This article, from RGA’s ReFlections, shows that as longevity reshapes insurance markets, underwriting for older applicants must move beyond standard age-based assumptions to account for later-life indicators such as frailty, cognitive function, functional capacity, and emerging digital biomarkers.
Aging is defined as “the process of accumulation of consequences of life, such as molecular and cellular damage, that leads to functional decline, chronic diseases, and ultimately mortality.”1
Although individuals age chronologically at the same rate, biological changes, such as molecular and cellular damage accumulation, can occur at different rates. While some people maintain good overall health in old age, others are impacted by negative external causes such as lifestyle and environmental factors. Understanding the difference between biological and chronological age – referred to as age deviation – and the causes behind this can allow for better mortality risk assessment at the underwriting stage.
A key consideration is when biological markers are first noted to be associated with accelerated aging and early mortality. Early influences on health, such as physical inactivity, being overweight, lifestyle (e.g., smoking, alcohol consumption), antibiotic use, and environmental factors (e.g., air pollution) have been associated with accelerated biological aging later in life. This article examines important markers of mortality and the challenges faced by insurers in underwriting older lives.
At present, there is little consensus on what components should be included as measurements of biological aging or how they perform in predicting mortality. Physiological biomarkers are used regularly in the underwriting process (e.g., blood pressure), but other markers such as resting heart rate (RHR) historically have not formed part of the underwriting process, particularly for older individuals. Research shows that the risk of mortality increases as RHR increases and that it is a powerful predictor of mortality. Importantly, this association remains consistent across different age groups. RHR is an easily measured metric, because it is non-invasive, can be completed as part of a medical examination, and can be easily integrated into current underwriting practices.
A recent collaborative study by RGA and the University of Leicester found that RHR significantly outperformed total cholesterol as a mortality predictor and has the potential to replace body mass index (BMI) without meaningful loss of predictive accuracy.2 While RHR measurements should be interpreted in context (e.g., medication use or prevalent disease), it adds incremental value to traditional underwriting metrics.
Increasing evidence shows that pulse pressure (the difference between systolic and diastolic blood pressure) is predictive of coronary heart disease in middle and older age, while the use of N-terminal pro B-type natriuretic peptide (NT-proBNP), a protein produced by the heart, has potential use in assessing mortality risk for older-age applicants with cardiovascular disease.3
High levels (3-10 mg/dl) of the inflammatory marker C-reactive protein (CRP) are also predictive of early mortality and physical decline. Age-related increases of interleukin IL-6 have been associated with cardiovascular disease, certain cancers, Alzheimer’s disease, and osteoporosis, while low levels of insulin-like growth factor-1 (IGF-1) have been correlated with increased mortality. Several of these markers, as well as high systolic blood pressure (OR 1.16), fibrinogen (OR 1.29), and creatinine clearance (OR 1.31) were significantly related to mortality in the National Health and Nutrition Examination Survey (NHANES) III sample of middle-aged and older adults.3
Another key marker of mortality risk in older lives is cognitive function, which appears to be one of the strongest and most consistent predictors of mortality. Functional capacity, particularly the ability to perform activities of daily living (ADLs), is also strongly associated with mortality risk, as too are frailty and walking pace – markers of physiological decline that are specific to older age.4 A frailty index (FI), noted to be a strong predictor of mortality, could be used to quantify frailty based on accumulation of various health-related deficits and has been shown to outperform chronological age as a predictor of mortality.5
Within the insurance industry, the term “older-age lives” typically refers to individuals aged 65 and above, although certain products and market segments target applicants from age 55 onward. It is important for insurers to adopt risk segmentation approaches that more accurately reflect the mortality and morbidity experience of older populations. There is an opportunity for insurers to maximize underwriting potential of life insurance products in this age group by designing products and underwriting journeys that reflect their needs while exploring the use of technology to help gather relevant information to appropriately assist with underwriting risk assessment. In doing so, insurers can not only improve their overall underwriting experience but also position themselves to offer a customer-centric journey and appropriate terms through more precise assessment of mortality risk presented by older lives.
