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Retiree health and welfare benefits: controversy over their duration.

As the cost of providing health-care benefits skyrockets, employers have begun to reduce or even to terminate health-care and life insurance benefits for retirees, often with little awareness of the possible repercussions. Retiree groups and unions have countered these actions with claims based on such theories as the "status benefits" argument--that retirement benefits should be viewed as earned compensation for years of service--or the "vested rights" view--that retirement rights may not be altered without the pensioner's consent. Crucial to these conflicts are the terms of the collective bargaining agreement. Case law indicates that employers can never feel themselves fully protected even if the agreement contains provisions explicitly stating the benefits' scope and duration. The authors demonstrate this point in their review of recent retiree benefits cases. They then explore in detail the problem of contract and document ambiguity, and offer guidelines for ascertaining intent. They conclude with a discussion of strategies for litigating retiree benefits cases.

Insurance, Health↗

The adolescent with simple or corrected congenital heart disease.

An ever-increasing number of congenital heart disease patients are surviving into and beyond adolescence. Despite the encouraging cardiac results, with the vast majority asymptomatic and requiring no medication and having few, if any, limitations, there are many challenges for this patient population. They are likely to find obstacles to attaining education, social development, health and life insurance, and employment. Most of these obstacles are attributable to the stresses upon children with congenital heart disease and their families, and the prejudices of a society that knows little about congenital heart disease. Practitioners caring for these young people must be familiar with these issues and knowledgeable about the facts of individual cases, so that they may anticipate needs and offer support to their patients in their progress toward adulthood.

Adolescent↗

Medical information bureau.

The Medical Information Bureau (MIB) is a nonprofit trade association with approximately 700 life insurance companies as members in the United States and Canada. A computer bank that contains primarily medical information is maintained by the MIB. Safeguards are taken to assure confidentiality, and there is no linkage with other computer banks. Information is submitted to the MIB only after the individuals involved give authorization, and they have access to their records and can make corrections if necessary. Dissemination of computer information is made only to member companies when they have a bona fide application or claim and then only with the consent of the person involved. Medical directors of member companies have the primary responsibility for maintaining integrity and seeing that their companies adhere to the rules of the MIB.

Canada↗

Appraisal of the double two-step exercise test. A long-term follow-up study of 3,325 men.

We made an evaulation of the double two-step exercise test in the diagnosis and prognosis of coronary artery disease, on the basis of the findings among 3,325 male applicants for life insurance who were given the test and observed for an average of nine years. The results suggest that (1) ischemic ST segment depression of any amount after exercise is pathognomonic of coronary insufficiency, for all practical purposes; (2) the amount of ischemic depression is related to the severity of the coronary insufficiency and the prognosis; (3) ischemic depression in multiple leads denotes widespread coronary insufficiency; (4) a nonischemic response practically excludes coronary disease of a type that will cause premature death; and (5) the exercise test is more reliable than the medical history in the diagnosis of silent coronary disease.

Coronary Disease↗

Cardiac valvular tumors: cardiac papillary fibroelastoma.

Case histories of proposed life insurance are presented to introduce the topic of cardiac valvular tumors. Using fibroelastoma as the prototypical cardiac tumor, pathology, diagnosis, echocardiographic findings and clinical course are reviewed, based on available clinical literature. Although the natural history of benign cardiac tumors is uncertain, because of the risk of adverse outcomes, cases must be underwritten on an individual basis until long-term studies become available.

Adolescent↗

Asymptomatic ST segment elevation.

Asymptomatic ST segment elevation in a life insurance applicant's ECG raises several prognostically important possibilities such as myocardial infarction, pericarditis, Brugada syndrome and early repolarization. This ECG case study discusses the ECG features involved in the differential diagnosis.

Adult↗

Giant negative T waves.

Marked T wave inversion in a life insurance applicant's ECG may suggest high risk. Careful analysis of the ECG, an informative attending physician statement, and judicious use of additional testing allows the medical director to put this striking ECG abnormality in its proper context.

Actuarial Analysis↗

Non-invasive assessment of the risk of coronary heart disease.

OBJECTIVE: Non-invasive evaluations for the presence of coronary heart disease (CHD) are being done with increasing frequency in clinical medicine and as part of the risk selection process for life insurance. The predictive value of testing depends on the pretest probability of disease and the sensitivity and specificity of the testing used. This paper reviews the accuracy of exercise treadmill testing (ETT), myocardial perfusion imaging, stress echocardiography and electron beam computed tomography (EBCT) in the assessment of CHD risk. METHODS: Literature review using Medline. RESULTS AND CONCLUSIONS: Non-invasive testing is most useful in assessing persons with known or suspected coronary heart disease. Although a low pretest likelihood of disease limits the predictive value in young subjects and subjects with no known risk factors, a positive ETT or EBCT calcium score >160 may be viewed as a risk factor for CHD.

