ABSTRACT OF PRESIDENT’S 
ADDRESS DELIVERED BE- 
FORE THE ASSOCIATION OF 
LIFE INSURANCE MEDICAL 
DIRECTORS BY AUGUSTUS S. 
KNIGHT, M.D., MEDICAL DI- 
RECTOR METROPOLITAN 
LIFE INSURANCE COMPANY 
NEW YORK 
October 20th, 1921 PRESIDENT’S ADDRESS 
A. S. Untight, M.D. 
Gentlemen—We are coming together most 
happily now, after another year of unpre- 
cedented prosperity of life insurance com- 
panies. The anxious expressions of 1918 and 
1919 have long since left the faces of Medical 
Directors, many of whom were expected at 
that time by their Executives to immediately 
stop the ravages of influenza with its death 
claims that appeared to be wiping out every- 
thing in sight; and they and the Doctors in 
general were severely blamed then by those 
Executives for not knowing just how to pre- 
vent and to cure that disease with its dread- 
ful complications. The year of exceedingly low 
mortality and of great increases of business 
that followed in 1920 brought us happily and 
with few cares to the Annual Meeting last 
October. But now in 1921 we have had 
throughout the United States and Canada a 
general death rate even lower, so that in this 
Company of ours, for instance, the rate for 
the first nine months of this year both in 
the Ordinary and Industrial Departments was 
about one-fifth less than for the same period 
last year, although 1920 was the lowest one 
on record. 
We still have our work and our routine 
problems, not the least of which is to find 
medical examiners in the Field, who are still 
willing to do careful, painstaking work and at 
fees which the Companies can afford to pay 
out of the premiums received. But with all 
the disturbances of financial structures 
around us, we are carefree in the knowledge 
that these life insurance companies by which 
we are employed are absolutely sound and 
successful, and it seems to me, therefore, that 
this is a good time to dig into our experiences 
1 and see what we can learn and profit by them. 
I shall therefore present for your consider- 
ation two studies. The first is the Final Re- 
port on Mortality of Cases Rejected During 
1905 to 1915 Because of Urinary Impair- 
ments. The work was done by Louis I. Dub- 
lin, Ph.D., Statistician of the Metropolitan 
Life Insurance Company, and it is to him 
that I am indebted for these facts. (A tech- 
nical discussion of this subject then followed). 
PERIODIC HEALTH EXAMINATIONS 
The second study for your consideration 
is that of Periodic Health Examinations. 
There is such widespread inquiry and con- 
sideration nowadays by business men, heads 
of institutions, physicians in charge of Indus- 
trial plants, and by Medical Directors and 
Executives of life insurance companies as to 
whether periodic examinations of employees 
or of policyholders, coupled with proper ad- 
vice to those who are found to have impair- 
ments, are worth while—whether the result- 
ing mortality among those who are thus 
examined is in fact sufficiently lowered to pay 
for the cost of it—and these questions are so 
difficult of categorical answer, so increasingly 
difficult when the complete actuarial demon- 
strations are required—that I think it may be 
profitable to present here as fully and as 
fairly as I can the experiences which the 
Metropolitan Life Insurance Company has 
been having with periodic health examina- 
tions of its Ordinary policyholders by the 
Life Extension Institute since February, 1914. 
Since that time the descriptive leaflets about 
the privilege have been sent to every Ordinary 
policyholder with every premium notice. 
These leaflets urge the examinations, tell the 
policyholders that the results will not be 
2 furnished to the Company, that these are 
strictly confidential between them and the 
Institute, which is a separate corporation, and 
that the examinations will not affect their 
insurance in any way. The leaflets also tell 
how if they are insured for $1,000 they can be 
examined after the policy has been in force 
for four years and every fourth year there- 
after; if for $2,000, after it has been in force 
three years, and every third year thereafter; 
if for $3,000 after it has been in force for two 
years, and every second year thereafter, and 
if over $3,000, after it has been in force for 
one year and every year thereafter. The Insti- 
tute has described the examination that it 
gives as: 
(1) A statement (made principally by 
the policyholder himself) of the physical 
condition and personal and family history 
of the policyholder. 
