Get cover for organ transplant

Top government officials and ministers have been in the news for undergoing an organ transplant. The ever-increasing cost of such procedures, easily running into lakhs, is what scares ordinary people. The rich can afford it, but can we? Yes, we can. Many people don't know that a medical/health insurance policy these days covers organ transplant expenses. Be, it kidney or liver or any other organ, health insurers are open to organ transplants. DNA Money spoke to health insurers about sum assured, claim process and other nitty-gritty such as donor expenses, pre and post hospitalisation spends, etc.

Coverage

Organ donation is the transplant of a biological organ or tissue from one individual, called the donor, to another, the recipient, that is, the person requiring the transplant. From a cost perspective, organ transplant procedures include pre-hospitalisation medicines and tests, in-patient hospitalisation for surgery and post-hospitalisation spends like medicines, diagnostic tests.

Organ transplant cover is offered as an inbuilt cover under health insurance policy or as an add-on, which provides coverage for both donor's and recipient's treatment-related expenses.

"It is always advisable to understand the scope of coverage to make the best use of your health insurance policy. A recipient gets cover for all the transplant-related expenses, including pre- and post-hospitalisation," said Nirmal Bhattacharya, chief–underwriter, Universal Sompo General Insurance.

It is important to understand the exact coverage. For instance, Cigna TTK's ProHealth Insurance and ProHealth Select covers the donor and the recipient. This means apart from insured person who is covered within the health insurance policy, it also covers the donor's in-patient hospitalisation expenses up to the full sum insured.

In Royal Sundaram's Lifeline and Family Plus policies, expenses for organ donation are covered without any sub-limit, said Nikhil Apte, chief product officer, product factory (health). Organ donor expenses to the extent of surgical procedures are covered, but pre- and post-hospitalisation expenses of the donor are not covered.

In the case of Star Health, organ donor expenses for organ transplantation, where the insured person is the recipient are payable, provided the claim for transplantation is payable and subject to the availability of the sum insured.

"Donor screening expenses and post-donation complications of the donor are not payable. This cover is subject to a limit," said Anand Roy, the company's executive director, and chief marketing officer.

ICICI Lombard's base hospitalisation product, Complete Health Insurance (CHI), offers donor expenses as an add-on cover. "Donor expenses are covered under the base plan for super top-up product – Health Booster. Both products cover hospitalisation expenses only, though the extent of cover varies for both products. Under CHI we have a maximum limit of Rs 50,000 and for Health Booster we cover up to the sum insured opted by the customer," said Sanjay Datta, chief - underwriting & claims, ICICI Lombard.

Some critical care policies of different companies cover major organ and bone marrow transplant. If an insured is diagnosed to be suffering from a covered critical illness, while the policy is in force, the sum assured money is paid in lumpsum or in installments.

In the benefit category, Cigna TTK offers Lifestyle Protection, Critical Care policy which covers major organs (heart, lung, liver, kidney, pancreas) and bone marrow transplant. "If an insured is diagnosed to be suffering with a covered critical illness while the policy is in force, a lump sum amount equal to the sum insured is paid at one go, or in instalments as opted by the policyholder post waiting and survival periods," said Jyoti Punja, chief operating officer and customer officer at Cigna TTK Health Insurance. However, this benefit does not cover expenses towards the donor when it comes to costs incurred to screen the right donor, direct or indirect costs to acquire the organ and any other medical treatment or complication in respect of the donor, consequent to harvesting, she added.

Costs

Organ transplants cost money. "It is not difficult to assume that Rs 10-20 lakh may be spent on a procedure,'' said Apte. Plus, post-hospitalisation costs can be an added burden of Rs 1-2 lakh. So, do remember that sum assured has to be a big amount for the policy to bear all the expenses. "If you have a Rs 5 lakh sum assured, it will be too little for an organ transplant in most cases," Apte added.

If the situation gets complicated, the post-hospitalisation costs can be a lot. Star Health's Roy said that post-surgery medication is covered, whilst the insured person is required to stay in hospital, and also up to the post hospitalisation period, allowed under the respective policy and the limits, if any.

Typically, you may require a medical care window of 60-180 days after transplant. ICICI Lombard covers the pre- and post-hospitalisation expenses of the recipient up to sum insured opted for 30 and 60 days respectively under CHI, and 60 and 90 days respectively under Health Booster. Royal Sundaram's Lifeline (top-end 'elite' plan) covers pre- and post-hospitalisation expenses for 60-180 days. All such covers are up to the sum assured.

Often, post-transplant, immunity is lowered via immunosuppressant medications. Plus, regular diagnostic costs are conducted to monitor health. This can be both for the donor and the recipient. Universal Sompo's Bhattacharya said that, unlike an insured recipient, there are certain restrictions on the part of cover for donors, and this varies from insurer to insurer.

"Mostly, expenses related to pre- and post-hospitalisation or any other medical treatment for the donor consequent on the harvesting or any other costs directly or indirectly associated with the acquisition of the donor's organ are not covered under the policy subject to terms and conditions," he pointed out.

There are also different factors to consider:

Firstly, organ transplant is a well-planned process and gives you enough time to make a correct assessment of costs. Post-operation period is very delicate. For post-hospitalisation expenses, maintain bills and records for insurance reimbursement.

Secondly, when you plan for the costs, include the donor expenses. "Always do the transplant in a network hospital. It will be cashless," said Apte.

Thirdly, do take care that organ transplant is not a result of a pre-existing disease This is because, for pre-existing disease insurance claims, there is often a two to four-year waiting period. If you suppress facts while buying the insurance policy, insurers will check all medical records and ultimately get to know you lied --- leading to claim rejection.

Fourthly, genuine insurance claims (and not due to pre-existing ailments) are payable after 30-45 days.

CONDITIONS FOR COVERAGE:

• Organ transplant costs can be between Rs 10-20 lakh
   
• Organ transplant cover is offered as an inbuilt cover under health insurance policy or as an add-on
   
• Check if policy covers both donor's and recipient's treatment related expenses
   
• Recipient may get cover for all the transplant-related expenses, including pre and-post hospitalisation
   
• Unlike an insured recipient, there are certain restrictions on the part of cover for donors, and this may vary from insurers to insurers