People are living longer, but increased longevity does not always translate into good health. Surveillance of healthspan-lifespan gaps across 183 World Health Organization (WHO) member states, representing the number of years burdened by disease, identified a widening healthspan-lifespan gap worldwide of 9.6 years, with the U.S. showing the largest gap of 12.4 years.6
Furthermore, there has been a significant and sustained downturn in fertility rates, a key driver of global population aging. Between 1950 and 2021, the global total fertility rate across 204 countries and territories more than halved, from 4.84 to 2.23 per female.7 The changing global demographic landscape brings significant challenges for insurers but also a fresh opportunity to revise product, underwriting, and service propositions.
There is growing expectation that insurers will need to adapt product and underwriting strategies to reflect longer working lives that result in:
In addition, economic factors such as interest rates and changes in tax policies impact demand for insurance products. Insurance protection sales for older lives show strong and significant growth in many countries, particularly within the high-net-worth (HNW) underwriting space. A 2024 wealth management market study reported that global HNW annual new business sales reached £41 billion (GBP) in 2024, a 25% growth from 2023, and are projected to grow to £67 billion by 2030.8
Increased demand for insurance products is in part being driven by economic factors, rising wealth among retirees with an increased interest in wealth planning, aging populations, and increasing life expectancy. As retirees seek secure and predictable retirement incomes, annuity markets also continue to expand. Asset decumulation through annuity products continues to gather pace; for example, in the UK, the total value of premiums paid into individual pension annuities grew 4% to £7.4 billion in 2025, alongside an 8% rise in the number of people aged 70 and over purchasing an annuity.9
Tailwinds propelling growth are projected to be long term, which may provide insurers with the reassurance to pursue investments in strategies to revise products and develop tailored underwriting solutions for life insurance.
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Insurers should tailor application journeys, underwriting requirements, and medical screenings according to applicant age, reflecting the distinct mortality and morbidity risks associated with increasing age. There are many well-established medical parameters associated with health outcomes and longevity; however, underwriting should also consider age-specific markers of mortality that can be reliably measured, objectively verified, and appropriately documented throughout the application process, including:
Current insurance customer journeys typically involve ineffective data capture processes, limiting the effective assessment and underwriting of older-age lives:
Digital biomarkers have recently been proposed as novel tools for older age risk assessment. Advances in digital technology and artificial intelligence (AI) are revolutionizing the assessment of biological age through the capture, integration, and interpretation of complex biological data. Wearables, facial imaging, and AI-enabled risk assessment tools are attracting growing interest for their potential to provide additional insights into an individual's health status and longevity risk.10
Using alternative biometrics, many of which are becoming easier to capture with modern technology, may improve the ability to more accurately differentiate morbidity and mortality risks in older lives.
They may even be used as substitutes for routine physiological markers of health in the future. Others, such as self-reported dietary insights, walking speed, and step-count are not as easy to apply in the risk assessment process, despite research showing their association with mortality.
While many individuals are affected by age-related decline at an early chronological age, others maintain good health and overall function well into older age. Novel biomarkers of health and longevity may help improve mortality risk assessment, particularly in older age groups. However, there is no single study providing information on all biomarkers that indicates the rate of aging in its entirety.
Insurers have a significant opportunity to revisit product design and underwriting journeys to better reflect the risk profiles of older-age applicants, including the use of age-specific mortality indicators. Advances in technology can streamline the underwriting process, improve the applicant’s experience, and reduce the costs associated with obtaining traditional medical evidence when medically validated. Importantly, underwriting frameworks should incorporate alternative approaches to risk assessment for older lives, recognizing that the most relevant predictors of risk often differ from those used for younger populations.
RGA experts are eager to engage with clients to better understand and tackle the industry’s most pressing challenges together. Contact us to learn more about RGA's capabilities, resources, and solutions.
