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.