Organ donor insuranceOnly 24% of Indians expressed their willingness to donate organs after death, with just 3% having registered their intent with the relevant authority, as per a recent study conducted by Edelweiss Tokio Life Insurance. Despite everyone agreeing that organ donation is a noble gesture, in practice very few do it. One of the reasons could be the costs associated with the entire organ donation exercise. Both the donor and the donee have to undertake significant expenses before and after the donation. Does health insurance cover organ donation related expenses? Let us find out.

Liver and kidney transplants constitute the majority of the demand for organ transplants. Always keep in mind that organ donation and transplant involves two parties: the donor and the receiver (donee).

Insurance for donee (one who receives)

Critical illness plans – Some critical illness plans give a cover for organ transplantation. Given that an organ transplantation process often involves a huge medical expense, often running into lakhs, some critical illness policies offer a financial shield. A kidney transplant procedure alone can set you back by Rs 8-10 lakh minimum while a heart transplant costs in tens of lakhs. Critical illness policies are not your usual health insurance policy.

In normal health insurance/mediclaim, the insurance money is paid after the procedure is done and you/hospital has to furnish bills for claim reimbursement. In a critical illness policy, the benefit is fixed and is paid upfront in a lump sum upon diagnosis of any of the listed critical illnesses covered in the policy.

So in case, your treating doctor recommends organ donation as the line of treatment, a critical illness plan will give you a lump sum benefit in one transaction that may be used to pay for the treatment, care, and recovery after you as a donee undergo organ donation. Do remember the money is usually paid on the first diagnosis or advice issued by a medical practitioner. Most critical illness policies do not insist upon hospital bills to process the claim.

Standard medical insurance plans – If the donee i.e. recipient is a policyholder, most expenses to the extent of the sum insured are covered by standard health policies. If your sum insured amount is big enough, you could bank-roll the entire financial costs of the transplant.

Good insurance plans will cover all hospitalisation expenses i.e. medical, surgical as well as pre- and post-hospitalisation, incurred by the insured (donee) recipient are covered under such policies. Refer to your health insurance policy document (policy wording document) to understand the scope of cover for the procedure.

Tip: Check out the exclusions to understand under what conditions claims may be rejected by the insurance company. If you have to go through an organ transplant, make sure that the hospital provides all details of expenses. Claim settlement is always a problem if bills and expenses are not clearly justified. Insist on a detailed break-up of costs with respect to donor and donee expenses. Your hospital may charge a lump sum ‘package’ cost for organ transplant procedures but get the details.

Insurance for donor (one who gives)

Health insurance for the organ donor is not as smooth as the donee.

Firstly, donor’s expenses are covered but they come may come with restrictions. Usually, the same health cover that shields the donee (organ recipient) can have a feature for covering donor. But, as we said, such plans may have caps. For instance, the same health policy that covers the donee may only provide in-patient hospitalisation expenses for the donor. Organ screening for compatibility is important but that expense may not be covered.

Two, health insurance plans are ideally designed to serve the purpose of covering financial costs that a policyholder incurs due to a health condition. In the case of a donor, it is not a health condition that requires treatment. A donor is usually healthy and is giving an organ. This makes the donor, in the eyes of medical science, high-risk. But altruism might cost you as a donor your health insurance. A health insurance company will likely not give you a health cover if you have donated an organ because the medical insurance underwriter knows that such people can lead to pay-outs.

Three, many donee health insurance policies that cover donor expenses may restrict the donor expenses to a percentage of the sum insured (10% of sum insured) or a defined limit, say Rs 50,000 to Rs 5 lakh.

Four, some donee health policies offer a cover for the organ donor as an add-on product. This means you have to pay more than the base premium.

Tip: Usually, the donee or their family funds the entire organ transplant procedure. The donor, usually from a weaker financial background, may not have the means to buy health insurance. While buying health insurance, you should check whether the plan covers pre- and post-hospitalisation of the donor as well as screening expenses. Find out whether the plan will cover expenses related to any complications arising consequent to harvesting.

Which policies cover organ transplant expenses

Health insurance policies like HDFC Ergo Health Suraksha, Apollo Munich Optima Restore, Religare Health Care, Star Health Family Health Optima and Max Bupa Health Companion are known to cover organ transplant expenses.

Critical illness policies like HDFC ERGO Critical illness also cover organ transplant cases, while LIC’s New Critical Illness Benefit Rider gives organ transplant expenses as an add-on benefit.

RupeeIQ take

Despite organ donation being marketed as a part of the health insurance coverage by many insurers, do not take this coverage at face value. Always delve deeper to figure out how comprehensive the coverage over organ transplant expenses is. Ask the following questions:

1. Which organ transplants are covered and by how much?

2. Which costs related to the hospitalisation or surgery of the organ donor will be covered and to what extent?

3. Which costs related to pre-hospitalisation of donor and donee are covered and by how much?

4. How much of post-surgical complications will be covered since they are not uncommon with respect to organ transplantation?

5. What is the list of exclusions for organ transplant claims?

Author
Kumar Shankar Roy

Kumar Shankar Roy is contributing editor with RupeeIQ. He can be contacted on kumarsroy@rupeeiq.com