Long Term Care Division

GE FINANCIAL ASSURANCE*

Long Term Care Division

Long Term Care

Agent's Field Underwriting Manual

To use manual: double click on ‘caduceus’ above, this will get you to the Table of Contents (TOC), the TOC is arranged alphabetically, find the history you are looking for and double click on the history (in ‘red’). To get back to the TOC, double click on the history heading.

8-6-03

Wherever used herein, GE Capital Assurance (GECA), or the Company includes its affiliate New York domiciled insurer, GE Capital Life Assurance Company of New York.

INFORMATION YOU SHOULD ALWAYS GATHER

If any medical conditions are admitted:

What is the current status (the same, better, or worse)?
Are there any current symptoms?
What is the current treatment?
Are there any complications?
Is the condition under evaluation or has surgery been suggested?
REFER TO GUIDELINES ON SPECIFIC CONDITIONS

For what reason or for what illness are you taking each of the medications you have listed on the application?
Have you needed home health care, physical therapy, occupational therapy, speech therapy, or any type of rehabilitation program within the past 12 months? If so, for what reasons? If currently receiving any therapy, what is the anticipated date of discontinuation?
Have you had any medical conditions in the past 10 years that have impacted your health?
Have you seen any other physicians in the past 5 years? Why were they seen?
If you answered yes to the disability question on the application, please explain why you are on disability. When did it begin? Are you currently receiving disability income, worker’s compensation, or Social Security Disability benefits?
Is there any other information, not covered on the application, that you feel is significant?

If you require further clarification on any of the guidelines, or encounter one not covered in this manual, please contact our UNDERWRITING HOTLINE at 1-800-354-6892, for further assistance.

FOREWORD

The purpose of this manual is to help those involved in the risk selection process by:

describing some of the conditions that are significant determinants of a need for long term care.

providing a list of questions to ask in order to elicit pertinent information.

providing the general guidelines used by the Company in evaluating the risk.

listing significant medications.

The manual is not all-inclusive. As our knowledge and experience increase, we will expand, amend, and refine the manual.

The information contained in the manual reflects our claim and underwriting experiences over a twenty-year period. This manual is a tool that should be used in combination with your experience, observations, and sound judgment.

If you require further clarification on any of the guidelines, or encounter one not covered in this manual, please contact our UNDERWRITING HOTLINE at 1-800-354-6892, for further assistance.

THE HOME OFFICE UNDERWRITER WILL MAKE FINAL RISK DETERMINATION.

