ABSTRACT
Insurance is a contract whereby one party undertakes to indemnify another against loss by a specified contingency or peril. It is a method of spreading risks for events that cannot be predicted with certainty. Several insurance products are used to insure against the financial consequences of illness, disability and death. Insurance underwriting involves risk assessment and risk classification, resulting in policy holders of similar risk being charged similar prices (Dicke 2004). In medical underwriting, the individuals’ future health risk is predicted based on past and current health, as well as other factors, such as age, occupation, body mass index and smoking status (Gleeson 2004). Genetics is the scientific study of heredity. As a result of the new insights and tech-
nologies associated with the Human Genome Project, the capacity of genetic testing to predict the likelihood of illness and even to estimate life expectancy has expanded greatly. Today, over 1,500 genetic tests are available in the clinical and research settings (Genetest.org 2008), which provide increasingly accurate predictions about the likelihood of any individual manifesting future, genetic-influenced health events. Traditionally, genetic tests focused on the risk of monogenic disorders, but the focus of many newer genetic tests is on more common, complex conditions caused by both genetic and environmental factors (Andrews and Zuiker 2003; Burke 2002). At first glance, it might appear that modern, predictive genetics and the traditional
risk-spreading function of insurance are on a collision course, and therefore insurance against future morbidity or mortality is unsustainable. Arguably, if an individual’s future health can be predicted with a degree of certainty, then the contingency at the heart of insurance would be eliminated or substantially reduced. Such a hypothesis is overly simplistic for two important reasons. First, scientifically, it fails to account for the significant effects of variable penetrance and expressivity, gene-environment interactions, as well as epigenetic and other biological processes that modern science is only beginning to understand. Second, in its various product lines, insurance plays a vital social role in funding health care and long-term care, providing income for individuals who have
become disabled, providing income replacement on the death of a family’s breadwinner, and in other important ways. The commercial insurance market thus complements social welfare systems. This chapter describes the role of insurance in general and insurance underwriting in
particular in the post-Human Genome Project world. After considering the widely differing contexts in which insurance operates, the chapter concludes that, from the standpoint of social policy, the role of expanded genetic information on each type of insurance must be separately assessed. The evaluation process involves difficult and contentious issues of political philosophy, public policy, ethics, economics, industry practices and law. After framing the issues with regard to each of the major insurance product lines, the chapter analyses the various responses of governments around the world and of the insurance industry. It concludes with general comments on the efficiency of these various mechanisms to protect the interests of all concerned stakeholders in the genomic era.
