Group Health Insurance

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Conditions for organ donation under group health insurance

While awareness about organ donation has increased in India, the cost associated with organ donation often acts as a barrier for both donor and recipient (a person who receives the organ).

Group health and organ donation

A group mediclaim policy, which covers the medical expenses of all members of a group, also covers organ donation expenses.

However, a group health insurance policy has certain conditions under which it offers cover for the medical expenses of an organ donor’s treatment. The organ donor’s costs are covered only if the organ recipient is insured. Even for insured recipients, the following conditions must also be met:

  • The donation follows the guidelines of the Transplantation of Human Organs Act, 1994.
  • The organ is for the insured person.
  • A doctor has specifically asked the insured to undergo an organ transplant.

The insurance provider can refuse to cover organ donation and expenses such as:

  • Any pre or post-hospitalization expenses or screening expenses incurred by the donor.
  • Costs associated with identifying a donor.
  • Costs associated with harvesting the donor’s organ.
  • Treatment for the policyholder that does not fall under the insurance cover.
  • Organ purchase costs, if illegal.

Read More: What Kind of Treatments Are Not Covered By Group Health Insurance Plans?

Case study: Inclusions and exclusions in organ donation

Rajiv Gupta, a Delhi-based resident, had been on dialysis for a few years when he suffered a kidney failure. His doctor advised a kidney transplant. The only matching donor in his family was his mother. However, since she was 65, the doctor was hesitant to harvest her kidney.

Sometime later, Rajiv found a matching donor in his extended family. His relative Manoj came forward to donate his kidney. Medical tests found Manoj fit for organ donation. The doctors then performed successful organ transplantation. The total cost of the organ transplant operation was Rs 15 lakh.

Luckily, Rajiv’s employer had a group health insurance policy. The insurance had taken care of the expenses related to Rajiv’s dialysis. So, Rajiv informed the insurer about his operation. The insurer agreed to cover medical expenses on a reimbursement basis, so Rajiv paid the hospital bills and filed for reimbursement.

Read More: What are maternity benefits available in group health insurance plans?

The insurer did not reimburse the full Rs 15 lakh. It did not settle expenses related to Manoj’s screening tests. The hospital conducted these tests to ensure Manoj’s fitness. It also did not cover the expenses incurred directly and indirectly in harvesting Manoj’s kidney. Rajiv had to bear these costs himself. However, this was a far lower burden than having to bear the entire medical costs for his procedure.