ReFlections: RGA’s Global Medical Newsletter – June 2026 ReFlections: RGA’s Global Medical Newsletter

Also in this issue

Letter From the Editor

What's New? AI is reshaping physiotherapy, a “swimming cap” to detect brain injuries in babies and the latest research updates.

Underwriting Updates GUM’s guidelines and information on Liver Function Test

Case ReView A case of neuroendocrine tumors

Claims Updates Claims management demands deep technical expertise and a human touch

Expert Q and A

RGA's Global Medical Newsletter

Neurodevelopmental Disorders and Life Insurance Risk by Dr. Peter Farvolden Under Pressure: Millennials’ mental health disability claims soar by Vanessa Back and Suzanne Whyte Alzheimer’s Disease Update: Progress against a progressive disease by Hilary Henly and Dr. Richard Russell

Featured Articles

BACK

Dr. Karneen Tam, MBBCHRegional Medical DirectorAsia Markets

Dr. SiNing Zhao, MBBS, FANZCA, FHKCA, FHKAM Regional Head of Business Solutions Underwriting, Claims and Medical, APAC

Assistant Editors

Neurodevelopmental Disorders and Life Insurance Risk

Longer Life Foundation

Neurodevelopmental Disorders and Life Insurance Risk

Neurodevelopmental conditions such as attention-deficit/hyperactivity disorder and autism spectrum disorder are common, heterogeneous, and increasingly recognized across the lifespan, with implications for morbidity and mortality. Risk assessment is best informed by functional status, comorbidity, and behavioral factors, rather than diagnosis alone. Incorporating a neurodiversity-informed perspective supports more accurate, equitable underwriting and more effective claims management.

Key takeaways

NDDs encompass a group of conditions with onset in early development, affecting cognitive, behavioral, and social functioning. Common conditions include attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, specific learning disorder, and Tourette syndrome.2 Prevalence estimates suggest that up to one in seven individuals may be neurodivergent.2 These conditions frequently co-occur and exist along a spectrum of severity and functional impact. It is clinically useful to distinguish between traits and disorders. Functional impairment can emerge when traits interact with comorbidity, environmental demands, and/or insufficient support. The long-term course and trajectory of NDDs are highly variable. While some individuals experience an attenuation of symptoms, others demonstrate persistence into adulthood. Key prognostic factors include symptom severity, cognitive and adaptive functioning, comorbid psychiatric conditions, and environmental support and early intervention.3

Overview of neurodevelopmental disorders

References

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, including the Hamilton Health Sciences Centre, The University Health Network, and the Centre for Addiction and Mental Health (CAMH), Canada’s largest mental health teaching hospital. Dr. Farvolden has held university appointments in the Department of Psychiatry at the University of Toronto and the Departments of Psychology at the University of Waterloo and Toronto Metropolitan University, formerly Ryerson University. In his research he has focused on basic processes in personality and psychopathology as well as the pharmacological and psychological treatment of mood and anxiety disorders. An early adopter of the internet as pathway for psychological treatment, Dr. Farvolden has spent 20 years designing, implementing, and evaluating digital mental health assessment and treatment programs with the goal of increasing access to evidence-based care. 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, CPsych

Mental Health Consultant, Global Medical

Peter.Farvolden@rgare.com

The neurodiversity framework emphasizes variation, rather than deficit.

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Neurodevelopmental disorders (NDDs) are increasingly relevant to life insurers as diagnostic rates rise and recognition extends into adulthood. Historically framed as childhood-onset disorders characterized by deficits in cognition, behavior, or social functioning, these conditions are now understood as persistent neurobiological variations with diverse clinical trajectories.1 In parallel, the concept of neurodiversity has reframed these conditions as part of the natural variation in human cognition. For insurers, this perspective does not diminish risk considerations but emphasizes that outcomes are shaped by the interaction between neurobiological traits, comorbid conditions, and environmental context.2 From a risk perspective, NDDs are less important as discrete diagnoses than as indicators of broader behavioral, psychiatric, and medical profiles.

Introduction

Neurodevelopmental disorders are increasingly relevant to life insurers, not as isolated diagnoses but as markers of broader risk profiles. A nuanced approach – integrating clinical understanding with a neurodiversity-informed perspective – supports improved risk selection, more effective claims management, and alignment with evolving clinical and societal perspectives. Moving toward function-based assessment allows insurers to better capture both risk and resilience, enhancing decision-making in an increasingly complex landscape.

Conclusion

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed., text rev. Washington (DC): APA; 2022.2. Doyle N. Neurodiversity at work: a biopsychosocial model and the impact on working adults. Br Med Bull. 2020;135(1):108-125.3. Franke B, Michelini G, Asherson P, et al. Live fast, die young? A review of ADHD lifespan outcomes. Eur Neuropsychopharmacol. 2018;28(10):1059-1088.4. Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD International Consensus Statement. World Psychiatry. 2021;20(2):244-274.5. Instanes JT, Klungsøyr K, Halmøy A, et al. Adult ADHD and comorbid somatic disease. Front Psychiatry. 2018;9:551.6. Dalsgaard S, Ostergaard SD, Leckman JF, et al. Mortality in ADHD. Lancet. 2015;385:2190-6.7. Hargitai LD, Hartman CA, et al. Adult ADHD and mortality. Br J Psychiatry. 2025.8. Sun S, Kuja-Halkola R, Faraone SV, et al. Attention-deficit/hyperactivity disorder and risk of cardiovascular diseases. JAMA Psychiatry. 2024;81(2):178-187.9. Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for ADHD. Lancet Psychiatry. 2018;5(9):727-738.

BACK

Comorbidity as a risk amplifier

Comorbidity is a central driver of risk. Common co-occurring conditions include major depressive disorder, generalized anxiety disorder, substance use disorder, and obsessive-compulsive disorder.4 Additional associations include conditions such as Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome, and irritable bowel syndrome, suggesting broader multisystem complexity in some individuals.5

Adult outcomes and functional implications

NDDs frequently persist into adulthood, although the presentation evolves. Many individuals learn to compensate effectively, while others experience a variety of ongoing functional challenges. Observed patterns may include educational attainment below expected levels, employment variability or underemployment, and increased absenteeism.3 At the same time, strengths such as creativity, adaptability, and high engagement in dynamic environments are common and increasingly recognized. Mental health and behavioral factors, including substance use, sleep disruption, and impulsivity, remain key contributors to long-term outcomes.3,4

Mortality and morbidity considerations

Individuals with ADHD show elevated mortality risk, with life expectancy reductions of approximately six to nine years in some cohorts.6,7 Excess mortality appears largely driven by modifiable factors, including accidental injury, substance use, cardiovascular risk, and suicide. The risk of accidental death is approximately two-fold higher, reflecting inattention, impulsivity, and comorbid conditions.6 Emerging evidence also suggests increased cardiovascular risk (HR ~1.5-1.7), although causality remains uncertain and under investigation.8 Risk does not arise from ADHD itself, but from the cascade of downstream effects, many of which are modifiable and responsive to intervention. Table 1 illustrates a simplified pathway linking neurodevelopmental traits to insurance-relevant outcomes.

Implications for claims management

Functional assessment, intervention and support NDDs often present as non-visible conditions. A functional assessment should focus on attention and executive functioning, emotional regulation, task completion, and fit with occupational demands. Effective strategies for intervention and support may include psychological interventions (e.g., CBT-based approaches, coaching), pharmacological treatment, workplace accommodations, and management of comorbid conditions.4,9 The appropriateness, intensity, and cadence of intervention will vary by individual, influenced by case-specific factors and the interplay of comorbid conditions. Table 3 outlines a practical framework for functional assessment in claims adjudication. This framework supports a shift from diagnosis-based adjudication to functional capacity-based evaluation, improving consistency in claims duration and return-to-work decision-making.

