Why health insurers refuse to cover certain treatments

While 12 modern treatments are covered, many advanced procedures are yet to be included

- Aprajita Sharma

Insurance companies charge hefty premiums for health policies and often raise them to adjust for medical inflation. It comes as a surprise, therefore, if they reject or only partially settle claims linked to modern treatment methods.

New Delhi-based Rahul Kumar's 67-year-old father was diagnosed with liver cancer that needed an advanced palliative treatment called Transarterial Radioembolization (TARE). Kumar's brother had a corporate policy with a private insurer. However, during pre-authorization, the company refused to approve the claim, saying, "TARE is an advanced procedure which is not covered under the policy; hence claim not admissible."

Kumar also had an alumni group insurance plan from the same insurer which covered his parents. It was a family floater plan with a fixed deductible of ₹5 lakh.

"I approached the insurance company to file a reimbursement. They accepted the documents and settled the claim in two months, probably thanks to some pressure the alumni group exerted on them. The same company had rejected it when my brother filed it under his corporate policy," said Kumar.

Bengaluru-based Parag Jain's mother-in-law was diagnosed with breast cancer in 2023 and was recommended "targeted" therapy. She needed to undergo six chemotherapy sessions followed by a surgery, radiotherapy and 14 post-surgery sessions over 1.5 years. The overall cost came up to ₹40 lakh.