Health insurance firms are denying us coverage, some organ donors allege

In 2009, Dr Ravi Wankhede, a pathologist and resident of Nagpur, donated one of his kidneys to a friend. Wankhede saved his friend’s life but his altruism might have cost him his health insurance.

When Wankhede turned 65 two years ago, his health insurance company told him that his policy could not be renewed because the company does not cover people older than 65. Assuming that this was common practice, Wankhede approached another private company, which specifically has health insurance for elderly people. To his dismay, this company also rejected his request. Wankhede believes that the company refused him insurance because he now has only one kidney.

“I got a reply which said ‘was rejected as per guided by our underwriting policy that endeavors to group individuals who exhibit homogeneous risk profiles’,” said Wankhede. “I had disclosed in my application that I was a kidney donor, which worked against me.”

Health insurance companies conduct health screenings of prospective clients, who have to disclose all known pre-existing medical conditions and answer questions about their lifestyles. This information is used to evaluate the application for health coverage – a process called medical underwriting – to calculate the chances that the person being insured filing a claim over a period of time, on the basis of which the application is rejected or accepted and the insurance premium calculated.

The companies create risk pools, which are groups of people whose predicted claims are combined in order for underwriters to calculate premiums at a rate that is meant to allow the company to pay claims while making a profit. This means the costs are effectively shared by all members of the pool, and the claims made by the less healthy are subsidised by the relatively fewer claims made by the healthy.

Scroll.in contacted Cigna TTK about why Wankhede’s proposal was denied. “The customer’s proposal was not accepted as per the filed underwriting guidelines. As per our policy we do not disclose confidential customer information,” a company spokesperson responded by email. While the insurance company has refused to clarify what it means by “homogeneous risk profile”, it seems that it judged that including Wankhede in the group could lead to higher insurance payouts.

A third insurance company rejected Wankhede’s application for health insurance without even asking for his medical tests. Wankhede had disclosed in this application that he had donated a kidney.

Wankhede has registered complaints with the companies he applied to for insurance as well as with the Insurance Regulatory and Development Authority of India contending that he has been denied insurance because of discriminatory policies against organ donors. He has not received responses to any of his complaints.

When Scroll.in repeatedly tried to contact TS Vijayen, the chairman of the Insurance Regulatory and Development Authority of India, about Wankhede’s complaint, he refused to comment.

A major deterrent

Wankhede said that he would have reconsidered his decision to donate his kidney if he had known that he would struggle to get health insurance. “I am sure that many donors would be discouraged from donating if they were aware that insurance companies would discriminate against them,” said Wankhede.

As it stands, the incidence of chronic kidney disease in India is rising and there are already too few kidney donors.

Doctors fear that people may be discouraged from donating organs, if they find out that insurance companies are not going to provide them with health coverage after donating their organs. In March 2017, resident of Beed district in Maharashtra Savitri Toshniwal donated a part of her liver to her husband who was suffering from end-stage liver failure caused by a tumour. The cost of the surgery was about Rs 25 lakh. The family took multiple loans from relatives and sold their land.

“My father’s surgery was unexpected,” said Vijay Toshniwal, son of the donor and donee. “My father had an insurance policy but it didn’t cover organ transplant surgeries.”

In June, the family decided to get a find health insurance coverage that would cover all its members. Vijay Toshniwal contacted an insurance agent who said he would be able to get health coverage for everyone, except Savitri and her husband.

“We understand that my father was not eligible for insurance because he underwent a liver transplant,” said Vijay Toshniwal. “But my mother is completely healthy.”

The insurance agent told the family that even if Savitri Toshniwal received health coverage, she would have to pay a very high premium and that the chances of her health claim being rejected were higher because she had undergone major surgery.

Opaque system

Scroll.in contacted several health insurance companies which claimed that they provide health insurance to individuals who have donated organs. However, none of the companies disclosed how many organ donors they had insured, citing company policy.

Sanjay Datta who is the chief of underwriting and claims at ICICI Lombard said that organ donors who have not suffered any complications from the transplant surgery and do not have pre-existing diseases or conditions can apply for insurance. “The acceptance of proposal is subject to the company’s medical underwriting guidelines,” he added.

Bhaskar Nerurkar, head of the health administration team at Bajaj Allianz General Insurance, said that his company provides health coverage to organ donors. “Coverage for person who has already donated an organ depends on various parameters viz. which organ was donated, when the surgery was conducted, what are the current pathology parameters, age of the prospect,” he said in an email interview.

Sandeep Patel, CEO and MD of Cigna TTK, said that the company considers multiple factors while deciding a prospective client’s risk category like age, gender, occupation, nature of job, what he wants to be insured for, the sum that he has opted to be insured for, family medical history, lifestyle habits and health status. “Medical history of organ donation is just one of the factors in deciding the risk class.”

Case by case

The challenge, doctors say, is a “case to case” policy that most companies adopt. “They [insurance companies] give flimsy reasons to reject the application of organ donors,” said Dr J Amalorpavanathan, former secretary of Transplant Authority of Tamil Nadu, who says that he has heard of cases of companies denying insurance to organ donors. “These companies are holding on to some archaic rules that say that if an organ is missing, the person should not be insured.”

Dr Vivekanand Jha, president of International Society of Nephrology, said that organ donors are healthy individuals as they undergo more extensive medical investigations than other health insurance applicants. “Ideally the government and the health system should ensure that an organ donor has health insurance,” said Jha. “It should be coinciding with the donation.”

But what happens to donors like Wankhede? “The premise is that the act of donation should not be seen as a risk,” said Jha. “Organ donors are doing a service to the society and they should be protected and not discriminated against.”

Dr Shrirang Bichu, a nephrologist from Bombay Hospital, and Dr Ravi Mohanka, a liver transplant surgeon, have both heard donors complain about not getting health insurance. “Companies have to understand that an organ donor is an healthy individual and there is no literature to suggest that organ donors are at higher risk of any medical complication as a result of donating the organ,” said Mohanka.

Dr Vimal Bhandari, director of the National Organ and Tissue Transplant Organisation, said that insurance companies should not deny health insurance to organ donors. “We will look into the matter urgently,” he promised. “We should be grateful to them [organ donors] and not penalise them for donating organs.”