For internal use only. Not to be shown or distributed to the public. Page 1 of 31 Medical Impairment Guide Conditions listed with an asterisk (*) are included in this guide. Other conditions are listed in italics and include the term under which you should search for the impairment within this guide. A Abscess Addison’s Disease Adjustment Disorder — See Mental or Personality Disorder Adhesions Adrenal Gland, Impared Function — See Addison’s Disease Affective Disorders — See Mental or Personality Disorder AIDS AIDS Related Complex Albuminuria —See UrineAbnormalities Alcohol, use of (ETOH) Allergies — See Hay Fever Alzheimer’s Disease Amputation Anemia Aneurysm Angina Pectoris (Chest Pain) Angioplasty Anxiety — See Mental or Personality Disorder Aortic Regurgitation — See Heart Murmur Aortic Stenosis — See Heart Murmur Arrhythmia (Tachycardia) Arteriosclerosis (Hardening of the Arteries) Arthritis (Osterarthritis, Rheumatoid) Asthma Atrial Septal Defect B Back Disorder Bantis Disease — See Spleen Disorder Bell’s Palsy Bladder Disorder, Urinary Blindness Brain Injury Brain Tumor Bronchiectasis Burns Bursitis Bypass Surgery (Coronary Artery Disease) C CAD — See Coronary Artery Disease Cancer (Malignancy) Carcinoma — See Cancer Cardiac Arrhythmia — See Arrhythmia Cardiac Hypertrophy Cardiomegaly — See Cardiac Hypertrophy Casts — See Urine Abnormalities Cataract Cerebral Embolism — See Stroke Cerebral Hemorrhage — See Stroke Cerebral Palsy CerebralThrombosis — See Stroke Cerebral Vascular Accident — See Stroke Check Up (Exam, Physical) Chest Pain Cholecystitis (Gall Bladder) — See Gall Bladder Disease Cholelithiasis (Gall Bladder) — See Gall Bladder Disease Cirrhosis of the Liver— See Liver Disorders Coarctation of Aorta Cocaine —SeeDrug Abuse Coccidioidomycosis —See Valley Fever Colitis Collagen Disease (Dermatomyositis, Periarteritis, Scleroderma, SLE, Systemic Lupus Erthematosis) Concussion Convulsions or Seizures (Convulsions) Coronary Artery Disease (Myocardial Infarction) Coughing of Blood (Spitting Blood, Hemoptysis/Hematemesis) Crack — See Drug Abuse Cretinism — See Thyroid Disorder Crohn’s Disease (Ileitis, Inflammatory Bowel Disease) Curvature of the Spine — See Spinal Curvature Cushing’s Syndrome CVA (Cerebral Vascular Accident) — See Stroke Cyst Cystic Fibrosis Cystitis D Deafness (Mute) Depression — See Mental or Personality Disorder Desert Fever — See Valley Fever Diabetes Mellitus Diarrhea Diplopia Diverticulosis/Diverticulitis Down’s Syndrome (Mongoloidism) Drug Abuse (Substance, Amphetamines, LSD, Heroin, Crack, Cocaine, Marijuana, Opium) Duodenal Ulcer — See Ulcer Dyspnea E Eating Disorders — See Mental or Personality Disorder Eclampsia — See Toxemia of Pregnancy Edema
Transcript
For internal use only. Not to be shown or distributed to the public. Page 1 of 31
Medical Impairment Guide Conditions listed with an asterisk (*) are included in this guide. Other conditions are listed in italics and include the term under which you should search for the impairment within this guide. A Abscess Addison’s Disease Adjustment Disorder — See Mental or Personality Disorder
Adhesions Adrenal Gland, Impared Function — See Addison’s Disease Affective Disorders — See Mental or Personality Disorder
AIDS AIDS Related Complex Albuminuria —See UrineAbnormalities
Alcohol, use of (ETOH) Allergies — See Hay Fever
Alzheimer’s Disease Amputation Anemia Aneurysm Angina Pectoris (Chest Pain) Angioplasty Anxiety — See Mental or Personality Disorder Aortic Regurgitation — See Heart Murmur Aortic Stenosis — See Heart Murmur
Arrhythmia (Tachycardia) Arteriosclerosis (Hardening of the Arteries)
Arthritis (Osterarthritis, Rheumatoid) Asthma Atrial Septal Defect B Back Disorder Bantis Disease — See Spleen Disorder
Bell’s Palsy Bladder Disorder, Urinary Blindness Brain Injury Brain Tumor Bronchiectasis Burns Bursitis Bypass Surgery (Coronary Artery Disease) C CAD — See Coronary Artery Disease
Cancer (Malignancy) Carcinoma — See Cancer Cardiac Arrhythmia — See Arrhythmia
Cardiac Hypertrophy Cardiomegaly — See Cardiac Hypertrophy Casts — See Urine Abnormalities
Cataract Cerebral Embolism — See Stroke Cerebral Hemorrhage — See Stroke
Cerebral Palsy CerebralThrombosis — See Stroke Cerebral Vascular Accident — See Stroke
Check Up (Exam, Physical) Chest Pain Cholecystitis (Gall Bladder) — See Gall Bladder Disease Cholelithiasis (Gall Bladder) — See Gall Bladder Disease Cirrhosis of the Liver— See Liver Disorders
Coarctation of Aorta Cocaine —SeeDrug Abuse Coccidioidomycosis —See Valley Fever
M Manic Depression — See Psychosis Marijuana — See Drug Abuse
Megacolon Meniere’s Disease Meningitis Mental or Personality Disorder (Psychoneurosis)
Mental Retardtion MI / Myocardial Infarction — See Coronary Artery Disease Migraine — See Headache Mitral Regurgitation — See Heart Murmur Mitral Stenosis — See Heart Murmur Mitral Valve Prolapse — See Heart Murmur
Mutiple Sclerosis Muscular Dystrophy Mute — See Deafness
Myasthenia Gravis Myocardial Infarction — See Coronary Artery Disease
N Narcolepsy Nephritis — See Kidney Disorder
Neuritis (Neuralgia) Neurosis — See Mental or Personality Disorder
O Obsessive Compulsive Disorder (OCD) — See Mental or Personality Disorder Opium — See Drug Abuse Osgood Schlatter’s Disease — See Osteochondrosis Osteitis Deformans — See Paget’s Disease Osteoarthritis — See Arthritis
Osteochondrosis Osteomyelitis Otitis Media Overactive Thyroid — See Thyroid Disorder
P Paget’s Disease (Ostetitis Deformans) Palsy — See Paralysis
Pancreatitis Panic Attack — See Mental or Personality Disorder
Paralysis Paranoia — See Psychosis
Parkinson’s Disease (Paralysis Agitatans) Patent Ductus Arteriosus Peptic Ulcer — See Ulcer Periarteritis Nodosa — See Collagen Disease
Pericarditis
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Peripheral Vascular Disease (Buerger’s Disease)
Phenylketonuria (PKU) Phlebitis (Thrombophlebitis) Phobias — See Mental or Personality Disorder Physical — See Check Up Physical Exam — See Check Up
Pleurisy Pneumothorax Polyp (Papilloma) Post Traumatic Stress Syndrome — See Mental or Personality Disorder Pregnancy, Toxemia of — See Toxemia of Pregnancy
Premature Birth Prostate Disorders Psychoneurosis — See Mental or Personal Disorder
Psychosis Pulmonary Embolism Pyelitis — See Kidney Disorder Pyelonephritis — See Kidney Disorder
Pyloric Stenosis R Raynaud’s Disease Regional Enteritis (Chron’s Disease) Rh Factor Rheumatoid Arthritis — See Arthritis Routine Exam — See Check Up Rupture — See Spleen Disorder
S San Joaquin Fever — See Valley Vever Schizophrenia — SeePsychosis Scleroderma — See Collagen Disease Scoliosis — See Spinal Curvature Shortness of Breath — See Dyspenea
Sickle Cell Anemia/Sickle Cell Trait SLE — See Collagen Disease Sleep Disorder — See Narcolepsy
Spleen Enlargement — See Spleen Disorder Spleenomegaly — See Spleen Disorder
Spondylolisthesis Spontaneous Pneumothorax — See Pneumothorax
