Protection Products

Ask an Underwriter: Don’t lose sleep over your sleep apnea cases


Sleep apnea is one of the most common, and often underdiagnosed, impairments we see in underwriting. It affects up to 18 million people in the United States alone.1 It can be defined as a disorder that causes someone to have one or more pauses in breathing or shallow breaths while sleeping, lasting anywhere from a few seconds to a few minutes. Typically, normal breathing starts again, sometimes with a loud snort or choking sound. These breaks in the sleep cycle can leave someone tired throughout the day, otherwise known as excessive daytime sleepiness, or EDS.


The most common type of sleep apnea is obstructive sleep apnea, or OSA. It happens when the tongue, tonsils or other tissues in the back of throat block the airway, causing someone to have shallow or paused breathing. Central sleep apnea is less common and happens when the brain doesn’t always signal the body to breathe when it should. Obstructive sleep apnea is most commonly seen in individuals who are overweight, but keep in mind that it can affect anyone.


Sleep apnea can have many negative long-term effects on health and mortality risk, including: 

  • Hypertension or high blood pressure
  • Lung damage
  • Heart disease and heart failure
  • Stroke
  • Arrhythmias or abnormal heart rhythms
  • Pre-diabetes and diabetes
  • Fatigue-related motor vehicle accidents and work accidents
  • Depression


The severity of sleep apnea can be determined by overnight polysomnography (also knowns as PSG, or a sleep study). This test determines an individual’s apnea-hypopnea index (AHI), the number of apneas they have per hour, and it also documents their blood oxygen levels. Treatment is recommended based on the study’s findings. And, the success of treatment is normally documented by a follow-up sleep study.



Basic treatment includes weight loss, the avoidance of stimulants (such as alcohol) before bed, and adjustment of sleep position. A CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure) machine is considered the “gold standard” of sleep apnea treatment. It prevents the collapse of the airway by pumping airflow during inhalation by face mask or nose cushions. Successful treatment includes regular, nightly use of the machine; however, some people cannot tolerate the device, mask and associated noise.


In recent years, popular alternative treatments have included:

  • Oral Appliance: Mouth device worn to prevent the collapse of the tongue and soft tissues in the back of the throat by supporting the jaw in a forward position; approved by the American Academy of Sleep Medicine as first-line treatment for mild to moderate OSA
  • Night Shift: Device worn on the back of the neck that begins to vibrate when users sleep on their backs
  • Winx Sleep Therapy System: Mouth device that generates negative pressure in the oral cavity, which draws the soft palate and uvula forward and stabilities tongue position



A life insurance offer for clients with OSA is determined by the severity of the disease, measured by AHI and oxygen levels during a sleep study. Favorable client conditions include mild disease (low AHI and minimal low oxygen levels or hypoxia), consistent use of CPAP/BiPAP (or possible alternative treatment), controlled blood pressure, no co-existing heart or lung disease and no risky motor vehicle events. 


Favorable cases can sometimes be considered unrated. For example, a client with mild sleep apnea who is compliant with CPAP/BiPAP, and has normal blood pressure with no associated impairments would not be rated, and they may be eligible for all preferred classifications with some carriers. Other cases may range anywhere from standard and up, depending on the severity of sleep apnea and compliance with treatment.


The Ash Brokerage underwriting team leverages our experience, carrier relationships and resources to identify viable solutions based on your client’s individual circumstances and insurance needs. For your next sleep apnea case, use our helpful questionnaire. And, contact us so we can suggest ways to help you obtain the most favorable offers. Let us awaken the possibilities!


About the Author

Lisa Oleski has been brokerage underwriting for the past 20 years. She is passionate about treating each case she touches as an opportunity to exemplify the Ash difference, with the ultimate outcome of finding the most favorable solutions for advisors and their clients.



Learn More

1National Sleep Foundation, Sleep Apnea:

Underwriting Sleep Apnea

Ask an Underwriter: What is NT-proBNP and why does it matter?