Complexity and uncertainty

Overlap with mood and anxiety disorders may complicate diagnosis and treatment, underscoring the importance of careful clinical assessment.1 Current key gaps in understanding and areas for further research include the long-term cardiovascular and cancer risk,5 impact of early intervention on lifetime outcomes, role of digital interventions, and interactions with the social determinants of health.3,8

Neurodiversity, risk and underwriting: Moving beyond diagnosisThe neurodiversity framework emphasizes variation, rather than deficit. For insurers, this supports a more nuanced interpretation of risk.2 Diagnosis alone has limited predictive value. We know that risk assessment is better informed by functional and behavioral indicators. Rising diagnosis rates reflect increased awareness and broader criteria, but that also introduces greater heterogeneity and reinforces the need for individualized assessment. Table 2 summarizes key domains relevant to underwriting risk stratification.

Under Pressure: Millennials’ mental health disability claims soar How insurers in Australia and New Zealand are pivoting to support recovery

Mental health is now the leading cause of total and permanent disability (TPD) claims in Australia, with a 732% increase among people in their 30s over the past decade.3 Insurers are looking at ways to redesign products with severity-based options and using AI-driven underwriting to improve fairness and limit exclusions. Mental health programs, holistic rehabilitation, early intervention, and employer engagement are key to sustainable outcomes for millennials.

Key takeaways

References

1. Stats NZ (2022): New Zealanders’ mental wellbeing declines: Retrieved October 2025 from: New Zealanders’ mental wellbeing declines | Stats NZ2. Australian Bureau of Statistics: Mental Health: Retrieved October 2025 from: https://www.abs.gov.au/statistics/health/mental-health3. CALI (2025): Mental Ill Health is Straining Australia’s Safety Net: Retrieved October 2025 from: https://cali.org.au/mental-ill-health-is-straining-australias-safety-net/4. Deloitte (2025): Gen Z and Millennial Survey: Retrieved October 2025 from: https://www.deloitte.com/nz/en/issues/work/genz-millennial-survey.html5. Mental Health Australia (2023): The Cost of Living Crisis is Dramatically Impacting Australian’s Mental Health New National Research Reveals: Retrieved October 2025 from: https://www.mentalhealthaustralia.org.au/sites/default/files/docs/media_release_cost_of_living_2023_report_to_the_nation_12092023.pdf6. Deloitte (2025): Gen Z and Millennial Survey: Growth and the Pursuit of Money, Meaning and Well-being: Retrieved October 2025 from: https://www.deloitte.com/content/dam/assets-shared/docs/campaigns/2025/2025-genz-millennial-survey.pdf7. AFLAC Workforces Report (2025): Mental Health and Employee Well-Being: Retrieved October 2025 from: https://www.aflac.com/docs/awr/pdf/2024-trends-and-topics/2024-aflac-awr-employee-well-being-and-mental-health.pdf8. KPMG (2024): Australia’s Mental Health Check Up: Retrieved October 2025 from: https://assets.kpmg.com/content/dam/kpmgsites/au/pdf/2024/australias-mental-health-check-up.pdf.coredownload.inline.pdf9. Robinson B. (2025): Forbes; Millennials Careers at Risk Due to AI 38% Say: Retrieved October 2025 from: https://www.forbes.com/sites/bryanrobinson/2025/01/19/millennial-careers-at-risk-due-to-ai-38-say-in-new-survey/10. Monash University (2021): Young Adults Avoid Seeking Medical Advice During Cases of Mental Ill-Health: Retrieved October 2025 from: https://www.monash.edu/news/articles/young-adults-avoid-seeking-medical-advice-during-cases-of-mental-ill-health11. System 2 (2025): Cost of Accessing Mental Health Services Spirals, Exposing a New Generational Divide: Retrieved October 2025 from: https://system2.org.au/cost-of-accessing-mental-health-services-spirals-exposing-a-new-generational-divide/12. Australian Association of Psychologists (2024): 1 in 3 Australians Experiencing Mental Health Challenges Have Not Sought Treatment: Retrieved October 2025 from: https://www.aapi.org.au/Web/Web/About-AAPi/Media/Media-Releases/1in3havenotsoughttreatment.aspx13. Foulkes L. and Andres J. (2023): Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis: Retrieved October 2025 from: https://www.sciencedirect.com/science/article/pii/S0732118X2300003X14. Mental Health Community Coalition ACT (2024): Millennial and Gen Z Self-Reported Social Media Harm in Australia: Retrieved October 2025 from: https://mhccact.org.au/wp-content/uploads/2024/11/Millennial-and-Gen-Z-self-reported-social-media-harm-in.pdf15. E-Safety Commissioner (2025): Advice to the Minister of Communications: Retrieved October 2025 from: https://www.infrastructure.gov.au/sites/default/files/documents/esafety-commissioner-advice-on-draft-online-safety-rules-19-june-2025.pdf?v=175937658631916. Acenda (2025): New TPD Severity Cover to Provide Greater Choice and Stability for Australians: Retrieved October 2025 from: https://www.acenda.com.au/about-us/media/new-tpd-severity-cover-to-provide-greater-choice-and-stability-for-australians17. Zurich (2024): Zurich Launches New TPD Option: Retrieved October 2025 from: https://www.zurich.com.au/latest-news/media-releases/2024/2024-10-0118. Acenda PIRS Fact Sheet: Psychiatric Impairment Rating Scale (PIRS): Retrieved October 2025 from: file:///C:/Users/s0050347/ChromeDownloads/AC6481%20PIRS%20Fact%20Sheelt.pdf19. CALI (2025): Life Insurance Code of Practice: Retrieved October 2025 from: https://cali.org.au/wp-content/uploads/2025/02/CALI_LICOP_2025)web.pdf20. Financial Markets Authority (2025): Key Terms Under the CoFI Regime: Retrieved October 2025 from: https://www.fma.govt.nz/business/legislation/conduct-of-financial-institutions-cofi-legislation/key-terms-under-the-cofi-regime/21. Zurich (2024): Zurich Collaborates with UTS on AI Solution for Underwriting Mental Health: Retrieved October 2025 from: https://www.zurich.com.au/latest-news/media-releases/2024/2024-05-2722. CALI (2025) Life Insurers Commit to Mental Health Action Plan: Retrieved October 2025 from: https://cali.org.au/life-insurers-commit-to-mental-health-action-plan/23. AIA (2023) AIA Vitality. Retrieved August 2023 from: https://www.aia.com.au/en/health-and-wellbeing/aia-vitality 24. MLC (2023) Vivo. Retrieved August 2023 from: https://www.vivowellbeing.com.au/vivo-services25. Turks Legal (2023): Redefining the role of life insurers. Retrieved October 2025 from: https://turkslegal.com.au/sites/default/files/2023-11/2023%20ALUCA%20Turks%20Life%20Insurance%20Scholarship%20-1st%20runner-up%20-%20Vanessa%20Back.pdf26. Douglas et al (2024): Special Report: Lifestyle Psychiatry Emphasizes Behaviors Supporting Mental Health: Retrieved October 2025 from: https://psychiatryonline.org/doi/10.1176/appi.pn.2024.03.3.1927. Ending Loneliness (2023): State of the Nation Report: Retrieved October 2025 from: https://endingloneliness.com.au/wp-content/uploads/2023/10/ELT_LNA_Report_Digital.pdf28. Yeo et al (2025): APA - How does perceived social support relate to human thriving? A systematic review with meta-analyses. Retrieved October 2025 from: https://psycnet.apa.org/doiLanding?doi=10.1037%2Fbul000049129. AIA: AIA Ending Loneliness Together. Retrieved October 2025 from: https://www.aia.com.au/en/products/for-brokers/aia-embrace/resource/aia-and-ending-loneliness-together#:~:text=About%20Ending%20Loneliness%20Together,those%20who%are%physically%20isolated30. KPMG (2019): The Impact of Psychosocial Factors on Mental Health and their Implications on Life Insurance: Retrieved October 2025 from: file:///C:/Users/s0050347/ChromeDownloads/The%20Impact%20of%20Psychosocial%20factors%20on%20Mental%20Health%20and%20their%20implications%20in%20Life%20Insurance%20-%20FSC%20KPMG%20Research%20Report_8%20November%202019.pdf

Access to timely and affordable mental healthcare remains a challenge for millennials in ANZ.