Stroke (Cerebral Vascular Accident, Transient Ischemic Attack, Cerebral Thrombosis/Embolism/Hemmorrhage) Substance Abuse — See Drug Abuse
Suicide Attempt Surgery Swelling — See Edema Syphillis — See Venereal Disease Systematic Lupus Erythemoatosis — See Collagen Disease
T Tachycardia — See Arrythmia
Tetralogy of Fallot Thrombosis Thyroid Disorder Thyroiditis — See thyroid Disorder TIA — See Stroke
Toxemia of Pregnancy (Eclampsia) Transient Ischemic Attack — See Stroke
Tumor U Ulcer (Duodenal/Gastric, Peptic) Urinary Disorder, Bladder — See Urine Abnormalities
Urine Abnormalities V Valley Fever (Desert Fever, Coccidioidonmycosis, San Joaquin Fever)
Varicose Veins Vasectomy Venereal Disease Ventricular Septal Defect Vertebra Displacement — See Spondylolisthesis Viral Infection — See AIDS Related Complex
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Medical Impairment Guide
Abscess
Description Localized collection of pus in cavity formed by the softening of dead tissue resulting from inflammation.
Required information Submit details on the cause and the location.
Long-Term Care underwriting action
Abscesses in skin or subcutaneous tissue, usually standard depending on cause. Others, if vital organs are involved, may be rated to decline.
Addison's Disease
Description Impaired function of the adrenal gland.
Required information Submit full details of how long the condition has existed. Type of treatment. Response to treatment. Dates of crises. Name and address of physician. Date last seen.
Long-Term Care underwriting action
Controlled with no complications standard to rated. Others individual consideration.
Adhesions
Description A fibrous band that holds together organs that normally are separated.
Required information Indicate whether or not still present or surgically corrected.
Long-Term Care underwriting action
Usually standard after recovered from surgery unless symptoms are still present.
AIDS
Description Acquired Immune Deficiency Syndrome
Required information Submit full details. Care must be taken to avoid the appearance of discrimination.
Long-Term Care underwriting action
Risk not acceptable
AIDS Related Complex
Description Viral infection attacking the immune system.
Required information Submit full details. Care must be taken to avoid the appearance of discrimination.
Long-Term Care underwriting action
Risk not acceptable
Alcohol, use of (ETOH)
Required information Determine details of current drinking habits. Submit information on the medical/ nonmedical assistance sought
to cure problem, whether member of AA or similar organizations, and any evidence of other medical impairments.
Long-Term Care underwriting action
Decline within five years of treatment. Thereafter, rated to decline depending on extent of drinking history and time elapsed since reform.
Alzheimer's Disease
Description A permanent or progressive decline in intellectual function that substantially interferes with the individual's normal social activity.
Long-Term Care underwriting action
Risk not acceptable.
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Amputation
Description Removal of a limb.
Required information Reason for amputation (disease or trauma injury). Date of surgery. Use of prosthesis, walker, wheelchair. Time lost from work. Any limitations in daily functioning.
Long-Term Care underwriting action
If due to trauma and recovered for 12 months, usually standard to rated. If due to disease, underwritten for cause.
Anemia
Description Blood disorder, usually involving a decrease in red blood cells.
Required information Include type of anemia (if known), cause (if known). Dates of symptoms. Dates of treatment. Date of most recent blood tests and where to obtain results of
these tests. (See Sickle Cell Anemia/Sickle Cell Trait, if applicable.)
Long-Term Care underwriting action
Standard to decline, depending on type of anemia, cause, severity, treatment and length of time since recovery. Decline if currently smoking or stopped in the past 36 months.
Aneurysm
Description A sac-like dilation of an artery or vein due to weakness of its wall, either congenital or caused by injury or disease.
Required information Submit full details including: Location. Dates of consultation. Whether or not surgery was performed. Any residuals (describe).
Long-Term Care underwriting action
Individual consideration; dependent on size, location and treatment.
Angina Pectoris (Chest Pain)
Description A squeezing or constricting chest pain which may radiate to shoulder or arm caused by insufficient blood flow to the heart. May be associated with arteriosclerosis or coronary artery disease.
Required information Characteristics of pain are important. Indicate: If transmitted to arms, neck or shoulders. Whether associated with exercise or relieved by rest. Number of episodes and dates. Date of last symptoms. Type and frequency of medication used to relieve pain. Where and when electrocardiograms were made.
Long-Term Care underwriting action
Consider six months after diagnosis. Standard to decline depending on severity of symptoms.
Angioplasty
Description Insertion of a balloon-tipped catheter into an obstructed artery.
Required information Describe any symptoms or residuals after surgery. Details regarding follow-up visits and tests. Date of surgery (surgeries). Date of procedure(s).
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Long-Term Care underwriting action
If surgery recommended or planned, decline. Postpone for six month after procedure if under age 75, twelve months if age 75 or older, then standard to decline depending on degree of obstruction and any other health conditions.
Arrhythmia (Tachycardia)
Description Any irregularity of the heart rate or rhythm. Includes bradycardia (slow pulse rate), tachycardia (fast pulse rate), premature beats or extrasystoles (irregular pulse rate), fibrillation (fast and irregular pulse rate).
Required information Type of impairment, when and where diagnosed, and treatment administered.
Frequency, duration and date of last episode. When and where electrocardiogram was performed.
Long-Term Care underwriting action
Depending on type, duration, cause, frequency, response to treatment, action varies from standard to decline.
Arteriosclerosis (Hardening of the Arteries)
Description A disorder of the walls of the arterial blood vessels.
Required information Submit full details including: Length of time since diagnosis. Treatment. Date of surgery. Any associated problems such as elevated blood pressure, heart
or kidney disease.
Long-Term Care underwriting action
Can be rated to decline depending on factors such as age, degree of involvement and associated impairments.
Arthritis (Osteoarthritis, Rheumatoid)
Description Term for a variety of diseases, usually inflammation or degeneration of a joint. May be acute or chronic; may be due to injury, infection, or aging process.
