Kathryn (00:00:06):

Hi everybody. I have Matt Rann back with me. We are on season seven, episode 14, the last episode of season seven before the summer break. Today we’re going to be talking about kidney disease. Hi Matt.

Matt (00:00:17):

Good morning Kathryn. How are you keeping?

Kathryn (00:00:19):

I’m very good, thank you. Hoping to get out in the sunshine today. How are you?

Matt (00:00:23):

Well, I’m jealous immediately because on the opposite side of the pennines it’s cloudy.

Kathryn (00:00:30):

It’s god of sunshine here, sorry.

Matt (00:00:34):

Well, most of the year I thought that the northeast was supposed to be cloudy and the northwest was supposed to be full of sun. So it’s a complete change around, but yes, I’m very well thank you. I have to say I’m going on holiday tomorrow morning for a rest having been fishing with a very good friend of mine and also watching a series of bands at our local festival, including, what can I say, including moley crew. I won’t say any more about that, but they were great fun. Very nice. So going on a holiday for a rest. I don’t think I’ll get off the Sunbed for at least three days.

Kathryn (00:01:09):

Well that’s good. I was going to say, and it wouldn’t be a podcast with you if you hadn’t just been back from a holiday or just being going onto a holiday.

Matt (00:01:17):

Well thanks Kathryn for that. I would refer you to my wife, who is the lady.

Kathryn (00:01:23):

Well, you may as well live life to the full

Matt (00:01:26):

Well indeed, yes indeed. When you have to live in the north of England. Well the northwest of England, should I say anything that’s has sun related to it, you have to grab with both hands. Absolutely. There we go.

Kathryn (00:01:38):

Absolutely. So we are going to be talking about kidney disease, the things that we need to know to ask as advisors and to be able to do our underwriting research properly and the potential terms to help our clients. So this is the Practical Protection Podcast.

Speaker 3 (00:02:01):

So

Kathryn (00:02:01):

To just give a little bit of background in terms of kidney disease, there are lots and lots of types of kidney disease and chronic kidney disease can affect anybody. And we’re going to talk about chronic kidney disease because it’s quite an interesting one. Me must have had some really good nattering over this at times because the readings that you need to know about it can be very much one of those things where doctors aren’t bothered by the reading that somebody has. But it’s very, very different to insurers. So we’re going to deep dive into that. But kidney disease, it’s usually older people. It’s not to say that it definitely is, but it’s kind of part of parcel in life. So as we get older, we tend to maybe have a bit more weight on us. Our blood pressure might increase a bit, our cholesterol potentially increases.

(00:02:48):

And it’s not to say that we’re going into bad or dangerous levels, it’s just part and parcel of us getting older. And it’s the same with the kidneys. Sometimes the function can change a little bit. Kidney disease in itself is more common within black and Asian communities. It can be linked to things like high blood pressure, diabetes, high cholesterol and enlarged prostate, some medications and linked to things like polycystic kidney disease and I believe that there are five stages of kidney disease. So to start us off, Matt, can you give us a bit of background about what kidney disease is, what classifies as kidney disease?

Matt (00:03:26):

Okay, well as you mentioned, there are many, many classifications of kidney disease and classified generally around the cause of the disease itself. You’ve touched on one polycystic kidney disease, which is genetic as many of our listeners who know you can get something, a wonderful technical name called omero nephritis where basically the, it’s thought the main cause of nephritis is autoimmune and just again, something that we’ve talked about historically, but that’s where the body starts attacking itself if you like. But the most common kidney disease is linked to urinary tract infections, UTIs for short, and that’s called pyelonephritis, which as opposed to an autoimmune GLO nephritis is in fact a caused by bacterial infection

(00:04:32):

And that effectively can start in the urethra and pass up into the bladder and then up through the tubes that connect the kidneys to the bladder and it can, sorry, cause damage to the kidneys themselves and if not treated, can eventually go move into the realms of kidney failure where you’ll need dialysis and potentially, hopefully for those who need a kidney transplant. And of course again, death unfortunately at the end of the day. So kidney disease is a rough polycystic kidney disease is really what it says on the tin. The kidneys themselves start to become very cystic cysts grow within the kidneys, generally fluid filled and that interferes with the working of the kidneys and as you alluded to, kidneys are incredibly important in the body without any shadow of a doubt. I mean just to go back to maybe a little bit of O level physiological kidney around news thoughts around kidneys, but as I said, most of the listeners will know, I’m sure that generally people have two kidneys, some people are born with one.

(00:06:07):

Sometimes if a kidney fails you can have the kidney can be taken out and the body and the human body can do just as well on one. You can think about all the pairs of organs that the body has and it’s amazing really about how we have evolved as human beings that somebody somewhere, or maybe it’s the body itself of course is decided to have two just in case one goes wrong. It’s quite incredible. That’s safe and sorry. Absolutely, that’s right. So generally kidneys are a pair of organs that lie on either side of the spine in your lower back and if anybody’s been unfortunate enough to have let’s say a kidney infection, then people generally get a feeling of pain and soreness generally on one side in the lower parts of the back and that can often be down to a kidney infection of some sort or another. Each kidney is a made up of millions of filtering units called nephrons and that’s where you get nephrology from to study the kidneys and each nephrons a filter called the ERUs and the tubial and basically as I’ve alluded to already with the nephrons, the ERUs actually filters the blood and the tubules themselves remove the waste matter from the body but also it’s clever enough to return the vital minerals and salts to the blood as well. So it has a two-way function as well as filtering in terms of the waste matter and minerals.

