Opinion
Heath insurance in India ought to cover preventive care as well
Summary
- A wide-angled approach can pave the way for healthcare that secures our overall health much better. We can hardly call it ‘care’ if it only starts at the hospital door.
India’s health insurance system ignores one of the most effective tools in modern medicine: preventive care. Despite overwhelming global evidence that early intervention reduces hospitalizations, disabilities and healthcare costs, Indian insurance policies rarely if ever cover the cost of preventive medication for chronic and life-threatening conditions. These are the very treatments that can keep patients out of hospitals—yet they remain out of reach for many simply because their value goes unrecognized.
Worse, this blind spot sits atop a system already failing patients. Policyholders are treated as afterthoughts, left to navigate a maze that seems designed to protect the interests of hospitals, third-party administrators and insurers more than the people it claims to serve. Claims are delayed or denied on technicalities. Post-hospitalization care is minimal and short-lived. Price distortions go mostly unchallenged.
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What we have today is not health insurance. It is hospitalization insurance—riddled with inefficiency, opacity and corruption. Until the Insurance Regulatory and Development Authority of India (IRDAI) begins to prioritize prevention, support continuity of care and put consumers ahead, meaningful reform will remain a distant dream.
Take the example of evolocumab, a cholesterol-lowering injection used globally to manage cardiovascular risk. In the US, this life-saving drug is available for as little as $5 a month under insurance plans when it’s prescribed for high-risk cardiac patients. Insurers recognize the long-term savings from preventing heart attacks, strokes and expensive hospitalizations.
But in India, the merit in that logic is overlooked. Health insurance policies routinely exclude the cost of such medications, even though they could avert catastrophic events. So we have a healthcare system that ignores science, side-steps economics and leaves patients exposed. We have forgotten that insurance is about pricing risks.
There is a strong case—economic, ethical and clinical—for India to shift from reactive hospitalization to proactive health management. Here’s why preventive medication must be included in health insurance.
It will lower long-term healthcare costs: Covering preventive drugs helps avoid costly hospitalizations and surgeries later.
It encourages early intervention: People are more likely to take essential medication if it’s affordable and accessible.
It enables a shift to proactive care: It aligns with global priorities on wellness and chronic disease management.
It promotes equity: Preventive drug coverage can bridge India’s healthcare gaps across geographies and income levels.
Health insurance reforms must begin with these changes, reflecting the clinical and epidemiological realities of our times. Apart from making claim processes smoother, for which efforts are being made, we should include chronic-disease management—such as diabetes, hypertension and hyperlipidemia—in basic health plans, mandate that preventive drugs approved under standard treatment protocols be covered or subsidized, and push insurers towards a ‘value-based coverage’ mindset—just as it is in the US, where illness prevention is seen as worthy expenditure.
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Beyond what is—or isn’t—covered, there’s another problem: the consumer experience. When policyholders engage with health insurers, they often feel ignored, dismissed and even defeated. The paperwork is burdensome and claims are denied too often. Customer service is slow, opaque, and unhelpful. To call the system ‘unfriendly’ would be generous. At its worst, it feels hostile.
The industry faces a trust deficit. Closing it requires more than new products. It demands consumer orientation that goes beyond promises of faster claim settlement. Covering preventive medication would make a big difference. Drugs that are clinically proven to reduce emergency hospital admissions are often expensive and need wider usage.
Finally, how we assess success in the health insurance industry needs a relook. Today, insurers celebrate premium growth and claim ratios. But these internal metrics say nothing about public health outcomes—or the policy-holder’s actual well-being.
If health insurance is meant to serve public-health goals, then it needs more meaningful yardsticks. We need to ask:
One, how many hospitalizations were prevented through early intervention?
Two, how many people with chronic illnesses improved their clinical indicators?
Three, how many policy-holders maintained good health over five years because of policy-supported care?
The above is what a functional and consumer-first insurance model should track. These metrics must also become central to how the IRDAI evaluates the sector’s performance. The regulator should move beyond its comfort zone of regulating forms, ratios and solvency margins, and act with more vigour as a custodian of consumer trust and public health. This is a vital sector and must not be allowed to underperform.
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The longer we delay such a shift, the steeper the price we will pay through overburdened hospitals, squandered premiums and a deepening chasm of distrust between citizens and insurers. If every approved pill is not covered and every illness is not fought as it develops, it amounts to a betrayal of the broad promise of health coverage. We cannot really call it ‘care’ if it only begins at the hospital door.
The author is a corporate advisor and author of ‘Family and Dhanda’.