NT-proBNP is a fairly new blood test, for both clinical medicine and insurance risk assessment. 


What is it? 

B-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are hormones produced by your heart to regulate blood pressure and fluid balance. Normally, circulating BNP and NT-proBNP levels are quite low – they increase when pressure in your heart changes due to increased blood volume, fluid retention or ischemia. 


How is it Used?


Due to its predictive value in assessing the strain to the heart, NT-proBNP is considered by American College of Cardiology to be the benchmark against other biomarkers for heart failure.1  Results may help determine if you have heart failure versus other causes of dyspnea (difficulty breathing or shortness of breath). Increased levels in patients with difficulty breathing show an increase in likelihood of heart failure.


Elevated NT-proBNP can also be found in other conditions, including acute lung injury, acute myocardial infarct, atrial fibrillation, cardiac amyloidosis, COPD, chronic renal failure, cirrhosis, hypertension, pulmonary hypertension, pulmonary embolism with associated right ventricular dysfunction and subarachnoid hemorrhage.


Normal NT-proBNP levels (based on Cleveland Clinic’s Reference Range2):

  • Less than 125pg/mL for patient’s age 0-74 years
  • Less than 450 pg/nL for patient’s 75 and older


If you have heart failure, the following NT-proBNP levels could mean your heart function is unstable:

  • Higher than 450 pg/mL for patients under age 50
  • Higher than 900 pg/mL for patient 50 and over


ProBNP levels are higher in women, older individuals and people with renal insufficiency. Some medications, such as ACE inhibitors, beta-blockers, spironolactone and diuretics have been known to decrease levels.


What’s it mean for underwriting?

NT-proBNP has been selected over BNP as the superior test for insurance companies, as it is easier for parameds to correctly administer the blood draw. This simple blood test is run by carriers for certain ages and amounts, often in lieu of resting EKGs, and has helped eliminate the need for stress EKG testing at larger face amounts.


In their risk assessment, insurance carriers use NT-proBNP along with many other cardiac risk factors (hypertension, hyperlipidemia, family history of coronary artery disease in first-degree relative, tobacco use and diabetes) and any known history of vascular disease, atrial fibrillation, congestive heart failure and/or renal insufficiency. 


Elevated NT-proBNP levels could prompt an underwriter to ask for additional cardiac work-up, such as a repeat blood test, stress test, echocardiogram and/or cardiology consult.


Ash Brokerage is here to assist you! To simplify your fact-finding process, use our NT-proBNP Client Questionnaire and reach out to us for help. We leverage our experience, carrier relationships and resources to identify viable solutions based on your client’s individual circumstances and insurance needs.  


Learn More 

1Journal of the American College of Cardiology, “NT-proBNP: The Gold Standard Biomarker in Heart Failure,” December 2016:

 2Cleveland Clinic, B-type Natriuretic Peptide (BNP) Blood Test:


About the Author

Diane Fulk has been in the life insurance industry for more than 40 years, helping many families secure much needed life insurance coverage and peace of mind. She approaches each case, like each person, individually. She is certified in EKG interpretations, has passed all three of the Academy of Life Insurance Underwriting exams and many LOMA exams.

Underwriting Blood Tests Cardiology

Protection and Longevity


What’s the one thing you want to live to see in your lifetime? For Mabel Ball, it was seeing the Cubs win the World Series for a second time. Mabel was born Aug. 6, 1908 – two months before the Cubs won the Series. She passed away at 108 years old, less than a week after celebrating their 2016 victory.

But baseball wasn’t her only passion – it was an outlet for the ups and downs she experienced through other aspects of her life.  As we move into 2017 and beyond, here are five areas where we can help others imagine, plan, and act differently during their working and retirement years, so they can find their own passion and live to see their dreams become reality.


It’s no surprise – we’re living longer. During Mabel’s 108 years on Earth, life expectancies increased by more than 30 years. Today, individuals over age 85 represent the fastest growing demographic segment within America. Current statistics indicate life expectancy trends will continue to increase by 2.5 years every 10 years.

