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Ulcerative Colitis: The Gut Feeling of Underwriting Critical Illness

Underwriting Ulcerative Colitis

Many Life Underwriters will tell you that when it comes to underwriting ulcerative colitis, you need to know the cold hard facts, such as:

  • When it was diagnosed,
  • The severity of the disease,
  • And whether it is for life or critical illness (CI) insurance.
It cannot be stressed enough how important it is to have information in excess regarding the details, complications and testing.

The underwriter will want an APS report in addition to the application itself. The more we know about the severity of the condition, the better we can assess the risk.

Ulcerative colitis most definitely can be insurable for CI, but it is often attached with a rating. The size of the rating will be determined by our understanding of the impairment. To better understand the disease, let's take an in-depth look at ulcerative colitis.

Originally written for, and reprinted with the permission of ON THE RISK, Journal of the Academy of Life Underwriting 

What Is Ulcerative Colitis?

Ulcerative colitis is defined as a chronic disease of the colon (large intestine). Classified as an IBD (irritable bowel disease), it can often come with unpleasant side effects. IBD is not to be mistaken for IBS (irritable bowel syndrome), which carries a much lower mortality risk and can be assessed at standard rates for both life and critical illness insurance.

Some of the factors to consider with ulcerative colitis is that it can be a very uncomfortable impairment to live with. Ulcers or open sores form in the colon on the inner lining of the bowel, causing inflammation, ulceration, bleeding and scarring along with a host of unpleasant symptoms. The symptoms are what can lead to complications. Complications in ulcerative colitis and the symptoms that go along with it can vary depending on the extent of inflammation in the rectum and the colon.

The rectum is always involved, but can extend a variable distance up to and including the entire colon. The extent of the disease is a major factor during the underwriting. The major risk factor with ulcerative colitis is colorectal cancer, and regular screening with colonoscopies can help reduce the risk.

An estimated 1.6 million Americans and 250,000 Canadians are currently living with IBD. Canadians have one of the highest rates of IBD. And, 104,000 people are living with ulcerative colitis in Canada and 907,000 in the US.

Symptoms and Complications of Ulcerative Colitis

Ulcerative colitis is often accompanied by gas, bloating, cramping, abdominal pain, fatigue, diarrhea (possibly bloody) and loss of appetite. Because the body is disrupted in how it digests food, absorbs nutrition and eliminates waste in a healthy manner, a wide array of uncomfortable symptoms will accompany it.

Complications of ulcerative colitis can include arthritis, eye inflammation, liver disease, osteoporosis, blood abnormalities, skin conditions, weight loss, anemia and colon cancer. The risk of cancer is much greater in individuals who have had ulcerative colitis for greater than 8 years with frequent flare-ups affecting the entire large intestine.


Treatment of ulcerative colitis can be through medication or surgery. Medications include corticosteroids for acute flare-ups and 5-aminosalicylate (5-ASA) drugs for continuous relief.

The course of treatment will be determined by the severity of the disease. A 5-ASA compound is typically used for mild to moderate severity. It is used to reduce inflammation and to maintain remission. Corticosteroids are used in combination for acute flare-ups and are not given long term because of the possible side effects.

Ulcerative colitis in a severe form would mean frequent hospitalizations and the inability to achieve relief with corticosteroids. Treatment would then lead to immunosuppressants and/or surgery.   

When removing the entire colon including the rectum (proctocolectomy), an ileostomy is created. An ileostomy is a stoma that is created when the ileum or small intestine is brought onto the surface of the skin allowing for waste to pass. Individuals who have had a proctocolectomy with ileostomy are cured of the disease. An alternate option is the ileo-anal pouch.

The pouch is created internally using the ileum (small intestine) and connecting it to the anus after the colon and rectum are removed. With this option there is no need for an ileostomy. Surgical treatment is a curative approach and eliminates the risk of colon cancer.

Once the underwriter has all the information from the physician and applicant, the next step is to determine the degree of severity of the ulcerative colitis:


Disease restricted to rectum. Intermittent diarrhea, 3-5 stools per day, no cramping. No symptoms of fever, weight loss, fatigue. Normal labs.


1/3 to 1/2 of the colon is involved. Gross blood and cramping with 5+ stools per day. Intermittent symptoms of fever, anorexia, weightloss, fatigue, anemia. Development of severe dysplasia.


Complete involvement of the colon. Toxic megacolon with intestinal perforation. Some hospitalization due to severe episodes of bloody mucus diarrhea and fever. Severe symptoms. Abnormal lab results.

Underwriting for Critical Illness

The type of treatment alone often can underline the severity of the disease to the underwriter. Of course an APS will be obtained and necessary details of treatment and complications will be outlined by the individual’s doctor.

Some red flags for CI in particular would include:

  • Degree and compliance of follow-ups.
  • Lab results - specifically abnormal serum protein or albumin, abnormal liver function tests.
  • Celiac disease.

These specific occurrences play a major role in helping to distinguish categories and severity of the disease for CI underwriters.

While family history is a very important factor for CI underwriting, a family history of ulcerative colitis alone is not seen adversely.

However, family history of colorectal cancer, and genetic familial cancer syndromes of the colon such as FAP (familial adenomatous polyposis) and HNPCC (hereditary nonpolyposis colorectal cancer), need to be carefully considered. FAP is a dominant cancer syndrome.

If this is not treated with a colectomy, cancer can develop prior to age 40. From 2-5% of colorectal cancer is caused by HNPCC. This is crucial information for CI underwriting in order to assess family history with either appropriate exclusions/ declinations.

Fundamentally for CI, the main concern for underwriting those with a personal history of ulcerative colitis is the risk for colon cancer. If we have information suggesting that the individual has a mild form of ulcerative colitis, with a favorable number of years since the initial diagnosis, then CI can be quite attainable.

Once we have determined the degree of symptoms, severity, type of treatment, current status and routine cancer surveillance, we can establish a case for individuals with ulcerative colitis.

Ultimately, we would like to keep the underwriting process moving along. When we have the information necessary to assess the CI risk, we can get the best outcome for ulcerative colitis cases.

Originally written for, and reprinted with the permission of ON THE RISK, Journal of the Academy of Life Underwriting 

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Written by: Seema Samad

Seema Samad is a Senior Underwriter at RGAX. She supports the RGAX Underwriting Solution Services team in providing comprehensive life insurance underwriting solutions to help carriers optimize risk management outcomes and better compete now and into the future. She began her career as a tele-interviewer at Manulife and has since accumulated over eight years of underwriting experience. Seema’s background as a registered practical nurse makes life underwriting a natural fit for her.