Category Life Insurance

Underwriting considerations high blood cholesterol

23 January 2013 Nicholas van der Nest: Divisional Director, Risk Products at Liberty
Nicholas van der Nest: Divisional Director, Risk Products at Liberty

Nicholas van der Nest: Divisional Director, Risk Products at Liberty

Liberty shares underwriting considerations should you client be suffering from high blood cholesterol

"Prediction is very difficult, especially if it's about the future.”  Niels Bohr, Danish Physicist

General overview

Hypercholesterolemia (or high cholesterol) associated with an unhealthy lifestyle, for example smoking and an unhealthy diet, is a growing cause of increasing premature death and disability.

Cholesterol is essential for good health as the body requires it for healthy cell development. More than 75% of cholesterol is produced in the liver. The rest comes from diet. It is only when it is raised above what clinicians regard as normal that cholesterol starts to cause problems.

Generally, total cholesterol levels below 5.2 mmol/L are considered healthy. This however depends on whether other cardiovascular risk factors are present (e.g. smoking, diet, etc.) and how the total cholesterol is made up in its different components (HDL, LDL and Triglycerides). Please refer to general guidelines in Table 1.

If you suffer from high blood cholesterol, the cholesterol gradually builds up in the arterial walls of the circulatory system. Eventually this build up will cause complete obstruction of the blood vessel, which could lead to death or disability without appropriate treatment. The time taken before treatment is started may impact on whether the dysfunction caused is permanent or only temporary.

Symptoms and diagnosis

Because hypercholesterolemia remains largely asymptomatic until such time as premature morbidity (e.g. heart attacks or strokes) or death results, clinicians have developed population screening criteria and methods.

Screening tests are generally considered a cost effective way to detect raised cholesterol levels and implement preventative measures when required. Experts suggest that everyone over age 20, who do not have any other risk factors, should have a screening test, preferably with a lipid profile. Thereafter it would be appropriate to have a test once every five years only. On the other hand, the following groups would benefit from having a test done at least annually:

  • Anyone (including children) with risk factors for heart disease (e.g. hypertension or diabetes);
  • Men over the age of 35 years;
  • Women over the age of 45 years; and
  • Women who are menopausal.

Where an individual is already on treatment for high cholesterol, it is suggested that more frequent testing takes place to monitor the progress of the condition and the efficacy of treatment. Those diagnosed with familial hypercholesterolemia may also need additional testing for specific lipid disorders.

Risk profile

The lipid profile has been shown to be a fair indicator of the future risk of a person experiencing a cardiovascular event. A lipid profile includes total cholesterol, triglycerides, LDL (bad cholesterol), HDL (good cholesterol) cholesterol levels.

A study published in the Journal of Insurance Medicine has shown that the total cholesterol/HDL ratio is the best single measure of all-cause mortality if stratified with age and gender, but is at best a moderate risk predictor.

Clinical studies have also indicated that looking at a single risk factor (like total cholesterol) provides a poor estimate of a person’s cardiovascular disease risk. Comprehensive risk assessment is generally more appropriate, as it takes into account the cumulative and synergistic effects of multiple risk factors.

Familial hypercholesterolemia

If you have inherited raised cholesterol levels, your condition is referred to as familial hypercholesterolemia. This generally means that your body is either producing too much cholesterol or you are unable to eliminate cholesterol efficiently from your body. In most instances, even with a healthy diet and adequate physical activity, those suffering from familial hypercholesterolemia tend to need medication in order to control their raised cholesterol levels.

What are the risk factors?

Risk factors for raised cholesterol levels are divided into modifiable and non-modifiable factors. Modifiable risk factors (i.e. those that can be changed or managed) include:

  • Smoking, which lowers your levels of good cholesterol;
  • Inactivity. Exercise generally increases your HDL cholesterol and lowers your LDL cholesterol.
  • Poor diet high in animal and saturated fats.Obesity, defined as having a BMI greater than 30 (BMI = Weight in Kilograms / Height in meters²)
  • Diabetes.
  • High blood pressure.

Non- modifiable risk factors (i.e. those that can’t be changed) include:

  • Age and gender - Males older than 45 and females older than 55 are generally at higher risk.
  • Family history of early heart disease.

Treating hypercholesterolemia

Treatment involves lifestyle changes such as quitting smoking, exercising, changing diet and losing weight, if appropriate. Medication will be necessary for people who are unable to change their cholesterol levels with these measures and for people who have familial hypercholesterolaemia.

Treatment choices will depend on other risk factors present for a cardiovascular event, as discussed above, as well as age, current health status and side effects of the medication. A lowered LDL is the primary target of treatment because it is a major modifiable risk factor that, if changed, affects the outcome positively.

Medical treatment may include Statins (Lipitor, Crestor, Zocor), Bile acid binding agents (Questran Lite), Fibrates (Gemfibrozil), Ezetimibe (Ezetrol), and Omega 3 supplements.

Underwriting considerations

In the South African market, hypercholesterolemia is one of the most commonly disclosed impairments on insurance applications.

Life insurance products typically provide for death, disability (permanent and or temporary) and dread disease cover. Claims can be made under all of these as a result of complications from raised cholesterol. Insurers’ respective underwriting philosophies will determine the testing and rating criteria for hypercholesterolemia, which differs from company to company.

At underwriting stage, it is important for the underwriter to consider not only the lipid profile, but also the associated risk factors which have a synergist effect on the future risk of morbidity and mortality.

General Guidelines Table 1

Total cholesterol


Below 5.2 mmol/L


5.2-6.2 mmol/L

Borderline high

Above 6.2 mmol/L



LDL cholesterol


Below 1.8 mmol/L

Best for people at high risk of heart disease

Below 2.6 mmol/L

Best for people at risk for heart disease

2.6-3.3 mmol/L

Near ideal

3.4-4.1 mmol/L

Borderline high

4.1-4.9 mmol/L


Above 4.9 mmol/L

Very high


HDL cholesterol


Below 1 mmol/L (men)


Below 1.3 mmol/L (women)


1.3-1.5 mmol/L


Above 1.5 mmol/L





Below 1.7 mmol/L


1.7-2.2 mmol/L

Borderline high

2.3-5.6 mmol/L


Above 5.6 mmol/L

Very high


Association of Cholesterol, LDL, HDL, cholesterol/HDL and Triglycerides with All-Cause Mortality in Life Insurance applicants - Journal of Insurance Medicine. 2009:41: 244-253

Cardiovascular risk assessment – South African Family Practice Journal 2011; 53(2):121-128

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