While awareness about organ donation has increased in India, the cost associated with organ donation many times, act as a barrier for both donor and donee (a person who receives the organ).

A group health insurance policy plays an important role by covering medical expenses of all the members of a group. In addition to covering medical expenses related to other ailments, a group health insurance policy also covers organ donation expenses as well –

However, a group health insurance policy will cover medical expenses for an organ donor’s treatment provided that:

  • The donation is as per the Transplantation of Human Organs Act, 1994
  • The organ is to be used for the insured person
  • The insured person has been specifically asked to undergo organ transplant by the doctor

However, the group health insurance company can refuse to cover organ donation and expenses in case of the following situations –

  • Any pre or post hospitalisation expenses or screen expenses incurred by the donor
  • Any expenses incurred on harvesting of the organ from the donor
  • Costs/expenses which are directly associated with the harvesting from the donor
  • Costs directly or indirectly associated with the acquisition of the donor’s organ
  • Treatment of the policyholder unless those expenses of the insured are covered under group health insurance policy

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

Case

Rajiv Gupta, a Delhi based resident, suffered a kidney failure in 2010. He was being kept on dialysis from the last few years. The doctor advised for a kidney transplant, and ironically, there was no matching donor available in his family, except his mother. However, his mother was 65 and considering her age; doctors were hesitant to harvest a kidney from her.

It was in 2012 that Rajiv found a matching donor when one of his close relatives, Manoj came forward to donate his one kidney. It was a moment of happiness and satisfaction for Rajiv and his family.

After doing all the medical tests of Manoj, doctors declared him fit for the organ donation. On the last day of the month, the doctors did a successful organ transplantation. The total medical expense of the organ transplant operation was Rs 15 lakh.

Luckily, Rajiv was covered under a group health insurance policy by its employer. The group health insurance company was taking care of the expenses related to dialysis so far, and therefore, Rajiv informed the insurer about his operation and asked for the coverage.

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

Here, the insurer agreed to cover medical expenses on a reimbursement basis. It means, Rajiv paid all the medical expenses beforehand and then filed for reimbursement with the group health insurer.

In this case, the group health insurance company paid the organ donation expenses only when it was satisfied that –

  • The donation was as per the Transplantation of Human Organs Act, 1994
  • The organ was to be used for the insured person
  • The insured person was asked to undergo organ transplant by the doctor

Though the total medical expenses were Rs 15 lakh; the group health insurance did not settle the entire expenses. There were some expenditures which were refused to settle by the insurer. These expenses were –

  • As the donor, e., Manoj was asked to undergo some screen tests to ensure that he was fit for the transplantation, the insurer did not cover all those pre and post hospitalisation expenses or screen expenses which were incurred by him
  • While the group health insurance company covered the expenses incurred on transplanting kidney into the body of Rajiv, it did not cover expenses which were incurred on harvesting of the organ from Manoj
  • The group health insurance company refused to cover all those costs/expenses which were directly/indirectly related to the harvesting of the organ from Manoj

Thankfully, group health insurance policy was there to give coverage as otherwise, Rajiv would have to bear all the expenses all by himself.

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