Part II: Lewy Body Dementias

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Mental health claims among millennials (those born 1981-1996) are rising at an unprecedented rate, transforming the life insurance sector across Australia and New Zealand (ANZ). As the largest working-age cohort, millennials are key to the sustainability of the economy and life insurance industry, yet they face a complex web of social and economic pressures. Cost-of-living stress, workplace risks, digital culture, workforce changes, and limited access to care may be driving higher income protection (IP) and TPD claims. RGA explored the drivers behind this trend, the implications for insurers, and opportunities to better support millennial mental health.

Mental wellbeing has significantly declined in ANZ over the past 15 years, especially in younger demographics. Youth mental distress in New Zealand has nearly doubled since 2016–17,1 and Australia has seen a 47% rise in youth mental health disorders.2 The life insurance industry has felt the impact of this surge, with Australian insurers paying more than $2.2 billion in mental health-related claims – almost double the amount from five years prior.3 According to the Council of Australian Life Insurers, mental health is now the leading cause of TPD claims, comprising nearly one-third of payouts among people in their 30s, an increase of 732% in the past decade.3 These trends highlight how mental health is now a central issue for younger age groups and a key driver of the claims experience in the ANZ insurance market. Figure 1: Total and permanent disability (TPD) mental health claims for 30–40-year-olds

The mental health claims landscape in Australia and New Zealand

BACK

The cost-of-living crisis is emerging as one of the largest contributors to declining mental health across ANZ. According to a 2025 Deloitte survey, 60% of New Zealand millennials cite this as their main concern,4 and more than half of Australians report significant effects on wellbeing, with one in five unable to afford mental health support.5 Millennials face financial pressures from housing costs, student debt, insecure employment, and the demands of supporting both young children and aging parents. This “sandwich generation” effect amplifies stress and limits capacity for recovery.

Cost-of-living and life-stage pressures

High job demands, low autonomy, poor support, and workplace bullying are often quoted as contributors to mental health issues, but millennials’ distinct workplace expectations also play a role. Deloitte’s 2025 survey found that millennials value money, meaning, and wellbeing.6 When these elements are lacking, psychological safety erodes, with 66% reporting moderate-to-high burnout.7 KPMG’s 2024 report shows more people in their 30s and 40s leaving the workforce permanently due to mental illness, with more people in their 30s claiming lasting disability.8 For life insurers, this brings an increase in mental health claims, durations, complexity, and potential recurrence when workplace expectations remain unmet.

Workplace psychological risks

Artificial intelligence (AI) is reshaping job roles and introducing new psychosocial stressors. While New Zealand millennials express optimism about AI’s benefits, concerns about job loss are widespread. A clear 74% majority fear AI will eliminate jobs, and 71% are looking for “AI-resistant” roles.4 Millennials appear particularly vulnerable, as they are disproportionately represented in mid-level, digitally dependent roles such as marketing, finance, and administration, where AI automation is most active.9 Uncertainty fuels job insecurity and makes return to work after injury or illness even more challenging for those less literate with AI. Figure 2: Views on GenAI in the workplace

AI and workforce disruption

Access to timely and affordable mental healthcare remains a challenge for millennials in ANZ, with less than half seeking professional help, despite growing awareness.10 Young Australians face higher out-of-pocket costs than those older than 45,11 and fear of judgment remains high, with 86% of 25–34-year-olds reportedly concealing their mental health issues.12 Delayed or insufficient treatment increases the risk of long-term disability, with flow-on effects to IP and TPD claims.

Access to mental healthcare

Mental health awareness initiatives and increased mental health literacy in younger generations are enabling earlier recognition and help-seeking. Conversely, milder forms of distress from life events may be interpreted as mental health issues, which can exacerbate symptoms. This social phenomenon, called the “prevalence inflation hypothesis,”13 may partly explain the increasing incidence of mental health claims in younger age groups. As society’s understanding of mental health evolves, it is important to critically assess how cultural shifts interact with public health messaging. Access to support is essential, but more targeted and evidence-based approaches to mental health education may be needed.

Social and cultural shifts

Millennials are the first generation to experience social media and online connectivity as an integral component of daily life, shaping how they communicate and view themselves. While platforms such as Facebook, Instagram, TikTok, and Snapchat can be used to foster connection, many users report psychological risks, including abuse, cyberbullying, and insecurity. A full 42% of Facebook and 34% of Instagram users have faced negative experiences.14 In response to rising mental health concerns among Australian youth, the government established the Online Safety Amendment Act of 2024, prohibiting those under 16 from joining major platforms.15 This move highlights growing recognition of the mental health risks embedded in digital culture, risks millennials have been navigating for more than a decade.

Social media and digital culture

Vanessa Back is a Senior Claims Consultant at RGA Australia and New Zealand, where she has been part of the team since 2022. Vanessa brings a unique perspective to her role, drawing on her background as a physiotherapist and more than 15 years of experience in the life insurance industry. Currently, Vanessa works within RGA’s claims solutions team, focusing on driving innovation for both clients and the business.

About the author

Vanessa Back

Senior Claims Consultant

Vanessa.Back@rgare.com

Suzanne joined the RGA claims team in 2015 and has dedicated her career to the life insurance industry for 30+ years. Suzanne has extensive experience of Group and Individual claim products across the Australia/NZ markets and previously the UK, where she obtained a Diploma in Life and Disability claims prior to immigrating to Australia in 2009.

About the author

Suzanne Whyte

Technical Claims Consultant

swhyte@rgare.com

Mental health claims among millennials are surging across Australia and New Zealand, driven by social and economic stressors – from cost-of-living pressures to digitally driven disconnection. Insurers are responding with innovative product design, data-driven underwriting, and holistic, proactive claims management to better support a vulnerable generation.

In brief

Social and economic drivers of mental health

TPD was originally intended as a lump-sum payment for individuals who were never going to be able to return to work. Definitions were built around injury and sickness, without mental health in mind. As traditional structures fail to address the complex nature of mental health conditions, insurers are developing severity-based and partial benefits for more relevant coverage. Acenda’s TPD Severity option assesses eligibility using objective medical criteria, such as the Psychiatric Impairment Rating Scale (PIRS) and Whole Person Impairment (WPI),16 while Zurich’s Continuous Care option supports customers needing long-term care for mental or other health issues.17 The shift toward flexible, severity-based products aims to keep premiums affordable, improve claims assessment objectivity, and support recovery, acknowledging that recovery from mental illness is possible. Figure 4: Factors for determining PIRS score claim threshold

Product design

Implications for life insurers

Regulations and consumer expectations are driving underwriting to be more inclusive and personalized. Australia’s Life Insurance Code of Practice19 and New Zealand’s Conduct of Financial Institutions20 regime emphasize fair, case-by-case assessments, rather than blanket mental health exclusions. Zurich, in partnership with the University of Technology Sydney, has implemented AI for life insurance applications involving mental health disclosures, using models trained on seven years of data to identify risk factors correlating with an exclusion being placed on a policy. Underwriting decisions are instant, without the need for lengthy doctor reports.21 As more insurers adopt data analytics and automation, millennials with a mental health history are less likely to be excluded from coverage. This reduces stigma and increases disclosure, supporting ongoing improvements in underwriting practices.

