What are the limitations of health insurance for Ayush treatment?

The government has been pushing for alternative treatments and so have regulatory initiatives such as the Insurance Regulatory and Development Authority of India (Irdai) mandating that Ayush (ayurveda, yoga and naturopathy, unani, siddha and homeopathy) treatments be covered by health insurance products.

It told all insurers to mandatorily offer, from 1 April 2020, Arogya Sanjeevani, a standard health insurance product that will cover Ayush treatments up to the sum insured. Some health insurance policies covered Ayush treatments earlier too, but with a sub-limit on the sum insured. Irdai first asked insurers to provide alternative treatment coverage in 2013, but the uptake of these treatments has picked up in recent years. “In the last three years, we have seen a huge increase in the demand for alternative treatments and medicines,” said Adarsh Agarwal, appointed actuary at Digit General Insurance Ltd.

The Ayush system is based on natural ingredients, but it can also include drug therapies to cure specific diseases. We tell you how Ayush benefits work under a health insurance policy, the key inclusions and exclusions, and what to keep in mind when taking a cover for Ayush treatments.

What do you get?

Arogya Sanjeevani as well as some other health insurance policies cover Ayush treatment. “If your policy has in-patient benefits for Ayush, then any treatment, which is an alternate procedure, is also covered under that plan. So, if you get admitted to, let’s say, an ayurveda hospital that may also be covered in the exact same way that normal treatments are covered,” said Amit Chhabra, business head, health, Policybazaar.com, an online marketplace for insurance.

Coverage: Arogya Sanjeevani covers Ayush treatments up to the sum insured, which has to be a minimum of  ₹50,000; there’s no upper limit.

“This is the first step towards recognition of Ayush treatment. In Arogya Sanjeevani, the product features are uniform across the industry and the companies are mandated that they should cover Ayush,” said Dr S. Prakash, managing director, Star Health and Allied Insurance Co. Ltd. Further, pre-hospitalization (30 days prior to admission) and post-hospitalization expenses (60 days from discharge) are also included in this plan.

Other health insurance policies usually cover Ayush treatment up to a maximum limit of ₹50,000. “Different policies have different limits. Some policies cover it till the sum insured. In some cases, there are caps on coverage. For example, Ayush coverage may be around 10% of the sum insured,” said Chhabra.

Cost: Overall, such treatments for certain ailments are said to be a lot more cost-effective than modern medicine. “There are some neurological, psychosomatic and chronic dermatological diseases where Ayush has been able to address issues at a lesser cost, particularity in semi-urban and rural areas,” said Prakash, who has a master’s in surgery.

Where can you get it? According to recent guidelines, Irdai classifies Ayush hospital as a healthcare facility wherein medical or surgical treatment procedures are carried out by Ayush medical practitioners having at least five in-patient beds and a qualified medical practitioner in charge. Citing National Health Portal data, Agarwal said that there are around 98 Ayush hospitals till July 2020 that have been set up in the country.

Further, hospitals in Ayush sectors do not necessarily need the National Accreditation Board for Hospitals and Healthcare (NABH) certification to be able to tie up with health insurers.

The Limitations

The Ayush benefits come with certain limitations currently, both for the insurers as well as the policyholders.

For insurers: Distinguishing the right practitioner is a challenge insurers are facing. “Ayush has its benefits, gives a remedy for some of the medical challenges in allopathy, but the biggest limitation is how to distinguish the right Ayush practitioner,” Prakash said.

The fear of misuse and abuse in terms of alternative treatments has also driven insurers to offer Ayush cover with some limited benefits. “We respect the system and acknowledge the benefits in select areas out of Ayush, but the biggest challenge is to identify the right connect and the right place where an evidence-based treatment is given,” he said.

Lack of clarity and quality control is another issue for insurers. “Ayush treatment is acceptable in certain cases, but overall there is a big question mark on the studies to determine the efficacy and the quality control of its medicines. Unless these issues are addressed, there is a big risk of having such treatments covered under insurance. People will tend to misuse it, as there are no indicators that can be monitored and there is lack of a standard line of treatment,” said Dr Bharat Gadhavi, president of Ahmedabad Hospitals and Nursing Homes Association (AHNA).

For policyholders: Alternative treatments such as homeopathy, unani or ayurveda in most scenarios are out-patient, and health insurance mostly covers in-patient treatment. This means that consultation or evaluation expenses for Ayush treatment may not get covered. “To claim for the expenses, one needs to be hospitalized for at least for 24 hours. Also, any preventive and rejuvenation treatments that are not medically necessary won’t be covered under Ayush benefits,” said Agarwal.

Further, treatment at a health care facility that is not approved and not a hospital is excluded, so choose the practitioner carefully.

While general health insurance offering Ayush benefits caps the claim amount, the Arogya Sanjeevani has a 5% co-pay (fixed out-of-pocket amount paid by the insured) and 2% sub-limit on room rent (the insurer will pay only up to 2% of the sum insured as room rent). The cost of other procedures are usually calculated based on the room rent.

To get the Ayush benefit, you might have to pay extra premium in case of a general health insurance plan.

Further, only a few insurance companies offer cashless treatment, and the majority of the claims are reimbursed later on the basis of bills.

Consider all aspect before opting for this plan.