Modern treatments rise, but health insurance in India still lags behind

In 2019, the Insurance Regulatory and Development Authority of India (Irdai) made it mandatory for insurers to cover 12 such modern treatments. However, insurers were allowed to set their own sub-limits—caps that now leave many patients underinsured.

As awareness grows, policyholders are discovering that their policies offer inadequate coverage. When they try to migrate or port to better plans, they often hit a wall of rejections and vague explanations.

Take the case of 62-year-old Jeram Damani, who has a family floater policy with his wife since 2015. They filed only one claim in 2019 for breast cancer and have remained healthy since.

“When I discovered my policy had sub-limits on modern treatments, I decided to migrate to another plan from the same insurer. It would have cost me more, but I was fine with that. The company rejected my proposal without giving any written justification. I’ve now sent them a legal notice," he said.

While migration or portability is a policyholder’s right, it’s subject to the insurer’s underwriting norms. And for those with major illnesses such as cancer, switching plans is often near impossible.

“We assess the product to which customer intends to migrate to, benefits, waiting periods etc in the current and the new product and accordingly perform assessment,"said Bhabhtosh Mishra, director and chief operarion officer, Niva Bupa Health Insurance.

While the process of portability is the same, different insurers follow different underwriting guidelines.

“There cannot be a common approach because it’s based on the underwriting decision and philosophy of the respective insurance company. As portability of health insurance guarantees the continuity benefits in terms of cumulative bonus, pre-existing diseases and exclusions, every insurer underwrites individual cases keeping in mind the immediate probability of claims post portability." said Parthanil Ghosh, executive director, HDFC ERGO.

Uneven acceptance of risky profiles

Despite the risks, insurers treat similar cases differently.

Devang Saini from Muzaffarnagar said his father, diagnosed with lung cancer eight months after buying a policy in 2021, was able to migrate to a better plan from the same insurer.

“We faced problems with claim settlement for immunotherapy under the new policy. Each time, we had to approach the Ombudsman to get reimbursement, but I eventually received the money. Had my father continued with the previous plan, we couldn’t have recovered much," said Saini.

Independent consultant Mitesh Dave said he has seen several such inconsistencies.

“I know a person who migrated to a different plan at 68 in 2025—at a lower premium—despite several claims, including one for cancer. In another case, a person who had heart surgery could move to another plan even with a BMI of 38–39. Migration or porting is the insurer’s prerogative, but there must be some transparency in how proposals are accepted or rejected," he said.

Sub-limits that hurt

Consider this: you have a ₹10 lakh health cover, but your policy caps robotic surgery at ₹1 lakh. Even if your hospital bill totals ₹7 lakh, the insurer pays just ₹1 lakh.

“The hospital bill will have separate heads like medicines, surgery, and others. Ideally, the sub-limit should apply only to the surgery component, but insurers apply it on the entire cost," said Dave.

Most comprehensive plans now cover modern treatments up to the full sum insured, but older or budget plans still carry sub-limits. Some insurers offer optional riders to enhance coverage—for a price.

“Our affordable plan, RISE, has sub-limits on modern treatments, but we offer an optional rider to extend coverage up to the sum insured," said Mishra.

However, these riders aren’t universally available.

“Riders can be denied based on health history, leaving policyholders stuck with weak coverage. They are also unavailable under group health insurance offered by employers or banks," Dave said.

Sub-limits are not prominently disclosed. “They appear only in the detailed policy wording, which most policyholders don’t read. Such limits should be clearly mentioned in the Customer Information Sheet upfront," Dave said.

Saini experienced this firsthand. He submitted a hospitalization claim of ₹3.93 lakh for his father, including all medical documents. The insurer short-settled the claim citing ‘immunotherapy sub-limit exceeded’.

“The policy wording clearly said there were no sub-limits. It had unlimited restoration benefit too. I had to approach the Ombudsman to get it settled," he said.

When claims face extra scrutiny

Another hurdle is proving the medical necessity of modern treatments.

“We observe that in many instances robotic surgeries are being offered as an alternative to the laparoscopy which pushes up the medical inflation, which will pinch the policyholders later," said Ghosh.

A recent case shared by Shrehith Karkera, co-founder of Ditto Insurance, highlights the issue.

A 47-year-old woman with 90% artery blockage was advised MICS (Minimally Invasive Cardiac Surgery) instead of conventional CABG. When the hospital sought pre-authorization of ₹9 lakh, the insurer approved just ₹99,000—citing tariff limits.

“We escalated the case with detailed medical justification, angiogram findings, and proof that MICS wasn’t excluded. The insurer finally approved about ₹7 lakh after discounts," Karkera said.

He added that the medical officers reviewing such claims are often not practising doctors. “Their assessment may not reflect what’s actually happening in hospitals. Policyholders must ensure they obtain a detailed medical justification from the treating doctor. A hurriedly written one-line note won’t suffice," he said.

Treatments beyond Irdai’s list

What if your treatment isn’t among the 12 specified by Irdai? Some insurers may call it “unproven" or “experimental."

Ghosh, however, clarified, “As long as the treatment is legally approved in India, it will be covered unless specifically excluded. Therefore it is advisable to read the terms and conditions of the policy carefully."

An insurance executive who didn't wish to be named said that health technology assessments by the Department of Health Research and the National Health Authority guide what’s considered “proven."

“When a new treatment emerges, we review its stated purpose and the approving authority’s indications before taking a call," he said.

Bottom line

Everything ultimately depends on medical justification and policy awareness. Policyholders must review their policies closely, confirm sub-limits, and seek detailed treatment notes from doctors.

It’s the only way to ensure that advanced medicine doesn’t leave them battling outdated insurance rules.