Underwriting

The Council of Australian Life Insurers (CALI) has announced the development of a mental health assessment framework to better align disability insurance with modern medical evidence and return-to-work practices.22 Meanwhile, early intervention and rehabilitation screening are gaining traction, with insurers focusing on wellness needs – including daily structure, access to care, and employer engagement – to optimize recovery and improve claim durations. Holistic rehabilitation plans are tailored to individuals and may include dietary advice, mindfulness, sleep support, job-seeking assistance, and return-to-work coaching, often delivered online through digital partners to appeal to younger generations.

Claims management

Lifestyle factors such as physical activity, nutrition, sleep hygiene, mindfulness practices, and social connection are strongly linked to overall mental wellbeing. Insurers are tapping into these by offering preventive health solutions, with programs built around rewards and premium discounts for those engaging in healthier lifestyles. Programs such as AIA Vitality and Acenda’s Vivo encourage proactive health behaviors through rewards, coaching, and digital engagement.23,24 With real-time data integration, predictive analytics, personalized digital engagement, dynamic rewards, and data-sharing platforms, insurers can move toward a proactive model of healthcare by engaging millennials with tailored support and incentivized prevention.25 Figure 6: Lifestyle factors supporting mental health

Prevention

Opportunities to support millennials

Social connectivity as a lifestyle factor significantly impacts mental health but is rarely prioritized in insurer-led prevention. Approximately 30% of Australians, especially younger and middle-aged adults, report moderate loneliness.27 Evidence links perceived social support to improved mental and physical health, as well as job performance.28 Although insurers in ANZ use group interventions for claims, they seldom take proactive measures. Recognizing low social connectivity as an upstream risk factor could prompt earlier support programs. Initiatives such as AIA’s partnership with Ending Loneliness Together29 show potential for embedding social connection into core wellbeing strategies.

Although early-intervention models have gained traction, RGA’s data shows workplace causation factors continue to dominate mental health claims – with employer involvement often lacking. Employer disengagement is a significant risk factor influencing overall claim duration and recovery. RGA found that 43% of mental health claims had no employer contact from a rehabilitative perspective. Structured employer liaison and processes that incorporate the workplace as part of recovery are likely to yield better results. Automated emails to the fund and employer-engagement scripts with non-medicalized questions can inform the rehabilitation review, promoting communication, collaboration, and opportunity for common goal setting. Notably, 98% of claims reviewed were linked to employers, signaling a key opportunity for proactive engagement. For millennials and their unique expectations of the workplace, such approaches may also address workplace factors affecting mental wellbeing. Figure 8: Employer engagement concept model

Employer engagement

Proactive claims models

Biopsychosocial (BPS) influences were identified in 45% of claims reviews by RGA in 2025, 67% of which were aged 25-44. Despite evidence that BPS factors play a crucial role in recovery, claims management remained heavily medicalized. Modifiable psychosocial and social variables significantly affect mental health and wellbeing, potentially compounding mental illness when they interact. Psychological factors, such as perceived work demands, job dissatisfaction, lack of social support, and low return-to-work expectations, hinder recovery, while optimism, resilience, employer contact, and adaptive coping promote positive return-to-work outcomes.30

Biopsychosocial factors

Mental health claims among millennials are driving changes in life insurance across ANZ. The industry must balance empathy and data-driven strategies to ensure affordability, fairness, and sustainability. RGA ANZ has invested in the development of mental health resources to help clients address customer needs. Moving forward, collective efforts in prevention, product redesign, and holistic claims management will better equip the industry to meet the needs of a generation facing unique challenges.

Conclusion

Source: Adapted for PIRS fact sheet18

Source: Foulkes L. and Andres J.13

Source: Deloitte (2025) Gen Z and Millennial Survey4

Source: KPMG (2024) Australia’s Mental Health Checkup8

Source: Special Report: Lifestyle Psychiatry Emphasizes Behaviors Supporting Mental Health26

By systematically identifying these factors, claims and rehabilitation teams can target interventions, structured intake forms, assessment templates and prompts that incorporate a subset of BPS questions, and AI assessment tools may be part of the solution. Automated analysis and recommendations for intervention could result in a more consistent approach to managing BPS factors and improved outcomes. Figure 9: Biopsychosocial paradigm

Source: KPMG (2019) The Impact of Psychosocial Factors on Mental Health and their Implication on Life Insurance30

Alzheimer’s Disease Update: Progress against a progressive disease Breakthroughs in detection, prevention, and treatment offer new hope for aging populations and potential impacts on future trends

Global figures show that Alzheimer’s disease (AD) currently affects an estimated 50 million people worldwide, and this number is expected to triple by 2050.1 Recent advances in neuroimaging and blood based diagnostic tools are improving the ability to earlier detect AD, the most common form of dementia. A new generation of therapies, with some targeting the underlying biology rather than just symptoms, is leading to more effective and personalized care. Historical AD incidence and mortality data can be affected by diverse reporting biases, from diagnostic practices to death certificate coding, making the interpretation of dementia trends far from straightforward. Furthermore, varied and evolving case definitions have created substantial heterogeneity, making it difficult to track dementia prevalence consistently over time and across regions. Carefully designed studies have shown a declining age-standardized incidence in many countries, including the U.S., Canada, Denmark, and the UK. The age-specific dementia prevalence rates have also declined in the U.S., falling by around two-thirds during 1984–2024 at a relative rate of 2.5%–3.0%.2 In contrast to incidence, the age-standardized dementia-related mortality rate has surged in U.S. and other countries. This sharp rise in age-standardized dementia mortality rates largely reflects greater recognition and reporting of dementia on death certificates.