Required information Classify whether: Rheumatoid Degenerative Other types
Indicate: Joints involved Whether generalized or localized Type of treatment; if steroid therapy has been administered,
when and how often Amount of time lost from work and activities Surgery
Long-Term Care underwriting action
Standard to decline depending on type of arthritis, treatment and extent of involvement.
Asthma
Description A lung disorder characterized by shortness of breath, cough, wheezing, spitting of mucus, and a sense of constriction of the chest.
Required information Indicate whether attacks are mild, moderate or severe. Indicate if attacks are occasional, on a seasonal basis, more
frequent or exercise induced. Indicate date of last attack. Indicate how much work lost due to attacks. Indicate type of treatment, if adrenaline or steroids used.
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Ask if hospitalization or emergency room visits required.
Long-Term Care underwriting action
Mild occasional asthmatic attacks standard, but more severe and frequent asthma, rated to decline.
Atrial Septal Defect
Description Hole between the top two chambers of the heart allowing blood to flow between these chambers.
Required information Size of hole. Treatment. Surgery (planned or anticipated) date of symptoms. Any other heart defects.
Long-Term Care underwriting action
Individual consideration.
Back Disorder
Required information Date of surgery (surgeries) if applicable. Occupational work record. Date of recovery. Symptoms. Dates of treatment. Number of episodes. Area of back affected. Cause. Date last consulted doctor.
Long-Term Care underwriting action
Standard to decline depending on severity of condition and type of treatment.
Bell's Palsy
Description Unilateral weakness or paralysis of the facial muscles.
Required information Date of onset. Length of time treated. Date of recovery.
Long-Term Care underwriting action
Standard to decline depending on severity of symptoms.
Bladder Disorder, Urinary
Required information Indicate: Cause. Frequency. Duration. Treatment. Date of surgery.
Long-Term Care underwriting action
Action ranges from standard to decline depending on diagnosis and severity.
Blindness
Description Visual acuity of 20/200 or worse.
Required information Cause of blindness. Degree of impairment. If blind in one or both eyes. Degree of independence or limitations. Time lost due to disability.
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Long-Term Care underwriting action*
Standard to decline depending on cause and if applicant is able to live independently.
Brain Injury
Description A result of head injury evidenced by unconsciousness which may be brief or last for hours. There may also be some degree of memory loss and symptoms such as headache, dizziness, nervousness, personality change, which may persist.
Required information Indicate date of injury and length of time unconscious. Symptoms or complications of concussion which are still
present. Treatment received and date of any surgery. Date(s) of surgery.
Long-Term Care underwriting action
Period of unconsciousness and residual determine action. May be necessary to postpone for 2 years or longer depending on extent of injury and residual effects.
Brain Tumor
Description Abnormal growth in the brain area.
Required information Indicate when tumor was discovered. Indicate type of tumor (benign or malignant). Indicate treatment. Indicate if surgery was performed or is planned. Indicate if there is any resulting brain damage or nervous
system impairment.
Long-Term Care underwriting action
Standard to decline depending on type of tumor and residual. Decline for cancer of brain within the past five years.
Bronchiectasis
Description Chronic dilatation (widening) of bronchial (bronchi) tubes. Many times caused by an infection. Some or all of the bronchi can be affected.
Required information Type of treatment. Date last consulted physician. If surgery performed and date(s). Time lost from work. Any limitations on daily activities.
Long-Term Care underwriting action
Standard to decline, depending on extent of involvement.
Burns
Required information Location. Severity and degree. Dates and treatment.
Long-Term Care underwriting action
Minor burns with no extensive scar tissue standard. More severe cases handled on an individual basis.
Bursitis
Description Inflammation of a fluid filled sac.
Required information Location, dates, number of attacks and dates of disability. Type of treatment. Date of surgery.
Long-Term Care underwriting action
Standard to decline depending on severity of symptoms.
Bypass Surgery (Coronary Artery Disease)
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Description Surgically installing an alternate route for blood to bypass an obstruction in a coronary artery.
Required information Number of vessels bypassed. Name of artery bypassed. (ex. left anterior descending, right
main coronary artery, circumflex, etc) Describe any symptoms after surgery. Details regarding dates of follow-up visits and tests.
Long-Term Care underwriting action
If surgery recommended or planned, decline. Postpone for six month after procedure if under age 75, twelve months if age 75 or older, then standard to decline depending on degree of obstruction and any other health conditions.
Cancer (Malignancy)
Description An abnormal growth of tissue also known as malignant tumor which may spread beyond site of origin (metastasize) and can be fatal.
Required information Location of tumor. Date of surgery or other treatment. If radiation treatment or chemotherapy, indicate date of last
treatment. Any evidence of metastasis (tumor spread to other organ). Staging of tumor (ex. stage 1b, t2c, in-situ, etc.) Name of cancer (ex. adenocarcinoma, sarcoma, etc)
Long-Term Care underwriting action
Standard to decline depending on type of cancer, location and date of last treatment.
Cardiac Hypertrophy
Description Also known as enlarged heart or cardiomegaly.
Required information Underlying condition causing heart enlargement. When first diagnosed. When and where chest x-rays and electrocardiograms were made.
Long-Term Care underwriting action
Standard to decline depending on cause and degree of cardiac enlargement.
Cataract
Description A disorder clouding the lens of the eye which impairs vision. May be congenital, result of injury, radiation, or associated impairment. Can affect one or both eyes.
Required information Date of pending surgery, or date of surgery if completed. Degree of visual impairment.
Long-Term Care underwriting action
Usually standard if symptoms, treatment and function stable.
Cerebral Palsy
Description Paralysis due to damage of the brain from injury or disease. May also result in mental retardation.
Required information Degree of physical and mental impairment. Inquire about grade level and IQ. Indicate if use of brace, cane or crutches required and if loss
of bladder or bowel control due to paralysis. Amount of time lost from school/work because of disability.
Long-Term Care underwriting action
Usually declined. May be ratable if no neurologic symptoms for five years, no use of assistive devices and no indication of progressive weakness or fatigue.
Check-Up (Exam, Physical)
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Required information Record reason for and results of check-up (whether routine or due to symptoms).
List any tests, such as electrocardiogram, X-ray, blood test, with results. Include dates.
Determine if follow-up studies advised and when scheduled.
Long-Term Care underwriting action
Depends on reason for and results of check-up.
Chest Pain
Required information Cause. Specific diagnosis given. Tests performed. Treatment. Dates(s) and physician consulted.
Long-Term Care underwriting action
Standard to decline, depending on cause.
Comments If related to heart, refer to angina.
Coarctation of Aorta
Description A congenital defect of the aorta consisting of a localized constriction of the blood vessel.
Required information Indicate if corrective surgery completed or anticipated. Date of surgery.
Question carefully about past or current blood pressure elevation and treatment administered.
If surgery done, indicate type of surgical procedure performed.
Long-Term Care underwriting action
Unoperated cases usually not acceptable. Certain operated cases may be accepted one year after surgery.
Colitis
Description Inflammation of the colon producing abdominal distress, diarrhea or constipation of varying degree. When bleeding occurs a more serious condition known as ulcerative colitis may be the underlying cause.
Required information Dates of symptoms, duration, type of treatment, and response to treatment.
Ask if bleeding has been noted. Ask if corrective surgery completed or suggested. Date of surgery.
