Also in this issue
Letter From the Editor
What's New? Digital twins, mental health in the digital age, and the latest research updates
Underwriting Updates GUM’s new mental health campaign
Case ReView Underwriting pulmonary nodule
Expert Q&A Insurance Medicine: Past, present, and future
Longer Life Foundation
RGA's Global Medical Newsletter
Understanding Smartphone ‘Addiction’ by Dr. Peter Farvolden The Evolving Science of Concussions: What insurers need to know by Dr. Pramodh Nathaniel Recent Trends and Impact of Viral Infectious Diseases: An insurer’s perspective by Dr. Dan Zimmerman
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Dr. Adela Osman
Vice President Head of Global Medical
adela.osman@rgare.com
Dr. Daniel D. Zimmerman, DBIM
Senior Vice President Chief Science Advisor
dzimmerman@rgare.com
I am pleased to share the latest installment of RGA’s medical newsletter, which is packed with valuable insights on a wide variety of medical issues impacting the insurance industry. In our feature articles, Dr. Peter Farvolden examines phone addiction and its impact on mental health, Dr. Pramodh Nathaniel investigates the evolving science of concussions, and Dr. Dan Zimmerman explores recent trends and impacts for three prominent infectious diseases. All three features delve into the medical science behind each topic and go on to consider implications for life and health insurers. Further insights can be found throughout the issue: Dr. Sheetal Salgaonkar’s Case ReView outlines the challenges of underwriting an incidental pulmonary nodule. In the What’s New section, Dr. Steve Woh reflects on the concepts of digital twins and mental health in the digital age. Research summaries look at mapping gut cells to find new ways to treat disease, the association between metabolic syndrome and risk of incident dementia, and repurposing GLP-1 drugs for alcohol use disorder. The Underwriting Update highlights “Advancing Mental Health in Insurance,” RGA’s comprehensive online library of mental-health focused tools, resources, and research. My personal favorite in this issue is a Q&A with Dr. Dan Zimmerman, longtime RGA Medical Director and ReFlections Editor, who is transitioning to a new advisory role within the company and serving as Editor-in-Chief of the next edition of Brackenridge’s Medical Selection of Life Risks. Dan’s contributions to this newsletter, RGA’s medical team, and the insurance medical profession are well known and respected throughout the industry. I look forward to continuing to work with Dan in his new role and building on his legacy at RGA and beyond. Looking ahead, I am excited to welcome RGA Asia Medical Directors Dr. Karneen Tam and Dr. Si Ning Zhao to the ReFlections team as our new Assistant Editors. I look forward to working with them in strengthening this publication’s mission to advance the field of insurance medicine. Thank you, Adela Osman
Welcome to the February 2025 edition of ReFlections!
ReFlections
From the Editor
In this issue
Understanding Smartphone ‘Addiction’
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Letter From the Editors
What's New? Digital twins, mental health in the digital age, and the latest research updates.
Case ReView Underwriting Pulmonary nodule
The Evolving Science of Concussions: What insurers need to know
Recent Trends and Impact of Viral Infectious Diseases: An insurer’s perspective
Features
In a relatively short time span, smartphones have become ubiquitous, and their many uses are ever expanding – from accessing information and communicating with others to transacting business and monitoring health. However, along with the many enhancements and conveniences they bring, mounting evidence suggests smartphones also can negatively impact mental health. While studies have established links between smartphone use and various mental health issues, such as anxiety, depression, stress, and sleep problems, the relationship is complex and influenced by multiple factors. Many researchers and psychologists now consider excessive phone use a behavioral addiction, given its similarities to gambling disorder, another recognized non-drug addiction. Life and health insurers will need to monitor research, weigh the various aspects of this evolving issue, and adapt risk stratification and claims assessment processes accordingly.
Abstract
References
Ericsson mobility report: mobile subscriptions to exceed world population by 2027. 2022. Available from: https://www.ericsson.com/en/mobility-report Pew Research Center. Mobile fact sheet: mobile phone and smartphone ownership statistics in the U.S. 2023. Available from: https://www.pewresearch.org Statista. Global mobile internet penetration and smartphone-only users in the U.S. 2023. Available from: https://www.statista.com Statista. Daily smartphone usage worldwide by country and demographic, 2023. Available from: https://www.statista.com Deloitte. Global Mobile Consumer Trends: Second Edition. 2023. Available from: https://www2.deloitte.com Pew Research Center. Technology adoption and smartphone ownership among younger and older demographics. 2023. Available from: https://www.pewresearch.org Elhai JD, Levine JC, Dvorak RD, Hall BJ. Fear of missing out, need for touch, anxiety and depression are related to problematic smartphone use. Comput Human Behav. 2017;63:509-16. doi:10.1016/j.chb.2016.05.079 Boumosleh JM, Jaalouk D. Depression, anxiety, and smartphone addiction in university students – A cross-sectional study. PLoS One. 2017;12(8):e0182239 doi:10.1371/journal.pone.0182239 Sohn SY, Rees P, Wildridge B, Kalk NJ, Carter B. Prevalence of problematic smartphone usage and associated mental health outcomes amongst children and young people: A systematic review, meta-analysis, and GRADE of the evidence. BMC Psychiatry. 2019;19(1):356. doi:10.1186/s12888-019-2350-x Exelmans L, Van den Bulck J. Bedtime mobile phone use and sleep in adults. Soc Sci Med. 2016;148:93-101. doi:10.1016/j.socscimed.2015.11.037 Cain N, Gradisar M. Electronic media use and sleep in school-aged children and adolescents: A review. Sleep Med. 2010;11(8):735-42. doi:10.1016/j.sleep.2010.02.006 Alonzo R, Hussain J, Stranges S, Anderson KK. Interplay between social media use, sleep quality, and mental health in youth: A systematic review. Sleep Med Rev. 2021;56:101414. doi:10.1016/j.smrv.2020.101414 Keles B, McCrae N, Grealish A. A systematic review: The influence of social media on depression, anxiety, and psychological distress in adolescents. Int J Adolesc Youth. 2020;25(1):79-93. doi:10.1080/02673843.2019.1590851 Primack BA, Shensa A, Sidani JE, Whaite EO, Lin LY, Rosen D, et al. Social media use and perceived social isolation among young adults in the U.S. Am J Prev Med. 2017;53(1):1-8. doi:10.1016/j.amepre.2017.01.010 Twenge JM, Spitzberg BH, Campbell WK. Less in-person social interaction with peers among U.S. adolescents in the 21st century and links to loneliness. J Soc Pers Relat. 2019;36(6):1892-913. doi:10.1177/0265407519836170 Orben A, Przybylski AK. The association between adolescent well-being and digital technology use. Nat Hum Behav. 2019;3(2):173-82. doi:10.1038/s41562-018-0506-1 Ellison NB, Steinfield C, Lampe C. The benefits of Facebook “friends”: Social capital and college students’ use of online social network sites. J Comput Mediat Commun. 2007;12(4):1143-68. doi:10.1111/j.1083-6101.2007.00367.x Twenge JM, Campbell WK. Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population-based study. Prev Med Rep. 2018;12:271-83. doi:10.1016/j.pmedr.2018.10.003 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text rev. Arlington, VA: American Psychiatric Association Publishing; 2022. Petry NM, Zajac K, Ginley MK. Behavioral addictions as mental disorders: To be or not to be? Annu Rev Clin Psychol. 2018;14:399-423. doi:10.1146/annurev-clinpsy-032816-045120 Billieux J, Maurage P, Lopez-Fernandez O, Kuss DJ, Griffiths MD. Can disordered mobile phone use be considered a behavioral addiction? An update on current evidence and a comprehensive model for future research. Curr Addict Rep. 2015;2(2):156-62. doi:10.1007/s40429-015-0054-y Wheelwright T. Cell phone usage stats 2025: Americans check their phones 205 times a day. Reviews.org. Published January 1, 2025. Available from: https://www.reviews.org/mobile/cell-phone-addiction Olson JA, Sandra DA, Colucci ÉS, Al Viki A, Chmoulevitch D, Nahas MH, et al. Smartphone addiction is increasing across the world: A meta-analysis of 24 countries. Comput Human Behav. 2022;129:107138. doi:10.1016/j.chb.2021.107138
About the author
As a member of RGA’s Global Medical team, Dr. Peter Farvolden collaborates with RGA’s teams around the world to provide clients with insights and strategies around mental health. Dr. Farvolden has worked for 25 years as a researcher, clinician, and administrator in a wide variety of inpatient and outpatient settings across Canada. Dr. Farvolden is a member of the College of Psychologists of Ontario, the Association for Behavioral and Cognitive Therapies, the Anxiety Disorders Association of America, the Canadian Psychological Association, the Canadian Association of Cognitive Behavioural Therapy, and the Ontario Psychological Association. He holds a Ph.D. in Clinical Psychology, a B.Sc. in Psychology, and a B.A. in Philosophy, all from the University of Waterloo.
Dr. Peter Farvolden, PhD, CPsych
RGA Mental Health Consultant
Peter.Farvolden@rgare.com
Numerous studies have established links between smartphone use and various mental health issues.
