Does Health Insurance Cover Treatment of Genetic Disorders?

• Written by Nidhi Goyal

  Reviewed by Munmi Sharma

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A genetic disorder is a disease that occurs due to any abnormality in the genome, i.e., the genetic material of a person. Earlier, people suffering from genetic diseases faced difficulties in getting health coverage. However, as per the recent guidelines of the Insurance Regulatory and Development Authority of India (IRDAI), genetic diseases or disorders will no longer be excluded from health insurance policies.

Health insurance companies will now cover genetic disorders under a standard health insurance policy. It is a significant move, especially since getting health insurance for genetic disorders in India will now be possible. It would enable these individuals to avail themselves of quality medical care without worrying about the expenses.

Genetic Disorders: Now are not a Part of the Exclusions

According to the guidelines issued in September 2019 under the Standardisation of Exclusions in Health Insurance Contracts, the IRDAI has standardised the wording of exclusions.

The treatment of internal congenital diseases, genetic diseases or disorders, mental illness, stress or psychological disorders and neurodegenerative disorders, puberty, and menopause-related disorders will now be covered in health insurance policies.

Also, the usage of drugs, stimulants or depressants prescribed by a medical practitioner will become a part of health insurance coverage.

Truth About Coverage of Genetic Disorders

Prince, a marketing professional who was diagnosed with a genetic disorder. He was worried about the treatment cost, constantly thinking, “is genetic testing covered by insurance?” But as he scanned through the policy documents, he realised that genetics is a broad term, and not all conditions are treated equally.

1. Coverage for genetic disorders isn’t universal. It means the coverage of genetic disorders in health insurance depends on policy terms, insurer’s guidelines and exclusions.
2. It is a myth that genetic disorders are fully covered because of court rulings. You must read the policy terms and conditions thoroughly, which Prince missed doing.
3. Insurance claims for genetic disorders are subject to policy terms and conditions. For example, there is a waiting period of a maximum of 36 months or as per policy terms.
4. Not all chronic or inherited conditions are automatically covered.

What could Prince do to be in a better position?

He needed to carefully review his policy exclusions, as health insurance for genetic disorders in India needs more clarity.

Also Read: How can Genetic Testing help Identify Genetic Disorders?

What to Look for in a Health Insurance Policy if You Have a Genetic Disorder

While genetic disorders can no longer be excluded outright from health insurance coverage (as per IRDAI’s directive), not all policies offer the same level of financial protection. There are still certain fine-print conditions that can affect your eligibility for claims or access to treatment. Here’s what to keep an eye on:

1. Check for Exclusions Beyond the Basics

Insurers may still exclude specific treatments, procedures, or advanced therapies, especially if they’re considered experimental or non-standard.

For example, a policy may cover blood transfusions for Thalassemia but exclude bone marrow transplants. Gene therapy, which is still emerging and costly, may not be covered under standard plans.

2. Pre-existing Condition Clauses

Many genetic disorders are diagnosed early or may be known at the time of purchasing insurance. These are often classified as pre-existing conditions.

What to look for:

• How does the insurer define a pre-existing condition?
• Does your plan cover pre-existing genetic disorders after a waiting period?
• Are there any permanent exclusions applied to your condition?

3. Waiting Periods

Insurance claims for genetic disorders come with some terms and conditions. Most health insurance policies have a waiting period before coverage for certain conditions begins, especially pre-existing ones. For example, our family health insurance comes with a waiting period for-

• Initial waiting period: 30 days
• Named Ailments: 24 months
• Pre-existing conditions: 36 months

But, you can reduce the waiting period with add-ons, Instant Cover or PED Modification. With the help of these add-ons, you can reduce the waiting period to 30 days and 1 or 2 years, respectively.

4. Coverage Limits: Will insurance cover genetic testing?

Genetic disorders often require specialised diagnostic tests such as DNA sequencing, genetic screening, or advanced imaging, all of which can be expensive. In addition, some treatments like gene therapy, enzyme therapy, or stem cell procedures involve high costs and may not be covered in full.

Key things to review:

• Are genetic diagnostic tests covered under the policy?
• Is there a financial cap on these tests or advanced treatments?
• Are modern or emerging treatment options included?

What Does the Future Look Like?

India’s health insurance industry is witnessing rapid evolution. Over 70 million people in India live with rare diseases. The country has been facing challenges in maintaining the number, but-

• Genetic disorders may soon become more treatable with advances in biotech, gene therapy, and personalised medicine. Treatments like gene editing for rare genetic disorders are changing the future.
• IRDAI (Insurance Regulatory and Development Authority of India) continues to refine its guidelines. Hence, it brings new relief and better clauses for policyholders.
• Awareness about genetic disorders is increasing, and so is the demand for more comprehensive coverage.

Why is Health Insurance Necessary?

In today’s world, where even genetic disorders like diabetes, heart disease, and certain rare conditions can unexpectedly impact lives, health insurance is more than just a financial tool; it’s a form of preparedness. With advancements in policy coverage, these once-excluded conditions are now part of many comprehensive plans. When illness strikes, your focus should be on recovery, not the rising cost of treatment. The cashless treatment provides sheer convenience. Thus, health insurance protects your savings and gives you uninterrupted access to quality care when it matters most.

Disclaimer: Underwriting of claims for Genetic Disorder is subject to policy terms and conditions.