This study aimed to explore whether patterns of insular impairment exist among adults with chronic physical diseases. Considering the relevance of interoception in the symptom experience, we also paid attention to analyses of the relationship between the insula and disease-related symptoms. In this systematic review we included primary research (all designs) assessing the structure and/or activity of the insula through (f)MRI in adults with chronic physical diseases (vs healthy-controls). We reported results as a narrative synthesis. We included fifty studies investigating the structure or activity of the insula in diabetes, cancer, heart failure, chronic pulmonary disease. Nineteen studies explored insular structure and found patients with chronic diseases having lower/damaged insular volume/density/thickness than healthy controls, or reduced insular blood flow. Twenty-two studies explored insular activity and the majority reported higher insular activity and lower connectivity in patients. Five studies explored the association between insular volume/activity and symptom severity: four reported a positive trend, one reported a negative association. In conclusion, people with chronic physical diseases have lower insular grey matter volume/density/thickness and abnormal insular activity (i.e., higher or lower) than healthy subjects. There seems to be a positive trend between insular activity and symptom severity. These results a) can better explain impaired interoceptive abilities in chronic physical diseases, b) shed light on the relevance to implement interventions addressing insular activity to improve interoceptive functioning and ultimately enhance body awareness and symptom management in patients with chronic diseases.