“Medical science in the field of arthritis has advanced significantly and insurers have to take that into consideration and design medical policies accordingly. The problem is that insurance companies classify arthritis under chronic disease. Hence, irrespective of the stage of the disease a patient is suffering from, insurers tend to reject their policies,” says Dr Shashank Akerkar, rheumatologist at Mumbai Arthritis Clinic & Research Centre.
A professional, who previously worked for a private insurance company, spoke to Business Standard to discuss why his application for a health insurance policy was rejected.
“The only reason the company and its agent rejected my application was because I disclosed that I have spondylitis. I expected a waiting period for the pre-existing condition or that the premium would be loaded, which I was willing to pay. I was open to options from companies, but they declined the policy outright,” he said, requesting anonymity.
BONING UP ON FACTS
180 mn Indians affected by arthritis
100+ rheumatological disorders listed by the World Health Organization
Of 180 mn arthritis patients, around 10% will require ‘total knee replacements’
80% of the population above 65 years of age suffer from osteoarthritis
Research studies indicate it is more likely to affect women than men in India
Under some health insurance policies, the knee replacement surgery is covered after a waiting period of two or three years, whereas if it is a pre-existing condition, it could be covered after a waiting period of four years.
Business Standard spoke to Apollo Munich Health Insurance - the company which rejected the professional’s policy - and sought to inquire into why health insurers do not cover arthritis or other joint disorders.
“We need to distinguish first between rheumatic arthritis, osteoarthritis, and rheumatoid arthritis. There are many types of arthritis - some which are covered, others which aren’t. Almost in all Apollo Munich’s health products, we cover osteoarthritis, but we make medical evaluations on the current state of the disorder. For knee replacement, we cover it after a two-year waiting period,” said Dr Bhabatosh Mishra, chief operating officer at Apollo Munich Health Insurance.
Health insurance policies fundamentally cover in-patient procedures or treatments. Given that arthritis is not an emergency condition and requires long-term outpatient treatment, like physiotherapy or pharmaceuticals, it is outside the ambit of what a majority of the health insurers do.
“The primary treatment for arthritis is a knee replacement, which can be very expensive, ranging from Rs 200,000 to Rs 250,000 per knee. If we provide cover for surgery for patients right after taking a policy, without any evaluation, that expenditure will fall on other healthy patients, at a significant premium load. Eventually, the economics of it has to work,” said Mishra.
The issue at the heart of the problem is that it is left entirely up to insurance companies, their boards, and actuaries to decide whether to cover rheumatic diseases. Experts say this is another case where the definition and coverage of pre-existing medical conditions needs regulatory intervention.
A Right To Information (RTI) request filed by the professional elicited a simple response, ‘reproducing’ provisions of the Insurance Regulatory and Development Authority’s (Irdai’s) regulations.
“Any proposal for health insurance may be accepted as proposed or on modified terms or denied wholly based on the board-approved underwriting policy. A denial of a proposal shall be communicated to the prospect in writing, by recording the reasons for denial. Provided the denial of the coverage shall be the last resort that an insurer may consider,” the RTI states.
Akerkar added that, “In many cases it has been see that if a person with a history of arthritis suddenly suffers a heart attack for which he is being treated in a hospital and has a legitimate policy cover for such an illness, insurance companies still refuse to pay claims because of past medical history in arthritis.”
The professional said that, “Even when one goes to another health insurer, the first thing they ask is if we have been rejected for a policy by another company, and if we are honest, that reduces our chances of getting cover.”
“Insurance executives say customers should be honest and upfront about their health conditions, but with such practices, insurance companies end up forcing customers to hide details,” they said.
“People who usually get arthritis are around 50-55 years old and if they have an existing policy, their treatments would be covered, but getting a new policy at that age is very tough. Most companies do not design policies for people in that age group, because it is very expensive and the exposure for the insurer is large,” said a senior insurance executive.
Business Standard sent queries to senior officials at Irdai, but did not receive any response.
“If the premium on a policy on average is Rs 15,000 and the surgery is Rs 250,000, premium ‘loading’ cannot specifically bridge that gap. Even in the case of pre-existing conditions, we still evaluate and then cover the patient, which is why there is a waiting period,” said Mishra.
While Irdai a few months ago notified insurance companies to begin designing health policies for mental illness, experts say the same is required in this area.
“Management of mental illness has been listed under the Ayushman Bharat or the Pradhan Mantri Jan Arogya Yojana. Arthritis also needs to be covered under the Ayushman Bharat scheme,” said Akerkar.