Checking the “female” box when buying health insurance is likely to cost extra — perhaps up to 50 percent more than a man would pay for the same coverage.

Gender-rating — or what some term as flat-out sexual discrimination — is linked to the simple fact that women, particularly those under age 50 or so, go to the doctor more often than men.

But outrage over how women are treated in the individual health insurance market is mounting as stories emerge of companies refusing to cover maternity benefits and denying coverage because of past domestic violence or cesarean sections, including a Colorado woman who was told she would have to get sterilized to qualify for insurance.

Federal proposals, as well as pending state legislation, would ban gender-rating and require maternity coverage, even as the insurance industry warns that lowering premiums for younger women could mean higher premiums for most everyone else.

Colorado women age 40 and under shopping for health insurance in the individual market, not through an employer, pay from 10 percent to 59 percent more than men, according to analysis by the National Women’s Law Center.

They pay more even when maternity coverage is not included. And in many cases, a female nonsmoker pays more for health coverage than a man who smokes.

“Women should not be penalized because their plumbing works differently and needs ongoing maintenance,” Colorado Insurance Commissioner Marcy Morrison told a state health care task force.

As a state lawmaker, Morrison fought insurance companies to stop “drive-through deliveries” so women could stay in the hospital longer after childbirth. She said gender-rating is discrimination tied to decades-old salary disparity, particularly in female-dominated professions such as nursing and teaching. And she is skeptical of insurance company claims that “the sky is going to fall” and premiums would rise if gender-rating were outlawed.

America’s Health Insurance Plans, the industry’s national association, proposed ending gender-rating and the practice of rejecting customers based on pre-existing conditions. In exchange, insurance companies want powerful legislation that would compel everyone to buy insurance.

Discrimination against women in the insurance market goes far beyond premium rates, reform advocates said.

Sterilization suggested

Take, for example, Centennial resident Peggy Robertson, who was denied insurance by Golden Rule Insurance Co. because she delivered her second child by cesarean section in 2006. Maternity benefits weren’t even part of the package.

Robertson, whose husband is a self-employed chiropractor, contacted the International Cesarean Awareness Network and filed a complaint with the state Division of Insurance, arguing the denial was unfair and that the company had asked her offensive questions during the application process.

Later, she received a letter from Golden Rule telling her the company would consider covering her if “some form of sterilization has occurred since the caesarean-section delivery.”

“It was just really horrific and terribly insulting,” said Robertson, a stay-at-home mom of two boys. “You felt like you were a herd of cattle or something.”

Robertson’s recent testimony before the U.S. Senate health committee in part prompted Sen. Michael Bennet, D-Colo., to write a letter to Senate leaders adding his voice to the call for reform to ban gender-rating and other “harmful insurance industry practices.”

Since denying Robertson, Golden Rule, an Indianapolis-based division of United Healthcare, now covers women who have had cesarean sections but only with increased premiums to cover the risk of a future cesarean birth or with exclusionary riders — clauses that deny coverage for cesareans for a certain number of years or forever.

“This helps us extend coverage to more people while keeping premiums lower for all of our customers,” said Ellen Laden, public relations director for Golden Rule. “The real issue is how to deal broadly with providing access to health care for everyone while still keeping health insurance from being cost-prohibitive.”

Bennet and others, including the National Women’s Law Center, are calling for an end to coverage denials based on pre-existing conditions such as pregnancy and surviving domestic violence or sexual assault — a problem revealed in a recent report from the law center.

Lack of maternity benefits

Another common frustration among women who buy insurance individually — and there are 125,000 such women in Colorado — is that maternity benefits are almost nonexistent.

Suzanne Pariser, a Denver lawyer and mother of 2-year-old Willa, is putting off expanding her family because she cannot find an affordable insurance plan that includes maternity coverage.

“That’s the main reason we’re not having a baby right now,” she said. “We definitely want to have another child.”

Pariser is annoyed that insurance company executives, in essence, are determining her family planning.

“My anger is mostly that insurance companies view having a baby as a medical complication that costs them money,” she said. “They view it as a disease.”

The only plan she could find that offered maternity coverage was more expensive in the long run than paying out of pocket to have a baby, Pariser figured.