Prevalence, incidence, and mortality

References

1. Zhang et al. (2025). Assessing and projecting the global impacts of Alzheimer’s disease. Frontiers in Public Health 12:1453489. Available from: Frontiers | Assessing and projecting the global impacts of Alzheimer’s disease 2. Satizabal, C.L. et al. (2025). Incidence of dementia over three decades in the Framingham Heart Study. NEJM 2016; 374(6): 523-532. Available from: Incidence of Dementia over Three Decades in the Framingham Heart Study 3. Eyting, M. et al. (2025). A natural experiment on the effect of herpes zoster vaccination on dementia. Nature, 2025; 641: 438-446. Available from: A natural experiment on the effect of herpes zoster vaccination on dementia | Nature 4. Xie, M. et al. (2025). The effect of shingles vaccination at different stages of the dementia disease course. Cell, 2025; 188(25): 7049-7064. Available from: The effect of shingles vaccination at different stages of the dementia disease course - PubMed 5. Bukhbinder, A.S. et al. (2026). Risk of Alzheimer Dementia After High-Dose vs Standard-Dose Influenza Vaccination. Neurology, April 1 2026;106 (8):e214782. Available from: Risk of Alzheimer Dementia After High-Dose vs Standard-Dose Influenza Vaccination | Neurology 6. Alzheimer’s Disease International (2024). Lancet Commission identifies two new risk factors for dementia and suggests 45% of cases could be delayed or reduced. News. Available from: Lancet Commission identifies two new risk factors for dementia and suggests 45% of cases could be delayed or reduced | Alzheimer's Disease International (ADI) 7. Ishak, E. et al. (2025). Population attributable fraction of incident dementia associated with hearing loss. JAMA otolaryngology-Head and Neck Surgery, April 17 2025; 151(6): 568-575. Available from: Population Attributable Fraction of Incident Dementia Associated With Hearing Loss | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network 8. Kim, B. et al. (2025). Ambient air pollution and the severity of Alzheimer’s disease neuropathy. JAMA Neurology 2025 Nov 1; 82(11):1153-1161. Available from: Ambient Air Pollution and the Severity of Alzheimer Disease Neuropathology - PubMed 9. Agronin, M. (2025). 2025 Breakthroughs in Alzheimer’s Disease. MedCentral, 17 Dec 2025. Available from: 2025 Breakthroughs in Alzheimer’s Disease 10. Huber, H. et al. (2026). A minimally invasive dried blood spot biomarker test for the detection of Alzheimer’s disease pathology. Nature Medicine (2026). Available from: A minimally invasive dried blood spot biomarker test for the detection of Alzheimer’s disease pathology | Nature Medicine 11. FDA (2021). Aducanumab (marketed as Aduhelm) Information. Available from: Aducanumab (marketed as Aduhelm) Information | FDA 12. Biogen (2024). Biogen to realign resources for Alzheimer’s disease franchise. Available from: Biogen to Realign Resources for Alzheimer's Disease Franchise | Biogen 13. FDA (2023). FDA converts novel Alzheimer’s disease treatment to traditional approval. FDA News Release. July 6, 2023. Available from: FDA Converts Novel Alzheimer’s Disease Treatment to Traditional Approval | FDA 14. Van Dyck, C.H. et al. (2023). Lecanemab in Early Alzheimer’s Disease. N Engl J Med. 2023 Jan 5;388(1):9-21. Available from: Lecanemab in Early Alzheimer’s Disease | New England Journal of Medicine 15. FDA (2024). FDA approves treatment for adults with Alzheimer’s disease. FDA. 7 Feb 2024. Available from: FDA approves treatment for adults with Alzheimer’s disease | FDA 16. Sims, J.R, et al. (2023). Donanemab in early symptomatic Alzheimer disease: The TRAILBLAZER-ALZ 2 Randomized Clinical Trial. JAMA. 2023 Aug 8;330(6):512-527.) Available from: Donanemab in Early Symptomatic Alzheimer Disease: The TRAILBLAZER-ALZ 2 Randomized Clinical Trial - PubMed 17. Nonino, F. et al. (2026). Amyloid‐beta‐targeting monoclonal antibodies for people with mild cognitive impairment or mild dementia due to Alzheimer’s disease. Cochrane Database of Systematic Reviews 2026, Issue 4. Art. No.: CD016297. Available from: Amyloid‐beta‐targeting monoclonal antibodies for people with mild cognitive impairment or mild dementia due to Alzheimer’s disease - Nonino, F - 2026 | Cochrane Library 18. Wu, C.K, Fuh, J.L. (2025). A 2025 update on treatment strategies for the Alzheimer’s disease spectrum. Journal of the Chinese Medical Association 2025 Jul 1; 88(7): 495-502. Available from: A 2025 update on treatment strategies for the Alzheimer's disease spectrum - PubMed 19. Biospace (2025). Novo Nordisk A/S: Evoke phase 3 trials did not demonstrate a statistically significant reduction in Alzheimer’s disease progression. Press Releases, 24 Nov 2025. Available from: Novo Nordisk A/S: Evoke phase 3 trials did not demonstrate a statistically significant reduction in Alzheimer's disease progression - BioSpace 20. Cummings, J.L. et al (2026). Efficacy and safety of oral semaglutide 14mg (flexible dose) in early-stage symptomatic Alzheimer’s disease (evoke and evoke+): two phase 3, randomised, placebo-controlled trials. Lancet March 19, 2026. Available from: Efficacy and safety of oral semaglutide 14 mg (flexible dose) in early-stage symptomatic Alzheimer's disease (Evoke and Evoke+): two phase 3, randomised, placebo-controlled trials 21. Edison, P. et al. (2026). Liraglutide in mild to moderate Alzheimer’s disease: a phase 2b clinical trial. Nature Medicine; 32(353-361) 2026. Available from: Liraglutide in mild to moderate Alzheimer’s disease: a phase 2b clinical trial | Nature Medicine 22. Roche (2025). Roche presents new insights in Alzheimer’s disease research across its diagnostics and pharmaceutical portfolios at AAIC. Media Releases, 28 Jul 2025. Available from: Roche presents new insights in Alzheimer’s disease research across its diagnostics and pharmaceutical portfolios at AAIC

About the author

Hilary Henly, FCII, is a Global Medical Researcher with RGA’s Strategic Research team. Based in Ireland, she is a Fellow of the Chartered Insurance Institute (FCII) and has more than 30 years of experience in underwriting, claims, and mortality and morbidity research.

Hilary Henly

Global Medical Researcher, Global R&D

hhenly@rgare.com

A new generation of therapies is leading to more effective and personalized care.

Advances in diagnostics, including blood-based biomarkers and finger-prick tests, are enabling earlier and more accurate Alzheimer’s identification, which could materially influence underwriting, anti-selection risk, and long-term claims patterns. Evidence is growing that lifestyle, vascular, and environmental risk factor management – plus emerging links between vaccination and reduced dementia risk – could significantly delay or reduce Alzheimer’s onset and progression. New disease modifying therapies, along with evolving research on GLP-1 drugs and monoclonal antibodies, point to a future of more targeted treatment strategies that may slow disease progression and reshape long-term mortality and morbidity expectations.

Key takeaways

Diagnostics The rise of detectable and measurable blood-based biomarkers has transformed the diagnostic process of AD, which previously was primarily based on clinical symptoms and a process of elimination. Newly approved diagnostics as well as those still in development could not only revolutionize the early diagnosis and treatment of AD but also significantly impact quality of life through tailored treatments. In May 2025, the U.S. Food and Drug Administration (FDA) approved the first diagnostic blood test for early detection of amyloid plaques in AD, demonstrating over 90% accuracy. If blood-based biomarker tests such as these were made widely available at cheap cost, they could be carried out routinely by local physician services, replacing expensive and cumbersome tests such as amyloid and tau-based positron emission tomography (PET) scans and electroencephalography (EEG).9 Most recently, the international DROP-AD project has demonstrated the accuracy of a finger-prick blood test in detecting AD biomarkers, showing 86% accuracy in predicting cerebrospinal fluid biomarker positivity for AD.10 While a self-administered, at-home pre-screening tool could allow for early disease detection years in advance of the onset of symptoms, it could also allow for anti-selection in life, long-term care, and other insurance products.

Risk factors Researchers have long focused on amyloid-beta as a central driver of dementia, but a growing body of science now points to the immune system and chronic inflammation as a critical part of the puzzle, while vaccination may help lower the risk of dementia by modulating immune activity. In one of the most rigorous analyses to date, scientists found that individuals who received the shingles vaccine were 20% less likely to develop dementia over the following seven years compared with those who remained unvaccinated.3 In December 2025, a follow up study revealed that the shingles vaccine may not only prevent dementia but also slow its progression. The vaccine was associated with a lower risk of mild cognitive impairment among cognitively healthy adults and a reduction in mortality among people already living with dementia.4 This suggests that the vaccine’s benefits may extend beyond prevention to potentially modifying the disease trajectory itself. Most recently, a U.S. study found that high-dose influenza vaccination in adults aged 65 and older is associated with a reduced risk of AD compared with standard-dose vaccination, with a greater difference among women than men.5 Other research suggests that up to 45% of dementia cases could be delayed or reduced if 14 identified risk factors were eliminated via lifestyle changes or population-based policy changes.6 Implementing preventive measures, such as increasing physical activity and socialization, stopping smoking, and decreasing alcohol consumption, can reduce the risk of early diagnosis of AD. Figure 1: Percentage reduction in cases of dementia if this risk factor is eliminated6

Hearing loss is also associated with cognitive decline and dementia. In an analysis using data from the Framingham Heart Study, participants with minimal hearing loss compared to those with no hearing loss had a 71% higher risk of developing any dementia over a 15-year period.7 However, as yet it remains undetermined to what extent hearing loss may be an associative or causative factor. Evidence continues to mount linking air pollution, specifically fine particulate matter (PM2.5), with an increased risk of developing dementia. Despite the exact causation being largely unknown, PM2.5 exposure is associated with brain volume loss, atrophy, accelerated aging, worsening cerebrospinal fluid amyloid-beta42 biomarker levels, and increased amyloid positron emission tomography (PET) positivity.8