(00:08:02):

No surprise to anybody that the kidneys also take out extra water from your blood and gets rid of it through the urine as well. So if you drink loads then your kidneys are working hard and you go to the new a lot, everybody will know that themselves. So very very important part, as I’ve said, main job of the kidneys are around filtering the blood itself but the kidneys also release hormones into the body and amongst a number of jobs that they do. One of the very important ones is to control blood pressure controlling the water levels themselves itself and you often when people are first checked I say first checked when they first checked and reviewed, then the medics will often look at not only the blood pressure itself but also the functioning of the kidneys. Sorry, probably didn’t explain that very well because they are blood pressure and kidneys are so intimately related.

(00:09:20):

One controls the other. If you do have hypertension raised blood pressure, then the kidneys are certainly something that is looked at and checked to see if there is a problem in the kidneys. Sometimes there can be, but more often than not the kidneys are absolutely fine but they will always look at that and it’s no surprise perhaps to everybody that underwriters are very interested in the wellbeing of the kidneys in their own right, but also with somebody who has raised blood pressure or problems with their blood pressure. The causes of kidney disease are many certain acute and chronic diseases can cause problems with the kidneys, toxic exposure to environmental pollutants or even certain medications as well. If you think of anti-inflammatory medicine, steroids and so forth, that can cause one with the kidneys and the medics will often obviously if you are on anti-inflammatories, we often look up the kidneys or monitor the kidneys to make sure that they’re all good. When I said about my teeth are forming out, again toxic exposure, bear in mind I just saw moly crew at the weekend, it made me smile when it said one of the causes is heavy metal poisoning. So I thought, yeah, well yes I know what that’s all about. But to be put to be more specific poisoning by, like I said mercury or arsenic can cause problems with the kidneys.

(00:11:08):

Again, not that common these days in terms of exposure, but there we go. And it goes without saying that if the kidneys are unable to function properly, the body can come overloaded with toxins because that filtration is not working, which leads in turn to kidney failure and as I’ve said already and if it’s not treated it can cause end up in death I’m afraid. So basically the type and there are many, as Kathryn has said already, many types of kidney disease or classifications of kidney disease. The one that I particularly wanted to talk about as it is certainly the most common use this technical name pyelonephritis is that is heavily linked to infections in the urinary tract. UTIs are much more common in women than they are in men and one of the reasons for that is the length of the urethra, which generally in men is much longer than it is in women. And when that urethra is short, it allows the fact that bacteria don’t have so far to travel, let me put it that way, like

Kathryn (00:12:33):

Build up in a smaller area,

Matt (00:12:36):

They can get through and get into the bladder and again if not sorted then they’ll get up into the kidneys and cause all types of problems. Symptoms of urinary tract infections, again, pain in the back or in the groin area caused by the inflammation itself. Chills, fever, nausea, vomiting again which I think are pretty common enough with infection, without infection. And also the medics will often ask about the color of your urine as well. So dark, cloudy and dare I say foul smelling urine are often signs of a urine tract infection and if anybody is any doubt these aren’t things to be ignored. Go and get your doctor, put a short course of antibiotics and that will sort it out. If you don’t get it sorted out it can lead to some quite nasty end results as I think I’ve alluded to already, Kathryn, does that help at all in terms of giving an overview of a little bit about the kidneys, the importance of what they do and believe me they’re incredibly important organs. What I should say is maybe also add that kidneys in a completely well individual completely fit individual can often be different sizes.

(00:14:14):

I dunno if you’ve come across that in the reports that you see

Kathryn (00:14:21):

Somebody just born with one.

Matt (00:14:23):

Yes, absolutely.

Kathryn (00:14:24):

I’ve definitely had that, but I dunno if I’ve come across one with different sizes

Matt (00:14:28):

Because of what I do. I suppose in the industry I see an awful lot of results of scans

(00:14:35):

And it’s quite a common feature that one is larger or one smaller than the other and also it’s not that uncommon as well to find isolated simple cysts On these scans I see a lot of scan results where the radiologist will comment on the kidneys but they’re in fact looking at something completely the reason for the scan is something completely different. So these are often incidental findings, the simple cysts and again they don’t cause any problems at all and nothing to be worried about. This is very difficult, sorry, very different to polycystic kidney disease I would add, which is a completely different situation, but

Kathryn (00:15:28):

That’s really, really helpful especially for me. I’m very aware of things like high blood pressure and stuff like that.

Matt (00:15:33):

Absolutely,

Kathryn (00:15:34):

Absolutely. But in my mind I’ve never linked how the blood pressure is affected by the kidneys and sort of thought of that process and that connection. So that’s really, really interesting to hear. That’s a thank you. No problem. So in terms of what an underwriter is going to want to know, so I’m coming to you as an advisor, you are the underwriter on the case. I’m going to say someone has kidney disease. What is it that you want to know from me?

