Coverage of Organ Transplant under Health Insurance in India

• Why do you need Organ Donor Coverage?
• Cost of Organ Transplantation
• Coverage for Organ Receiver’s transplant surgery in Health Insurance
• Coverage for Organ Donor’s surgery in receiver's Health Insurance
• Understanding the expenses involved in an organ transplant
• What is covered in the Organ Receiver’s policy?
• What should the Organ Receiver keep in mind?
• What should the Organ Donor keep in mind?
• Comparison of top health insurance companies in India that offers organ donor coverage

Investing in personal health insurance is like investing in your retirement. You need to start investing right now if you really want a good one. Personal health insurance is a healthcare package you are subscribing to for the future.

The risk of organ failure is real.

Now there is no disagreement that our lifestyle and habits have a direct impact on our physical, mental, and emotional health. A mentally fast-paced but physically sedentary lifestyle can invite chronic diseases, as you grow older some of which can eventually result in organ failure. India has seen a sharp rise in the number of cases of organ transplant be it liver, heart, kidney, or cornea. (A report I read says there is a need for two lakh kidneys, 50,000 hearts and 50,000 livers for transplantation every year.)

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While the law makes the organ free, the cost of transplantation can be super expensive.

Apart from the standard complications in organ transplantation, you already know that there are two surgeries required - one for the patient and the other for the donor.

At present, in India, hardly any government hospitals perform organ surgery. The private hospitals charge a bomb - anything between Rs. 10 lakhs and Rs. 30 lakhs for a heart transplant surgery, whereas for a liver transplant, the cost ranges from Rs. 15 lakhs and Rs. 35 lakhs. These costs vary from one private hospital to another.

Such expenses call for full coverage of organ transplantation in your health insurance policy. Organ transplantation like a kidney transplant or heart transplant is covered by health insurance under the organ coverage benefit. 

We go step-by-step and decode the type of expenses involved and map it with the coverage available for both the surgeries.

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In the case of the organ receiver’s health insurance policies are fairly clear. The cost of surgery, as well as screening, tests, the procedure involved with getting the organ transplanted in most cases, will be covered up to the sum insured.

This will include post-surgical complications, for instance, functioning with one kidney, is not uncommon with respect to organ transplant. Therefore, there is a high possibility of the increased cost of recovery, medicines, stay in the hospital – all this is usually covered in the Organ receiver’s policy.

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Things are complicated when covering the Donor. Here's why

• The receiver’s policy will usually cover surgeries for the illness/injury of the receiver and not for anyone else.
• On the other hand, the donor’s policy will cover surgeries with respect to illnesses of the donor, not the receiver.

That’s where the organ donor coverage comes into the picture.

A number of health insurance companies in India have stepped up and now offer health insurance plans which have an in-built cover for the hospitalization of the organ donor.

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First, let’s understand the type of expenses incurred during an organ transplant. There are primarily six medical expenses involved in organ transplant as far as the organ donor is concerned:

1. Organ screening: To check the overall compatibility and see if blood groups are matching
2. Pre-hospitalization expenses: Once the organ donor has been finalized, he/she may have to undergo certain medication before proceeding with the surgery.
3. Hospitalization expenses: This basically includes room rent and nursing expenses
4. Cost of surgery: This includes the transplant cost and surgeon fee
5. Post-hospitalization expenses for the organ donor: The cost of follow-ups with the doctor, medication, etc.
6. Post-surgery complications: This includes hospitalization and treatment with respect to complications that arise due to the organ transplant.

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However, it is important to note that insurance companies do not cover all the expenses related to the hospitalization of the donor. In most cases, only expenses incurred on the donor for harvesting, i.e. surgery and storage of organs are covered, which means only #4 and #5 in the above list are covered. Therefore, the organ recipient may have to bear such costs.

Here's a quick table that should help clear the confusion.

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• Medical treatment for the donor post-harvesting is not covered. It is therefore critical to understand exclusions and sub-limits. You must ask the hospital for a detailed break-up of expenses for both donor and receiver before the surgery.
• There are certain strict guidelines when it comes to organ transplants. Therefore, the organ donor whose organ has been made available should comply with the Transplantation of Human Organs Act, 1994 and the organ donated is for your personal health purpose only.

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If you are willing to go for organ donation, here are a few things you should keep in mind regarding your health insurance:

• If you want to buy a new policy and are an organ donor already, then it is the insurance company’s judgment whether it wants to cover you or not. Some insurers may decide not to sell you a health insurance plan as they may consider you a high-risk case.
• Remember, if you are an organ donor and already have a Mediclaim policy, the insurance company can't deny a renewal. Moreover, keep in mind that if you have donated an organ before buying a health insurance policy and did not declare it to the insurance company at the time of purchase, the insurer can rightfully deny renewal if it finds out that you hid such information.

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Of course, the higher the cover the better.** Also, having an absolute financial limit can get very tricky –say Rs. 50000 may be good enough right now, but not in the next 20 years, when you actually need it – thanks to inflation!**

Last word:

While purchasing a health insurance plan, it is important to imagine what expenses may be incurred when you say 50 or 60 years old. Because an organ transplant - like a kidney or heart transplant may cost you a lot. Hence, you must look for covers for all types of treatments and surgeries, find out if there is a comprehensive insurance policy for all the expenses that you may incur.

In the end, insurance companies like to protect their own interest with extremely detailed policy documents that you must go through before signing up for any health insurance policy. Analyze each area in your policy document with a fine-toothed comb, in order to make sure that you are making the most of the organ donation part of your health insurance policy.