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 for coverage.

Robertson had been shopping for individual health insurance, the kind that people buy themselves. 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 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 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 nonprofit 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 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, Udy says, insurers are adding insult to injury.

Not only are women feeling pressure to have Caesareans they do not want and may not need, but they can 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,” Udy said.

Insurers’ rules on prior Caesareans vary by company and also by state, because states regulate insurers, said Susan Pisano, a spokeswoman for 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,” Pisano said. Sometimes, she said, applicants with prior Caesareans are charged higher premiums.

“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,” 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 people are becoming self-employed or taking jobs without health benefits.

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.

© Copyright 2008 Globe Newspaper Company.