Long-Term Scare.

The vast majority of long-term-care policyholders have never filed a claim. Insurers are hoping they'll be ready when the claims start pouring in.

Long-term-care insurance ranks close to life insurance in the time elapsed from purchase to claim. But while insurers have a good handle on mortality trends, they face some uncertainty about the future frequency and duration of long-term-care claims.

A couple of significant factors account for this uncertainty. One is that insurers haven't written long-term-care policies for nearly as long as they have written life coverage, so they don't have much history on which to draw. In fact, insurers wrote nearly as many long-term-care policies from January 1993 to June 1998 as they wrote in the approximately 30 years that the coverage has been around, according to the Health Insurance Association of America's most recent long-term-care study, and other evidence indicates that annual sales of long-term-care coverage continue to grow at a double-digit rate. The other reason is that insurers can't use nursing-home data exclusively to project long-term-care utilization trends, since people will seek other settings for long-term care, including their homes, and longer life expectancies may result in more people needing long-term care.

Despite the uncertainties, an average of 120 companies sold long-term-care insurance from 1993 through mid-1998, and more than 69% of them have been in the business for at least nine years, according to HIAA. And while actuaries and consultants have worked hard to anticipate trends, they also have warned that claims are not easy to predict. Some companies have left the business or have avoided getting into it.

Early Exit

One major insurer to exit the market was Lincoln National Corp., which decided in 1998 to move its headquarters to Philadelphia from Fort Wayne, Ind. Lincoln also divested its disability and health insurance businesses. Chief Executive Officer Jon Boscia predicted that long-term-care writers are headed for problems when claims come in earlier and last longer than anyone has anticipated.

"We got out of this market, because we didn't believe that there was a way of underwriting long-term care," he said. "In our view, long-term care, like disability; lends itself to social underwriting. There are different forms of social underwriting, and, unfortunately, this lends itself to more false claims."

This social underwriting, which is underwriting with permissive standards, usually for large groups, will happen with long-term care because the triggers for benefits--the inability to perform specified activities of daily living--are set low and can be arbitrary, Boscia said.

Long-term-care expenditures for the elderly in the United States were expected to reach $120 billion in 2000, but private long-term-care insurance was expected to pay for only about $5 billion, according to the American Council of Life Insurers and the Congressional Budget Office. When first sold in 1972, policies covered only skilled care in a nursing home following hospitalization, the ACLI said. Policies today, however, might pay for a variety of services, including bed reservations, care coordination/management services, caregiver training, homemaker services, medical equipment and home modifications, hospice care, assisted-living facilities and even some limited payment for home-delivered meals.

"They're getting so liberal with product design that the trend is almost identical to disability income insurance in the late 1980s and early 1990s," said Mark Ameigh, partner of Disability Insurance Specialists LLC, Bloomfield, Conn. "We've been saying that for several years:' The big unknown is how insureds will find a way to use their policies in ways writers didn't imagine, he said, "and we're very concerned for our clients' sakes."

Ameigh is particularly wary of product forms that may increase claim levels, such as providing benefits on an indemnity basis regardless of expenses incurred by the policyholder, or providing benefits without requiring that expenses be incurred, such as care provided by a family member.

Morbidity on the Rise

Tad Verney, managing partner at Disability Insurance Specialists, said a recent study by the Schaumburg, Ill.-based Society of Actuaries LTC Experience Committee indicates that morbidity has increased. The study said that for many policies, morbidity is significantly greater than that indicated by a 1995 study by the society's LTC Insurance Valuation Methods Task Force. "This phenomenon may be the result of better data or changing utilization patterns as the elderly care services industry matures," Verney said.

Earlier studies depended more on data on the general population, which actuaries tried to adjust for characteristics of the insured population and policy components. "The higher claims costs could be driven by demographics or by insured vs. noninsured populations," he said. "There wasn't a lot of good data out there when companies jumped into this market. They did the best they could and jumped in."

Those familiar with the disability income market of a dozen years ago might see some parallels. Verney said insurers then made elements of product design more liberal but still priced on old assumptions. The disability liberalizations of that time included own-occupation coverages--which pay benefits if a disability prevents a person from doing his or her present job--high inflation riders, willingness to write high income-replacement ratios and noncancelable provisions, all of which led to horrendous results. But Verney was reluctant to say long-term-care writers could expect poor results due to the kinds of benefits they currently offer.

