Organ Transplants and Health Insurance



The past few centuries have witnessed great strides in medical science with revolutionary medical breakthroughs. Be it the invention of vaccines and antibiotics or the more recent developments in artificial intelligence, advancements in the field of medicine have not only increased life expectancy but also helped improve the overall quality of human life. Organ transplantation was one such life-altering medical discovery.

A procedure in which an organ is removed from one body (the donor) and placed in another (the recipient), it is a therapy that has saved countless lives. The heart, kidneys, lungs, liver, pancreas, uterus, cornea, bone, skin, and blood vessels have all been successfully transplanted so far. 

A living donor can donate one kidney, a portion of the pancreas, and part of the liver, and for transplantation of other organs, only deceased donors are permitted. 

Organ transplantation is a complex medical procedure comprising various stages like screening of the donor, surgeries on both the donor and the recipient followed by postoperative treatment and monitoring.

Depending on the organ to be transplanted, the cost of the entire procedure could run into several lakhs (a heart transplant could cost up to Rs. 25 lakh, and a liver transplant could cost as much as Rs.35 lakh!). It is, therefore, imperative to have a health insurance policy with adequate coverage so that you are prepared to bear these expenses.

Organ Transplant Coverage in Health Insurance

Most health insurance plans nowadays offer coverage for organ transplantation. Expenses for the diagnostic tests, hospitalization, and surgery along with pre and post hospitalization costs are all covered in the policy, the only conditions being that the cover will become active after a waiting period of 2-4 years and the organ transplant should be done in strict compliance with the Transplantation of Human Organs Act 1994.

What is important to note here, however, is that total coverage is available only to organ recipients. It is the recipients who have to claim benefits under their policies both for themselves and the donors. Donors cannot use their health policies to claim compensation. Even so, health policies usually cover the donor only for surgery and organ harvesting.

This leaves out expenses of the donor such as pre and post hospitalization costs, donor screening costs, and treatment costs for postoperative complications if any. Some policies also apply sub-limits to various donor expenses. 

It is, thus, the recipient’s responsibility to ensure that there is adequate coverage in the health policy for the entire organ transplant procedure.

There are two aspects to this:

Reviewing the terms of the policy: It is very important to go through the terms and conditions to understand the coverages and exclusions before purchasing a health policy. At the time of making a claim, if you discover that a treatment that you underwent or need to undergo is excluded from coverage, then the insurance policy will not have served its purpose and you will be left without any financial assistance for the required treatment.

Evaluating the sum insured: Organ transplants are expensive procedures. If you find that your basic health insurance plan is not sufficient for an organ transplant, you may need to make arrangements for additional insurance.

One way to do this is to supplement your health policy with a critical illness policy. A critical illness policy is a benefit policy that pays a lump sum amount directly upon diagnosis of any of the illnesses listed in the policy. It provides payouts for various conditions including organ transplants and thus provides additional financial protection when a transplant is needed. 

Organ transplant cover – A tool to promote organ donation 

An increase in the prevalence of lifestyle diseases in the country has, in turn, led to a rise in organ transplant cases. And for those facing imminent organ failure, the only hope for survival is organ transplantation. This is why organ donation is considered a noble act. 

However, due to religious beliefs, lack of awareness, and inadequate health facilities, Indians lag behind in organ donation. In 2019, the organ donation rate in India was only 0.65 per million population (pmp) which is much lower than that of developed countries like Spain which has a donation rate of 35.1 pmp, the United States 21.9 pmp and the United Kingdom 15.5 pmp.

While various government and non-government organizations constantly strive to promote organ donation, there is also a responsibility that lies with the insurance industry.

In 2017, Savitri Toshniwal, a resident of Beed, Maharashtra donated a part of her liver to her husband who was suffering from end-stage liver failure. The surgery was successful but since the existing health insurance policy did not have adequate coverage, the family sought to purchase a new health insurance policy that would cover everyone within the family.

Unfortunately, insurers refused to cover both Savitri and her husband who were termed high-risk because of the surgery.

There have been many grievances about organ donors and receivers being discriminated against by insurance companies post organ transplant surgery. In a country that already faces an acute shortage of organ donors, such practices by insurers will further dissuade the public from donating their organs.

Factors such as age, medical history, and pre-existing ailments are vital to assess the risk profile of a customer, but the sole fact that they had undergone a transplant surgery should not make them ineligible for insurance protection.

Organ donors help save lives and should be provided with all the support that they can get. Insurers, being important stakeholders in the organ transplantation process, need to play their part to ensure maximum protection, especially for organ donors, so that more people are inspired to donate their organs and many more are able to receive the gift of life.

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Susheel Agarwal

Susheel is the CEO of Ethika Insurance Broking P Ltd. This company, which has a current value of 10 million dollars, was bootstrapped by him and two of his friends. He attributes his success to his ability to inspire others to seek happiness at work.