Extend insurance coverage to congenital anomalies, say paediatric surgeons

Children born with congenital anomalies, be they external or internal, should benefit from insurance but few insurers include children in policies that parents take, say paediatric surgeons.

In October, the Indian Association of Paediatric Surgeons wrote to the Insurance Regulatory and Development Authority of India (IRDAI) appealing that treatment for congenital anomalies, internal or external, be included in insurance policies. In developed countries when parents take policies, their children are automatically covered for all ailments. In India, however, children with congenital anomalies are not included, they pointed out.

“An anomaly is no fault of the child or parent but a pure accident of nature. An external anomaly has a huge negative impact on the child’s quality of life and indirectly burdens the nation if not treated timely,” say paediatric surgeons. While the Pradhan Mantri Swasthya Suraksha Yojna (Ayushman Bharat) and State-sponsored health insurance schemes include children, the same does not apply when parents take policies on their own even from government insurance companies, they added.

Association president Ramesh Babu said insurance cover would especially help families excluded from State-sponsored health schemes, as they were not under the below poverty line. An earlier direction from IRDAI advised private insurance companies to not exclude congenital internal diseases but is silent on external defects. The association wants IRDAI to revise a circular including the term ‘external or internal’ as not an exclusion if parents own a policy.

In an article Reasons Behind Patients Defaulting From Elective Pediatric Urology Procedures at a Tertiary Private Teaching Hospital in South India, whichappeared in Journal of Indian Association of Pediatric Surgeons 2023, the authors Manjarie A.R., Raj S., and Babu R. said insurance denial was mainly responsible for parents postponing their children’s elective paediatric urology procedures in India. “Universal insurance coverage for congenital anomalies might help overcome this most important cause of cancellations,” the article concluded.

Ramesh Babu, one of the authors, recalled incidents where parents opted out of treatment. A three-year-old child with hernia was denied insurance as the insurer said it was an external anomaly. The parents bore the emergency surgery expenses. Another child with recurrent urinary tract infection was denied an insurance claim as it termed the condition ‘congenital’. The child went on dialysis for renal failure 15 years later.

“Studies have shown that congenital anomalies form just 3% of all causes of infant mortality. Why can’t children be covered for anomalies? It is a win-win situation for insurers as 97% of those who take the policy will not make claims,” Dr. Ramesh said. Friday will be observed as Paediatric Surgery Day, and the surgeons are hoping for relief for affected children.