Navigating life insurance underwriting can be challenging when working with clients in less than perfect health. Paramedical exams and blood work that are part of the underwriting process may highlight clients’ elevated levels of NT-proBNP, which often come as a surprise to both clients and advisors and, more importantly, can significantly impact how carriers assess mortality risk. 

Elevated NT-proBNP is a difficult impairment to overcome in the underwriting process. However, when armed with a clear understanding of the blood test, how to prepare clients for medical exams, and a specialized brokerage with underwriting expertise, like Modern Life, advisors can help improve clients’ chances of securing the best coverage.

What is NT-proBNP?

NT-proBNP, or N-terminal brain natriuretic peptide, is a protein released by the heart when it’s under stress. Elevated levels of NT-proBNP might signal that the heart is working harder than usual, potentially due to conditions like heart failure, kidney disease, or lung problems. Carriers often use NT-proBNP as an early indicator of cardiovascular risk, even in clients with no known history or apparent symptoms.

Not all NT-proBNP elevations are linked to serious illness. Stress, overhydration, or even heavy exercise can cause temporary increases. Understanding the root cause of an elevation—and how carriers interpret these results—can help advisors manage expectations and navigate the underwriting process more effectively.

How is NT-proBNP tested?

NT-proBNP is measured through a blood test, which has become standard practice for many life insurance carriers, especially in larger cases with high death benefits or older clients. Many carriers have even opted to eliminate electrocardiograms (EKGs) from their standard underwriting workups in favor of testing for NT-proBNP.

NT-proBNP levels can change as a person ages. Generally, the medical field considers NT-proBNP levels under 125 pg/mL normal for individuals under 75, while levels up to 450 pg/mL are acceptable for clients over 75. 

Carriers have their own guidelines and standards to determine underwriting risk. Generally, they tend to have stricter thresholds than those used in the medical field, aiming to identify potential risks earlier.  

Carrier manuals are subject to change, but as of October 2024, most carriers associate NT-proBNP levels above 75 pg/mL with increased mortality risk and will rate the client accordingly. This can lead to higher-than-expected premiums or a decline, even if a client’s levels are within normal medical ranges.

Clients with NT-proBNP levels below 75 pg/mL can still receive a preferred or preferred best rating, while those with slight elevations can get standard ratings. Some carriers have more liberal manuals than others, and working with a skilled underwriting team can help position the client’s case to the best carrier. 

Best practices for preparing clients for medical exams

Clients are often unaware of their NT-proBNP levels before their medical exam. Many have never even heard of the study. So it’s important for advisors to properly prepare clients for the examination to avoid potentially elevating their NT-proBNP levels:

• Avoid strenuous exercise 48 hours before the exam, as it can elevate NT-proBNP levels.
• Encourage clients to manage stress by practicing relaxation techniques like deep breathing or meditation in the days leading up to the test.
• Limit caffeine intake before the exam–it can increase heart rate and potentially affect results.
• Stay hydrated, but not overly hydrated, as overhydration can also lead to elevated NT-proBNP levels.

By following these steps, clients can reduce the likelihood of non-cardiac factors artificially inflating their NT-proBNP levels and affecting underwriting outcomes.

Elevated NT-proBNP and insurability

Elevated NT-proBNP levels can adversely affect a client’s insurability based on factors like age, gender, and the severity of the elevation. For example, a client with slightly elevated NT-proBNP and no history of cardiac illness might still qualify for standard or better coverage.

However, a client who also has other risk factors, such as high blood pressure or a recent cardiac diagnosis in addition to elevated NT-proBNP levels, is more likely to receive a substandard rating or even be denied coverage.

No alternative tests can replace NT-proBNP for underwriting purposes, and as mentioned earlier, many carriers opt for this lab work over other tests like an EKG. Some advisors think that having other clean cardiac tests can help them overcome a debit from the carrier. However, NT-proBNP is an inclusive test used as an indicator of risk rather than a diagnostic test, and it can be difficult to overcome elevated results. 

That said, identifying the underlying cause of the elevation is key to positioning the case. As previously mentioned, elevated levels of NT-proBNP are not always linked to heart issues. If the client can demonstrate that the elevation is not linked to serious heart, pulmonary, or renal issues, they may be able to improve their rating. 

Keep in mind, more comprehensive tests could uncover other health issues that further impact the underwriting decision. Balancing the need for additional information against the risks is key to managing the case.

Setting expectations with clients

If a client knows they have elevated NT-proBNP levels or a diagnosed cardiac condition, setting realistic expectations from the start is critical. Have open conversations about their medical history and any previous cardiac workups, especially if they’ve had a complete cardiac evaluation in the last 12-18 months. Recent medical records will help streamline the application process.

In some cases, repeating the NT-proBNP test after rest and proper preparation may improve results. How long a client should wait between tests depends on their underlying condition. If a client just completed a heavy workout or was under stress, they can redo the test fairly quickly. For other clients, focusing on long-term health improvements, like lifestyle changes that manage cardiac risk factors, might yield better results in future applications.

Communicating with carriers and underwriters

Clear communication with the carrier is essential when submitting an application for a client with elevated NT-proBNP. Provide as much context as possible, especially if the elevation is due to factors like recent heavy exercise or stress. While carriers take a conservative approach to elevated NT-proBNP, a cover letter outlining the client’s health history or explaining mitigating factors can help strengthen the case.

If the elevated NT-proBNP levels are due to an underlying cardiac issue, an advisor can suggest lowering the death benefit to help account for a substandard rating. For example, some permanent products allow better crediting or table shave programs to help overcome debits associated with elevated NT-proBNP. 

How Modern Life can help

At Modern Life, we don’t just assist with underwriting challenges—we work side by side with advisors, leveraging our expertise and carrier relationships to uncover every possible advantage for clients. 

When faced with elevated NT-proBNP or other impaired risks, we dig deep into the client’s health profile to find every possible angle to improve their outcome.

If a better rating isn’t immediately achievable, we provide guidance on how to potentially improve the client’s future health profile so they can reapply later. Our holistic approach ensures that no opportunity is missed when securing the best coverage for clients.

For example, Modern Life recently assisted an advisor with a client who initially received a substandard rating due to elevated NT-proBNP levels. The client, who was young and otherwise healthy, was searching for a $2 million Universal Life policy for estate planning.

Leveraging our carrier relationships, we worked closely with the underwriters to emphasize the client’s healthy lifestyle—including regular exercise, young age, and the absence of any family history of cardiac conditions. This comprehensive presentation enabled us to negotiate an improved rating from the carrier.

Additionally, through our in-depth understanding of carrier underwriting guidelines for NT-proBNP, we identified an alternative provider that offered a more competitive solution. With multiple options, the client was able to select the policy that best met their needs, ultimately securing the desired coverage at a more favorable rate.

Next steps

Elevated NT-proBNP levels can pose a challenge in life insurance underwriting, but with proper preparation, clear communication, and the right support, these obstacles can be successfully navigated. 

If your client is dealing with elevated NT-proBNP or other impaired risks, Modern Life is here to help. Contact us today to explore how we can assist with your next case.