Insurance coverage

Your health insurance coverage is expanding: know which modern treatments are now covered

Health insurance companies in India are quite orthodox and were hesitant to cover any disease beyond the traditional list of diseases without any intervention from the Insurance Regulatory and Development Authority of India (IRDAI).

After having forced insurers to cover the treatment of Covid, the insurance regulator has now pushed them to cover the treatment of a number of modern treatments.

“In June 2020, the Insurance Regulatory and Development Authority of India (IRDAI) issued new guidelines for health insurance policies. These new guidelines required insurers to standardize important policy clauses (especially exclusions ) and to make sure that customers could easily understand them. Some guidelines required insurers to deduct claims in a more user-friendly way. And, for the first time, there were guidelines which instructed insurers to cover a few modern treatments that were generally exclusions until then,” said Avinash Ramachandran, COO, Assurekit.

Some of the health conditions covered by standard health insurance plans in India now include:

Psychiatric disorders

The following illnesses are covered by mental health insurance as mental illness:

  • Acute depression
  • Obsessive-compulsive disorder (OCD)
  • Anxiety disorders
  • Bipolar disorder
  • post-traumatic stress disorder
  • Schizophrenia
  • Dementia
  • Psychotic disorder
  • Attention deficit or hyperactivity disorder
  • Mood disorder

Mental illness was supposed to be covered by the Mental Health Care Act passed in 2017, but it wasn’t until around 2020 that insurers filed products covering treatment for mental illness. However, health insurance is in fact hospitalization insurance, and therefore benefits are only paid if you are hospitalized, and not for medical consultations, etc.

Refractive error correction

Health insurance plans generally did not cover the cost of refractive or laser eye surgery (LASIK). Because LASIK is used to treat myopia, astigmatism, farsightedness, it was considered a cosmetic procedure and therefore not covered.

However, some companies paid if certain criteria were met. IRDAI formalized this and told insurers that LASIK must be covered by health insurance policies provided the refractive error (lens power, in simple terms) is greater than 7.5. Since then, all health plans cover it, except for a few old legacy health insurance products.

Functional endoscopic sinus surgery

Functional endoscopic sinus surgery, or FESS, is used to treat sinusitis. Generally, most insurers cover this as a daycare procedure (where you are in and out of the hospital on the same day), provided an ENT has deemed it medically necessary. ENTs approve of surgery when they have tried other non-invasive treatments and the problem persists. Insurers will also request scans showing sinusitis from before surgery was approved, to ensure it is a medically necessary procedure.

FESS also requires post-care procedures, where the ENT ensures that the passages heal properly. Insurers cover surgery costs, but post-care sessions are sometimes under-limited or excluded, depending on your plan. Some policies cover up to 3 postoperative sessions.

Cochlear implant treatment and surgery

Health insurance policies cover what is classified as internal congenital disease, but cochlear implant surgery is classified as treatment for external congenital disease and is generally excluded.

However, some group health policies (health insurance taken out by a pre-existing group, such as employees of a company) cover surgery, with some sublimits. The sub-limit is usually around 50% of the cost of the surgery, but this can vary. The cost of the implant itself is also excluded in most cases.

Additional covers, however, would be optional and incur an additional premium – which may vary from insurer to insurer – if chosen.

“Modern treatments which are now included in insurance cover – there are standard covers and custom covers available under the GMC policy, below is the list of standard covers, in case companies want cover higher / suitable for their GMC policy, it can be used by discussing with the insurer at the time of policy renewal”, Komal Chhabra, AVP – Customer Success, Pazcare.

However, there would be limits to the maximum amount per treatment/procedure per period of insurance, as shown in the following table:

List of modern treatments now supported by mutuals.

Chhabra provides terms and conditions that may be imposed on treatments offered to be covered by health insurance companies.

Psychiatric disorders: Although it is part of the global health insurance but in India the cover has gone through its existence during the time of pandemic. Before Covid, awareness of psychiatric cover was not talked about much on either side, but with Covid -19 affecting the way of life through, even when companies emphasized police cover, insurers in the PSU and private segment have honored it. There are 2 categories, IPD and OPD, so it is important to have both types included in the policy as the major processing takes place in the OPD category.

Prime: loading is expected and may vary from insurer to insurer.

Refractive error correction: There are 4 subtypes of refractive error corrections that are covered. However, this coverage is not yet considered a standard inclusion. This blanket comes with an additional premium loadout.

Functional endoscopic sinus surgery: Various insurers cover it. But may have a sub-limit depending on the insurer’s product.