Was diagnosis "ulcerative" colitis?" "Ulcerative proctitis?" Was diagnosis "functional colitis?" Length of time since last symptoms.
Long-Term Care underwriting action
Mild functional colitis generally standard. Ulcerative colitis, standard to decline depending on number of episodes, date of last attack and treatment.
Description A group of clinical syndromes involving connective tissue. These diseases typically involve more than one organ system, (kidney, skin, joints, heart). Some of these diseases are:
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When diagnosed. What symptoms were and are present. Date of last symptoms. Type of treatment received. Which specific disorder.
Long-Term Care underwriting action
Standard to decline depending on specific disorder, severity, duration and treatment.
Concussion
Description A result of head injury evidenced by unconsciousness which may be brief or last for hours. There may also be some degree of memory loss and symptoms such as headache, dizziness, nervousness, personality change, which may persist.
Required information Indicate: Date of injury. Length of time unconscious. Symptoms or complications of concussion which are still
present. Treatment received and any residuals.
Long-Term Care underwriting action
Period of unconsciousness and residual determine action. May be necessary to postpone for two years or longer depending on extent of injury and residual effects. See Brain Injury.
Convulsions or Seizures (Convulsions)
Description Involuntary contraction of muscles which may be caused by high fever, epilepsy, and other congenital or acquired brain defects or damage.
Required information Frequency and date of last seizure. Type of medication used and when last taken. If diagnosed as epilepsy, include specific type (Grand Mal,
Petit Mal or Jacksonian). If not epilepsy, specify cause.
Long-Term Care underwriting action
Recent onset or undiagnosed convulsions or seizures require postponing for one year. Others standard to decline depending on type, frequency, cause and other factors.
Coronary Artery Disease (Myocardial Infarction)
Description May be associated with myocardial infarction, heart attack, coronary occlusion, and coronary thrombosis. An obstruction to the normal circulation of the heart through the coronary arteries potentially resulting in heart tissue damage of varying degree (heart attack).
Required information Number of episodes and dates. Date returned to work. Where and when electrocardiograms were made. Any occurrence of chest pain or discomfort. Medications being used.
Long-Term Care underwriting action
Standard to decline depending on date of onset, age, degree and location of obstruction, symptoms and treatment.
Coughing of Blood
(Spitting Blood, Hemoptysis/Hematemesis)
Required information Indicate cause, whether respiratory disorder or gastric disorder, frequency and dates attended by physician, as well as where to obtain results of tests.
Long-Term Care underwriting action
Cause of symptoms indicates required action. If adequate investigation not completed, may be necessary to postpone.
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Description Disorder of intestines. Also referred to as regional enteritis, Crohn's Disease and inflammatory bowel disease.
Required information Ask how often symptoms have occurred. Dates of surgery.
Long-Term Care underwriting action
Declined if symptoms within past year. Thereafter rated to decline, depending on number of episodes, date of last attack and treatment.
Cushing's Syndrome
Description Weakness, hypertension, obesity caused by excessive amounts of hormones.
Required information Describe symptoms. Results of any tests performed. Treatment and if and when surgery done.
Long-Term Care underwriting action
Standard to decline depending on onset, type of treatment, stability of symptoms, time elapsed since treatment and if tumor, whether it was benign.
Cyst
Description A sac containing fluid, semi-solid material or gas that can develop in any tissue or organ of the body. Cysts can be single or multiple, and size can vary depending on type and location.
Required information Location of cyst. If infected and draining. Type of treatment received. If surgical removal planned or completed, date. If known, list medical description (pilondal cyst, sebaceous
cyst).
Long-Term Care underwriting action
Most cases with this history standard if proven benign. If cyst is causing impairment of any body organ function, postpone until after recovery from surgery.
Cystic Fibrosis
Description An inherited disorder in which the pancreatic glands are replaced by cysts and fibrous tissue. Similar changes may occur in the lungs, liver, and other organs.
Required information Include symptoms. Treatment. Dates attended by physician.
Long-Term Care underwriting action
Risk not acceptable.
Cystitis
Description Inflammation of the urinary bladder. It is rarely a primary condition, usually being secondary to an infection of the kidney, prostate or urethra.
Required information Number of episodes with dates. Type of medication prescribed. Date of recovery.
Long-Term Care underwriting action
If single, mild attack, usually standard. If chronic, depends on findings, rated to decline.
Deafness (Mute)
Required information Cause, if congenital or due to injury or disease. Degree of deafness; mild, moderate, or severe. If hearing impaired in both ears.
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If hearing aid used. Indicate if questions fully understood and how you communicated
with proposed insured.
Long-Term Care underwriting action*
Usually standard.
Diabetes Mellitus
Description A chronic disorder of carbohydrate metabolism resulting from a disturbance of the normal insulin mechanism and characterized by hyperglycemia (excess sugar in the blood) and glycosuria (sugar in the urine).
Required information Date of diagnosis. Type of treatment. Date of last consult. Last blood sugar reading and whether fasting or nonfasting. Complications (eye, kidney, neuropathy, retinopathy,
cardiovascular, recurrent infections, etc.).
Long-Term Care underwriting action
New onset or unstable diabetes, postpone for twelve months. Standard to decline depending on type, severity, control and related impairments or other health conditions.
Diarrhea
Required information Indicate if condition is prolonged or recurrent. Indicate if passage of blood has ever been detected. Indicate treatment prescribed. Any weight loss. Cause, if known.
Long-Term Care underwriting action
Of little significance unless recurrent or chronic. If history of passing blood, may be serious and require rating or postpone until diagnosed.
Diplopia
Description Double vision caused by a wide variety of disorders which range from relatively insignificant to severe.
Required information Cause is most important. Indicate: How long symptom has been present. If attending physician diagnosed cause. Date last consulted physician.
Long-Term Care underwriting action
Depends on cause. May be necessary to postpone until cause has been determined.
Diverticulosis/Diverticulitis
Description Pouches or pockets extending from the gastrointestinal tract, most commonly in the large intestine.
Required information If diverticulitis, date of last occurrence. If surgery has been completed or if it is anticipated. Type of treatment.
Long-Term Care underwriting action
Standard to decline depending on severity, date of last occurrence and degree of symptoms.
Down’s Syndrome (Mongoloidism)
Description A congenital condition which results in both physical and mental retardation and deficiency.
Required information Provide details indicating degree of mental and physician deficiencies.
Ask for IQ or mental age.
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Description Excessive or continued use, usually by self-administration, of any habit forming drug in a manner that deviates from the approved medical and social patterns within a culture.
Required information Date last used and frequency of use. Current physical condition. Morals, family life and occupation record. Evidence of reform should be well supported. Whether member of NA or similar organization. Submit information on the medical/nonmedical assistance sought
to cure problem, whether member of AA or similar organizations, and any evidence of other medical impairments.
Long-Term Care underwriting action
Decline within five years.
Dyspnea
Description Difficult or labored breathing, shortness of breath.
Required information Indicate if symptoms occur after unusual exertion, normal effort such as walking or climbing stairs or at rest.
Indicate if shortness of breath is mild, moderate or severe Indicate if cause has been investigated.
