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Modern Treatment Procedures: How health insurance policies coverage cover modern treatments.

Modern Health Insurance Policies: Up until 2019, a lot of general and health insurance providers were hesitant to cover advanced medical treatments including stem cell therapy, robotic surgery, oral chemotherapy, and so on.

Written by Thelearnvine

Modern treatments are covered by health insurance, but only up to a point.
Even though medicine has made huge progress and patients have better results, health insurance companies still don't cover some new treatments because they haven't been "proven."

The Insurance Regulatory and Development Authority of India (IRDAI) told insurers in 2019 that they had to pay back the cost of "modern" medical procedures that weren't covered by health insurance. Along with a list of 12 treatments that should be covered, it gave insurance the freedom to cover more.
Since then, all new and updated health insurance plans have had to pay for these costs. Here's how health and general insurers handle claims about these kinds of treatments now:

What is meant by "modern" therapeutic practices according to IRDAI?

The insurance regulator listed 12 "modern" procedures in a 2019 circular that insurers be required to pay for when processing hospitalization, home therapy, and day care claims.
These include deep brain stimulation, oral chemotherapy, uterine artery embolization (a non-surgical procedure for treating fibroids), balloon sinuplasty (a type of endoscopic nasal surgery), immunotherapy (injectable monoclonal antibodies), robotic surgeries, stereotactic radio surgeries, bronchical thermoplasty, vaporization of the prostrate (green or holmium laser treatment), intra-operative neuro monitoring, and stem cell therapy.

Furthermore, insurance providers may choose to pay for other contemporary therapy modalities.

Why are insurance companies reluctant to pay for these kinds of procedures?

These techniques are considered experimental by several insurers. The standardization of exclusions circular by IRDAI permits insurers to exclude therapeutic techniques that are deemed to be "unproven." "Unproven treatments are treatments, procedures, or supplies that lack substantial medical documentation to support their effectiveness," states the regulator's 2019 circular.

However, because of certain insurers' inflexible positions, numerous beneficial medicines were also given short shrift. Two such instances are bariatric surgery for those who are very obese and oral chemotherapy for cancer patients. Because of this, the IRDAI was forced to intervene and demand that insurers pay for a minimum of 12 certain treatment procedures.

But why are there sub-limits (restrictions on the number of eligible claims) attached to coverage for these therapeutic procedures?

This is due to the high expense of some of these cutting-edge treatments. Internal ceilings have been permitted by the IRDAI for certain products; sub-limits are not set in stone and instead fluctuate according on the insurer and product.
For example, 50% of the total covered amount is the sub-limit for both ICICI Lombard's Health Advantage and Future Generali's Health Absolute when it comes to contemporary operations and bariatric surgery. Similarly, the updated super top-up insurance from United India Insurance reimburses oral chemotherapy costs up to 20% of the total covered, with a maximum ceiling of Rs 2 lakh.

Now, the sub-limits may actually work against the goal of requiring coverage for new treatments by discouraging patient-policyholders from choosing them over traditional ones.
Insurers counter that new and inventive practices do not always indicate that they are superior than more traditional approaches.
Make sure you perform a cost-benefit analysis on your end before choosing the new approach over the traditional one. Before deciding on a procedure, consider safety, recuperation time, side effects, dangers, and, lastly, associated expenses.


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