Matt (00:16:02):

Okay, well the first thing that would be the most useful is what type of kidney disease are we talking about? People I say generally certainly 50 50 basis will know the type of kidney disease. So if I look at glomerulonephritis or nephritis then a good number of people will remember that name unusual. Often people will just say they have nephritis or a history of nephritis, not sure about which one it was, but the advisor can probe a little bit in terms of most likely, most common is plon nephritis. So the advisor, if we could probe a little bit and say did you have any for many urinary tract infections and then that will give you a clue that is very, the answer is yes, give you a big clue that it is likely to be lon nephritis. So it’s the classification if known, if it’s not really known just simply get it was a problem in my kidneys or similar probe. A little bit more about urinary tract infections.

(00:17:27):

The usual questions around when were you first diagnosed, when were you last, have you been discharged pyelonephritis? Often people are discharged because simple course of the antibiotics can sort everything out. Some cases you will is worth asking whether they know they’ve had their their kidney function or renal function tested and I would suggest that most people will come back with yes, but they are unlikely to know the numbers. Blood pressure can be tricky. It can be with I think particularly with renal disease because you are looking at some quite technical headings here. One of you’ve got the renal function on a standard blood test and biochemistry, so they’ll look at things like blood urea and creatinine and things like that.

(00:18:37):

When the medics want to look into the actual function with the kidneys, they will tend to look at or use GL GL filtration rate or A GFR done for short and this is the one that’s always the test result always makes me query quite what is going on because as you again alluded to Kathryn at the very, very beginning here, very about the kidneys just through age become less good at their job. Let me put it as plainly as that in terms of that filtration as you get older and that’s completely normal as, but you youer filtration rate does drop and it never ceases to amaze me when references to CKD. So chronic kidney disease stage eight, well it’s a numerical 1, 2, 3, 4 or whatever come up in gprs and the client, sorry, the report from the doctor and their patient, our client turns around and says, nobody’s ever told me there’s anything wrong with our kidneys.

(00:19:58):

It comes up and I know you and I have spoken about this before completely out of the blue and then underwriters jump on it and say, oh goodness gracious, CK, D, that’s really, really bad. But I think the underwriters need to ask a lot more questions before they make that judgment call. Certainly the doctors don’t tend to do anything about it, would they do anything about it? And somebody who is naturally their kidneys are slowly reducing their effectiveness, what can they do about it? Is A and B, do they want to tell their patient because it may get them worried that their kidneys are starting to fail when in fact it’s just part of the normal aging process. I think some questions about how they treat those type of random findings, the challenge you have is as an underwriter you get this completely out of the blue CKD three or whatever and of course because the doctor’s not doing anything about it then you don’t have any readings, you don’t have any tests from renal function tests, kidney function tests or anything like that because nothing is being done.

(00:21:15):

Obviously bear in mind what we’ve been saying looking at the blood pressure, it is important to make sure that’s absolutely fine but as I say, I don’t have at this moment in time I’m still investigating it to be perfectly honest with you, a magic silver bullet to say twin underwriter or give guidance twin underwriter about really what they should do. But as I’m sure most of them will know, the GFR reading tends to come up with a label and that label isn’t as often as frightening as it sounds and therefore we could be applying terms to cases that are far more heavy then perhaps warrant. So it is still something I’m afraid I’m still investigating and trying to come up with an idea even for me let alone anybody else. But all I would say my gentle prod at underwriters is please just don’t take those particular comments at face value. Try and look at it in the whole,

Kathryn (00:22:29):

We’ve had some really interesting ones recently and obviously things that pop into my mind. So as an advisor because of the way that it works, when I speak to underwriters, I usually will not do research without that EGFR reading just because of the fact that if you speak the general response that we get when we speak to underwriters, if we were to mention kidney disease, they would say, well it comes down to what their kidney function is. If it’s below this number it’ll all be a decline. If it’s between these numbers it might be this rating. If it’s above this then we should be looking okay and just quite very minimal rating maybe. So it’s really hard because as with anything, unless from an advisor’s point of view when we’re trying to manage client’s expectations and it is hard because I can understand it from the underwriter’s point of view, an underwriter can’t say specifically what it’s going to be because there’s such a range in terms of what they’re seeing in terms of their underwriting manuals as to what these certain cutoffs are for. Yes, we can cover no we can’t cover.

(00:23:38):

And ultimately and I believe as well is that the higher the numbers the better isn’t it? I think when it comes to the kidney function. So it is usually about them saying if it’s under this number then that’s when we’re going to not be able to cover. So for me when I speak to clients, I’ll just say I cannot give you an accurate indication, I can’t choose the right insurer because I don’t have enough information. And so when you were saying about people don’t often know the numbers, you’re right, a lot of the time people say to me, well I’m not sure. And so what I tend to say to people is, look, just very quickly ring up your GP and say to them, can you let me know this? One of the things I do say to people as well is, and this isn’t trying to get around any kind of agreements that are in place or anything, but obviously gps are told that if somebody wants something for insurance purposes, that there’s a specific routes to take, the insurer has to pay the GP for a report and that’s obviously all set up and it’s absolutely fine, but what’s important is to make sure the client’s aware to in a sense, to not hide it from the gp.