Long-Term Care underwriting action
Standard to decline depending on cause.
Edema
Description Swelling of tissues due to the presence of abnormal amounts of fluid, which may be localized or generalized throughout the body, depending on cause.
Required information Indicate part of body affected and cause, if known. How long condition has been present. Any medication(s) prescribed.
Long-Term Care underwriting action
Standard to decline, dependent on cause.
Embolism
Description The sudden blocking of a blood vessel by a blood clot or other substance brought to its place by the circulating blood. This may cause death of the surrounding tissue at the site of the blocked vessel.
Required information Cause of embolism, if known. Part of body affected (brain, heart, lung). Length of time disabled. Description of residuals. Number of episodes. Treatment. Extent of remaining disability.
Long-Term Care underwriting action
Uninsurable within six months of episode. Thereafter standard to decline, depending on cause and location.
Emphysema
Description A term to describe a variety of lung disorders the most common and important being chronic obstructive pulmonary disease. It is a
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progressive impairment in which the tiny "air sacs" lose their elasticity and lung function is slowly impaired.
Required information Indicate if symptoms (shortness of breath, coughing) are mild, moderate or severe; how long they have been present, and if normal activities are restricted.
Provide dates and where to obtain results of pulmonary function tests.
Indicate any medications prescribed or if oxygen use.
Long-Term Care underwriting action
Risk not acceptable.
Encephalitis
Description Inflammation of the brain resulting from a variety of causes including infections and viral diseases.
Required information Cause, if determined. Remaining effects (headaches, paralysis, visual defects). Date of recovery.
Long-Term Care underwriting action
Usually not acceptable if within two years of illness. After two years, standard to decline depending on extent of residuals.
Epilepsy
Description A chronic disorder of brain function characterized by attacks of unconsciousness, seizures or both.
Required information Frequency of epileptic seizures; dates of first and most recent seizure.
Indicate if seizure consists of unconsciousness, seizure or both.
If possible, identify whether classified as Grand Mal, Petit Mal, or if other type epilepsy.
Include name of medication, if known, and frequency taken.
Long-Term Care underwriting action
Recent onset or undiagnosed convulsions or seizures require postponing for one year. Others standard to decline depending on type, frequency, cause and other factors.
Fainting
Description Also called syncope.
Required information Cause. Length of time unconscious. Number of episodes. Date of last episode. Type of treatment administered.
Long-Term Care underwriting action
Usually acceptable standard unless fainting is recurrent and cause significant, in which case, it may be necessary to postpone, rate or decline.
Fracture (Broken Bone)
Required information Location of fracture If single or multiple fracture Length of time disabled Date of return to normal activities Date of surgery Residual limitations or arthritis
Long-Term Care underwriting action
Standard to decline depending on where fracture occurred, recovery and residuals.
Gall Bladder Disease
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(Cholecystitis/Cholelithiasis)
Description Inflammation of or stones in gall bladder.
Required information Type of treatment. Date surgery performed or anticipated. Any symptoms since surgery.
Long-Term Care underwriting action
Usually standard if diagnosis firmly established and symptoms are stable.
Gastric Resection
Description Removal of the stomach for surgical cure of stomach or duodenal ulcer and for removal of tumors.
Required information Diagnosis at time of surgery. Indicate if symptoms have recurred since surgery.
Long-Term Care underwriting action
Individual consideration after recovered for one year. When surgery for tumor, action depends on type of tumor (see “Cancer (Malignancy) ”).
Gastric Stapling, Banding, Bypass (Gastroplasty)
Description Surgical bypassing a section of the stomach or small intestine for weight loss and control in histories of morbid obesity.
Required information Obtain the following information: Date of surgery. Type of surgical procedure. Description of residual symptoms. Amount of weight loss. If weight has stabilized at reduced level.
Long-Term Care underwriting action
Best cases considered on individual basis twelve to twenty-four months after successful surgery and no other associated findings.
Gastritis
Description Inflammation of the stomach lining.
Required information Type of medication used. Duration of symptoms.
Long-Term Care underwriting action
Standard when diagnosed as simple indigestion. If symptoms are recurrent or severe with no diagnosis, may be necessary to postpone or rate.
Glaucoma
Description An increase of pressure within the eye, which, if unrelieved, may lead to blindness.
Required information Medication used to control it. If surgery is planned in the future. Any progressive visual loss noted. Extent of visual loss.
Long-Term Care underwriting action
Standard to decline depending on onset of symptoms and progression of visual impairment.
Gout
Description A disorder of uric acid metabolism which causes painful arthritic attacks, commonly in the great toe or other joints in the body.
Required information Ask: How severe and disabling attacks have been. Frequency of attacks.
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Date of last attack. Type of medication. If classified as primary gout or is it secondary to another
problem. When and where last blood tests were made.
Long-Term Care underwriting action
Standard to decline depending on joint involvement, symptoms or related surgery.
Hay Fever (Allergies)
Description Allergic disease of the mucous membranes of the nose.
Required information Frequency of attacks. Amount of time lost from work.
Long-Term Care underwriting action
Standard to decline depending on severity of symptoms and stability of respiratory status.
Description Abnormal sound(s) heard upon examination of the heart.
Required information Obtain medical terminology used to describe murmur (if known). Ask if there is a history of rheumatic fever or other illness
which may be a cause of the murmur, or if the murmur has been heard since birth.
Ask if any heart surgery has ever been performed or recommended. If heart surgery performed, get type and date of surgery.
If the proposed insured has had a cardiac work-up within the past twelve months, arrange for an APS instead of an MD exam.
Long-Term Care underwriting action
Action varies widely because there are many types of heart murmurs. Some are standard, but in many cases it is necessary to rate or decline.
Heart Surgery (Open Heart Surgery)
Required information Provide full details, if known, for condition which made surgery necessary.
Describe any symptoms after surgery. Provide details regarding follow up visits and tests. If surgery done for Coronary Artery Disease, see Bypass Surgery
(Coronary Artery Disease)
Long-Term Care underwriting action
Action varies according to reason for surgery and length of time since surgery. From standard to declined, depending on history.
Hemophilia
Description Hereditary blood disease characterized by greatly prolonged coagulation time.
Required information Type (A, B, other). Clotting factor. Complications.
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Long-Term Care underwriting action
Risk not acceptable.
Hemorrhoids
Description Dilated, tortuous veins in the rectum.
Required information Indicate if present or operated.
Long-Term Care underwriting action
Usually standard.
Hepatitis
Description Inflammation of the liver.
Required information Obtain detailed history, when last blood tests were made and where they can be obtained.
Type of treatment and if recovery is complete. List any indication of alcohol abuse. Indicate if acute or chronic. Type of hepatitis (A, B, C).
Long-Term Care underwriting action
Single acute attack of short duration with complete recovery, standard to rated. Recurrent attacks or chronic condition usually declined. HBV or HCV treated in past 12 months decline.
Hernia
Description A defect of the normal muscular wall, allowing protrusion of an organ or other part.
Required information Include location of hernia, such as inguinal, hiatal. Indicate if surgery had been performed, or if surgery is
planned for the future. List medications used.
Long-Term Care underwriting action
Standard in most cases. May be necessary to postpone if recent surgery or surgery is planned.
