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From the NYTimes June
1, 2008 edition
After Caesareans, Some See Higher
Insurance Cost
By Denise Grady
When the Golden Rule Insurance Company rejected her application
for health coverage last year, Peggy Robertson was mystified.
“It made no sense,” said Ms. Robertson, 39, who lives in
Centennial, Colo.
“I’m in perfect health.”
She was turned down because she had given birth by Caesarean section. Having the operation once increases the odds that it will be performed
again, and if she became pregnant and needed another Caesarean, Golden Rule did
not want to pay for it. A letter from the company explained that if she had
been sterilized after the Caesarean, or if she were over 40 and had given birth
two or more years before applying, she might have qualified.
Ms. Robertson had been shopping around for individual health insurance, the kind that people buy on their own. She already had insurance
but was looking for a better rate. After being rejected by Golden Rule, she
kept her existing coverage.
With individual insurance, unlike the group coverage usually
sponsored by employers, insurance companies in many states are free to pick and
choose the people and conditions they cover, and base the price on a person’s
medical history. Sometimes, a past Caesarean means higher premiums.
Although it is not known how many women are in Ms. Robertson’s
situation, the number seems likely to increase, because the pool of people
seeking individual health insurance, now about 18 million, has been growing
steadily — and so has the Caesarean rate, which is at an all-time high of 31.1
percent. In 2006, more than 1.2 million Caesareans were performed in the United States,
and researchers estimate that each year, half a million women giving birth have
had previous Caesareans.
“Obstetricians are rendering large numbers of women uninsurable
by overusing this surgery,” said Pamela Udy, president of the International
Caesarean Awareness Network, a group whose mission is to prevent unnecessary
Caesareans.
Although many women who have had a Caesarean can safely have a
normal birth later, something that Ms. Udy’s group advocates, in recent years
many doctors and hospitals have
refused to allow such births, because they carry a small risk of a potentially
fatal complication, uterine rupture. Now, Ms. Udy says, insurers are adding insult
to injury. Not only are women feeling pressure to have Caesareans that they do
not want and may not need, but they may also be denied coverage for the
surgery.
“You have women just caught in the middle of this huge triangle
of hospitals, insurance companies and doctors pointing the finger at each
other,” Ms. Udy said.
Insurers’ rules on prior Caesareans vary by company and also by
state, since the states regulate insurers, said Susan Pisano of America’s
Health Insurance Plans, a trade group. Some companies ignore the surgery, she
said, but others treat it like a pre-existing condition.
“Sometimes the coverage will come with a rider saying that
coverage for a Caesarean delivery is excluded for a period of time,” Ms. Pisano
said. Sometimes, she said, applicants with prior Caesareans are charged higher
premiums or deductibles.
“In many respects it works a lot like other situations where
someone has a condition that will foreshadow the potential for higher costs
going forward,” Ms. Pisano said.
Her group has reported that although most Americans with health
insurance, 160 million, have group plans through employers, the number needing
individual policies will probably keep rising, because more and more people are
becoming self-employed or taking jobs without health benefits.
In a letter to Ms. Robertson, Golden Rule, which sells
individual policies in 30 states, said it would insure a woman who had had a
Caesarean only if it could exclude paying for another one for three years. But
in Colorado,
such exclusions are considered discriminatory and are forbidden, so Golden Rule
simply rejects women who have had the surgery, unless they have been sterilized
or meet the company’s age requirements.
“If you don’t work for someone who has insurance, and you have
to get insurance on your own, this is terrifying,” Ms. Robertson said.
A spokeswoman for Golden Rule declined to explain how long it
had been excluding Caesareans, how it had decided to do so or how many were
affected, saying the information was proprietary. The company, based in Indianapolis, is owned by
UnitedHealthcare, which collects more than $50 billion a year in premiums and
has 26 million members, most with group coverage.
