Chronic Traumatic Encephalopathy (CTE) is emerging as a complex, longtail mortality risk with implications that extend well beyond sports. Once viewed as a niche issue, it is now becoming increasingly relevant to life and health insurers, with potential impacts on underwriting and claims across multiple markets and products due to global litigation cases.
This article explores how repeated head impacts from concussion to sub concussive injury translate into evolving morbidity and mortality risk, why traditional underwriting frameworks may underestimate exposure, and what life insurers and reinsurers should consider as relevant medical evidence, diagnostics, and legal pressures continue to develop.
CTE is a progressive neurodegenerative disease associated with repeated head impacts, including both concussive and sub-concussive injuries[1]. CTE can only be definitively confirmed post-mortem, while symptoms during life, often described under Traumatic Encephalopathy Syndrome (TES), overlap with depression, dementia, substance misuse, and other neurological or psychiatric disorders[2].
Concern for this disease has intensified as it has been diagnosed in athletes as young as 17 years old. In the two largest brain bank studies of contact-sport athletes, more than 80% of the brain donors who played American football, Canadian football, soccer, rugby and ice hockey were diagnosed with CTE. [3] Many professional and amateur athletes never even have a formal concussion recorded may experience repetitive head impacts over the course of a career.[4]
Another development is the issue of moving from medical debate into public, legal, and financial focus. High-profile litigation involving former players in rugby and football, together with the legacy of concussion-related settlements in American football[5], has increased scrutiny on what governing, sporting-bodies, and employers knew, or should have known, about long-term neurological risk.
For insurers, that combination of broader exposure, imperfect diagnosis, and rising legal awareness makes CTE relevant now not only as a medical issue, but as an underwriting, claims, and litigation challenge.
While most individuals recover fully from a concussion, repeated head injuries, particularly those sustained before complete recovery, may increase the risk of long-term neurological consequences.
Over time, it is the cumulative effect of repeated head impacts, rather than any single concussion, that is most relevant to Chronic Traumatic Encephalopathy (CTE). These symptoms may include mood and behavioral changes, cognitive impairment, and, in advanced cases, dementia.
From an insurance perspective, several characteristics of CTE are particularly significant:
CTE has implications for both mortality and morbidity risk, with effects that may emerge through overlapping cognitive, neurological, and behavioral pathways. For insurers, the challenge is not only the severity of potential outcomes, but also the delayed onset, non-specific presentation, and difficulty of diagnosing during life.
From a mortality perspective, concern centers on the association between CTE pathology and progressive cognitive decline, depression, and suicidality. While data continues to evolve, CTE introduces added complexity into mortality assessment, particularly where behavioral risk may emerge well beyond typical select periods and where prior exposure is not fully captured in the medical record.
For life insurers, this raises important considerations around:
The implications of CTE are not limited to mortality. Its cognitive, psychiatric, and neurological manifestations may also create significant morbidity exposure, particularly where functional impairment develops gradually over time. Commonly observed symptoms include:
These symptoms can have meaningful functional and psychosocial consequences, with potential impacts on personal and professional relationships, as well as social interaction.
Case ExampleConsider a former amateur contact-sport athlete with a long playing history but no formally documented concussions. At underwriting, the available medical evidence may suggest standard or only moderately increased risk, because the true exposure profile is not fully visible in the record.
Key takeaway: This scenario highlights the gap between recorded medical history and true cumulative exposure. For insurers, the challenge is that risk may be shaped by years of unrecorded impacts, while the eventual claim may present decades later through symptoms that are difficult to diagnose, attribute, and adjudicate with certainty. |
CTE highlights a broader challenge for insurers where traditional underwriting frameworks are often designed to assess discrete medical events rather than cumulative lifetime exposure. As understanding of repetitive head trauma continues to evolve, insurers may need to look beyond documented concussions and consider the totality of an individual’s exposure history.
Current applications typically focus on diagnosed conditions, treatment history, or prior concussions. However, many athletes experience numerous sub-concussive impacts that are never diagnosed or reported, making it difficult to fully assess exposure through traditional underwriting questions alone.
Risk may be influenced not only by whether an individual sustained a concussion, but also by factors such as years of participation, level of competition, position played, and cumulative head-impact exposure.
While CTE may ultimately contribute to mortality, i Cognitive decline, behavioral changes, and functional impairment can create significant exposure for critical illness, disability, and long-term care coverage.
The delayed onset and non-specific symptoms associated with CTE can complicate claims adjudication. As diagnostic criteria continue to evolve, questions surrounding causation, impairment, and coverage eligibility may become increasingly complex.
More broadly, CTE represents a shift from event-based risk assessment toward evaluating the long-term health consequences of cumulative exposure, a challenge that extends beyond professional athletes and may influence future underwriting approaches across multiple lines of business.
CTE is not a risk that can be addressed through simple exclusions or point-in-time underwriting questions. It reflects cumulative exposure over time, with impacts that may emerge long after exposure has ended.
For insurers and reinsurers, the focus is not on diagnosing CTE, but on better understanding how long-term neurological risk develops and how it may influence different product lines, particularly where morbidity exposure is more pronounced. As clinical understanding, diagnostics, and litigation continue to evolve, underwriting and claims frameworks will need to remain flexible as the definition and interpretation of risk continue to shift.
Please contact us if you would like to learn more about developments in neurological conditions such as CTE, or to discuss its mortality and morbidity implications. We would be happy to set up a meeting with you.
Cillian Tierney, Head of Medical Underwriting Propositions & Products, Global Life & Health
[1] About Repeated Head Impacts | Traumatic Brain Injury & Concussion | CDC
[2] https://www.cdc.gov/traumatic-brain-injury/about/repeated-head-impacts.html
[3] https://concussionandcte.org/wp-content/uploads/2024/07/CTE-prevention-protocol-112023.pdf
[4] Leveraging football accelerometer data to quantify associations between repetitive head impacts and chronic traumatic encephalopathy in males | Nature Communications
[5] https://www.nflconcussionsettlement.com/FAQDetails.aspx?q=154