Health Insurance & Organ Transplants

The medical success of transplantation has not translated into benefits for most patients with end stage organ failure in our country because of several reasons, primarily limited organ availability and affordability of a transplant.

Transplant costs

There are many facets to calculating the cost of transplants and costs differ depending on whether they are living transplants or deceased donor transplants.

Most patients undergo living donor transplants at private hospitals. The cost of transplantation is highly variable at different centres. While the reason for a disparity is obvious between a government and private hospital, often the difference between different private hospitals may also be quite significant.

The direct costs are that of pre-transplant recipient evaluation, living donor screening and evaluation, deceased donor transplant waiting list registration, pre-transplant medications (may be significant for ABO-incompatible transplants), deceased donor maintenance and retrieval, donor and recipient surgery, post-operative care and drugs and follow-up investigations and medications.

Most often transplants are offered as a package at private hospitals, either fixed or open. The indirect costs typically involve that of pre-transplant medical treatments and care such as dialysis, LVAD, maintenance of acute liver failure patient in ICU, etc. which may be very high.

Costs of the patient and family staying in another city waiting for a deceased donor organ or in the post-operative period for close follow-up can also be significant. Loss of wages and earnings during illness may contribute to the difficulty, especially if the patient is the primary bread earner in the family. The uncertainty of any complications and associated costs can upset any financial plans for the transplant.

Health Insurance and Transplants

Health insurance in India has a low penetration (15- 20%), a large majority of which is provided by the government for its employees and for workers in small businesses. Generally, health insurance is not a profitable business for insurance companies compared to other types of insurance, and will not be so until a critical mass of market penetration is achieved.

There are two types of health coverage i.e. Health Insurance and Critical illness Plan. While health insurance is to cover hospitalization expenses, critical illness plan provides a lumpsum payment at the time of transplant. Patients buying private insurance often overlook the fine print and buy insurance that is either inadequate or does not cover transplantation.

Insurance companies have also developed a strong mechanism for checking the authenticity of patients’ claims because patients often hide pre-existing diseases and addictions in the application and sometimes make false claims, leading to rejection of claims. Please always remember that pre-existing diseases are typically covered after 3-4 years of buying insurance.

Treatments using newer medical technologies, (e.g. absorbable cardiac stents, robotic surgery, etc.), may be rejected because they did not exist when the policy was bought or the underwriters and doctors in insurance companies may not be aware of them.

The huge variation in the cost of treatment across various private hospitals makes it difficult for insurance companies to accurately estimate the risk. There is also lack of trust due to suspected practice of over-billing or differential pricing for insurance patients. While it is common for pre-authorization information sent for claims to be incomplete, queries about the diagnosis, plan, etc. by insurance companies are often not liked by treating doctors, and inadequate information may be a reason for rejection of claims.

Government & Private Insurance Cover – What You Need To Know

The government insurance schemes offer rates that may be inadequate for transplant at private hospitals. Due to paucity of transplant facilities at government hospitals, patients often find it difficult to avail of the same or pay the difference.

Private insurance policies may not include transplant or may not include cost of donor surgery, this should be clarified at the time of buying insurance. In case of Live Transplants, the Donor surgery will not be covered by donor’s own insurance. Insurance companies often insist on break-up of costs in the package, which hospitals are reluctant to provide, often delaying approvals or claims. Most cashless insurance cover requires hospitalization for one day, thus pre-transplant evaluation which is often done on OPD basis may not be eligible for cashless cover needs to the claimed for reimbursement. Any deposits for registration for a deceased donor transplant required months before the operation may not be covered by the insurance.

Any Illness due to smoking, tobacco, alcohol or drug intake, illness due to internal or external congenital disorders are typically not covered but may be indications for transplant. Islets or stem cell transplant, treatments outside India, transplants not in compliance with THOA are not covered. In case of complications, the cost may escalate significantly, more that the planned expenditure.

