Heath insurance in India should also cover preventative care

Copyright © HT Digital Streams Limit all rights reserved. Opinion Srinath Sridharan 4 min Read 16 Apr 2025, 12:30 IST Reforms for Health Insurance must reflect the clinical and epidemiological realities of our time. (Pixabay) Summary A wide approach can pave the way for healthcare that ensures our overall health much better. We can hardly call it ‘care’ if it only starts at the hospital door. India’s health insurance system ignores one of the most effective instruments in modern medicine: preventative care. Despite overwhelming global evidence that early intervention reduces hospitalizations, disabilities and cost of health care, Indian insurance policies rarely cover, if ever the cost of preventative medication for chronic and life -threatening conditions. These are the treatments that patients can keep out of hospitals – but it stays out of reach for many, simply because their value is not recognized. Worse still, this blind spot sits on top of a system that already does not have patients. Policies are treated as reflection, which is left to navigate a maze designed to protect the interests of hospitals, third-party administrators and insurers more than the people they claim. Claims are delayed or denied on technical aspects. After hospital care is minimal and short-lived. Price distortions are mostly undisputed. Also read: The rights of nominated insurance policy need legal clarity we have today are not health insurance. It is hospitalization insurance – with inefficiency, opacity and corruption. Until the Insurance Regulatory and Development Authority of India (Irdai) begins to prioritize the prevention, support the continuity of care and submit consumers, meaningful reform will remain a distant dream. Take the example of Evolocumab, a cholesterol -lowering injection used worldwide to manage cardiovascular risk. In the US, this life-saving drug is available for as little as $ 5 a month under insurance plans when prescribed for high-risk heart patients. Insurers recognize the long -term savings by preventing heart attacks, strokes and expensive hospitalizations. But in India, the merits in that logic are overlooked. Health insurance policies regularly exclude the cost of such medication, even if they can prevent catastrophic events. So we have a healthcare system that has ignored science, the economy of the side steps and exposed patients. We forgot that insurance is about price risks. There is a strong case – economic, ethical and clinical – for India to switch from reactive hospitalization to proactive health management. This is why preventative medication should be included in health insurance. This will reduce long-term health care costs: the coverage of preventative medicine helps to avoid expensive hospitalizations and operations later. It encourages early intervention: People are more likely to take essential medication if it is affordable and accessible. This enables a shift to proactive care: it ties in with global priorities for managing well -being and chronic diseases. It promotes equity: Preventive medicine -coverage can bridge India’s geographical areas and income levels. Health insurance reforms must begin with these changes, reflecting the clinical and epidemiological realities of our time. Apart from making claim processes smoother, for which efforts are being made, we must include the management of chronic diseases-such as diabetes, hypertension and hyperlipidemia-in basic health plans, mandate that preventative medicine approved under standard treatment protocols is covered or subsidized, and that the assurances of a ‘value-based cover’ Prevention of diseases as a value amount is seen as a value amount. Also read: India insures by 2047: Insurance companies must be profitable to achieve it above what – or not – is covered, there is another problem: the consumer experience. When policyholders are involved with health insurers, they often feel ignored, rejected and even defeated. The paperwork is troublesome and claims are denied too often. Customer service is slow, opaque and useful. To call the system ‘unfriendly’ would be generous. At its worst, it feels hostile. The industry has a trust deficiency. To close this requires more than new products. It requires consumer orientation that goes beyond promises of faster demand. If you cover preventative medication, it would make a big difference. Medicines that are clinically proven to reduce surveys in emergency hospital are often expensive and need greater use. Finally, how we assess the success in the health insurance industry should be recharged. Insurers celebrate premium growth and claim ratios today. But these internal statistics say nothing about public health outcomes-or the actual well-being of the policy holder. If health insurance is intended to serve the goals of public health, it needs more meaningful criteria. We must ask: one, how many hospitalizations were prevented by early intervention? Two, how many people with chronic illness have their clinical indicators improved? Three, how many policy holders have maintained good health over five years due to the care of the policy? The above is what should detect a functional and consumer first insurance model. These statistics should also be central to how the Irdai evaluates the performance of the sector. The regulator needs to go beyond its comfort zone of regulating forms, relationships and solvency margins, and acts with more vitality as a custodian of consumer confidence and public health. It is an important sector and may not be underperformed. Also read: Rahul Matthan: Data-rich insurance models can fail as a point, the longer we delay such a shift, the steep the price we will pay through congested hospitals, ruin premiums and a deepening gorge between citizens and insurers. If every approved pill is not covered and every disease is not fought as it develops, it is a betrayal of the broad promise of health coverage. We can’t really call it ‘care’ if it just starts at the hospital door. The author is a corporate adviser and author of ‘Family and Dhanda’. Catch all the business news, market news, news reports and latest news updates on Live Mint. Download the Mint News app to get daily market updates. More Topics #Healthcare #Health Insurance #Hospitals Mint Special