How Being Nonbinary Affects Getting Life Insurance

Identifying as nonbinary, genderqueer, agender, or bigender doesn’t disqualify a person from getting life insurance. Still, one must apply as either male or female because despite widening awareness that not everyone identifies as one gender or the other, the underwriting process hasn’t changed to keep pace.

Why Life Insurers Ask About Gender

Life insurers ask about gender because of the correlation between gender and mortality. Women around the world typically outlive men. By the middle of the 20th century, mortality of men older than 45 was twice as high than for women, due to “men’s greater vulnerability to cardiovascular disease and differential uptake of smoking,”  according to the international study published in Clinical Chemistry in 2019.

If you look at the Social Security Administration’s actuarial life tables, for example, you’ll see that a man in 2019 has a life expectancy of 76.22, while a woman in 2019 has a life expectancy of 81.28. A longer life means a lower probability of paying a death benefit on that policy.

“Life insurance underwriting frameworks are backwards looking by design—based on actuarial studies of large sets of historical data—so are susceptible to being dated in how they categorize people for risk-analysis purposes,” says Jake Tamarkin, co-founder and CEO of Everyday Life Insurance. “They are also highly regulated and are not easily or quickly changed.” Tamarkin says his company asks applicants for their birth gender.

Do people who identify as nonbinary have significantly different life expectancies than those who are cisgender? The nonbinary population is small and has only gained significant visibility in the last few years, so actuaries may not have the data they need to offer different and potentially more accurate rates to these individuals.

We don’t know if someone who was assigned female at birth but identifies as nonbinary has a life expectancy that’s significantly different from cisgender. There isn’t enough medical research—especially well-designed studies—to provide that information, though the limited data we do have often show worse health in transgender populations.

Choosing a Gender on Your Life Insurance Application

At some point, we may see more than two options on life insurance applications (or we may not even have to answer the male or female question). Right now, we don’t. Which box should you check when you don’t identify with either and when your answer could affect how much you’ll pay for insurance? Finding the right way to proceed may be difficult.

As vice president of public affairs at the American Council of Life Insurers (ACLI), a public policy advocacy organization, Jack Dolan says, “ACLI cannot speak with authority on the internal operations of individual life insurance companies. We do not collect data or information on individual company underwriting practices.” But, he added, “Carriers’ underwriting practices, including the reflection of [a] person’s sex, vary.” He also noted that the underwriting criteria used by respective life insurance companies are proprietary.

Insights From Insurance Brokers

To get more insight into how these practices vary, we talked to insurance brokers, who connect clients with policies from numerous agencies. Some of the best information we found comes from Long-Term Care Associates, a long-term care (LTC) insurance broker, and from Quotacy, an online life insurance broker. Much of the information available deals with trans people, the larger umbrella under which nonbinary identity falls, and not specifically with nonbinary people.

In a blog post on underwriting applicants who are transgender, Stephen D. Forman, CLTC (Certified in Long-Term Care), noted that the life insurers he works with were more likely to underwrite a policy based on the gender an individual identifies as, while long-term care insurers were more likely to look at an individual’s gender assigned at birth.

Quotacy says that insurers’ responses to underwriting trans people are all over the map, ranging from only underwriting based on the individual’s assigned gender at birth to underwriting based on the individual’s gender identity. But these responses don’t address the unique circumstances of nonbinary applicants.

The Insurance Information Institute’s retired chief economist, Dr. Steven Weisbart, told us, “As for treating LGBTQ applicants, I believe there is a great variety of approaches currently being taken by insurers. Some are using unisex (blended male/female) rates, some are using birth-gender rates, some are using gender-preferred rates, and I suspect most or all are underwriting based on drug/hormone treatment, surgeries, other health issues, etc.”

On his blog, Tim Bain, founder and life insurance agent with QuickQuote.com, wrote that his company has only received a few applications from transgender individuals. He noted that it was more challenging to find the best life insurance company for this applicant because “life insurance company guidelines for transgender individuals vary significantly from company to company.”