Global smartphone market penetration is very high, with the number of mobile phone subscriptions set to surpass the world population in 2027. North America, Western Europe, and East Asia have penetration rates near or above 100% for both mobile phones and smartphones. In 2023, approximately 66% of the global population had access to the internet via mobile devices, with growth driven by increasing access in developing markets.1,2,3 Globally, people use their phone three to five hours per day on average, although this can vary by country, with youth and younger adults tending to have higher usage rates.4,5,6 Smartphones have many positive uses and will continue to expand people’s capabilities, boundaries, and opportunities. However, it is important to consider their potential harm to mental health and happiness. Numerous studies have established links between smartphone use and various mental health issues, including: Anxiety and depression – Studies have shown a link between high smartphone use (especially social media) and increased symptoms of anxiety, depression, and stress in teens and adults, largely due to factors such as social comparison, cyberbullying, and fear of missing out (FoMO).7,8,9 Sleep problems – Blue light emitted by phone screens interferes with melatonin production, and the mental stimulation from content can prevent restful sleep. Excessive phone use, particularly before bed, is linked to poorer sleep quality, insomnia, disrupted circadian rhythms, and exacerbation of mental health issues.10,11,12 Loneliness/social isolation – Excessive use can contribute to feelings of loneliness and social isolation, as people substitute virtual interactions for in-person relationships, leading to a sense of disconnection in the real world. Heavy social media users (three or more hours per day) are twice as likely to feel lonely or socially isolated.13,14,15
Smartphones and mental health
Smartphones and addictive behaviors
From an insurance perspective, accurately accessing mortality and morbidity risk due to phone addiction will require building on current knowledge in a variety of ways, including: Longitudinal studies – Most studies on smartphone use and mental health are cross-sectional, meaning they examine data at one point in time. Longitudinal research, which tracks individuals over time, is needed to better understand the long-term effects of smartphone use on mental health. Impact of new technologies – The rapid evolution of technology, including artificial intelligence, virtual reality, and new social media platforms, means that the specific risks to mental health are continually shifting. The rise of platforms like TikTok and their immersive nature (e.g., short video formats, instant feedback) may introduce new challenges for mental health requiring up-to-date research. Individual factors – Research should continue exploring factors that make certain individuals more vulnerable to the negative effects of smartphone use, such as underlying mental health conditions, personality traits (e.g., neuroticism), or social circumstances. While smartphone addiction is not currently an underwritten condition, insurers will need to monitor research, weigh the various aspects of this evolving issue, and adapt risk stratification and claims assessment processes accordingly. They might also proactively seek opportunities to enhance client engagement on this issue through wellness initiatives, client education, and screening tools.
Insurance considerations
Although studies have consistently shown that excessive phone use can contribute to poor mental health outcomes, several factors complicate the understanding of smartphone use and mental health.16,17,18 These factors include: Complex relationship – The relationship between smartphone use and mental health is curvilinear (vs. linear). Moderate smartphone use (two to three hours per day) may have neutral or even positive effects on wellbeing, while both very low use (less than two hours per day) and very high use (more than five hours per day) are linked to negative outcomes. Individual differences (e.g., age, personality, purpose of use) further complicate this relationship – what may be harmful for one individual might not be for another. Content and context – Studies indicate that the type of use (e.g., passive consumption vs. active interaction) is more predictive of mental health risks than total time spent on phones. Passive use – such as scrolling through social media – is more strongly linked to negative emotions, FoMO, and social comparison. Active use – such as communicating with friends or family, or participating in online communities – may be less harmful and, in some cases, even beneficial for emotional wellbeing. Role of individual and social context – Demographic factors such as age, gender, socioeconomic status, and pre-existing mental health conditions affect how individuals respond to smartphone use. Adolescents and young adults tend to be more vulnerable to the negative effects of smartphones, especially in the context of social media use. Cultural factors also play a role, as different societies have varying norms around smartphone use and its social significance. Inconsistent and mixed research findings – Some studies show significant negative impacts of excessive smartphone use, while others find weak or no clear association. This inconsistency arises partly because studies use different methodologies that make comparisons difficult, and the definitions of “excessive use” vary, as do the specific measures of mental health outcomes. In addition, the rapid evolution of digital platforms means research can quickly become outdated. Bias in self-reported data – Much of the research relies on self-reported data, which can be unreliable. People may underreport or overestimate their phone use, and mental health symptoms such as anxiety and depression are subjective, making accurate measurement difficult. Association vs. causation – It is often unclear whether excessive smartphone use causes mental health issues or whether people with pre-existing conditions (e.g., depression, anxiety) are more likely to engage in excessive phone use. Other variables, such as sleep deprivation, social isolation, or lack of physical activity – which can accompany high phone use – are also likely contributing factors.
Should excessive phone use be considered an addiction? According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), addiction falls under the category of substance use disorder (SUD) and is characterized by a compulsive pattern of substance use despite harmful consequences. The DSM-5-TR does not use the term “addiction” explicitly but outlines the criteria for SUD based on behavioral, cognitive, and physiological aspects. These include impaired control, social impairment, risky use, and pharmacological criteria (tolerance and withdrawal).19 Although gambling disorder is the only officially recognized non–substance-related addictive disorder in the DSM-5-TR, researchers have suggested that other behaviors done in excess, such as internet gaming, shopping, pornography, sex, exercise, and phone use, may also be formally classified as addictive behaviors in future editions, pending further research evidence.20 People can develop a non–substance-use behavioral addictive disorder (e.g., problem gambling) through their smartphone. Problematic smartphone use is sometimes classified as a form of behavioral addiction, where users exhibit symptoms such as craving, withdrawal, and tolerance.21
While increasingly researched, the mental health risks of smartphone use are not fully understood. Although numerous studies have established links between smartphone use and mental health issues, the relationship is complex and influenced by multiple factors. The rapid evolution of smartphone technology and social media platforms adds further complexity, making it difficult to draw conclusions about the full extent of risks. Mobile phone use has been described as the biggest non-drug addiction of the 21st century. Studies highlight that excessive phone use activates the brain’s reward system, releasing dopamine, which reinforces habitual checking of notifications, social media, and apps. Researchers and psychologists often refer to mobile phone addiction as a behavioral addiction, given its similarities to gambling disorder. The constant accessibility and engagement of smartphones have amplified this issue globally. Smartphones are now inextricably integrated into modern life. Understanding how to optimize this relationship with technology while mitigating risks presents an ongoing challenge not only for medical professionals and insurers but for every individual.
Conclusions
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27% use or look at their phones while driving.
A study found 76% of 3,534 internet users aged 12-77 experienced more than five of 23 phone addictive behaviors. Overall, 46% of the study participants suffered from feelings of depression, 70% from levels of anxiety, and 14% from some form of sleep disturbance.5 A larger study reported that approximately one-third of people around the world may be at a high risk for smartphone addiction, with younger women and people in parts of Asia more likely to report problematic use.23 While not currently described as such, the DSM-5-TR criteria for diagnosing non-substance use addictive disorders provide a structure for further research into whether some patterns of excessive smartphone use may be best described as an “addiction.”21 For example: Craving and compulsive use – Individuals with excessive phone use feel an uncontrollable urge to check their phones frequently, even when it interferes with daily activities or relationships. This behavior can resemble compulsions seen in SUDs. Loss of control – An inability to reduce phone use is common. Users may plan to check their phones for a minute but find themselves scrolling for hours. Tolerance and escalation – Over time, individuals may need to spend more time on their phones to achieve the same sense of satisfaction or relief. The constant use escalates, much like substance users developing tolerance and requiring more of a drug to achieve the same effects. Withdrawal symptoms – When phone access is limited, individuals may experience anxiety, irritability, restlessness, or distress. This mirrors withdrawal symptoms seen in SUDs. Interference with daily life – Excessive phone use can disrupt normal functioning in social interactions, work, and academic performance and can impact sleep and physical health (e.g., eye strain, headaches, and poor posture). Mood modification – Like other addictive behaviors, phone use can serve as a coping mechanism to alter mood. Users may turn to their phones to escape stress, boredom, loneliness, or depression, leading to a cycle of reliance. Salience – Excessive phone use can become a dominant activity in life, with users prioritizing phone engagement over other important activities, such as exercise, spending time with loved ones, or pursuing hobbies. Psychological and social impact – Constant notifications and multitasking can affect cognitive functioning, reducing attention span and impairing memory. Overuse of phones often leads to neglect of real-life relationships, creating a sense of isolation even when surrounded by others. Research links excessive phone use, especially social media consumption, with heightened anxiety, depression, and feelings of inadequacy.
By the numbers
A recent survey from Reviews.org22 indicates these phone use patterns:
https://www.reviews.org/mobile/cell-phone-addiction/
Americans spend 4 hours, 25 minutes each day on their cell phones.
Americans check their phones 144 times per day.
89% say they check their phones within the first 10 minutes of waking up.
75% feel uneasy leaving their phones at home.
75% check their phones within five minutes of receiving a notification.
60% sleep with their phones at night.
55% say that they have never gone longer than 24 hours without their cell phones.
47% of people say they feel a sense of panic or anxiety when their cell phone battery goes below 20%.
46% use or look at their phones while on a date.
Driven by a surge in reported cases and high-profile incidents involving athletes, awareness of concussions – and their long-term neurological impacts – has reached unprecedented levels. These traumatic brain injuries (TBI), often linked to conditions like chronic traumatic encephalopathy (CTE), have become a pressing public health concern far beyond the world of sports, impacting millions of people from all demographics. The developments underscore the critical need to understand the connection between repetitive head injuries and long-term neurological conditions. As research advances, the insurance industry must be prepared to pivot quickly, reassessing policies, benefits, and claims processes to address the evolving complexities of concussions. This article examines concussions and their related clinical conditions, highlighting key considerations for healthcare insurers navigating this shifting landscape.
The exact mechanisms behind concussive symptoms remain unclear. Research suggests that trauma stretches nerve cell membranes and fibers (axons), triggering a neurometabolic cascade that leads to neuroinflammation and potential injury or cell death. A common misconception is that concussions require loss of consciousness, which occurs only in a minority of cases. While severe neurological symptoms like post-traumatic amnesia, disorientation, epilepsy, or paralysis can result, mild traumatic brain injuries often present subtler signs, such as headaches, difficulty concentrating, a sense of mental fog or pressure, fatigue, irritability, and drowsiness.
