Modern treatment procedures: How health insurance policies cover advanced treatment procedures

Health insurers cover modern treatment procedures, but with restrictions

Despite giant leaps in the field of medicine that have resulted in better outcomes for patients, several new treatment procedures are still considered 'unproven' by health insurance companies.

Until 2019, many general and health insurance companies were reluctant to pay for advanced treatment procedures such as stem cell therapy, robotic surgery, oral chemotherapy, and so on.

In 2019, the Insurance Regulatory and Development Authority of India (IRDAI) directed insurers to reimburse the cost of 'modern' treatment procedures that were out of health insurance policies' scope of coverage. It put out a specific list of 12 procedures that ought to be covered, with the leeway to insurers to cover more.

All health insurance policies issued and renewed since then have to now pay for such expenses. Here's a look at how claims related to such procedures are now treated by general and health insurers:

What does IRDAI mean by ‘modern’ treatment procedures?

In a 2019 circular, the insurance regulator specifically named 12 ‘modern’ procedures that insurers have to mandatorily cover as part of hospitalisation, home treatment, and day care claims.

These include uterine artery embolisation ( a procedure to treat fibroids without surgery), balloon sinuplasty (a type of endoscopic nasal surgery), deep brain stimulation, oral chemotherapy, immunotherapy-monoclonal antibodies given as injections -intra-vitreal injections, robotic surgeries, stereotactic radio surgeries, bronchical thermoplasty, vaporisation of the prostrate (green laser treatment or holmium laser treatment), intra-operative neuro monitoring, and stem cell therapy.

In addition, insurance companies have the option of covering other modern treatment procedures too.

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Why do insurance companies hesitate to cover such procedures?

Many insurers see these procedures as experimental in nature. IRDAI’s standardisation of exclusions circular also allows insurers to exclude ‘unproven’ treatment procedures.

“Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness,” the regulator’s 2019 circular notes.

However, many effective therapies, too, got a short shrift due to some insurers’ rigid stance. For instance, oral chemotherapy for cancer patients or bariatric surgery for morbidly obese individuals are two such examples. This is why the IRDAI had to step in and ask insurers to cover a bare minimum of 12 specific treatment procedures.

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But why does coverage for such treatment procedures come with sub-limits (restriction on eligible claim amount)?

This is because the cost of some of these advanced therapies is high. The IRDAI has allowed them to incorporate internal ceilings on such products - there are no standard sub-limits, but they vary as per the insurer and product.

For instance, Future Generali's Health Absolute and ICICI Lombard's Health Advantage both come with sub-limits of 50 percent of the sum insured in the case of modern procedures and bariatric surgeries. Likewise, United India Insurance’s revised super top-up policy offers to reimburse oral chemotherapy bills to the extent of 20 percent of the sum insured, with Rs 2 lakh being the maximum cap.

Now, the sub-limits could actually discourage patient-policyholders from picking modern procedures over conventional ones, thus defeating the purpose of mandating coverage for such methods.

However, insurers argue that simply because certain procedures are new and innovative does not necessarily mean that they score over conventional methods.

At your end, ensure that you carry out a cost-benefit analysis of picking a modern method over the one that is established. Take into account safety, recovery time, side effects, risks, and, finally, costs involved before zeroing in on the procedure.