AGENT'S LTC FIELD UNDERWRITING MANUAL

Table of Contents

Information You Should Always Gather ______see inside front cover

FOREWORD ______

INTRODUCTION ______

LONG TERM CARE UNDERWRITING ______

Field Underwriting______

Home Office Underwriting______

- Underwriting Requirements

THE FIVE I's ______

(1)Intellectual Impairment______

(2)Immobility______

(3)Instability______

(4)Incontinence (Bowel and Bladder)______

(5)Iatrogenic Drug Reactions______

DECISION TERMINOLOGY ______

UNINSURABLE CONDITIONS ______

SPECIFIC UNINSURABLE MEDICAL CONDITIONS ______

UNINSURABLE FUNCTIONAL DEFICIT ______

UNINSURABLE COMBINATION MEDICAL HISTORIES ______

HEIGHT/WEIGHT TABLE ______

Overweight:______

Underweight:______

ADDISON'S DISEASE ______

ALCOHOLISM ______

(Alcohol abuse, Ethanolism, ETOH disease)______

ALZHEIMER'S DISEASE ______

AMYOTROPHIC LATERAL SCLEROSIS (ALS) )______

Lou Gehrig's Disease______

ANAL & RECTAL IMPAIRMENTS, BOWEL INCONTINENCE ______

ANEMIA ______

ANEMIA, IRON DEFICIENCY ______

ANEMIA, MEGALOBLASTIC ______

ANEMIA OR CHRONIC DISEASE ______

ANEMIA, APLASTIC ______

(Pancytopenia)______

ANEURYSMS ______

ANEURYSMS, AORTIC ______

ANEURYSMS, CEREBROVASCULAR ______

ANGINA PECTORIS ______

Coronary Artery Disease, CAD______

ANKYLOSING SPONDYLITIS (AS) ______

(Rheumatoid Spondylitis, Marie-Strumpell Disease)______

ARRHYTHMIAS ______

(Conduction Disturbances, Palpitations, Rapid Heartbeat)______

ASTHMA ______

(Bronchial & Allergic Asthma)______

ATHEROSCLEROSIS & THE CAROTID ARTERIES ______

ATRIAL FIBRILLATION (A-FIB) ______

BLADDER DYSFUNCTION OR INCONTINENCE ______

(Neurogenic Bladder, Stress Incontinence,______

Urinary Incontinence)______

CANCER ______

(Carcinoma, CA, malignancy, neoplasm)______

CANCER OF THE BREAST ______

CANCER OF THE COLON AND RECTUM ______

(LARGE BOWEL)______

CANCER OF THE ESOPHAGUS ______

CANCER OF THE HEAD, NECK AND THROAT ______

CANCER OF THE KIDNEY ______

CANCER OF THE LUNG ______

CANCER OF THE OVARY ______

CANCER OF THE PROSTATE ______

CANCER OF THE SKIN ______

CANCER OF THE STOMACH (GASTRIC) ______

CANCER OF THE THYROID ______

CANCER OF THE URINARY BLADDER ______

CANCER OF THE UTERUS ______

CARCINOID TUMORS ______

CARDIAC FAILURE, CONGESTIVE HEART FAILURE (CHF) ______

CONGESTIVE HEART FAILURE (CHF)______

CARDIOMYOPATHIES ______

CEREBRAL PALSY ______

CHRONIC FATIGUE SYNDROME ______

(CFS)______

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) ______

Asthma, Chronic Bronchitis, Emphysema______

CIRRHOSIS, ALCOHOLIC LIVER DISEASE ( ALS)______

PRIMARY BILIARY CIRRHOSIS ______

CORONARY ARTERY BYPASS SURGERY OR CORONARY ANGIOPLASTY ______

(Coronary Artery Bypass Graft [CABG], Percutaneous Transluminal Coronary Angioplasty