The science of concussive symptoms
“Estimating the global incidence of traumatic brain injury” J Neurosurg 2018 Apr 27;130(4):1080-1097 https://pubmed.ncbi.nlm.nih.gov/29701556/ “Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans” Definitions of Traumatic Brain Injury https://www.ncbi.nlm.nih.gov/books/NBK542588/ “Postconcussive Syndrome” Permenter et al. Aug 28, 2023 https://www.ncbi.nlm.nih.gov/books/NBK534786/ "Examination of postconcussion-like symptoms in healthy university students: Relationships to subjective and objective neuropsychological function performance” Wang et al. Archives of Clinical Neuropsychology, Volume 21, Issue 4, May 2006, p339-347 https://academic.oup.com/acn/article-abstract/21/4/339/2860?redirectedFrom=fulltext) Prevalence of post-concussion-like symptoms in the general population in Italy, The Netherlands and the United Kingdom Voormolen et al. (2019) Brain Injury, 33(8), 1078-1086 https://www.tandfonline.com/doi/full/10.1080/02699052.2019.1607557#abstract “Prevalence of Post-Concussion-Like Symptoms in the General Injury Population and the Association with Health-Related Quality of Life, Health Care Use, and Return to Work” Van der Vlegel et al. J Clin. Med. 2021 Feb 17;10(4):806 https://pmc.ncbi.nlm.nih.gov/articles/PMC7922247/ “‘Postconcussive’ symptoms in persons with chronic pain” Iverson and McCracken Brain Inj. 1997;11(11):783-90 “Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review” McInnes et al. PLos One. 2017 Apr 11;12(4):e0174847 https://pmc.ncbi.nlm.nih.gov/articles/PMC5388340/ “A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury” Polinder et al. Front Neurol., 19 December 2018, Volume 9 – 2018 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2018.01113/full “Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults. A Systematic Review and Meta-analysis and Guideline Recommendation” Malá Rytter et al. JAMA Netw Open. 2021;4(11) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785878 “The Role of Neuropsychology in Traumatic Brain Injury: Comprehensive Literature Review” Halalmeh et al. World Neurology Vol183, March 2024, p128-143 https://www.sciencedirect.com/science/article/pii/S1878875023017928?via%3Dihub#bib8 “Concussion and Brain Health Position Statement 2024” Australian Sports Commission June 2024 https://www.concussioninsport.gov.au/__data/assets/pdf_file/0004/1133545/37382_Concussion-and-Brain-Health-Position-Statement-2024-FA.pdf “Chronic Traumatic Encephalopathy: The Neuropathological Legacy of Traumatic Brain Injury” Hay et al. Annu Rev Pathol. 2016 Jan 13;11:21-45 https://pmc.ncbi.nlm.nih.gov/articles/PMC5367053/ “Chronic Traumatic Encephalopathy: A Brief Overview” Fesharaki-Zadeh Front Neurol 2019 Jul 3;10:713 https://pmc.ncbi.nlm.nih.gov/articles/PMC6616127/ “Post-Concussion Syndrome and Chronic Traumatic Encephalopathy: Narrative Review on the Neuropathology, Neuroimaging and Fluid Biomarkers” Mavroudis et al. Diagnostics (Basel) 2022 Mar 18;12(3):740 https://pmc.ncbi.nlm.nih.gov/articles/PMC8947595/ “Chronic traumatic encephalopathy (CTE)—features and forensic considerations” Byard et al. Forensic Science, Medicine and Pathology Vol 19, p620-624 (2023) https://link.springer.com/article/10.1007/s12024-023-00624-3 “Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022”Patricios et al. British Journal of Sports Medicine Vol 57, Issue 11 https://bjsm.bmj.com/content/57/11/695 “Sports-Related Concussions in Youth: improving the Science, Changing the Culture” (2014) Chapter 3 Concussion Recognition, Diagnosis, and Acute Management Editors Graham, Rivara, Ford, and Spicer https://www.ncbi.nlm.nih.gov/books/NBK185340/ “Neurofilament light chain in patients with a concussion or head impacts: a systematic review and meta-analysis” Karantali et al. Eur J Trauma Emerg Surg 48, 1555–1567 (2022) https://doi.org/10.1007/s00068-021-01693-1 “Thorough overview of ubiquitin C‐terminal hydrolase‐L1 and glial fibrillary acidic protein as tandem biomarkers recently cleared by US Food and Drug Administration for the evaluation of intracranial injuries among patients with traumatic brain injury” Wang et al. Acute Med Surg. 2021 Jan 19;8(1):e622 https://onlinelibrary.wiley.com/doi/10.1002/ams2.622 “UCH-L1 and GFAP Testing (i-STAT TBI Plasma) for the Detection of Intracranial Injury Following Mild Traumatic Brain Injury” Middleton Am Fam Physician. 2022;105(3):313-314 https://www.aafp.org/pubs/afp/issues/2022/0300/p313.html “Accuracy of a rapid glial fibrillary acidic protein/ubiquitin carboxyl‐terminal hydrolase L1 test for the prediction of intracranial injuries on head computed tomography after mild traumatic brain injury” Bazarian et al. Acad Emerg Med. 2021 Sept 7;28(11):1308-1317 https://pmc.ncbi.nlm.nih.gov/articles/PMC9290667/ US Food and Drug Administration – 510(k) Substantial Equivalence Determination Decision Summary https://www.accessdata.fda.gov/cdrh_docs/reviews/K223602.pdf Accessed August 18, 2024 “Abbott receives FDA clearance for whole blood rapid test to help with assessment of concussion at the patient’s bedside” Abbot Release dated 1st April 2024 Accessed August 20, 2024 “Army Announces FDA Clearance of Whole Blood Rapid Test to Help with Assessment of Traumatic Brain Injury.” Vander Linden https://www.army.mil/article/274997/army_announces_fda_clearance_of_whole_blood_rapid_test_to_help_with_assessment_of_traumatic_brain_injury Accessed August 20, 2024 “Diffusion Tensor Imaging Correlates of Concussion Related Cognitive Impairment” Gonzalez et al. Front Neurol. 2021 May 24; 12:639179 https://pmc.ncbi.nlm.nih.gov/articles/PMC8180854/
Dr. Pramodh Nathaniel is the Chief Medical Officer for RGA Australia and New Zealand. He is an experienced medical director with a broad range of specialities, including insurance medicine, occupational medicine, travel and tropical medicine, public health, emergency medicine, and aviation and retrieval medicine. Dr. Nathaniel served as the Regional Deputy Medical Director for International SOS, where he managed lifesaving and life-changing evacuation arrangements on a global scale. He has held the position of Chief Medical Officer for leading life insurance and superannuation companies in Australia for more than 15 years. In these roles, he provided high-quality medical advice, contributed to underwriting and claims assessments, and offered medical input into product development and policy definitions. During the COVID-19 pandemic, he served as a Chief Medical Advisor to banks, public utility and security companies. Dr. Nathaniel holds degrees in science from the University of Melbourne and medicine from the University of Sydney. Furthering his expertise, Dr. Nathaniel has pursued postgraduate studies in public health, tropical medicine, aviation medicine, aeromedical evacuations, occupational health, and travel medicine.
Dr. Pramodh Nathaniel
Chief Medical Officer RGA Australia and New Zealand
Pramodh.Nathaniel@rgare.com
Advancements in biomarkers and imaging technologies offer promising new tools for diagnosing mild traumatic brain injuries.
Part II: Lewy Body Dementias
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Traumatic brain injuries (TBI) are a significant global public health issue and a leading cause of disability. An estimated 69 million people worldwide experience TBI annually, with most cases occurring in low-to-middle-income countries, primarily due to motor vehicle accidents.1 The terminology and diagnostic criteria for TBI are complex, with no universally accepted definitions.2 For example, the ICD-10 criteria for post-concussion syndrome differ from those outlined in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). While these systems rely on symptoms to define conditions, chronic traumatic encephalopathy (CTE) remains distinct, requiring postmortem brain analysis for definitive diagnosis.
Understanding concussion and related terms
Managing PCS is particularly challenging due to the complexity of symptoms and limited evidence for some treatments. Current approaches include: Non-pharmacological interventions Cognitive rehabilitation: Helps improve cognitive deficits in attention, memory, and executive functioning. Psychotherapy such as cognitive behavioral therapy (CBT): Provides coping strategies for emotional symptoms like irritability, depression, and anxiety. Pharmacological treatments Antidepressants and anti-anxiety medications: Used symptomatically to manage emotional and psychological symptoms. Stimulants: Sometimes prescribed to improve attention and concentration. Rehabilitation therapies Vestibular and vision therapy: Addresses cervical soft tissue damage often associated with mTBI, although evidence of efficacy remains limited. The Australian Sports Commission’s 2024 “Concussion and Brain Health” position statement highlights a physiotherapy-guided rehabilitation plan, focusing on five key areas – the autonomic system, cervical spine, vestibular function, vision, and cognition – to guide an athlete’s safe return to activity.13,14,15 Traumatic encephalopathy syndrome and chronic traumatic encephalopathy The neuropathological hallmarks of chronic traumatic encephalopathy (CTE-NC) include hyperphosphorylated tau (pTau) protein and neurofibrillary tangles (NFTs) or pretangles in specific brain regions characteristic of the condition. These abnormalities cluster around small blood vessels in the cerebral cortex, leading to progressive and debilitating neurodegeneration. While tau deposition is common in several neurodegenerative diseases, such as Alzheimer’s, and in normal aging, the pattern and distribution of tau and NFT pathology in CTE are distinct enough to be considered diagnostically definitive. The mechanisms underlying CTE remain unclear, but repetitive mild traumatic brain injuries (rmTBI) are believed to cause abnormal phosphorylation of tau protein. This misfolded and cleaved protein aggregates into clumps, potentially promoting the accumulation of other aggregate-prone proteins. These pathological changes can be confirmed only through autopsy, as they are not detectable via imaging. The pathological stages of CTE are illustrated below:
Treating PCS
Controversies surrounding CTE
With no specific test or biomarker available, concussion diagnosis and monitoring rely on identifying relevant symptoms and clinical signs. However, advancements in biomarkers and imaging technologies offer promising new tools for diagnosing mild traumatic brain injuries.
