Peritoneal Dialysis in Health Insurance: Coverage, Eligibility, Costs, and Claims Process (India)

Chronic Kidney Disease (CKD) is on the rise in India, and peritoneal dialysis (PD) is increasingly prescribed as a home-based alternative to haemodialysis. While many assume health insurance will cover all dialysis procedures, coverage for PD varies significantly across insurers and often depends on plan benefits, sub-limits, and fine-print exclusions.

For patients and families, the lack of clarity can lead to unexpected out-of-pocket expenses, delayed treatment, and claim disputes.

This guide explains how health insurance covers PD in India, what to check before treatment, and how to file a successful claim.

Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen (peritoneum) to filter blood.
It is typically performed at home, making it more convenient than in-centre haemodialysis.

Common types:

1. CAPD (Continuous Ambulatory Peritoneal Dialysis)
   
2. APD (Automated Peritoneal Dialysis)

Cost: ₹40,000–₹70,000 per month depending on frequency, disposables, and medications.

Yes, most modern health insurance plans cover peritoneal dialysis — but conditions apply.

Coverage depends on:

1. Type of plan (basic, disease-specific, or comprehensive)
   
2. Day-care coverage terms
   
3. Sub-limits on renal treatments
   
4. Consumables coverage
   
5. Waiting periods
   
6. Co-payments & deductibles

Important: Under IRDAI guidelines, dialysis is recognised as a day-care procedure, so it should not require 24-hour hospitalization to be covered.

However, home-based dialysis consumables are not always covered. Some insurers accept them; others deny.

1. Hospitalization for PD catheter insertion
Covered as surgery/day-care subject to policy terms.

2. In-hospital dialysis sessions
Usually covered, up to policy limits.

3. At-home dialysis procedures
Coverage varies:

1. Some insurers cover consumables with bills + prescriptions
2. Others deny under “domiciliary treatment”

4. CAPD/APD machines
Generally not covered, except under specific plans or riders.

Before beginning treatment, evaluate the following:

1. Disease Waiting Period

1. Pre-existing disease (PED): 2–4 years
2. Specific kidney disease waiting period: may apply

2. Day-Care Procedure Coverage
Must explicitly include dialysis.

3. Consumables & Equipment
Check coverage for:

1. Dialysis kits
2. Dialysate fluids
3. Tubing
4. Masks & disinfectants

4. Sub-limits
Renal treatment may have limits like:

1. ₹10,000–₹20,000 per session
2. ₹50,000–₹2 lakh per year

5. Co-payment
Senior citizen plans often have:

10%–30% co-pay on all claims

6. Hospital Network
For cashless claims, choose network hospitals.

You can claim PD in two ways:

1. Cashless (if treatment done in-network hospital)
   
2. Reimbursement (home dialysis or non-network)

1. Select a network hospital
   
2. Share policy and ID proof
   
3. Submit doctor prescription & diagnosis
   
4. TPA verifies eligibility
   
5. Treatment proceeds
   
6. Final bill settled directly with insurer

1. Co-pay
   
2. Non-medical items
   
3. Charges beyond sub-limits

1. Collect all monthly bills and prescriptions
   
2. Maintain treatment records, frequency, dosage
   
3. Submit the following to insurer:

• Doctor prescription for PD
  
• Discharge summary (if applicable)
  
• Bills for dialysis solutions & consumables
  
• Payment receipts
  
• Diagnostic reports
  
• Claim form

4. Submit within 15–30 days of purchase
5. Track claim status through app/web

If denied, request a written repudiation letter
It helps in grievance escalation.

1. No coverage for home-based treatment under your policy wording
   
2. Claim submitted without prescription
   
3. Consumables not treated as medical necessity
   
4. PED waiting periods not completed
   
5. Sub-limit exhausted
   
6. Inadequate documentation

Tip: If insurer denies consumables, request a written reference to policy clause, not a verbal explanation.

1. Ask nephrologist to include medical necessity justification
   
2. Submit consumables bill monthly, not quarterly
   
3. Capture lot number and batch details on invoices
   
4. Avoid pharmacies without GST invoices
   
5. Keep photos of packaging if asked for verification

If rejection persists, escalate to:

1. Insurer grievance cell
   
2. IRDAI portal (IGMS)
   
3. Insurance Ombudsman (no fees)

PD may cost ₹4–8 lakh per year.
Insurance may cover 40–80%, depending on:

1. Sub-limits
   
2. Consumables coverage
   
3. Co-pay
   
4. Annual sum insured

Patients often face high financial burden, especially long-term.

These may offer better coverage:

1. Renal disease specific plans
   
2. Senior citizen comprehensive plans
   
3. High SI plans with day-care enhancements
   
4. Family floater without disease sub-limits

Avoid policies with:

1. Disease caps
   
2. Consumables exclusions
   
3. High co-pay

1. Share your policy with hospital billing team
   
2. Ask for written confirmation of coverage
   
3. Estimate monthly out-of-pocket cost
   
4. Explore top-up insurance

At Insurance Samadhan, we help patients:

• Understand policy benefits
  
• Review dialysis coverage
  
• File claims correctly
  
• Fight unfair rejections
  
• Escalate grievances

If you need help:
Upload your documents and we will guide you.

Click here to register your complaint with Insurance Samadhan

Visit our website: insurancesamadhan.com

Mail us at corporate@insurancesamadhan.com

Peritoneal dialysis is covered under most insurance plans, but benefits differ widely.
Patients often face denials or partial payments due to unclear terms, sub-limits, and documentation gaps.

To avoid financial stress:

• Validate coverage before treatment
  
• Understand sub-limits & exclusions
  
• Keep detailed documents
  
• File claims proactively

If you face rejection, don’t accept it silently—many denials can be overturned.