[PTCA])______

CROHN'S DISEASE, IRRITABLE BOWEL SYNDROME , ------

ULCERATIVE COLITIS, DIVERTICULITIS

(Colitis, Regional Enteritis, Ileitis, Proctitis, Spastic colitis)______

CUSHING'S SYNDROME ------

DEPRESSION ______

(Anxiety, Mania, Manic Depression, Bipolar Disorder)______

DIABETES MELLITUS (DM) ______

DIZZINESS ______

EMPHYSEMA (see COPD)______

EPILEPSY ______

(Seizures)______

EYE DISORDERS ______

FIBROMYALGIA ______

FRACTURES ______

HEMOCHROMATOSIS ______

HEMOPTYSIS ______

HEPATITIS ______

(Acute and Chronic Viral Hepatitis)______

HODGKIN'S DISEASE ______

HYPERTENSION ______

(High Blood Pressure)______

KIDNEY STONES (Nephrolithiasis)______

(Renal Colic, Calculus or Stone)______

LEUKEMIA ______

LEUKEMIA, CHRONIC LYMPHOCYTIC (CLL) ______

LEUKEMIA, HAIRY CELL (HCL) ______

LYMPHOMA ______

MALIGNANT MELANOMA ______

MEMORY LOSS ______

(Frequent/persistent forgetfulness)______

MENINGITIS ______

MULTIPLE MYELOMA ______

MULTIPLE SCLEROSIS (MS) ______

DEMYELINATING DISEASE ______

MUSCULAR DYSTROPHY ______

MYASTHENIA GRAVIS ______

MYOCARDIAL INFARCTION (MI) ______

(Heart Attack, Coronary)______

NEUROPATHY ______

NON-HODGKIN'S LYMPHOMA (see Lymphoma) ______

NORMAL PRESSURE HYDROCEPHALUS (NPH) ______

OSTEOARTHRITIS (OA) ______

(Degenerative Joint Disease [DJD], hypertrophic arthritis)______

OSTEOPOROSIS (OP) ______

PAGET'S DISEASE OF THE BONE ______

PARKINSON'S DISEASE ______

PERIPHERAL VASCULAR DISEASE (PVD) ______

(Peripheral Atherosclerostic Disease)______

PHYSICAL THERAPY

POLIOMYELITIS - POST POLIO SYNDROME ______

POLYCYSTIC KIDNEY DISEASE (PCKD) ______

POLYCYTHEMIA ______

POLYMYALGIA RHEUMATICA (PMR) ______

POLYMYOSITIS - DERMATOMYOSITIS ______

PROSTATE DISORDERS ______

RENAL FAILURE, ACUTE (ARF) ______

(Kidney Failure, Acute)______

RENAL FAILURE, CHRONIC (CRF) ______

(Kidney Failure, Chronic)______

RHEUMATOID ARTHRITIS (RA) )______

SJOGRENS SYNDROME ______

SARCOIDOSIS ______

SCHIZOPHRENIA OR OTHER PSYCHOSIS ______

(Paranoia and Delusional States)______

SCLERODERMA ______

(CREST Syndrome) ______

SLEEP APNEA ______

SLIPPED/RUPTURED DISC ______

(Herniated Nucleus Pulposus)______

SPINAL STENOSIS ______

STROKE (CVA) ______

Cerebral Vascular Accident (CVA)______

SURGERY ______

SYNCOPE ______

(Fainting or Black out)______

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) ______

Disseminated Lupus, Discoid Lupus Erythematosus______

THROMBOCYTHEMIA ______

(Thrombocytosis)______

THROMBOCYTOPENIA ______

THROMBOEMBOLISM ______

(Venous, Arterial or Pulmonary embolism)______

TRANSIENT GLOBAL AMNESIA (TGA) ______

TRANSIENT ISCHEMIC ATTACK (TIA) ______

TRANSPLANTATION OF BONE MARROW ______

TRANSPLANTATION OF THE CORNEA ______

TRANSPLANTATION OF THE HEART ______

TRANSPLANTATION OF THE KIDNEY ______

TRANSPLANTATION OF THE LIVER ______

TREMORS AND OTHER INVOLUNTARY MOVEMENTS DISORDERS ______

TUBERCULOSIS (TB) ______

ULCERS OF THE SKIN ______

VALVULAR HEART DISEASE ______

DRUG INDEX ______

GLOSSARY ______

INDEX ______

INTRODUCTION

LONG TERM CARE UNDERWRITING

The primary objective of the underwriting process is to collect, review and correlate all available information regarding an applicant for LTC coverage and to evaluate the risk to the Company of issuing coverage to that applicant.

Field Underwriting

The purpose of the Field Underwriting process is to:

evaluate and report on the applicant’s

–past and present health

–current functional status

determine if all factors would be acceptable to the Company

submit a completed application for qualified applicants to the Home Office

Home Office Underwriting

The purpose of Home Office Underwriting is to:

evaluate the

–completed application and any attachments containing additional information

–completed Agent's Report section of the application

–copies of medical records

–results of the Health Interview, when required

–results of a telephone interview, when required (Personal History Interview [PHI])

issue coverage to those applicants who qualify.

Unique factors of LongTerm Care Underwriting

The underwriting of long term care insurance differs from the underwriting of other products (such as life insurance) in that the Field Underwriter and the Home Office underwriter must consider many things which, for another type of insurance, might not seem important. A few of these unique factors are listed below.

 Cognitive status

 Functional capacity

- The ability to perform the Activities of Daily Living (e.g. dressing, transferring)

- The ability to perform the Instrumental Activities of Daily Living (e.g. shopping, meal preparation)

Medical histories that may result in a need for care (e.g. osteoporosis, falls, and fractures)

Multiple medical problems that, in combination, are more significant than each problem alone (e.g. diabetes in combination with heart disease)

Multiple medications(being taken for multiple medical problems) that may have adverse effects

Treatment modalities (e.g. current physical therapy)

Chronological Age vs Physiological Age - There may be a significant difference between the applicant's chronological age and physiological age (e.g. The applicant may seem much younger or older than his/her actual age)

Frailty - Serious disabilities can result from relatively minor accidents and illnesses

Personal IndependenceFactors that play an important role in maintaining an applicant's personal independence are:

Working, either full or part-time

A spouse in good health

Family or friend(s) living in the household

Volunteering at service clubs

Participating in hobbies and outside activities

The current ability to drive

The ability to travel and visit independently

UNDERWRITING REQUIREMENTS

REQUIREMENT ORDERING IS DRIVEN BY CLIENT AGE AND PREFERRED DISCOUNT QUALIFICATION / No Requirement / Telephone Interview / Medical Records
(MRR) / Health Interview
18 to 64