(2) A thorough physical examination by 
the Institute’s local examiner, covering an 
examination of the heart, lungs, abdominal 
organs, nervous system, vision, nose and 
throat, physique, blood pressure, and gen- 
eral bodily condition. 
(3) An examination of the urine at the 
Home Office Laboratory of the Institute 
covering chemical and microscopical con- 
ditions. 
Under this privilege during the seven years 
and seven months—February, 1914, to July 
31, 1921—94,998 initial and subsequent ex- 
aminations have been authorized and this is 
about 7.83% of the estimated maximum 
number of eligible requests that could have 
been received, which is 1,214,000. And of 
these that asked for those examinations and 
had them authorized, 62,478 actually were 
examined completely or partially and this 
is about*444% of the 1,214,000 that could 
3 have been examined. As to the matter of cost 
of the examinations, the Company has paid 
the Institute: 
Year 1914 $11,346.40 
Year 1915 io,733-°5 
Year 1916 10,474.35 
Year 1917 25,284.60 
Year 1918 38>533-85 
Year 1919 43>569-95 
Year 1920 44,050.55 
Year 1921—First 7 months 41,114.30 
Total amount paid during 
7 years 7 months . .$225,107.05 
It can be seen at a glance that most of 
these examinations were of too recent date 
to permit of much enlightenment from a 
study of the subsequent mortalities among 
them, but our Statistician, Dr. Dublin, has 
made an exhaustive survey of those who were 
examined during the first two years of the 
experiment—1914 and 1915—and those ex- 
amined in later years can be studied similarly 
when the experiences are old enough. For 
this purpose and for this statistical study only 
the original examination record s were put at 
our disposal by the Institute. Our study cov- 
ered 5,987 males whose physical examinations 
were complete. We also have a record of all 
subsequent examinations made on these per- 
sons. 
Our method of study was to determine the 
actual mortality experienced by these 5,987 
male persons during the years subsequent to 
their first examination up to November 15, 
1920, when the period was arbitrarily closed. 
We compared our findings, with due regard to 
the age of the examined, with the expected 
mortality according to certain standard tables. 
The group as a whole had an exposure of 
33,629 years, making an about five 
4 and one-half years per person since the initial 
examination. The tracing through the Com- 
pany’s records showed that there had been 
actually 217 deaths among the close to six 
thousand persons during this period. There 
should have been 412 deaths according to the 
American Expeiience Table, and 303 deaths 
according to the American Men Table (Ulti- 
mate). In other words, the group as a whole, 
gave a mortality rate 53 per cent, of the 
American Experience Table, and 72 per cent, 
of the American Men Table (Ultimate). 
The policyholders examined by the Life 
Extension Institute had a lower death rate 
than that expected by the various tables at 
practically every age period. By age groups 
the actual mortality compared with the ex- 
pected by the American Men Ultimate Table, 
follows and shows a favorable mortality for 
all age groups except 70 and over, bearing in 
mind, however, that the exposures for ages 
under 30 were insufficient to give reliable 
data, it seems as though the favorable mor- 
tality for the group as a whole resulted from 
the very favorable experience among those 
aged 40 to 60, inclusive. 
ATTAINED AGE 
PER CENT. ACTUAL CLAIMS 
TO PROBABLE A. M. (5) 
Under 30 . 
88 
3°-39 • • • 
96 
40-49 . . . 
78 
5°-59 • • • 
53 
60-69 • 
97 
70 and over . 
IOI 
It is evident that these examined persons 
were highly self-selected and very favorable 
lives. This is confirmed by the fact that about 
one-half of them actually had $5,000 or more 
of insurance in the Company at the time of 
their examinations. They represent economi- 
5 cally the most select lives in the Ordinary De- 
partment, in their favorable occupations and 
in their knowledge of and interest in personal 
hygiene and probably in their determinations 
to follow such courses as will keep them well 
and prolong their lives. All of these points 
help to explain the very low death rate which 
occurred among them. 