Verney agreed, however, that insurers ought not take too much comfort in the fact that they write long-term-care policies in a guaranteed-renewable form, which, unlike noncancelable, allows for raising premiums. The price increases still must be approved by regulators, who are not always sympathetic to pricing deficiencies. Insurers themselves are aware that higher rates could drive healthy policyholders off the books, leaving only those expecting to file claims. Insurers also understand that higher rates can create "public-relations nightmares," to which regulators are very sensitive, Verney said.

Insurer loss ratios in 1998 and 1999 were close to what the companies expected, according to consultants at Tillinghast-Towers Perrin, but results of individual companies varied significantly. Despite the loss-ratio records however, the longest any insurer is willing to guarantee not to increase long-term-care premiums is 10 years, they observed.

Underpricing

Absent claims experience on an insured population, some companies writing business in the early 1970s did not guess well on their pricing, said Jack Lucas, a consultant with Tillinghast-Towers Perrin in St. Louis. The Society of Actuaries has since conducted a couple of studies, and individual insurers have built up their own records, but prices still vary by company and by regions of the country, he said.

The industry also has been surprised by the high level of policy persistency, said Abe Gootzeit, a Tillinghast principal in St. Louis. The higher-than-expected persistency has diminished the overall profitability of insurers, he said.

Older blocks of business used less rigorous underwriting standards than those of today, and their experience with cognitive-impairment claims has been worse than expected, said Saul Goodman, a Tillinghast actuarial consultant. But Goodman said the triggers for long-term-care benefits are more objective than the triggers in the disability income policies of a decade ago, such as own-occupation coverage. Also hurting those policies was that they were noncancelable and offered high levels of income replacement.

"Insurers have learned some of those lessons and taken precautions," Gootzeit said. "The industry has done a reasonable job in its prediction of claims."

The persistency issue has both pros and cons. Higher persistency is good because insurers build profit into policies, and the longer they are in force, the more years insurers have to amortize the upfront commission, said Jonathan Nemeth, a vice president and actuary at Aon Consulting, Somerset, N.J., where he manages the health and welfare consulting practice.

Nemeth said that insurers, in general, are probably better off with higher persistency, but lower persistency is better if they lose policyholders who are more likely to file claims. "However, people that tend to lapse are probably smarter than you think," he said. "They are the people less likely to have claims. For one client that provides long-term disability coverage, the probability of people going on disability was much higher among those with 70% salary-replacement policies than those with 50%. This ability to voluntarily select against an insurer is similar for LTC policies."

It's not as though experts aren't working to decipher long-term-care claims trends. Nemeth said the Society of Actuaries' LTC committee published an intercompany study of 1984 to 1993 insurance company claim experience. (Tabulating long-term-care data takes a significant amount of time, he explained.)

The main problem with predicting long-term-care claims is the lack of credible experience as well as the long-term nature of the benefit. The time frame from long-term-care insurance purchase to claim can be 25 years or more, Nemeth said.

Over that time, much is unpredictable. The main wild cards are the government's role, medical advances and the expertise of any given company

Federal or state governments could play a major role in long-term care. If government provides more funding for nursing homes, and that funding makes them more appealing, people might be more amenable to living in one. That would put more financial pressure on the insurance industry, since long-term-care insurance pricing today does not reflect changes in government policy, Nemeth said.

But if the government provided a tax credit to individuals to look after their parents, more people might choose to become family caregivers, and fewer elders would opt for nursing homes, he said.

Living Longer

One of the greatest American achievements in the last century was the increase of longevity, but how will the next advances in medicine affect long-term-care claims? A cure for Alzheimer's disease would reduce pressure on nursing homes, but cures for other types of illnesses could exacerbate it, Nemeth said.

A former regulator with the New York State Insurance Department, Nemeth predicts that some companies will continue to be better predictors of trends than others. "I noticed as a regulator that the difference was not whether a company was large or small," he said. "Some simply have their acts together, and some don't. As this all shakes out, some companies will have done a much better job in predicting future events than others."

