This series presents individual medical cases that feature challenging conditions, uncommon diseases, or an unusual presentation of symptoms. Below, we summarize a case, explain our research and analysis, and suggest an underwriting recommendation. Munich Re’s team of global medical directors continually tracks medical research so that primary insurers may benefit from evidence-informed risk assessments. It is our hope that analyses of more challenging cases will foster a greater awareness of medical progress and will help to expand insurability.
Case: Ehlers-Danlos syndromes
The Munich Re medical team evaluated the insurability of a 38-year-old female applicant with a history of Ehlers-Danlos syndrome diagnosed during her teenage years. She had presented with multiple joint dislocations while playing varsity basketball. Additional symptoms included joint hypermobility and easy bruising. She had no history of bone fractures, bleeding episodes, or cardiovascular disease. One year prior to application, she underwent cardiovascular screening, including an echocardiogram, which showed no valvular disease or aneurysms. She was not taking any medications and had stopped playing basketball and other contact sports. The underwriting team asked, “Is she insurable?”
Munich Re medical's response
- The Ehlers-Danlos syndromes (EDS) are a group of disorders characterized by skin hyperextensibility, joint hypermobility, and tissue fragility. There are at least 13 various subtypes of EDS, distinguished by the degree and nature of involvement of the skin, joints, skeleton, and vasculature.
A genetic basis and different modes of inheritance have been found for all but the most common type, hypermobile EDS, thereby allowing confirmatory genetic testing for many types. The hypermobile type remains a clinical diagnosis that is based on signs and symptoms.
- The overall frequency of EDS is estimated at 1 in 5,000, with hypermobile EDS being the most common form.1
The clinical findings range from joint hypermobility and instability (as seen in the hypermobile EDS) to arterial fragility with dissections, aneurysms, and rupture (as seen in vascular EDS). Other features may include mitral valve prolapse, foot deformities, impaired growth, and organ rupture as seen in other forms of this syndrome.
Patients with EDS should undergo cardiovascular evaluation, including echocardiography, for detection of complications such as valvular and vascular disease as well as aortic aneurysms. Any suggestion of systemic involvement (outside of the joints and skin) other than simple mitral valve prolapse (MVP) would imply a higher mortality risk.
1What is EDS?, The Ehlers-Danlos Society.
When underwriting people with EDS, it is important to delineate which type is present, as the mortality and morbidity risk varies by type. Review of any bleeding history along with prior cardiovascular testing is important. The Munich Re medical team was satisfied that the applicant met the clinical diagnosis of hypermobility type EDS. There was no evidence of MVP or other systemic involvement. The team felt this represented a mild mortality risk, whereas morbidity risk was considered uninsurable.
The information provided herein is for general information purposes only and should not be relied upon as professional advice. Munich Re, and its employees, directors, officers, and representatives do not warrant, represent or guarantee the accuracy, completeness, or currency of any of the information provided herein and accept no liability whatsoever arising in any way from the use of or reliance on such information, including liability for direct, indirect, special, incidental or consequential damages.
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