Here are a few things to keep in mind:

• Patients on dialysis, cirrhosis, heart failure etc. should buy health insurance early and declare their disease
to get covered after 3 years, when transplant may be needed.
• Patients should enroll in a government insurance scheme if eligible.
• Patients should be advised to buy an adequate health insurance policy and a critical illness plan and ensure coverage of transplant and donor surgery in the policy.
• Donors should buy insurance well before the surgery, as it may be difficult to buy one later.
• Donors with pre-existing policy should inform the insurance company about the donation.

Transplant Schemes

Some states have started schemes for covering the cost of transplants, the most prominent being Tamil Nadu CM scheme where 22.5 lakhs is funded for liver transplant and 6 lakh for a kidney transplant. Aarogyasri scheme in Telangana funds 10.5 lakhs for a deceased donor liver transplant and 14.5 lakhs for a living donor liver transplant. In Assam, pediatric transplants are funded through the National Rural Health Mission.

Dr. Ravi Mohanka

Dr. Ravi Mohanka is the Chief Surgeon and Head of Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery at Global Hospitals, Mumbai. His unit is one of the fastest growing programs with success rates of acute liver failure and liver transplant at par with the best in the world. Dr. Mohanka has trained and worked at some of the most reputed hospitals in India and USA, including the prestigious Thomas E Starzl Transplantation Institute at the University of Pittsburgh. His areas of expertise and current practice include living donor and deceased donor (cadaveric) liver transplantation, intestinal transplantation, pancreas transplantation and hepato-biliary surgeries in adults and children. He has undergone advanced training in laparoscopic and robotic liver surgery at leading institutes in France and Italy. He has organized, conducted and chaired many national and international level conferences, delivered faculty lectures, presented and published his research work at scientific meetings and international journals.

9 Comments

  1. Nergish Italia · November 7, 2016 Reply

    I have recently become a member, but when I received the donor card along with a lot of literature, I found that you only accept organs of a brain-dead person and not from people who die of natural causes/old age. I don’t know the reason for this, but it seems to me that you are further losing out on donated organs because of this clause.

    Please let me know why this is so.

    Thank you

    • ORGAN India
      ORGAN India · April 27, 2017 Reply

      Dear Nergish,

      Please go to our website http://www.organindia.org and read up on organ donation. Yes someone who is Brain Dead can donate organs. This makes the donor pool very small and therefore we need everyone to pledge their organs.

      Regards,
      ORGAN India Team

  2. Geetha · December 14, 2016 Reply

    Does your insurance company cover charges for heart transplant? If yes what would be the procedure?

  3. Albin Issac · January 25, 2017 Reply

    Dear Sir/Ma’am,

    I would like to know about post surgery health insurance details.
    I have underwent for Kidney Transplant on January 2014.
    Am i eligible for taking any of the health insurance?
    And can you please share me the details if i am eligible for health insurance.

  4. K rajesh · April 27, 2017 Reply

    Sir
    I had a transplant operation on October 2010.
    Am I eligible for health insurance policies.

  5. Jagannath Mahaot · August 9, 2017 Reply

    Please guide me to know that what are the complications faced be the alive kidney donor post donation. Like –

    i) What is the life expectancy after kidney donation.
    ii) Does it effect other organs normal function.
    iii) Can a donor live a normal life after donation.
    iv) How much cost donor have to bear to live a healthy life post donation.
    v) Who bears the cost of transplantation before and after donation.

  6. Dharmesh Solanki · September 8, 2017 Reply

    Dear Sir,

    My brother suffering for leaver cirrhosis and to transplant the leaver as soon as possible.

    Any health insurance available for this is to be done with same day?

    Please suggest

  7. k rajan · November 12, 2017 Reply

    Dear sir
    My brother is recently tested as fatty liver and also hepatitis-B positive but virus is not active. he is at 49 years of age.In future if any complications including liver trans plantation may be required, but doctor did not tell it. Hence i request you sir please suggest any type of insurance which covers pre-existing disease coverage, after 3 or 4 years of period.

    Thanking you sir

  8. P.das · February 12, 2018 Reply

    My son had kidney transplant in April 2017.can he go for any health insurance?of yes which insurance company?Ppl intimate details.

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