In the field of medical progress advancements that have significantly improved patient outcomes, some cutting-edge treatments still face skepticism from health insurance providers. Until 2019, health and general insurance companies were reluctant to cover expenses related to innovative procedures like stem cell therapy, robotic surgery, oral chemotherapy, and more.
In a positive turn of events, the Insurance Regulatory and Development Authority of India (IRDAI) took a noteworthy step in 2019. It directed insurers to reimburse the costs of ‘modern’ treatment procedures that were previously excluded from health insurance coverage. The IRDAI released a list of 12 procedures that insurers were mandated to cover, with the flexibility to include more at their discretion.
All health insurance policies issued or renewed since then are now required to cover the expenses associated with these advanced treatment procedures. Let’s delve into how insurance claims related to these procedures are currently handled by health and general insurers:
What Defines ‘Modern’ Treatment Procedures?
In a circular from 2019, the IRDAI specifically identified 12 ‘modern’ procedures that insurers must include in their coverage for hospitalization, home treatment, and day care claims. These encompass various treatments, such as uterine artery embolization, balloon sinuplasty, deep brain stimulation, oral chemotherapy, immunotherapy with monoclonal antibodies, robotic surgeries, stereotactic radio surgeries, bronchial thermoplasty, prostatic vaporization, intra-operative neuro monitoring, and stem cell therapy.
Insurers also have the option to extend coverage to additional modern treatment procedures of their choosing.
Why the Hesitation?
Many insurers initially viewed these procedures as experimental, leading to apprehension in providing coverage. The IRDAI’s circular allowed insurers to exclude ‘unproven’ treatment procedures, defining them as those lacking significant medical documentation to support their effectiveness.
However, some effective therapies faced neglect due to insurers’ rigid stances, prompting the IRDAI to intervene and mandate coverage for at least 12 specified treatment procedures.
Understanding Sub-limits
The coverage for these advanced treatment procedures often comes with sub-limits, restricting the eligible claim amount. The high costs associated with some of these therapies led the IRDAI to permit insurers to incorporate internal ceilings, which can vary among insurers and products.
For instance, Future Generali’s Health Absolute and ICICI Lombard‘s Health Advantage impose sub-limits of 50 percent of the sum insured for modern treatment procedures and bariatric surgeries. Similarly, United India Insurance’s super top-up policy offers reimbursement for oral chemotherapy bills, capped at 20 percent of the sum insured or Rs 2 lakh.
While these sub-limits are meant to manage costs, they could discourage policyholders from choosing modern procedures over conventional ones, potentially defeating the purpose of mandated coverage.
Considerations Before Choosing
Insurers argue that the novelty of certain procedures doesn’t necessarily mean they surpass conventional methods. It’s crucial for policyholders to conduct a comprehensive cost-benefit analysis before deciding on a procedure. Factors such as safety, recovery time, side effects, risks, and overall costs should be carefully weighed to make an informed decision.
In conclusion, while insurance coverage for advanced treatments has made significant strides, policyholders must navigate sub-limits and thoroughly evaluate the pros and cons of modern procedures versus established methods.
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