Organ Donor Expenses Cover in Health Insurance

Medical sciences have come to a stage where patients with dysfunctioning organs can get a chance at life, again, due to organ donation. Besides the struggles of finding a prospective donor, the cost of opting for such a procedure can easily take up all your life savings. But recently, health insurance coverage has started to adapt to the new medical care requirements and today you can find insurance plans with an organ donor cover. Such a benefit might be in-built into your health insurance policy or available as an add-on cover at an additional premium.

Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024.

 

The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918

Organ donation is not just a single surgery but involves numerous steps before and after getting the organ transplant. So, let us deep dive into the types of healthcare expenses that may be incurred for organ donation:

• Test for Compatibility

To determine if the donor is a match to the recipient of the organ, a number of compatibility tests are carried out. This might include blood tests, crossmatch, screening tests, etc. to check if you have a match. 

• Pre-Hospitalisation Cost

The medical care expenses that may be incurred for tests, consultations, etc. before the donor is admitted to the hospital for the operation shall be covered under pre-hospitalisation 

costs. 

• Hospitalisation

The actual cost of hospitalisation such as the room rent, doctor’s fees, ICU, etc. is another crucial component of organ donor expenses. 

• Organ Donation Surgery 

The healthcare expenses of harvesting the organ, transplanting it into the recipient, the surgeon’s fee, the actual cost of the surgery, etc.

• Post-Surgery Recovery

Any post-surgery complications or medical care will be included as the organ donor expenses.

• Post-Hospitalisation Expenses

Post-hospitalisation expenses shall include the cost of medications, follow-ups and medical check-ups.

Let’s look at what’s covered under organ donor cover in health insurance:

• In-Patient Hospitalisation

Many health insurance plans with organ donor cover provide coverage for in-patient hospitalisation expenses. However, it is recommended to check the policy terms of your plan. Some insurers may not cover the in-patient hospitalisation costs incurred by the organ donor and only offer coverage for the policyholder who is the recipient.

• Surgery-Related Expenses

The cost of organ donation surgery is also covered under health insurance policies. Although the extent of coverage may vary from one insurer to another, many insurance providers cover the expenses of harvesting the organ. Moreover, the surgery-related costs incurred by the recipient are also included.

Here are some aspects of organ donor cover in health insurance that are not covered by the insurer:

• Pre and Post-Hospitalisation Expenses

Insurance providers may not cover the Pre and post hospitalisation incurred by the organ donor. Furthermore, any post-surgical complications, treatment and medication expenses are excluded as well.

• Transportation of the Organ

The expenses incurred for transporting the organ to the recipient are not covered under your health plan.

• Medical Screening

Your health insurance policy with organ donor cover may not include the cost of medical screening.

An individual may require an organ transplant in case of one or more organ failures or due to an ailment or disease. This is when a medical professional might advise an organ transplant. Here are some health conditions when a patient might be recommended to opt for an organ transplant:

• Heart Transplant

 In case of ailments such as coronary heart disease, congenital heart disease, cardiomyopathy, etc.

• Kidney Transplant

For kidney failure or end-stage chronic kidney disease.

• Liver Transplant

In case of liver failure or liver damage due to cirrhosis.

• Lung Transplant

For ailments such as cystic fibrosis, idiopathic pulmonary fibrosis, pulmonary hypertension, Chronic Obstructive Pulmonary Disease (COPD), etc.

• Pancreas Transplant

For cases of severe kidney disease, diabetes or other health complications.

• Intestine Transplant

In case of short bowel syndrome caused due to necrotising enterocolitis, gastroschisis, Crohn's disease, etc.

Let us take an example to understand health insurance claims raised for organ donation in case the policyholder has to undergo an organ transplant. Imagine Miss Nanda has liver cirrhosis and has been advised to opt for liver transplant surgery. After months of waiting to find the right donor, Miss Nanda finally finds a match. She undergoes a successful organ transplant and recovers from the surgery when it is time to file her health insurance claim.

 

The total organ donation surgery expenses come out to be ₹20 Lakh. As she had purchased a health insurance policy with an organ donor cover, most of the hospitalisation cost shall be covered by the insurance company. But certain terms and conditions had to be met for a successful insurance claim payout, which are: 

• The organ donation was in accordance and in compliance with the Transplantation of Human Organs Act, 1994.

• The organ transplant surgery was approved by the insurance company.

• The transplant surgery was completed under the medical advice of a healthcare professional.

However, Miss Nanda observed that during claim settlement, she had to bear some part of the treatment cost. Aspects such as the medical screening and the in-patient hospitalisation cost of the donor were not covered under her health insurance plan. Apart from this, the insurance policy covered a significant part of her hospitalisation and treatment expenses.

• The organ donated for transplant should be made available in compliance with the Transplantation of Human Organs Act, 1994, and should be donated for the use of the policyholder only.

• Every health insurance policy does not cover the healthcare expenses incurred by the organ donor for harvesting the organ and post the surgery.

• The organ donor cover may have a set waiting period before you can start availing this benefit under your health plan.

How to File a Claim Under Organ Donor Cover in Health Insurance

To make sure your claim is successfully settled by the insurance company, here’s how you can raise an organ donor insurance claim:

• Cashless Claim

To avail a cashless insurance claim under your health plan, you must undergo the transplant surgery in a network hospital associated with the insurer. Moreover, you must inform the insurance company about the organ transplant surgery in advance but this may vary from one insurer to another. The hospitalisation expenses incurred shall be directly settled by your provider. However, you might have to pay for certain costs based on the policy terms and cover the applicable deductibles.

• Reimbursement Claim

You can also choose to get organ transplant surgery at a hospital of your choice. In this case, you need to raise a reimbursement claim under your health insurance policy. But you must bear the medical care expenses incurred for the treatment and later file for reimbursement.

Bearing the expenses related to organ donation and transplant can be extremely expensive without the right insurance plan. Although many insurance policies may not have a built-in feature for such a treatment, you can find an organ donor add-on cover. But when it comes to organ donor cover in health insurance, it is crucial to know the coverage and exclusions of the policy for maximum protection!

But have you still not opted for comprehensive health insurance? As you may know, medical risks can affect anyone which is why you should always have sufficient insurance backup. Browse through the health insurance policies available on Bajaj Markets for extensive coverage at an affordable premium rate!  

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