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Organ Donor Expenses Cover Under Health Insurance

Team AckoJul 16, 2021

It is possible to perform life-saving surgeries for replacing certain organs in the human body for better chances of survival. These are intricate medical procedures that require expert health care professionals and advanced technology. The related expenses are also high due to the delicate nature of the surgeries. But are such high organ donor expenses covered under organ transplant insurance? Let's understand this in detail in the following sections.

Organ Donor Expenses Cover Under Health Insurance

About organ transplant expenses cover in health insurance

Organ transplant requires a large amount of money just for performing the surgery. Next comes the hospital stay and follow-up procedures. The overall costs mount up to lakhs of rupees. These expenses can be covered under health insurance if you have the right plan. The related expenses can be covered under the donee’s health insurance policy

Are organ donor expenses covered in Group Health Insurance?

Group Health Insurance is generally available for employees of any organisation that fulfil certain basic criteria. For example, the minimum number of employees in the organisation. Employers bear the premium incurred towards providing health insurance, and the coverage is a wide array of medical situations that a person can face. Some insurance companies, like ACKO, do include a cover for these expenses under the “Donor Expenses” coverage of a Group Health Insurance Policy if the employer chooses to opt for this cover. This helps in providing a financial backup in case an employee is in need of an organ transplant.

Which type of medical expenses are incurred during organ donation?

Harvesting an organ from a donor and transplanting it to the recipient requires extreme medical attention. This is not limited to a single surgery, and the process can take several days to complete. Following medical expenses are usually incurred for organ donation.

Testing for compatibility

Checking the compatibility between the organ and the recipient's anatomy is crucial for increasing the success rate of the transplant. Medical screening or tests can confirm this.

Pre-hospitalisation

The treatment for getting the donor prepared for the surgery for harvesting the organ.

Hospitalisation and surgery

The actual cost of performing the surgery and hospitalisation.

Recovery and post-hospitalisation

The donor must take all necessary care after the organ is removed from his/her body.

Inclusions of donor cover 

ACKO covers the in-patient hospitalisation of the donor under the Group Health Insurance Plan of the insured person. Here, the insured person is the recipient of the organ. The in-patient expenses can be claimed only if the main claim for hospitalisation for the insured is approved.

Exclusions of donor cover

Exclusions are a part of a health insurance policy that states situations in which one cannot raise a claim. Following is the list of exclusions of the donor cover at ACKO.

List of conditions for organ donation in Group Health Insurance

The insured person may require an organ transplant because of an illness or injury. These may impair the normal functioning of the organ, and a replacement may be advised. Here is a list of some conditions where a doctor may suggest an organ transplant.

  • Kidney failure

  • Heart disease

  • Liver damage

  • Blood-related conditions

  • Damage to cornea

  • Lung disease

  • Dysfunctioning of heart valves

Organ donation health insurance claim case study

Mr. H suffered from chronic liver failure and was advised to undergo liver transplant surgery. He had to wait for some time before the right donor was available but was lucky enough to soon find a candidate. The liver transplant went successfully, and now was the time to file the health insurance claim. The overall cost of a liver transplant was around Rs. 25,00,000, which Mr. H paid and then filed a claim for reimbursement.

The insurance company approved the claim for liver transplant under the 'Donor Expenses' cover of Mr. H's Group Health Insurance policy as the following conditions were met.

  • The original claim for Mr. H's condition - Cirrhosis was approved

  • Organ donation was in accordance with the Transplantation of Human Organs Act, 1994.

  • The transplant took place under the medical advice of the treating medical practitioner.

The claim of Rs. 25,00,000 was partially admissible as the insurance company rejected the cost of medical screening of the donor under the exclusions of the policy. However, a significant part of the liver transplant expense was borne by Mr. H's health insurance company, greatly reducing his financial burden.

Organ donation facts in India

Here are some facts and figures related to organ donation in India.

  • Only 0.01 per cent of Indian people donate organs after death as per the WHO

  • Religious beliefs, superstitions, and lack of awareness are major reasons behind the low number of organ donation

  • Around 2 lakh people need corneal donation each year in India, according to Organ India. However, only 25% of the requirement is fulfilled.

  • More than 5 lakh people need organ transplants each year, but most of them die due to a lack of donors

  • Of total deaths in 2017, only 0.0009% of people donated their organs

  • Roughly for every 160,000 patients, only 12,000 donors are present 

How to file an organ donation claim?

The claim for organ donation expenses is similar to any other health insurance claim, with one exception. You need to submit the organ donor’s hospitalisation summary. Here are two ways of filing a health insurance claim.

Cashless claim

The insured and his donor must undergo hospitalisation for the transplant in a network hospital to avail of a cashless claim. Here the patient can intimate the insurance company and take necessary actions to file a claim at the time of admission. The insurer will contact the network hospital and settle the approved bill amount directly. The insured may have to bear the cost of deductibles and other exclusions as mentioned in the policy document.

Reimbursement claim

It is not mandatory to avail treatment in a network hospital if the insured intends to file a reimbursement claim. However, he/she must inform the insurance company about the treatment. Here, the insured will settle the entire hospital bill and then file a reimbursement claim to get the approved claim amount.

Why choose ACKO for organ donor cover in Group Health Insurance?

ACKO is a digital-first insurance company where claim settlement can be done much faster as compared to traditional health insurance companies. Here is a detailed list of benefits of buying a Group Health Insurance Policy with a donor cover from ACKO.

Paperless experience

ACKO assures paperless experiences for buying, renewing your health insurance policy and for claim settlement. We don't need physical documents, so no hassle of documentation.

Free primary care 

You can get access to primary care modules like teleconsultations, emotional assistance, wellness programs, chronic care management, and more for free from ACKO app.

Additional coverages for employees

The employer can select a set of health insurance add-ons for the employees to choose from. 

Wide network of hospitals

ACKO has access to more than 6,300 hospitals, 35,000 doctors and 4,500 laboratories across the country.

Flexible premium structure

ACKO offers a flexible premium payment structure with Monthly, Quarterly, Semi-Annual, and Annual payment options.

Frequently Asked Questions

Following are common queries about organ donation in health insurance. Please get in touch with ACKO by sending an email to [email protected] in case of more questions.

Does health insurance cover liver and heart transplants?

Yes, liver and heart transplant is covered in health insurance under the Donor expense cover.

Who will bear the cost of harvesting an organ?

You can claim the cost of hospitalisation for the donor under your health insurance policy. Thus, the health insurance company will bear the cost of hospitalisation for harvesting the organ.

What is meant by an organ transplant?

Harvesting an organ from the donor and transplanting it into the recipient is called an organ transplant. The costs of this surgery are very high, and health insurance can help reduce the financial burden.

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Category: Non-Life Insurance

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