What Are Modern Treatments in Health Insurance?
- Introduction
- What are Modern Treatments?
- Does Health Insurance Cover Modern Treatments?
- How Do You Evaluate the Coverage of Modern Treatments While Buying a Policy?
- Coverage Of Modern Treatments Under Different Health Insurance Plans
- 5 Points to Remember Before Availing of Modern Treatment Coverage
- How Do Limits on Modern Treatments Affect You in the Long Run?
The future of healthcare is shaping up in front of our very eyes. By blending itself with technologies, such as artificial intelligence, VR/AR, 3D-printing, robotics or nanotechnology, healthcare is revolutionising.
Brain-computer interfaces are helping restore the ability to speak and move in patients who have lost these abilities. Modern technologies are also improving the quality of life for patients with ALS, strokes, or spinal cord injuries.
Treatments are becoming more proactive, personalised, and convenient than ever before. And of course, we all want to avail the best of everything.
However, as treatments become more advanced, their complexity and costs of R&D increase. This makes modern treatments quite expensive.
So does Health Insurance cover such treatments? If so, are there any T&Cs, exclusions? Let’s find out!
These are treatments that use ultra advanced technologies, like - radio surgeries, stem cell therapy, etc. Keeping pace with the science and embracing the latest tools, they seek to cure the incurable.
For instance, Robotic Spine Surgery is a minimally invasive neurosurgery process, where robotic technology is used to assist the surgeons. It reduces blood loss, time in surgery, and radiation exposure in the operating room. Hence, the patient can heal more quickly and safely than with traditional open surgery.
The flip side of such modern treatments is that they are quite expensive, because of the innovative new technologies used. The costs of getting the above-mentioned Robotic Spine Surgery done, across 15 cities in India in Indian Rupees (INR), are as follows -
| City | Lowest Cost (INR) | Average Cost (INR) | Highest Cost (INR) |
| New Delhi | 5,00,000 | 6,00,000 | 7,50,000 |
| Mumbai | 5,25,000 | 6,25,000 | 7,75,000 |
| Chennai | 5,25,000 | 6,25,000 | 7,75,000 |
| Bangalore | 5,50,000 | 6,50,000 | 8,00,000 |
| Hyderabad | 5,75,000 | 6,75,000 | 8,25,000 |
| Ahmedabad | 5,50,000 | 6,50,000 | 8,00,000 |
| Nagpur | 5,00,000 | 6,00,000 | 7,50,000 |
| Pune | 5,25,000 | 6,25,000 | 7,75,000 |
| Gurgaon/Gurugram | 5,00,000 | 6,00,000 | 7,50,000 |
| Kolkata | 5,75,000 | 6,75,000 | 8,25,000 |
| Chandigarh | 5,50,000 | 6,50,000 | 8,00,000 |
| Jaipur | 5,25,000 | 6,25,000 | 7,75,000 |
| Noida | 5,00,000 | 6,00,000 | 7,50,000 |
| Thiruvananthapuram | 5,25,000 | 6,25,000 | 7,75,000 |
| Panaji | 5,50,000 | 6,50,000 | 8,00,000 |
[Source: Beshak Research]
Fortunately, as per IRDAI’s guidelines, health insurance covers as many as 12 modern treatments under the 'Modern Treatment Benefit'.
[Source: Insurance Regulatory and Development Authority of India (IRDAI)]
If you undergo any of the above-mentioned modern treatments, under the insurer’s terms, the medical expenses shall be taken care of.
For instance, Mikesh is diagnosed with severe asthma that was once considered incurable. Thanks to a medical advancement - bronchial thermoplasty - the frequency of asthma attacks can be decreased and Mikesh can be treated effectively. The treatment cost shall be covered by his health insurance.
In September 2019, IRDAI - in a circular - asked insurers to include the 12 modern treatments/procedures in their health insurance policy contracts.
So what some insurers did was - they simply removed the modern treatments/procedures from their permanent exclusion list, WITHOUT providing any further details on coverage, conditions, or limits. However, other insurers actually revised their policy wording and brochures accordingly. They specifically added the coverage for these modern treatments/procedures, along with the associated conditions and limits.
So now, when you set out to buy a policy, check if there's any sub-limit on any or all modern treatments. And try to buy a policy that has no such limits. Because, as we saw earlier, the cost of modern treatments is pretty expensive. And having a policy that has sub-limits on these treatments, may make you incur major out-of-pocket expenses.
However, if a policy does not have any conditions or limits on modern treatments specified in the scope of coverage, it invariably means that that policy will cover all those treatments - as specified by IRDAI - up to the sum insured amount you have opted for.
Note:
- The data in the table has been taken in March 2023.
- For insurers who haven’t mentioned modern treatments in their policy wordings, we’ve assumed that they cover modern treatments up to the sum insured.
- For Niva Bupa ReAssure 2.0, the limit for robotic surgeries does not apply to the following - robotic total radical prostatectomy, robotic cardiac surgeries, robotic partial nephrectomy, and robotic surgeries for malignancies. These will be covered up to the sum insured.
1️⃣ In-patient, day care, and domiciliary treatments covered
Modern Treatments shall be covered either as in-patient treatments, or as day care and domiciliary procedures that don’t require a 24-hour hospitalisation.
For example, Deep Brain Stimulation surgery can help people with Parkinson's disease improve their symptoms of tremors and stiffness. Generally, the hospital stay after DBS surgery is 24 hours, but it may be longer depending on how much time the patient takes to recover. This hospitalisation will be covered under inpatient care.
On the other hand, Uterine Artery Embolization is a procedure that treats fibroids (benign tumours) without surgery, and it usually takes 1-3 hours. This will be covered as a part of day care procedure.