Increased life expectancies should be a great thing, but it creates a big question: how can we best be prepared to address the individual financial issues that accompany a long lifespan?  There’s no longer a choice; longevity risk must be addressed as part of any financial conversation.

The insurance industry is uniquely positioned to address longevity risk.  Over the coming years, insurance products that provide solutions to longevity – such as income annuities, DIAs, QLACs, asset-based long-term care insurance and cash-value life insurance – will become even more essential tools. It’s why we are investing heavily in a patent-pending analytical program to change the way Americans think about, plan for and enjoy retirement.  Look for more information to come in 2017 as we continue to change the conversation.

Health Care

In recent years, health care has been on a wild political ride, but no matter what happens with government regulations, the economic impact is certain.  Mabel was an anomaly, maintaining fair health until suffering a heart attack earlier this year.  Still, as we live longer, we generally need more care and assistance, and it doesn’t come cheap. 

We know long-term care can be costly – the current average nursing home cost is about $92,000 per year, and with inflation, that may double in 20 years. Unfortunately, very few Americans have affirmatively addressed this risk.

Today, only 8 million Americans have long-term care insurance.  Very few individuals and families will be able to absorb the economic shock of an extended health care event. And, the economic impact will be exacerbated by the emotional challenges associated with a loved one who needs assistance.

It’s time to think differently about the impact that long-term care, home health care or nursing home care can have on the dignity of the impacted individual and the financial and emotional impacts on their loved ones.  The question should not be, "Can we afford some type of long-term care protection?" The real question should be, "How can we best plan for these life events and ensure that our family is protected?"


A wise man once commented, "... In this world nothing can be said to be certain, except death and taxes."  It’s true, even if you live to 108. 

Mabel shows us why we’re now issuing life insurance policies at older ages.  Traditionally, life insurance was only useful once you died. Today, thinking of a policy as only providing a financial benefit after death is short sighted.  Many extremely successful advisors have realized that life insurance should be thought of as a valuable asset within an overall financial portfolio.

2017 is the year to re-imagine life insurance as an asset uniquely positioned to offer more effective and efficient value than any other financial product.  We should change the conversation in order to focus on the current and positive attributes of life insurance. Properly designed and structured, life insurance policies and portfolios can accomplish all of the following objectives:

  • Essentially provides the equivalent internal rate of return of a high-quality bond
  • Addresses longevity income issues through tax-efficient cash withdrawal plans
  • Generates robust income streams to fund long-term care and chronic illness expenses
  • Provides a pool of money – or an income stream – to support legacy and charitable dreams and objectives
  • Provides tax deferral and offers an extremely tax-efficient design

As you can see, the value of these policies is not simply embedded in a benefit that becomes available at death – life insurance can be extremely beneficial while individuals are alive. Additionally, these are terrific financial products that offer individuals an opportunity to make a meaningful impact in the future through legacy and charitable actions.  


And speaking of taxes … the recent election has created a lot of uncertainty around income and estate taxes. While we do not know what the future holds – we do know that the government needs tax revenue to function.  


Take the federal estate tax for example:

  • We do not know if the federal estate tax will be repealed, tweaked or fundamentally changed
  • We do not know the impact on gift taxes, potential carryover basis expansion, etc.
  • Most importantly, we do not know what the federal estate tax will be at the date of any individual's death  


With uncertainty, individuals may have a bias toward inaction. We believe inaction is not only counterproductive, but can be financially devastating in the future.  As people age, their health conditions generally deteriorate and insurance becomes costlier.

There are many strategies to optimize estate tax planning under current federal laws, and allow for flexibility if those laws change.  Prudent planners will not sit on the sidelines waiting for the future to unfold. Instead, they will take action and analyze current estate plans, irrevocable trusts, etc.