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Treatments Following the withdrawal of Biogen’s Aducanumab (AduhelmTM), a disease-modifying therapy for AD, in January 2024,11 the company focused its resources on lecanumab (Leqembi), an anti-amyloid beta treatment designed to treat people with early signs of AD.12 Approved by the FDA in 2023, it is designed to reduce amyloid plaques in the brain and is indicated for use in patients with mild cognitive impairment or a mild dementia stage of AD.13,14 Donanemab (Kisunla) was authorized by the FDA in 2024.15 It too is an anti-amyloid immunotherapy designed to reduce amyloid plaques in patients showing signs of early-stage AD.16 Both drugs are administered via intravenous infusions and have been shown to slow cognitive decline over 12–18 months by roughly 30%.1 However, a recent meta-analysis of amyloid‐beta‐targeting monoclonal antibody disease-modifying therapies indicated that they result in little to no difference in cognitive function and dementia severity at 18 months.17 Older drug treatments include Donepezil, a cholinesterase inhibitor (ChEI) that blocks the breakdown of the neurotransmitter acetylcholine involved in memory and learning, and N-methyl-D-aspartate (NMDA) receptor agonists such as Memantine, which inhibit the action of NMDA receptors in the brain. The figure below shows changes in clinical dementia rating scores over a 15-year follow-up period, with higher values showing greater cognitive decline.18 Figure 2: Effect of different treatment strategies on cognitive decline over time18

Disease modifying therapies In November 2025, Novo Nordisk announced topline results from two Phase 3 clinical trials (Evoke and Evoke+), stating that while their oral glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide treatment improved AD-related biomarkers in both studies, it did not translate into a delay in disease progression.19 Further results published in March 2026 showed that mean changes in Clinical Dementia Rating-Sum of Boxes (CDR-SB) score from baseline (mean CDR-SB score 3.7) to week 104 were negligible (estimated difference with semaglutide versus placebo: −0.08 in Evoke and 0.10 in Evoke+).20 Despite the failure of the Evoke and Evoke+ trials to meet their primary endpoints, semaglutide may still have relevance in AD research, particularly in prevention or earlier intervention, rather than treating established disease. Separately, in December 2025, results from a phase 2b clinical trial of the GLP-1 drug liraglutide showed promising results in people with early to moderate AD, with roughly half as much brain volume loss and an 18% slower decline in cognitive function. The trial found that injectable liraglutide entered the brain (a key challenges for any new potential AD treatment) albeit in small amounts.21 Oral semaglutide, on the other hand, is optimized for stability and absorption in the gut and for prolonged systemic exposure, properties that also appear to reduce its ability to enter the brain. This may explain why these two trials produced different results. Trials of other disease-modifying therapies include the use of monoclonal antibodies such as trontinemab, which is specifically designed to cross the blood-brain barrier and rapidly remove amyloid plaques in the brain. In a Phase 1b/2a trial in 114 subjects, 91% of patients on the highest dose of trontinemab achieved amyloid negativity at 28 weeks. Importantly, the drug incurred a rate of less than 5% for brain bleeds or swelling – three to five times lower than existing immunotherapies.22

Putting it all together: An insurance perspective Early diagnosis expands the window during which patients may benefit from therapies that reduce symptoms or slow disease progression. This shift alone could significantly decrease disease progression and AD-mortality trends in future. By the early-to-mid 2030s, prevalence of dementia is expected to accelerate as large segments of the population enter advanced age. However, ongoing improvements in the modifiable risk factors that increase dementia risk might help to reduce incidence rates. While the evidence is currently very limited, increased use of GLP-1 drugs and targeted vaccination efforts could help to prevent or delay AD onset. Conversely, worsening environmental hazards and unhealthy lifestyle trends leading to obesity and diabetes could lead to higher-than-expected dementia incidence. From an underwriting perspective, earlier diagnosis may influence product eligibility and underwriting pathways for younger lives across life insurance, critical illness (CI), and long-term care (LTC) cover. It also increases the likelihood of anti-selection by applicants who fail to disclose a positive biomarker result but who display no symptoms of AD. Clarity of CI definitions for payout upon diagnosis of AD is imperative, to ensure that it includes the requirement of a significant reduction of cognitive function, and not just a diagnosis from a positive biomarker test. As blood based biomarkers look set to enable earlier detection, insurers face both new opportunities and new challenges. If biomarker testing for AD becomes commonplace, it could trigger adverse selection, particularly in CI and LTC insurance. Similarly, the rapid evolution of disease modifying therapies, public health recommendations, and regulatory approvals can reshape life expectancy projections, requiring insurers to continuously recalibrate pricing, product design, and reserve assumptions.

Richard Russell is Vice President of Biometric Research within RGA’s Global Research & Development team. Since joining the company in 2013, he has led specialist biometric research capabilities that help RGA anticipate and prepare for the trends shaping health, longevity, and financial stability. Richard and his team support nearly every aspect of RGA’s business. By combining advanced analytics and biometric expertise with RGA’s extensive data and research assets, they enhance RGA’s mortality and morbidity modelling, including actuarial pricing, underwriting research, and innovation initiatives. Richard is a frequent speaker at conferences, seminars, and industry events, presenting on topics such as COVID 19 and emerging biometric trend drivers, including GLP 1 therapies and multi cancer early detection technologies. Richard holds a Bachelor of Science in biotechnology, a Master of Science in bioinformatics (with distinction), and a Ph.D. in Statistics, all from Imperial College London. He has authored more than 30 peer reviewed publications in leading journals, including The Lancet, BMJ Open, PLOS One, and Annals of Actuarial Science.

About the author

Dr. Richard Russell

Vice President, Biometric Research, Global R&D

rrussell@rgare.com

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Magliano D, Morton J, Chen L et al. Trends in cause-specific mortality among people with and without diabetes in high-income settings: a multinational, population-based study | The Lancet Diabetes & Endocrinology, 2026; 0 https://doi.org/10.1016/S2213-8587(25)00398-5

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Editor's note: Early evidence linking microplastic accumulation to prostate cancer raises emerging questions about long term health risks and environmental exposures. For life insurers, this evolving science highlights the importance of monitoring potential shifts in morbidity trends as research on microplastics expands.

NYU Langone Health/NYU Grossman School of Medicine. “Microplastics found in 90% of prostate cancer tumors, study reveals.” ScienceDaily. ScienceDaily, 25 February 2026. www.sciencedaily.com/releases/2026/02/260225001250.htm

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A large multinational study reviewing mortality data from 2000 to 2023 shows that cardiovascular disease (CVD) mortality has declined substantially in people with and without diabetes, with five year reductions ranging from 8% to 25% among those with diabetes. As CVD deaths fall, cancer has emerged as the leading cause of death for people with diabetes in several high income countries, while dementia related mortality has risen markedly, regardless of age. Mortality due to diabetes itself has also declined in most jurisdictions. Overall, the findings indicate a major shift in mortality patterns: CVD is no longer the universal leading cause of death among people with diabetes, with cancer and dementia becoming increasingly prominent contributors.

A new study from NYU Langone Health found microplastics in 90% of prostate cancer tumors, with cancerous tissue containing 2.5 times more plastic than nearby healthy tissue. These microscopic particles – originating from everyday plastics – were detected even under strict contamination controlled conditions, suggesting that microplastics can accumulate and persist in human tissue. Although the study does not prove causation, researchers note that microplastics may trigger chronic inflammation, a known contributor to cancer development, underscoring the need for further investigation.

This large, systematic review of 54 Randomized Control Trials (2,477 participants) found minimal high quality evidence supporting cannabinoids as effective treatments for most mental disorders or substance use disorders. Small benefits were seen only for cannabis use/withdrawal, sleep duration in insomnia, tic severity, and autistic traits, but these effects were backed by low certainty evidence and were limited mostly to mixed CBD-THC products. Cannabinoids also carried a higher risk of adverse events, although not serious ones. Overall, the evidence does not support routine clinical use, underscoring a significant gap between widespread use and proven efficacy.