To determine further the value of the ex- 
aminations, we must take into consideration 
the constituency of the group examined. We 
must determine the kind and the extent of the 
impairments found at the time of these ex- 
aminations and determine the mortality of 
the respective classes into which the material 
must be divided. In this connection we had 
the assistance of Assistant Medical Director 
Coolidge, who went over the records with the 
Statistician and evaluated the impairments 
found. As the result of this work, we were able 
to divide our material into four main classes. 
The first consisted of 1,620 persons, or 27 per 
cent, of the total, whose defects were so 
trivial that we did not hesitate to consider 
them Preferred risks. These persons would 
correspond to our best $5,000 Whole Life 
policyholders, with their mortality expecta- 
tions of 100% or less. The second group con- 
sisted of 1,269 persons, or 21 per cent, of the 
total, who showed minor impairments on the 
examination, such as slightly thickened ar- 
teries, some digestive disturbance, functional 
heart defects, etc., which would have justified 
issuing Ordinary insurance on their lives but 
would have excluded them from the $5,000 
Whole Life group according to our present 
Medical Division standards. The third group 
consisted of 1,728 persons, or 29 per cent, of 
the total, who had no very serious impair- 
ments except that they showed albumin in 
6 the urine in amounts from a very slight trace 
to and including a large trace. It is our present 
practice to limit the great majority of these 
to sub-standard policies. These three classes 
make up more than three-fourths (77 per 
cent.) of the total. The rest, a little less than 
one-quarter, included principally persons 
whose impairments would ordinarily be con- 
sidered serious enough to warrant rejection 
for standard policies. They include persons 
with high blood pressure, organic heart dis- 
eases, lung troubles, and other organic dis- 
eases, although among them was a relatively 
small number of persons who would have been 
limited to Intermediate insurance with mor- 
tality expectation from 120 to 150 per cent, 
or to Special Class A insurance with mortality 
expectation from 150 to 200 per cent., or to 
Special Class B insurance with its expectation 
of 200 to 250 per cent, mortality, but their 
numbers are so small as not to justify any 
special treatment of them. 
We may now consider the actual mortality 
as compared with the expected in each one 
of these four classes. 
I. PREFERRED RISKS 
This group, with an exposure of 9,181 years 
of life, had 34 actual deaths. The ratio of ac- 
tual to expected on the American Experience 
Table was 33 per cent, and on the American 
Men (Ultimate) Table 47 per cent. In view of 
the fact that 62 per cent, of these persons were 
still within the first five years of their insur- 
ance, we also valued them on the American 
Men Select and Ultimate Table and, on this 
basis, found their mortality 51 per cent, of the 
expected, which is only slightly higher than 
on the Ultimate Table. The group would ap- 
pear at first sight to have profited from the 
7 service of the Institute in spite of the difficul- 
ties that must be met in improving the mor- 
tality of people already in excellent physical 
condition. We hesitate to draw this conclusion 
finally because it is impossible to say how 
much credit should be given to these persons 
for their interest in hygiene, as evidenced by 
their taking these examinations, many of 
them more than once. They are the kind of 
people who under ordinary circumstances 
avoid injurious excesses, take care of them- 
selves and would, therefore, ordinarily live 
longer than even most super-standard policy- 
holders, irrespective of whether they took 
these examinations or not. 
That the examinations were found valuable 
and appreciated by the policyholders is indi- 
cated by the fact that 41 per cent, of them 
came back for subsequent examination. A 
number availed themselves of the privilege 
each year in spite of their fine physique. 
2. ORDINARY RISKS 
The second class was exposed a total of 
7,111 years and had 44 actual deaths. The 
ratio of actual to expected deaths on the 
American Experience Table was 52 and, on 
the American Men (Ultimate) 72. In this class, 
54 per cent, were within five years of their 
original insurance examination and were, 
therefore, select lives. This fact is undoubt- 
edly an element in their favorable mortality. 