Hodgkin's Disease
Description A disease of the lymph nodes.
Required information What body area (location, organ or group of lymph nodes) is involved?
Staging if known. (ex. stage 1a, 2b, etc) Types of treatment (surgery, chemotherapy, radiation, etc.). Length of time since last treatment. Any recurrence.
Long-Term Care underwriting action
Risk not acceptable.
Hospitalization
Required information
Reason hospitalized. Date(s) hospitalized.
Long-Term Care underwriting action
Postpone until released. Also, evaluation needed for reason for hospitalization and stability since release.
Hypertension (High Blood Pressure)
Description Higher blood pressure than normal.
Required information
Last blood pressure reading and date. Date last consulted physician. Medication(s) taken.
Long-Term Care Standard to decline, depending on blood pressure control.
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underwriting action
Hysterectomy
Description Total or partial removal of uterus.
Required information
Reason for hysterectomy. Any indication of malignancy. Any follow-up care. Medical terminology for pathological findings, if known. If malignant, see Cancer (Malignancy)
Long-Term Care underwriting action
Postpone until after surgery. Usually standard after recovery if no malignancy.
Jaundice
Description Yellowness of the skin, mucous membranes, and secretions, due to bile pigments in the blood. If jaundice of newborns, see Rh Factor.
Required information
Determine underlying cause. See Hepatitis if this was cause. Important to include dates, diagnosis, and treatment and date of most
recent blood work.
Long-Term Care underwriting action
Depends on cause, length of time since recovery and residuals, if any.
Joint Replacement (Hip/Knee Replacement)
Required information
Determine: which joint(s) replaced date of surgery any residuals or limitations after surgery. cause
Long-Term Care underwriting action
Standard to decline depending on duration since surgery and residuals.
Kidney Disorder (Pyelonephritis, Pyelitis)
Description Many types of kidney disorders including congenital disorders, nephritis, stones, injury, polycystic kidney disease. Symptoms include albuminuria, hematuria (blood in urine), pyuria, casts.
Required information
Include specific diagnosis and symptoms. Dates. Treatment, if past or future surgery.
Long-Term Care underwriting action
Action varies widely depending on specific problem involved, including combinations with other symptoms such as elevated blood pressure, urinary findings.
Labyrinthitis
Description Disorder of inner ear, often causing dizziness.
Required information
Cause, if known. Frequency and severity of symptoms. Dates and treatment.
Long-Term Care underwriting action
Standard to decline, depending on duration since onset, and stability of symptoms.
Leukemia
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Description A malignant disease of the blood.
Required information
Provide: Type. Treatment. Information regarding follow up care including date last seen by
doctor. Date of last treatment.
Long-Term Care underwriting action
Uninsurable for five years after completion of treatment. Thereafter standard to decline depending on type.
Liver Disorders
Description There are several types including liver enlargement, fatty liver, cirrhosis, hepatitis, liver abscess, traumatic injury, etc.
Required information
Obtain detailed history, including exact diagnosis and terminology for specific problem.
When and where last blood tests were made, results. Obtain treatment, date, and if recovery is complete. List any indication of alcohol abuse.
Long-Term Care underwriting action
Action varies from standard to decline, depending on specific type of liver disorder, cause, date of most recent history and recovery.
Lupus Erythematosis (Discoid Lupus)
Description Discoid Type - A disease of the skin usually occurring in the exposed area of face, scalp and hands. Disseminated Type - A progressive disease with involvement of joints, kidney, liver, and brain.
Required information
It is important to record exact diagnosis. Include extent of symptoms. Disseminated type sometimes called systemic. Type of treatment. Date of last physician consult.
Long-Term Care underwriting action
Action varies from standard to decline depending on type, date of most recent history and recovery.
Lymph Gland Disorder
Description Disorder of lymphatic system which could include lymph node, lymphadenitis, various tumors and leukemia.
Required information
Obtain specific cause, if known. When present. How treated.
Long-Term Care underwriting action
Depends on specific diagnosis, standard to decline.
Megacolon
Description Congenital disorder of large intestine, also called Hirschsprung's Disease.
Required information
Include if any past or planned future surgery.
Long-Term Care underwriting action
Depends on treatment and date of last symptoms. Could vary from standard to decline if unoperated.
Meniere's Disease
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Description Recurrent episodes of dizziness or vertigo. Usually accompanied by ringing or other noises in the ear and hearing loss.
Required information
Include dates of symptoms and treatment.
Long-Term Care underwriting action
Risk not acceptable if onset within the past year. Thereafter, standard to decline depending on treatment or severity of symptoms.
Meningitis
Description Inflammation of membranes covering brain and spinal cord due to a variety of causes.
Required information
Obtain specific cause, if known: bacteria or viral, syphilis, tuberculosis, mycosis.
Dates. Treatment; and if any residuals.
Long-Term Care underwriting action
Risk not acceptable if active within the past two years. Thereafter, standard to decline depending on residuals.
Mental or Personality Disorder (Psychoneurosis)
Description A broad term referring to a group of functional mental disorders characterized by emotional imbalance (less serious than Psychosis). Classifications include anxiety, depression, obsessive compulsive disorder, phobic reaction, affective disorders, adjustment disorder, panic attacks, eating disorders, post-traumatic stress syndrome.
Required information
Include: Medical term for diagnosis. Frequency and Severity of symptoms. Duration of illness. Type of treatment, including if hospitalized. If shock therapy used. Date of most recent symptoms. Date of most recent consultation.
Long-Term Care underwriting action
Standard to decline depending on diagnosis, frequency, severity of symptoms and length of time since last symptoms.
Mental Retardation
Description Various degrees of subnormal mental function due to a number of causes such as congenital deficiency, brain injury, infection or disease.
Required information
Include degree of retardation, if known. For older children or adults, include extent of ability to care for
self, progress in school and ability to hold a job and be self-supporting.
Include information regarding IQ, mental age and classification of retardation, if known.
Long-Term Care underwriting action
Usually decline.
Multiple Sclerosis
Description Chronic slowly progressive disease of the central nervous system. May be in a course of periods of time of active disease and periods of remission.
Required information
Active disease or in remission. Type of treatment. Limitations in activity. Time lost from work.
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Number of episodes of active disease. Type of treatment. Date of recovery from last episode of active disease.
Long-Term Care underwriting action
Risk not acceptable
Muscular Dystrophy
Description Progressive muscle degeneration. Wasting away and atrophy of muscles.
Required information
Type. Body area(s) involved. Extent of limitations in activity.
Long-Term Care underwriting action
Risk not acceptable.
Myasthenia Gravis
Description Disease characterized by muscle weakness and progressive fatigue. May have periods of active disease or period of remission. Ocular or general disease.
Required information
Severity/progression of disease. Type of treatment.
Long-Term Care underwriting action
Risk not acceptable.
Narcolepsy
Description Uncontrollable, recurrent attacks of drowsiness and sleep.
Required information
Type of treatment. Time lost from work. Driving record (accidents). Extent of limitations on daily activities.
Long-Term Care underwriting action
Decline for two years from diagnosis. Thereafter, standard to decline depending on frequency and severity of episodes.
