The underwriting process in the life settlement industry has changed in the past two decades, as the accumulation of more data, and the increasing accuracy of that data, along with a generally expanding mortality profile of humans, has seen life expectancies (LEs) extending. Greg Winterton spoke to Dr Rahul Nawander, Medical Director at Fasano Underwriting, to get his views on what is impacting LEs generally from a medical perspective.
GW: Rahul, to begin, what are the current factors, from a medical perspective, that are having the greatest impact on mortality rates in the senior population in the US? Is anything improving anywhere?
RN: The main ones are still cancer and cardiovascular illnesses. There is a lot of stability in cardio deaths – there has not been much of an observable increase or decrease in the life expectancy of those with cardiovascular diseases. There has been some improvement in mortality in people with cancer, but it’s specific to only a few types of cancers that are responding to immunotherapy medications, e.g., metastatic melanoma.
The main other one is dementia in the life settlement space. Again, we’re not seeing any specific mortality improvements here – there has been stability in the LE profile of people with dementia since 2022. There is limited choice of medications and despite the research that is going on, there hasn’t yet been any significant outcomes that have impacted a positive outcome for mortality.
In terms of life expectancy improvements, we’re definitely seeing this in the organ transplant space. The development of immunosuppressants that adapt to the individual has been significant here. These drugs work so well that the insureds are living for another 10-15 years depending on the type of solid organ transplant, e.g., a heart transplant. We see these cases in the life settlement space; 10 years ago, the median LE was only five-eight years, and now it’s up to 10-15 years. In the early years, no one knew. There has been a 100% jump in improvement – six to 12 years, three to six years, etc. – just in the last few years. When you see these individuals, they are mostly completely fine. And it’s not just the immunosuppressants – improved techniques in surgery are contributing, too.
GW: You wrote an article that Life Risk News published in January this year that discussed the obesity paradox within BMI ranges. How much of an influence does obesity have when producing life expectancy data? Is it on a par with other comorbidities?
RN: It’s important to remember that obesity in of itself is not a primary driver of mortality, it’s that obesity contributes significantly to other ailments. If someone is obese, they have a higher risk of developing cardiovascular disease, for example. A sedentary lifestyle will lead to many illnesses, like osteoporosis. It’s not just ‘because you’re obese, you’re going to die’. It’s that it causes other things – diabetes, hyperlipidaemia, fatty liver, are great examples of that – where the underlying reason is obesity. Obesity increases the risk of these cardiometabolic illnesses and contributes to ill health and accelerates the mortality.
Obesity also leads to hypoventilation – there is a lower oxygen concentration in your body, so everything starts to get compromised over time. Mortality is lower for the non-obese than someone who is obese but it’s not the primary driver.
GW: You’ve been working in the insurance industry and related markets for a while. What are some of the notable changes that you have seen insurers implement in terms of adjusting their approaches to medical research and understanding?
RN: That’s right, I’m now 20 years into this industry. Quite a lot has changed, and much of it recently. Going back to 2010 for example, you would not see many individuals with cancer accepted for insurance (and hence less of these applied for insurance) because it was beyond most insurance companies’ risk-taking capacity. And there wasn’t that much research into this and understanding of it at that time.
But that’s changed since 2010. We’re seeing a better understanding of these medical fields and research and then evidence-based underwriting for complex illnesses really began in earnest in 2012. By 2015, pretty much every insurance company had robust research to understand how to model things like cancer, and consequently, they have come up with products on the critical illness, living benefits, and even life insurance; for example, that reference and cover specific cancers. The adoption and incorporation of evidence-based underwriting brought newer products and improved the risk-taking capacity of insurers.
GW: What are your views on artificial intelligence in terms of analysing medical conditions and data? Is it something that is a help or a hindrance?
RN: AI has a lot of ‘hallucination’. It’s a term – it means that an AI model produces incorrect, misleading, or illogical information. I have seen an AI model where it goes and looks into the medical records and creates a summary and then starts to analyse conditions on its own and give a diagnosis. But that’s a doctor’s job. It’s a clinical thing, with legal implications. We need to eliminate these hallucinations but there are companies trying to do this.
That said, it is a help. It’s still pretty new, nascent. When the AI fully starts to understand these issues, we can actually start using it effectively. It’s there but it’s not there, if that makes sense.
One example is that I asked AI about an LE for stage IV ovarian cancer. It gave me LE of four years. I asked it how it came to that conclusion, and it said that it went to a website and found it. What website? On what basis did the author publish that conclusion? The AI said that it didn’t have any studies to tell the basis for this, nor it could reference any studies or research.
Part of the reason is that research libraries are paid libraries. Every article costs money; $50, $75, $130, whatever. You have to realise that AI is just collecting data from websites – that’s what Google does – and summarising. That is not a strong basis on which to calculate an LE. The credibility and quality of the evidence needs to be critically assessed and then adjusted for the type of product (life, health, living benefits, and life settlements); which is not what AI has yet achieved.
GW: Lastly, Rahul, onto something that is very much in the news at the time of writing, which is Ozempic. There is talk now that it could actually slow ageing. Is it too soon to understand its impact on mortality, or are there any data trends emerging? If so, what are they?
RN: Ozempic was only prescribed for control of diabetes in its initial time but now it’s for control of weight. I’ve spoken to several people/patients who take it and researchers who have published studies and people do seem to be losing 25-30 lbs – around 8-10 % of their body weight on average. Some lost up to 15%.
It does seem to be stabilising at that point, however – people who take it are not continuously losing weight. If you weigh 100lbs and go to 85, you’re doing well, and you might go to 80, but then you’re stabilising. In terms of how it’s helping, because obesity is an underlying cause of cardiometabolic and cardiovascular illnesses, the risk of someone getting a cardiovascular disease is going lower, and we’re seeing the same in blood lipids – there is a possible circulating effect. The drill down effect is very positive – if you have a 15% to 25% reduced risk of getting a cardio illness, that is a statistically significant number.
Dr. Rahul Nawander is Medical Director at Fasano Underwriting