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References: https://www.nature.com/articles/s41746-024-01073-0 https://www.theactuary.com/2024/04/04/power-two-digital-twins-insurance

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In Q1 and Q2, we also updated the underwriting guidance for the following topics: Pap test Proteinuria Benign colon polyps Glomerulonephritis RGA remains committed to equipping underwriters with the tools, education, and guidance needed to make informed and effective decisions.

To support deeper learning, underwriters are encouraged to explore the related Learning Gateway modules and recorded webinars, which provide additional clinical context and practical insights into the application of liver function testing. This update is part of a broader focus on delivering topic deep dives and calculator enhancements designed to streamline workflows and support smarter risk assessment.

Explore the Alcohol Consumption Resource Hub

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

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We look forward to providing you with news and updates regarding the Global Underwriting Manual in future issues of ReFlections. *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.

By Brooke Butler, Director, Marketing and Communications – Global Underwriting Philosophy

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Case summary:A 45-year-old man had applied for a life insurance policy with face amount of $10 million. As part of his underwriting risk assessment, he submitted medical evidence, including a Medical Examination Report (MER) and blood tests (fasting blood glucose, liver and kidney function tests). On the MER, he disclosed that he was taking levothyroxine for hypothyroidism. All other tests were normal. He also submitted his previous blood test reports which are as follows. Key thyroid laboratory findings:• Serum TSH – 6.391 mIU/L (elevated) (normal ≤4.5 mIU/L)• Total T4 – 171.21 nmol/L (elevated) (normal ≤158 nmol/L)• Total T3 – 1.54 nmol/L (normal)• Free T3 & Free T4 – normal• Anti-TPO antibodies – 97.10 IU/mL (elevated) (normal ≤9 IU/mL)• Anti-thyroglobulin antibodies – normal• Serum prolactin – 332.11 mIU/L (elevated) (normal 56-278 mIU/ml)

Key underwriting questions: Q1. What is the abnormality in the thyroid profile and what does it signify?Both serum TSH and total T4 are elevated, which does not fit with the diagnosis of simple thyroid disorder such as hypothyroidism. Normally, the hypothalamic-pituitary-thyroid axis relies on a negative feedback loop. If circulating T4 levels rise, supraphysiologic (i.e., above the normal physiological range) levels of circulating thyroxine (T4) exert direct inhibitory feedback on the anterior pituitary gland, suppressing thyrotropin (TSH). Seeing both TSH and T4 elevated at the same time is a classic presentation of the Syndrome of Inappropriate TSH Secretion (SITSH). This uncoupling of the feedback loop narrows the differential diagnosis to two main conditions: A central driver, such as a TSH-secreting pituitary adenoma (thyrotropinoma), or a rare genetic receptor defect, such as Resistance to Thyroid Hormone (RTH) syndrome. Q2. How does the elevated prolactin change the diagnostic picture?The hyperprolactinemia is the key finding that points directly to a structural pituitary lesion. Pure TSH-secreting pituitary adenomas are rare, making up less than 1% of functioning pituitary tumors. However, up to one-third of them are plurihormonal, meaning they co-secrete other hormones, most commonly growth hormone or prolactin. Q3. What is the significance of elevated anti TPO antibodies in the presence of an elevated T4? The simultaneous presence of elevated Total T4 and high Anti-TPO antibodies in this clinical context suggests two overlapping but distinct disease processes in the same patient. Elevated Anti-TPO antibodies are strongly indicative of autoimmune thyroid disease, most commonly Hashimoto’s thyroiditis. In Hashimoto’s thyroiditis, autoimmune-mediated injury to the thyroid gland typically results in reduced thyroid hormone production and eventual hypothyroidism, which likely explains the prior diagnosis of thyroid disorder and the use of levothyroxine therapy. However, the coexistence of autoimmune thyroiditis with a suspected TSH-secreting pituitary adenoma (TSHoma) is a recognized but diagnostically challenging scenario. This combination is clinically significant because the presence of Hashimoto’s thyroiditis may lead to the assumption that the abnormal thyroid profile is solely due to a primary thyroid disease, potentially delaying recognition of an underlying central cause such as a pituitary tumor. Q4. What was the underwriting decision?The combination of elevated TSH and Total T4 is an unusual finding that suggests a central/pituitary etiology. When accompanied by elevated prolactin levels, there is a high clinical suspicion of a multihormonal TSH-secreting pituitary adenoma. The case was therefore postponed pending completion of a full evaluation, including the required investigations, such as neuroimaging. Post-investigation clinical findings:Following the postponement, the applicant was evaluated by a neurologist. A brain MRI demonstrated a 1.8x1.5 cm pituitary macroadenoma, for which surgical management was recommended. The case was further deferred until surgical intervention was completed. Key takeaways: The simultaneous elevation of TSH and Total T4 points to a central/pituitary tumor or a genetic defect, and not typical thyroid disease. The concurrent presence of hyperprolactinemia serves as a critical localizing biomarker that strongly shifts the differential diagnosis toward a structural pituitary lesion, such as a plurihormonal TSH-secreting adenoma. Elevated anti‑TPO antibodies are suggestive of autoimmune thyroid disease, most commonly Hashimoto’s thyroiditis, although this condition is usually associated with a low T4. The simultaneous finding of elevated Total T4 and high anti-TPO antibodies indicates that the patient is likely experiencing two distinct, coexisting thyroid pathologies. Therefore, this case requires referral to the medical director for further risk evaluation. Cases with elevated TSH and total T4 should be postponed for complete evaluation, including neuroimaging.

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Claims Updates

Excellence in claims management continues to advance across the industry, and at RGA we remain committed to equipping claims professionals with the knowledge, confidence, and practical tools they need to navigate increasingly complex casework. Through the Global Claims Guide/Manual and our Pathfinder claims training program, we continue to strengthen both the depth and usability of our content to better support the needs of an expanding community of users worldwide.

Global Claims Manual survey results Thank you to everyone who participated in the recent Global Claims Manual survey. The feedback was extremely positive, with four of every five respondents reporting high satisfaction, and many noting that the manual has strengthened their decision making and training capabilities. The feedback has been invaluable in helping us understand how the manual is being used. It highlights where it delivers the greatest value and where opportunities exist to further enhance the content, functionality, and overall user experience. These insights reaffirm the Global Claims Manual’s role as a trusted resource, and they will directly inform our priorities as we shape future enhancements. → Discover key findingsThank you to everyone who contributed feedback – your input plays a critical role in ensuring the Global Claims Manual continues to meet the needs of claims teams worldwide. If you would like further details about the survey results or upcoming enhancements, please reach out to the Global Claims team.

Webinar (scheduled for June 2026)Tough conversations: Turning discomfort into constructive dialogueSupporting claims assessors in navigating sensitive, emotionally charged customer conversations remains one of the most frequent requests we receive from clients worldwide. In response, RGA will produce a new global webinar designed to build assessor confidence and equip teams with practical, repeatable communication techniques for some of the most challenging claim scenarios. The session blends behavioral science insights with real world claims expertise, as we explore: how customers process difficult information; why misunderstandings occur; and how behavioral factors influence disclosure and decision making. This webinar is ideal for claims teams working directly with policyholders, as well as leaders seeking to strengthen the quality and consistency of their teams’ customer conversations.

Pathfinder Training: Your course to claims excellencePathfinder remains central to RGA’s global professional development for claims teams. Designed for busy claims assessors, the modules offer flexible, self paced learning enriched with real world case studies, engaging interactions, and multimedia content. The program allows claims professionals to tailor their learning by selecting modules most relevant to their role and the types of claims they manage. We continue to enhance and expand the program to ensure high quality, engaging education is accessible across global markets – supporting consistent, best practice claims management.

Explore Pathfinder. All Pathfinder modules are available through the Global Claims Manual. Click here for a menu of Pathfinder modules by benefit type and experience level.