Investigations for diagnosing concussion
Post-concussion syndrome and persistent symptoms
The development of PPCS likely involves a complex interplay of biological factors, such as diffuse axonal injury, neuroinflammation, and altered cerebral blood flow, alongside psychological, socio-demographic, and personality factors. Incidence rates vary widely across studies due to differing diagnostic criteria, and controversy persists over whether PCS can be fully attributed to mild TBI. Subjective symptoms, which include headaches, fatigue, and mood changes, are non-specific and may predate the injury, complicating definitive diagnosis. Studies have even observed similar symptoms in healthy populations, non-head trauma patients, and individuals with chronic pain.4,5,7 An estimated 15% of individuals with mTBI develop PPCS, although some studies suggest rates as high as 25%, depending on the criteria used.8,9
The NOVA food classification system, which is commonly used to describe population dietary patterns, defines UPFs as “industrial formulations of ingredients that undergo a series of physical, chemical, and biological processes.” First developed in Brazil in 2009, NOVA organizes foods into one of four groups, based on the level of processing involved.3
Categories of UPFs
Table 1: The NOVA Food Classification System3
Groups
Description
Examples
NOVA 1
NOVA 2
NOVA 3
NOVA 4
unprocessed or minimally processed foods
Unprocessed food items (e.g., seeds, fruits, leaves, stems, roots, eggs, milk, fungi) Food items minimally processed via drying, crushing, grinding, roasting, boiling, pasteurizing, chilling, freezing
Oils, butter, lard, sugar, salt; items derived from NOVA1 foods; and items that combine two such ingredients (e.g., salted butter) Items not intended to be consumed on their own but used to enhance the NOVA1 foods from which they are derived
Canned meat, fish, fruit, beans, vegetables; cured meats; fermented beverages; food items with added ingredients from NOVA1 or NOVA2 (e.g., bread) Items containing two or three ingredients that make modified versions of NOVA1 foods
Sweetened beverages (including soft drinks), sweets, cookies, potato/tortilla chips, re-formed meats (e.g., Spam), and ready-to-eat meals composed of substances derived from foods and additives Items containing additives such as preservatives, antioxidants, stabilizers, dyes, flavors, enhancers, sweeteners, and emulsifiers
processed culinary ingredients
processed foods
UPFs (industrial formulations)
The relationship between repetitive mild traumatic brain injuries (rmTBI) and chronic traumatic encephalopathy (CTE-NC) remains controversial, with ongoing debate over whether rmTBI causes CTE-NC or is correlated with it. CTE-NC is a condition that develops over decades, requiring evaluation of head trauma from the distant past. Each mTBI is typically brief, often ambiguous, and rarely quantified, making rigorous clinical studies difficult.12 Research on CTE-NC largely consists of case reports, retrospective studies, and post-mortem analyses, often with selection bias. Many diagnoses come from retired athletes who donated their brains to sports brain banks. Environmental factors, such as substance use, genetic predisposition, mental health history, and education level, further complicate causation studies. A 2023 study of 636 cases from the Sydney Brain Bank confirmed a low prevalence of CTE-NC in the general population (0.8%), with only five cases identified -three involving a history of TBI and two without.12 The Concussion in Sport Group’s 2023 “Consensus Statement on Concussion in Sport” acknowledged the potential link between extensive repetitive head impacts, such as those experienced by some professional athletes, and the neuropathology of CTE-NC. This influential group’s concussion protocols are widely adopted across elite and community sports worldwide.17
The term CTE-NC (neuropathological changes) refers specifically to the condition diagnosed postmortem. In contrast, traumatic encephalopathy syndrome (TES) describes the clinical signs and symptoms associated with CTE-NC in individuals who are still alive. Both conditions share features such as impairments in higher executive functioning, including short-term memory loss, mood instability, depression, and difficulties with decision-making and multitasking. TES is also linked to later-life conditions such as dementia and Alzheimer’s disease, and movement disorders like Parkinson’s disease.16
Fluid biomarkers
TBI
PCS
CTE
UCH-L1 YKL-40 SNTF MCP-4 MCP-1β
GFAP S100B NSE
EXTRACELLULAR VESICLES
IL1 IL6 IL8 IL10 TNF-α
AMYLOID β
sTREM2
NFL TAU
Brain injuries can cause proteins to leak from damaged cells into cerebrospinal fluid (CSF) or cross the blood-brain barrier into the bloodstream, where they can be measured. This evolving area of research shows promise for diagnosing mTBI. Biomarkers in blood, CSF, saliva, and urine are under investigation to help distinguish concussions from non-concussive head injuries, differentiate mild from severe intracranial injuries, and identify individuals at risk for prolonged symptoms. The schematic below illustrates biomarkers currently being studied for diagnosing concussion-related conditions.15,18,19
Adapted from “Post-Concussion Syndrome and Chronic Traumatic Encephalopathy: Narrative Review on the Neuropathology, Neuroimaging and Fluid Biomarkers” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8947595/
In February 2018, the US Food and Drug Administration (FDA) approved the first blood test for detecting intracranial injury following a mild traumatic brain injury. This test measures two proteins: ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), markers of neuronal and glial cell damage. Because each protein originates from different brain cell types, their combined measurement provides complementary insights into intracranial injury. The test was approved specifically for emergency care use in adults over 18 to reduce unnecessary CT scans in patients with mTBI. A negative result within 12 hours of injury is associated with the absence of acute intracranial lesions on CT imaging. The test is used alongside clinical information, Glasgow Coma Scale (GCS) scores (13-15 for mTBI), and clinical imaging guidelines, such as the Canadian CT Head Rule.21,22 Limitations Not validated for individuals under 18 years old Detects intracranial bleeding rather than diagnosing concussions specifically Approved only for use in emergency settings and within 12 hours of injury In April 2024, the FDA approved a portable version of the test that delivers lab-quality results within 15 minutes and can evaluate patients up to 24 hours after injury.24 The US Army has partnered with a manufacturer to deploy this proprietary TBI test in field settings, citing nearly 500,000 troops who experienced TBI during training or deployment from 2000 to 2023.25 While these advancements show promise, current biomarkers cannot determine when the brain has fully healed, making them insufficient for guiding return-to-work or return-to-sport decisions. Furthermore, the longer the delay between injury and testing, the less sensitive the results. Continued research into biomarkers holds significant potential for improving concussion diagnostics and care.
FDA-approved biomarker testing
Imaging Conventional CT and MRI scans are not effective for evaluating mTBIs or concussions, as these injuries often fall below the detection threshold or are too mild for individuals to seek imaging. While useful for ruling out structural damage and bleeding, these methods lack the sensitivity needed to diagnose mTBIs. Even with normal CT results, individuals can experience persistent symptoms for months or years following an mTBI. Over the past decade, significant advances in imaging technology have improved the ability to detect milder TBI damage. However, the high cost and limited availability of these advanced modalities, especially in low- and middle-income countries, pose barriers to widespread adoption. Specialized MRIs Diffusion tensor imaging (DTI): DTI detects microstructural white matter changes associated with diffuse axonal injuries, a critical finding in mTBI. By measuring the magnitude and direction of water diffusion in the brain, DTI provides a detailed view of neural pathways that standard MRIs cannot detect. This technique shows promise for earlier and more accurate diagnoses of mTBI-related damage. Functional MRIs (fMRI): Used in surgical planning for epilepsy and brain tumor removal, fMRI maps brain activity during specific tasks (e.g., motor, language, visual, or memory tasks). In concussions, fMRI reveals disruptions in brain networks, including the “default mode network,” which is most active during resting states. Similar disruptions are seen in conditions like Alzheimer’s disease and schizophrenia, although the exact reasons remain unknown.15 Other diagnostic tests Positron emission tomography (PET): PET scans measure areas of reduced brain metabolism to assess the severity of neural disruption. While studied for detecting abnormal tau tangles seen in CTE, current results are inconsistent, with low sensitivity and specificity, limiting their utility. Neuropsychological testing (NPT): NPT identifies cognitive and behavioral deficits following TBI. When combined with imaging modalities like DTI or fMRI, NPT may enhance the identification of affected brain regions, paving the way for more individualized treatment and rehabilitation strategies.11 Implications for the insurance industry The growing recognition of concussion-related conditions like chronic traumatic encephalopathy (CTE) and persistent post-concussion symptoms presents unique challenges for insurers. With evolving medical research and increasing legal and regulatory scrutiny, the industry must adapt to manage these risks effectively. From underwriting models to claims management and policy design, insurers face significant opportunities and responsibilities to address the long-term implications of concussions. Risk assessment and underwriting – Underwriting must account for concussion-related risks, not only in high-contact sports but also across broader demographics. Individuals with a history of mTBI or rmTBI may face an increased likelihood of persistent symptoms or long-term conditions like CTE. Insurers may need to revise traditional underwriting models, incorporating evidence-based risk assessments and exclusions to mitigate potential long-term liabilities, particularly in disability insurance. Claims management – Persistent concussive symptoms and related conditions often lack a clear resolution timeline, requiring vigilance from claims teams. Training claims assessors to manage complex neurological claims and coordinate with healthcare providers is essential for timely interventions. Insurers must prepare for the possibility of extended claims as these conditions may progress over time. Policy design and coverage limits – Policy structures may need adjustments to balance adequate coverage for concussion-related injuries and long-term risks like CTE with sustainability. This applies both to high-risk groups, such as athletes, and to broader populations. Legal and regulatory considerations – The growing body of research and legal precedents surrounding concussion-related injuries, particularly in high-contact sports, poses challenges. Insurers may face disputes over coverage or exclusions and should stay informed about litigation trends and regulatory changes. If a definitive causal link between mTBI and CTE emerges, insurers may also need to consider occupational health and safety regulations, as such risks could be deemed preventable. Policyholder education and awareness – Insurers can contribute to concussion awareness by educating policyholders on prevention, early recognition of symptoms, and the importance of timely treatment. Resources could include safety guidelines for sports, post-TBI care recommendations, and advice on managing risks. Navigating the Uncertainty: The path forward for insurers The challenge for insurers lies in identifying individuals at risk of long-term consequences from mild traumatic brain injuries (mTBIs) while distinguishing them from the majority who recover without complications. Predicting and assessing this risk remains complex, with current medical science offering limited tools to address the uncertainty. Until advancements in medicine and science provide more definitive answers, insurers face a difficult balancing act: managing a complex clinical condition while mitigating financial exposure. To navigate this uncertainty, insurers must adapt underwriting practices, refine risk models, and ensure policies address emerging needs. Staying informed about the latest research and innovations is essential for building strategies that both support policyholders and maintain sustainability. By addressing these challenges with a proactive and informed approach, insurers can better serve their policyholders while navigating the complexities of an ever-evolving healthcare landscape. With thanks to Dr. John Mayhew for sharing his generous time and deep expertise on this topic.