PD = Yes

/ X
18 to 64

PD = No

PCP Seen within 2 Years / X
18 to 64
PD = No
PCP Not Seen within 2 Years / X
65 to 79
PCP Not Seen within 2 Years / X
65 to 71
PCP Seen within 2 Years /

X

72 to 79
PCP Seen within 2 Years / X / X

THE FIVE I's

The elderly are subject to certain problems that are called the Five I's of geriatrics. They are:

(1)Intellectual impairment
(2)Immobility
(3)Instability
(4)Incontinence
(5)Iatrogenic drug reactions

(1)Intellectual Impairment

Senile dementia or senility is a major cause of LTC usage. It is estimated that senility affects approximately 10% of the population over age 70 and greater than 20% of the people over age 80. More than half of these people suffer from Alzheimer's type of senility. Other conditions that may mimic senility include multiple drug effects, depression, or brain tumors.

(2)Immobility

Specific conditions that contribute to immobility include malnutrition, anemia, orthopedic conditions (such as osteoarthritis and osteoporosis), neurologic conditions (such as stroke), and psychiatric conditions (such as depression).

(3)Instability

Instability may result in falls and injuries. Causes of instability include vertigo (dizziness), musculoskeletal conditions (e.g. arthritis), alcohol, or drugs.

(4)Incontinence (Bowel and Bladder)

Incontinence is a lack of bowel and/or bladder control. This may be caused by conditions such as multiple sclerosis (MS), stroke (CVA), benign prostatic hypertrophy (BPH), drug effects, or urinary tract problems. Some of these conditions can be treated with surgery or medication.

(5)Iatrogenic Drug Reactions

Iatrogenic drug reactions are common in the elderly. Older applicants are more likely to be taking various prescription medications and over-the-counter (OTC) drugs. Studies have shown that the average geriatric patient takes eight different medications daily. Thus, there is a significant potential for drug interactions, drug toxicity, and dosage errors that may adversely affect intellectual capacity and/or physical ability.

DECISION TERMINOLOGY

The following defines the decision terminology used by the Home Office Underwriter.

APPROVED: Requested benefits were approved.

DECLINED: Coverage is not issued as the risk is uninsurable.

RECONSIDERATION AVAILABLE: A conditional offer to review another application at a later date.

RECONSIDERATION NOT AVAILABLE:There is no offer to reconsider at a later date as the risk is uninsurable.

UNINSURABLE CONDITIONS

Uninsurable conditions include functional deficits and medical conditions that have a high probability of resulting in a need for long term care use. The risk associated with these conditions is unacceptable.

Most uninsurable conditions cannot be reconsidered because:

recovery is rare or a cure is not available at this time (e.g. Alzheimer's disease).

the symptoms are severe and tend to be progressive (e.g. emphysema requiring oxygen).

Applications should not be taken on individuals with known uninsurable conditions. If an application containing one or more of these uninsurable conditions is submitted, the application will be declined without medical records or a personal interview. Processing an application containing a declinable history is costly and time consuming for all. Do not submit applications for individuals with functional deficits, or medical/cognitive impairments that are uninsurable.

SPECIFIC UNINSURABLE MEDICAL CONDITIONS

Below is a list of specific uninsurable medical conditions that will not be acceptable at any time.

Acquired Immune Deficiency Syndrome (AIDS)

ADL limitation, present

AIDS Related Complex (ARC)

Alzheimer's Disease

Amputationdue to disease, e.g. diabetes or atherosclerosis

Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's Disease)

Antiphospholipid Syndrome

Aplastic Anemia

Ascitespresent

Ataxia, Cerebellar

Autonomic Neuropathy(excluding impotence)

Autonomic Insufficiency(Shy-Drager Syndrome)

Beurger’s Disease

Binswanger’s Disease

Blindnessdue to disease or with ADL/IADL limitations

Brain Disorder (Organic Brain Syndrome)

Cerebral Vascular Accident (CVA)

Chorea

Chronic Memory Loss

Cystic Fibrosis

Dementia

Dialysis, Kidney (Renal)

Diabetes treated with insulin

DWR failed

Forgetfulness (frequent or persistent)

