Intravitreal injection claim rejected or cut?
Intravitreal injections (such as anti-VEGF drugs) are given into the eye to treat conditions like wet macular degeneration, diabetic macular oedema and retinal vein occlusion. They are given in a clinic or day care setting, often as a course of several injections. If your insurer has rejected or cut the claim, these are the reasons that come up most for intravitreal injections, the rules that apply, and what to do next.
Why intravitreal injections claims get rejected or cut
- “OPD treatment, not covered”: the injection takes minutes, so insurers sometimes treat it as outpatient care.
- A sub-limit on modern treatments that caps the amount per injection or per year.
- Pre-existing disease: if the eye problem comes from diabetes, the insurer may say the diabetes was not disclosed.
- “Age-related macular degeneration excluded”: some policies exclude ARMD, and the insurer may apply this even when the injections were for a different eye condition.
- A named drug rejected on the basis of an internal circular or guideline that isn’t part of your policy.
Rules that apply
- Under 24 hours in hospital: check your policy’s day care list. If intravitreal injections is on it, a short stay is no reason to reject.
- Intravitreal injections is on IRDAI’s list of modern treatments. Any sub-limit must be written in your policy wording.
What decided these disputes
In 19 published Insurance Ombudsman awards on intravitreal injections claims that we reviewed, the policyholder got paid in full or in part in 89% of cases. Past awards don’t predict any one case.
- Records showing the injection was given in an operation theatre under sterile conditions often decided whether it counted as covered treatment rather than OPD care.
- Where the policy wording didn’t specifically exclude the drug or the eye condition, rejections based on internal circulars generally did not stand.
- Where the policy clearly excluded the condition treated, such as age-related macular degeneration, the exclusion was usually applied as written.
Documents to keep ready
- The retina specialist’s treatment plan with the number of injections advised
- OCT scan reports before treatment
- The drug invoice with its batch number for each injection
- The discharge summary, the itemised final bill and the rejection or settlement letter
How to challenge the decision
Write to the insurer’s Grievance Redressal Officer, who must reply within 14 days. If that fails, use Bima Bharosa or go to the Insurance Ombudsman within one year. The guides below have the letter format and the steps.
Questions people ask
Are intravitreal injections covered by health insurance?
They are on IRDAI’s list of modern treatments that insurers should endeavour to cover. Most policies cover them, often with a sub-limit. The sub-limit must be stated in your policy wording.
Each injection is a separate claim. Does that matter?
Each one is usually claimed separately. Keep the treatment plan and OCT reports with every claim so each is clearly part of the same advised course.
Is a full course of injections covered, or only the first?
Each injection is usually claimed and assessed on its own. If your policy has a per-injection or yearly sub-limit, it applies across the course, so check how much is left before each one.
Does it matter that the injection was given in an operation theatre?
Yes. Records showing it was given in an operation theatre under sterile conditions by a retina specialist, with observation afterwards, help show it was a procedure and not routine OPD care.