(00:24:36):

I’m not going to say that at all, but just be very clear that this isn’t an insurer asking, this is themselves asking because they need to do research so we’re not triggering into this whole thing of the GPR process yet because as soon as it’s mentioned that it’s insurer, then there can be times that I’ve certainly come across it where someone said, well I said to them it’s because I’m going for insurance and they’ve said no, they can’t tell me. And that’s quite an issue in terms of data protection as well because it is their own data, they should be given that information from the gp but it’s when that insurance is set in. So what I tend to say to people is because of the fact that I say I’m not an insurer, I’m just doing research from the start, I will say to people, ask your GP and just say for your own knowledge you’d like to know what those readings were.

(00:25:26):

Some people can get it off their patient’s summaries that they can access online. They’re not always on there but they do seem to be getting better and better at putting things on there. So that can be quite good. I have to say as well advisors, I have had it before where people have actually said that they were going to give me their logins for their NHS patient summaries. I’ve always refused and I would strongly suggest that anybody else also refuses because yes, we can go in and find the information we need quickly and yes we do have their permission but I do think that that is stepping over a line, going in and having someone’s login details. Luckily I’ve always stopped it before I’ve ever been given those information but certainly not something that I would like. But then in terms of difficulties, there’s two main difficulties that I’ve come across in the past because I think we’ve said before Matt when we were chatting that when we are looking at the normal ranges for kidney function, that’s set up generally based upon white European men between the ages, sorry, between 20 and 40, is that correct?

(00:26:29):

Yep, yep. So if we’ve got that then basically, so they’re the standard ones. So whereas with blood pressure and with diabetes type two diabetes and high BMI insurers kind of there as far as I’m aware to the best of my knowledge, a lot of their underwriting guides will kind of flow and adapt with age to go, well actually we would expect someone’s blood pressure to be a bit different once they reach the age of 60. We wouldn’t expect it to still be the same as if they’re in their twenties. So we’ll consider someone in their sixties for their readings to be this and for that to be considered normal and things like that. And it’s the same with type two diabetes. It’s sometimes seen as a bit part and parcel of getting older but with the kidney function that doesn’t happen does it? It’s not because I’ve certainly come across it where there’s been people who have been told that they’ve got the chronic kidney disease in a sense or the reading is suggesting chronic kidney disease and their doctors just like, but this is just you’re in your seventies, it’s normal but the insurers still.

(00:27:33):

But no, it’s outside of this normal range and that normal range is set to that. And the reason I’m being very specific by saying white European men, is there something else I’ll come on to that is to do with ethnicity and it is for people who are maybe a good 20, 30 years younger than the people that we’re maybe trying to get underwritten. It’s a tricky one.

Matt (00:27:54):

It is a tricky one. No, you’re absolutely right and

Kathryn (00:28:03):

It’s probably not an answer, there’s not an answer in

Matt (00:28:05):

Podcast. No, I just think I was alluding to before, I don’t think there is no silver bullet answer that I can advise or just even discuss to that apart from to we’ve got underwriters out there who specialize in kidney disease underwriting, certainly insurers have these people, but rather than, I would totally advise rather than just take a random reading, sorry, a random reference to this person has CKD three or CKD four which often occur in gp particularly all the people is just to question really what that is all about.

Kathryn (00:28:57):

Absolutely

Matt (00:28:58):

Quite what is that reference actually meaning? I mean I do remember many years ago going to a lecturer from a nephrologist insurance related lecture and he talked about EGFR. So the E by the way to anybody the E represents estimated so estimated grammar filtration rate. He actually said that and I think anybody who is very well medical trained would probably agree EGFR is only one part of the picture and a nephrologist looking at a treatment regime for somebody will look at numerous angles, not just the EGFR. And I think again that points back to my advice to underwriters is look at each case in the round and not just take a particular reading as the be all and end all of the case that they are looking at in their underwriting decision.

(00:30:08):

I do remember very simple comment that the consultant who was doing that lecture was saying also EGFR can be influenced by the amount of water you just had before it was taken that you’ve just taken. So if we go back to this wonderful scenario and writing scenario where you actually have a limit on something so it can’t be below this, let’s to use an extreme example. If it’s below this then it is a decline. The fact that they’ve just had, I must admit I’m not quite sure which way around it is, but if you’ve just had a load of water before your test then and that influences your GFR and in fact it goes up, that could put you into the actually acceptable limit. So what I’m really trying to say there is something quick is as simple as a drinking a load of water can affect that EEG FR rate and can change the outcome and that really is an example of what I mean is look at the case in the round.

(00:31:26):

Also I think with EGFRs the important thing there is we talked about age, putting that to one side just for a second is look at serial readings. In other words if you have an up-to-date EGFR, great, but let’s also look at one maybe that was taken six months before that, six months before that and six months before that to see if there is any progression in the deterioration of the kidney function. That’s quite often something which again underwriters don’t take into account, let me say some underwriters because they’re looking simply the manual and not looking at the case an underwriting manual, they’re not looking at the case in the round, they forget to look at how a case is progressing. Somebody might have a low EGFR but has actually had no progression in terms of what I mean by progression is deterioration the kidney. So for five years that’s very different to somebody who started off at let’s say these are random numbers by the way. I’m going to quote starts off at a hundred and it went down to 50 in five years. That’s different because showing a progressive deterioration in kidney disease. So again I just go back to and it sounded like aoke record underwriters I think owe it to their clients to look at each case on its merits and in the round and not just take a single reading as the be all and end all.