What can be frightening for the industry is the potential risk associated with underestimating long-term-care utilization. Although most long-term-care policies have maximum benefit limitations, the exposure is still significant. Most individuals are predicted not to use coverage, so small gradations in utilization could have a significant financial effect, he said.

Dan Cathcart's company, formerly Duncanson & Holt and now AUL Long Term Care Solutions Inc., Avon, Conn., has tracked long-term-care insurance claims on policies issued since the early 1980s. It has found that claims steadily declined from about 5% of policies (two and four years after issue) to about 1% on those issued in 1992 to 1995. The company is a division of American United Life Insurance Co., Indianapolis.

The drop in claims is the result of a tightening of contract language and advancements in geriatric claim coordination, said Cathcart, vice president of product development. On policies issued since 1995, however, the percentage of policyholders filing claims has climbed back to about 2% for policies in their third and fourth years. Cathcart expects that trend to continue as long-term-care insurance becomes more widespread, services become more widely available and appealing and insureds become more educated on what policies provide. AUL has 46 clients in its database and has recorded 28,000 claimants since 1982.

"Some of the predictions Jon [Boscia] discussed could be relevant," Cathcart said. "Claims could come in earlier as people become aware of how LTC services can help them. Claims will consistently become longer, too. As mortality decreases and more and improved treatments are available, people will last longer. The length of claim is the biggest unknown risk."

Cutting Costs

Long-term-care insurers, however, still stand to benefit from their contract language, better underwriting and their ability to manage claims. (See "Coordinating Care Can Control Claims," below.) Cathcart said AUL, through its underwriting, claims management and contract language, has been able to reduce clients' claim costs by about 30%.

Long-term-care insurers also could head in the same direction as disability writers of a dozen years ago, Cathcart warned, especially if carriers introduce a noncancelable product. "The industry knows that potential exists and is trying to find other ways to address rate stability," he said. The National Association of Insurance Commissioners is trying to establish rate stability without the use of noncancelable policies, primarily by putting more responsibility on carriers to price accurately from the beginning, he said.

Companies Selling Long-Term-Care Insurance

Companies may sell individual group association or employer-sponsored policies or policies with an accelerated death benefit rider specific to long term care.

'87  75
'88 105
'89 118
'90 143
'91 135
'92 135
'93 118
'94 121
'95 125
'96 120
'97 119
Source: HIAA LTC Survey, 1999

Long-Term-Care Insurance Policies Sold Cumulatively, 1987 through June 1998

Types of long-term-care insurance policies include individual, group-association, employer-sponsored policies, and accelerated death benefits (life insurance riders).

'87     0.82
'88     1.13
'89     1.55
'90     1.93
'91     2.43
'92     2.93
'93     3.42
'94     3.84
'95     4.35
'96     4.96
'97     5.54
'98 [*] 5.84
(*.)Through June
Source: HIAA LTC Survey, 1999

Few Claims Made on Connecticut Partnership's LTC Policies

In its first eight years through September 2000, the Connecticut Partnership for Long-Term Care and the writers of policies it sponsors sold 16,818 policies, of which 13,692 were still in effect. So far, fewer than 100 policyholders have received benefits, or about 0.7% of policies still in force.

Connecticut is one of four states--along with California, New York and Indiana--to establish a partnership with long-term-care insurers. Under the programs, developed in part with grants from the Robert Wood Johnson Foundation, Princeton, N.J., Connecticut helps market private policies that meet its standards. In return for buying partnership policies, individuals who exhaust their private benefits are sheltered from having to use up their assets before they qualify for Medicaid coverage. Partnership policies cost no more than similar policies sold outside the program.

While the percentage of partnership policyholders filing claims is low, it is nonetheless higher than program officials expected, said Project Director David Guttchen. The reason may be that the average age of a policy purchaser is 60, seven years younger than the national average for the buyer of an individual policy.

"It could be 20 to 25 years before our policyholders need their policies, so we wouldn't have expected much claim utilization," Guttchen said. But he saw the claims numbers as good news. "It shows that people are using the benefits," he said. "The criticism of long-term-care insurance in general is that buyers will never access benefits, but we're seeing the direct opposite, and insurance is paying 93% of the cost of their expenses."

Guttchen added that many people who have claimed benefits so far had died before they exhausted those benefits, and they never needed to access the Medicaid benefit provided by the partnership program.