Specialized MRIs and other diagnostic tests
Adapted from “Post-Concussion Syndrome and Chronic Traumatic Encephalopathy: Narrative Review on the Neuropathology, Neuroimaging and Fluid Biomarkers” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8947595
STAGE I Macroscopic: Unremarkable changes Microscopic: NFTs (perivascular space) Molecular: P-tau immunoreactive glial processes TPD-40+ neurites
STAGE II Macroscopic: Mild hypertrophy (lateral ventricles and third ventricle, cavum septum pellucidum); Discoloration (locus coeruleus, substantia nigra) Microscopic: NFTs (perivascular space, frontal, temporal, parietal, insular and septal cortices, locus coeruleus and substantia nigra) Molecular: Subcortical U-fibres clusters of mild TDP-43+ and reactive microglia
STAGE III Macroscopic: Brain weight decrease; Mild atrophy (frontal, temporal lobes); Mild hypertrophy (lateral, third ventricles); Septal fenestrations and perforations Microscopic: NFTs (perivascular patches, cortex, frontal and temporal poles, temporal and parietal cortices, olfactory bulbs, hippocampus, entorhinal cortex, amygdala, hypothalamic area, mamilliary bodies, nucleus basalis of Meynert, substantia nigra, locus coeruleus, dorsal and median raphe nuclei); Astrocytic tangles (depth of the sulci)
STAGE IV Macroscopic: Severe atrophy (frontal and temporal lobes, anterior thalamus, white matter, corpus callosum); Atrophic hypothalamus, thin mammillary bodies; Pallor (locus coeruleus, substantia nigra); Cavum septumpellucidum/ total absence of the posterior septum Microscopic: Myelin loss; Neuronal loss (cerebral cortex, hippocampus, substantia nigra, frontal and temporal lobes) Molecular: Deposits and inclussions of immunoreactive TDP-43+
Traumatic brain injury (TBI) Concussive and non-concussive events where the head impacts or is subjected to acceleration/deceleration forces due to a direct or indirect force to the head or body, resulting in a disruption of brain function or in signs of brain damage.
Concussion TBI resulting from a head impact or acceleration/deceleration event and causing neurological symptoms. Also can be termed mild TBI (mTBI).
Sports evaluation tools, such as the SCAT6 (Sport Concussion Assessment Tool) designed for individuals aged 13 and older, are used within 72 hours of injury, while the SCOAT (Sport Concussion Office Assessment Tool) assesses symptoms after three days. These tools help identify non-specific symptoms, track recovery, and grade concussions as mild, moderate, or severe, depending on the classification system.15 Treatment focuses on managing symptoms through rest and avoiding further head impacts. However, early, light activity is often recommended over complete rest. Ensuring full symptom resolution before returning to high-risk activities is critical to avoid “second impact syndrome,” a rare but life-threatening condition.
Post-concussion syndrome (PCS)/persistent post-concussive symptoms (PPCS) Persistence of a constellation of physical, cognitive, behavioral, and emotional symptoms that occur after TBI.
When concussive symptoms persist for four weeks to three months, the condition is termed post-concussion syndrome (PCS) or persistent post-concussive symptoms (PPCS). These terms, used interchangeably, can arise from repetitive mild TBIs (rmTBI), as well as moderate or severe TBIs.
Single Mild TBI
Repetitive Mild TBI
Single Major TBI
Repetitive Major TBI
Post Concussion Syndrome
Traumatic Encephalopathy Syndrome
Chronic Traumatic Encephalopathy
Insurers historically have monitored and assessed the risk of infectious diseases on new business underwriting, in-force block performance, and investment outcomes. These activities, which are accomplished by teams of actuaries, medical directors, and data scientists, also include modeling for best estimate and extreme impact scenarios for principles-based economic capital (PBEC) planning. In the wake of the COVID-19 pandemic, viral diseases have garnered even more interest and awareness among insurers and investors. This article will address three noteworthy viral infectious pathogens, describe their clinical and epidemiological characteristics, and provide an assessment of their risk to both the general and insured populations.
A(H5N1) avian influenza A(H5N1) or H5N1 bird flu viruses first emerged in southern China in 1996. Those viruses caused large poultry outbreaks in Hong Kong in 1997, which resulted in 18 human infections. The 1997 bird outbreak was controlled, but the H5N1 bird flu viruses were not eradicated in birds and resurfaced in 2003 to spread widely throughout Asia, and later in Africa, Europe, and the Middle East, causing poultry outbreaks and sporadic human infections.3,4 The H5N1 virus is described as “highly pathogenic avian influenza” or HPAI and refers to mortality in experimentally infected poultry that, importantly, does not necessarily correlate with the severity of human infections. Nonetheless, H5N1 virus infections have been reported in more than 925 people, with approximately 50% case fatality rates (CFRs) since 1997, including 20 cases and seven deaths in Hong Kong between 1997-2003.5 Bird flu viruses currently circulating in wild birds and poultry in much of the world are genetically different from earlier versions of the virus, and multiple spillover events to mammals have been documented in several countries.3 The most recent concerning development stems from an outbreak of H5N1 in dairy cows in the US, first reported on March 25, 2024. As of November 2024, 508 dairy herds in 15 states have been affected. Several farm workers have been infected, but they generally present with mild symptoms that include conjunctivitis. Notably, human-to-human transmission has not been documented. H5N1 can be detected in raw milk; however, pasteurization does cause inactivation of the virus.6,7 Vaccines for H5N1 do exist and evidence suggests these would be protective, if needed, until updated versions of the vaccines could be developed and produced.8 There is concern H5N1 could present a pandemic risk in humans. However, it has not acquired the capability of human-to-human transmission since its emergence. Both the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) currently deem the pandemic risk as low, while the risk of infection for occupationally exposed persons is low-to-moderate, depending on the risk mitigation measures in place.9,10 Nonetheless, careful monitoring is required to detect any changes in transmission patterns or case frequency in humans that could signal a significant impact on public health.
Three to Watch
Daniel D. Zimmerman, M.D., is Senior Vice President and Executive Medical Editor and Advisor for RGA Reinsurance Company. In this role, he serves as the Editor-in-Chief of Brackenridge’s Medical Selection of Life Risks 2025 revision and advises senior corporate leadership on scientific and medical topics. He is also a member of the board of the International Committee for Insurance Medicine (ICLAM). Dan previously served as the Managing Director of The Longer Life Foundation, www.longerlife.org. This not-for-profit collaboration between RGA and Washington University School of Medicine in St. Louis funds the study of factors that either predict the mortality and morbidity of select populations or influence improvements in longevity, health, and wellness. Prior to his current role, Dan was Head of Global Medical and Chief Science Advisor, where he was responsible for thought and medical leadership, case consultation, product development, client support, training and education, and executive advising. Before joining RGA, he was a medical director with Northwestern Mutual Life Insurance Company and had previously practiced primary care internal medicine and pediatrics in Tampa, Florida. Dan received his medical degree from the University of Wisconsin School of Medicine and Public Health and his undergraduate degree in Medical Microbiology and Molecular Biology from the University of Wisconsin – Madison, Wisconsin (US). Professional certifications currently maintained include those from the American Board of Pediatrics, American Board of Internal Medicine, and the Board of Insurance Medicine. He has held leadership positions with the American Council of Life Insurers (ACLI), participated in program committees of the American Academy of Insurance Medicine (AAIM), and frequently represents RGA to key industry professional organizations. He has also contributed several articles to the Journal of Insurance Medicine, On The Risk, ThinkAdvisor, and Best’s Review.
Dr. Dan Zimmerman
Senior Vice President, Executive Medical Editor and Advisor, RGA
For insurers, collaboration among actuaries, medical directors, and data scientists is necessary to monitor and assess infectious disease risk as it evolves over time.