He had to find out how life insurers would decide which gender applies, and discovered that answers varied by company. Another finding: gender-affirming surgery may affect which gender the applicant would be treated as by some companies but not others, and could even affect eligibility and rates depending on how much time had passed since the surgery.

Bain concluded that transgender applicants need to spend more time than cisgender applicants finding an insurer that will offer them the most favorable rating for their circumstances and use their gender identity.

Selecting ‘Male’ vs. ‘Female’ May Not Matter That Much

Choosing male or female isn’t likely to be a nonbinary person’s preference. Still, selecting a box may not make much difference. That’s because life insurers look at many factors when setting an applicant’s premiums, and all go into determining the consumer’s insurability and how much the person will pay. That’s true no matter who you are or how you identify.

Insurers will also, in the course of reviewing your medical records, learn how doctors have identified your gender in the past. The only way around this is to get a policy that doesn’t require medical underwriting, which will typically result in less coverage and higher rates.

How Life Insurers Set Premiums

Life insurance premiums are based on many factors besides gender:

• Age
• Occupation
• Blood pressure
• Build (height and weight)
• Cholesterol
• Physical health history
• Mental health history
• Surgical history
• Family health history
• Prescription history
• Chronic health conditions
• Tobacco use
• Illegal drug use
• Driving record
• Criminal record
• Bankruptcy
• Travel to dangerous countries
• Participation in high-risk recreation
• Type of life insurance (term, whole, etc.)

All of these factors (except the last one, of course) influence the age at which someone is likely to die. The longer the insurer expects to collect premiums and the less likely it is that they’ll pay a claim, the lower the premiums will be. However, certain factors are especially likely to affect nonbinary individuals, and they may lead to paying extra for insurance.

Build (Height and Weight)

One area of underwriting where the box you check can directly affect your premiums is build, or body mass index (BMI). Despite the well-documented flaws in this metric, many insurers still use it to determine whether an applicant’s build puts them at higher risk of premature death. And the build tables underwriters use are different for men than for women.

Applicants at the high or low end of what’s considered an acceptable weight for their height could potentially pay a different rate depending on the gender they are underwritten as. An applicant who is 5’5” and weighs 174 pounds, for example, would have a BMI of 29. An insurer might say 30 is the upper limit for BMI for a male to get the best rates, but 28 is the upper limit for a female.

An applicant with this build who is underwritten as female is more likely to pay less, all else being equal, than the applicant with this build who is underwritten as male. However, some insurers do not apply different BMI standards to each gender.

Mental Health History

Gender dysphoria is a common challenge for nonbinary individuals and is a recognized diagnosis by the American Psychiatric Association. It can include, among other concerns, a strong desire to be treated as a different gender from the one assigned at birth and to have the primary or secondary sex characteristics of the opposite sex, along with significant distress or problems functioning for at least six months.

Not all nonbinary people experience gender dysphoria, and this entry in the profession’s diagnostic manual doesn’t mean that gender dysphoria is a mental illness. A diagnosis may help some people get access to medications and treatments that can improve their quality of life.

Suicide and Depression

Receiving any mental health diagnosis may mean paying higher insurance premiums, however. Life insurers take some diagnoses, such as major depressive disorder, especially seriously because suicide is the tenth leading cause of death in the United States, according to a 2019 CDC report.

Studies have found that transgender individuals are more likely to attempt suicide, and gender-affirming care reduces suicide attempts. Transgender people are verbally harassed, physically attacked, sexually assaulted, and fired from jobs at high rates, which can lead to problems with mental and physical health that can affect life insurance rates and eligibility.

The severity of a condition and how it’s been managed can influence how an insurer weighs a mental health diagnosis in deciding whether to offer someone a policy and at what cost. Some insurers, for example, rate a diagnosis of depression more favorably than others. One company might give people with that diagnosis its most preferred rates despite their mental health history while another might give them substandard rates.

