Being an organ donor may affect one's ability to obtain life, disability and health insurance. We conducted a systematic review to determine if insurability is affected by living organ donation, and if concern about insurability affects donor decision making. We searched MEDLINE, EMBASE, SCI, EconLit and Cochrane databases for articles in any language, and reviewed reference lists from 1966 until June 2006. All studies discussing the insurability of living organ donors or its impact on donor decision making were included. Data were independently abstracted by two authors, and the methodological quality appraised. Twenty-three studies, from 1972 to 2006, provided data on 2067 living organ donors, 385 potential donors and 239 responses from insurance companies. Almost all companies would provide life and health insurance to living organ donors, usually with no higher premiums. However, concern about insurability was still expressed by 2%-14% of living organ donors in follow-up studies, and 3%-11% of donors actually encountered difficulties with their insurance. In one study, donors whose insurance premiums increased were less likely to reaffirm their decision to donate. Based on available evidence, some living organ donors had difficulties with insurance despite companies reporting otherwise. If better understood, this potential barrier to donation could be corrected through fair health and underwriting policies.