Will my insurance cover daycare treatment of retinopathy? | Mint

I have been diagnosed with diabetic retinopathy. The doctor recommends intravitreal injections over a few months. It’s a daycare procedure and doesn’t require hospitalisation. However, it is an expensive treatment. Will my health insurance cover the expenses? 

-Name withheld on request

Insurance coverage for intravitreal injections, an essential treatment for diabetic retinopathy, depends on the specific terms and conditions of an individual’s health insurance policy. The Irdai circular (IRDAI/HLT/REG/CIR/117/09/2019) mandates that all insurers cover modern therapies, which include intravitreal injections. These procedures are covered when medically indicated, regardless of whether they are conducted as inpatient treatments, domiciliary hospitalizations, or daycare procedures in a hospital. This regulatory framework ensures broader accessibility for patients needing these advanced medical treatments.

While the mandate provides a strong foundation for coverage, there are essential considerations that patients must keep in mind. Many insurers require pre-authorization for such procedures, and obtaining this approval often hinges on submitting the correct documentation. It is crucial to have a medical necessity certificate and other supporting documents from the treating doctor to avoid any claim-related hurdles. 

Additionally, certain policies may have sub-limits or specific restrictions regarding treatments for conditions like diabetic retinopathy. These limitations can affect the amount reimbursed, making it imperative for policyholders to thoroughly review their insurance documents for clarity.

Another critical factor is whether the condition falls under the category of pre-existing diseases. If diabetes or its associated complications, such as diabetic retinopathy, are classified as pre-existing conditions in the policy, they may be subject to a waiting period. The duration of this waiting period varies across policies, so it is essential to confirm its completion before proceeding with a claim.

Comprehensive health insurance plans may also cover retinal examinations when they are deemed medically necessary. Patients should review the inclusions and exclusions in their policies to ensure coverage extends to both the diagnostic and treatment phases of diabetic retinopathy management.

To avoid unexpected challenges, policyholders should proactively consult their insurers or third-party administrators (TPAs) for details about coverage, pre-authorization requirements, and any associated sub-limits. Understanding the policy’s terms and staying informed about documentation requirements can significantly streamline the process of filing a claim for intravitreal injections.

Shilpa Arora is co-founder and chief operating officer at Insurance Samadhan.