Someone with mild to moderate depression or anxiety that is being treated with a maximum of two medications, neither of which is an anti-psychotic, may still be eligible for the best rates, depending on the insurer.

On the other extreme, a suicide attempt within the past two years can make someone uninsurable for the time being, as can a mental disorder requiring hospitalization within the past year. An attending physician statement may be necessary for approval after that.

Physical Health History

Some nonbinary people are not in their best physical health because of medical mistrust, lack of access to gender-affirming care, or outright discrimination by healthcare providers. Studies have found that transgender individuals avoid seeking healthcare for fear of mistreatment and that when they do seek care, they are, in fact, often mistreated.

Even when someone overcomes these obstacles and seeks preventive or acute care, they may not follow medical advice if they do not trust their provider. The result can be higher life insurance premiums based on physical health issues caused by health discrimination, such as a provider’s refusal to treat, an insurer’s refusal to provide coverage for treatment, or an individual’s avoidance of the healthcare system.

As for some of the specifics of an applicant’s health history, when it comes to blood pressure and cholesterol, it can matter whether one is being underwritten as male or female. The ideal diastolic pressure—the bottom number in the blood-pressure ratio—that an insurer uses for women may be lower than the one for men. And an applicant with a cholesterol-to-HDL ratio of 4.8 might be rated more favorably if they are male than if they are female.

Transgender people are also more likely to be HIV positive, a condition that can mean being declined for life insurance.

Surgical History

Nonbinary individuals, just like cisgender individuals, sometimes have surgery to feel happier and more comfortable in their bodies. Someone who is assigned female at birth but identifies as nonbinary, for example, may have breast reduction surgery, and someone assigned male at birth may have breast augmentation surgery.

Since life insurers consider surgical history when evaluating any applicant, any gender-affirming surgery could affect life insurance premiums. Nonbinary individuals may be less likely to have surgery, or may have less extensive surgery, than transgender individuals who identify as male or female.

Insurers don’t publicly disclose exactly how they set rates, but here’s what we found about the effects of gender-affirming surgeries and how that information could affect your rates.

How Surgical History Might Affect Rates

Insurer Munich Re recommends that insurers not accept a life insurance application until a year has passed after breast augmentation surgery because about 15% of these patients require an additional surgery within 12 months. The insurer also notes that not a lot is known about the long-term risks of many procedures that are classified as cosmetic, but that breast augmentation does not seem to increase mortality.

Karsten Filzmaier, a life insurance industry veteran and cardiologist in Munich, notes that transgender interest groups have been challenging Europe’s life insurance industry to disclose how it assesses the medical risks of insuring transgender individuals. He co-authored a paper that found that four in five transgender individuals who had gender reassignment and were monitored medically afterward had “a distinct improvement of their psychological symptoms and a gain in their quality of living.”

Available studies show that hormone use seems to have a smaller effect on heart problems and cancer rates than previously thought, according to Filzmaier, and that the medical risk from gender reassignment and long-term hormone therapy is minor to insignificant. He encourages underwriters to focus on each individual applicant’s risk profile and says the biggest issues affecting transgender underwriting are likely suicide and risky behavior. Again, these findings are not specific to nonbinary people, but they may still be applicable.

Munich Re has also weighed in on underwriting gender dysphoria, saying that transgender individuals have “mild to moderate extra mortality,” though male-to-female individuals have a higher mortality risk than female-to-male individuals, mainly due to suicide and, to a lesser degree, cardiovascular events.

Prescription History

Nonbinary individuals who experience gender dysphoria may take androgen blockers, estrogen, or testosterone to alleviate mental distress. If you’ve taken gray market or black market hormones, they won’t show up in your prescription history, but they may show up in the routine blood and urine screenings that life insurers often require. 

