cigarette and marijuana smoking

Smoking raises red flags for insurers across the board – applicants are usually rated if they produce a positive cotinine test. Further, tobacco use can lead to the potential onset of additional health risks, such as cancer, heart disease, stroke, diabetes and/or lung diseases. Aside from these health concerns, studies show a correlation of tobacco use and marijuana use. Statistics also reveal an increased risk of positivity for other drugs of abuse.

The likelihood of a tobacco user testing positive for marijuana

Our data scientist, Brian Lanzrath, extracted a sample of ExamOne applicant data to identify what, if any, correlation exists between the use of tobacco and marijuana. From 2017-2018, nearly 6.6% of ExamOne life insurance applicants tested positive for cotinine. You can see the states with the highest cotinine positivity rates on this map with Ohio, Kentucky, Indiana, Arkansas and Mississippi being among the five highest. Within each of those states, the positivity of those who tested positive for both THC and cotinine is as follows:

cotinine positivity by state







Overall, tobacco users are nearly 5 times as likely to test positive for THC as non-tobacco users.

Study finds tobacco users 25x more likely to test positive for PCP

Brian also discovered tobacco users were 5x more likely than non-tobacco users to test positive for methadone, PCP and cocaine. Further, marijuana users were nearly 25x more likely than non-marijuana users to test positive for PCP. They were also 15x more likely to test positive for cocaine and 10x more likely to test positive for methamphetamines. As the opioid epidemic continues to spread, it’s important for insurers to be diligent in their testing requirements. Laboratory expert, Betsy Sears, says as a result of the compelling data, there is a growing interest among carriers in using cotinine as a reflex for drug/expanded opioid screens.

Underwriting with precision

It’s important to understand that a positive cotinine test could mean more for insurers. Not only could it mean the applicant is at high risk for multiple health conditions, there is an increased risk the applicant could be misusing other substances that increase mortality. Navigate through the smoke by ensuring you are receiving a complete profile of your applicants.

To review your parameters, discuss reflex testing or to complete an analysis on your applicants, please contact us.

blood draw

We all know the routine. The examiner draws blood during a mobile exam. Delays in processing allow those hungry red blood cells to gobble up glucose. The underwriter sees an extremely low glucose reading or the dreaded not valid glucose (NVG) on the laboratory report. Or the laboratory report notes hemolysis is present. Then there are the results of a CBC where the blood was collected Friday afternoon, but not analyzed until Monday morning.

Now what? Does any of this matter to the underwriter?

What changes?

We used to think glycolysis was a seasonal issue. While it is more severe during the warm summer months, ExamOne data shows this issue is present throughout the year. But the question is: does very low glucose or not valid glucose still matter to life insurers?

With the majority of insurers now routinely testing A1c on every blood specimen, concerns with glycolysis are almost eliminated. A1c measures average blood glucose level for the preceding two to three months and is unaffected by glycolysis. Thus, it is a superior underwriting tool for measuring glucose control and is the recommended testing protocol for diagnosing diabetes by the American Diabetes Association.

Companies foregoing A1c testing must order a blood collection recheck or roll the dice and hope the applicant does not have a risk of glucose intolerance or diabetes.

What about hemolysis?

Hemolysis is the breakdown or rupturing of red blood cells. Hemolysis has a minor effect on a few blood analytes—particularly the aspartate aminotransferase (AST)—and is generally of minimal concern to the underwriter. Underwriters can feel comfortable underwriting specimens reported as having slight hemolysis.

Severe hemolysis, however, may have a significant effect on the AST, alanine transaminase (ALT), alkaline phosphatase (ALP), bilirubin, protein, triglyceride and glucose. If the hemolysis is too severe, the laboratory may result those analytes as “not valid – hemolysis” (NVH). Basing underwriting decisions on severely hemolyzed specimens can be risky.

Hemolysis and specimen processing delays can affect complete blood count (CBC) results by falsely decreasing or elevating a number of components in the CBC. Prompt processing of the CBC is critical, especially in cases where the underwriter orders the CBC “for cause.”

