Insurance for diabetes

Health costs are a major expenditure for any society. The burden of health care increases exponentially when a chronic disease such as diabetes mellitus reaches epidemic proportions. Although some societies bear this burden through social security programs, others leave the onus of health care upon the individual concerned. In many countries, health insurance companies step in to fill this void, by providing various schemes to offset the financial burden of unexpected disease. This prevents the “medical bankruptcy”[1] so frequently observed in “pay-from-pocket” environments, where patients have to bear the economic costs of treatment on their own.

India has a comprehensive public health program, delivered through an impressive network of primary health care centers, community health centers and civil hospitals. This is supplemented by Government - owned Medical Colleges and referral institutes. The Indian Public Health Standards and National List of Essential Medicines provide basic standards to meet at each level of health care and offer a bench mark against which health care system performance can be assessed.[2] [3] [4] [5] [6] [7] [8] [9] This large system, however, is unable to meet the ever - increasing health demands of the population, especially as chronic disease, including diabetes mellitus, become more and more prevalent.

The private sector, therefore, pitches in to fulfill this demand. The need to pay from pocket, to avail private health care facilities, however, puts avoidable stress upon the sick. Again, this is truer for people living with diabetes, who bear a disproportionate proportion of medical costs,[10] both outdoor and indoor.

In fact, one can rightfully list financial strain or “wallet complications” along with the other chronic macro- and micro-vascular complications of diabetes. Financial strain may also be a cause of poor glycemic control and may contribute to vicious cycle of hyperglycemia: Financial challenges lead to suboptimal health care, which worsens diabetes, which then leads to complications, which in turn increase the cost of management and increase wallet complications. The health insurance industry ostensibly provides coverage to offset such challenges, even though they are limited to people living with type 2 diabetes or with pre-diabetes.

The health insurance industry had for a long time kept diabetes as exclusion factor for providing health insurance for any individual. Any individual with pre-existing diabetes would not get reimbursed or insured for any diabetes related complication. However, this scenario is changing and several new schemes have been initiated for individuals with diabetes. Certain offerings, however, leave much to be desired. One diabetes health insurance scheme covers six critical illnesses or complications of the syndrome, but with riders which defeat the very purpose of medical insurance.[11] Although heart attack is insured, stable and unstable angina are excluded from payment benefits. Similarly, coronary artery bypass grafting is insured, but all forms of angioplasty and minimally invasive cardiac surgery are excluded. Though cancer is covered for payment benefits, early stages of the disease are excluded, with specific mention being made of two endocrine tumors: Papillary micro carcinoma of the thyroid and carcinoma prostate with a Gleason score of six or less. In the same vein, stroke, end stage renal disease requiring regular dialysis or transplant, and major organ transplants are included as critical illness, but transient ischemic attacks, end stage renal disease not requiring dialysis and stem cell transplants are listed as not being acceptable for payment.[11]

The insurers do use a diabetes control index to practice risk stratification[11] and reduce premiums if adequate composite endpoint goals are achieved by their clients. While this strategy may work in the early stages of diabetes, it is not effective for persons with relatively advanced chronic complications.

Another insurance provider offers insurance only for “diabetic foot ulcer requiring micro vascular surgical correction,” thus excluding the vast majority of foot ulcers, which are neuropathic in origin, or need amputation. The provider agrees to pay for “diabetic retinopathy requiring laser treatment of the eyes” and “diabetic nephropathy leading to chronic renal failure,” but excludes the major costs associated with the syndrome: Treatment of type 2 diabetes and cost of immune suppressive drugs and medicines. These riders create a disadvantage for persons with diabetes, who are refused reimbursement for the vast majority of their expenses.[12]

Yet another diabetes insurance extension, which requires extra premium, allows payment only for retinal laser therapy and limb amputation, not for simpler forms of treatment.[11] This in effect means that preventive efforts on part of the physician and the person with diabetes, to prevent progression of chronic complications such as retinopathy, neuropathy, peripheral arterial disease or cardiovascular disease, are not encouraged. Rather, failure to achieve effective control is rewarded in the form of payments when “incurable” stages of illness are reached.

While medical insurers look at diabetes insurance as a commercial product, to earn profit from, endocrinologists and other diabetes care providers view it as a means of help and support for patients under their care. The fine print associated with most of the diabetes insurance products in India makes them meaningless for the majority of people living with the condition.

