Genome mapping, genetic testing, DNA banks, reproductive technologies, pharmacogenetics – all of these reflect scientific breakthroughs and new opportunities in medicine that are both fascinating and disturbing. Over the past decade, the potential of genetics to help us understand and control health and disease in radically new ways has been widely discussed. Some observers view these spectacular advances as part of a larger process they refer to as “Genetic Revolution”. Others raise questions as to its ethical, legal and social repercussions, suggesting that this genetic turn will lead to the creation of a genetic underclass.

The fear of genetic discrimination...

In the wake of my general research chronicle, this chapter focuses specifically on the insurance industry’s concerns regarding the issue of genetics. In particular I am interested in the ways in which insurers frame the issue of genetics and articulate their understandings for their business.¹²In the first sections, I will sketch how the insurance world originally conceived of genetics. Next I will show how ideas with respect to this developed beyond the policy debates. Although it is hard to discern a strictly linear trend, the initial position of most professional associations in insurance differs from their more recent position....

The study of the process of risk assessment serves the broader purpose of offering more insight into the everyday practices of medical underwriting. This chapter is the first of three in which I address the risk trajectory of Karen, from her initial application to her final insurability result. As such, these chapters have a linear organisation: they trace the process by which Karen is gradually transformed from anunknownentity into aknowninsurability risk. In so doing, a host of actors is introduced, including underwriters, actuaries, medical advisors, questionnaires, lab tests, statistics and many others who have a role...

In this chapter, I will follow another step in Karen’s risk trajectory by focusing on the medical risk assessment itself. If the previous chapter demonstrated how insurance companiesa prioriselect specific medical information from the applicants, this chapter deals with how they use this information for establishing risk categories and final decisions on insurability. Before moving on, let us first return to Karen and see how she is faring at this particular stage of the risk trajectory.

Flash 1: Leuven, 21 April 2002, at home – Fictional prologue:

Karen is filling out her medical questionnaire.

Flash 2: Leuven, 2...

In the previous chapter, I addressed the various medical and statistical tools involved in risk assessment. Although this “numerical rating system” is considered an invaluable tool, the process of risk assessment is not finished here. Throughout its deployment there is room for the application of expert judgement in arriving at any decisions. This judgement dimension of the risk trajectory is the central focus of this chapter. As Balay notes above, it is specifically devoted to “the vast, mysterious mental processes” of underwriters.

Underwriters ground their decision making in the guidelines provided to them. How, then, do underwriters use these devices...

Having explored the general process of underwriting in the previous chapters, we now turn to the use of predictive medicine in life insurance. As already demonstrated in chapter I, the recent focus on genetics can be situated within a broader transformation in medicine, from a clinical, complaints-bound medicine to a predictive, risk-oriented medicine (de Vries and Horstman 2004). Since the 1970s, new disciplines have taken shape within modern epidemiology, public health and prenatal care that have contributed to a framework in which problems of health and disease have become problems ofhealth risks,shifting the focus from symptoms and treatment...

A research trip is not complete without reflection on the sites visited and the distance covered. The main objective of my retrospective effort in this chapter is to analyse what my own journey, such as it is, contributes to my object – to the world of underwriting in the context of the life insurance business, with special attention for one of its major challenges in recent years, the genetic turn. What, in other words, have welearnedalong the way?⁶⁵

By opening the black box of medical underwriting, this book demonstrates themakingof insurance risks and traces openings, co-constructions...