Coordinating Care Can Control Claims

Most long-term-care policyholders hope they won't ever have to live in a nursing home. Most insurers feel the same way, but to keep it from happening to their clients, they need to take more initiative in managing claims.

"We are strong proponents of a mandatory approach to care coordination," said Barbara Prescott, senior vice president of claims management at AUL Reinsurance Management Services, a subsidiary of American United Life Insurance Co. in Indianapolis. "What that allows us to do is have early intervention at the time of the first claims notice, so we are sure that we take the most appropriate course of action."

Care coordination aims to delay costly institutionalization and support informal caregivers, such as family members, who provide 85% of long-term care in the United States today, Prescott said. It also seeks to manage the insured's illness, preserve function and prevent deterioration. Home- and community-based care is more effective and more cost effective, but it has to be managed up front, she said.

AUL believes that using an independent, licensed and objective third party is the best way to assess an insured's needs, determine a course of action and coordinate the plan. The coordinator's first step is to visit the insured at home. "You really have to take a holistic approach on an individual basis," Prescott said. "That's why the initial evaluation is so important. You're not sitting back as an insurer and reading a statement from the insured's doctor, who might have a self-interest in prompting utilization. A care coordinator will balance that. A coordinator cannot also be a provider."

A lot of states are not in line with AUL's thinking, because they associate it with the case-management element of managed care, the part that employs a primary-care physician, Prescott said. "But care coordination is proactive, because it takes the wishes of family into consideration," she said. "Very seldom will a physician get involved. Physicians really aren't in a position to evaluate, because they don't see patients in their homes."

This year, AUL has started a pilot program that introduces disease-management components to its care coordination. The idea is to identify certain chronic conditions that could lead to further disabilities. For example, AUL's coordinator might schedule a bone-density test and take steps to prevent the insured from falling and fracturing an arm or leg. Or the coordinator might compile a full listing of an insured's prescribed drugs and share that information with a doctor or pharmacist. "We know that the elderly can be overmedicated and that there can be adverse drug interactions," she said, and sometimes the insured's doctor isn't aware of all medications he or she is taking.

Sometimes, the reason for disability can be an acute medical condition that might be covered under a medical policy, not simply a chronic lack of ability to perform an activity of daily living. Some individual insurers, including John Hancock Financial Services and Aegon, are trying to identify those situations as well, Prescott said.

"Best practices are still evolving," she said. "You'll see more clinicians in the process. How these clinicians are used is another story. Some are involved in the decision making on claims, but I'm of the school that the business side of the house is making the benefit decisions. The clinician is there to provide for continuous quality improvement and appropriateness of plan recommendation. Once a claim is approved, it's vital you monitor it appropriately and intervene at the appropriate points."

