Life insurance, the medical examination and cultural values

The Added Value of Medical Testing in Underwriting Life Insurance

Background

In present-day life-insurance medical underwriting practice the risk assessment starts with a standard health declaration (SHD). Indication for additional medical screening depends predominantly on age and amount of insured capital. From a medical perspective it is questionable whether there is an association between the level of insured capital and medical risk in terms of mortality. The aim of the study is to examine the prognostic value of parameters from the health declaration and application form on extra mortality based on results from additional medical testing.

Methods

A history register-based cohort study was conducted including about 15.000 application files accepted between 2007 and 2010. Blood pressure, lipids, cotinine and glucose levels were used as dependent variables in logistic regression models. Resampling validation was applied using 250 bootstrap samples to calculate area under the curves (AUC’s). The AUC was used to discriminate between persons with and without at least 25% extra mortality.

Results

BMI and the overall assessment of the health declaration by an insurance physician or medical underwriter showed the strongest discrimination in multivariable analysis. Including all variables at minimum cut-off levels resulted in an AUC of 0.710 while by using a model with BMI, the assessment of the health declaration and gender, the AUC was 0.708. Including all variables at maximum cut-off levels lead to an AUC of 0.743 while a model with BMI, the assessment of the health declaration and age resulted in an AUC of 0.741.

Conclusions

The outcome of this study shows that BMI and the overall assessment of the health declaration were the dominant variables to discriminate between applicants for life-insurance with and without at least 25 percent extra mortality. The variable insured capital set by insurers as factor for additional medical testing could not be established in this study population. The indication for additional medical testing at underwriting life-insurance can possibly be done on limited variables instead of the obligatory medical testing based on age and the amount of insured capital.

The mutual shaping of life insurance and medicine in Finland

This article examines the mutual shaping of medicine and private life insurance in Finland before the Second World War. Based on historical texts and archival material, it shows the important effects that the involvement of medicine in client selection for life insurance companies had on medical knowledge and practice. The analysis focuses on the tensions between the main actors in life insurance underwriting--candidates, insurance agents, examining physicians and the central office--as well as the medical examination as the key site of these tensions. The article shows how the introduction of a set of procedural and technical innovations reshaped the medical examination and helped to stabilize the fraught network of life insurance underwriting. These innovations re-scripted medical work. They stressed objective measurable knowledge over the personal skill and clinical acumen of the examining physician, propagated the physical examination and the use of diagnostic technologies and vital standards, multiplied medicine's administrative tasks, and contributed to the introduction of a risk factor approach to medicine. Moreover, the social organization of life insurance promoted the spread of these objects, practices and tasks to other fields of medicine. The case displays how medical innovations are developed through the situated interplay of multiple actors that cuts across the science-society boundary.