Kathryn (00:32:57):

Absolutely And I think moving bit further with that as well and from an advisor point of view, so this is something that we specifically came across is, and this is really really hard because I mentioned I was mentioning before about white European men and there’s a very specific reason for that because we do find, and I mentioned before that obviously chronic kidney disease can be more common in the black and Asian communities, but the people who are white, their normal kidney functions and their readings are slightly different to those of white people. And the difficulty that we have is, and obviously I would never suggest that we don’t ask about ethnicity in the applications and it’s right that we don’t, but it actually can be a negative that we don’t. So I distinctly remember that we were supporting somebody and this person is famous so we knew that they’re black and obviously we hadn’t asked or anything like that.

(00:34:04):

It’s just we knew because obviously you can see them because famous and there was something that came up about the kidneys and because we knew they were black, we challenged it and we said, well hang on a minute, you are underwriting this person based upon the normal readings of a white European male. What happens if you look at the normal readings for somebody that is black and was obviously it was this challenge that was put to the insurer. And what was really positive actually is that the insurer said, you know what? You’re right actually. And we’ve gone now and we have looked and we’ve looked at what would be the normal readings for somebody who is black and his readings are in completely normal ranges so it’s fine, we don’t have an issue and it’s that really difficult thing and obviously there’s certainly not a solution for this at all and we should never be asking people about ethnicity, but that is an example of where ethnicity and actually being aware of that massively helped this person because it went from it being a rateable disclosure to it actually being discounted.

(00:35:21):

And I don’t really know the solution for that. I don’t even think that there is a solution for that. But at the same point it does mean that because the underwriting is hard because we can’t have both ways can we can’t not ask but then also expect to be able to tap into the underwriting the different medical outcomes or different normalities of different ethnicities. We can’t have it both ways in a sense. If we’re going to be accessing that and making sure that people are assessed based upon what is their normal bodily function based on their ethnicity, then we would need to ask about ethnicity at point of application. But obviously it’s not okay to ask a point of application about ethnicity. So we can’t then do these challenges unless we’re in a very unique situation we were where we just so happen to know about this person’s ethnicity. So I know that that’s obviously very, very tricky thing but it is something where I don’t think there’s a solution and I feel uncomfy that there’s not a solution but I can’t see how we could make it work unless people obviously wanted to volunteer their ethnicity. Obviously they could do that.

Matt (00:36:41):

There isn’t an answer in the world that we live in, which it sounds such a flippant comment but it it’s just one of those fairly rare areas where obviously somebody with the Caribbean African ethnicity can be penalized unfortunately. But if I always go back to if the client is known to the IFA or the introducer, sorry, then by all means use that information

Kathryn (00:37:30):

For people who do face-to-face meetings. Obviously it’s very absolutely clear, but there’s many of us who don’t do face-to-face meetings and it’s just an interesting dynamic and I think it’s, yeah, I don’t think there’s an answer but it is something that if you are face-to-face with somebody and there is something that’s maybe happening with the kidney, it might be something that pops up in a medical that maybe you’re unaware of or anything like that. Maybe they’ve not even been told that there’s something going on with the kidneys previously might

Matt (00:38:01):

Not even know

Kathryn (00:38:02):

Exactly. They might not even know. But it is something just to be mindful of. Yeah, absolutely. And in a sense of we never don’t want to point out ethnicities, we certainly don’t want to do anything like that but it can potentially lead to a positive outcome. Absolutely. And I think that’s the thing and it’s a good reason to mention it’s because there is that potential positive outcome from it if we are able to do that. We’ve had such a good nama we we’ve had, I was going to say we’re really pushing our time today.

Matt (00:38:34):

Goodness. I’m sorry about that. I would just go back to just throw another question out there. How would that case have gone if the client had been mixed race?

Kathryn (00:38:52):

Well Matt, I know I’m a doctor, however touche, I think we are pushing my limits. I don’t often admit that there’s a limit to my knowledge, but that is absolutely, that’s definitely pushing me.

Matt (00:39:09):

That’s an interesting one I have to say. But either which way, but I’m very glad, bear in mind most of my life I’ve spent on the underwriting side of it, I’m very glad that the insurer in my opinion saw complete sense not allowing that case as a normal case. Lemme put it that way. I can see, I’m not sure if you get many insurers, but you can just see somebody somewhere saying, well we can’t take that into account therefore the gentleman is still rated.

Kathryn (00:39:43):

Absolutely. I was going to say Mark, there is absolutely, there’s a few in mind that I just would not

Matt (00:39:51):

Oh right, okay.

Kathryn (00:39:52):

There’s a few in mind I would just not approach. The thing is with certain conditions and that’s part of who we are at curate, there’s different conditions, there’s some conditions that I’ll know I’m not going to go to that insurer in the slightest. And then there’s other ones where it’s just like, you know what? They’ll be really good for this and that is part and parcel. I know some people say, well some people especially aren’t in the space and aren’t involved in as depth as say like me and you are. They’ll probably say, well there should be more consistency. But ultimately insurers our business, they take on risks and what you do find as well is that insurers will flow. So I know for well that some insurers they’ll suddenly improve in one area but then that means that they’ve actually in a sense almost feels like they’ve gone backwards in a different area and they’ve made a different area worse because they’re changing what their risk appetite is. That’s what it’s referred to isn’t it? I believe. Yeah, absolutely. But then there’ll be another insurer who is taking on the one that’s gone backwards. There’ll be someone else who’s actually gone forwards in that space and it’s just the very nature of business to be honest. But it doesn’t help people who’ve go to the one who’ve gone a bit backwards though, which is obviously why there’s people like ourselves around who are doing everything we can to help.

