After COVID‑19 shut down the U.S. in March 2020, everyone went through major adjustments dealing with an unprecedented pandemic: Many of us were suddenly working from home, amongst fear and anxiety about our loved ones, schools and non-essential businesses closed, and long lines to get into grocery stores. Already having many remote underwriters in the U.S., we were able to quickly adjust to the new work-from-home reality.

Although Gen Re was able to keep current with our underwriting of policies, many of our clients needed our assistance helping them continue to sell business by making the Disability underwriting process easier. We were able to help clients create strategies to sell and service Individual Disability insurance policies, while providing a balanced risk assessment.

COVID‑19 Pandemic – A Catalyst for Change

COVID-related issues have forced many Disability carriers to ease or adjust medical requirements. For example, medical limits for routine testing have been raised, and there were times that medical records were waived due to the temporary closures of physician practices. Many Disability carriers now allow streamlined underwriting with less focus on medical exams and labs, instead using vendors to obtain electronic health records and lab data.

The pandemic has motivated carriers to expedite digitization of all aspects of the insurance operation, from application forms and policy delivery to online claims submissions.

We continue to see the effects of the pandemic on applications and medical records we review. For example, physician and dentist applicants were showing decreased income in 2020 and part of 2021 due to practice shut downs, but by midyear 2021 and into 2022 incomes have bounced back and even risen above pre‑pandemic levels.

Medically, we are seeing much more treatment for stress, anxiety and depression, along with subjective complaints such as muscle aches and pains, insomnia, headaches and fatigue. These symptoms may be labeled as symptoms of Long COVID.

The broad impact and limited understanding of Long COVID (also called Post-COVID condition) have captured intense public, scientific, and medical interest. Post-COVID condition is a focus of global research, including the NIH RECOVER multi-stakeholder initiative.¹ This sensitive topic presents an opportunity for us to demonstrate excellence in risk assessment and empathic communication.

Diagnostic Challenges

There are some challenges with diagnosing and studying Post-COVID condition, including:

• Multiple (>200) possible subjective and nonspecific symptoms (most commonly fatigue) may occur. Medical tests are often negative or nonspecific.
• Laboratory confirmation of past infection is inconsistent; “probable” COVID‑19 (no test confirmation of past infection) is included in the diagnostic definition.
• Gaps in symptoms following recovery from acute illness may occur.
• Diverse populations have variable outcomes and access to care issues impact recovery.
• Study design may include ascertainment bias, confounding factors.
• No long-term data with consistent, measurable outcomes.
• Comorbidities may contribute to the symptoms and impairments.

For a detailed look at Long COVID’s symptoms and effects, you can refer to another Gen Re blog.

Impairment and Post-COVID Condition

There is significant ongoing discussion, globally, about prolonged disability among a large number of individuals with Post-COVID condition – and whether the long-term condition could create a “mass disabling event”. Considerations include:

• Uncertainty, fear of the unknown and the increased prevalence of mental health issues during the pandemic amplifies this anxiety.
• Access to multidisciplinary care is needed, but disparities have become glaringly evident.
• Effective care will require early intervention, patient and community engagement, and consideration of the biopsychosocial context. Managing relevant comorbidities that contribute to symptoms, ongoing monitoring and research will improve outcomes.
• At this time, we do not have evidence supporting indefinite, large-scale population impairment but ongoing global monitoring continues.
• While we don’t know how long impairment will last, we know that increased awareness, early intervention and a biopsychosocial supportive approach will yield the best outcomes.

Application Scenarios

Will the risk of Post-COVID conditions alter our underwriting for Disability insurance? Let’s look at how COVID‑19 severity impacts underwriting analyses in two application scenarios:

> Hospitalized with severe COVID‑19 including an ICU stay
It is understandable that survivors of severe COVID infections may have long-term impairment related to organ damage, resembling sequelae from a post‑ICU condition called Post-Intensive Care Syndrome (PICS). A recent study revealed that among those with one-year survival after ICU treatment, 75% had ongoing physical symptoms.² Our risk assessment for those with severe illness will require allowing time for the applicant to fully recover from sequelae, including subjective symptoms.

> Mild or asymptomatic COVID‑19
Underwriting those with history of mild disease will be challenging since the cause of Post-COVID condition is not clearly understood. We will need to understand the overall medical context, including biopsychosocial factors, and assess potential red flags for impairment. As insurers, we need to provide a balanced risk assessment, while considering the underwriting principle of “What is most likely?”. We will need to confirm full recovery of all subjective symptoms but cannot predict gaps in impairment that can be seen in Post-COVID condition.

Underwriting the risk for those hospitalized with COVID‑19 will be associated with less uncertainty. However, most applicants have a history of mild/asymptomatic COVID‑19. This risk is less predictable.

The full impact of Long COVID has yet to be seen. What we do know with certainty is that the ramifications of the pandemic will be felt in the Disability insurance industry for years to come.

Endnotes

1. https://recovercovid.org
2. Hidde Heesakkers, MD; Johannes G. van der Hoeven, MD, PhD; Stijn Corsten, MD; et al., “Clinical Outcomes Among Patients With 1‑Year Survival Following Intensive Care Unit Treatment for COVID‑19”, Jan. 24, 2022. https://jamanetwork.com/journals/jama/fullarticle/2788504.