It is also important, given the uncertainty, to address asset allocation and asset location. A clients' overall financial picture should include a blend of taxable, tax-deferred and tax-free assets.  This approach will optimize financial positioning today and well into the future.  

Multiple Markets

When Mabel was born, the idea of a computer – let alone a smart phone or the internet – was nothing more than science fiction.  Today, technology continues to transform the insurance industry and make it more accessible.  Innovations such as electronic applications and accelerated underwriting will make smaller policies more readily available and easier attainable, opening up more solutions not just for the wealthy, but for everyone. 

We’re very excited about opportunities that will allow business owners, high-net-worth individuals and middle-income Americans to achieve what is important to them.  We’ve designed action-oriented plans, structures and processes which address the needs and opportunities of various demographic and industry groups.


We can’t all be lucky enough to live to see our dreams come true.  In addition to being a loyal lifelong Cubs fan, Mabel illustrates many of the reasons why we should be incredibly optimistic about the state of our industry today, tomorrow and well into the future.

While we cannot predict the future, we can take certain financial and longevity risks off the table and plan for not only for today but also tomorrow. It’s an obligation and a privilege to make sure that these issues are addressed and acted upon. We truly believe the best is yet to come!

Life Insurance Longevity Healthcare Finance

Life Insurance: Changing up the Traditional Recipe


This is such a magical time of year – so many fond, heartwarming memories, both old and new traditions year after year, from one generation to the next. It’s fair to say, regardless of your beliefs, many holiday traditions are centered around two things:

  • Loving others
  • Expressing that love through giving


My favorite holiday tradition involves a full blown baking marathon weekend, where we prepare 30 different types of cookies and treats, then make gift trays for family, friends, coworkers and neighbors. Having carried on this tradition for more than 20 years – from my mother and my mother’s mother – it’s been an amazing gift to see the joy it brings to others, especially when watching our children give trays to our neighbors.


Old Meets New

You may think traditions are hard to maintain in today’s fast-paced, commercialized society. I would challenge that thinking because many “old” traditions are easily upgraded – my family’s included! I have a pantry full of modern baking gadgets, a wealth of recipes/tips from the Internet and an abundance of stores where I can easily buy ingredients. All of these advancements provide the opportunity to do more, do it better and do it all in less time. The tradition remains, but the convenience is greatly improved.


The same applies to how our industry is evolving. Life insurance has been a “traditional” product in the eyes of most consumers, but we’re working to change up the recipe. Just like your holiday traditions, life insurance is based on:

  • Loving others
  • Expressing that love through giving


Complicated Meets Streamlined

Let’s start by changing the perception that all meaningful gifts are tangible, and that life insurance is “old fashion and complicated.” Over the last year, we’ve seen carriers progressively adopt automated underwriting enhancements to do just that.


Today, seven of our carriers offer streamlined underwriting programs, with face amounts from $50,000 up to $1 million, for ages 18-60. Qualifications vary from carrier to carrier, of course, but the majority of these programs target preferred/healthy clients. In an effort to improve the process of obtaining life insurance, carriers are utilizing conveniences like e-applications, streamlined underwriting and e-delivery.


We’re changing the recipe for traditionally underwritten coverage, too. We’ve seen carriers reduce age/amount requirements, many eliminating resting EKGs, physician’s exams and inspection reports – all of which are highly invasive for clients. As medical advancements extend our life expectancy, carriers are adjusting their expected mortality, as we’ve witnessed with specific impairments like hepatitis C, prostate cancer and even HIV.


Tradition Meets Improvement

These are the very beginnings of the changes we need to reach new markets, find new customers and start an improvement of traditions within our industry. The Ash Brokerage family will always honor of the tradition of helping you make the right choices for your clients – we’re also striving to improve that tradition and make it easier to give the gift of love.