Gangrene due to diabetes or peripheral vascular disease

Gaucher’s Disease

Hemiplegia

Hoyer Lift

Huntington’s or other forms of Chorea

Immune Deficiency Syndrome

Incontinence

Bowel incontinence

Bladder incontinence requiring assistance

Korsakoff’s Psychosis

Leukemia-except for Chronic Lymphocytic Leukemia (CLL) and Hairy Cell Leukemia (HCL)

Memory Loss, chronic

Mesothelioma

Multiple Sclerosis (MS)

Muscular Dystrophy (MD)

Organ Transplants, except a kidney & liver transplant

Organic Brain Syndrome (OBS)

Oxygen use except if used for headaches or sleep apnea

Paralysis/Paraplegia

Parkinson's Disease

Pneumocystis Pneumonia

Postero-Lateral Sclerosis

Quad Cane use

Quadriplegia

Senility

Short Portable failed

Spinal Cord Injurywith ADL/IADL limitations

Stroke (CVA)

Surgery scheduled or anticipated (except cataract surgery under local anesthesia)

Total Parenteral Nutrition (TPN) for regular or supplementary feeding or administration of medication

Walker use

Wernicke-Korsakoff Syndrome

Wheelchair use

UNINSURABLE FUNCTIONAL DEFICIT

It is important that you know which applicants are successful candidates for Long Term Care insurance. One of the most difficult aspects is determining how well your applicant functions independently with both the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs). Observing your applicant during your initial interview can provide you with vital information.

Observations you should make:

Does the applicant walk without difficulty?

Do you notice any imbalance or obvious limp?

Do you notice a tremor?

Do you notice any shortness of breath after minimal activity?

Questions you should ask:

Does the applicant require any assistance with daily activities?

Is an assistive devise used? What type?

Does the use of an assistive device prevent the applicant from independently carrying the groceries or laundry?

Can housekeeping, shopping, cooking, and laundry be performed independently?

Can the applicant use the phone book, arrange transportation, write checks, balance the checkbook, and select items at the grocery store independently?

Uninsurable ADL Deficits:

Any suggestion of current disability requiring supervision or assistance in any of the following ADLs is uninsurable:

Dressing

Bathing

Eating

Toileting

Transferring (e.g. moving from bed to chair)

Continence, either Bowel or Bladder

Mobility/Ambulation

Uninsurable IADL Deficits:

Any information implying current supervision or assistance by someone in two or more of the following IADLs:

Shopping

Meal Preparation

Transportation

Housework (Chores)

Managing Finances

Laundry

Using the Telephone

Taking Medications (uninsurable if assistance needed with this single IADL)

Additional Uninsurable Deficits:

Use of a walker, quad cane, wheelchair, electric cart or scooter, electric chair lift, Hoyer lift, or hospital bed
The use of oxygen, respirator, or kidney dialysis
Current institutionalizationin any facility (e.g.,hospital, nursing home, Assisted Living/Care Facility, home for the aged, etc.)
Current use of Home Care Services(e.g. Skilled, Custodial, HospiceCare, etc.), or Adult Day Care Use
Beginning use within 6 months of any of the following:

Catheter or Other Drainage Device

Hospital Bed

Ostomy Care

Any Nursing Home Use(Skilled, Intermediate or Custodial) within the past 12 months
Any Home Care Service Use(Skilled, Custodial, or Hospice Care) within the past 12 months
Any Adult Day Care Services within the past 12 months

UNINSURABLE COMBINATION MEDICAL HISTORIES

The following combination medical histories are not acceptable:

Asthma

Congestive heart failure (CHF) within 5 years/Cardiomyopathy

Chronic Bronchitis

Congestive heart failure (CHF) within 5 years /Cardiomyopathy

Congestive Heart Failure (CHF) within 5 years

Heart attack or angina

Emphysema/COPD

Asthma/chronic bronchitis

Diabetes

Tuberculosis (TB)

COPD (Chronic Obstructive Pulmonary Disease)/Emphysema

Congestive heart failure (CHF) within 5 years /Cardiomyopathy

Diabetes

Congestive heart failure (CHF) within 5 years

Diabetic skin ulceration or infections

Amputation due to diabetes

Diabetic blindness

Heart disease or heart surgery

Kidney failure

TIA or Amaurosis fugax

Heart surgery

TIA

Cardiomyopathy/Post-surgical congestive heart failure (CHF)