Liver enzyme testing (LFTs) are part of virtually every blood profile obtained on a potential insured. They are also one of the leading causes of a completely unexpected rating or decline on a case. Most clients do not provide a specific history for an elevation, and no broker or agent expects such an outcome with what seemed to be a clean history. Knowing how to approach this situation can be key to a favorable underwriting outcome.
Liver function tests generally include alanine aminotransferase (ALT), aspertate aminotransferase (AST), gamma glutamyl transpepetidase (GGT) and alkaline phosphatase (ALP). Albumin and bilirubin are also considered LFTs but usually in context with one of the “big four” preceding it. ALT, AST, GGT and ALP generally show an irritation or injury going on the hepatobiliary system, and the number of possible causes is quite varied. The challenge is in figuring out which are benign causes and which elevations do not affect mortality outcome.
Just as problemsome in underwriting abnormal LFTs is the inconsistent approach from insurers on the handling of the same blood profile information. Companies have different ratings on both individual and paired combinations of abnormal LFTs, so a standard offer in one instance may be a rated case or rarely even a decline on submission to a different insurer. The best approach is to find out how abnormal the liver function tests are, and to problem solve with the underwriter or even the insured’s personal medical doctor to hopefully establish that the cause is not a serious or even a transient one.
Small elevations in liver function tests may have no mortality consequences whatsoever. This is particularly true when one test is elevated in the absence of concurrent increases in any or all of the others. Sometimes the proportion of the pairs may be helpful—in most cases an elevated ALT/AST ratio is less problemsome than the other way around. Yet another situation is when the elevated liver test is already accounted for in consideration of a separate non-liver cause; for example, Paget’s disease of the bone that has already been underwritten may also be the cause of an elevated alkaline phosphatase, since both liver and bone increase the same measured value. A key step then is in having the insured request the results of the blood profile personally or have the insured send the request to the attending physician.
Some non-ratable, more benign causes may elevate liver function tests. Obesity, diabetes mellitus or the use of some administered medications may be at fault. Lipid lowering drugs and oral contraceptives, for example, may elevate liver function tests in and of themselves. A recent viral infection (such as mononucleosis) may even be a cause as well. Re-questioning for immediate medical history as well as getting an accurate medication list is an important next step. Withdrawing an offending medication and substituting a different one by the insured’s physician may solve the problem in and of itself.
Many insurers reflex certain tests that help the underwriter to pinpoint the cause of liver function test elevation. Serology for hepatitis may indicate an old (but perhaps still active) hepatitis B or C infection of which the insured was previously unaware. Blood markers for alcohol excess may indicate drinking as a possible etiology. Carbohydrate deficient transferrin (CDT) is a test now used in conjunction with high liver enzymes to pinpoint alcohol excess as a cause. Generally, the picture is filled in with adjunct other tests—alcohol is much more likely to be involved when the full picture is filled in by elevated HDL cholesterol, high MCV testing, and elevated triglycerides. Excess drinking is a difficult explanation in a non-accepting client—remembering that everyone’s alcohol tolerance is different and, despite a person’s perception, if the liver is being inflamed by alcohol, no matter what the intake, it is the telling tale.
Many concurrent diseases may be the origin of liver function test elevation and may make the rating for the causative problem worse. Infiltrating diseases such as sarcoidosis and hemochromatosis may be primary causes in and of themselves. Congestive heart failure, inflammation of the bile ducts, and inflammatory bowel disease are just a couple of the many etiologies of increased LFTs. And while severe diseases such as metastatic cancer and marked lung disease may be obvious uninsurable instances, just as obvious ones and normal ones such as pregnancy may cause an increase in LFTs as well.
When the answer isn’t obvious, or the results don’t seem to be matching the clinical picture, enlisting the help of the insured’s personal physician is key in helping the case along. Attending physicians want to know the cause of patient lab abnormalities as much as anyone and may re-draw or add additional testing to pinpoint a cause. Sometimes they will find a treatable problem that allows a resolution of the elevation once treatment is completed. Other times the new result will have normal liver enzymes, and the request for either a redraw by the insurer or a reconsideration in view of newer lab results will have a favorable outcome.
Lastly, particularly when the lab results aren’t markedly abnormal and when there doesn’t seem to be an obvious cause for elevation (such as excessive alcohol), submitting the case to a different insurer (or having the case shopped to an additional reinsurer) may result in a better outcome. Either way, elevations of LFTs do not have to be the end of the case, rather a starting point for investigation and either a treatable or resolvable outcome and even, in addition, a placeable case.
Robert Goldstone, MD, FACE, FLMI
MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1991. Goldstone does consulting full or part-time as well as on a fill-in basis for companies who need a medical director/physician. He can be reached by telephone at 949-943-2310. Emaill: [email protected]