About the Author

Jennifer Glessner knows every opportunity she’s entrusted with is truly a gift, whether it’s the advisor’s first or 100th policy. With 20 years of life insurance experience, she grew up in the business and has a vital understanding of where we were, where we are and where we are going as an industry. Her diverse background includes underwriting, sales, operation and leadership, and she’s also an Associate of the Life Management Institute and an Associate of the Academy of Life Underwriting.

Life Insurance Process Improvement Tradition

Ask an Underwriter: Why should clients be screened for diabetes?


November is American Diabetes Month and, ironically, the month for pumpkin pie! But … diabetes is about far more than skipping or modifying dessert. It’s a common condition affecting millions of Americans with potential life-threatening complications.

In fact, according to the American Diabetes Association, 29.1 million Americans, or 9.3 percent of our population, had diabetes in 2012, and 1.4 million Americans are diagnosed with diabetes every year.

So, even if your clients haven’t been diagnosed as diabetic or pre-diabetic, it’s important to understand the disease and its risk factors. One simple screening could save a life or a lifetime of complications! Unfortunately (or fortunately), their lab results can come back with surprising results.


Types of Diabetes

Type 1 diabetes

usually develops in childhood or adolescence (prior to age 30) and accounts for 10-15 percent of all cases. In Type 1, the cells in the pancreas responsible for producing insulin have either been destroyed or produce no insulin. Since no natural insulin is available, treatment involves injection of laboratory-manufactured insulin for effective control of glucose metabolism. Risk factors for Type 1 include autoimmune disease and a family history of diabetes.

Type 2 diabetes

is commonly associated with obesity and onset after age 30. A family history of diabetes is common, and sufferers probably inherit a predisposition to glucose intolerance, which is exacerbated by obesity. 

Gestational diabetes

starts or is first recognized in pregnancy, in a previously non-diabetic woman. It usually becomes apparent during the 24th to 28th week of pregnancy. Risk factors include family history of diabetes, obesity, birth weight over 9 pounds in a previous infant, unexplained death in a previous infant, congenital malformation in a previous child and recurrent infections. Thirty to 50 percent of women with a history of gestational diabetes develop non-insulin dependent diabetes within 10 years. 


Potential Complications

  • Diabetes Mellitus

    is a group of metabolic disorders characterized by chronic hyperglycemia from insulin deficiency or resistance, or both. It is usually irreversible and, although a reasonable lifestyle can be enjoyed, the late complications result in reduced life expectancy. Macrovascular disease leads to an increased prevalence of coronary artery disease, peripheral vascular disease and stroke. 

  • Neuropathy

    is damage to the small blood vessels that supply all nerves, causing numbness and tingling in the extremities, abnormal sensations and muscle weakness.

  • Nephropathy

    is a progressive kidney disease caused by damage to the capillaries due to longstanding uncontrolled diabetes.

  • Retinopathy

    is damage to the retina in the eye from microvascular changes which can cause blurry vision and, in extreme cases, blindness.

  • Proteinuria

    is the presence of excess levels of protein in the urine due to damage to the kidneys.


Testing – Hemoglobin A1C

The industry gold standard for identifying applicants with, and those at risk for, diabetes is an A1C screen. This test measures a person’s average levels of blood glucose, or blood sugar, for the past two to three months. It is measured as a percentage, and the ideal range is less than 5.7.

A hemoglobin A1C screen is stable, is not affected by glycolysis and does not require fasting, making it more reliable and accurate that a glucose test. These screenings can empower applicants to take control of their health, especially those who are pre-diabetic and have the chance to make life-saving changes.

So let’s all become aware – about diabetes or any disease. Ask questions. Educate yourself. Be an advocate for yourself and your clients. More importantly, know your number!


Learn More

Statistics About Diabetes, American Diabetes Association:


About the Author

Debra Misko is passionate about her work and gratified to help clients find security for their family’s future. She has worked in underwriting for 21 years and has been with Ash Brokerage for more than eight years. A graduate of Schoolcraft College, she has a business degree and has also completed two of the Academy of Life Insurance Underwriting exams. 


UW Underwriting Diabetes