Few of the deaths which occurred among 
them were from the chronic diseases. The rate 
from tuberculosis was especially low, 42 per 
100,000, about half that in the Ordinary De- 
partment. Bright’s disease and heart disease 
likewise showed very low rates. There were 
twelve deaths from influenza and pneumonia 
in this group. 
8 These people were found on examination 
to have such defects as functional heart dis- 
turbances, high pulse rates, somewhat thick- 
ened arteries, relatively high or low blood 
pressure, and other conditions which are usu- 
ally considered important enough to require 
medical care, although not of so serious degree 
as to bar them from Ordinary insurance. The 
fact that this group had a mortality rate 
better than that of the Ordinary Department 
over the same period is a favorable indication 
as to the value of these examinations. Thirty- 
seven per cent, of this class returned for sub- 
sequent examinations. 
3. CASES WITH ALBUMIN 
The third group of 1,728 persons with al- 
bumin gave a total experience of nearly 9,850 
years of life. There were 38 deaths among 
them. The ratio of actual to expected was 33 
per cent, on the American Experience Table 
and 46 per cent, on the American Men (Ulti- 
mate) Table. In other words, this class had a 
mortality rate virtually the same as that of 
the Ordinary Preferred, who had no impair- 
ments worthy of record. This is one of the 
points of our study which is very startling but 
we must remember that albuminurias in 
otherwise standard lives uniformly give low 
mortalities in the initial period. It must be 
noted also that the finding of albumin among 
these people was limited to one examination. 
We cannot say that they had persistent al- 
buminuria. Some of them undoubtedly had 
persistent albuminuria; others had inter- 
mittent albuminuria and the remainder only 
temporary or accidental albuminuria. But, 
even if we disregard the presence of albumin 
in these persons altogether and consider them 
for the other defects, we find that about one- 
9 half of them had conditions which would have 
excluded them from the $5,000 Whole Life 
policy, although they all would have been 
granted Ordinary insurance. In spite of these 
facts, these persons experienced a low death 
rate in the five subsequent years. In the light 
of their impairments, they have done well. 
The facts perhaps suggest that the mere 
presence of albumin on one examination must 
not be considered in itself as a serious im- 
pairment, at least not during the next five 
years after examination. There were only 
three deaths from Bright’s disease among 
them during the entire period subsequent 
to the examination, or a rate of 30 per 100,000, 
which is about the same as in our Ordinary 
Department. There were four deaths from 
heart disease; eleven died of influenza and 
pneumonia; four died of tuberculosis, or at a 
rate of 41 per 100,000. The group has enjoyed 
a favorable mortality during the period sub- 
sequent to the Institute examination. Thirty- 
three per cent, of them returned for reexam- 
inations in later years. 
4. MISCELLANEOUS CASES 
The fourth is a miscellaneous group. It is 
composed of 1,370 individuals, exposed for a 
total of 7,485 years of life. There were 101 
deaths among them and the ratio of actual to 
expected mortality was 94 per cent, on the 
American Experience Table and 117 per cent, 
on the American Men (Ultimate) Table. This 
is the only group which had a higher mortality 
rate than obtains in the Ordinary Depart- 
ment. No conclusions can be drawn from the 
experience as a whole, however. It is too he- 
terogeneous. There were 77 persons among 
them who, according to Dr. Coolidge, would 
have been granted Intermediate (120-150 per 
10 cent, mortality) policies if they were appli- 
cants for insurance; 202 Special Class A 
policies (150-200 per cent, mortality); and 48 
Special Class B policies (200-250 per cent, 
mortality). In addition, 133 would have been 
postponed. This makes a total of 460 persons 
who are the least impaired of the group; the 
rest, or 910, appeared to be so seriously im- 
paired that they would have been rejected 
outright for any plan of insurance issued by 
the Company. 