Neuritis (Neuralgia)
Description Nerve pains. The terms are used to describe a variety of painful conditions.
Required information
Obtain specific medical term for diagnosis. Cause. Frequency. Severity. Time lost from work. Type of treatment. location
Long-Term Care underwriting action
Standard to decline depending on duration since onset, cause and severity of symptoms.
Osteochondrosis
Description Impairments of bone and cartilage including Legg-Calve-Perthes, Osgood Schlatter's Disease.
Required information
Obtain specific terminology for disease, extent of symptoms and treatment.
Long-Term Care Usually standard.
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underwriting action
Osteomyelitis
Description A bone infection.
Required information
Record: Number of episodes. Dates. Bones affected. Treatment including any amputations or other surgery.
Long-Term Care underwriting action
Standard to decline depending on length of time since onset, symptoms or residuals.
Otitis Media
Description Infection of middle ear.
Required information
Indicate if it is a single occurrence or if it is a chronic problem. Include if any complications such as hearing loss or dizziness.
Long-Term Care underwriting action
Most cases standard unless chronic or severe with complications.
Paget's Disease (Osteitis Deformans)
Description Skeletal disease with chronic inflammation (thickening and softening) of bones. Bowing of long bones. May be progressive. There is increased incidence of sarcoma in bones affected by Paget's.
Required information
Indicate: Date diagnosed. Rate of progression. Skeletal involvement. Degree of deformity. Any other complications.
Long-Term Care underwriting action
Standard to decline depending on rate of progression degree of deformity and any complications.
Pancreatitis
Description Inflammation of pancreas.
Required information
Number of episodes. Dates and treatment. Cause. Acute or chronic weight loss. Recovery.
Long-Term Care underwriting action
Standard to decline depending on duration since last episode and severity of symptoms.
Paralysis
Description Loss of muscle function or sensation.
Required information
Ask for: Specific medical diagnosis. Cause. Extent of involvement, including which parts of body are affected. If normal bowel and bladder function.
Long-Term Care Risk not acceptable.
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underwriting action
Parkinson's Disease (Paralysis Agitans)
Description Chronic disorder of central nervous system involving tremors of head and extremities.
Required information
Severity. Length of time symptoms present. Treatment.
Long-Term Care underwriting action
Risk not acceptable.
Patent Ductus Arteriosus
Description Failure of blood vessel which functions during fetal life to close after birth, usually detected by a heart murmur.
Required information
Type of treatment Date of surgery Any residuals, such as a heart murmur or any other impairment Details regarding regular cardiac follow up
Long-Term Care underwriting action
Not applicable.
Pericarditis
Description Inflammation of the outer lining of the heart which may be caused by numerous disorders such as a virus, rheumatic fever or pulmonary disease.
Required information
Include the following: Date of last episode. Number of episodes. Dates, if surgery was performed or is planned. Date last electrocardiogram made and where to obtain. If any remaining symptoms.
Long-Term Care underwriting action
Standard to decline depending on duration since recovery.
Peripheral Vascular Disease (Buerger's Disease)
Description A number of conditions in which the blood flow through the extremities is decreased or obstructed causing symptoms such as pain, numbness, and changes in skin color.
Required information
Obtain the following information: Location of symptoms. Treatment including any surgery performed or planned. Nature of symptoms.
Long-Term Care underwriting action
Standard to decline. Action depends on age, specific diagnosis, duration and treatment and other risk factors such as diabetes.
Phenylketonuria (PKU)
Description A hereditary disorder sometimes resulting in neurological disorders, including mental retardation and seizures.
Required information
Important to know: Age of child when diagnosis was made. Date treatment was begun. Results of tests made by attending physician.
Long-Term Care Individual consideration.
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underwriting action
Phlebitis (Thrombophlebitis)
Description Inflammation of a vein.
Required information
Include the following: Location(s). Date of most recent occurrence. Treatment. If there is edema, swelling, or if one or more open sores (ulcers) are
now present. Number of episodes.
Long-Term Care underwriting action
Standard to decline. Action depends on dates since last episode, number of episodes and any complications.
Pleurisy
Description Inflammation of the tissue sac around the lungs.
Required information
Number of episodes. Date of last episode. Whether chest X-rays completed. Cause.
Long-Term Care underwriting action
Standard to decline based in information listed above.
Pneumothorax
Description Varying degrees of lung collapse due to the presence of air in the pleural cavity.
Required information
Indicate if it was spontaneous, (no known cause), due to an injury, or done as part of treatment for tuberculosis.
If spontaneous, indicate how many attacks there have been, if more than one lung involved and the date of the last attack.
Ask if any surgery was performed or planned.
Long-Term Care underwriting action
Standard to decline depending on duration since recovery.
Polyp (Papilloma)
Description A nodule usually found on mucous membranes in nose, bladder, stomach, intestines or uterus.
Required information
Include: Location. Any surgery performed or planned, dates. Pathological findings.
Long-Term Care underwriting action
Usually standard.
Premature Birth
Required information
Weeks gestation. Birth and current weight. Complications, if any. Whether or not still hospitalized.
Long-Term Care underwriting
Not applicable.
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action
Prostate Disorders
Description Conditions of the prostate gland including prostatitis, benign prostatic hypertrophy, prostatism.
Required information
Diagnosis. Type of treatment. Date last consulted physician. Date of surgery or biopsy including findings (benign or malignant). PSA.
Long-Term Care underwriting action
Usually standard if no indication of malignancy and symptoms stable. Otherwise rated to decline.
Psychosis
Description A general term applied to a number of mental disorders of a more serious nature. Specific types include Manic Depression, Paranoia, Schizophrenia, and others.
Required information
Ask for specific medical diagnosis, if known. Treatment, including if hospitalized and if ECT treatment used. Medication taken. Date of last consult with doctor. Follow-up care.
Long-Term Care underwriting action
Risk not acceptable.
Pulmonary Embolism
Description The sudden blocking of a blood vessel by a blood clot or other substance brought to its place by the circulating blood. This may cause death of the surrounding tissue at the site of the blocked vessel.
Required information
Length of time disabled. Extent of remaining disability. Number of episodes.
Long-Term Care underwriting action
Decline if within six months of episode. Thereafter standard to decline depending on number of episodes and respiratory status.
Pyloric Stenosis
Description A narrowing of the pyloric portion of the stomach. Usually a congenital defect in infants; a more serious problem if present in adults.
Required information
If an infant, determine if any surgery performed or planned. If an adult, list cause, if known (ulcer, cancer). Weight.
Long-Term Care underwriting action
Individual consideration depending on cause.
Raynaud's Disease
Description Disorder of blood circulation in extremities, usually causing discoloration and coldness in fingers or toes.
Required information
Obtain: Location of symptoms. Treatment, including any surgery performed or planned. Dates of diagnosis and beginning of treatment. When symptoms ceased, if no longer present.
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Long-Term Care underwriting action
Usually standard.
Regional Enteritis (Crohn's Disease)
Description Inflammatory disease of lower portion of small intestine which may spread throughout intestinal tract, including the colon.
Required Information
Obtain the following information: Number of attacks. Duration of attacks. Date of symptoms, duration. Treatment, including any medication taken and past or future surgery. Length of time since last symptoms. Response to treatment.
