For roughly thirty years, an HIV-positive applicant could not buy individual life insurance in the United States at any price. That changed in December 2015, and it changed abruptly rather than gradually.
Our HIV and life insurance page covers where the market stands now. This one is about how it got there, because the sequence explains most of what is still confusing about this category — including why so much of the advice online is describing a market that no longer exists.
Why the market was closed
Underwriting runs on mortality tables, and mortality tables run on data. Through the 1980s and 1990s the data on HIV described a terminal illness with a short and predictable course. There was no rate class to put such a file in, so carriers declined, and declining became the default long after the clinical picture had changed.
The clinical picture changed first. Combination antiretroviral therapy arrived in the mid-1990s and progressively turned HIV into a managed chronic condition. What did not exist for another two decades was credible actuarial data on treated, virally suppressed patients over a long enough horizon to price a twenty-year policy. Prudential said as much publicly: the opportunity had been visible for years, and what was missing was a defensible way to calculate the mortality.
That gap is the whole explanation. It was not principally a legal barrier, and by the later years it was not really a clinical one either. It was an absence of data with which to build a price.
December 2015: the market reopens
Prudential became the first major US carrier to offer individual life insurance to people living with HIV, with 10- and 15-year convertible term products. (POZ)
Five months later, in April 2016, John Hancock became the second, and published its criteria — which is why that announcement is still the most useful public document in the category. Its terms were:
- Applicants aged 30 to 65
- Face amounts up to $2,000,000
- A favourable and stable clinical course
- Strict adherence and response to antiretroviral therapy
- No significant immunosuppression
- No significant co-morbid conditions
Read that list again, because it is not a list about HIV. It is a list about treatment adherence and stability. That is the shift: the diagnosis stopped being the underwriting question and became one input among several.
What the underwriting actually looks at now
The criteria that opened the market are still the criteria that price a file. In practical terms, carriers writing this business look at:
- Viral load. Sustained undetectable is the single most important line on the file. One undetectable reading is not the same as three years of them.
- CD4 count, and its trajectory. A stable count in a healthy range matters more than any single figure.
- Adherence. Documented, uninterrupted antiretroviral therapy. Gaps in the pharmacy record are read as instability, and prescription data is checked regardless of what the application says.
- Time since diagnosis and time on treatment. A longer stable record is a better file, which inverts the usual intuition that a recent diagnosis is somehow easier to insure.
- Co-morbidities. Hepatitis B or C co-infection, cardiovascular disease, kidney impairment and any cancer history are all weighted, and often move the file further than the HIV does.
- The ordinary factors. Build, smoking status, blood pressure, substance use history. The same list everyone else is assessed on.
The evidence base underneath this has continued to strengthen. Cohort studies now report that people starting antiretroviral therapy with a healthy CD4 count and achieving sustained suppression approach general-population life expectancy — which is a materially different actuarial statement from anything available in 2010.
What is still constrained
Three honest limitations, because this category attracts a lot of over-claiming in both directions:
The carrier list is short. Most carriers still do not write this business. That is the practical constraint, and it is why a decline from a randomly chosen insurer tells you nothing at all — you may simply have applied somewhere with no product for you. Working with someone who knows which carriers participate matters more here than in almost any other category.
Age bands are narrower than usual. The published terms started at 30 and stopped at 65, and that shape persists across the market. Applicants under 30 are the group most likely to find nothing available, largely because the long-horizon data thins out.
Pricing carries a loading. Cover is obtainable; it is not obtainable at the same price as an identical applicant without the diagnosis. That is a real cost and worth planning for rather than being surprised by.
Routes that do not depend on underwriting
Two are worth knowing about, and both are commonly overlooked.
Group cover through an employer is issued without individual medical underwriting up to the guaranteed issue amount. It is the cleanest cover available to many HIV-positive people, and it usually carries a conversion right when you leave — which is worth understanding before you leave, not after. See group conversion.
Guaranteed issue asks no health questions at all. It should not be the first stop, because face amounts are small and the first two or three years are subject to a graded death benefit, but it is a genuine floor for anyone the individual market cannot place.
What to do next
Pull together your viral load and CD4 history — ideally three years of it — and your treatment start date. A documented record of sustained suppression is the file, and assembling it before you apply is worth more than any comparison shopping you can do afterwards.
Then check your employer’s group cover and what it converts to, since that may already be more than you expect. And when you do approach the individual market, go through someone who knows which carriers currently write it. Applying at random in this category produces declines that mean nothing and sit on your record anyway — the problem our page on applying after a decline deals with.