Insurers Reveal Tough Stance on Claiming Modern Healthcare Treatments
Insurance companies are increasingly rejecting or partially settling claims linked to modern treatment methods and advanced procedures, leaving policyholders with substantial out-of-pocket expenses. The reluctance of insurers to pay for these expensive treatments is attributed to rising medical inflation.
Rahul Kumar's experience with his 67-year-old father's liver cancer diagnosis mirrors that of many others. Despite having an insurance plan that initially approved the claim, the insurer later revised its decision, citing that the advanced treatment was not part of the policy coverage.
Bengaluru-based Parag Jain's mother-in-law underwent six chemotherapy sessions and multiple surgeries for breast cancer, with a total treatment cost of ₹40 lakh. The insurers rejected the claim twice, despite having super top-ups in their policies. Jain eventually had to follow up repeatedly with the insurer before they agreed to settle the claim.
Experts point out that regulatory guidelines mandates insurers to cover 12 modern treatments and procedures, including balloon sinuplasty, robotic surgery, and stereotactic radiosurgery. However, many insurance companies set sub-limits or caps on these treatments, leaving policyholders with limited financial protection.
For instance, Niva Bupa's Reassure 2.0 plan limits claims against few robotic surgeries to ₹1 lakh per claim. Similarly, HDFC Ergo Optima Restore and Secure sets a limit of 100% coverage up to sum insured for modern treatments.
"Lower sub-limits defeat the purpose of buying a high sum assured," said Abhishek Bondia, co-founder and principal officer at SecureNow Insurance Broker.
Policyholders are advised to carefully review their insurance policy's terms and conditions and opt for new plans that offer full coverage up to the sum insured. Some popular insurers with 100% coverage for modern treatments include HDFC Ergo Optima Restore and Secure and Niva Bupa Aspire.
While medical treatment costs continue to rise, policyholders must navigate the fine print of their insurance policies to ensure they receive adequate financial protection.
What This Means for Policyholders:
- Carefully review your insurance policy's coverage and terms
- Consider porting to a new plan that offers full coverage up to sum insured
- Choose treatments accordingly based on available options
- Be aware of sub-limits or caps on specific treatments
Experts Warn Against Uncertainty
Insurance company Bhaskar Nerurkar warns against unproven treatments, including drug experimental therapy. He advises insurers and policyholders alike to prioritize established standard medical practices over novel treatments.
Bajaj Allianz General Insurance's head of the health administration team noted that popular modern treatments such as gene therapy, CAR-T cell therapy, proton beam therapy are typically not covered in retail insurance policies but may be included in group insurance plans.
Recommendations for Policyholders:
- Porting option: Consider opting for a new plan with full coverage up to sum insured.
- Research and comparison: Look into various insurance options before making a decision.
- Consult your treating doctor: Ensure you have access to the best medical treatment, regardless of insurance policy limitations.
Key Takeaway
Insurance companies will no longer tolerate claims for unproven treatments if they don't follow established guidelines, leaving only patients facing uncertainty in expensive modern healthcare procedures.