              1999 Top Group Long-Term-Care Insurance Writers
                  Rank based on 1999 net premiums written.
                                              1999
                                            Market    1999 Net Percent
Rank Company                          State  Share    Premiums  Change
  1  Unum Life Ins Co of America      ME    19.71% $41,721,559  52.53%
  2  Aetna Life Ins Co                CT    19.52   41,320,327  10.92
  3  John Hancock Life Ins            MA    10.27   21,746,957 -29.97
  4  Conseco Senior Health Ins Co     PA     7.60   16,084,058 -15.02
  5  PFL Life Ins Co                  IA     7.50   15,883,710  -4.10
  6  Pioneer Life Ins Co              IL     5.68   12,027,255  -1.21
  7  Life Investors Ins Co of America IA     4.99   10,569,641  53.27
  8  Mutual of Omaha Ins Co           NE     4.52    9,561,747   0.71
  9  New York Life Ins Co             NY     3.68    7,797,648  -8.25
 10  American Republic Ins Co         IA     2.51    5,315,454 -10.49
 11  General & Cologne Lf Re of Am    CT     2.19    4,642,000 -19.35
 12  Allianz Life Ins Co N America    MN     1.67    3,541,634   4.51
 13  Provident Life & Accident        TN     1.54    3,267,981   1.94
 14  Life Ins of North America        PA     1.36    2,872,513   3.89
 15  First Unum Life Ins Co           NY     1.15    2,437,176  60.93
 16  United Teacher Associates Ins    TX     1.13    2,392,468   0.00
 17  Manulife Reins Corp (USA)        MI     1.11    2,354,114  39.17
 18  Transmerica Occidental Life      CA     0.98    2,065,291  18.18
 19  Hartford Life & Accident Ins     CT     0.63    1,340,063  58.15
 20  Washington National Ins Co       IL     0.54    1,146,553 -40.61
 21  Cooperative de Seguros de Vida   PR     0.40      847,516  88.14
 22  Fidelity & Guaranty Life Ins     MD     0.21      449,994   0.00
 23  Provident Life & Casualty        TN     0.21      438,261   1.64
 24  Guarantee Trust Life Ins Co      IL     0.17      354,465   0.00
 25  Monumental Life Ins Co           MD     0.15      319,081  -2.87
 26  IdeaLife Ins Co                  CT     0.11      225,450 270.64
 27  Great Republic Life Ins Co       WA     0.08      175,678 -50.32
 28  ReliaStar Life Ins Co            MN     0.08      168,167  -3.73
 29  Government Personnel Mutual      TX     0.06      130,109  -7.55
 30  American Progressive L&H NY      NY     0.04       94,379  31.30
 31  Bankers Life & Casualty Co       IL     0.04       89,799  26.81
 32  BCS Life Ins Co                  IL     0.04       88,812 -26.57
 33  Conseco Direct Life Ins Co       PA     0.04       84,421 -19.51
 34  Medical Life Ins Co              OH     0.03       69,737 -76.68
 35  Highmark Life Ins Co             CT     0.02       47,826 -32.82
 36  Trustmark Life Ins Co            IL     0.00       10,282   0.00
 37  MONY Life Ins Co                 NY     0.00        9,247   0.00
 38  PacifiCare Life & Health Ins     IN     0.00        9,220   0.00
 39  Peoples Benefit Life Ins Co      IA     0.00        5,825 -16.34
 40  Great American Life Ins Co       OH     0.00        4,318   0.00
        1998 Net Percent    1997 Net Percent   1996 Net
Rank    Premiums  Change    Premiums  Change   Premiums
  1  $27,353,610  29.45% $21,130,576 999.99%  -$903,728
  2   37,253,866   0.00            0 -99.99  40,249,338
  3   31,054,469 -26.85   42,452,520 -31.85  62,292,048
  4   18,926,504 -10.52   21,150,572   0.00           0
  5   16,563,524  -4.39   17,324,127  -3.86  18,020,507
  6   12,174,011 -39.69   20,186,401  54.35  13,078,249
  7    6,896,075  80.52    3,820,048  47.56   2,588,876
  8    9,494,124  -3.15    9,802,509   0.08   9,795,052
  9    8,498,745   1.00    8,414,579  -5.61   8,914,545
 10    5,938,130  -2.00    6,059,516  -0.25   6,074,696
 11    5,755,877  62.67    3,538,304  62.38   2,179,000
 12    3,388,891 -29.82    4,828,660 -30.22   6,920,065
 13    3,205,770  -4.78    3,336,613  -3.71   3,496,450
 14    2,765,007 -11.71    3,131,822  11.85   2,799,935
 15    1,514,457  54.96      977,293  39.50     700,570
 16            0   0.00            0 -99.99         196
 17    1,691,527  45.44    1,163,063   0.00           0
 18    1,747,555   0.00            0   0.00           0
 19      847,319   7.17      790,647 -22.32   1,017,797
