The American Medical Association estimates that nearly 30 million people in the U.S. have sleep apnea. This can pose a significant challenge in the underwriting process if not properly positioned with carriers. 

However, some clients–with proper treatment–can still receive preferred ratings. Understanding what sleep apnea is, its impact on insurability, and strategies to prepare clients for underwriting can help advisors secure the best possible outcomes for their clients.

Understanding sleep apnea

Sleep apnea is a disorder characterized by repeated interruptions in breathing during sleep that can lead to loud snoring, daytime fatigue, and restless sleep. Sleep apnea is a significant consideration for life insurance underwriting not only because of the immediate risks associated with temporary oxygen deprivation but also because it increases the risk of long-term health complications. 

Prolonged sleep apnea is associated with cardiovascular issues like heart disease and high blood pressure, and it raises the risk of stroke due to fluctuating oxygen levels during sleep. In some cases, sleep apnea can be triggered by obesity, which can further complicate the client’s underwriting risk. 

In severe cases, chronic oxygen deprivation can also result in organ damage. Moreover, the condition’s effect on sleep quality often leads to cognitive impairments like memory loss and difficulty concentrating.

There are three primary types of sleep apnea, and each can lead to various underwriting outcomes based on the client’s health profile:

• Obstructive sleep apnea (OSA): OSA is the most common type, caused by structural issues such as an enlarged tongue, tonsils, or obesity that partially block the airway. 
• Central sleep apnea: This occurs when the brain fails to signal the body to breathe while asleep. Central sleep apnea is often considered more serious than OSA because it can be linked to underlying neurological problems such as structural issues with the brainstem or (in some cases) brain tumors.
• Mixed sleep apnea: Also known as complex sleep apnea, this occurs when both obstructive and central sleep apnea are present. This dual presence can complicate diagnosis and management due to the physical airway obstruction and the neurological signaling issues. Carriers will treat mixed sleep apnea the same as central sleep apnea.

How underwriters evaluate sleep apnea

Underwriters will evaluate a range of documentation to establish the client’s overall risk profile. However, for sleep apnea specifically, they will rely on a recent sleep study. Key metrics from a sleep study include:

• Apnea-hypopnea index (AHI): This index measures the number of significant breathing interruptions (apneas) and shallow breathing events (hypopneas) per hour of sleep. An AHI score helps classify the severity of sleep apnea, with higher values indicating more severe cases.
• Respiratory disturbance index (RDI): RDI includes not only apneas and hypopneas but also less severe breathing irregularities. This metric provides a more nuanced view of sleep quality and overall respiratory health.
• Oxygen desaturation levels: This metric assesses how often and to what extent blood oxygen levels drop below 90% during sleep. Chronic oxygen desaturation is associated with increased risks of cardiovascular complications, organ damage, and cognitive decline, making it a critical factor in underwriting evaluations.

In addition to these metrics, underwriters examine reported symptoms such as excessive daytime sleepiness, morning headaches, and cognitive difficulties, which may indicate the broader impact of sleep apnea on the client’s daily life. 

Underwriting outcomes

The underwriting outcomes for clients with sleep apnea can vary by type and severity:

• Central and mixed sleep apnea: These cases can still be rated as standard, but getting a better-than-standard rating is difficult due to the incurable nature of this type of sleep apnea. Clients who are non-compliant with treatment are more likely to be declined.
• Obstructive sleep apnea: Clients with mild, well-managed OSA can get preferred ratings from some carriers, especially when there is consistent evidence of treatment. Moderate to severe cases can receive standard or standard-plus ratings if treatment compliance and symptom control are well documented.

Carriers also consider contributing factors, such as obesity, which can exacerbate obstructive sleep apnea and increase overall health risks, along with cardiac and other effects of untreated sleep apnea. Comprehensive documentation of medical history, sleep studies, and treatment adherence is essential for clients to secure the most favorable ratings possible.

Keep in mind that each carrier has their own guidelines. Some carriers may be more lenient than others when evaluating sleep apnea. Working with a skilled brokerage that understands carrier stances on complex underwriting issues can help improve the client’s chances of securing coverage. 

Treatments and interventions

In some cases, effective management can improve insurability, though treatment alone does not guarantee better ratings. For clients who use CPAP devices, carriers often rely on documented CPAP compliance, including machine readouts or physician notes. 

However, clients who discontinue CPAP use after interventions such as ENT surgery or significant weight loss may face greater scrutiny. In these cases, carriers typically refer back to the original diagnosing study. They may treat the client as non-compliant unless a subsequent sleep study demonstrates that the condition has resolved or improved significantly. 

Advisors should encourage clients to maintain compliance with their prescribed treatments and, when necessary, obtain updated documentation to substantiate their health improvements.

 Key interventions include:

• CPAP machines: This is the standard treatment for most sleep apnea cases. Many modern CPAP machines collect extensive data on the client's condition that can help strengthen their underwriting case. 
• Weight loss: For clients with OSP, weight loss can decrease airway obstruction and potentially improve the severity of the condition.
• Surgical options: Some procedures, such as a tonsillectomy, can help open the airway and improve sleep apnea. However, it’s important to note that carriers require updated sleep studies after surgery to confirm treatment success.
• Positional therapy and dental devices: Though less common, these treatments can be effective for mild cases. However, carriers might not consider this a reliable treatment option for moderate to severe cases.

Strategies for advisors

Proper underwriting preparation is crucial to maximizing the client's chances of securing the best ratings. Here are some strategies that can help improve their chances of success:

• Encourage treatment compliance: Clients should follow their treatment plan for at least 3-6 months before undergoing an underwriting exam. 
• Set realistic expectations: Preparing clients for potential underwriting outcomes, especially for moderate to severe cases, is crucial. Ask clients pre-underwriting questions like when they were diagnosed, the type of sleep apnea they have, and if they’re compliant with their treatments, and discuss the underwriting outcomes they can expect.
• Exam preparation: Generally, clients should avoid caffeine, alcohol, and strenuous activities before underwriting medical exams to ensure accurate results. Proper CPAP data collection is also essential for underwriting decisions.

How Modern Life supports advisors

Modern Life’s underwriting expertise empowers advisors to confidently navigate the complexities of impaired-risk cases. Our approach begins with a holistic case review, where we analyze all available data to understand the client’s condition and pinpoint ways to position the client’s case in the best possible light. 

Modern Life advisors have access to digital tools that make working with clients seamless. For example, our digital fact finder allows advisors to capture their clients’ basic financial information, details on existing coverage, health and lifestyle information, as well as provide HIPAA consent electronically.

Additionally, we leverage our knowledge of carrier guidelines to tailor recommendations for clients. This strategic approach can enhance outcomes for both advisors and their clients.

Next steps

If you have clients with sleep apnea or other impairments, reach out to Modern Life for a second opinion and learn how our expertise can position your cases for the best outcomes.