2️⃣ Treatment must be medically necessary
Your health insurance will cover your modern treatment only if it has been prescribed in writing by a verified medical practitioner, and is considered medically necessary. A treatment is said to be medically necessary if it -
- Is required to heal the illness or injury suffered.
- Does not exceed the level of care needed to provide safe and adequate medical care.
- Is recommended by a medical practitioner who isn’t related to you.
- Conforms to standards widely accepted in the international medical practice, or by the Indian medical community.
3️⃣ Certain conditions may be applied for pre and post-hospitalisation coverage
Pre-hospitalisation costs are incurred before you are admitted to the hospital, and include diagnostic tests, medical checkups etc. Post-hospitalisation costs include follow-up tests, medication, etc. that are required after discharge. Policies, like Niva Bupa - ReAssure 2.0, National Insurance Mediclaim Plus, cover such expenses only if they are incurred for the same illness you got the modern treatment for.
4️⃣ Insurers may have some sub-limits for coverage
Not every insurer will cover your medical costs up to the sum insured. For instance,
- In Niva Bupa’s Health Companion Plan, 11 modern treatments are covered up to sum insured, the exception being Robotic Treatments - which have a sub-limit of Rs. 1 Lakh. However, Robotic Total Radical Prostatectomy, Robotic Cardiac Surgeries, Robotic Partial Nephrectomy, and Robotic Surgeries for Malignancies are covered up to sum insured.
- Royal Sundaram - Lifeline (Supreme) Plan has a sub-limit of 50% of sum insured - for all modern treatments covered.
- National Insurance (Mediclaim Plus) Plan has a sub-limit of 25% of sum insured - for all modern treatments covered.
5️⃣ Additional conditions to be fulfilled
In addition to the above conditions, there may be other conditions that need to be met before your policy covers your expenses.
For instance, under United India (Family Medicare) Policy, Robotic Surgeries (including Robotic Assisted Surgeries) are covered with the following conditions -
👉Costs are covered upto 75% of sum insured per policy period for claims involving Robotic Surgeries for the treatment of:
- Any disease involving Central Nervous System, irrespective of aetiology
- Malignancies
👉 Costs are covered upto 50% of sum insured per policy period - for claims involving Robotic Surgeries for other illnesses.
Please note: Many insurance plans like Aditya Birla - Active Assure, HDFC Ergo - Optima Restore, HDFC Ergo - Optima Secure, IFFCO Tokio - Individual Health Protector, Future Generali - Health Total Vital, Chola MS - Flexi Health, TATA AIG - MediCare, Edelweiss General - Health Insurance, etc. - have neither specified that they will cover the ‘Modern Treatment Benefit’, nor have they added the same in the exclusions. However, these insurers will cover them since IRDAI guidelines mandate coverage. Hence, if something isn't explicitly mentioned in the policy, take it up with the insurer and get it clarified.
Sub-limits in health insurance cap benefits for specified conditions/treatments, and people are mostly unaware of them or miss them out. With these financial limits in place, at the time of claims, you may have to pay a heavy chunk of the bill - despite having health insurance. So if you are totally dependent on the policy to cover your medical expenses, sub-limits can be a huge barrier.
Let’s understand this with the help of an example.
Say, you have bought Niva Bupa’s Health Companion plan. It covers 11 modern treatments up to sum insured. However, Robotic Treatments have a sub-limit of Rs. 1 Lakh - except for a few types of robotic surgeries. Now, if you reside in Mumbai and have to undergo Robotic Spine Surgery, it will cost you around Rs. 6.25 Lakhs (as mentioned in the table above). Since Robotic Spine Surgery has a sub-limit of Rs. 1 Lakh, you will have to pay Rs. 5.25 Lakhs from your own pocket.
Hence, it is very important to buy a policy with low or no sub-limits on modern treatments, so you don’t have to incur a major part of the expenses.
Along with that, definitely make sure you opt for an adequate sum insured. Remember, the base coverage you get today will ensure there are no heavy out-of-pocket expenses in the future.
It feels good to live in a time where every healthcare question has a possible answer, and every disease has a potential cure. As modern treatments are developing and healing lives, health insurance aims to be there for you and cover the expenses. However, there are certain underlying conditions that you need to be aware of. We hope this article will help you stay well-informed.
Want to know the exact exclusions/T&Cs/hidden conditions your health insurance policy might be having? Unravel it all with Beshak Decoder - in just a few taps and clicks!
- Modern Treatments cure diseases or conditions that were once considered incurable. However, they are pretty expensive and you may need health insurance to help you out with the expenses.
- Thanks to IRDAI's guidelines, health insurance covers as many as 12 modern treatments under the 'Modern Treatment Benefit'.
- There are, however, some conditions that need to be fulfilled before your policy covers for the costs.
- Modern Treatments shall be covered either as in-patient treatments (which require a 24-hour hospitalisation), or as day care and domiciliary procedures (which don’t require a 24-hour hospitalisation).
- The treatment should be medically necessary and prescribed by a doctor in writing.
- Insurers may have certain limits and sub-limits for coverage. It is, thus, prudent to go through the policy document carefully.
- Make sure you buy a policy with low or no limits on the coverage of modern treatments, to avoid major out-of-pocket expenses.
- If something is not clearly mentioned in the policy, you should check it with your insurer and get clarified.
Aishwarya is a Creative Editor and Writer at Beshak. She is an M.Tech. engineer, who has always been passionate about the sacred amalgamation of science and art. She is a published writer, and wants to prove that everything, including insurance, can be fun, — if presented with a gentle touch of creativity.