Matt (00:41:08):

No, absolutely. I would also just throw in one more sentence on that. If advisors are looking for consistency amongst underwriters, are advisors looking for consistency from medical doctors because medical doctors have different views on different risks.

Kathryn (00:41:28):

Oh absolutely.

Matt (00:41:29):

And when I say risks, I mean risks in their day-to-day job as in treating people they will have a different view. They’re not consistent, hence why they get a second opinion kind of scenario. So please don’t feel, I always say to advisors out there batter the underwriters too much for being inconsistent when a lot of the data that they get and obviously they’ll take advice from chief medical officers and doctors is inconsistent in its own right.

Kathryn (00:42:03):

Absolutely.

Matt (00:42:04):

That’s all part of the skill of the underwriter, the skill of the doctor.

Kathryn (00:42:09):

And I think what’s interesting about that as well, when we’re saying everybody’s got to be subjective, but I think as well sometimes it depends because you, Matt, a seasoned underwriter can look at things and probably feel like, you know what I’m actually with all my experience, I can look at that and I’m feeling okay about this and I’ll do that. And you can get different underwriting outcomes within the same insurer. But I think we all need to be very aware of as well is that there’ll always be people who are starting off as junior underwriters as well and you’ll have junior underwriters who are, and I have to say if I was a junior underwriter, I would be pretty by the book because I’d be too nervous not to be and my job would be to follow the rules and for the manuals and I wouldn’t necessarily feel the ability to kind of take, for me, I wouldn’t feel the ability to take some kind of intuitive leaps in some instances. And I think we’ve got to understand that. So it is often your more senior underwriters who can look at things with a bit more,

Matt (00:43:09):

I think it’s in the round. I’ve used in the round that phrase quite a bit during our conversation today around kidney disease underwriting. Yeah, it’s all a part of that learning curve curve. There’s no two ways about it and I’ve been very, very lucky. I had 18 years worth of reinsurance, which every single case you saw there was a medical problem or some form of risk related problem and I had tutorage from the great Dr. Bracken Ridge as I allude to and then another 18, 17 years or whatever it was in Insurance World before for the last 10 years or whatever it is I came into, introduced the world if you like. So I’ve been very, very, very lucky and not all underwriters have had that kind of lucky route to develop their experience and to look at things in the round. So I totally honestly agree with you.

Kathryn (00:44:11):

Yeah, absolutely. And I think it’s good as well to point out comments on that and towards advisors as well. You get someone who’s advising the first year in, they are going to be so different 10 years later as to what they do once they’ve seen changes in the market. All of us are progressing, all of us are learning all the time and we might not necessarily get the answers that we want from insurers. And I think sometimes as well, sometimes those answers are rightfully so because sometimes the risks are too intense and we need to go more specialists, but there are times that we can push back as well. There’s certainly plenty of times where we’ve needed to push back because the underwriting has seemed a bit harsh. And then to be honest, you speak to someone who’s senior and you get a mix, there’ll be a mix of them saying, no, actually this is right, this decision because, and they’ll maybe have the more experience to explain it in depth and in an understandable way, which helps us as advisors to learn for next time supporting a client in similar situation.

(00:45:09):

And then there’ll be other times where they’ll go, you know what, actually this was a bit overzealous and we’re actually okay with this. Okay, so last couple of things then and then we’ll do some case studies. So very, very quick on these ones. Is there any kind of long-term symptoms, Matt, that we need to be aware of now? I’m sure blood in the urine is going to be something that insurers are going to be. Well what’s going on there? I’ve certainly, and to be honest, I’ve had quite a lot of people I’ve been supporting this year who there’s been blood in the urine, but there doesn’t seem to be any concern on the medical side. It seems to just speak the medical side, just go, yeah, it’s happening, just carry on, do your thing. But obviously in insurance world it’s a thing, but are there any other kind of symptoms we should really be looking out for that would make us think?

Matt (00:45:59):

Yeah, absolutely. It depends on the type of information that you have in terms of the more generically then you are looking at protein in the urine as well as load protein is more, it’s a bit scary. That’s

Kathryn (00:46:17):

What I meant. I meant protein in the urine rather.

Matt (00:46:19):

No, it’s okay if somebody has protein or blood in their urine, just like if they had sugar in the urine, they should be followed up to find out the root cause of it. No two worries. If they have blood in the urine in particular immaterial, then that needs very quick follow up because worst case scenario is cancer protein is more likely to be either infection related or a disease in the kidneys itself. White blood cells should be looked at. Again, very typical of an infection. If you’ve got a lot of white blood cells hanging around in your urine, then there’s likely to be an infection going around. Again, infections, we’ve talked about urinary tract infections and so on and so forth. The obvious one, just to restate it again is blood pressure.