Long-Term Care underwriting action
Decline if single flare in past year, two years for multiple flares. Thereafter rated to decline depending on number of episodes, symptoms and treatment.
Rh Factor
Description Jaundice of the newborn. Cause involves blood Rh factor between father, mother and fetus.
Required information
Obtain information about how treated (transfusion, lamp only, other). Seek results of tests such as bilirubin. Ask if other congenital anomalies noted. Obtain history of weight gain.
Long-Term Care underwriting action
Not applicable.
Sickle Cell Anemia/Sickle Cell Trait
Description Hereditary chronic form of anemia causing sickle shaped red blood cells.
Required information
Type of treatment. Date last consulted physician.
Long-Term Care underwriting action
Individual consideration.
Spinal Curvature
Description Includes backward curvature (Kyphosis), forward curvature (Lordosis), and sideward curvature (Scoliosis). May be the result of illness such as polio, arthritis, spondylitis, injury, or nutritional deficiency.
Required information
Indicate: Type and degree of deformity and if other organs of the body are
affected. If a body brace, cane or crutches necessary.
Long-Term Care underwriting action
Action varies from standard to decline, depending on severity.
Spleen Disorder (Spleen Enlargement)
Description Abnormalities may be inherited or acquired and include Banti's Disease, Hypersplenism, Hemolytic Icterus, Rupture and Splenomegaly.
Required information
Include: Diagnosis. Treatment. Dates of last consultation. Ask if any surgery performed or planned.
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Long-Term Care underwriting action
Depends on diagnosis, treatment and time since last symptoms. Some may be considered standard; others rated to decline.
Spondylolisthesis
Description Forward displacement of one vertebra over another, sometimes causing severe pain and may require surgery.
Required information
Indicate if any surgery performed or planned. Ask how it has affected normal activities and the amount of time lost
Description Decrease in blood flow to the brain caused by disease, injury, blood clot, or rupture. Presents symptoms such as paralysis, speech impairment, convulsions, or memory loss.
Required information
List cause, number of occurrences and resulting impairment or disability.
Indicate time lost from normal activities and date released from doctor's care.
Indicate if surgery performed. If so, date. Whether transient ischemic attack (TIA) or stroke (CVA).
Long-Term Care underwriting action
Risk not acceptable.
Suicide Attempt
Required information
Give: Number of attempts. Dates. If any mental disorders were diagnosed and treated at the time.
Long-Term Care underwriting action
Usually uninsurable. Individual consideration 5 years after single attempt, 10 years after multiple attempts.
Surgery
Required information
Reason for surgery Date Recovery date
Long-Term Care underwriting action
Postpone if surgery pending or advised to have surgery.
Tetralogy of Fallot
Description A congenital abnormality consisting of four defects in the formation of the heart.
Required information
Include the following information: Whether surgery has been performed. Dates last seen by doctor(s). Any ECG findings. Regular cardiac follow up
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Long-Term Care underwriting action
Individual consideration.
Thrombosis
Description The sudden blocking of a blood vessel by a blood clot or other substance brought to its place by the circulating blood. This may cause death of the surrounding tissue at the site of the blocked vessel.
Required information
Part of body affected (brain, heart). Length of time disabled. Number of episodes.
Long-Term Care underwriting action
Action depends on location, date of attack and type of treatment.
Thyroid Disorder
Description Disorders of thyroid gland include Cretinism, Goiter, Grave's Disease, Hyperthyroidism (over-activity), Hypothyroidism (under-activity), Thyroiditis.
Required information
Include description of diagnosis. How treated. If any surgery.
Long-Term Care underwriting action
Action varies from standard to decline depending on diagnosis, treatment and duration since last symptoms.
Toxemia of Pregnancy (Eclampsia)
Description Complications occurring late in pregnancy or during labor. May include convulsions, muscular spasms, unconsciousness, elevated blood pressure and edema.
Required information
Includes date(s) of occurrence. If it occurred during more than one pregnancy. If any history of elevated blood pressure or urinary abnormalities
after child birth.
Long-Term Care underwriting action
Individual consideration.
Tumor
Description Abnormal growth of cells or tissues, usually progressive and of unknown cause.
Required information
Important to identify if classified as benign or malignant. Obtain exact medical term for diagnosis, if known, how treated and
dates. See Cancer (Malignancy), if applicable. Location Number of episodes
Long-Term Care underwriting action
Action depends on exact diagnosis and whether benign or malignant. History of benign tumors usually standard depending on location.
Ulcer (Duodenal/Gastric, Peptic)
Description Erosion of the lining of a portion of the digestive tract. Most commonly found in stomach or duodenum. May include inflammation.
Required information
Type of treatment. Date of diagnosis.
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Date of surgery. Identify any recurrence of symptoms since surgery. Specify location (stomach, duodenum), number of attacks, date. Indicate if bleeding.
Long-Term Care underwriting action
Action varies from standard to decline depending on diagnosis, treatment and duration since last symptoms.
Urine Abnormalities
Description Abnormalities found upon laboratory examination of urine samples. These findings may indicate the presence of a variety of disorders of the kidney, bladder, urinary tract, or prostate due to disease or injury. Findings include Albuminuria (albumin/protein), Casts (protein material), Glycosuria (sugar), Hematuria (blood), Pyuria (pus).
Required information
Obtain specific information for findings, diagnosis, tests and treatment.
Long-Term Care underwriting action
Action depends on cause of abnormalities, duration, diagnosis, treatment and if any related impairments. Could be standard to decline depending on cause.
Valley Fever
(Desert Fever, Coccidioidomycosis, San Joaquin Fever)
Description An infection usually occurring in the southwestern part of the United States which can affect the skin and lungs and also spread to other parts of the body.
Required information
Indicate parts of body affected, dates, and treatment and if completely cured.
Long-Term Care underwriting action
Action varies from standard to decline, depending on duration, symptoms and part of the body affected.
Varicose Veins
Description Swollen, knotted, tortuous blood vessels, most commonly present in lower extremities.
Required information
Indicate the following: Treatment received. If ulcers (open sores) or edema (swelling) developed as a result of
varicose veins. Areas of the body affected.
Long-Term Care underwriting action
Consider standard if uncomplicated
Vasectomy
Description A surgical operation of male reproductive organs usually done for birth control, but sometimes for more serious problems such as malignancy.
Required information
Indicate reason for vasectomy.
Long-Term Care underwriting action
Usually standard.
Venereal Disease
Description Gonorrhea An acute infection of the mucous membranes of the genital tract of either sex. Syphilis A contagious venereal disease. May be acquired or congenital.
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Required information
Gonorrhea Obtain dates. Types of treatment and if recovered. Ask if any remaining complications exist.
Syphilis Include type (congenital, primary, secondary or tertiary). When discovered and treated. If recovery is complete. Where to obtain results of last lab tests. Any cardiovascular or neurological involvement
Long-Term Care underwriting action
Individual consideration.
Ventricular Septal Defect
Description Hole between the bottom two chambers of the heart allowing blood to flow between these chambers.
Required information
Size of hole. Treatment. Surgery (planned or anticipated) date of symptoms. Any other heart defects.