By Jennie Calder Brown, Executive Director, Global Claims Philosophy and Education Gayle Kanchanapume, Executive Director, Global Claims Philosophy and Education

Innovation and Continuous ImprovementWe remain committed to delivering training, thought leadership, and tools that empower claims professionals worldwide. For more information or to access these resources, visit the Global Claims Manual/Guide or contact the Global Claims team.

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Excellence in claims management demands deep technical expertise and a human touch. To support this, RGA delivers high-quality training and continuing education through our Pathfinder claims training program, available exclusively to RGA clients via the Global Claims Manual/Guide.

Expert Q&A

Dr. Adela Osman and Dr. Daniel D. Zimmerman

Senior Vice President, Executive Medical Editor and Advisor, RGA

ReFlections editor Dr. Adela Osman spoke with Dr. Dan Zimmerman, recently retired from RGA after 11 years and having served in several roles. For his final project, he was Editor-in-Chief of the 6th edition of Brackenridge’s Medical Selection of Life Risks. Below is an excerpt from their conversation.

How did the idea to update the Brackenridge textbook evolve?

About two and a half years ago I remember attending an AAIM conference in Washington D.C., where I had the opportunity to speak with Dr. Ross MacKenzie – a co-editor of the 5th edition of Brackenridge published in 2006. I asked him what the chances of updating the textbook were since it was rapidly becoming outdated due to the advances in clinical medicine and changing mortality patterns. He distinctly said, “About zero!” In retrospect, I think he had good reasons for answering that way, yet I saw this as a challenge and we started the process.

What steps did you have to take, and what were some of the barriers to bring about the revision?

I have to say the old adage “If I knew then, what I know now” proved true! The entire project became a labor of love. I was transitioning into retirement and felt it would be a great way to give back to the industry – but there was a very steep learning curve. Fortunately, Ruth Lefevre, Senior Editor at Palgrave Macmillan (the publisher), had worked on the 5th edition of the textbook and knew Dr. MacKenzie well. She guided the editorial team as we embarked on author recruitment, dealt with legal and copyright hurdles and organized a project management philosophy and plan. I am grateful to RGA and my manager, Tim Rozar, for being so supportive of the revision, as well as all the other authors’ companies.

What are some of the major changes we can expect in the 6th edition?

The 6th edition is almost a complete re-write of the 5th edition; however, we preserved most of the historical material originally created by Dr. Brackenridge. For the other chapters, the goal was to update the scientific and medical content with new literature published over the last 20 years, focusing on insurance medicine relevance. Given the vast amount of medical information readily available today, we wanted to give our readers a “value-add” that they can’t get elsewhere. One major change is this edition will not provide numerical impairment ratings. The editorial team believes ratings are proprietary projections of long-term outcomes which are not only based on data but also underwriting and business philosophy. While 1% extra mortality is often equated to +1 debit, this is not universally true. However, throughout the textbook, risk assessment considerations are discussed and guide the reader to interpret the insurance medicine implications. Additional changes include new chapters, such as critical illness, underwriting rare diseases and post-acute infection syndrome.

Now for perhaps the most important question – when is the 6th edition of Brackenridge going to be available?

Very soon. We are about 95% finished with the work. Production is ongoing, but we are hoping it will be available by mid-year 2026 – in both print and electronic formats. Pricing is set and commensurate with other textbooks of its size, content and caliber.

Daniel D. Zimmerman, M.D., Executive Medical Editor and Advisor (Retired) 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.

About Dr. Zimmerman

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Are there any final comments you would like to make?

I want to thank everyone who made this revision of Brackenridge possible, especially Ruth Lefevre and Tula Weis with the publisher and, very importantly, Ian Brackenridge, the son of the late Dr. R. D. C. Brackenridge. There is the entire editorial team, which includes Drs. Rod Richie, Mike Moore and Ross MacKenzie, who never missed a bi-weekly call over the last year and a half! I am also very grateful for all the chapter authors – 61 in total – who volunteered their time and effort. Finally, one last thank-you to RGA leadership for believing in this project and supporting this industry endeavor.

Editor’s note: For more information about the 6th edition of Brackenridge’s Medical Selection of Life Risks, please visit here.

Dr. Adela Osman is the Senior Vice President and Head of Global Medical at RGA, where she oversees the development and execution of the company’s Global Medical strategy. She provides strategic guidance to executive leadership on complex medical issues, particularly those with implications for biometric risk. She holds a Bachelor of Medicine and Surgery from the University of Witwatersrand and began her career as a Medical Officer in public hospitals before transitioning to private practice, focusing on family health. In the insurance industry, Adela brings extensive expertise across claims, underwriting, medical marketing, product development, pricing, and legal consulting on medical matters. She has completed specialized training in disability medicine and impairment through the American Board of Independent Medical Examiners, including medico-legal report writing and court testimony, qualifying her as an independent medical examiner and expert witness. Adela previously chaired the Medical and Underwriting Standing Committee of ASISA, where she advocated for underwriting rights and best practices in South Africa. She currently serves as President-Elect and Board Member of the International Committee for Insurance Medicine (ICLAM) and is the Chief Editor of ReFlections magazine.

About the Dr. Osman

Muscle is not simply the tissue that moves us. It is one of the body’s largest metabolic organs and can both signal and accelerate decline. For Dr. Rita Brookheart, that insight has driven years of research at Washington University School of Medicine in St. Louis (WashU Medicine), where she leads a lab focused on studying factors that disrupt skeletal muscle function. Dr. Brookheart is the first researcher to be featured in the Longer Life Foundation’s newly launched Voices of Discovery video series, a multipart initiative designed to introduce LLF’s community of researchers to the public. In the inaugural installment, Dr. Brookheart shares what drew her to skeletal muscle biology, why muscle health is central to how we age, and what her LLF-supported research may mean for the future of longevity science. The series is available on the LLF LinkedIn page and at longerlife.org, with new installments planned throughout 2026.

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What the research reveals WashU Medicine Assistant Professor of Medicine Dr. Rita Brookheart leads a lab investigating how cellular stressors damage skeletal muscle at the molecular level. Her focus encompasses the mechanisms by which harmful factors impair muscle cell function over time, contributing to the loss of mass and regenerative capacity associated with aging and chronic disease. This line of inquiry echoes some of the most pressing questions in longevity science: Why do some individuals maintain muscle function well into old age while others decline rapidly? What cellular events precede visible muscle loss, and can they be detected, or interrupted, before damage becomes irreversible? The answers have implications that extend well beyond the laboratory. A clearer understanding of muscle deterioration pathways could eventually support the development of targeted interventions, inform biomarker research, and refine how clinicians and underwriters think about functional aging.

Why skeletal muscle research? Skeletal muscle loss is one of the most clinically consequential features of aging, yet historically the condition has received less research attention than cardiovascular disease or cognitive decline. Still, attitudes are changing as new evidence reveals muscle’s role in glucose regulation, immune signaling, and physical resilience. Insurers and risk professionals, in particular, are taking note. Sarcopenia, the progressive loss of muscle mass and strength that accompanies aging, is strongly associated with increased rates of mortality, hospitalization, frailty, and functional dependence. Research that illuminates the molecular triggers of muscle decline could, over time, support earlier identification of individuals at elevated risk, leading to increased underwriting accuracy and improved product design.

The LLF model: Early investment, long-term return Dr. Brookheart’s work is supported by the Longer Life Foundation, a collaboration between the RGA Foundation and WashU Medicine to support early-stage research into factors that influence longevity, health, and wellness. This early-stage, hypothesis-driven research rarely makes headlines but consistently seeds the discoveries that do. The foundation has operated since 1998, backing researchers across more than 170 investigations, with results that have appeared in over 180 peer-reviewed publications. Learn more about the foundation's many recent activities in our June 2026 newsletter.

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An RGA Foundation/WashU Medicine Collaboration

Pioneering Research for Healthy Aging: Dr. Rita Brookheart