Coronary Disease↗

VEBAs--ordinary and necessary expenses--deductions and constructive dividends. Neonatology Associates, P.A. v. Commissioner of Internal Revenue.

Contributions made by professional medical corporations into voluntary employee benefit program plans (VEBAs), which were well in excess of the cost of the term life insurance provided to the participants, were not ordinary and necessary business expenses, and the distributions of surplus cash to owner physicians upon conversion to individual policies constituted constructive dividends taxable to the individual taxpayers.

California↗

Tall R wave in lead V1.

Tall R waves in lead V1 present the life insurance company medical director with a diagnostic dilemma. This ECG pattern may be present in applicants with right bundle branch block, right ventricular hypertrophy, Wolff-Parkinson-White syndrome, posterior myocardial infarction, hypertrophic cardiomyopathy, muscular dystrophy, dextrocardia, misplaced precordial leads, as well as in normal individuals. This ECG case study discusses the ECG features involved in the differential diagnosis.

Diagnosis, Differential↗

Second-degree AV block.

Second-degree AV block includes a variety of conduction patterns of variable prognostic significance. Careful analysis of the pattern of PR and R-R intervals, the QRS axis and duration, as well as the presence or absence of structural heart disease should allow the medical director to assess the applicant's risk for life insurance.

Electrocardiography↗

Short PR interval.

A short PR interval may be associated with an otherwise normal electrocardiogram or a myriad of bizarre electrocardiographic abnormalities. Clinically, the individual may be asymptomatic or experience a variety of complex arrhythmias, which may be disabling and rarely cause sudden death. In life insurance applicants, it is important to recognize these abnormalities and to assess their risk appropriately.

Adult↗

Right atrial abnormality.

Occasionally, a prominent P wave is encountered in a life insurance applicant's electrocardiogram. Prominent P waves may be normal variants or alert the medical director to prognostically significant structural heart or pulmonary disease. This case study reviews the commonly used criteria for the ECG pattern of right atrial abnormality and some of the pitfalls associated with its use.

Adult↗

Positive computer-generated exercise electrocardiogram.

The use of computerized averaging of the electrocardiogram (ECG) during stress testing has facilitated the removal of motion artifacts and baseline shifts. However, this process can introduce errors, which may not be appreciated by medical directors. Such errors can lead to significant ST depression in the absence of coronary artery disease. Such false-positive tests may lead to anxiety in the applicant, delays in accepting the application and unnecessary additional testing. This case study illustrates a common pitfall associated with using only a computer-generated exercise ECG for risk assessment of a life insurance applicant.

Actuarial Analysis↗

Increased QRS voltage in the limb leads.

Increased QRS voltage accompanied by repolarization abnormalities in a life insurance applicant's electrocardiogram should alert the medical director to the possibility of left ventricular hypertrophy. If confirmed, left ventricular hypertrophy or increased left ventricular mass is a strong independent risk factor for future cardiac events and all cause mortality. The use of the electrocardiogram to diagnose left ventricular hypertrophy can be helpful, but there are limitations that need to be considered. This ECG case study illustrates some of the pitfalls in the electrocardiographic diagnosis of left ventricular hypertrophy.

Aged↗

[Suicidal behavior and "individual freedom"].

There are two conceptions of suicides: suicide as completion of a pathological development and suicide as a voluntary, well premeditated rational act. Between these poles we see a spectrum of various modes in the genesis of suicidal acts. In its conceptional framework this spectrum is placed on two different levels which are incommensurable to each other. Suicide as a pathological event and suicide as a free act (voluntary death) are two aspects, related to each other in a relationship of mutual concealment. Against the background of this ambiguity we discuss a discrepancy of two different aspects: The aspect of the suicide-statistics of private life-insurance-companies and the conception of suicide in psychiatry. There is stated a higher suicide-rate among insurants, which we attempt to interpret. Following reasons are to be discussed: 1. different areas of experience; 2. correlations between traits of the personality of insurants and traits of the personality of men or women who later on will commit suicide; 3. a preference of suicides by temptation to commit suicide in order to get money for the surviving family (we leave undecided wether primarily planned or secondarily promoted). There might be a broader interest in the second hypothesis (= people with a "Typus-melancholicus"-personality structure [Tellenbach] seem to become more often depressive than other people). This hypothesis should be examined in further research.

Expert Testimony↗