For the purpose of studying this group par- 
ticularly, we singled out first a group of 683 
from these who would have been rejected but 
who were fairly homogeneous with respect to 
the seriousness of their impairment. Some had 
abnormal blood pressure with various com- 
plications; a considerable number had or- 
ganic heart affections, some had evidence of 
lung disease. They were seriously impaired 
lives but not as yet very sick people. They 
were, we thought, immediately below the 
grade which would have been acceptable for 
Special Class B insurance where the mortality 
of 200 to 250 per cent, is expected. Yet, this 
impaired group gave a ratio of actual to ex- 
pected deaths on the American Experience 
Table of 66 per cent, and on the American 
Men (Ultimate) Table, 82 per cent. This, too, 
is an interesting showing in view of the im- 
paired lives which went into the group. Ob- 
viously, these people are of the class which 
when informed of physical defects are par- 
ticularly careful to lead hygienic lives. 
In our anxiety to be as certain as possible 
whether these findings and interpretations 
were correct, or how they ought to be modified, 
we enlisted the services of our Actuaries who 
studied the problem, went over all the cards 
and checked the result. Their total figures dif- 
11 fered slightly from the Statistician’s because 
they included a number of additional cases to 
those used in Dr. Dublin’s study, and they 
found a very few more deaths that had oc- 
curred during the period but that had not 
been reported at the Home Office before the 
Statistician’s studies were finished. Neverthe- 
less the general results that they obtained 
were very much the same “raising the total 
from 53 to 57 per cent, on the American ex- 
perience and still indicating light mortality.” 
And inasmuch as these policyholders under 
study were all examined by the Institute in 
1914 or 1915 the Actuaries took our total 
Ordinary experience on policies issued prior 
to 1915 and tabulated the experience by years 
of duration, making the policy years date 
from July 1st of one year to June 30th of the 
next year, and compared the mortality by 
years with that of the Institute cases. During 
the year July 1, 1915, to June 30, 1916, the 
cases examined by the Institute showed a 
mortality of 39 per cent, of the American 
Table, while the total Ordinary policies 
showed a mortality of 70 per cent. During the 
next year the total mortality remained the 
same, but the mortality on the lives examined 
increased from 39 to 47 per cent. The mor- 
tality experience of the Ordinary policies for 
the five years compared with the experience 
on those cases examined by the Institute ap- 
pears in the following table: 
12 Table showing Percentages of American 
Table experienced in each year from July 
/, /p/5, to June jo, 1920, on total ordi- 
nary policies issued prior to 191J and on 
policies of those examined in 1914 and 
1915 by the Life Extension Institute. 
TOTAL 
ORDINARY 
EXAMINED BY 
LIFE EXTEN- 
PER CENT. 
YEAR policies. 
SION INSTITUTE. OF TOTAL FOR 
PER CENT. OF 
' PER CENT. OF 
INSTITUTE 
EXPECTED 
EXPECTED 
July 
l9lS 1 
to 
\ 7° 
39 
56 
June 
3°> 
1916 J 
July 
i, 
1916 j 
to 
\ 7o 
47 
67 
June 
3°> 
1917 J 
July 
i, 
1917 1 
to 
r 73 
62 
85 
June 
3°j 
191s J 
July 
J9l8 1 
to 
f 112 
87 
78 
June 
3°> 
1919 j 
July 
i, 
1919 ) 
to 
66 
60 
91 
June 
3°> 
1920 J 
The increasing scale indicates that had the 
experience been taken for the second five 
years instead of the first five years, the mor- 
tality ratio would not have been so low. It is 
the low mortality in the early years that makes 
the low ratios for the entire period. This point 
is especially important with reference to the 
large number of cases of albumin that were 
found among the examined. Experience has 
shown that those who show the presence of 
albumin have a relatively low mortality dur- 
ing the first five years after examination. For 
13 example: In the Medico-Actuarial investiga- 
tion, it was shown that albumin cases had a 
mortality of 78 per cent, for the first five years 
and 200 per cent, for the next five years. This 
result for the first five years tallies also with 
the Metropolitan’s experiences as reported by 
Dr. Ogden. Those who had albumin had a 
particularly low or favorable mortality for 
this initial period. What the future will show 
among these people is another question, al- 
though we already have some information 
that the rate of mortality increases with dura- 
tion of policy. It would, therefore, be safe to 
say that the benefits of the Life Extension ex- 
aminations are pretty well limited to the years 
immediately following the examinations, and 
run out at the end of about five years. 
