A recent report highlights that health insurers, on average, cover only about 70% of cancer-treatment expenses, leaving thousands of families to manage the remaining cost themselves. Despite having health insurance, many policyholders still end up paying lakhs out-of-pocket for chemotherapy, targeted therapy, immunotherapy and newer FDA-approved cancer drugs.
This gap between coverage promised and coverage received is where most claim disputes arise — and where awareness is urgently needed.
Where the Gap Began: IRDAI Guidelines of 27 September 2019
The IRDAI Standardisation of Exclusions Guidelines (2019) provided benchmark rules for what treatments could or could not be excluded under a health insurance policy. While it was a progressive move at the time, these guidelines did not anticipate the medical advancements that emerged afterward — especially in cancer care.
Since 2019, oncology has seen tremendous breakthroughs:
- Targeted drugs
- Immunotherapy & monoclonal antibodies
- Oral chemo drugs
- Personalised & gene-based cancer therapies
However, many of these fall into grey areas of policy coverage. This creates confusion and, often, claim rejection or partial approvals that leave families financially burdened.
Why Policyholders Are Struggling
Insurance Samadhan regularly receives queries from cancer patients, caregivers, pharma stakeholders and support groups asking the same question:
Why are life-saving modern cancer treatments not clearly covered under health insurance?
The issue is simple: policies reference the 2019 framework, while treatment science in 2025 has moved far ahead. When coverage clarity is missing, reimbursement becomes complex — and claim disputes increase.
The Need for Regulatory Revision
To protect policyholders, the industry must evolve. India needs updated IRDAI guidelines that:
- Clearly recognise modern cancer therapies
- Define coverage terms for new drugs
- Reduce ambiguity on exclusions & sub-limits
- Improve transparency in policy wording
- Ensure that “cancer cover” actually covers today’s cancer treatment
Insurance is meant to reduce financial trauma, not redirect it.
How Insurance Samadhan Helps
At Insurance Samadhan, we work with policyholders facing claim denials, partial settlements, non-disclosure issues, co-pay disputes and exclusion-based rejections. Our team helps interpret policies, draft representation, analyse treatment narratives and escalate cases when necessary — so you can focus on recovery, not paperwork.
We stand for fair treatment, clarity in cancer coverage, and better protection for Indian families.
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Yes, but coverage varies. Many policies cover hospitalisation & chemo, but modern drugs and targeted therapies may not be fully covered.
Because of sub-limits, exclusions, drug restrictions and outdated coverage standards under IRDAI guidelines issued in 2019.
Some are, many are not. Coverage clarity depends on policy wording. Always check exclusions before treatment.
Yes, in some policies — but may require justification. Documentation strength impacts approval.
Seek expert support from Insurance Samadhan to review documents, draft representation and escalate if needed.
Medical advancement now demands revision. Industry stakeholders, including cancer groups & pharma, are pushing for it.
