is variable Pre-Core mutant is particularly dangerous

16. Hepatitis C Used to be called non-A, non-B hepatitis Three strains (1,2,3) with strain one being the most pathologic and most common It’s symptoms can remain hidden for decades Many exposures occurred prior to testing especially blood products Since testing blood, most exposures are related to IV drug use or sexual contact 75% of HCV are unaware they are infected

17. Hepatitis C Feb 21, 2012 CDC study showed: 3.2 million Americans infected, 170 million worldwide, most- undiagnosed 1 in 33 baby boomers (born 1945-1965) are infected in 2007 it surpassed HIV in number of deaths “It is a silent epidemic” Dr John Ward, CDC hepatitis chief Treatment is similar to Hepatitis B with interferon and anti-virals Liver biopsy is essential to determine severity of disease; the extent of disease is not proportional to liver enzymes 40% of incarcerated inmates are Hep C positive It is a leading cause of liver failure, cirrhosis, and liver cancer Hepatitis C is the leading cause for liver transplantation in the US

18. The famous with Hepatitis C

19. What information is useful for underwriting hepatitis Is this a new finding or well studied? What studies have been done? Serology, viral loads, what strain? How long ago? liver biopsy - gold standard to establish degree of damage Treatment given The more information the better, underwriters typically do not assume the best case scenario

20. Surprises: Elevated liver enzymes Diverse etiologies Obesity - steatohepatitis Alcohol NSAIDs Gallbladder disease Hepatitis- infectious and non-infectious Toxins

21. Elevated liver enzymes Wilson’s disease - copper storage disease Hemochromatosis - iron overload Drugs- especially anti-seizure medications Acute illnesses Tumors Pancreatic Disease

22. Surprises: HIV See an occasional unexpected result Many positive tests are never requested by applicant - “likely knew”

23. Electrocardiograms For many, the insurance examination EKG is their first Many electrical changes that occur in the heart (and on the EKG) have no symptoms Many times the doctor does not discuss EKG findings with their patient Obtaining a good quality, properly run EKG in the field can be a challenge

24. Other reasons for Surprises Applicants don’t know what’s in their medical records For example: “Mr Smith tells me that he is only drinking two beers a week but I find that very hard to believe. I estimate that he must be drinking at least a six-pack every day”. Applicants don’t follow through with recommended tests: For example: “Bob’s chest pain has several elements that are very worrisome for coronary artery disease. I have recommended that he undergo a stress thallium treadmill.” Bob considered this a “suggestion that he could follow or not”. He elected “not”.

25. Other reasons for Surprises Applicants hear a different story from their doctor Bob hears: “You are doing great, keep up the good work!” In reality: For an obese, hypertensive, diabetic who smokes and just had a heart attack you are doing great. Wrong information in the chart Patients mislead themselves about the state of their health

26. Why do applicants hear a different story from their personal doctor and insurance medical director? Our “headlights” are set on different scales: The average physician’s field of vision is at greatest 5 years ahead The med director is projecting out perhaps many decades (age 85 or more) and has “one bite at the apple”. Physician uses his experience and some clinical studies of limited duration Med Director uses actuarial data

28. Actuarial table- Male, (tobacco not considered) AGEStd150%200%300%500% 27368656054 255147443934 502824221915 75129864

29. Why do applicants hear a different story from their personal doctor and insurance medical director? Our “headlights” are set on different scales: The average physician’s field of vision is at greatest 5 years ahead The med director is projecting out perhaps many decades (age 85 or more) Physician uses his experience and some clinical studies of limited duration Med Director uses actuarial data “Poker Chip Syndrome” Typical phone conversation Physician’s duty is to represent his patient and their best interests

30. Why do applicants hear a different story from their personal doctor and insurance medical director? Survey published February 2012 issue of Health Affairs set off a round on controversy 1,891 physicians across the country Over fifty percent admitted describing a patient’s prognosis in a way “they knew was too rosy” 20% said they hadn’t fully disclosed a medical mistake for fear of being sued 1 in 10 admitted telling a patient something that wasn’t true in the past year.

31. Popular Myths on Aging 100 year olds are growing rapidly In 1990: 37,306 In 2000: 50,454 In 2010: 71,991 The two week challenge What is middle age at what age does the roller coaster cross the summit? Pro athletes and celebrities are great risks Money buys good health Money buys access to good health care

32. Why do different companies rate differently?

33. Example: 45 year old man applies for $2.5 million in term life. He denies any previous medical history but his cholesterol is modestly elevated and his father died at age 55 from a heart attack. No medications. Slightly hypertensive on exam and a bit overweight. He smokes. His electrocardiogram shows the following:

34. Normal Tracing

35. Applicant’s Tracing

36. Why do different companies rate differently? Example: 45 year old man applies for $2.5 million in term life. He denies any previous medical history but his cholesterol is modestly elevated and his father died at age 55 from a heart attack. No medications. Slightly hypertensive on exam and a bit overweight. He smokes. His electrocardiogram shows the following: Based on his EKG we elected to make no offer but decided to send the case to 3 reinsurers. Each Reinsurer got exactly the same information.

37. Reinsurers’ Responses Reinsurer A Decline Reinsurer B Table H Reinsurer C Standard

38. How to explain? different reinsurance reference manuals Beauty is in the eye of the beholder!!

39. We want to help you sell....If you don’t make money, we don’t make money! Our goal is to make your job and your client’s underwriting process as convenient as possible but still gather the necessary information to underwrite properly. Surprises do come up in the underwriting process mainly due to unanticipated medical history and lab results Differences in underwriting offers can be hard to explain! On Your Side is not just a slogan for Nationwide Conclusions:

40. Questions?