Now then, with all these facts at hand, let 
us try to see, if possible, what money saving, 
if any, there has been for the Metropolitan 
Life Insurance Company from these Life Ex- 
tension Institute examinations. With this in 
mind, we compiled an experience on our 
Ordinary policies using the same proportion 
of business by years of issue and the same pro- 
portion of 15,000 Whole Life policies as that 
prevailing in the Institute cases. This control 
experience was observed from the years 1915 
to 1920. We thus obtained the annual mor- 
tality on a group very similar to those ex- 
amined by the Institute except as to the aver- 
age amount of insurance per policy (being 
about three times that of the average policy 
in the Ordinary Department) and, also, that 
the control group were not medically reex- 
amined lives. The difference between the 
death rates of the two sets of figures is the 
first indication of the saving for each one of 
the five years of the experience. To obtain the 
ultimate saving, select death rates for the first 
14 five years were computed assuming American 
Men Ultimate mortality thereafter. To cal- 
culate the mortality gain, select commutation 
columns on a three and one-half per cent, in- 
terest basis were constructed. The present 
value of the total mortality gains as of July, 
1920, was computed as $126,477. From this 
amount must be subtracted the cost of the 
original and the subsequent examinations 
made on the 6,000 persons examined by the 
Institute. This was approximately $40,000. 
The net gain was $86,000, and if we deduct 
Home Office expenses of $8,900 it still leaves 
a profit of $77,100. 
It would appear, therefore, that the Com- 
pany has on this particular group of people 
had its principal returned and made a 200 per 
cent, profit on this investment, during a 
period of approximately five years, provided 
that the subsequent experiences on these lives 
does not exceed the expected according to the 
American Men Table. 
I must not be interpreted as saying that 
any one arranging for a series of examinations, 
such as the Institute gives, say, for a group of 
employees in a factory, will save $2 over a re- 
turn of $1 expended in the period of the first 
five years. Much will depend upon the char- 
acter of the examinations and also upon the 
group that is selected for the examinations, 
and to a far greater extent whether the ex- 
aminations are optional or not. In our case, 
the group selected itself. In a factory or other 
establishment, it might be arranged to have 
every one take the examinations. Personally, 
I would not expect a similarly favorable re- 
sult to follow, although the after-results might 
very well justify the expenditures incurred in 
making such examinations. I should be seri- 
ously disappointed if they did not. The em- 
15 ployer might gain enough from the added 
efficiency of his employees to pay the entire 
expense, quite apart from the lessened mor- 
tality and morbidity. But our results must not 
be taken without reservations as an indication 
of what would follow if a whole group of per- 
sons were examined, irrespective of their own 
wishes. I emphasize this point, especially be- 
cause I am much impressed with the impor- 
tance of the factor of self-selection. The 
Metropolitan policyholders sought out these 
opportunities, and came for these examina- 
tions year in and year out, even though many 
of them showed no serious impairment. They 
were persons who take their personal condi- 
tion seriously and who do the usual things to 
protect themselves from ill-health. They are 
a special lot of people, quite unlike the usual 
run of policyholders or employees, generally. 
It is this fact which colors our results, and I 
confess my inability to measure the effect of 
this fact. I do not believe, however, that it is 
sufficiently large to negative the highly favor- 
able results that appeared in our experience. 
Certainly the favorable results for the im- 
paired lives suggest that excellent results fol- 
lowed and we cannot, with fairness, omit to 
say that this particular organization that has 
been making the examinations for our Com- 
pany had only begun its work in 1914, so that 
with an incomplete equipment and with no- 
where near as good examiners as compared 
with those it has today we have every reason 
to believe that the examinations and the ad- 
vices that our policyholders get today are far 
superior to what they were given in 1914 and 
1915. We therefore think that our experiences 
with the Institute have been more than justi- 
fied, and that the policyholders have been 
correspondingly benefited thereby. 
16