Robotic surgery or modern treatment claim cut?
Newer treatments are often expensive, and they are often where policies put special limits. The rules set expectations, and your policy sets the exact cover.
The modern treatments IRDAI lists
IRDAI’s 2024 health insurance master circular says insurers shall endeavour to cover these treatments:
- Uterine artery embolisation and HIFU, balloon sinuplasty, deep brain stimulation and oral chemotherapy
- Immunotherapy (monoclonal antibody injections), intravitreal injections, robotic surgery and stereotactic radiosurgery
- Bronchial thermoplasty, vaporisation of the prostate, intra-operative neuro monitoring, and stem cell therapy (haematopoietic stem cells for blood conditions)
What “endeavour” means
This is softer than the earlier 2020 rule, which said these treatments shall not be excluded. So check your policy: most wordings have a modern treatment section, often with a sub-limit. If the policy covers the treatment with a sub-limit, the sub-limit applies; it isn’t a reason to reject the whole claim.
When a cut may be wrong
- The insurer applied a sub-limit that isn’t written in your policy or schedule.
- The whole claim was rejected when the policy covers the treatment up to a limit.
- The robotic part was cut, but the rest of the surgery, room and medicines were also disallowed.
- The letter doesn’t cite the clause it relies on.
What to do
- Find the modern treatment section and any sub-limit in your policy wording.
- Ask for the itemised settlement sheet showing what was cut and under which clause.
- Write to the Grievance Redressal Officer, then go to the Insurance Ombudsman if needed.