Are Organ Transplants Covered By Your Health Insurance Plan?

With the advance of humanity, medical science has kept pace – it can help extend our lifespan and protect us from deadly viruses. It has advanced so much that a malfunctioning human organ can now be replaced with a fully functional one. This is called organ transplantation. Thanks to medical science, the number of deaths that were attributed to organ failure have reduced, and lots of lives have been saved. In 2019 alone, India saw more than 12000 organ transplants.

However, organ transplantation can be super expensive.Apart from the standard complications in harvesting and screening the organ, there are two surgeries required - one for the patient and the other for the donor. Next comes the hospital stay and follow-up procedures. The overall costs can mount upto lakhs.

At private hospitals in India, cornea transplants cost within Rs. 50,000 to Rs 1 Lakh, heart transplants range between Rs. 10 Lakhs and Rs. 16 Lakhs, and liver transplants can be as expensive as Rs. 25 Lakhs to Rs. 30 Lakhs.

We know the costs sound overwhelming, but there’s a silver lining - your health insurance Policy. Yes, it may take the load off.

In this article, we’ll go step-by-step and decode the type of expenses involved, and map it with the coverage available. Let’s start with the basics.

• List Of Conditions For Organ Donation

You may require an organ transplant because of a serious illness or injury - where the organ is impaired and a replacement is advised. A doctor may suggest an organ transplant in cases of

1. Kidney failure
2. Liver damage
3. Heart disease
4. Damage to cornea
5. Lung disease
6. Dysfunctioning of heart valves

• Expenses Involved In An Organ Transplantation

  For both the donor and the recipient, there are mainly 6 medical expenses involved.

  Type of expense	Description
  Organ screening	To check the overall compatibility, and to see if blood groups of the donor and the receiver match.
  Pre-hospitalization	Once the organ donor has been finalised, the person undergoing the transplantation (organ recipient) must be brought to an accurate medical condition - by the use of some medication.
  Hospitalisation	Includes the hospital room rent, doctor’s charges, and nursing expenses.
  Cost of surgery	Includes the transplant costs and surgeon fees.
  Post-hospitalization	Post surgery, the recipient and donor are monitored and their conditions tracked. This entails the cost of follow-ups with the doctor, medication, tests, among others.
  Post-surgery complications	Includes hospitalisation and treatment because of complications that may arise due to the transplant.

• Expenses Covered Under Health Insurance

  It is important to note that insurance companies will not cover all the expenses incurred by the organ donor. There are some exclusions and the organ recipient may have to bear these costs.

  The table below portrays both the inclusions and exclusions.

  Type of expense	Organ Receiver’s Expenses	Organ Donor’s Expenses
  Organ screening	Covered	Not Covered
  Pre-hospitalization	Covered	Not Covered
  Hospitalisation	Covered	Covered under organ receiver’s policy
  Cost of surgery	Covered	Covered under organ receiver’s policy
  Post-hospitalization	Covered	Not Covered
  Post-surgery complications	Covered	Very rarely covered

• Things The Organ Receiver Should Keep In Mind

  There are some strict guidelines when it comes to organ transplants. Hence, the organ donor should comply with the Transplantation of Human Organs Act, 1994, and declare that the organ donated is for personal health purpose only.

  A lot of expenses that the organ donor will incur are not covered and the organ receiver may have to bear them. It is, thus, important to understand the exclusions and limitations. Ask the hospital for a detailed breakdown of the expenses for both donor and receiver.

  Ask the hospital for a detailed break-up of expenses - for both donor and receiver - before the surgery.

• Things The Organ Donor Should Keep In Mind

  If you want to buy a new health insurance policy and are an organ donor already, then it is at the discretion of the insurer whether to cover you or not. Some insurers may consider you a high-risk case and decide not to sell you a plan.

  If you are an organ donor and already have a mediclaim policy, the insurer cannot deny your policy renewal.

  If you had donated an organ before buying a health insurance policy, but while purchasing it, did not declare that to the insurer - the insurer can rightfully deny renewal. This is because you withheld an important piece of information. So always be transparent and honest with your insurer, and they will try to give their best to you.

Let’s Take A Look At An Example.

Mr. Verma suffered from chronic renal failure and was advised to undergo a kidney transplant surgery. After waiting for some time, he was lucky enough to find the right donor. The kidney transplant went successfully, and now was the time to file the health insurance claim.

The overall cost of the kidney transplant in a private hospital was around Rs. 55,00,000 - which Mr. Verma paid and then filed a claim for reimbursement.

As the following conditions were met, the insurer approved the claim for kidney transplant - under Mr. Verma’s Health Insurance Policy -

The original claim for Mr. Verma’s condition - renal failure - was approved.

Organ donation was in accordance with the Transplantation of Human Organs Act, 1994.

The transplant took place under the medical advice of a verified medical practitioner.

The claim of Rs. 55,00,000 was partially admissible, because the insurer rejected the cost of medical screening and pre and post-hospitalizations of the donor - under the policy exclusions. However, a significant part of the transplant expense - Rs. 35,00,000 - was taken care of under Mr. Verma’s health insurance, hugely reducing his financial burden.

Not all superheroes wear capes, some donate their organs and save lives. If you are one of those superheroes, we celebrate you with our whole heart. And if you are an organ recipient, we hope things go well and you heal faster. Remember to choose a good health insurance policy, and protect yourself and the donor from financial trouble.