title: Life insurance and breast cancer risk assessment: adverse selection, genetic testing decisions, and discrimination.
abstract: Life insurance industry access to genetic information is controversial. Consumer groups argue that access will increase discrimination in life insurance premiums and discourage individuals from undergoing genetic testing that may provide health benefits. Conversely, life insurers argue that without access to risk information available to individuals, they face substantial financial risk from adverse selection. Given this controversy, we conducted a retrospective cohort study to evaluate the impact of breast cancer risk information on life insurance purchasing, the impact of concerns about life insurance discrimination on use of BRCA1/2 testing, and the incidence of life insurance discrimination following participation in breast cancer risk assessment and BRCA1/2 testing. Study participants were 636 women who participated in genetic counseling and/or genetic testing at a University based clinic offering breast cancer risk assessment, genetic counseling, and BRCA1/2 testing between January 1995 and May 2000. Twenty-seven women (4%) had increased and six (1%) had decreased their life insurance since participation in breast cancer risk assessment. The decision to increase life insurance coverage was associated with predicted breast cancer risk (adjusted OR 1.03 for each 1% absolute increase in risk, 95% CI 1.01-1.10) and being found to carry a mutation in BRCA1/2 (OR 5.10, 95% CI 1.90-13.66). Concern about life insurance discrimination was inversely associated with the decision to undergo BRCA1/2 testing (RR 0.67, 95% CI 0.52-0.85). No respondent reported having life insurance denied or canceled. In this cohort of women, these results indicate that information about increased breast cancer risk is associated with increase in life insurance purchasing, raising the possibility of adverse selection. Although fear of insurance discrimination is associated with the decision not to undergo BRCA1/2 testing, there was no evidence of actual insurance discrimination from BRCA1/2 testing.
authors.affiliation: Department of Medicine, University of Pennsylvania School of Medicine, USA. karmstro@mail.med.upenn.edu
authors.forename: Katrina
authors.initials: K
authors.lastname: Armstrong
authors.forename: Barbara
authors.initials: B
authors.lastname: Weber
authors.forename: Genevieve
authors.initials: G
authors.lastname: FitzGerald
authors.forename: John C
authors.initials: JC
authors.lastname: Hershey
authors.forename: Mark V
authors.initials: MV
authors.lastname: Pauly
authors.forename: Jean
authors.initials: J
authors.lastname: Lemaire
authors.forename: Krupa
authors.initials: K
authors.lastname: Subramanian
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
mesh_terms: D001943:Breast Neoplasms / Q000453:epidemiology* / Q000235:genetics; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D005820:Genetic Testing; D006801:Humans; D015273:Insurance Selection Bias; D007352:Insurance, Life; D008875:Middle Aged; D018570:Risk Assessment