The Insurance Regulatory and Development Authority (IRDA) have recently issued guidelines for the standardization of medical terminology and equipment.[13] These guidelines seek to bring clarity and consensus to a field hitherto marked by confusion and adhoc-ism. These comprehensive guidelines are relevant from an endocrinology perspective. IRDA specifically excludes payments for many important endocrine interventions including “weight control programs supplies, services,” hormone replacement therapy, “infertility, assisted conception procedure,” obesity (including morbid obesity) and hospitalization for evaluation/diagnostic purpose.

The guidelines also mention that “diabetic chart charges” are not payable, though “nutrition planning charges, dietician charge, diet charges” are payable if supported by a prescription. Diabetic foot wear is clearly excluded from the list of payable items.[13]

The Endocrine Society of India has been a strong votary of advocacy for patients with diabetes and other endocrine diseases. Concern for well-being of persons with endocrinopathy is manifested in clinical care, educational activities and public awareness campaigns. We need to extend these activities, to address issues which affect patients in our care. Ensuring adequate health insurance coverage for people with diabetes, through pragmatic schemes, delivered at low costs, is one of our duties. The Journal of Social Health in Diabetes strongly advocates for diabetes-friendly insurance regulation in India, to help minimize the financial complications of diabetes.

How to cite this article: Sahay R, Das AK, Kalra S. Insurance for diabetes. J Soc Health Diabetes 2014;2:64-6.

Source of Support: Nil.

Conflict of Interest

None declared.

• References

• 1 Nettleman MD. Betting the farm: Medical bankruptcy. S D Med 2013; 66: 399
• 2 National list of essential medicines of India. Available from: http://www.cdsco.nic.in [Last updated on 2012 Oct 06].
• 3 Indian Public Health Standards (IPHS). Guidelines for Sub-Centres. Available from: http://www.mohfw.nic.in/NRHM/IPHS_Revised_Guidlenes_2012/Sub_Centers.pdf [Last accessed on 2012 Nov 26].
• 4 Indian Public Health Standards (IPHS). Guidelines for Primary Health Centres. Available from: http://www.mohfw.nic.in/NRHM/IPHS_Revised_Guidlenes_2012/Primay_Health_Centres.pdf [Last accessed on 2012 Nov 26].
• 5 Indian Public Health Standards (IPHS). Guidelines for Community Health Centres. Available from: http://www.mohfw.nic.in/NRHM/IPHS_Revised_Guidlenes_2012/Community_Health_Centres.pdf [Last accessed on 2012 Nov 26].
• 6 Indian Public Health Standards (IPHS). Guidelines for Sub-District/Sub-Divisional Hospitals (31-100 Bedded). Available from: http://www.mohfw.nic.in/NRHM/IPHS_Revised_Guidlenes_2012/Sub_District_and_Sub-divisional_Hospital.pdf [Last accessed on 2012 Nov 26].
• 7 Indian Public Health Standards (IPHS). Guidelines for District Hospitals (101-500 Bedded). Available from: http://www.mohfw.nic.in/NRHM/IPHS_Revised_Guidlenes_2012/District_Hospital.pdf [Last accessed on 2012 Nov 26].
• 8 Kalra S, Das AK, Chowdhury S, Shah S. Indian Public Health Standards 2012 and the diabetes pharmacopoeia. Indian J Endocrinol Metab 2013; 17: S1-S3
• 9 Kalra S, Bajaj S, Mithal A. Endocrinology and the essential list. Indian J Endocrinol Metab 2012; 16: S133-S135
• 10 Ramachandran A, Ramachandran S, Snehalatha C, Augustine C, Murugesan N, Viswanathan V. et al. Increasing expenditure on health care incurred by diabetic subjects in a developing country: A study from India. Diabetes Care 2007; 30: 252-256
• 11 Why diabetes care?. Available from: http://www.iciciprulife.com/public/Health-plans/DiabCare.htm [Last accessed on 2013 Dec 15].
• 12 Health insurance for diabetics. Available from: http://www.medimanage.com/my-health-insurance/medical-insurance-articles/health-insurance-for-diabetics.aspx [Last accessed on 2013 Dec 15].
• 13 Guidelines on Standardization in Health Insurance. Available from: http://www.irda.gov.in/ADMINCMS/cms/Uploadedfiles/Guidelines%20on%20Standardization%20in%20Health%20Insurance%2020-02-2013.pdf [Last accessed on 2013 Dec 15].