Kathryn (00:47:23):

Yeah,

Matt (00:47:24):

Think kidney, think blood pressure, think blood pressure, think kidney, very, very intimately linked. There are many tests which we talked about. We talked about OMA filtration rates, we talked about blood uea, nitrogen, we talked about creatinine and things like that, which all the blood, the latter anyway, certainly a blood test. But for underwriters, and I think we’ve alluded to this is quite a difficult area to underwrite primarily because often there is a limitation of information, a limit of the information available. But those are the type of things that under I still look at. Does that help?

Kathryn (00:48:10):

Yeah, absolutely. And something that pops up in our family medical history questions before the age of 60 or before the age of 65, polycystic kidney disease, how’s that going? If we take a yes for that, how’s that going to be affecting our applications do we think?

Matt (00:48:28):

I think in terms of polycystic kidney disease for a start usually you get the symptoms. So look at blood pressure, dare I say usually between the ages 30 and 40, but it can be seen in childhood. So again, the ages was stuck to give you a clue in terms of your applicant. So your client, if somebody is positive it’s been tested and is positive for cystic kidney disease, then there is I believe for life insurance then dare I say it again rather depends on the term of the policy, shorter the more likely you likely to get it, but also the extent of the invasion of those cysts and therefore the impact on the renal function itself. So again, the dreaded tests start to come out here, but I think you should be, well be able to get cover as long as there isn’t a significant deterioration and dependent on the age of the client, et cetera, et cetera, in terms of the living benefits, critical illness and income protection, then I don’t think you’d be able to get it.

Kathryn (00:49:51):

There are some potential. Should

Matt (00:49:53):

I leave it at that by the way?

Kathryn (00:49:55):

No, that’s fine. So that was the potential. Sorry, can I just check as well, did we clarify how family history would affect it? So if it’s a family member,

Matt (00:50:02):

Oh, if it’s a family member and the person has never been tested, then if they are over the age of 40, let’s say, so this is your client, the applicant, if they are let’s say 50 or 60 and they have aban history, then I think it can be ignored because the condition is autosomal dominant. So technical expression, which basically means why I mentioned that is that every child of one of the parents who has that disease, it says a 50 50 chance of getting the disease. So therefore you could well be a child and can be completely absolutely fine. Normally, particularly these days, last 10 years or so, if a parent is positive or has the disease which has then been found because of high blood raging hypertension, something like that, often the children are genetically tested. And then obviously if the genetic test can be produced that is negative, then people can get terms obviously on virtually normal terms

Kathryn (00:51:17):

And that’s really important as well. So just yeah, absolutely. I think as well just be clear everybody, so obviously the insurer won’t ask about genetic tests, but if the person has the genetic test and it was negative, you can volunteer that information.

Matt (00:51:28):

Absolutely.

Kathryn (00:51:29):

But as I’ve mentioned before as well, if you are speaking with somebody and this is kind of conversations that are happening and they say, should I get a genetic test? That is where we’re starting to get to an area where we need to sort of step back a little bit in terms of what we’re saying because if somebody is aware of this, similar to the Huntington’s question as well, if somebody is aware of a familial condition where there could be a genetic test and they’ve previously decided not to get it tested, for them to go and get tested purely to get insurance, that’s a huge emotional decision and it’s not one to take lightly. And also as well, the ultimate outcome is that it could come back positive and then the insurance still isn’t going to necessarily work the way that we are wanting it to, but then that person now actually has the outlook that they’d previously wanted to avoid. So just be very, very careful if you’re going to that kind of area. And as always, if you are faced with that kind of discussion with a client, I’m always happy to chat with them, chat with you and see if you want to have a bit of a testing out of your wording and things like that. But yes, for things like the GON math,

Matt (00:52:39):

No, I was just going to say you’re absolutely a hundred percent right. It’s not something that introducers should really get involved with the clinics that do genetic testing. If it is a bonafide clinic experience and all this type of thing, genetic testing, they will have specialist people working for them that can discuss the pros and cons of having a genetic test. And to my knowledge, they won’t do a genetic test until somebody has had that counseling. The challenge that we have these days is there are genetic tests that you can go off the internet.

Kathryn (00:53:20):

Well you know what Matt? I’ve gone for genetic testing

Matt (00:53:23):

Off the internet,

Kathryn (00:53:24):

Not off the internet with your private

Matt (00:53:25):

Medical. Don’t tell me you didn’t have any counseling please.

Kathryn (00:53:28):

I didn’t have any counseling

Matt (00:53:30):

In which case I stand corrected,

Kathryn (00:53:32):

I stand corrected. So I went through a legitimate private medical company and I know because we use them sometimes with our private medical insurance, one of the hospitals that we would be using for that

(00:53:47):

And we use them and it was a saliva collection and it was a doctor. So a doctor does ring and basically says this is going to be happening if any basically along the lines of this is going to be happening if something pops up, we’ll obviously provide counseling, stuff like that. But there was no kind of pre counseling. But what I have to say is in terms of the conditions that were being tested for, none of them are specifically linked to if it was a positive diagnosis it would be terminal. So I think that’s a key thing. It is something like we’re getting tested for the 30 most common cancers. There’s familial hypercholesterolemia and a few other things as well, but we’ve not got the cystic kidney disease of Huntington’s, anything like

Matt (00:54:46):

That. No, I’m with you. You know what? I still feel a little uneasy with no pre-counseling to be perfectly honest with you. Maybe that’s just there was a potential, that’s just a personal thing. Maybe

Kathryn (00:55:04):

There was mention potentially I think when we booked, I think there was a mention of potential, but maybe it was just that when they spoke to us we were just so look, we’re absolutely fine. Don’t worry that they just went. Okay, fair enough. But that might be it. But yeah, I know what you mean in terms of that. Or maybe it’s because mine says doctor on it, they’re just like, well she must know.

