Sub-limits blunt coverage of Irdai's modern care mandate

Insurers continue to cap payouts despite 2019 Irdai mandate covering 12 modern procedures

- Aprajita Sharma

Robotic surgeries, stem cell therapy, and other advanced treatments are now common in India. But health insurance coverage hasn't quite kept pace. In 2019, the Insurance Regulatory and Development Authority of India made it mandatory for insurers to cover 12 modern treatments. However, insurers were allowed to set their own sub-limits—caps that now leave many patients underinsured.

As awareness rises, more policyholders are realising their policies don’t offer enough coverage. But when they try to migrate or port to better plans, they often face rejections and unclear explanations. Take 62-year-old Jeram Damani, who has held a family floater policy with his wife since 2015. They made a single claim in 2019 for breast cancer and have stayed healthy since.

“When I saw my policy had sub-limits on modern treatments, I decided to migrate to another plan from the same insurer. It would have cost me more, but I was fine with that. The company rejected my proposal without giving any written justification. I've now sent them a legal notice,” he said.

Migration or portability is a policyholder's right but depends on an insurer's underwriting norms. For those with major illnesses like cancer, switching plans is nearly impossible. “We assess the product to which the customer intends to migrate, benefits, waiting periods, etc, in the current and new product and accordingly perform assessment,” said Bhabhtosh Mishra, director and chief operations officer, Niva Bupa Health Insurance.