CBC results are fairly stable for approximately 72 hours at room temperature. Refrigerated specimens are stable even longer—for another two days. Delays in processing yield questionably accurate results, especially when evaluating anemic applicants.

Two options for reducing or eliminating glycolysis and hemolysis

According to ExamOne data, 15 percent of specimens are impacted by glycolysis and 4 percent are impacted by hemolysis. Advancements in testing protocol and availability of clinical exam centers have helped reduce the prevalence of specimen degradation.

specimen quality

A1c is stable for the life of the purple top tube—28 days—and it is unaffected by pre-analytic conditions such as heat and time, eliminating the risk of glycolysis. ExamOne’s routine risk assessment screen includes A1c testing so every specimen is tested upon arrival at the laboratory.

In addition to being a convenient option for applicants, exam centers provide a level of confidence unmatched in the life insurance industry. ExamOne data shows NVG rates of specimens drawn at exam centers are less than 0.1 percent, while NVH rates are less than 0.5 percent. Blood collected at an ExamOne or Quest Diagnostics exam center is processed and analyzed within 48 hours so the chances of specimen degradation due to temperature or processing delays are significantly reduced, giving insurers confidence they are basing underwriting decisions on accurate health insights.

Customer survey: Using your insights to empower our decisions

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Throughout the past year, ExamOne has been changing. We’ve taken steps to ensure we are focused on the right thing—you, our customer. We also established a new mission to empower your decisions with health-based insights, a mission we believe supports both insurers and applicants on the journey to protecting more families with life insurance. In […]

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Three things an insurer should consider when implementing a pilot

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Implementing a pilot program can be an effective tool for measuring the impact of a new product or workflow. Over the years, we’ve helped dozens of insurers pilot new tests and tools. We have found the most successful studies have 3 things in common: a specific goal, sufficient data and a measurable outcome. Setting up […]

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Cystatin C: Transforming cognitive and frailty screening

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Using Cystatin C in older-age life insurance assessments. Our clients tell us that controlling costs during the decision-making process and reducing application-to-issue cycle time are priorities within their new business teams. As older-aged individuals apply for life insurance, requirements designed for this market can become more time-consuming and cumbersome. Many of today’s older-age evaluations include […]

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Ask the Expert: Drug trends in America

October 3, 2018 Ask The Experts

During one of our summer webinars, Betsy Sears, Executive Vice President, Laboratory Strategy and Sales, and Dr. Barry Sample, Quest Diagnostics Senior Director, Science and Technology, examined two of America’s populations for drug positivity rates by various drug classes. This included a workforce population and ExamOne life insurance applicants. Understanding the drug trends and positivity […]

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Transforming life insurance into a lifetime of benefits

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An insurance company that has sensors on a customer’s water pipes to detect leaks? Or how about one that guarantees the aging population a spot in a retirement-type home? These are just a couple of customer loyalty benefits insurance companies in other countries are offering to their customers. Now, let’s translate this into life insurance […]

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First-hand experience about the importance of life insurance

September 11, 2018 #Committed2 You

September is Life Insurance Awareness Month, an industry-wide campaign that educates people about the importance of protecting their loved ones with life insurance. I have had first-hand experience of how coverage or lack of coverage can change families’ lives. Appreciation for protection early in my career As I think about the significance of this campaign, […]

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September celebrates Life Insurance Awareness Month

August 31, 2018 Brokers

As a leading provider of decision support products for life insurers, we are excited to support one of the industry’s important initiatives – Life Insurance Awareness Month (LIAM). Today, nearly 60% of adults own some type of life insurance, but research shows the coverage they have may not be enough. More than one-third of all […]

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The rise in workforce drug positivity may be a concern among the life insurance population

June 22, 2018 Carriers

2018 Quest Diagnostics Drug Testing Index™ The 2018 Quest Diagnostics Drug Testing Index™ (DTI) has been released and workforce drug positivity remained at the highest rate we’ve seen in a decade. The positivity rate held steady at 4.2 percent which was the same in 2016. One of the biggest shifts in drug positivity was seen […]

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