Cookbook and Cognition

[In his Journal of Insurance Medicine article titled, “The Cognitive Versus the Cookbook Medical Director” (2025;52:34)], Dr. Iacovino undervalues the cookbook of underwriting guidelines and misplaces the cognitive effort required for his case examples.

In Case 1, corporate underwriting policy determines whether a 22-debit risk falls into the standard risk bucket. That policy governs all such cases and all such medical director decisions.

Case 2 illustrates overlapping impairments where the sum of the debits may overstate the total risk. While directionally and qualitatively reasonable, insurance carriers require a quantitatively appropriate decision. No one has an intuitive solution to the amount of the difference between the sum of the debits and the true excess mortality. With considerable analysis, one could estimate the result. The conclusion belongs in the underwriting guidelines, for all medical directors and underwriters to follow.

Insurance carriers must price similar risks equally, to satisfy regulatory obligations and to deliver financial results in line with actuarial projections. Idiosyncratic decisions of medical directors or underwriters undermine those goals.