Hormone use may have led to side effects that can affect life insurance premiums. Feminizing hormones can increase cholesterol, raise levels of potassium in the blood and affect heart function, cause blood clots or anemia, increase body fat, and affect mood. Masculinizing hormones can change cholesterol and increase red blood cells, potentially causing or worsening a cardiovascular problem. Gender confirmation surgeries can have complications that make an applicant a riskier prospect to insure.

People who have taken medications to support their mental health will also have these drugs in their prescription history, and such medications, depending on the medication and the insurer, could lower their premiums by demonstrating that they’re getting treatment to improve their mental health. Alternatively, these medications could increase premiums because of the risks associated with the drugs themselves and the conditions they treat.

^{Source: Centers for Disease Control and Prevention}

Tips for Life Insurance Applicants Who Are Nonbinary

Consider leveraging technology to minimize potentially uncomfortable interactions with people during the application and underwriting process.

Get group life insurance through an employer. This can be a great way to sidestep a potentially awkward underwriting process and/or higher rates because you’ll get insurance at low group rates without medical underwriting. The downside is that you may not get enough coverage through your employer and you may lose your coverage if you get laid off or change jobs. Another issue is that trans people tend to have less stable employment, which can make trying to rely on work-based life insurance extra challenging.

To find life insurers that are more likely to treat you with respect, turn to the Human Rights Campaign Foundation’s Corporate Equality Index of companies that are top-rated places to work for LGBTQ individuals. One requirement for earning a spot on this list is “Equal health coverage for transgender individuals without exclusion for medically necessary care.” The report’s “Appendix A, Employer Ratings,” includes the following life insurance companies in its 2022 report with score of 100:

• AIG
• Allianz
• American Family Insurance
• Assurant
• Asurion
• Chubb
• Cigna
• Farmers
• Guardian
• The Hartford
• Liberty Mutual
• Lincoln National
• MassMutual
• MetLife
• New York Life
• Northwestern Mutual
• Prudential
• The Standard
• State Farm
• Sun Life
• TIAA
• Transamerica
• Unum
• USAA
• Voya

Some of these companies don’t sell life insurance directly to individuals but do provide life insurance through employers.

Here’s one more tip, and it comes from Ty Stewart, CEO and president of Simple Life Insure, a small, independent, life insurance broker. “Nonbinary folks looking to receive comprehensive life insurance should make sure to research protections under their home state’s laws,” he said. “Most states prohibit policy discrimination based on someone’s gender identification.”

California and Delaware are two states with explicit policies prohibiting discrimination based on gender identity. You can file a complaint with your state department of insurance if you feel you are discriminated against during the insurance application or underwriting process.

The Bottom Line

The dominant culture in the United States treats gender as binary: you’re either male or female. Life insurers do this, too. But for an individual with a nonbinary gender identity, being forced to constantly choose between two options that don’t apply can mean feeling invisible. Simple changes in business practices can make customers with nonbinary gender identities feel included and respected. Offering an all-gender bathroom or asking for patients for their pronouns could help solve this problem.

Individuals who openly identify as nonbinary make up a small percentage of the U.S. population, which means there may not be much incentive for life insurers to update their policies to serve a small group. And even when there is an incentive, changing long-established business practices, especially in a highly regulated industry, can be a slow process.

The experts we contacted all said they weren’t aware of any movement within the life insurance industry to set premiums without regard to an applicant’s biological sex or gender identity.

“Unless you live in Montana, if you want life insurance, you will need to accommodate this outmoded framework, very probably for years to come,” Tamarkin said.

Still, there is no reason to think the life insurance industry can’t or won’t change and begin offering unisex rates. This is already happening in Montana and in Europe. And throughout the United States, life insurers no longer use race as a factor in setting premiums or approving coverage amounts thanks to civil rights movements. Beginning in 2004, Europe offers unisex rates through group policies. The same shift in public opinion that has recently led to the Supreme Court’s affirmation of LGBTQ rights in the workplace may soon lead to a better insurance underwriting process for nonbinary individuals, too.