Fifty- Six- Year- Old Ravi Sinha (name change) was taken aback when his insurance provider denied coverage for complications related to his liver cirrhosis, despite his long history of paying premiums and disclosing his drinking habits. He found himself paying out- of- pocket for his treatment, unaware that any condition directly related to his drinking would disqualify him from benefits. “Yet I had paid premiums for over five years,” he says.
Insurers often reject claims linked to conditions arising from smoking or drinking – like liver diseases and lung cancers – viewing them as deliberate risks. They fear there would be too many claims if the patient continues to smoke and drink frequently while dealing with habit- related pre- existing ailments. This would then seem like under- writing a patient’s self- indulgence. This is what dissuades health insurance companies from accepting such proposals.
“People with conditions such as liver cirrhosis are denied insurance coverage because it is mostly the result of alcohol abuse. Many patients worry about their insurance money and request us not to mention drinking as the cause of liver damage. I then tell them to change their doctor. Many patients do that, trying to get their costs reimbursed,” says Dr SK Sarin, vice- chancellor of the Institute of Liver and Biliary Sciences (ILBS).
If you are a heavy smoker or drinker, you are likely to be denied insurance coverage altogether. The disclosure may work against you for certain diseases such as liver cirrhosis or heart attacks, say insurance advisors. For those who get the policy without declaring their smoking or drinking status, their claims for unrelated diseases could be denied on investigation of medical reports.
Explains Dr Suranjit Chatterjee, senior consultant of internal medicine at Indraprastha Apollo Hospital, New Delhi, “For instance, a person is admitted to the hospital for dengue. If the insurance company realises that they did not disclose their smoking or drinking habit while vetting their claims, it may refuse to process it altogether. This can happen even though dengue is in no way related to smoking or drinking habits.”
What are Grey Areas?
While most insurance providers say that smokers and drinkers are covered, in reality they might find it extremely difficult to get coverage. “While insurance premiums go up for term plans – insurance plans that provide benefits to the nominee if the policy- holder dies – most companies do not have a separate pricing for health coverage. If a person smokes more than six cigarettes a day or drinks more than 50 ml alcohol every day, they will not be able to get an insurance policy,” says insurance advisor Aditya Shah.
Most companies do not check for smoking or drinking status prior to selling a policy but a user must declare it or risk denial of coverage. “The condition of the lungs or liver can very easily be detected on liver function tests, X- rays and scans that are routinely done when a person is admitted to hospitals. If the company finds evidence of smoking or drinking in these tests, they are likely to refuse coverage,” adds Shah. Even for those who make proper declarations, the insurer can refuse coverage for certain conditions.
However, this doesn’t mean that smokers and drinkers cannot get any coverage at all. “This is where the role of the treating doctor comes in. Coverage will be refused if they say that a certain condition is caused specifically due to smoking or drinking. All companies have a standard exclusion for self- harm in their policy wording. While this applies for, say hospitalisations due to suicide attempts, it also applies to smoking and drinking that cause harm to the policy- holder,” says Shah.
The Doctors’ Dilemma
This assessment poses a challenge for Dr Chatterjee in arriving at the right diagnosis. “Insurance providers always insist on a diagnosis. Sometimes we may treat persistent fever symptomatically without diagnosing what led to the fever. Insurance providers, however, always insist on a diagnosis,” he says. This leads to a lot of back and forth between his team and the insurance providers. “We have to answer questions just to ensure that our patients actually get covered even after they have paid their premiums.”
A Sympathetic View
Dr Sarin says that while consumption of alcohol or tobacco may be a harmful pursuit, there has to be a sympathetic approach for those who have these habits. “It is an addiction at the end of the day and they should be entitled to receive treatment,” he adds. He suggests a middle- of- the- road approach where insurance companies could charge higher premiums for people who smoke or drink – because they are at a higher risk of several diseases. “This will not only ensure that they receive timely, appropriate treatment but also honesty in reporting their smoking or drinking habits. Right now, people are worried that they will not be covered and hence do not want to give a proper history to their treating doctors,” he says.
The Cost of Tobacco Consumption
A 2020 study from India shows that for every Rs 100 that is received as excise duty from tobacco products, a sum of Rs 816 is imposed on society for its consumption. This can be in the form of direct costs such as the money spent on the treatment, transportation and living expenses incurred during treatment, among others. And indirect costs such as loss in productivity when a person misses work for treatment. “The highest impact of tobacco consumption is felt in poorer families that are more likely to pay out- of- pocket for treatments or at least the allied costs,” says Rijo M John, adjunct professor of economics at Rajagiri College of Social Sciences.
He argues that patients who have paid for coverage should not be denied claims. “The insurance products are designed by companies, so they can choose to have higher premiums for those who consume tobacco. Having paid that, there should be no grounds for rejecting claims. Increasing coverage for services such as de- addiction therapies, however, will not be effective,” says John.
“For a person who is already paying a higher premium because they are smokers, offering deaddiction services will not help much. Once you purchase the policy, what is the motivation for going for these services? People can kick their habits only if they want to. And, that intention will come only when these services are a part of the routine check- ups or consultations,” he adds. The Indian Express