 20    1,930,634 130.26      838,471  58.27     529,758
 21      450,467 -13.28      519,460  13.31     458,446
 22            0 -99.99      566,890  -1.51     575,590
 23      431,205  -4.73      452,612  -7.62     489,925
 24            0   0.00            0   0.00           0
 25      328,510   0.40      327,200  -5.23     345,259
 26       60,827 999.99          831 -97.25      30,266
 27      353,632   0.00            0 -99.99     436,309
 28      174,677  -3.29      180,618  -7.57     195,414
 29      140,730 -14.64      164,872  -5.80     175,032
 30       71,883  75.76       40,899   0.00           0
 31       70,815 247.69       20,367   0.59      20,248
 32      120,953  20.76      100,159 -25.26     134,006
 33      104,884 -15.60      124,273   0.00           0
 34      299,096 -48.39      579,477  42.95     405,383
 35       71,187   0.00            0   0.00           0
 36            0   0.00            0   0.00           0
 37        9,247   0.00        9,247   0.00       9,247
 38            0   0.00            0   0.00           0
 39        6,963 -14.20        8,115  -8.25       8,845
 40            0   0.00            0   0.00           0
Source: A.M. Best voluntary response questionnaire. The complete
study, which includes data from 40 companies, is available in
Best's Sales Studies, Health Sales Results, 2000 edition.
                      1999 Top Individual Long-Term-
                          Care Insurance Writers
                  Rank based on 1999 net premiums written.
                                              1999
                                            Market     1999 Net Percent
Rank Company                          State  Share     Premiums  Change
  1  Conseco Senior Health Ins Co     PA    16.05% $391,326,893   1.90%
  2  American Fam Assur Columbus      GA    14.37   350,394,045  12.03
  3  Bankers Life & Casualty Co       IL    12.98   316,404,124  17.44
  4  Travelers Ins Co                 CT     9.83   239,665,242  12.45
  5  John Hancock Life Ins            MA     7.24   176,671,597  15.73
  6  Penn Treaty Network America      PA     7.18   175,083,549   0.00
  7  Fortis Insurance Co              WI     4.12   100,468,760  -2.06
  8  Bankers United Life Assurance    IA     4.08    99,397,272  14.49
  9  Unum Life Ins Co of America      ME     3.81    92,845,987  69.05
 10  PFL Life Insurance Co            IA     2.72    66,404,939  18.17
 11  New York Life Ins Co             NY     1.38    33,544,168  39.00
 12  Teachers Ins & Annuity Assoc     NY     1.34    32,767,652  14.12
 13  National States Ins Co           MO     1.33    32,521,481   7.73
 14  Life Investors Ins Co of America IA     1.20    29,216,849   2.58
 15  Fortis Benefits Ins Co           MN     1.15    28,140,989 563.54
 16  Mutual of Omaha Ins Co           NE     1.15    28,059,398  17.16
 17  General & Cologne Lf Re of Am    CT     1.12    27,191,940  50.11
 18  Pioneer Life Ins Co              IL     0.99    24,028,711  28.12
 19  Equitable Life & Casualty        UT     0.75    18,286,567  22.57
 20  Physicians Mutual Ins Co         NE     0.74    18,012,644  29.39
 21  American Network Ins Co          PA     0.69    16,894,265   0.00
 22  American Heritage Life Ins Co    FL     0.63    15,467,122  -0.28
 23  Kanawha Ins Co                   SC     0.60    14,726,400  71.00
 24  First Unum Life Ins Co           NY     0.54    13,280,340 103.82
 25  Conseco Life Ins of New York     NY     0.39     9,408,524  62 53
 26  Medico Life Ins Co               NE     0.35     8,627,430   0.25
 27  United American Ins Co           DE     0.34     8,282,708  12.82
 28  Standard Life & Accident Ins     OK     0.27     6,544,592  -4.53
 29  Country Life Ins Co              IL     0.24     5,743,263   0.00
 30  United Teacher Associates Ins    TX     0.23     5,710,771   0.00
 31  Continental Assurance Co         IL     0.23     5,557,526  48.96
 32  Monumental Life Ins Co           MD     0.20     4,838,327 -13.59
 33  Guarantee Trust Life Ins Co      IL     0.20     4,770,687  -4.32
 34  American Pioneer Life Ins Co     FL     0.19     4,543,859   0.00
 35  Trustmark Life Ins Co            IL     0.14     3,504,283   1.06
 36  American Fidelity Assurance Co   OK     0.12     2,818,313  75.30