Viruses are the most abundant and diverse biological entities on Earth, with a staggering 10 nonillion (or 1031) viral particles existing in all habitats at any point in time. They can infect all types of organisms, ranging from animals (including humans) and plants to bacteria and archaea. The Global Virome Project estimated the existence in birds and mammals of 631,000 to 827,000 viruses with the potential ability to infect humans. A recent study created an atlas of human viruses derived from public databases and produced the online Human Virus Database (HVD), containing 1,131 virus species documented to infect humans.1 Humans survive in the virus-filled world relatively free of disease primarily because viruses are very selective about which cells they infect. Only a tiny fraction of viruses poses any threat to humans. However, as SARS-CoV-2 taught the world, outbreaks of novel human illness do occur, which is not unexpected. In fact, most new infectious diseases cross over to humans from animals, at which point they are referred to as zoonoses. For a virus to successfully jump to a new species, it must overcome a number of biological hurdles. Then, it needs to be able to spread within members of that new species. These “spillover” events are often dead-ended and never progress beyond the first individual; however, some do succeed.2
Introduction and Virology 101
Marburg Marburg virus (MARV) first emerged in 1967, when lab researchers in Marburg and Frankfurt, Germany and Belgrade, Yugoslavia were infected with a previously unknown infectious agent. The 31 patients (25 primary, six secondary infections) developed severe disease that led to the deaths of seven people. The original source of infection was African green monkeys that had been imported from Uganda. An etiologic virus was identified within three months and was named after the city with the most cases. MARV is clinically similar to Ebola virus, and both are now classified as Filoviridae, due to their distinctive thread-like structure. Since the original outbreak in 1967, 17 subsequent MARV outbreaks have occurred, primarily in African countries.17 Marburg virus disease (MVD) occurs after prolonged exposure to mines or caves inhabited by certain types of fruit bats, which are the virus' reservoir. The virus can spread from human to human via direct contact with blood, secretions, organs, or other bodily fluids. Healthcare workers are frequently infected by patients. Symptoms include high fever, headache, and fatigue. Gastrointestinal symptoms, including diarrhea and abdominal pain, subsequently develop. Hemorrhage can occur with bleeding from multiple areas of the body. There is no treatment for MVD other than supportive care. Case fatality rates (CFRs) have varied, depending on the location of the outbreak, but are quite high - between 24% and 88%.18 The most recent Marburg virus outbreak began in Rwanda and was reported by the Ministry of Health on September 27, 2024. As of November 11, 2024, 66 cases and 15 deaths (CFR = 23%) have occurred. No cases have been detected outside of Rwanda, and the risk to distant countries, including the US, is low. However, a risk of spread to other countries by infected travelers from Rwanda remains. As a comparison, during the Ebola outbreak of 2014, no community spread occurred in the US after two case introductions and seven medical evacuations. Trials with an investigational vaccine are underway, with an emphasis on preventing MVD in healthcare workers.19,20
Dengue Dengue is an Aedes mosquito-transmitted virus and a significant global health threat. Dengue fever is the leading cause of arthropod-borne viral disease worldwide. With over 100 million cases annually resulting in approximately 25,000 deaths, dengue has produced epidemics across different regions globally. Dengue is caused by four distinct, but closely related, viruses abbreviated as DENV-1, -2, -3, and -4. While infections are asymptomatic in up to 75% of affected individuals, the disease ranges from self-limiting dengue fever to severe hemorrhagic shock. A fraction of infections, between 0.5% and 5%, develop into severe dengue; however, a second infection with a different type of DENV increases the risk of severe dengue. Without proper treatment, fatality rates can exceed 20%, particularly among children.11,12,13 The incidence of dengue fever has increased dramatically over the past few decades, and the infection is now endemic in some parts of the world, possibly due to increased global travel. Climate change may also be playing a role in the expansion of dengue-carrying Aedes mosquitoes into more temperate regions of the world and to higher elevations. Nineteen percent of the current global dengue burden is attributed to climate change and could increase by 40%-60% by 2050. In the US, local transmission of DENV has been limited, with sporadic cases or small outbreaks in Florida, Hawaii, Texas, and the US Virgin Islands. However, confirmed local DENV transmission has been reported in Arizona and California in recent years. Additionally, a major DENV outbreak was declared in March 2024 in Puerto Rico.11,12,13,14,15 Infection with one type of DENV induces life-long protection against infection from that specific DENV but not against the others. Two dengue vaccines have been developed and are used in countries with high dengue transmission intensity. Vaccination does not prevent all cases of dengue, and other strategies should be employed, including vector (mosquito) control.16
Viral infectious diseases continually provide challenges to public health officials and insurers. While some are deemed low risk, vigilance must be maintained as drivers, such as climate change and international air travel, can widen the geographic range of viral diseases. Additionally, viruses that currently do not have human-to-human transmission capability can acquire it, leading to significant public health impacts. For insurers, collaboration among actuaries, medical directors, and data scientists is necessary to monitor and assess the risk as it evolves over time.
Conclusion
Sifan Ye, Congyu Lu, Ye Qiu, Heping Zheng, Xingyi Ge, Aiping Wu, Zanxian Xia, Taijiao Jiang, Haizhen Zhu, Yousong Peng. An atlas of human viruses provides new insights into diversity and tissue tropism of human viruses. Bioinformatics. Volume 38, Issue 11, June 2022. Pages 3087–3093. https://doi.org/10.1093/bioinformatics/btac275 Katherine Wu. There are more viruses than stars in the universe. Why do only some infect us? National Geographic. April 15, 2020. https://www.nationalgeographic.com/science/article/factors-allow-viruses-infect-humans-coronavirus Past Reported Global Human Cases with Highly Pathogenic Avian Influenza A (H5N1) (HPAI H5N1) by Country, 1997-2024. October 25, 2024. https://www.cdc.gov/bird-flu/php/avian-flu-summary/chart-epi-curve-ah5n1.html Influenza (Avian and other zoonotic). https://www.who.int/news-room/fact-sheets/detail/influenza-(avian-and-other-zoonotic) Reported Human Infections with Avian Influenza A Viruses. https://www.cdc.gov/bird-flu/php/avian-flu-summary/reported-human-infections.html Current Situation: Bird Flu in Dairy Cows. https://www.cdc.gov/bird-flu/situation-summary/mammals.html Investigation of Avian Influenza A (H5N1) Virus in Dairy Cattle. https://www.fda.gov/food/alerts-advisories-safety-information/investigation-avian-influenza-h5n1-virus-dairy-cattle Study suggests earlier US-licensed H5N1 vaccines prompt antibodies to current strain. https://www.cidrap.umn.edu/avian-influenza-bird-flu/study-suggests-earlier-us-licensed-h5n1-vaccines-prompt-antibodies-current Influenza Risk Assessment Tool – Virus Report (IRAT). https://www.cdc.gov/pandemic-flu/media/pdfs/2024/08/IRATATexas.pdf Updated joint FAO/WHO/WOAH assessment of recent influenza A(H5N1) virus events in animals and people. https://www.woah.org/app/uploads/2024/08/updated-joint-assessment-of-recent-flu-a-virus-events-in-animals-and-people.pdf Dengue Fever. National Library of Medicine. StatPearls, March 5, 2024 . https://www.ncbi.nlm.nih.gov/books/NBK430732/ Increased Risk of Dengue Virus Infections in the United States. June 25, 2024. https://emergency.cdc.gov/han/2024/han00511.asp Current Dengue Outbreak. September 11, 2024. https://www.cdc.gov/dengue/outbreaks/2024/index.html The Increasing Burden of Dengue Fever in a Changing Climate. https://www.rockefellerfoundation.org/insights/perspective/the-increasing-burden-of-dengue-fever-in-a-changing-climate/ Amid record year for dengue infections, new study finds climate change responsible for 19% of today’s rising dengue burden. 16 Nov 2024. https://www.eurekalert.org/news-releases/1063547 Vaccines and immunization: Dengue. World Health Organization. https://www.who.int/news-room/questions-and-answers/item/dengue-vaccines Forty-Five Years of Marburg Virus Research. 2012 Oct 1;4(10:1878-1927. doi: 10.3390/v4101878. https://pmc.ncbi.nlm.nih.gov/articles/PMC3497034/ Marburg virus disease – Rwanda. 13 November 2024. https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON544 Marburg Outbreak in Rwanda Situation Summary. 13 November 2024. https://www.cdc.gov/marburg/situation-summary/index.html Risk to the United States from Marburg Virus Outbreak in Rwanda. 21 October 2024. https://www.cdc.gov/cfa-qualitative-assessments/php/data-research/marburg-risk-assessment.html
What’s New?
Digital twins in healthcare and insurance
Dr. Lauren Acton, MBChb, has joined RGA South Africa as Chief Medical Officer. Lauren completed her medical studies and obtained her Bachelor of Medicine, Bachelor of Surgery degree at the University of Pretoria in South Africa in 2006. After her internship and community service in Johannesburg, she pursued a Master’s degree in bioethics at the University of Stellenbosch, also in South Africa. Her experience encompasses both clinical and insurance medicine, having worked in a private practice as well as for a direct insurer and a reinsurer before coming to RGA.
After a quarter-century with RGA South Africa, Dr. Anthony (Tony) Crosley, the branch’s Chief Medical Officer, is retiring. Tony came to the South Africa office soon after its 1999 launch, and has played a major role in the success and market standing of the underwriting and medical teams. A physician and veteran of more than half-century in insurance medicine, Tony is a doyen of the field: his immense medical and insurance knowledge, work ethic, capabilities, and collegiality are well known, and will be missed. We wish him the very best in his life’s next journey.
Medical Team Updates
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Drug Watch: Additional Copy
Tomasik J, et al. JAMA Psychiatry. 2023 October 25; 81(1):101-6. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2811312
Metabolomic biomarker signatures for bipolar and unipolar depression
Editor's note: These findings emphasize the need for nuanced risk assessments in insurance that consider the duration and timing of metabolic syndrome, leading to more accurate underwriting, better pricing, and targeted wellness programs.