Matt (00:55:25):

They made the assumption you were medical. Exactly.

Kathryn (00:55:30):

So yeah, life insurance would probably be considering if there’s somebody who does have kidney function outside the normal ranges, probably some kind of rating depending upon how recent those changes have been shown. And if there’s still a bit of an uming and ahing as to the cause, I would expect postponements or declines. But if we know the reason, then I think we should be able to have a look at most places. But interesting you saying there about the term Matt. So that is something as an advisor it’s really important to know. So you might go to an insurance and say, can I have 20 years for this person? And they go, no, sometimes with some conditions if you say, well what about 10 years? And they maybe will offer the risk over a shorter period of time. So it’s always worth having a double check

Matt (00:56:12):

Situations

Kathryn (00:56:13):

That the cover and income protection side of things, they are going to be potentially specialists, not necessarily, but they can be a more likely going to be specialist. It could be high premiums, it could be exclusions, and then it comes down to what the person feels comfortable with in terms of critical illness cover. If there was exclusions, I think I would feel more than certain of that than income protection. Just on the basis that with critical illness cover, especially with the kidney, obviously you’re immediately taking out in terms of major organ transplant of the kidney, you’d be taking out the potentially heart attacks and strokes due to the combined link with blood pressure. And I imagine somewhere, Matt, there’s some kind of analysis that shows that kidney disease increases the risk of cancer somewhere along the line because there usually is something somewhere that shows an increase of cancer.

(00:57:13):

Obviously I’m not saying that from a medical or an underwriting point of view, it’s just that usually when we say these things, that usually pops up somewhere. Absolutely. So I would be more dubious of critical illness cover than the income protection side. Right. Then some case studies very quickly to finish us off and then that was it done for the summer of 2023. So first case study that we support was somebody who was a male in the early fifties or a non-smoker working in the care industry. They’ve been diagnosed with polycystic kidney disease for over 10 years. They had ongoing medication very well controlled, had BMI of 35, so not excessively high but higher in terms of what the insurers like to go for standard ratings on premiums and things. It’s usually going to be a rating we’ll get to that level. So for this person, we were able to arrange an income protection policy that had 1,100 pounds worth of monthly benefits.

(00:58:12):

Age 70, there was a four week defer, a max one year claim period and it was 34 pounds per month. Now I personally considering that there is policies, the kidney disease there, which is quite a significant condition. The fact that we don’t have exclusions on there, the fact that this person was in their fifties as well, 34 pounds per month I think is quite a positive outcome. We would ideally, obviously want to have it as a longer claim period than a year, but better to have something than nothing. Yeah, totally agree on that one. Then the second case study, it was a female in her late twenties. She was a non-smoker.

(00:58:55):

She’d had inherited PKD cystic kidney disease diagnosed three months before the application and that was a genetic test. So this is where we’re talking about those testing things. So she didn’t have polycystic kidney disease in the sense of it wasn’t a diagnostic test, so there hadn’t been symptoms or anything like that, but there’d been a family member with it. She had been tested and had been shown that she had a positive test result. She’d had some MRIs and they were all very favorable. So we were able to arrange level life insurance of 200,000 pounds over 25 years for 31 pounds per month. So that’s a good example to show that even if there is a positive test, genetic tests, it doesn’t mean that the answers are no, but there is consideration there that we need to just be aware of. Say this person had very favorable readings, there were nowhere near having any kind of diagnostic situation happening, so she wasn’t symptomatic. So good answers there for both.

Matt (00:59:57):

Sorry to interrupt you. Any recollection of the age of the client?

Kathryn (01:00:02):

Sorry? Sorry. She was late twenties.

Matt (01:00:04):

Late twenties. Okay, interesting. Yeah.

Kathryn (01:00:08):

Yeah. So that was, that is it. Thank you for listening everybody. We are at the end of season seven, end of episode 14. We’ll be back in September with season eight. Do remember that we now have 97 episodes on the podcast and it’s giving you over 70 hours of structured CPD to listen to. You can get your CBD certificates on the website, www.practicalprotection.co uk. Do feel free to go on there. It’s all nicely automated to get everything over to you nice and quickly. And you may as well do if you’ve had a good listen. So we might have to think of something fun to do for the hundredth episode, Matt.

Matt (01:00:46):

Sounds good. Sure what to do. I’ll put my thinking cap on.

Kathryn (01:00:49):

Absolutely. As always, lovely to speak to you Matt, and we’ll speak to you soon.

Matt (01:00:54):

Yeah, have a lovely summer break.

Kathryn (01:00:56):

You too. Bye. Take

Matt (01:00:57):

Care. Bye.