Live donor adult liver transplantation (LDALT) using right lobe grafts has become an accepted treatment for end-stage liver disease. The procedure is of clear benefit to the recipient, who frequently faces the very real possibility of dying before an acceptable deceased donor liver becomes available. The donor derives benefit from the knowledge that transplantation has saved the recipient's life. However, this otherwise healthy individual faces morbidity and mortality risks that are difficult to quantitate. Several centers that offer LDALT and the NIH-sponsored Adult-to-Adult Living Donor Liver Transplantation (A2ALL) cohort study are investigating the impact of donation on the donor's health and quality of life. Most of the published reports on this subject have a relatively short follow-up focusing on postoperative complications, psychosocial issues, lost wages, or out-of-pocket expenses. This issue of whether or not right lobe donation will affect an individual's ability to obtain life insurance has not been addressed prior to the publication of Nissing and Hayashi.1
In this report1 the investigators contacted by telephone 10 agents of 10 different, large life insurance companies. Two fictitious profiles of a healthy, 33-year-old nonsmoking man were given, differing only in a history of uncomplicated right lobe donation 12 months prior (Donor Profile). Eight of the 10 agencies were national firms, and the remaining 2 covered 13 and 17 states each. The investigators requested a premium quote for a 20-year term life insurance policy with a $100,000 benefit. The authors report right lobe donors to be half as likely to obtain insurance at preferred premium rates and may even find a carrier that denies them coverage. In addition, donors can expect to spend twice as much time obtaining an initial quote and will make 3 times as many phone calls to the agent. They conclude that donors should be able to find a company willing to underwrite a life insurance policy; however, it may take more effort and more money to do so.
The availability of insurance for living kidney donors has been investigated over a 30-year period of time. Studies by Santiago et al. in 1972 and several by Spital et al., the most recent in 2002, indicate that living kidney donors are able to acquire insurance at rates comparable to the general population and are not considered to be at significantly increased risk for medical complications or shortened life expectancy.2–6 These reports reflect surveys of major insurance companies as opposed to surveys of actual donors. Both authors cite anecdotal reports of individual donors who encountered difficulties obtaining insurance. They speculate that the responses may reflect official company policies that may not be adhered to by individual underwriters. Spital et al.5 also note a lower response rate by insurance companies polled in their most recent paper compared with their earlier work3 and suggest that this may represent increased discomfort with this issue on the part of some insurers. However, both survey results and clinical practice indicate that the majority of living kidney donors do not encounter overt difficulties in obtaining (or maintaining) insurance.
The experience of living kidney donors is encouraging regarding insurance prospects for right lobe liver donors. There are, however, significant differences between the two groups of living donors in terms of operative risks and potential for subsequent complications. Costs associated with evaluation, surgery, and perioperative complications are generally covered under the recipient's insurance. Late complications such as incisional hernias may occur in a time frame remote from donation and may or may not be covered by the recipient's insurance. It is possible that some health insurance carriers may decline coverage for these types of complications. Life insurance underwriters may consider right liver lobe donation as putting an individual at increased risk for health problems and may increase premiums accordingly or deny coverage.
The transplant community is in agreement that any outcome that penalizes living donors for the act of donation is unacceptable. It is currently unclear whether or not “insurability” of live liver donors is an actual or anticipated problem. To determine the nature and extent of right lobe donation on insurance issues, specific information should be collected from donors at least on an annual basis. Transplant centers performing living donor transplants should initiate contact and inquire as to whether life or health insurance has been denied or if premiums have increased. They should also determine whether specific claims with existing policies have been denied. A centralized group should analyze the information gathered, and insurance providers must be held accountable if patterns of discrimination are documented. The process could be modeled after the system reported by the Southeast Organ Procurement Foundation (SEOPF) for living kidney donors.7 SEOPF began a program available to all transplant centers in the United States to prospectively track living kidney donors. Donors from participating centers complete surveys at the time of donation, at 3 and 6 months after donation, and yearly thereafter.
An additional aspect of this program is worthy of discussion. Each participating donor is eligible for an insurance policy, underwritten by American International Group, Inc. (AIG), with a total benefit of $250,000. It covers accidental death related to donation and surgical and medical expenses of complications not otherwise covered, and it provides limited disability income during the recuperation period. To date, no claims have been reported to AIG due to donor death or for unpaid medical expenses related to postdonation complications in the 104 donors currently registered in the study. However, one claim has been filed for disability income during recuperation from a donation-related complication.7 A modification of this program, administered on a regional or perhaps national level, could be developed to protect donors from inability to obtain insurance and to provide payment for donation-related complications disallowed by the donor's private health insurance carrier. At the very least, the transplantation community must continue to monitor the health and long-term outcome of the right lobe liver donor. Financial disincentives to donation and the donor's ability to obtain and maintain health and life insurance must continue to be investigated.