New Delhi-based Rahul Kumar’s 67-year-old father was identified with liver most cancers that wanted a sophisticated palliative therapy referred to as Transarterial Radioembolization (TARE). Kumar’s brother had a company coverage with a non-public insurer. However, throughout pre-authorisation, the corporate refused to approve the declare, saying, “TARE is an advanced procedure which is not covered under the policy; hence claim not admissible.”
Kumar, who studied on the Indian Institute of Management Bangalore, had an alumni group insurance coverage plan from the identical insurer which lined his mother and father. It was a household floater plan with a set deductible of ₹5 lakh.
“I approached the insurance company to file a reimbursement. They accepted the documents and settled the claim in two months, probably thanks to some pressure the alumni group exerted on them. The same company had rejected it when my brother filed it under his corporate policy,” mentioned Kumar.
Bengaluru-based Parag Jain’s mother-in-law was identified with breast most cancers in 2023 and was really useful “targeted” remedy. She wanted to bear six chemotherapy periods adopted by a surgical procedure, radiotherapy and 14 post-surgery periods over 1.5 years. The total price got here as much as ₹40 lakh.
“In my wife’s corporate plan and in my personal plan, we had super top-ups. But the insurers told us that modern treatment is not covered in the super top-up plans,” mentioned Jain.
Regulatory mandate
To make certain, the insurance coverage firm had not shared the right protection particulars with Kumar’s brother and Jain. In September 2019, the Insurance Regulatory and Development Authority of India (IRDAI) had mandated that insurance coverage insurance policies should cowl 12 fashionable remedies together with balloon sinuplasty, oral chemotherapy, robotic surgical procedure and stereotactic radiosurgery.
However, the regulator left it to the insurance coverage corporations to determine sub-limits. That mentioned, not all medical insurance insurance policies supply full protection as much as the sum insured for these remedies. Some of them apply sub-limits or caps on the utmost quantity for some or all remedies.
Jain adopted up with the insurers, citing the IRDAI round.
“Finally, they covered it but after a lot of back and forth. Many cancer treatments fall under the purview of modern treatment. Policyholders can be taken for a ride if they do not know about IRDAI’s circular,” mentioned Jain.
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Ravi Jakareddy (54) from Pune has a coverage from a public insurer. He was informed to purchase a rider, which price him an extra ₹20,000, to get fashionable therapy protection as much as 100% of the sum assured (SA).
“My insurer informed me that the bottom coverage doesn’t cowl it,” he mentioned.
Aayush Dubey, co-founder and head of analysis at Beshak.org, explains why some insurers are inclined to reject claims beneath fashionable therapy of their first communication.
“When the IRDAI mandated insurers to include 12 modern treatments/procedures in their policy contracts, some of them simply removed them from their permanent exclusion list, without providing any further details on coverage, conditions or limits. Others revised their policy wording and brochures accordingly and specifically added the coverage for them along with the associated conditions and limits. The former set of insurers tends to reject claims,” he mentioned.
Regardless of whether or not or not data on fashionable therapy is talked about in a coverage doc, all insurers need to cowl it, as mandated by IRDAI, as much as specified sub-limits.
Understanding sub-limits
Ahmedabad-based Sureshchandra Chechani (61) had a mediclaim coverage from a public insurance coverage firm with a base cowl of ₹1 lakh and ₹50,000 bonus. He was identified with prostate most cancers and admitted to a hospital in Ahmedabad. The therapy price got here in at about ₹4.65 lakh.
“More than 90% of the claim amount was denied. They gave us only ₹37,500, saying robotic surgery is covered only up to 25% of the sum insured,” mentioned Chechani.
Chechani argued that it ought to have been lined as much as the sum insured. However, the general public insurer in his case doesn’t supply full protection. Some public insurers set even decrease sub-limits.
For instance, New India Assurance Co. covers solely 10% of the sum insured in oral chemotherapy as much as ₹1 lakh in its floater mediclaim coverage. The Oriental Insurance Co. has set related limits in its household floater plans. Among personal insurers, whereas Niva Bupa covers 11 fashionable remedies totally, it caps claims towards few robotic surgical procedures at ₹1 lakh per declare in its Reassure 2.0 plan.
“Lower sub-limits defeat the purpose of buying a high sum assured. In some cases, treatments are limited to ₹50,000. This is lower than the cost of traditional treatment for the same ailment. So, insured will have to bear a substantial cost out of pocket,” mentioned Abhishek Bondia, co-founder and principal officer at SecureNow Insurance Broker.
According to Dubey of Beshak.org, insurance policies with the bottom sub-limits embody IFFCO Tokio Family Health Protector, IFFCO Tokio Individual Health Protector, National Insurance – Mediclaim Plus, National Insurance, Parivar Mediclaim Plus, Royal Sundaram – Lifeline and SBI General – Arogya Supreme.
Porting choice
Policyholders ought to think about porting to a brand new plan if their current plans have sub-limits on fashionable remedies.
“HDFC Ergo Optima Restore and Secure, Niva Bupa Aspire, Bajaj Allianz My Healthcare, Star Health Assure and Comprehensive and Aditya Birla Activ Fit and Activ One are some of products offering 100% coverage up to sum insured for modern treatments,” he mentioned.
Parthanil Ghosh, director and chief enterprise officer at HDFC Ergo General Insurance, advises individuals to be aware of their protection and select remedies accordingly. He mentioned that within the US, there’s a gatekeeper mannequin during which a panel of medical doctors from the insurance coverage firm decides the kind of therapy for a affected person and at which hospital. They say that if they’re the financiers, they need to have a say in how a lot cash is spent on the therapy with out jeopardising the affected person’s well being.
“In India, we’re free to get admitted at any hospital. Policyholders should deal with this facet themselves. An individual having ₹50 lakh protection going for robotic surgical procedure is sensible, but when an individual with ₹5 lakh protection does so, she or he will exhaust protection very quickly. Out of pocket bills shall be big,” mentioned Ghosh.
What about fashionable therapy procedures past the mandated 12?
“There is no specific list of exclusions. Admissibility is decided based on the claim documents and line of treatment suggested. Any unproven treatment, including drug experimental therapy, which is not based on established standard medical practices or experimental or unapproved, shall be a standard exclusion,” mentioned Bhaskar Nerurkar, head of the well being administration staff at Bajaj Allianz General Insurance.
Dubey mentioned insurance coverage corporations sometimes don’t cowl well-liked fashionable remedies reminiscent of gene remedy, CAR-T cell remedy, proton beam remedy, hyperbaric oxygen remedy (HBOT), transcatheter aortic valve substitute (TAVR), and transcranial magnetic stimulation (TMS) in retail insurance coverage insurance policies.
“Some group insurance coverage insurance policies cowl these remedies,” he mentioned.