 37  Allianz Life Ins Co N America    MN     0.11     2,653,763 -13.01
 38  Great Republic Life Ins Co       WA     0.10     2,476,717  -6.06
 39  Combined Ins Co of America       IL     0.10     2,419,454 138.33
 40  American Republic Ins Co         IA     0.09     2,153,966  17.70
 41  Pyramid Life Ins Co              KS     0.07     1,687,865  71.11
 42  American Progressive L&H NY      NY     0.06     1,526,508  32.56
 43  First Fortis Life Ins Co         NY     0.05     1,290,250   0.00
 44  ReliaStar Life Ins Co            MN     0.05     1,247,731 -13.30
 45  Southern Farm Bureau Life Ins    MS     0.05     1,114,357  88.03
 46  Union Labor Life Ins Co          MD     0.04     1,093,002  -0.42
 47  Continental Life Ins Co TN       TN     0.04     1,035,231  47.64
 48  Florida Combined Life Ins Co     FL     0.04       869,948  54.34
 49  Connecticut General Life Ins     CT     0.03       777,039  -8.43
 50  CUNA Mutual Life Ins Co          IA     0.03       708,551 105.70
         1998 Net Percent     1997 Net Percent     1996 Net
Rank     Premiums  Change     Premiums  Change     Premiums
  1  $384,018,892   2.27% $375,488,674   7.94% $347,869,834
  2   312,754,622  -6.25   333,620,830  -1.09   337,309,946
  3   269,406,463  18.76   226,848,816  17.88   192,447,810
  4   213,132,461  15.94   183,828,053  43.98   127,679,804
  5   152,652,306  10.80   137,767,523  45.31    94,810,139
  6             0 -99.99   163,235,669 284.59    42,443,840
  7   102,584,339  16.04    88,406,041  29.16    68,445,827
  8    86,814,784  11.46    77,885,690  20.29    64,750,178
  9    54,920,654  17.41    46,775,513  10.47    42,341,308
 10    56,193,056  15.77    48,537,573  26.74    38,298,104
 11    24,131,789  31.39    18,366,170  41.27    13,000,825
 12    28,712,661  14.00    25,187,171  30.33    19,326,200
 13    30,188,359  25.96    23,966,426  21.84    19,669,795
 14    28,482,895   4.84    27,167,431  16.90    23,239,789
 15     4,241,052   0.00             0   0.00             0
 16    23,949,628   8.48    22,077,080  -0.50    22,188,424
 17    18,115,106 -33.15    27,098,882 151.63    10,769,484
 18    18,754,989 -26.58    25,545,602 100.75    12,725,348
 19    14,919,487  26.95    11,752,065  68.71     6,965,705
 20    13,921,056  33.68    10,413,973  29.35     8,051,160
 21             0   0.00             0 -99.99     5,498,410
 22    15,510,080  15.56    13,422,179  63.03     8,232,762
 23     8,611,688  96.52     4,382,068 113.84     2,049,223
 24     6,515,846  65.34     3,940,766  81.16     2,175,318
 25     5,788,861   0 00             0   0.00             0
 26     8,605,723  13.63     7,573,776   1.54     7,458,776
 27     7,341,240  15.77     6,341,231  16.59     5,438,873
 28     6,855,296   2.62     6,680,406 271.25     1,799,437
 29             0 -99.99     3,023,518  -1.32     3,064,085
 30             0   0.00             0 -99.99     8,129,718
 31     3,730,846  49.09     2,502,387 165.44       942,722
 32     5,599,405 -24.06     7,373,368 -11.05     8,289,109
 33     4,986,042  -4.91     5,243,390   0.22     5,231,849
 34             0 -99.99     1,289,812 999.99        78,168
 35     3,467,481 -63.85     9,591,269   0.00             0
 36     1,607,714   0.00             0   0.00             0
 37     3,050,719 150.02     1,220,210 143.57       500,975
 38     2,636,399   0.00             0 -99.99     4,109,265
 39     1,015,176  71.83       590,801  -5.05       622,224
 40     1,830,101  -7.67     1,982,028  -2.00     2,022,506
 41       986,400  44.63       682,001  30.63       522,072
 42     1,151,549  66.31       692,410   0.00             0
 43             0   0.00             0   0.00             0
 44     1,439,212  13.83     1,264,405 -23.10     1,644,126
 45       592,637 104.27       290,124 999.99         9,057
 46     1,097,641  11.09       988,052  90.72       518,076
 47       701,184 264.04       192,610  31.99       145,932
 48       563,657  69.57       332,399  45.05       229,163
 49       848,618 -14.18       988,821  -7.00     1,063,194
 50       344,456 124.39       153,508  50.84       101,766
Source: A.M. Best voluntary response questionnaire.
The complete study, which includes data from 88
companies, is available in Best's Sales Studies,
Health Sales Results, 2000 edition.