Experts agree that bridging the insurance gap for transplant patients require both regulatory intervention and government support.
Published Aug 22, 2025 | 7:00 AM ⚊ Updated Aug 22, 2025 | 7:00 AM
Representational image. Credit: iStock
Synopsis: In many cases, insurers rely on data from the proposal form and personal judgment, with some also considering factors like BMI to determine premium loading.
For many organ transplant recipients in India, surviving surgery is only the beginning of a long and uncertain journey. Even after a successful transplants, patients often struggle to secure health insurance, a critical safety net for managing lifelong medications, follow-up visits, and routine monitoring.
Insurers frequently classify these individuals as “high risk” and either deny new policies or impose restrictive conditions, despite medical evidence showing that with proper care, transplant recipients can live full and productive lives. The gap between medical reality and insurance practices leave patients navigating not just health challenges but financial and emotional strain as well.
The problem is compounded by a lack of clear regulatory oversight. The Insurance Regulatory and Development Authority of India (IRDAI) is yet to mandate coverage for post-transplant patients and issue binding guidelines on how insurers should assess risks.
This regulatory vacuum means that decisions often rest on the discretion of individual insurance companies, with no transparency in criteria or data to justify denials. For patients, this translates into months or years of uncertainty, high out-of-pocket costs, and in some cases, compromised health due to interrupted care.
For transplant recipients seeking health insurance, the challenge begins after surgery, particularly for those applying for a new policy. According to H S Nagaraja Rao, former senior official of National Insurance Co. Ltd., patients who already hold active insurance policies cannot be denied renewal, except in cases of fraud.
“If you have a policy and fall sick or undergo transplant, the insurance company cannot refuse renewal,” he added.
This protection, however, does not extend to individuals seeking coverage for the first time post-transplant, many of whom face outright rejection.
Rao acknowledged that insurers often consider kidney and liver transplant recipients to be ‘higher-risk’ patients, which influences their willingness to accept new policies. However, the classification is largely discretionary, and there is no scientific evidence that all transplant recipients are uniformly high-risk.
“It is left to the discretion of the insurance company whether to accept the proposal or not. If I find the risk is too much, I may avoid it,” he said.
The process of assessing risk is opaque and inconsistent. In many cases, insurers rely on data from the proposal form and personal judgment, with some also considering factors like body mass index (BMI) to determine premium loading.
“Nowadays, some insurers are going by the BMI. Beyond a certain point, they may load the premium or even reject the proposal,” Rao noted. Yet, the criteria vary widely between companies, leaving applicants uncertain about whether and how they will be accepted.
The regulatory framework provides limited guidance. IRDAI mandates that insurers file products and rate ranges but does not intervene in claims or the assessment of high-risk groups.
“IRDAI does not get into the claims portion at all,” Rao said.
The lack of mandatory rules or transparency in underwriting leaves transplant patients navigating a system that offers little clarity, even as insurers exercise broad discretion in deciding who qualifies for coverage.
Post-transplant patients face a unique set of medical and financial challenges, compounded by limited insurance coverage. Speaking to South First, Dr Elizabeth Abraham, Assistant Professor, Department of Sociology, St Teresa’s College, who conducted a PhD study on the qualitative lives of transplant recipients, highlighted that “not only are the recipients not covered under the insurance policy, but their donors are also excluded,” creating a double burden for families.
While many transplant recipients can live near-normal lives with strict adherence to immunosuppressive medication, the risk of complications remains high. Missing doses or delaying follow-ups can quickly lead to infections, organ rejection, or other severe complications.
“Because of immunosuppressive medication, they are prone to many kinds of infections because their immune system is compromised,” Dr Abraham explained. This medical reality, she noted, likely deters private insurance companies from offering coverage.
The financial burden of lifelong medication is another pressing concern. Some patients spend ₹10,000–20,000 monthly on immunosuppressants alone, a cost that is unsustainable for many families.
Dr Abraham stressed on the need for government intervention.
“The best option is that the government provides some support. Government has to take the responsibility of covering the medical cost and also providing the immunosuppressive medication at a discounted rate,” she said.
Dr Abraham suggested a broader responsibility beyond the patients themselves. Both recipients and living donors should be included in public insurance schemes, ensuring continuous care and reducing financial strain.
Drawing comparisons with the West, she observed, “In the US and other Western countries, the government provides support to ordinary sick people and to the donors. I don’t think the insurance companies will take the risk,” highlighting the limits of private insurers in addressing this critical healthcare need.
Experts agree that bridging the insurance gap for transplant patients require both regulatory intervention and government support.
Dr Abraham stressed the need for public financing, suggesting that “guaranteed inclusion in public schemes for recipients and living donors” could ensure uninterrupted care. She also recommended measures such as premium subsidies or vouchers for low-income patients, reducing the risk of treatment interruption caused by high out-of-pocket costs.
Certain state-level initiatives offer promising models. For instance, Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme covers transplant procedures up to ₹22 lakh, providing a blueprint for more comprehensive national programs.
Similarly, proposals from the National Organ and Tissue Transplant Organization (NOTTO) suggest including heart and liver transplants with lifelong immunosuppressants under Ayushman Bharat. Such measures could reduce inequities, ensuring that post-transplant patients and their donors receive the support they need.
Ultimately, experts argue that systemic reforms should balance risk assessment with patient protection. By combining government-backed coverage, transparent regulatory guidelines, and targeted subsidies, India could create a healthcare ecosystem where transplant recipients can lead healthy, productive lives without facing insurmountable financial barriers.