Role of age and exposure duration in the association between metabolic syndrome and risk of incident dementia: a prospective cohort study
Oliver, A.J. et al. Single-cell integration reveals metaplasia in inflammatory gut diseases. Nature 635, 699–707 (2024). https://www.nature.com/articles/s41586-024-07571-1
Mapping 1.6 million gut cells to find new ways to treat disease: Single-cell integration reveals metaplasia in inflammatory gut diseases
Publications relevant to insurance medicine appearing recently in research literature.
Research Watch
Health View I
Industry Event
Drug Watch
RGA Thought Leadership
As the healthcare industry embraces digital transformation, the integration of digital twin technology promises to unlock new avenues for innovation, cost optimization, and enhanced patient outcomes – and new opportunities for life and health insurers.
Read more about this topic on RGA’s Knowledge Center
Editor’s note: GLP-1 agonists could potentially reduce healthcare costs and improve health outcomes associated with AUD and SUD. However, it is important to consider their high cost and the need for more longitudinal data in this context.
Repurposing semaglutide and liraglutide for alcohol use disorder
Editor’s note: Gaining deeper understanding of the inflammation cycle could lead to new ways to prevent or treat inflammatory bowel disease and provide learnings applicable to other conditions. This could improve risk assessments, underwriting, and health outcomes, leading to more personalized and cost-effective insurance coverage.
Qureshi D. et al. The Lancet Healthy Longevity, Volume 5, Issue 12, 100652 https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(24)00185-5/fulltext
Lähteenvuo M. et al. JAMA Psychiatry. 2025;82(1):94-98. doi:10.1001/jamapsychiatry.2024.3599 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2825650
In this comprehensive study, researchers integrated over 25 single-cell datasets to create the largest information resource of the human gut, encompassing samples from both healthy and diseased individuals. This Gut Cell Atlas, a significant component of the Human Cell Atlas project, aids in identifying changes associated with conditions such as ulcerative colitis and Crohn’s disease, thereby facilitating the discovery of new drug targets. Additionally, the study revealed that gut metaplastic cells are involved in inflammation. This invaluable resource is freely accessible to researchers worldwide, and its approach can be applied to other organs, significantly advancing our understanding of health and disease.
Read more
Editor’s note: Metabolomic profiling has the potential to improve the differential diagnosis of mood disorders in clinically relevant scenarios which will impact risk assessment and claims adjudication in the future.
This population-based study of over 20,000 individuals aged 50-79 years with 25 years of follow-up found that metabolic syndrome significantly increases the risk of developing dementia. The risk was particularly high for those with metabolic syndrome in mid-life (60-69 years) and for those with prolonged exposure to metabolic syndrome over 20 years. No significant association was found in late-life (70-79 years) or for those with newly developed metabolic syndrome. These findings highlight the importance of both the presence and duration of metabolic syndrome in assessing dementia risk and suggest critical periods for intervention.
In a Swedish nationwide register-based study, glucagon-like peptide-1 (GLP-1) agonists semaglutide and liraglutide were linked to a significantly reduced risk of alcohol use disorder (AUD) and substance use disorder (SUD) hospitalizations, as well as somatic hospitalizations. No significant changes in suicide attempt risk were observed, although semaglutide showed a potential decrease. These GLP-1 agonists performed better than traditional AUD medications (naltrexone, disulfiram, and acamprosate), but comparisons should be interpreted cautiously. The study suggests GLP-1 agonists might help treat various addictions due to their effects on craving and reward pathways. However, as an observational study, it shows only associations, not causality. Randomized clinical trials are needed to confirm these findings.
Patients with depressive symptoms with misdiagnosed BD showed a distinct profile of metabolites compared with patients with depressive symptoms with MDD, and this metabolic signature enhanced the predictive value of diagnostic models based on self-reported patient information.
Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD) because of overlapping symptoms and the lack of objective diagnostic tools. This diagnostic study, which was approved by the University of Cambridge Human Biology Research Ethics Committee, used samples and data from the Delta study, conducted in the U.K. between April 27, 2018, and February 6, 2020, to identify BD in patients with a recent (within the past five years) diagnosis of MDD and current depressive symptoms. Digital questionnaire data were used along with dry blood samples, which were analyzed for 630 metabolites using a targeted mass spectrometry–based metabolomic platform.
Health View
Article
Dr. Steve Woh, Medical Director and Health Claims, RGA Global Medical Simon Dreyer, Vice President and Chief Actuary, RGA Global Health Raajeev Bhayana, Head of Health Underwriting, RGA Global Underwriting
Global Health Brief: The rise of GLP-1 receptor agonists and their impact on health insurance
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Colin M. DeForge, Vice President, Underwriting, US Underwriting, US Individual Life Leigh Allen, Associate Vice President, Strategic Research Trey Reynolds, Executive Vice President, Strategy & New Business Development, MIB, Inc.
How Insurers Combat the Complexities and Challenges of Fraud
Hilary Henly, Global Medical Researcher, Strategic Research, RGA
The Cost of Cancer: Price Versus Life
Dr. Adela Osman, Vice President, Head of Global Medical, RGA
For recent ReFlections articles, click here.
Underwriting Update
References: https://www.nature.com/articles/s41746-024-01073-0 https://www.theactuary.com/2024/04/04/power-two-digital-twins-insurance
Dr. Steve Woh
Medical Director and Health Claims
steve.woh@rgare.com
Dr. Lauren Acton, MBChb
Chief Medical Officer RGA South Africa
Lauren.Acton@rgare.com
Dr. Steve Woh, Medical Director and Health Claims, RGA
A digital twin is a virtual representation constructed from real-time data of a physical entity, continuously updated with ongoing data to simulate and predict its behavior. Conceived in the 1960s, the digital twin concept is now gaining traction in the healthcare industry, offering a wealth of potential applications that could revolutionize patient care and streamline treatment delivery, which affects the insurance sector in many ways. In healthcare, digital twins can simulate patient-specific models, integrating data from medical records, genetic information, and real-time health monitoring devices. This allows for personalized treatment plans, predictive diagnostics, and improved patient outcomes. Furthermore, digital twins can facilitate clinical trials and drug development by providing a safe, controlled environment for experimentation. Together, these advances could potentially lead to more accurate predictive analytics and sharper risk stratification, allowing insurers to tailor coverage and pricing based on individual health profiles rather than demographic details. By creating detailed simulations of policyholders, digital twins can improve risk assessment and healthcare cost prediction, which leads to more accurate underwriting and policy pricing. Additionally, digital twins enable continuous monitoring of policyholders’ health, allowing insurers to offer dynamic and effective insurance models. This proactive approach can help promote a longer lifespan and a more robust “healthspan,” as well as facilitate early detection of health issues, potentially reducing the frequency and severity of claims.
Health View II
References: https://www.dw.com/en/how-australias-social-media-ban-could-affect-us/video-70972818 https://oxford.shorthandstories.com/social-media-digital-mental-health/index.html https://theconversation.com/australias-social-media-ban-for-kids-under-16-just-became-law-how-it-will-work-remains-a-mystery-244736 https://theconversation.com/the-government-has-introduced-laws-for-its-social-media-ban-but-key-details-are-still-missing-244272
To address these issues, authorities are studying ways to protect vulnerable people. In Australia, for example, a controversial law to ban social media use for children under 16 was introduced in November 2024. There remain more questions than answers as to whether the law will be effective in mitigating negative outcomes. As the digital age continues its rapid evolution, it is crucial to strike a balance between leveraging technology’s potential benefits and mitigating its negative impacts on mental health. A nuanced approach incorporating education, regulation, and the development of healthy digital habits is essential for promoting overall wellbeing.
The digital age has profoundly impacted mental health, producing both promising advances and significant challenges. On one hand, technology has democratized access to mental health resources and support networks. Online communities and forums provide platforms for individuals to share experiences and seek support, fostering a sense of belonging and reducing feelings of isolation. Additionally, mental health wellness apps and emerging digital therapeutics have made interventions more accessible, allowing users to manage stress, anxiety, and depression conveniently. In the UK, the National Institute for Health and Care Excellence (NICE) recommended digital tools to help children and young people with anxiety, some of which were adopted by the National Health Service (NHS). On the other hand, the digital age has introduced new stressors and challenges. Social media, while connecting people, often promotes a culture of comparison, leading to feelings of inadequacy and negatively impacting self-esteem for some people. The constant connectivity and bombardment of information can also contribute to feelings of anxiety and overwhelm. Social media use has been linked to increased rates of digital burnout and depression, particularly among young adults. Additionally, cyberbullying and online harassment bring potentially severe psychological consequences. One study found significant potential for harm from online behavior, particularly noting high levels of internet use and internet addiction and websites with self-harm or suicide-related content.
Mental health in the digital age
Dr. Anthony Crosley
Dr. Anthony (Tony) Crosley
acrosley@rgare.com
Dr. Lauren Acton
ICLAM 2025 The International Committee for Insurance Medicine (ICLAM) will host the ICLAM 2025 Conference May 11-14, 2025 in Estoril, Portugal. This four-day conference, a leading industry event, will welcome expert speakers from around the world and draw a global audience. Information and registration can be found at www.iclam2025.org.