Costs vary by hospital or birthing center, but the average bill for a vaginal birth with no complications is about $7,500 and for a cesarean section, $13,200.

The insurance industry in Colorado has not taken an official position on statehouse bills that would ban gender-rating in the individual market and require maternity coverage. Their stance likely depends on national reform — and in particular, whether federal law will force everyone, even the healthiest people, to buy insurance.

But industry officials point out that higher premiums for women are based on analysis from actuaries, which show women are much more likely to visit the doctor. The rate at which women visit primary care physicians is more than 50 percent higher than for men, according to the New America Foundation.

By about age 50 or 55, men typically begin using health services more than women, and premiums for older men are typically more expensive than those for older women, said Ben Price, executive director of the Colorado Association of Health Plans.

“The insurance industry is engaged in its own internal discussion on this issue, and health plans here in Colorado are of course taking a fresh look at gender-rating and many other issues that have been raised as a part of the debate both in Washington and here in Colorado,” he said.

Officials with Anthem Blue Cross Blue Shield of Colorado have “strong reservations” about eliminating gender-rating and requiring maternity coverage. The practice is rampant in the auto insurance industry, they argue.

“The most expensive purchase in auto (insurance) is the young, invincible male; they are the risk-takers,” said Rebecca Weiss, director of government affairs. “For some reason, auto insurance doesn’t seem as inflammatory to people as health insurance.

“Shouldn’t health insurance premiums be based on some degree on how many medical services you receive so that everyone is paying according to what they are using?”

“It would raise prices”

Insurance companies probably would have to raise prices on other groups to make up the difference if they were forced to lower prices for younger women, said Tom Gosselin, director of small-group underwriting at Anthem.

“It definitely would raise the prices, is the simple thing,” he said. “You are now charging the 22-year-old guy who has no concept in the world about having a baby for maternity. He’s more likely to choose not to have health insurance at all.”

Eleven states ban gender-rating in the individual insurance market.

A review by the National Conference of State Legislatures found that those states had not determined whether their bans caused health insurance rates to rise.

In Montana, which outlawed gender-rating in 1983, some lawmakers want to repeal the ban, arguing fewer insurers are willing to operate in the state because of it.

Colorado is among several states that have banned gender-rating in the small-group insurance market, which in this state applies to businesses with 50 or fewer employees. For businesses with more than 50 employees, insurance companies can consider age and sex when setting rates — but the risk is spread throughout the company so everyone’s premiums are equal.

Reform advocates argue the policy adversely affects businesses where the workforce is predominantly female, such as child-care centers or home health agencies.

Care requires doctor visits

A Denver Post review of online health insurance quotes found that a woman living in the same Denver ZIP code with the same date of birth would pay $20 to $35 per month — or up to $420 more per year — than a man for the same coverage. The rates reviewed were for basic, high-deductible plans, ranging from $71 to $158 per month.

NARAL Pro-Choice Colorado is among those fighting for change in the law, arguing that women are typically the responsible sex when it comes to birth control and that those prescriptions often require an annual doctor visit.

“Under the current health care system, women are penalized for taking responsibility for their own health,” said Toni Panetta, NARAL’s political director.

State Rep. Beth McCann, a Denver Democrat sponsoring the bill banning gender-rating, said insurance companies failed to produce “sufficient factual basis to charge different premiums for women and men.”

“It seems as though it’s somewhat arbitrary,” she said. “It’s a matter of equality and fairness.”

If the state legislation passes during the next legislative session, it probably would take effect about two years ahead of national reform.

Mary Saracino, a self-employed writer in Lafayette who has had to purchase insurance on the individual market, said she is shocked “and, dare I say, angry” that monthly premiums for women are higher.

“It seems highly discriminatory,” said Saracino, 55. “Would consumers put up with that if, say, men had to pay more for tires than women because some statistic says that male drivers are harder on their cars than female drivers?”

Jennifer Brown: 303-954-1593 or jenbrown@denverpost.com

Some protection

These 11 states ban gender- rating by insurers in the individual insurance market:

California

Maine

Massachusetts

Montana

Minnesota

New Hampshire

New Jersey

New York

North Dakota

Oregon

Washington