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Organ donor expenses - Health Insurance

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08 Feb, 2021 by Shubham Kumar

Hello everyone!


I have almost finalised a health insurance policy for my father (~55 years) by ICICI Lombard - Health Shield. I was going for a Base Cover of 10 lacs and a Super Top-up of 10-15 lacs. It covers almost all the basic pointers discussed on the forum -


  • Zero Co- pay
  • 2 year waiting period for PED
  • No room rent/category limit


However, I came across this article on organ donor expenses written by Mahavir for MoneyControl. I also came across this article on the Beshak forum as well.


After reading these articles, I went back to read the policy wordings.


Under policy exclusions, this is written -


Expenses related to donor screening, treatment, including surgery to remove organs from a donor in the case of transplant surgery.


The policy comes with built-in Donor Expenses cover. The policy wordings describe it as follows-


In consideration of the payment of additional premium to Us, We will indemnify the Insured person up to the sum insured as specified in the policy schedule for the Medical Expenses incurred in respect of the donor for any of the organ transplant surgery, provided the organ donated is for the insured person’s use and We have admitted the In patient Hospitalization Claim under the base plan.


  • Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor.
  • Screening expenses of the organ donor.
  • Any other Medical Expenses as a result of the harvesting from the organ donor.
  • Costs directly or indirectly associated with the acquisition of the donor’s organ.
  • Transplant of any organ/tissue where the transplant is experimental or investigational.
  • Expenses related to organ transportation or preservation.
  • Expenses incurred by an Insured Person as a donor.
  • Any other medical treatment or complication in respect of the donor, consequent to harvesting.


Can someone please guide me regarding what exactly is covered and what is not? Also, is this standard? Are there any better plans offered by other companies that have better coverage with regards to organ donor expenses?



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09 Feb, 2021
Mahavir Chopra

Hello Shubham,


First of all, let me compliment you for the effort taken to understand the nitty-gritty of the policy. Kudos! You are truly the kind of community members we imagined when we were conceptualizing Beshak as a community platform. So cheers!


Now, answering your question.

  1. The exclusion you have reproduced in your post is for the Standard Health Shield health insurance policy from ICICI Lombard. So if you don't take the extension this is what will be applicable to you.
  2. However, if you apply and pay for the extension, then Organ Donor expenses will be covered as mentioned below from point #3 to #5.
  3. The scope of the cover is extensive. I haven't seen any other plan that provides such extensive cover for Organ Donor. Covers every aspect of expenses that could be required to be covered for a Donor, in case of an organ transplant.
  4. However, the cover is available only up to the sum insured mentioned specifically for Organ Donor expenses. When we checked the Organ Donor add-on on the quote form - the maximum cover for the organ donor expenses is restricted to Rs. 50000/- which in our view is toooo low, especially in the long run (say 10 years from now)
  5. Plus, organ donor is bundled with the Critical Illness rider, due to which the premium nearly doubles when you choose this extension.


The bottom line is as follows: While the scope of the cover is excellent, the limits and the premium are unattractive. We would recommend you evaluate other insurance plans (almost all leading plans - like HDFC Health Optima Restore, Max Bupa Reassure, Star Health Comprehensive) where Organ Donor is covered without any sum insured limit. (Do check the terms and conditions here too - to understand the scope of coverage which could be limited only to harvesting, and not include complications, screening, etc.) Here's a primer we wrote on Coverage of Organ Transplant under Health Insurance in India (beshak.org)


Hope this was useful


Regards,

Mahavir

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09 Feb, 2021
Shubham Kumar
Thank you for your kind words, Mahavir. It means a lot. I really appreciate you taking time out to address my query. However, I think, I have (unknowingly) made an omission in the above post. The above-mentioned points (1-8) are under the following subheading inside the ‘Organ Donor Add-on’ — ‘We shall not be liable to pay for any claim under this Benefit which arises directly or indirectly for or in connection with any of the following:’ Having said that, I have fair idea regarding what this policy doesn’t cover (as mentioned in the points 1-8). What I don’t really understand is, what is policy DOES COVER? It mentions under exclusions (mentioned above) — ‘Expenses related to donor screening, treatment, including surgery to remove organs from a donor in the of transplant surgery.’ -------------------------- As per the latest policy wordings, the ‘Donor Expenses’ coverage under this scheme is upto Rs 10 lacs or SI (whichever is lower). I am attaching the link below to the policy wordings for your reference. The Standard ICICI Lombard Health Shield policy comes with BUILT-IN Donor Expenses coverage. Link to policy wordings - https://www.icicilombard.com/docs/default-source/default-document-library/complete-health-insurance-(health-shield).pdf?sfvrsn=39fd6b94_0
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09 Feb, 2021
Shubham Kumar
I think Star Health Comprehensive has a Single AC Private Room clause. That's why, I skipped it. I am going through the policy wordings of HDFC Health Optima Restore and Max Bupa Reassure. Thanks!
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09 Feb, 2021
Shubham Kumar
Also, what did you mean by 'Plus, organ donor is bundled with the Critical Illness rider, due to which the premium nearly doubles when you choose this extension' ?
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11 Feb, 2021
Mahavir Chopra

Hello Shubham,


Yes, there was some misunderstanding on my part too. Apologies.

Let's go step by step and attempt relooking at this >>


POLICY WORDINGS MENTIONS ORGAN DONOR AS EXTENSION:

  • Policy Wordings for "Health Shield (ICICI Lombard Complete Health Insurance)" say that Organ Donor expenses cover is not ordinarily available, and is available as a paid extension. Referring to the link to the policy wording you shared.
  • As per the policy wordings, this policy ordinarily, without any add-on, does not cover Organ Donor expenses. This is mentioned under Section 3: WHAT WE WILL NOT PAY (EXCLUSIONS UNDER THE POLICY) as follows:
Expenses related to donor screening, treatment, including surgery to remove organs from a donor in the case of
transplant surgery
  • This policy talks about providing an add-on at an additional cost for Donor Expenses. This coverage will provide cover for the expenses of organ harvesting - the process of removing the organ from the donor's body for transplantation in the insured person's body. The list of 8 exclusions you have reproduced basically means that no other expense apart from the surgery cost to harvest the organ from the organ donor's body will be covered. Cost related to transportation, complications, pre & post-hospitalization, etc is hence excluded. No mention of Sum Insured restrictions found here.


HOWEVER, THERE ARE SOME CONTRADICTIONS COMPARING TO BUYING JOURNEY:

However, when you compare this with this buying journey page it only complicates the matter further. Neither the benefits match nor the cover amount (on the same page!).

  • Organ Donor Inbuilt: On the buying journey, the Organ Donor cover is shown under inbuilt 13 benefits instead of as an add-on anywhere for Health Shield.
  • Organ Donor coverage confusion: Further, on the same buying page at two places the sum insured for Organ Donor Expenses is drastically different. (Extracts below from this link >> Select CHI Plans (icicilombard.com)


Under Benefits Covered:

Under Benefits Covered (13)

In case you are interested in buying this policy only, I would recommend you speak to the call center to clarify the exact cover available with additional payment or inbuilt. Do record the call for your future reference.


Do share your findings for the benefit of everyone else.

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