Kaitlyn Fleigle, Actuary, Strategic Research, Global Actuarial Pricing and Research Hilary Henly, Global Medical Researcher, Strategic Research
A Post-Pandemic View of Alcohol Consumption
Dr. Peter Farvolden, Mental Health Consultant Dr. Adela Osman, Vice President, Head of Global Medical
Psychological Resilience: Health impacts and implications for insurers
Casey Wang, Senior Assistant Actuary, Strategic Underwriting Initiatives Guizhou Hu, Vice President, Head of Risk Analytics, Global Underwriting, Claims, and Medical, RGA
RGA Study: The connection between mental health disorders and all-cause mortality
Industry Event:
Quantifying the Early Underwriting Efficiencies Gained by DigitalOwl’s APS Summaries
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In hac habitasse platea dictumst
From Data to Decision: How AI-enhanced workflows transform underwriting efficiency
RGA Asia Seniors Survey, Part III: Rethinking underwriting and claims for senior applicants
Please click the articles below to see some of RGA's recently published thought leadership on underwriting topics.
This issue’s Underwriting Update highlights a new online resource developed through a cross-functional collaboration among RGA’s global underwriting, claims, and medical teams. RGA recognizes the insurance industry’s opportunity – and responsibility – to drive improvements in mental health inclusion, delivery, and support. Our Global Mental Health Survey revealed the urgent need for collective industry action – one that champions advocacy, education, and research.
We invite underwriting, medical, and claims professionals to explore this new online resource – and please do not hesitate to submit questions or comments. Additional mental health resources are currently in development and scheduled to be made available throughout 2025. *GUM guidelines in North America can vary from those applied across all other markets. RGA clients in US and Canada, please click here to access your customized GUM resources.
RGA teams across the organization are working collaboratively to foster a more inclusive and accessible future for mental health coverage. As part of that effort, we recently launched “Advancing Mental Health in Insurance,” a comprehensive online library of mental-health focused tools, resources, and research. Features include access to: Global Underwriting Manual (GUM) updates* Claims Mental Health Toolkit RGA Learning Gateway modules Thought leadership articles and the latest RGA research
Explore “Advancing Mental Health in Insurance”
An underwriting manual you can count on GUM by the numbers 2024: 695,000+ logins 1.3 million+ calculations 800,000+ Precision Calculator uses 3.2 million+ topic views
Case ReView
Dr. Sheetal Salgaonkar, MBBS, MD, DBIM, FALU
Vice President and Director Global Medical, RGA India
ssalgaonkar@rgare.com
Underwriting an incidental pulmonary nodule
Case presentation: A 56-year-old male smoker applies for $15 million of life insurance. His application revealed a four-month-old health checkup which included a CT chest report. The CT chest report indicates the following: Noncalcified pulmonary nodule about 0.7 cm in left upper lobe Small perifissural nodule (along right major fissure) at the anterior basal segment of RLL measuring 0.5 cm Recommendation – Pulmonary nodules seen; need to correlate clinically
Key underwriting considerations: What is a pulmonary nodule? What are the high-risk features of pulmonary nodules? Chief Medical Officer (CMO) response: Pulmonary nodules are predominantly solitary or multiple focal rounded/irregular radiographic opacities, measuring <3 cm. The increasing frequency of CT scan utilization globally has produced a marked increase in reported incidental pulmonary nodules over the past two decades. At least 95% of all pulmonary nodules identified are benign, most often granulomas or intrapulmonary lymph nodes. However, in some instances, they may signal a lung malignancy. Risk factors for malignancy include: a. Clinical features: older age, smoking, family history of lung cancer, personal history of cancer, and emphysema b. Nodule characteristics: larger nodular size, number of nodules (<5), irregular or spiculated margins, upper lobe location, and increased growth What is a subsolid nodule? Is there any difference in prognosis? CMO response: Incidental pulmonary nodules can be classified as solid and subsolid. Subsolid nodules are further divided into ground-glass nodules and part-solid nodules. Solid nodules are common but associated with a lower risk of malignancy. Subsolid nodules are encountered less frequently than solid nodules but have a higher risk of malignancy. Subsolid nodules are associated with indolent malignancies and require a longer follow-up (3-5 years) than solid nodules (2 years). What is the significance of perifissural nodules [PFNs]? CMO response: PFNs constitute up to one-third of all nodules found via screening. These are well-circumscribed nodules attached to the fissures. Generally, no malignancy risk is associated with these nodules, and they can be taken at standard rates. What is the underwriting decision? CMO response: The updated 2017 Fleischner Society guidelines for incidental pulmonary nodule management include size of the nodule, high-risk factors, and solid/subsolid features for recommended follow-up and evaluation. In the above case, for a pulmonary (solid) nodule sized 7 mm with three high-risk features (age, smoking, upper lobe location), the guidelines recommend a repeat CT at 6-12 months and again at 18-24 months. So, the case needs to be postponed for further follow-up for at least one year. If the CT scan after one year shows nodule stability with no change in size and morphology, a moderate offer can be made. Once stability is confirmed after two years, the case can be offered at standard rates. The perifissural nodule, due to very low malignancy risk, can be taken at standard rates. Key takeaways: Incidental pulmonary nodules are common, and most are benign in nature. Clinical features such as older age, smoking, family history of lung cancer, personal history of cancer, and emphysema increase the malignancy risk. Nodule characteristics such as larger nodular size, number of nodules (<5), irregular or spiculated margins, upper lobe location, and increasing size indicate potential malignancy. Subsolid nodules are associated with indolent malignancies and hence require a longer follow-up duration than solid nodules.
Expert Q&A
Q
Dr. Daniel D. Zimmerman
During your roughly 20 years in the insurance industry, what have been the most significant changes you have seen?
Dr. Zimmerman: I suspect every generation of insurance medical directors has seen its share of change over the years. These changes have historically reflected advancements in technology and the favorable impact on mortality and morbidity outcomes. Without a doubt, one of the most notable developments within my career has been the incredible improvement in life expectancy for those with HIV. It’s been so uplifting to see these individuals do so well with modern anti-retroviral treatments and become eligible for life insurance cover in many markets. The effectiveness of pre-exposure prophylaxis (PrEP) to prevent HIV infection has been equally noteworthy. One of my other personal areas of interest has been studying and following the advances in genetics and the multiple applications in clinical medicine. While genetics remains a challenge for insurers from a regulatory point of view, the potential for genetics to improve health outcomes is now starting to be realized and appears almost limitless.
What lasting impact did the COVID-19 pandemic have on insurers and the insurance medicine profession?
Dr. Zimmerman: Insurance was perhaps the industry best prepared for a pandemic. We not only anticipated it, but we modeled and reserved for it. This is not to say it wasn’t difficult, but insurers were able to meet our obligations, and we helped so many people during a time of global crisis. That’s gratifying to know. Moving forward, we need to learn from the experience of the pandemic and be even more prepared for the next one – which will happen. With regard to medical directors during the pandemic, I think most of us were viewed as more than subject matter experts. While senior management did rely on us for scientific interpretation and prognostication, we were also integrated as members of the decision leadership team at our respective companies. This has resulted in a new and broader role for insurance medical directors than had been traditionally expected.
Speaking of tradition, you have not had the traditional insurance medicine career path. In fact, your journey has been quite different from others. How has your role evolved over time and to what extent were you able to direct your own course?
Dr. Zimmerman: My entry into the insurance medicine profession was quite by accident, like many others. I was introduced to it by a childhood friend, who was recruiting for a medical director role at Northwestern Mutual. At that time, I didn’t even know what an insurance medical director did! But I took the opportunity, and I never looked backed. I went through all the usual hoops, including the traditional underwriting and claims training, which I found very challenging. But other, non-traditional opportunities arose, such as medical editing, investor relations, and executive advising. The pandemic changed the playing field and expanded the role of the medical director to include business decisioning. And now, I’m looking forward to bringing a diverse and global team of medical experts together to update the well-known Brackenridge’s Medical Selection of Life Risks textbook in 2025. I am looking forward to this opportunity to give back and support the insurance medicine profession.
The “practice” of insurance medicine is very different than clinical medicine but can be equally rewarding.
Insurance Medicine: Past, present, and future Dr. Adela Osman, RGA’s Head of Global Medical and ReFlections Editor, recently sat down with RGA’s Dr. Dan Zimmerman to reflect on his industry observations and views on the role of the insurance medical director. While not retiring, Dr. Zimmerman is modifying his work schedule in 2025 and embarking on a new endeavor as Editor-in-Chief of the next edition of Brackenridge’s Medical Selection of Life Risks.
References: 1. https://www.science.org/doi/10.1126/science.1058040 2. https://pubmed.ncbi.nlm.nih.gov/23168792/ 3. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/screening-for-fetal-chromosomal-abnormalities 4. https://www.nature.com/articles/s41525-024-00404-0
About Dr. Zimmerman
What advice would you give to medical professionals considering a career in insurance medicine?
Dr. Zimmerman: The “practice” of insurance medicine is very different than clinical medicine but can be equally rewarding and is usually less stressful. I think the best advice is to focus on developing core skills in epidemiology and statistics and learning to apply them to defined populations while also acquiring the necessary business acumen to fully understand the insurance industry – not just the medical aspects. It’s important to seek opportunities to learn, such as through courses offered by The American Academy of Insurance Medicine. Social networking is also key as opportunities in insurance medicine are somewhat limited and word-of-mouth and personal referrals are often the pathway to securing a position. Last, and I think most importantly, one has to have genuine passion about their work and career in order to succeed and experience true professional satisfaction. I have always loved what I do, and I am extremely grateful for that.
The Longer Life Foundation (LLF) is a collaboration of more than a quarter century between RGA and Washington University School of Medicine in St. Louis. We are pleased to bring you our January 2025 newsletter, which discusses the foundation’s many recent activities. To find out more about LLF and the research it has funded to date, please visit www.longerlife.org or reach out to Dr. Preeti Dalawari at preeti.dalawari@rgare.com or Dr. Joesph Zhang at wzhang@rgare.com.
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