Modern Treatments in Health Insurance: List & Coverage

Posted on: Dec 17, 2024 | 3 mins | Written by: HDFC ERGO Team

Modern Treatments in Health Insurance: List & Coverage

Q: Are modern treatments expensive?

Yes, modern treatments can be expensive, and some insurers may apply sub-limits on the sum insured. Choosing a policy with low or no sub-limits can help reduce out-of-pocket expenses.

Q: Are there any conditions for claiming modern treatments in health insurance?

Yes, modern treatments must be prescribed in writing by a registered medical practitioner and declared medically necessary. Claims may be rejected if there is no valid prescription.

Q: How many times can I claim for modern treatments during a policy period?

The number of claims allowed for modern treatments depends on the policy terms and conditions. Some plans may limit the number of claims, while others may allow multiple claims within the policy period.

Q: Do I need to pay extra for modern treatment coverage?

In most cases, no additional premium is required for modern treatment coverage, as IRDAI mandates coverage of at least 12 modern treatments. However, certain policies may have limits, waiting periods, or co-payment requirements.

Getting diagnosed with a serious condition can be scary, and it is natural to worry about surgery and a long recovery. However, thanks to modern treatments, patients now have access to advanced procedures that are minimally invasive. They often reduce hospital stays, cause less pain and scarring and help patients recover faster than traditional methods.

While modern treatments offer many benefits, they can be expensive, making them hard for many people to afford. To help patients access these advanced procedures, the IRDAI has made it mandatory for health insurance plans to cover 12 modern treatments¹. This blog explains what is modern treatment in health insurance, and which procedures are covered.

Modern Treatments in Health Insurance

Modern treatments in health insurance refer to procedures that use advanced or high-end technologies to cure diseases once considered incurable. These procedures are minimally invasive, allowing the patient to recover faster than with traditional open surgeries. They are also more effective but quite expensive because of the advanced technologies used.

Are Modern Treatments Covered in Health Insurance

Yes. In 2019, the IRDAI directed insurance companies to cover as many as 12 modern treatments under the 'Modern Treatment Benefit'. The expenses incurred on any of the modern procedures, such as hospitalisation, pre- and post-hospitalisation, daycare procedures, and domiciliary care, are covered by health insurance plans. However, some policies may impose sub-limits on treatments, meaning there is a cap on the amount the insurer will pay for a specific treatment. It's good to be aware of the sub-limits and other exclusions related to modern treatments so you are financially prepared for any out-of-pocket expenses.

List of Modern Treatments Covered by Health Insurance

The 12 modern treatments covered by health insurance plans are:

1. Robotic Surgeries

2. Stem Cell Therapy

3. Immunotherapy

4. Oral Chemotherapy

5. Intra-vitreal Injections

6. Deep Brain Stimulation

7. Stereotactic Radio Surgeries

8. Bronchial Thermoplasty

9. Intra-Operative Neuro Monitoring (IONM)

10. Uterine Artery Embolisation and HIFU

11. Balloon Sinuplasty

12. Vaporisation of the Prostate

Things to Keep in Mind While Claiming Modern Treatment in Health Insurance

While claiming modern treatments in health insurance, here are some things you must not ignore:

◦ Coverage:

Understand what are modern treatments or procedures and pick only those that you may need in the future. This will also reduce your premium costs.

◦ Waiting Periods:

All health insurance plans have an initial waiting period of about 30 days, during which you cannot raise any claim. If you have a pre-existing condition, the waiting period is 1 to 3 years, depending on the insurer.

◦ Sub-Limits:

When a health insurance plan has a sub-limit or cap, the insurer will pay only a portion of the total claim amount based on the sub-limit, and the policyholder must bear the remaining amount. In the case of modern treatments, while some insurers cover up to the sum insured, others have a cap of, say, 25% or 50% of the sum insured. You must be aware of the sub-limits for modern treatments mentioned in the health insurance plan.

◦ Medically Necessary:

Modern treatments will be covered only if prescribed by a medical practitioner and are medically necessary. The policyholder has to submit a written prescription.

◦ Terms and Conditions:

Always check the policy terms and conditions, such as co-payments, room rent limits, and other exclusions.

Is Robotic Surgery or Laser Therapy Covered by Insurance?

Yes, many health insurance plans now cover modern treatments like robotic-assisted surgery and laser therapy. These procedures are part of the modern treatments list that insurers are required to cover.

However, coverage can vary depending on the specific plan and certain conditions:

▪ Laser surgery is generally covered when done for medical reasons, such as removing kidney stones or tumours, but cosmetic procedures are not included.

▪ Advanced treatments usually require prior approval from the insurance company.

▪ Insurers usually allow cashless claims only if the treatment is done at approved, high-tech hospitals.

Conclusion

Since health insurance policies now cover 12 key modern treatments, policyholders can choose these advanced options for safer procedures and better results. Although coverage may vary depending on the plan, having health insurance makes it easier to access the latest medical treatments. This helps you get the right treatment without worrying about the cost.

FAQs

1. Are modern treatments covered by health insurance?

Yes, modern treatments are covered by health insurance. As per IRDAI regulations, all insurers must cover 12 modern treatments under 'Modern Treatment Benefit’.

2. Is there a waiting period for claiming modern treatments?

There is no separate waiting period for claiming modern treatments. As with all health insurance plans, you can claim after the initial waiting period of 30 days from the date of policy purchase. However, you must check the policy document carefully to ascertain whether there is any waiting period for a particular treatment.

3. Are modern treatments expensive?

Yes, they are quite expensive, and some insurers may have sub-limits on the sum insured. Make sure you buy a policy with low or no sub-limits to avoid out-of-pocket expenses.

4. Are there any conditions for claiming modern treatments in health insurance?

Yes. The treatment must be prescribed in writing by a medical practitioner, stating that it is medically necessary. Without a valid prescription, the insurer can reject your claim.

5. How many times can I claim for modern treatments during a policy period?

This depends on the policy terms and conditions and the insurer. While some plans may have a limit on the maximum number of claims, others may not have any limit.

6. Do I need to pay extra for modern treatment coverage?

You usually don’t have to pay extra for modern treatment coverage, as IRDAI requires all health insurance policies in India to cover at least 12 specified modern treatments. However, some policies may have limits, waiting periods, or co-payment requirements, so it is wise to check the details of your plan.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

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