In Colorado,
people denied individual health insurance can obtain it through a state
program, Cover Colorado, which insures about 7,200 people. But the premiums are
high, 140 percent of standard rates, a spokeswoman said, adding that some women
had enrolled specifically because prior Caesareans had disqualified them from
private insurance.
Blue Cross Blue Shield of Florida, which has about 300,000
members with individual coverage, used to exclude repeat Caesareans, but
recently began to cover them — for a 25 percent increase in premiums for five
years. Like Golden Rule, the company exempts women if they have been
sterilized.
“After five years, if there is not a complication of pregnancy, another C-section, or
if they get their tubes tied and are no longer in that risk situation, that
rate-up goes away,” said Randy M. Kammer, the vice president for regulatory
affairs and public policy.
The higher rate is based on a Caesarean costing an average of
$2,700 more than a vaginal birth (assuming no complications in either type of
delivery). Ms. Kammer said Blue Cross Blue Shield could not provide a tally of
how many members were paying the higher rates because of Caesareans.
“The aggravating thing is, there are a lot of elective
Caesareans, and that adds to costs,” she said.
Elizabeth Bonet, who lives in Sunrise,
Fla., learned
about the higher rates this year when she applied to Blue Cross Blue Shield of
Florida.
“I was very angry, outraged, shocked,” Ms. Bonet said. “It made
me feel very helpless. These were not Caesareans I wanted. They were not
elective Caesareans. I very much wanted natural births with both babies and was
not able to have them, and to have to pay for that for years is outrageous, and
I feel it’s discriminatory as well.”
Each state’s Blue Cross Blue Shield plan sets its own policies.
In Texas, a
spokeswoman said, a prior Caesarean will not affect a woman’s premiums or
insurability, as long as she has recovered fully.
A spokeswoman for another major insurer, Wellpoint, said the company’s
decisions about prior Caesareans varied case by case, but declined to explain
further.
Aetna does not treat a
Caesarean itself as a pre-existing condition, but does factor in chronic or
recurring problems that might have led to the Caesarean, like diabetes or high blood pressure, a spokeswoman said.
A spokeswoman for another company, Mega Life and Health
Insurance, in North Richland Hills,
Tex., said: “If the Caesarean
section was considered by the physician to be medically necessary for the
safety of the mother or child then coverage is issued without conditions. If
the procedure was determined to be ‘elective,’ coverage would be offered with a
temporary waiver or at a higher premium rate.”
Insurers often accuse women and obstetricians of scheduling
unneeded Caesareans for their own convenience — to deliver the baby at a
certain time, or to avoid labor. But it is not known how much of the overall
increase in Caesareans is because of a rise in unnecessary operations, or how
many Caesareans are done at the mother’s request, according to a 2006 report by
the National Institutes of Health.
“I think it’s really a very small amount, but we need more
data,” said Dr. Mary D’Alton, chief of obstetrics and gynecology atColumbia University Medical Center, and an author of the report.
She said she was amazed to hear that insurers would charge
higher premiums or deny coverage because of a past Caesarean.
“I would think if it’s happening, the medical profession has to
take a stand,” Dr. D’Alton said.
But to people familiar with the rough and tumble world of
individual insurance, the companies’ practices are no surprise.
Individual insurance differs sharply from the group coverage
with which most people are familiar. Group policies generally require that the
insurer cover everybody in the group, and charge the same rates for all. But
with individual coverage, insurers in many states can vary their prices based
on medical history, exclude certain services or reject anyone they consider a
bad risk. (Several states, however, including New York,
New Jersey and Massachusetts, ban such practices.)
Insurers say they need these strategies to protect themselves,
because some customers apply only after they get sick or pregnant, skewing the
pool toward people with high expenses.
Ms. Robertson said that had she known a Caesarean was grounds
for rejection, she would not have even applied to Golden Rule, because the
denial may be held against her in the future. Insurers routinely ask applicants
if they have ever been denied, and red-flag anyone who says yes.
“My understanding is that once you’re denied it’s hard to get
other insurance,” Ms. Robertson said. “Man, is that a scary thing.”
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